Elsevier

Children and Youth Services Review

Volume 70, November 2016, Pages 315-323
Children and Youth Services Review

Effectiveness of ACT Raising Safe Kids Parenting Program in a developing country

https://doi.org/10.1016/j.childyouth.2016.09.038Get rights and content

Highlights

  • We evaluated the effectiveness of a parenting program in a Brazilian sample.

  • After the parenting program improvements on parenting practices were observed.

  • Decrease in child behavior problems was observed after the parenting program.

  • The study used multiple informants about child behavior.

Abstract

The present study evaluated the effectiveness of the Adults and Children Together (ACT) Raising Safe Kids Parenting Program for violence prevention in a developing country. The specific objectives were the following: (i) to compare parenting practices according to the mothers' perceptions pre- and post-intervention and (ii) to compare child behavior problems and resources according to mothers' and other caregivers' perceptions pre- and post-intervention. The participants were 82 Brazilian mothers of 3- to 8-year-old children. Another caregiver of the child was included in the study as a second informer about child behavior (n = 72). Mothers participated in the ACT program and pre- and post-intervention evaluations. The other primary caregiver only participated in the two evaluations of child behavior. The results showed that parenting practices improved significantly from pre- to post-intervention. Mothers and the other primary caregivers reported a significant decrease in child behavior problems from pre- to post-intervention with regard to total behavioral difficulties, emotional symptoms, and peer relationship scales. Mothers also reported a significant decrease in scores for conduct problems and hyperactivity and improvements in child behavioral capabilities with regard to prosocial behavior. In conclusion, improvements on parenting practices and child behavior were observed after the ACT program.

Introduction

Child maltreatment is a substantial problem in every society around the world, including in developed countries and developing countries (World Health Organization, 2009). Violence against children by adults within the family is one of the least visible forms of child maltreatment, but it is nonetheless widely prevalent in all societies (Butchart, Harvey, Mian, & Furniss, 2006). Within a broader set of risk factors, violence threatens adaptive child development and can lead to mental and physical health problems, representing a high cost to society (Christian & Schwarz, 2011). Exposure to violence through victimization or witnessing a violent act can have significant, negative implications for children's self-regulatory development (McCoy, 2013). If violent events occur during early development, then this experience can act as a toxic stress that threatens healthy development (Shonkoff, 2010).

In developing countries, including Brazil, exposure to violence was significantly associated with mental health problems in children and adolescents, especially when combined with other social and familial disadvantages, such as poverty and maternal mental disorders (Ribeiro, Andreoli, Ferri, Prince, & Mari, 2009). In Brazil, negative parenting practices that involve violent acts have been reported by families in different studies (Moura et al., 2008, Rocha and Moraes, 2011, Weber et al., 2004). A study of 278 families who were registered in a Family Health Program showed that psychological aggression occurred in 96.7% of the families, and corporal punishment occurred in 93.8% of the households (Rocha & Moraes, 2011). Another study of 472 children and adolescents showed that the majority of the participants (88%) claimed that they had received physical punishment (Weber et al., 2004). The prevalence of violence against children that was reported by users of two emergency hospitals were 94.8% for psychological aggression, 60.3% for negligence, and 47.2% for physical violence (Moura et al., 2008).

Stable and nurturing relationships are relevant positive contexts for healthy child development (Shonkoff, 2010). However, parents can interact inadequately with their children and use negative parenting practices, including abuse and negligence (Bornstein & Cheah, 2006). Therefore, particular difficulties are encountered when designing strategies for prevention in the family context because the perpetrators of maltreatment are also the source of potential nurturing for children (Butchart et al., 2006).

Parenting programs that promote safe, stable, and nurturing relationships between caregivers and children at early ages are effective strategies for preventing child maltreatment (Centers for Disease Control and Prevention, 2014, World Health Organization, 2009). Conversely, negative parenting practices are risk factors for behavioral and emotional problems in children, but such practices can be modifiable through parenting intervention programs (Sanders, 2012). These programs provide support, experiences, and opportunities for parents to develop effective parenting practices and improve their knowledge and confidence in supporting their children's development, managing child behavior, and appropriately facing current challenges in raising their children (Trivette and Dunst, 2009, Haslam et al., 2016, Hardcastle et al., 2015).

