This week we share with you an exciting paper just published in Pediatrics, by Judith Carta and coworkers, entitled  Randomized Trial of a Cellular Phone-Enhanced Home Visitation Parenting Intervention, Pediatrics 2013;132:S167–S173.  We know well that the families most in need of parenting supports are the ones hardest to engage in services. Carta and her colleagues hypothesized that frequent contact with cell phones would improve outcomes.  We have been anxiously anticipating the publication of this study because it is the first randomized controlled trial to assess parenting using the Keys to Interactive Parenting Scale as an outcome measure.

The intervention used the manualized Planned Activities Training, a component of the SafeCare model. This study randomly assigned 371 low-income mothers with a 3.5 to 4.5 year old child and at least 1 risk factor for child maltreatment (e.g., <18 years at first birth, <high school/GED education) into 3 groups: 1) received the usual Planned Activities Training, 2) received the Planned Activities Training supplemented with cell phone supports, and 3) assigned to a wait list.   

Randomized controlled trials (RCTs) are considered by many to be the most rigorous ways to test an intervention.  RCTs are difficult to get approved because some families are randomly assigned to a non-treatment group, or in this case a wait-list group, so the intervention was delayed.   The wait-list group received the intervention after the study was completed.  In this study the participating families were assessed prior to the intervention, as well as at post-intervention and again six months afterwards.  

SafeCare Planned Activities Training

The Planned Activities Training consists of five individualized sessions, aimed at improving parent-child interactions and preventing challenging child behaviors.  The curriculum is tightly focused on a short set of specific strategies:

1)      Planning activities in advance,

2)      Explaining activities,

3)      Establishing rules and consequences,

4)      Giving choices,

5)      Talking about what you are doing,

6)      Using positive interaction skills,

7)      Ignoring minor misbehavior,

8)      Giving feedback, and

9)      Providing rewards or consequences.

This brief focused approach is relatively unusual in the field of parenting services, but it shouldn’t be discounted.  We recently reviewed a study showing another brief focused parenting intervention as a supplement to Head Start that dramatically improved children’s learning.   There are two powerful features of this program.  First, Family Coaches offer parents specific “positive and corrective feedback” on their parenting skills as they practice with their children.  Second, the parents are observed and assessed on their use of the skills and expected to reach “80% correct mastery criterion on the strategies” using the program’s checklist.   Coincidently, this blog started with a 10-part series discussing the importance of feedback and how to provide quality feedback to parents (here is a link to the first in the series).

The cell phone supplement to the Planned Activities Training included twice daily individualized text messages and a weekly phone call with the Family Coach.  These are inexpensive supplements that could be added to almost any program.  

So What Happened?

Mothers receiving parenting training plus the cell phone supplement demonstrated higher quality parenting than the wait-listed control group, as assessed by KIPS.  In fact, for such a brief intervention, the change of 0.5 point on the KIPS 5-point scale observed by Carta and her colleagues is quite remarkable.  The effect size, a measure of the magnitude of the impact, was large (.62 for the Planned Activities Training and 0.78 for the cell phone supplement group), when compared to the control group.  For comparison, in a 1-year longitudinal study we conducted with a comprehensive intervention, we found no significant change in KIPS scores for the first 5 months, then a 0.7 point change in KIPS scores at 12 months (see Comfort, et al. (2010). Keys to Interactive Parenting Scale: KIPS Shows How Parents Grow. Zero to Three Journal, 30(4), 33-39).  

Thus, this brief 5-session intervention produced a change of comparable magnitude in a fraction of the time when this was the sole focus of services.  One might reasonably be concerned that easy come: easy go.  So it is also remarkable that 6 months later, a significant difference in parenting quality of about 0.3 point was still detectable using KIPS (effect size of 0.34 and 0.46 respectively).   

Carta and coworkers performed multiple regression analyses to examine the relation of changes in children’s positive engagement to changes in parents’ positive behavior supports, parenting quality (KIPS score), maternal depression, and parenting stress from pre-test to post-test.

Only the KIPS score measuring changes in parenting interactions was a significant predictor:  children demonstrating gains in positive engagement were most likely to have mothers who showed improvements in positive parenting interactions as measured by the KIPS ratings. Carta et al 2013, page S171

Regular readers of this blog will not be surprised by this finding that parenting behavior is what matters to children. 

So What about the Cell Phone?

The cell phone supplement to this home visiting parenting program enhanced mothers’ learning of the strategies assessed by the checklist and reduced maternal depression and stress. In addition, the cell phone group children showed higher adaptive behavior at the 6-month follow up.

Summary and Conclusion

Thus, a short focused parenting intervention produced a substantive change that was retained for at least 6 months.  Contacts with a Family coach via cell phone enhanced certain aspects of the program.  It is remarkable that modest, focused interventions or a few text messages and weekly phone calls can make such a difference.  Unlike some studies, these interventions can be readily incorporated into practice.

The KIPS parenting assessment was designed primarily to guide parenting services and to document program outcomes.  This is the first of several research studies to be published using KIPS in randomized controlled trials.  We are pleased that KIPS proves useful in sophisticated research too.