September/October 2016 Issue

Parenting Skills Training: When Does It Fit?
By Deborah H. Siegel, PhD, LICSW, DCSW, ACSW
Social Work Today
Vol. 16 No. 5 P. 22

When considering a parenting skills training program, one size does not fit all. Individualized and evidence-based choices are best.

Suzanne, age 30, is the single parent of six children, ages 3 to 11. She loves her kids with all her might and is mortified that while she was high on heroin one afternoon her then 2-year-old fell when running with a stick in his hand, stabbing himself in the eye and blinding it permanently. A neighbor heard the child's screams, saw that Suzanne was out of it, and raced him to the emergency department, where staff called child protective services. The children were placed into six different foster homes that day. The public child welfare agency, following protocol, created a case plan for Suzanne, which required that she work full time, maintain stable housing, attend drug treatment counseling sessions three days a week, do random toxicology screens, attend weekly parenting skills classes, weekly psychotherapy, and visit every other week with each child individually at the child welfare office. Suzanne has done her best to comply with these expectations.

Suzanne and her parents immigrated to the United States from Colombia when she was a baby. Her father raped her daily from the time she was age 3 until she ran away from home at age 14. Homeless, she fell prey to sex traffickers who housed and fed her and gave her drugs in order to control her. Her children were all conceived by rape during those years. Suzanne has no contact with or support from any of their fathers. Suzanne struggles with PTSD; depression; addiction to alcohol, opioids, and cocaine; and social isolation. She now works full time as a housekeeper at a motel, never earning enough money to cover the rent. She has no car, bus service is infrequent and erratic, and getting to work, food shopping, and attending appointments is an exhausting, time-consuming ordeal that impairs her ability to earn a living and supervise her children.

Questions to Ask
Sadly, there are many clients in the child welfare system with complex, trauma-ridden stories and difficult economic predicaments such as Suzanne's. Parenting skills training is often part of the standard package of interventions aimed at reuniting clients such as Suzanne with their children; the assumption is that parents with adequate parenting skills do not neglect or abuse their children. This seems to be a reasonable assumption, as some research shows that many parents who complete a home-based parenting skills program are less likely to abuse or neglect their children than are parents in a control group (DuMont et al., 2011; Chaffin, Hecht, Bard, Silovsky, & Beasley, 2012). But there is a wide array of different parenting skills training programs and packages aimed at different kinds of parents and different kinds of children, and outcome research on the impacts of these programs use designs of variable rigor and produce different conclusions. The question to ask, then, is not, "Does parenting skills training work?" but rather, "What kind of parenting skills training works with what kinds of parents with what kinds of children under what conditions?" and, "Is parenting skills training called for in this particular case?"

In a landscape of severely constrained resources, social workers need to favor evidence-based practices, particularly when vulnerable lives are at stake. However, a review of research on the effectiveness of parenting skills training can lead to uncertainty and confusion about when, and what kinds of parenting skills training should be part of the case plan.

Assessing the Need for Parenting Skills Training
Much of the research on parenting skills training focuses on programs aimed at improving the child's behavior; an assumption appears to be that children who misbehave do so at least in part because the parents lack parenting skills. Clearly, in Suzanne's case, a 2-year-old running with a stick in his hand when an adult is not watching him is more a problem of an adult's inattention than a problem of a toddler's misbehavior. The goal in this situation would be to enable Suzanne to supervise her children to ensure their safety. Parenting skills training might or might not be the most effective intervention to pursue that goal in Suzanne's situation. Suzanne's addiction, trauma, exhaustion, social isolation, inadequate transportation, and need to work countless hours at low pay may have been more central concerns.

Research on Effectiveness
Carefully examining research on the effectiveness of parenting skills training to address child abuse and neglect is crucial for making informed intervention plans. Research in this area indicates that parent skills training may in some situations produce positive results. For example, the Promising Practices Network on Children, Families and Communities website (www.promisingpractices.net) notes that, compared with parents in a control group, parents who participated in the Healthy Families New York program were less likely to engage in harsh, abusive, or neglectful parenting behaviors (DuMont et al.). Another program, SafeCare, targets parents of children from birth to 5 years old, focusing on parent-child interaction skills, among other things, in weekly home visits; research suggests that this program also has promising outcomes (Chaffin, Hecht, Bard, Silovsky, & Beasley).
Other reviews of research are less definitive. Knerr, Gardner, and Cluver (2013), in a systematic review of "the effectiveness of parenting interventions for reducing harsh/abusive parenting," concluded that a meta-analysis was not possible due to the wide variety of research questions and designs used. For example, while 12 studies reported favorable results, Knerr et al. question the studies' validity due to risks of bias. Nonetheless, they note that some interventions may be effective and that there is a "well-established evidence base for parenting interventions in high-income countries."

