Family-centered Prevention Research Articles

What Doesn't Work for Whom? Exploring Heterogeneity in Responsiveness to the Family Check-Up in Early Childhood Using a Mixture Model Approach.

This study applied latent class analysis to a family-centered prevention trial in early childhood to identify subgroups of families with differential responsiveness to the Family Check-Up (FCU) intervention. The sample included 731 families with 2-year-olds randomized to the FCU or control condition and followed through age 5 with yearly follow-up assessments. A two-step mixture model was used to examine whether specific constellations of family characteristics at age 2 (baseline) were related to intervention response across ages 3, 4, and 5. The first step empirically identified latent classes of families based on several family risk and adjustment variables selected on the basis of previous research. The second step modeled the effect of the FCU on longitudinal change in children's problem behavior in each of the empirically derived latent classes. Results suggested a five-class solution, where a significant intervention effect of moderate to large size was observed in one of the five classes-the class characterized by child neglect, legal problems, and parental mental health issues. Pairwise comparisons revealed that the intervention effect was significantly greater in this class of families than in two other classes that were generally less at risk for the development of child disruptive behavior problems, albeit still low-income. Thus, findings suggest that (a) the FCU is most successful in reducing child problem behavior in more highly distressed, low-income families, and (b) the FCU may have little impact for relatively low-risk, low-income families. Future directions include the development of a brief screening process that can triage low-income families into groups that should be targeted for intervention, redirected to other services, monitored prospectively, or left alone.

A Family-Centered Preventive Intervention Within Pediatric Oncology: Adapting the FOCUS Intervention for Latino Youth and Their Families

ABSTRACTPediatric cancer can disrupt the behavioral and emotional well-being of youth and their families, representing a potential psychological health risk for the entire family. Among ethnic minority families, cultural factors such as acculturation and language competency may affect the experience of this illness, which can, in turn, affect overall functioning. Integrating psychological health services within medical care settings is one method to enhance engagement in psychological health services and reduce barriers, including access and stigma. Given the paucity of evidence-based screening procedures and trauma-informed preventive interventions delivered within pediatric settings, the FOCUS consultation model was implemented within an outpatient pediatric oncology clinic. A case illustration is described to highlight the modifications made to the FOCUS consultation model to provide culturally sensitive and responsive treatment to Latino families. The article includes implications for future research on integrating culturally relevant, family-centered prevention approaches for reaching ethnic minority families.

Engaging School Mental Health Professionals to Deliver Evidence-Based Interventions to Hispanic Families.

Research has demonstrated that a number of evidence-based programs can be effectively implemented in different community settings, such as schools, to target Hispanic youth and their families; however, successful implementation of such programs represents a challenge for practitioners. This article describes experiences and strategies associated with recruiting, training, and supervising school mental health professionals in the school-based implementation of an evidence-based, family-centered prevention program for Hispanic families. School mental health professionals were recruited and given intensive training, weekly supervision for adherence monitoring, and ongoing technical assistance, in addition to intervention manuals and materials. We emphasize how strategies based on the prevention program itself were used to recruit, engage, and train school mental health professionals to deliver a family-based evidence-based program, blending research and practice in a large public school system. Implications of lessons learned are discussed, as well as the specific strategies to overcome challenges when engaging and training community partners in delivering a manualized intervention with rigorous adherence to the program.

Family-centered prevention ameliorates the association between adverse childhood experiences and prediabetes status in young black adults.

