Unit VIII (Soc Psy)

Parent Engagement in an Integrated Care Parenting Intervention to Prevent Toxic Stress

Briana Woods-Jaeger, Julia E. Thompson, Angelique Foye-Fletcher, Emily Siedlik, Ayanda Chakawa, Katie Dalbey, and Rupal C. Gupta

Children’s Mercy, Kansas City, Kansas City, Missouri

Objective: This study assessed parent engagement and satisfaction with an evidence- based parenting intervention delivered within a pediatric primary care clinic serving families at-risk for toxic stress. Method: Ten pilot study parent participants (all female; 80% African American; mean age � 26.1 years) completed sociodemographic, adverse childhood experiences (ACEs) history, depression, social support, and session satis- faction measures to assess parent characteristics and intervention satisfaction. Parent attendance was assessed and thematic analysis of session notes was conducted to assess parent engagement in intervention sessions. Results: Sixty percent of respondents had elevated ACE scores (Total Score �4), and 27% of respondents had elevated Edin- burgh (Total Score �10). Attendance in intervention sessions was inconsistent. The- matic analysis indicated that parents demonstrated several engagement behaviors during sessions they attended, including sharing opinions/disclosing information and providing one’s point of view. Follow-through with activities recommended during intervention sessions was more likely when linked to parents’ personal strengths or concerns. Parents reported all session content as “helpful or “very helpful” and would recommend the program to others. Conclusions: Parents experiencing risk factors for toxic stress may face challenges in consistently attending integrated care parenting intervention sessions but engage in sessions they attend. Strategies for engaging parents at risk for toxic stress in a primary care-based parenting program include building from parent strengths, addressing identified parent concerns, offering proactive support including parent mental health promotion, and building trusting relationships.

Implications for Impact Statement This is a small pilot study that assessed parent engagement in a parenting program connected to infant well-child visits. The intervention was designed to promote respon- sive caregiving by strengthening parents’ understanding of their infant’s behavior and supporting parents in responding to their child’s emotional and physical needs. The study found that building from parent strengths, responding to identified parent con- cerns, offering proactive support (including parent mental health referrals), and building trusting relationships may promote parent engagement.

Keywords: toxic stress, integrated primary care, parenting intervention, racial health disparities, parent engagement

Supplemental materials: http://dx.doi.org/10.1037/cpp0000361.supp

Briana Woods-Jaeger, X Julia E. Thompson, X Angelique Foye-Fletcher, Emily Siedlik, X Ayanda Chakawa, X Katie Dalbey, and X Rupal C. Gupta, Children’s Mercy, Kansas City, Kansas City, Missouri.

Katie Dalbey is now at the Operation Breakthrough, Inc., Kansas City, Missouri.

This work was supported by the David Woods Kem- per Foundation. The authors are grateful to the Two Generations Thrive Community Advisory Board mem-

bers; Operation Breakthrough, Inc.; and, most impor- tantly, the parents who willingly contributed their expe- riences to inform this work.

Correspondence concerning this article should be ad- dressed to Briana Woods-Jaeger, who is now at the De- partment of Behavioral Sciences and Health Education, Em- ory Rollins School of Public Health, 1518 Clifton Road NE, Atlanta, GA 30322, USA. E-mail: bwoodsjaeger@emory .edu

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Clinical Practice in Pediatric Psychology

© 2020 American Psychological Association 2020, Vol. 8, No. 3, 298–303 ISSN: 2169-4826 http://dx.doi.org/10.1037/cpp0000361

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Infancy is a critical period in a child’s life. Early adverse childhood experiences (ACEs) that put children at risk for toxic stress or “pro- longed activation of stress response systems in the absence of protective relationships” (Na- tional Scientific Council on the Developing Child, 2017) can have immediate and long-term impacts on development, health, and quality of life (Danese & McEwen, 2012). Children of parents with histories of ACEs are at greater risk for ACEs themselves (Randell, O’Malley, & Dowd, 2015). The intergenerational cycle of toxic stress can contribute to socioeconomic and racial disparities in behavior, health, and learning (Dawson-McClure, Calzada, & Brot- man, 2017).