Many parenting skills training programs address child behavioral outcomes rather than parental abuse and neglect, so their applicability to clients such as Suzanne may be limited. Some parenting skills training may occur, for example, as part of a larger package of interventions, such as in multisystemic therapy (MST), an intensive home-based intervention for families of youngsters who have social, emotional, and behavioral challenges. Teasing out the effectiveness of the parenting skills training component of MST is difficult. While a Cochrane review of research on MST's effectiveness concludes that "results are inconsistent across studies that vary in quality and context" (Littell, Campbell, Green, & Toews, 2005), the Promising Practices Network deems MST a "proven program." In short, experts disagree.

Another Cochrane review of research concludes that, at least in the short term, parenting programs delivered in group settings may help parents develop parenting skills that improve behavior in children ages 3 to 12, while also lowering parental anxiety, stress, and depression (Zwi, Jones, Thorgaard, York, & Dennis, 2011). But the long-term results of such programs are not yet known. This review of five randomized controlled studies of parent training for ADHD in children concludes that there is "no evidence to say whether parent training is better delivered in groups or individually." The studies in this review are, according to the authors, of uncertain methodological rigor. Also, while there were some encouraging results, findings were "uncertain" regarding some important behaviors. In short, conclusions about the effectiveness of parenting programs delivered in group settings must be stated cautiously, with attention to the rigor of the research designs used.

A similarly mixed picture emerges from a review of The Positive Parenting Programme (Triple P), a family intervention program used throughout the world. Triple P appears to have a strong evidence base; four meta-analyses indicate it has positive impacts on child behavior, and the Promising Practices Network deems it a "promising practice" rather than a "proven program." On the other hand, Wilson et al.'s (2012) careful examination of meta-analyses of Triple P outcomes notes a number of limitations in the research designs, including sample self-selection, and concludes that long-term impacts are undetermined.

There are many possible reasons why reviews of the literature on the effectiveness of parenting skills training produces mixed pictures regarding effectiveness. First, there is no one definition of parenting skills training, and there are many different parenting skills training packages, each using different methods to teach different skills and designed for children of different ages with different target issues, and for different kinds of parent populations. For example, some packages are aimed at parents of children with developmental disabilities, sensory integration issues, ADHD, involvement in the juvenile justice system, and other unique challenges. Different children need different kinds of parenting. Different studies address different research questions using different research designs of varying rigor. For all of these reasons, drawing definitive conclusions across studies is elusive. For the social worker seeking clear guidance in choosing interventions for families at risk, this is a confusing and frustrating scenario.

Thinking Critically
The uncertain picture about the effectiveness of different parent training programs is only one of many reasons to think critically about routinely requiring parent training for parents who abuse or neglect their children.

Consider the possibility that some parents who abuse or neglect a child actually have in their behavioral repertoires the parenting skills they need but may simply not have access to those skills when hobbled by fatigue, overwhelming financial worries, or stressors that trigger trauma reactions. When triggered, a traumatized parent may unconsciously dissociate, freeze, flee, or self-medicate with substance use—in short, be unable to access her or his parenting skills.

A parent who endured trauma as a child may be triggered by his or her own child's behavior or by the normal stressors that accompany parenting any child. The parent's highly activated limbic system, when stress hits, may overwhelm that parent's prefrontal cortex, blocking his or her rational, logical thought processes in the moment. What that parent needs is not training in how to create daily routines at home, use active listening, set limits, be consistent, or use rewards, time out, or logical consequences. Rather, that parent needs help acquiring distress tolerance, emotional self-regulation, grounding, self-compassion, and mindfulness skills so he or she can self-soothe and bring his prefrontal cortex back in line in stressful moments. Similarly, standard parenting skills training might not fit a child who is neuroatypical, unable to process verbal instructions, or dealing with trauma, innate impulsivity, anxiety, depression, and a host of other conditions.

When determining whether and what parenting skills training package to use with a client, the most relevant question social workers should ask themselves is, "What does this particular client need? What, if any, specific evidence-based parenting skills training package is the right fit for this person?"

Individualizing Intervention
One of the challenges in the evidence-based practice movement is the tempting assumption that if there is research showing that an intervention worked, it should be used with every client. It's important to remember that just because an intervention worked for most clients that doesn't mean it will work for another client. One size does not fit all. Clients often get interventions that are deemed evidence-based or readily available or that workers prefer, rather than interventions that are best fits for the particular client at hand.