Individuals exposed to adverse childhood experiences (ACEs) are vulnerable to various health problems later in life. This study was designed to determine whether participation in an efficacious program to enhance supportive parenting would ameliorate the association between ACEs and prediabetes status at age 25. Rural African American parents and their 11-year-old children (N=390) participated in the Strong African American Families (SAAF) program or a control condition. Each youth at age 25 provided a total ACEs score and a blood sample from which overnight fasting glucose was assayed. Logistic regression equations were used to test the hypotheses. The logistic regression analyses revealed a significant interaction between total ACEs and random assignment to SAAF or control, OR=0.56, 95% CI [0.36, 0.88]. Follow-up analyses indicated that, for participants in the control condition, a 1-point increase in ACEs was associated with a 37.3% increase in risk of having prediabetes. ACEs were not associated with the likelihood of having prediabetes among participants in the SAAF condition. Control participants with high total ACEs scores were 3.54 times more likely to have prediabetes than were SAAF participants with similar scores. This study indicated that participation at age 11 in a randomized controlled trial designed to enhance supportive parenting ameliorated the association of ACEs with prediabetes at age 25. If substantiated, these findings may provide a strategy for preventing negative health consequences of ACEs.

Resilience to adversity and the early origins of disease.

For the past quarter century, scientists at the Center for Family Research at the University of Georgia have conducted research designed to promote understanding of normative developmental trajectories among low socioeconomic status African American children, youths, and young adults. In this paper, we describe a recent expansion of this research program using longitudinal, epidemiological studies and randomized prevention trials to test hypotheses about the origins of disease among rural African American youths. The contributions of economic hardship, downward mobility, neighborhood poverty, and racial discrimination to allostatic load and epigenetic aging are illustrated. The health benefits of supportive family relationships in protecting youths from these challenges are also illustrated. A cautionary set of studies is presented showing that some psychosocially resilient youths demonstrate high allostatic loads and accelerated epigenetic aging, suggesting that, for some, "resilience is just skin deep." Finally, we end on an optimistic note by demonstrating that family-centered prevention programs can have health benefits by reducing inflammation, helping to preserve telomere length, and inhibiting epigenetic aging.

Preventing adolescent depression with the family check-up: Examining family conflict as a mechanism of change.

Family-centered prevention programs are understudied for their effects on adolescent depression, despite considerable evidence that supports their effectiveness for preventing escalation in youth problem behavior and substance use. This study was conducted with 2 overarching goals: (a) replicate previous work that has implicated the Family Check-Up (FCU), a multilevel, gated intervention model embedded in public middle schools, as an effective strategy for preventing growth in adolescent depressive symptoms and (b) test whether changes in family conflict may be an explanatory mechanism for the long-term, protective effects of the FCU with respect to adolescent depression. This trial was conducted with 593 ethnically diverse families who were randomized to intervention (offered the FCU) or middle school as usual. Complier average causal effect (CACE) analysis revealed that engagers in the FCU evidenced less growth in depressive symptoms and family conflict from 6th through 9th grade, and post hoc analyses indicated that the FCU is related to lower rates of major depressive disorder. The second set of analyses examined family conflict as a mechanism of change for families who participated in the FCU. Families who reported short-term intervention benefits had significantly less escalation in family conflict over the middle school years; in turn, growth in family conflict explained risk for adolescent depressive symptoms.

Family-centered prevention ameliorates the longitudinal association between risky family processes and epigenetic aging.

Research has suggested that 'risky' family processes have unforeseen negative consequences for health later in life. The purpose of this study was to further understanding of risky family environments and development of health vulnerabilities by (a) examining the likelihood that elevated levels of parental depressive symptoms when children are age 11 forecast accelerated epigenetic aging 9years later at age 20; (b) determining whether participation in an efficacious family-centered prevention program focused on enhancing supportive parenting and strengthening family relationships will ameliorate this association; and (c) testing a moderation-mediation hypothesis that prevention-induced reductions in harsh parenting across adolescence will account for prevention effects in reducing accelerated epigenetic aging. In the rural southeastern United States, parents and 11-year-old children from 399 families participated in the Strong African American Families (SAAF) program or a control condition. Parents reported their own depressive symptoms when their children were 11, and both youths and parents reported youth exposure to harsh parenting at ages 11 and 16. Blood was drawn from youths at age 20 to measure accelerated epigenetic aging using a marker derived from the DNA methylation of cells. Elevated parental depressive symptoms forecast accelerated epigenetic aging among youths in the control condition, but not among SAAF participants. Moderated-mediation analyses confirmed that reductions in harsh parenting accounted for SAAF's protective effects on epigenetic aging. Subsequent exploratory analyses indicated that accelerated epigenetic aging forecast emotional distress among young adults in the control condition but not among those who participated in SAAF. This study is unique in using a randomized prevention trial to test hypotheses about the ways risky family processes contribute to accelerated epigenetic aging. The results suggest that developmentally appropriate family-centered interventions designed to enhance parenting and strengthen families can buffer the biological residue of life in a risky family.