Responsive caregiving early in life, which is characterized by attention to children’s emo- tional and physical needs (Morris et al., 2017), can prevent some of the damaging effects of toxic stress (Garner, 2013). However, many ra- cial minority parents living in poverty are nav- igating the demands of child rearing while con- fronted with compounding chronic stressors, such as low-quality educational environments, dangerous neighborhoods, lack of adequate and accessible public services, and discrimination, which can hinder responsive caregiving (Lakind & Atkins, 2018). In addition, mothers and chil- dren of color and lower socioeconomic status experience numerous health disparities includ- ing lower rates of breastfeeding, higher parent- ing stress, higher infant disease burden, and higher rates of maternal and infant mortality (Bartick et al., 2017; Nomaguchi & House, 2013). Effective and accessible parent support interventions have the potential to reduce socio- economic and racial disparities for families of color living in poverty (Dawson-McClure et al., 2017).

Integrated primary care emphasizes coordi- nation between behavioral health and primary care providers in a patient-centered model of care (McDaniel et al., 2014). A meta-analysis of interventions for parents of young children in the primary care setting indicated overall im- provements in parent– child interactions and cognitively stimulating activities across inter- ventions (Shah, Kennedy, Clark, Bauer, & Schwartz, 2016). The integrated care model can reduce barriers to parenting interventions, en- hance intervention reach, and improve parent

engagement for families in poverty (Lakind & Atkins, 2018).

Incredible Years Well-Baby (IYWB) is an evidence-based parenting intervention specifi- cally designed for use in primary care settings (Webster-Stratton & Reid, 2010; see online sup- plemental material for additional information on IYWB). The purpose of this study was to examine parent engagement and satisfaction with IYWB within a pediatric clinic serving families living in urban poverty with high levels of ACEs. Engagement was defined as meaning- ful participation both in interactions with pro- viders and follow-through with intervention recommendations (Haine-Schlagel & Walsh, 2015). Better understanding of engagement within this population may guide implementa- tion of integrated care parenting interventions in pediatric settings that aim to reduce behavior, health, and learning disparities among racial minority families living in urban poverty.

Method

Study Design

The IYWB intervention was initiated as a universal primary prevention intervention in a pediatric clinic colocated with a Head Start in the Midwest with approximately 90% of pa- tients insured under Medicaid. To better under- stand parent engagement in this integrated care parenting intervention, we initiated the IY Well- Baby pilot study. The hospital institutional re- view board approved all study procedures.

Recruitment

Primary care providers in the clinic discussed IYWB with caregivers at well visits and offered a recruitment flyer describing the pilot study. If parents expressed interest, they met with a member of the research staff who reviewed the study letter, enrolled the patient, and obtained verbal consent. Once enrolled in the pilot study, the caregiver participated in IYWB at each sub- sequent well-child visit through 9 months of age. IYWB interventionists included licensed psychologists and licensed social workers. Pa- tients were scheduled in-person or by phone for their well visit and received a personal phone reminder the business day before the appoint- ment to encourage appointment attendance. Par-

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ticipants received $20 for the baseline assess- ment, a booklet on topics covered in the sessions, and a small toy for each subsequent visit. Participants received $30 for the postint- ervention assessment.

Data Collection

Data sources include self-report baseline as- sessments with IYWB pilot study participants, self-report session satisfaction data, and inter- vention session progress notes. Participants completed self-report questionnaires before, during, and after intervention completion elec- tronically or on paper. Baseline questionnaires included a sociodemographic questionnaire, the Expanded ACE Questionnaire for parent partic- ipants (Cronholm et al., 2015), the Multidimen- sional Scale of Perceived Social Support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1988), and the Perceived Stress Scale (PSS; Cohen, Kamarck, & Mermelstein, 1983). At each well-visit, parents completed the Edin- burgh Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987) and the IYWB Session Sat- isfaction Questionnaire. The licensed psycholo- gist and social worker IYWB interventionists were qualified to respond to any safety concerns (i.e. suicidality) that were indicated by the EPDS. Postintervention questionnaires were the same as baseline with the exception of the Ex- panded ACE Questionnaire, which was only given at baseline. See online supplemental ma- terial for additional information on specific measures.