Parenting programs can improve knowledge, skills, and parental support and can be effective in preventing child abuse and neglect (Holzer, Higgins, Bromfield, & Higgins, 2006). Such programs also appear to be effective in reducing the risks of child maltreatment (Mikton & Butchart, 2009) and have achieved satisfactory results in reducing aggression by parents against children (Santini & Williams, 2016). Previous reviews have reported the effectiveness of parenting programs in improving parenting behavior (Kaminski et al., 2008, Rios and Williams, 2008) and parents' psychosocial wellbeing (Barlow, Smailagic, Huband, Roloff, & Bennett, 2012), preventing child behavior problems (Kaminski et al., 2008, Rios and Williams, 2008), modifying disruptive child behavior (Lundahl, Risser, & Lovejoy, 2006), and improving child emotional and behavioral adjustment (Barlow, Smailagic, Ferriter, Bennett, & Jones, 2010). Additionally, interventions that enable mothers to manage their emotional reactions and avoid harsh parenting can also have a positive influence on maternal mental health (Wong, Gonzales, Montaño, Dumka, & Millsap, 2014).

Parenting programs can be delivered universally (i.e., to all parents in an entire population group) or can be targeted to high-risk families and the parents of children who are at risk of conduct disorders (Hardcastle et al., 2015). A systematic review of universal violence and child maltreatment prevention programs for parents reported that all the studies reviewed, presented improvements in effective parenting strategies post-intervention, and regarding child behavior in 90% of the studies that assessed this outcome (Altafim & Linhares, 2016). Therefore, considering the difficulty in identifying child maltreatment within families, universal prevention programs can be a great opportunity to prevent violence and maltreatment (Altafim & Linhares, 2016) and avoid the risk of stigmatization (Byrne et al., 2014, Heinrichs et al., 2014).

The World Health Organization cites the Adults and Children Together (ACT) Raising Safe Kids Program as a universal parenting program that can be used to prevent child maltreatment (Hardcastle et al., 2015). This program was developed by the American Psychological Association (APA) and is designed to help caregivers develop positive parenting practices and prevent child maltreatment (Silva, 2009). The California Evidence-Based Clearinghouse for Child Welfare (2015) and National Institute of Justice (2015) CrimeSolutions.gov website rated this program as having “Promising Research Evidence”. Additionally, the program is listed in the Compendium of Parenting Interventions (National Center for Parent, Family and Community Engagement, 2015) as an evidence-based parenting intervention that is most likely to be effective for families of young children.

The great advantage of the ACT program is that it directly addresses issues of the prevention of violence and maltreatment against children using a universal preventive approach. It also has a low startup cost, and a significant number of peer-reviewed publications (National Center for Parent, Family and Community Engagement, 2015). The program is based on Social Learning Theory (Bandura, 1977) and emphasizes that early development (i.e., 0–8 years old) constitutes a critical time-window when children are learning basic skills that can have a long-lasting impact on their lives (Guttman et al., 2006, Miguel and Howe, 2006).

Previous studies reported the effectiveness of the ACT program in modifying parenting practices, reducing inappropriate parenting practices, and promoting improvements in positive parenting practices (Portwood et al., 2011, Knox et al., 2013, Knox and Burkhart, 2014, Knox et al., 2010, Weymouth and Howe, 2011). These improvements included reductions of physical discipline (Knox et al., 2013, Knox et al., 2010, Porter and Howe, 2008, Portwood et al., 2011), low rates of psychological and verbal violence (Knox et al., 2013, Portwood et al., 2011), and decreases in harsh parenting and negative discipline (Knox & Burkhart, 2014). The results also showed improvements in knowledge about child development (Knox et al., 2010, Weymouth and Howe, 2011), behaviors and beliefs related to violence prevention (Knox et al., 2010), the use of positive discipline (Porter & Howe, 2008), media violence literacy, anger management, prosocial problem solving (Weymouth & Howe, 2011), positive parenting behaviors (Knox et al., 2013), and nurturing behavior (Knox et al., 2013, Knox and Burkhart, 2014, Portwood et al., 2011).

Some studies have evaluated the effectiveness of the ACT program in reducing child behavior problems (Burkhart et al., 2013, Knox and Burkhart, 2014, Knox et al., 2011, Porter and Howe, 2008). The results demonstrated the effectiveness of the program in reducing externalizing behavior problems (Knox and Burkhart, 2014, Knox et al., 2011), aggressive behavior (Porter & Howe, 2008), and bullying behavior (Burkhart et al., 2013). The measures that were most used in these studies were the Strengths and Difficulties Questionnaire (SDQ) and Child Behavior Checklist (CBCL). A study that used these two instruments showed that the SDQ appears to be more sensitive to the issues that are addressed by the ACT program (Knox et al., 2011). However, these studies focused only on the SDQ conduct problems scale, and this instrument has other scales (e.g., emotional symptoms and hyperactivity), a total difficulties score, and clinical classification, which can also be used. Furthermore, studies of the ACT program suggested that future research should use an observational design and multiple informants for reporting child behavior (Knox et al., 2013, Knox et al., 2011). Multiple-informant assessment regarding child behavior problems is an important strategy to decrease the chances of bias (Kerr, Lunkenheimer, & Olson, 2007).