Implementing Family-Centered Prevention in Rural African American Communities: a Randomized Effectiveness Trial of the Strong African American Families Program.

Efforts to disseminate evidence-based prevention programs are hampered by a lack of real-world effectiveness trials undertaken with community providers. The Strong African American Families (SAAF) program is an empirically validated intervention designed to prevent problem behavior among rural African American youth. To evaluate the effectiveness of SAAF and its implementation protocols when delivered by a community provider, we conducted a randomized, wait-list-controlled trial with outcome measurements assessed longitudinally at baseline and 6 months after baseline. A total of 465 African American youth and their parents were recruited randomly from public school lists of fifth- and sixth-grade students in eight rural counties in south Georgia. Youth and parents assessed targeted outcomes in their homes. The main outcome, problem behavior vulnerability, was operationalized as a latent construct comprising three indicators: tolerance for deviance, intentions to engage in risky behavior, and affiliations with risk-taking peers. SAAF was implemented with uniformly high levels of adherence (85.5%; SD = 10.8) and attendance (M = 4.1, SD = 2.9, range = 0-7). Intent-to-treat and complier average causal effect analyses revealed significant program effects on intervention-targeted parenting practices, youth self-regulatory processes, and problem behavior vulnerability. SAAF influenced problem behavior vulnerability indirectly via effects on targeted parenting and youth processes. This study supported the effectiveness of SAAF in a community setting when a systematic implementation model supports participant engagement and intervention adherence.

Prevention effects on trajectories of African American adolescents' exposure to interparental conflict and depressive symptoms.

The present study investigates the trajectory of children's exposure to interparental conflict during adolescence, its effects on adolescents' psychological adjustment, as well as the ability of a family-centered prevention program to alter this trajectory. A total of 331 African American couples with an adolescent or preadolescent child participated in a randomized control trial of the Promoting Strong African American Families program, a newly developed program targeting couple and cocaregiving processes. Using a multi-informant, latent growth curve approach, child exposure to interparental conflict during adolescence was found to be stable over a period of 2 years among families in the control group, but significantly declined among families in the treatment condition. Rates of change were significantly different between intervention and control groups based on parents' report of youth exposure to interparental conflict, but not for child's report. Structural equation models found trajectory parameters of interparental conflict predicted changes in adolescent depressive symptoms, with increasing rates of changes in conflict associated with increases in adolescent internalizing symptoms over the 2-year duration of the study. Finally, a significant indirect effect was identified linking treatment, changes in parents' reports of child exposure to interparental conflict, and adolescent depressive symptoms. The implications for research and intervention are discussed.

Longitudinal relations between observed parenting behaviors and dietary quality of meals from ages 2 to 5

Objectives: Parents influence a child's diet by modeling food choices, selecting the food they make available, and controlling the child's intake. Few studies have examined the covariation between parent's behavior management practices and their guidance and support for a young child's nutritional environment in early childhood. We hypothesized that parents' positive behavior support (PBS), characterized as skillful behavior management and proactive structuring of children's activities, would predict dietary quality over the course of early childhood (age 2 to 5 years), a critical period for the development of a dietary lifestyle. Methods: Participants included 731 culturally diverse, low-income families in a randomized, controlled trial of the Family Check-Up. Families participated in a yearly home visit videotaped assessment PBS and dietary quality of meals parents served to their children were assessed by coding videotapes of structured parent–child interactions. A cross-lagged panel model was used to evaluate the longitudinal relation between PBS and the dietary quality of meals served during a meal preparation task. Results: Analyses revealed that PBS repeatedly predicted meals' dietary quality the following year: age 2–3 (β = .30), age 3–4 (β = 0.14), age 4–5 (β = 0.37). Dietary quality significantly predicted PBS 1 year later: age 3–4 (β = 0.16), age 4–5 (β = 0.14). As expected, the relative strength of the relationship from PBS to dietary quality was significantly stronger than the reverse, from dietary quality to PBS. Conclusions: Positive behavior management and proactive parenting practices are an important foundation for establishing a healthy nutritional environment for young children. These findings suggest that family-centered prevention interventions for pediatric obesity may benefit from targeting PBS in service of promoting better dietary quality.