The IYWB interventionist completed a stan- dardized session note for each IYWB encoun- ter. Drawing from Haine-Schlagel and Walsh’s (2015) work, these notes were used to explore parent engagement using the following behav- ioral indicators of engagement: sharing opin- ions or disclosing information, asking ques- tions, providing one’s point of view on a problem or solution, engaging in therapeutic activities such as games and role plays, and following through with suggested at-home ac- tivities and techniques. Coding was completed by one of the IYWB interventionists after the completion of the study. A coding key with operational definitions for each parent engage- ment indicator was used to thematically analyze behavioral descriptions of in-session parent en- gagement recorded in the session notes. The

coder was not blind to session number or inter- ventionist.

Data Analysis

Descriptive statistics summarized key so- ciodemographic characteristics and mean sur- vey scores for all participants at baseline. Due to a high rate of attrition, within-group analyses were not conducted to evaluate changes from baseline to postintervention. To assess parent attendance, we calculated the percent of ses- sions attended. Participant satisfaction re- sponses were summarized at each session and for the program overall. To assess parent en- gagement, we conducted a deductive thematic analysis on session notes by coding parent par- ticipation during the session using the behav- ioral indicators outlined above (Haine-Schlagel & Walsh, 2015).

Results

Participant Descriptives

Eleven participants enrolled and completed some or all baseline surveys. Only 10 of the 11 enrolled participants provided sociodemo- graphic data. See Table 2 in the online supple- mental materials for further details regarding sociodemographic characteristics and baseline indicators of IYWB research participants. Of the 10 caregiver participants who provided so- ciodemographic data, all were female, with a mean age of 26.1 years old (SD � 4.0). Eighty percent (80%) of participants identified as Af- rican American or Black, and 10% identified as Hispanic. Seventy percent reported high school graduate or less as the highest degree of educa- tional attainment and 60% were unemployed. Sixty percent of participants had 1–3 children under 18 years of age in the household. The remaining 40% had 4–6 children under 18 years of age in the household. Sixty percent of respondents had elevated ACE scores of 4 or higher at enrollment (See Table 3 in the online supplemental materials for further details), and 27% of respondents had elevated Edinburgh scores of 10 or higher. The mean total Perceived Stress Scale (PSS) score for all participants was 15.1 (SD � 5.6), which is above the norm table mean for females of 13.7 (SD � 6.6). Respon- dents reported high support on the Multidimen-

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sional Scale of Perceived Social Support (MSPSS; M � 5.5, SD � 1.3).

Parent Engagement

Overall, the thematic analysis indicated that parents engaged in the IYWB visits primarily through (a) sharing opinions or disclosing infor- mation and (b) through providing one’s point of view on a problem or solution. For example, one note indicated how a parent shared infor- mation and indicated how she could use IYWB tools to support a solution:

Parent expressed some concern that the daycare was overfeeding the baby. She set a goal to use the IY home activity handout “A Typical Day with your Baby” to record feeding, diaper changes, fussy times, play and alert times, and bowel movements in order to educate the baby’s day care workers about her needs.

Another parent disclosed mental health chal- lenges she was having, thus providing an op- portunity for the IYWB interventionist to col- laboratively problem-solve with her:

Parent also described struggles with fatigue, competing demands, limited social support, and depressive symp- toms. IYWB interventionist provided psychoeducation about depression and assessed if Parent has adequate professional resources to support dealing with these issues and determined that Parent does not attend standing weekly appointment with a therapist. After some problem solving with IYWB interventionist, Par- ent reported planning to attend next therapy session scheduled for next week.

The thematic analysis also indicated that par- ents followed through with suggested at-home activities or techniques that were linked to per- sonal concerns/problems or strengths that were directly discussed during the visit, versus gen- eral recommendations/strategies. Examples of follow through included:

(1) Parent reported completing the “Supports Hand” home practice activity with her niece over the holidays as an activity. (Prior visit: Parent described a number of positive social supports, including her boyfriend, mother, and step-mother.)