In Suzanne's case, she may benefit most immediately from intensive case management services focused on meeting compelling, concrete needs. She needs full-time employment that pays a living wage; quality childcare so she can remain employed; safe, affordable housing; and adequate transportation. The lack of income, housing, and transportation can be formidable barriers to child safety and family reunification. Focusing primarily on parenting skills locates the problem in the person instead of in the person-in-situation configuration that is a hallmark of the social work profession. Basic needs must be met before many parents can feel safe and stable enough to focus on their children's safety. Sometimes the most important interventions are not with the client but with the social policies that prevent clients' access to essential resources.

Once Suzanne's situation is environmentally stable, she needs trauma-informed care and substance use treatment so she can cope with her trauma history in ways that enhance, instead of interfere with, her parenting. Suzanne's treatment plan instead sent her hither and yon, from parenting classes to substance abuse treatment sessions, psychotherapy appointments, six different visits every two weeks with each of her children, and monthly meetings with her child welfare worker, while expecting her to maintain stable full-time employment and travel hours each day on multiple inconsistent busses. Suzanne needed integrated, coordinated care. Perhaps she needed parenting skills training—perhaps not. Before inserting parenting skills training into her case plan, a careful assessment of her parenting knowledge and skills was necessary. In short, sometimes clients experience our well-intentioned efforts to help them as oppressive, unrealistic, unnecessary harassment that sets them up for failure.

For example, without reliable, affordable transportation, it was impossible for Suzanne to get to her job and all of her appointments and commitments. Her former pimp agreed to drive her so she could comply with the case plan and reunite with her children. But the child welfare agency insisted that if she spent time with him reunification could not occur. She was caught in an unresolvable conundrum.

Suzanne's clinical social worker, to whom the child welfare agency referred her for trauma-informed psychotherapy, asked Suzanne what she would like to work on in treatment. Suzanne said, "Help me see my kids more often. Once every two weeks for one hour is just not enough." When the social worker's efforts to advocate for this with the child welfare agency failed, she decided to use psychotherapy appointments as an opportunity for Suzanne to visit in the social worker's office with any of her children whose foster parents were able to bring them at those times. Hence, in therapy the social worker had many opportunities to observe Suzanne's interactions with her children. Suzanne's parenting skills were superb. She came prepared to visits with activities and snacks; responded with genuine empathy to her children's direct and indirect expressions of feeling; used behaviorally specific praise; set appropriate limits which she enforced in a calm, clear, nonpunitive manner; and used logical and natural consequences. Clearly, in Suzanne's case, parenting skills were not her focal problem.

Final Thoughts
One of the many challenges today in clinical social work is to individualize treatment in an environment that celebrates protocols, evidence-based practices and provides services that are sometimes based on funding availability rather than client needs. Social workers must carefully ground interventions in available outcome research, think critically about the limitations of that research, and ensure that interventions match clients' needs.

— Deborah H. Siegel, PhD, LICSW, DCSW, ACSW, is a professor at the Rhode Island College School of Social Work in Providence, RI. She specializes in working with people whose lives are touched by adoption and with families coping with distress.

References
Chaffin, M., Hecht, D., Bard, D., Silovsky, J. F., & Beasley, W. H. (2012). A statewide trial of the SafeCare home-based services model with parents in child protective services. Pediatrics, 129(3), 509-515.

DuMont, K., Kirkland, K., Mitchell-Herzfeld, S., Ehrhard-Dietzel, S., Rodriguez, M. L., Lee, E., et al. (2011). A randomized trial of healthy families New York (HFNY): Does home visiting prevent child maltreatment? Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/232945.pdf.

Knerr, W., Gardner, F., & Cluver, L. (2013). Improving positive parenting skills and reducing harsh and abusive parenting in low- and middle-income countries: A systematic review. Prevention Science, 14(4), 352-363.

Littell, J. H., Campbell, M., Green, S., & Toews, B. (2005). It is premature to draw conclusions about the effectiveness of MST compared with other services. The Cochrane Database of Systematic Reviews, 4, CD004797.

Wilson, P., Rush, R., Hussey, S., Puckering, C., Sim, F., Allely, C. S., et al. (2012). How evidence-based is an 'evidence-based parenting program'? A PRISMA systematic review and meta-analysis of Triple P. BMC Medicine, 10, 130.

Zwi, M., Jones, H., Thorgaard, C., York, A., & Dennis, J.A. (2011). Parent training interventions for attention deficit hyperactivity disorder (ADHD) in children aged 5 to 18 years. The Cochrane Database of Systematic Reviews, 12, CD003018.