Military and Veteran Families and Children: Policies and Programs for Health Maintenance and Positive Development and commentaries

Military and Veteran Families and Children: Policies and Programs for Health Maintenance and Positive Development and commentaries

Prevention Effects Ameliorate the Prospective Association Between Nonsupportive Parenting and Diminished Telomere Length

Telomere length (TL) is an indicator of general systemic aging, with diminished TL associated with several chronic diseases of aging and with heightened mortality risk. Research has begun to focus on the ways in which stress contributes to telomere attrition. The purposes of this study were (a) to establish whether exposure to nonsupportive parenting, defined as high levels of conflict and rancor with low levels of warmth and emotional support, at age 17 would forecast TL 5years later; and (b) to determine whether participation in an efficacious family-centered prevention program could ameliorate any associations that emerged. Rural African American adolescents participated in the Adults in the Making (AIM) program or a control condition. Primary caregivers provided data on nonsupportive parenting during a pretest when adolescents were age 17. Adolescents provided data on anger at the pretest and at a posttest administered 7months later. When the youths were age 22, TL was assayed from a blood draw. The results indicated that heightened nonsupportive parenting forecast diminished TL among young adults in the control condition but not among those who participated in AIM; socioeconomic status risk, life stress, and the use of alcohol and cigarettes at age 17, and blood pressure and body mass index at age 22, were controlled. Subsequent exploratory analyses suggested that AIM-induced reductions in adolescents' anger served as a mediator connecting group assignment to TL. The results suggest that the cellular-level sequelae of nonsupportive parenting and stress are not immutable.

Dissemination of Family-Centered Prevention for Military and Veteran Families: Adaptations and Adoption within Community and Military Systems of Care

In response to the needs of military families confronting the challenges of prolonged war, we developed Families OverComing Under Stress (FOCUS), a multi-session intervention for families facing multiple deployments and combat stress injuries adapted from existing evidence-based family prevention interventions (Lester et al. in Mil Med 176(1): 19-25, 2011). In an implementation of this intervention contracted by the US Navy Bureau of Medicine and Surgery (BUMED), FOCUS teams were deployed to military bases in the United States and the Pacific Rim to deliver a suite of family-centered preventive services based on the FOCUS model (Beardslee et al. in Prev Sci 12(4): 339-348, 2011). Given the number of families affected by wartime service and the changing circumstances they faced in active duty and veteran settings, it rapidly became evident that adaptations of this approach for families in other contexts were needed. We identified the core elements of FOCUS that are essential across all adaptations: (1) Family Psychological Health Check-in; (2) family-specific psychoeducation; (3) family narrative timeline; and (4) family-level resilience skills (e.g., problem solving). In this report, we describe the iterative process of adapting the intervention for different groups of families: wounded, ill, and injured warriors, families with young children, couples, and parents. We also describe the process of adopting this intervention for use in different ecological contexts to serve National Guard, Reserve and veterans, and utilization of technology-enhanced platforms to reach geographically dispersed families. We highlight the lessons learned when faced with the need to rapidly deploy interventions, adapt them to the changing, growing needs of families under real-world circumstances, and conduct rigorous evaluation procedures when long-term, randomized trial designs are not feasible to meet an emergent public health need.

Psychological health of military children: longitudinal evaluation of a family-centered prevention program to enhance family resilience.