(2) Parent states utilizing her deep breathing in mo- ments of stress and/or anxiety. (Prior visit: Parent set a goal to utilize deep breathing technique when [Parent] feels overwhelmed by crying and chaos in the home.)

The session note documentation typically noted that parents were engaged in watching the video vignettes (e.g., made comments on points of interest or relatable content, answered fol- low-up questions about the content presented,

highlighted examples of problem solving pre- sented in the vignette). However, parents asking questions and engaging in therapeutic activities such as games and role plays was rarely noted in the encounter documentation.

Parent Attendance

Overall, 73% percent of parents attended 50% or more of the six IYWB visits. While all participants were recruited at their newborn visit, only 82% participated in the IYWB new- born session (two participants were able to com- plete the enrollment assessments but not the IYWB session at the time of newborn visit), 36% participated in the 1 month session, 55% in the 2 months session, 55% in the 4 months session, 45% in the 6 months session, and 45% in the 9 months session. The mean number of sessions attended was 3 (SD 1.3). No parents completed all sessions.

Parent Satisfaction

Parents reported finding all session content to be “Helpful” or “Very Helpful,” with the ex- ception of the 6 months session for which one participant felt “Neutral” about the content. Par- ents reported finding the video examples to be “Helpful” or “Very Helpful” across all sessions without exception. Parents endorsed high levels of satisfaction with the interventionists’ teach- ing of the program (80% reported intervention- ist(s) teaching was “Excellent”) and their rela- tionship with the interventionists (80% reported relationship was “Above Average” or “Excel- lent”). Eighty percent (80%) of participants in- dicated that the feeling of overall support and connectedness they felt since taking the pro- gram was “Slightly Improved” or “Greatly Im- proved.” All parents said they would recom- mend IYWB to a friend or relative with a baby.

Discussion

For children at-risk for toxic stress due to high levels of parent ACEs and living in pov- erty, responsive caregiving early in life has the potential to prevent toxic stress. Developing effective parenting intervention engagement strategies for racial minority parents with ACE histories living in poverty provides an opportu- nity to mitigate disparities in behavior, health,

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and learning through early intervention (Lakind & Atkins, 2018). Data from the current study support that building from parent strengths, re- sponding to identified parent concerns, offering proactive support (including parent mental health referrals), and building trusting relation- ships may promote parent engagement in struc- tured behavioral health interventions and should be examined in future parent engagement stud- ies. Future research should also assess strategies to promote other aspects of parent engagement such as asking questions and engaging in ther- apeutic activities such as games and role plays. Potential strategies include providing more op- portunities for brief, open discussion guided by parents’ questions or concerns and setting aside time for rehearsal of techniques.

Satisfaction and session attendance data indi- cate that while intervention session attendance is inconsistent, the majority of parents in our sample participated in more than one session and reported benefit and satisfaction from this engagement. This suggests that providing par- enting interventions flexibly (e.g., not requiring attendance at all sessions) and offering them universally to all parents within the pediatric primary care setting may improve access. Fu- ture research should examine the adequate dose of IYWB to reduce risk and promote protective factors among parents with ACE histories living in poverty.

Limitations of the study include small sample size and participant attrition which prevented within-group analyses from being conducted. Future research should examine recruitment and retention strategies for research studies with this population. We also did not measure exposure to other interventions which may have modified results. Despite these limitations, this study sug- gests that while parents experiencing risk fac- tors for toxic stress face challenges in consis- tently attending integrated care parenting intervention sessions, they report high satisfac- tion with the intervention and engage in ses- sions they attend. Strategies identified in this study are promising approaches to improve ac- cess and engagement in parenting interventions for racial minority parents with ACE histories living in poverty. Future studies should examine if implementing these strategies improves out- comes for parents and infants and reduces so- cioeconomic and racial disparities for families of color living in poverty.

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Received January 15, 2020 Revision received June 26, 2020

Accepted June 29, 2020 �

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