As a parent herself, Joanne Wood, MD, MSHP, knows that parenting is stressful. As a pediatrician-researcher who has worked with high-risk populations including children in foster care, she has seen how the challenges of parenting, combined with behavioral problems that are extremely common in young children, can sometimes add up to a negative cycle that can spiral into serious consequences.
“Problematic behaviors from young children can prompt negative and reactive parenting that then increases the child behavior problems,” Dr. Wood said. “We know that child behavior problems are associated downstream with decreased school readiness, worse academic outcomes, increased risks of mental health issues, as well as increasing risk of harsh parenting.”
So she decided to find ways to break the cycle by helping parents in need at a primary care practice.
“Often for mental health interventions, children have to have a diagnosed condition to receive services,” said Dr. Wood, an attending physician and faculty member in PolicyLab at The Children’s Hospital of Philadelphia. “And really we want to keep kids from getting there.”
She found a promising tool to do so in a group parenting intervention called CARE, which she helped implement and evaluate during PolicyLab’s work with the city of Philadelphia helping caregivers in the foster care system develop positive parenting skills.
As she and her colleagues report in the journal Academic Pediatrics, providing a six-week version of this program to parents of preschool-age children at CHOP’s primary care facility in South Philadelphia was effective at improving ratings of child behavior and improving parent attitudes. The intervention, called PriCARE for its adaptation to a primary care setting, is now being offered to more parents in multiple classes at CHOP’s new South Philadelphia facility and at the Karabots Pediatric Care Center in West Philadelphia. The classes are funded by support from The Pew Charitable Trusts, Oscar G. & Elsa S. Mayer Family Foundation, and a private donor.
The main feature of PriCARE is its emphasis on positive parenting. Parents who attend this small-group program learn skills to focus on and reinforce desirable and prosocial behavior in children while ignoring milder misbehaviors. Providing labeled praise such as, “I like how you are sitting up in your chair,” and, “Thank you for sharing your toy,” helps parents establish a healthier, more supportive baseline relationship with their child. That healthy relationship pays dividends as parents later develop ways to address their child’s undesired behaviors.
Deliberately practicing these skills can feel a little awkward at first, Dr. Wood noted. Parents and caregivers go home from the PriCARE classes with homework assignments to try out specific behaviors during play sessions with their child. When they return the next week, they can share what worked well and where they struggled in discussions with the program’s two facilitators (both mental health therapists) and with other parents and caregivers.
The classes take place in the pediatric primary care facility in part to help reduce stigma associated with receiving a behavioral health intervention, and in part because it is a convenient location for families in their community. Child care is provided so parents can give the sessions their undivided attention. The classes combine lectures with discussions, role plays, and other interactive elements to help parents grow familiar with new parenting and stress-management skills for themselves and for their child.
The stress reduction techniques are part of a trauma-focused education component of PriCARE that also helps parents to understand that some of the behaviors they might see in their child may be a result of traumatic stressors in the community, such as violence and poverty.
“It’s not that the child is acting up because they’re bad or mean or upset at their parent, but it may be a reaction to something that they’ve been exposed to, and stress is leading to that behavior,” said Dr. Wood, who is also an assistant professor of Pediatrics at the Perelman School of Medicine at the University of Pennsylvania. Coming from a place of understanding that possibility helps many parents take a more constructive and less punitive approach to misbehavior.
In Dr. Wood’s study of PriCARE, families were invited to participate if they had behavioral concerns about their 2- to 6-year-old child. The study team enrolled 120 families and randomized them to either receive the PriCARE intervention right away or to be on a wait list and serve as a control group before receiving the intervention later if they wished. The researchers surveyed both groups before and after the intervention group attended PriCARE sessions, focusing on parent reports of their child’s behavior and parents’ attitudes about parenting techniques.
They found that children whose parents were randomized to the intervention group had greater decreases in behavioral problems over time compared to the waiting list children, and that after attending PriCARE their parents had decreased belief in use of corporal punishment and increased empathy toward their children.
“These are things we were hoping to affect with a focus on positive parenting,” Dr. Wood said.
With the next phase of classes getting underway, Dr. Wood plans to build on this preliminary evidence base about PriCARE’s impacts by seeking more direct observational measures of children’s behavior among a subset of participants. Over the next three years, she expects to enroll 180 parent/child dyads in a follow-up study. Parents will also be welcome to enroll in PriCARE sessions without being part of a study.
Ultimately, Dr. Wood hopes this work can build a strong evidence base showing that PriCARE helps improve the trajectory for young children with behavioral problems. By intervening preventively, she wants to support parents helping their children get on the right track to help more children thrive without the need for complex and expensive behavioral health interventions.