Family-centered preventive interventions have been proposed as relevant to mitigating psychological health risk and promoting resilience in military families facing wartime deployment and reintegration. This study evaluates the impact of a family-centered prevention program, Families OverComing Under Stress Family Resilience Training (FOCUS), on the psychological adjustment of military children. Two primary goals include (1) understanding the relationships of distress among family members using a longitudinal path model to assess relations at the child and family level and (2) determining pathways of program impact on child adjustment. Multilevel data analysis using structural equation modeling was conducted with deidentified service delivery data from 280 families (505 children aged 3-17) in two follow-up assessments. Standardized measures included service member and civilian parental distress (Brief Symptom Inventory, PTSD Checklist-Military), child adjustment (Strengths and Difficulties Questionnaire), and family functioning (McMaster Family Assessment Device). Distress was significantly related among the service member parent, civilian parent, and children. FOCUS improved family functioning, which in turn significantly reduced child distress at follow-up. Salient components of improved family functioning in reducing child distress mirrored resilience processes targeted by FOCUS. These findings underscore the public health potential of family-centered prevention for military families and suggest areas for future research.

Integrating condom skills into family-centered prevention: efficacy of the Strong African American Families-Teen program.

The Strong African American Families-Teen (SAAF-T) program, a family-centered preventive intervention that included an optional condom skills unit, was evaluated to determine whether it prevented unprotected intercourse and increased condom efficacy among rural African American adolescents. Ancillary analyses were conducted to identify factors that predicted youth attendance of the condom skills unit. Sixteen-year-old African American youths (N = 502) and their primary caregivers were randomly assigned to SAAF-T (n = 252) or an attention control (n = 250) intervention. SAAF-T families participated in a 5-week family skills training program that included an optional condom skills unit. All families completed in-home pretest, posttest, and long-term follow-up interviews during which adolescents reported on their sexual behavior, condom use, and condom efficacy. Because condom use was addressed only in an optional unit that required caregiver consent, we analyzed efficacy using complier average causal effect analyses. Attendance in both SAAF-T and the attention control intervention averaged 4 of 5 sessions; 70% of SAAF-T youth attended the condom skills unit. Complier average causal effect models indicated that SAAF-T was efficacious in reducing unprotected intercourse and increasing condom efficacy among rural African American high school students. Exploratory analyses indicated that religious caregivers were more likely than nonreligious caregivers to have their youth attend the condom skills unit. Results suggest that brief condom skills educational modules in the context of a family-centered program are feasible and reduce risk for sexually transmitted infections and unplanned pregnancies.

Evaluation of a Family-Centered Prevention Intervention for Military Children and Families Facing Wartime Deployments

We evaluated the Families OverComing Under Stress program, which provides resiliency training designed to enhance family psychological health in US military families affected by combat- and deployment-related stress. We performed a secondary analysis of Families OverComing Under Stress program evaluation data that was collected between July 2008 and February 2010 at 11 military installations in the United States and Japan. We present data at baseline for 488 unique families (742 parents and 873 children) and pre-post outcomes for 331 families. Family members reported high levels of satisfaction with the program and positive impact on parent-child indicators. Psychological distress levels were elevated for service members, civilian parents, and children at program entry compared with community norms. Change scores showed significant improvements across all measures for service member and civilian parents and their children (P < .001). Evaluation data provided preliminary support for a strength-based, trauma-informed military family prevention program to promote resiliency and mitigate the impact of wartime deployment stress.

Effects of a Family Intervention in Reducing HIV Risk Behaviors Among High-Risk Hispanic Adolescents

