Daniel S. Shaw University of Pittsburgh Integrating Evidence-Based Parenting Programs into Public Health Systems: Opportunities and Challenges (Lessons Learned the Hard Way) Daniel S. Shaw University of Pittsburgh

Why embark on this challenging task? If parenting programs so desperately needed in public health, why aren’t they already located there? If you build it, will they (the parents and children) come? Even if you have a good idea and good fit, initial funding and sustainability a challenge Insurance reimbursement for work with young children Why embark on this challenging task?

Some evidence to suggest that intervening early in parenting during early childhood more effective than later ages Albeit recent paper of Incredible Years that doesn’t reach this conclusion We do have data from my own lab and elsewhere that developmental precursors of adolescent and young adult problem behaviors (antisocial, drug use, high-risk sexual behavior) can be identified for children as young as 1.5-2 (Sitnick et al., 2017) Includes direct paths and cascading effects Similar patterns emerge in intervention results of Family Check-Up ages 2 - 16 From public health and economic perspective, seems reasonable to think that preventive strategies could attenuate trajectories of high risk by targeting such factors as parenting, parental well-being, and child self-regulation skills Impetus

If so, how and where? Use of public health systems Pediatricians, day care providers, WIC providers, and preschool teachers & administrators suggest need but lack expertise and/or time How to identify children and families? Do we leave it to informal processes (Head Start example) Once identified, how to engage families in these settings If so, how and where? Use of public health systems

Parents already have regular to semi-regular contacts with these systems Primary care, Early Head Start, Head Start, Child Care, WIC In some cases, parents might have positive to very positive relationships with these systems Pediatrician’s office, Early Head Start and Head Start In cases where trust is already high, can capitalize on this trust to increase probability of engagement in your intervention In cases where trust is mixed to low, might be way of convincing health system how your intervention might improve engagement in their health service WIC, child welfare So what are advantages of using public health systems to provide preventive interventions

Unless you have data to suggest your intervention has universally positive effects for every family, behooves researchers to “do the work” that identifies families for whom the intervention is most or least effective If moderators of treatment response have been identified, leads to the need to screen families within the public health system to reliably identify children at risk that are likely to benefit from trt. Will show you example in next part of talk about how this process has evolved using Family Check-Up at WIC sites in 3 states The Need to Screen

Engaging Families: Learning the hard way As part of a passive longitudinal study on low-income boys initiated in toddlerhood, we referred parents to our in-house psychology clinic if parents or children demonstrated clinically-elevated scores Of the 310, 148 families referred where for $2 a session they could see doctoral clinical psychology students Guess how many of 148 showed up? Transportation, child care, trust, and motivation Engaging Families: Learning the hard way

Engagement: Capitalizing on Strengths By definition, families likely not expecting to receive parenting services in this setting Plan for engaging families & using current system’s staff to facilitate Need of in-house champions from top-down and bottom-up Investment time in organization to make connections deep with multiple staff Huge individual differences among staff at outset in implementing intervention One more thing I have to do, luke-warm attitude in telling families about program Who will be point of contact person for intervention in health system? In Pediatrics, might have 1-2 docs on board, but what about the 6-8 residents, nurses, receptionists? Engagement: Capitalizing on Strengths

Making Impact at Population Level Are you thinking about working with families most in need or more concerned with reaching a larger number of families within public health systems? Large differences in populations of at-risk children served among systems Identifying systems within your region and state In Pittsburgh/Allegheny County, we have 27 Family Support Centers located in low- income neighborhoods, and special programs in child welfare for first-time offenders Early Head Start vs. pediatrics In 2011, 91% of American children < age 2 had > 2 well child visits Making Impact at Population Level

“Making” the intervention function in new setting How adaptive/mobile is your intervention Video Interaction Project and working with opiate-addicted mothers with newborns How much is public health setting a passive recipient vs. active collaborator in implementing and/or designing the intervention? Are you willing to modify content and/or structure to make intervention adaptive to needs of public health setting Focus on nutritional development and other social work issues at WIC How can we make the intervention work for your agency? “Making” the intervention function in new setting

Exciting and somewhat daunting time Clearly have the empirical and theoretical impetus for implementing early childhood parenting programs in public health settings Clearly have some programs, many of which you will hear about today, that have begun this journey Clearly also lots of challenges to navigate, but an abundance of opportunities to make a real impact to promote the future success of the coming generations of our nation’s children Exciting and somewhat daunting time