Positive Parenting Program to Improve Problem Behaviors in Preschool-Age Children (PriCARE)
Less than half the children with a behavioral or emotional disorder receive needed services; those living in poverty are at an even higher risk yet less likely to receive treatment. Our intervention, PriCARE, is an innovative six-week group parenting program designed to improve child behavior, strengthen parent-child relationships, and decrease stress. The intervention is effective because it identifies parents directly at their pediatric primary care practice. The challenges of parenting, combined with behavioral problems that are extremely common in young children, often create a negative cycle that escalates into serious consequences. Child behavior problems are associated with increased risk of negative outcomes for children, including poor academic performance, mental health issues and increased risk of harsh parenting. PriCARE aims to break this negative cycle in disadvantaged populations through a combination of group discussions, role plays and interactive elements, providing parents with positive techniques and stress-management skills. The training encourages parents to give attention to children’s positive, pro-social behaviors, while ignoring minor misbehaviors. The second phase of training teaches techniques for giving children effective commands in order to set age-appropriate limitations. In a randomized control trial, PriCARE was shown to be effective in promoting positive parenting and reducing child behavior problems.
Pediatricians can refer patients to behavioral health specialists, but many children never receive treatment due to long wait times, cost, distrust of a new provider, and stigma, among other barriers. Thus, we integrated PriCARE into the primary care setting to help reduce stigma associated with receiving a behavioral health intervention, and because it is a familiar/convenient location for families. To further reduce barriers to care, we provide childcare and food during PriCARE sessions and can assist with transportation costs. Many of the families and children served by our primary care practices have experienced traumatic stressors such as community violence, and they face significant medical and social risks due to poverty. In addition to providing parents with effective stress-management skills, we incorporated a trauma and stress education component to help parents understand that some of the behaviors they see in their child could be a result of these traumatic stressors.
PriCARE is a collaborative effort leveraging the combined expertise and resources of PolicyLab, Safe Place, Pediatric Research Consortium (PeRC), and the urban Primary Care Centers at Children’s Hospital of Philadelphia (CHOP), as well as Hall-Mercer Community Mental Health Center of Pennsylvania Hospital. Capitalizing on the expertise and infrastructures of PeRC and PolicyLab, which coordinate CHOP’s practice-based research, the team expanded the number of families served while simultaneously conducting a rigorous evaluation of the efficacy of PriCARE. The leadership team includes pediatricians, psychiatrists, psychologists and researchers. This collaborative, multi-disciplinary effort has enabled clinicians to seamlessly provide PriCARE within the primary care setting. The dual implementation/evaluation approach is critical in achieving high-quality interventions that impact children and families, and demonstrate that the model can be replicated and scaled. PriCARE is being further disseminated and evaluated by colleagues in our partnering groups. Findings are shared through peer-reviewed publications, blogs, websites, and regional/national meetings.
Given the promising results of PriCARE for children and parents and the lack of other treatment options available for this population, we applied for funding and were fortunate to receive generous support from Pew Charitable Trusts, Mayer Family Foundation and a private donor through 2018. Prevention programs are typically not reimbursed by Medicaid or insurance, so foundation support has been critical in launching PriCARE. In designing PriCARE, we wanted to ensure that we could provide the intervention to all parents who felt they could benefit from support to manage their children’s behaviors before the situation required more costly and intensive treatment of a diagnosed behavioral disorder. Thus, we do not require that children have a behavioral disorder diagnosis for participation in PriCARE. Ultimately, by rigorously evaluating and demonstrating the effectiveness of PriCARE we seek to make a case for reimbursement to increase long–term sustainability of the intervention.
The PriCARE intervention has been successfully replicated across primary care centers at CHOP, and dissemination and evaluation are also in progress in other settings. A comprehensive PriCARE manual and training kit were created to help facilitate replication and include parent handouts, a training video, and fidelity checklists. These materials will help further disseminate PriCARE in primary care settings outside of our hospital system. PriCARE can be implemented in primary care practices that do not offer mental health services, because the model facilitates partnerships between primary care practices and mental health agencies. In developing PriCARE, we adapted Cincinnati Children's Hospital Medical Center’s two-session CARE intervention for delivery in primary care settings that serve families facing high rates of adversity. We provided another adaptation of CARE to over 200 foster caregivers in Philadelphia. Adaptations for delivery in additional settings are possible, but should be evaluated to ensure effectiveness.
We have collected compelling evidence of PriCARE’s success. To date, over 150 parents have enrolled in PriCARE and over 100 have attended PriCARE groups. Additionally, over 200 foster caregivers participated in a two-day version of the intervention. To evaluate the effectiveness of PriCARE, 120 families were enrolled in a randomized controlled trial. Measures of child behavior problems and parenting attitudes were collected prior to PriCARE, immediately after PriCARE, and 7 weeks after PriCARE. Children whose parents were randomized to PriCARE had significant improvements in behavioral symptoms, compared to those randomized to the control. After attending PriCARE, parents reported improvements in key parenting behaviors, including a decreased belief in the use of corporal punishment and increased empathy toward their children. These findings were presented at national meetings and published in Academic Pediatrics. A larger evaluation of PriCARE, which includes qualitative interviews with parents and innovative evaluation approaches, is ongoing.
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