To determine the efficacy of a family intervention in reducing human immunodeficiency virus (HIV) risk behaviors among Hispanic delinquent adolescents. Randomized controlled trial. Miami-Dade County Public School System and Miami-Dade County's Department of Juvenile Services, Florida. A total of 242 Hispanic delinquent youth aged 12 to 17 years and their primary caregivers completed outcome assessments at baseline and 3 months after intervention. Participants were randomized to either Familias Unidas (120 participants), a Hispanic-specific, family intervention designed to reduce HIV risk behaviors among Hispanic youth, or a community practice control condition (122 participants). Self-reported measures included unprotected sexual behavior, engaging in sex while under the influence of alcohol and/or drugs, number of sexual partners, and incidence of sexually transmitted diseases. Family functioning (eg, parent-adolescent communication, positive parenting, and parental monitoring) was also assessed via self-report measures. Compared with community practice, Familias Unidas was efficacious in increasing condom use during vaginal and anal sex during the past 90 days, reducing the number of days adolescents were under the influence of drugs or alcohol and had sex without a condom, reducing sexual partners, and preventing unprotected anal sex at the last sexual intercourse. Familias Unidas was also efficacious, relative to community practice, in increasing family functioning and most notably in increasing parent-adolescent communication and positive parenting. These results suggest that culturally tailored, family-centered prevention interventions may be appropriate and efficacious in reducing HIV risk behaviors among Hispanic delinquent adolescents. clinicaltrials.gov Identifier: NCT01257022.

Families Overcoming Under Stress: Implementing Family-Centered Prevention for Military Families Facing Wartime Deployments and Combat Operational Stress

The toll of multiple and prolonged deployments on families has become clearer in recent years as military families have seen an increase in childhood anxiety, parental psychological distress, and marital discord. Families overcoming under stress (FOCUS), a family-centered evidence-informed resiliency training program developed at University of California, Los Angeles and Harvard Medical School, is being implemented at military installations through an initiative from Navy Bureau of Medicine and Surgery. The research foundation for FOCUS includes evidence-based preventive interventions that were adapted to meet the specific needs of military families facing combat operational stress associated with wartime deployments. Using a family narrative approach, FOCUS includes a customized approach utilizing core intervention components, including psychoeducation, emotional regulation skills, goal setting and problem solving skills, traumatic stress reminder management techniques, and family communication skills. The purpose of this study is to describe the development and implementation of FOCUS for military families. A case example is also presented.

Participation in a family-centered prevention program decreases genetic risk for adolescents' risky behaviors.

The present research addressed the following important question in pediatric medicine: can participation in an efficacious preventive intervention ameliorate the risk that a genetic vulnerability factor is hypothesized to confer on increases in risk behaviors across preadolescence? As part of the Strong African American Families preventive intervention study, data were collected from 641 black families in rural Georgia, assigned randomly to the prevention or control condition. The prevention condition consisted of 7 consecutive meetings at community facilities, with separate parent and youth skill-building curricula and a family curriculum. Each meeting included separate, concurrent sessions for parents and youths, followed by a joint parent-youth session in which families practiced skills they learned in the separate sessions. Involvement in risk behaviors was assessed when the youths were 11 (pretest), 12 (posttest), and 14 (long-term follow-up) years of age. A genetic vulnerability factor, that is, a variable-nucleotide repeat polymorphism in the promoter region of the SLC6A4 gene (5HTT), was assessed 2 years after the long-term follow-up assessment. Youths at genetic risk who were assigned to the control condition displayed greater increases in risk behaviors across the 29 months that separated the pretest and long-term follow-up assessments, compared with youths at genetic risk who were assigned to the Strong African American Families condition and youths without genetic risk who were assigned to either condition. This is the first study to demonstrate that participation in an efficacious preventive intervention can ameliorate a genetic risk for increasing involvement in health-compromising risk behaviors across preadolescence.

Child Abuse Prevention During Infancy: Intervention Implications for Caregivers' Attitudes Toward Emotion Regulation

Increasing numbers of states are in the process of passing laws requiring all new parents to receive educational materials to prevent shaken baby syndrome (SBS). These laws create powerful opportunities to reach large numbers of families with an important prevention effort. Results from the effort to raise SBS awareness described here indicate that not only is the content of SBS prevention (e.g., consequences of shaking; emotion regulation/coping skills; safety planning) an important consideration; so too is the approach any given prevention program utilizes. By incorporating social work theory on family-centered practice, social workers, home visitors, and other prevention professionals strengthen the likelihood of having a meaningful impact on caregivers' safe strategies for coping with the frustrations of caring for an infant.