Adopting a population-level approach to parenting and family support interventions
Ronald J. Prinz, Matthew R. Sanders
Evidence-based treatments and preventive interventions in the child and family area have not met with widespread adoption by practitioners.
(What is this about, do you think? What makes change, even for the better, so hard for us? What's it going to take to rationally choose methods with better evidence and outcomes over traditional and less effective ones?)
Despite the high prevalence of child behavioral and emotional problems, many parents and families in need are not receiving or participating in services, and when they do, the most efficacious interventions are not what is usually provided.
(Is this a clinical and ethical issue or what? When parents overcome all the barriers to access that exist, including stigma and discrimination, don't they deserve the very best in the most efficient manner?)
Simultaneously addressing the issues of low penetration and insufficient dissemination of evidence-based programming requires a population approach to parenting and family support and intervention. Process issues are important, particularly in relation to engagement of stakeholders, recruitment of practitioners, consideration of organizational factors, and use of media and communication strategies. This article discusses why there is a need for a population-based approach, provides a framework of how to conceptualize such an approach, and describes an example from our own work of a recently initiated prevention trial that illustrates a population-based approach in action. The rationale, structure, and goals of the Triple P System Population Trial are described in the context of the aforementioned population framework.
(Working with large populations - school-wide, city-wide and district-wide - it makes sense to use a "population approach to parenting and family support and intervention" instead of primarily trying to serve students and their families one by one. This is especially true considering the shrinking resources and increased demands!)
Applying a public health perspective to child and family intervention, a relatively new, innovative, and potentially paradigm-shifting approach is to adopt population-wide strategies that seek to optimize impact and reach larger segments of the child/family population.
(This is so exciting, let's usher in a revolution in the way we do business.)
Surveys of parents indicate that as much as a quarter to a third of children in the general population exhibit behavioral and emotional problems that present parenting challenges and risk for subsequent adverse outcomes. Unfortunately, a high proportion of children with behavioral or emotional problems never receive either preventive or treatment services, and those who do typically do not receive empirically supported parenting interventions.
(We can do better than this, simply by doing things differently. We don't have to work harder, although change seems always to be harder initially. This becomes less true for me when I focus on the ultimate goal, which is very motivating and gives me juice to overcome the hurdle of inertia.)
From an efficacy standpoint, family-based programming, based on social-learning, functional analysis, and cognitive-behavioral principles, is the treatment of choice particularly for early behavioral problems and conduct problems in general. Parenting and family support programs that are based on the same conceptual models have also proven efficacious for prevention.
(It is scary, as a trapeze artist, to let go of the last bar unless your other hand has a firm grip on the next bar. The next bar is better! Trust and let go, baby!)
Despite high prevalence rates for child behavior problems, only a small proportion of parents ever participate in a parenting/family intervention of any kind, and even fewer in one that is evidence based. If the delivery of programs is restricted for example to mental health clinics and private-practice clinicians, then parental access to programming is like to be quite limited. In fact, most contact points where parents routinely confer with frontline professionals (e.g., primary care, educational and daycare, public health) do not provide evidence-based information and support for effective parenting. The problem of access is multi-faceted: (1) most professionals with whom the general population of parents has contact are not prepared to provide evidence-based consultation about parenting and child behavior; (2) by and large, many parents who need assistance with child behavioral and emotional issues either cannot get adequate services or do not seek it out; and, (3) as a result, evidence-based interventions are reaching only a tiny proportion of children and families in the population.
(Let's change this, baby! Let's revolutionize the services to which the most vulnerable have access. Let's bring the best science to vulnerable communities! Revolution, baby! Access, baby! Tell me you are feeling the call!)
Empirical support for family-based treatments and preventive interventions has been well established. Practitioner adoption of evidence-based interventions for both treatment and prevention has been quite limited in a number of application areas, and the family/parenting area is no different. Much of the services in the child and family area are non-evidence based.
(Enough of this, now! Let's step out of the darkness and into the light. We know so much more now. Let's do better.)
The presumption underlying the deployment of population level interventions is that the component programs have shown evidence of efficacy and effectiveness. Going to scale at a population level, though potentially cost effective, is nonetheless a major investment that cannot be predicated on programs that have not been sufficiently validated. The field is just beginning to formulate standards of evidence necessary for broad dissemination of an intervention program. For example, the Society for Prevention Research (2004) has promulgated standards of evidence for viable preventive interventions. According to these standards, a program that is deemed ready for broad dissemination must have clear evidence for efficacy and effectiveness (described in detail in the standards), have materials and services that facilitate going to scale (e.g., manuals, training, and technical support), provide clear cost information, and have appropriate monitoring and evaluation tools. These criteria are important for understanding what is needed to conduct broad dissemination of a preventive intervention, including interventions for parents and families. However, there is an additional distinction that is relevant, namely that dissemination of parenting interventions on a broad scale and taking a population approach to parenting programming, while overlapping, are not entirely synonymous. In addition to the aforementioned dissemination criteria, a successful population approach requires evidence of flexibility, ease of accessibility, cost efficiency and practicality at a population level, and effectiveness in population-level applications.
I hope this abstract with additional article excerpts has peaked your interest. Check out the full article for more information. You too can be a nerd for social justice, efficacious and efficient interventions.
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