Previous studies of the ACT program have been conducted only in the United States, with a focus on different ethnic groups, including Euro-Americans, African-Americans, and Hispanic/Latino families. The program was especially efficacious for Spanish-speaking participants, who improved more than English speakers, suggesting that it can be adapted for use in diverse cultures (Weymouth & Howe, 2011). The ACT program is already underway in several countries, including Brazil, Bosnia, Colombia, Greece, Guatemala, Japan, Peru, and Turkey. Therefore, scientific research in these other countries is needed to confirm its effectiveness and applicability in different cultural contexts.

There are different levels of research evidence of intervention studies. The studies delivered in naturalistic settings are considered effectiveness research, and rigorously controlled studies with random assignment (randomized controlled trials; RCT) are considered efficacy research (APA Presidential Task Force on Evidence-Based Practice, 2006). The studies conducted in the United States with the ACT program showed a progress considering these levels. Six studies showed the ACT program effectiveness, including designs using within-group comparisons (pre-intervention vs. post-intervention; Knox and Burkhart, 2014, Porter and Howe, 2008, Weymouth and Howe, 2011), and within- and between group comparisons with intervention and control group without randomization (Knox et al., 2011, Knox et al., 2010, Burkhart et al., 2013). Additionally, two studies conducted a RCT showing the efficacy of the program (Knox et al., 2013, Portwood et al., 2011). Although, in the United States RCT studies have been already conducted, there is a gap of studies in other countries. Therefore, the conduction of studies about the effectiveness, the ecological validity, and applicability of the ACT program in these countries is considered a scientific breakthrough.

Most parenting interventions have been developed, evaluated, and implemented in high-income countries (Haslam et al., 2016). There is a need to invest resources to implement and evaluate parenting interventions in countries with low- and middle-income economies (Altafim and Linhares, 2016, Knerr et al., 2013, Mejia et al., 2012, World Health Organization, 2009). A study conducted in nine low and middle income countries showed improvements in parenting practices and children's behavior problems after the intervention and highlighted the need for such programs on countries with low- and middle-income economies (Maalouf & Campello, 2014). Furthermore, there is an urgent need to assess the applicability of the ACT program in Brazilian samples and evaluate not only maternal reports of their own behavior but also outcomes of children's behavior based on the reports of more than one caregiver.

The main hypothesis of the present study was that there would be significant improvements in parenting practices after mothers participated in the ACT program, based on the mothers' own perceptions, and improvements in adaptive child behaviors, based on the mothers' and other caregivers' perceptions. The main objective of the present study was to evaluate the effectiveness of the ACT program in a Brazilian sample. The specific objectives were the following: (i) to compare parenting practices, according to the mothers' perceptions, pre- and post-intervention, (ii) to compare child behavior problems and resources according to mothers' and other caregivers' perceptions, pre- and post-intervention, and (iii) to compare the effectiveness of the program, according to the age of the children.

Section snippets

Study design

The present study conducted an intervention study with one-group pretest-posttest design to assess the effectiveness of the ACT program using within-group comparisons, and between groups comparisons differentiated by the age of the children.

Ethical aspects

The Research Ethics Committee approved the study, and informed consent was obtained from all of the parents prior to participation. Considering that participation in the study may involve risk or discomfort with regard to triggering the participants'

Sample characteristics

Table 1 shows the main sociodemographic characteristics of the 82 mothers, their children, and the 72 other caregivers who participated as child behavior informants. The sample had a slight predominance of boys (55%), with a median of child age of 4–5 years old. Most mothers were stable in their marital status. Mothers' average of years of education was 12 and the average number of children was two (see Table 1 for additional descriptive statistics). The caregiver informants were the majority

Discussion

The present study examined the effectiveness of the universal intervention ACT Raising Safe Kids Program in improving parenting practices and reducing child behavior problems in a developing country. We hypothesized that after completing the ACT program, the mothers would report improvements in parenting practices. We also hypothesized that mothers and other caregivers would perceive a decrease in child behavior problems post-intervention. These two hypotheses were fully supported.

The

Conclusion

In conclusion, the results of the present study provide preliminary evidence of the effectiveness of the ACT program to improve positive parenting practices, decrease child behavior problems, according to the mothers' and other caregivers' perceptions, and increase child pro-social behavior, in a Brazilian sample. These results support the effectiveness of the ACT program in achieving positive parent and child outcomes in a developing contry. The present study provides a scientific basis for

Acknowledgement

Francine Belotti da Silva and Rebeca Cristina de Oliveira , who participated in the data collection, as researcher assistant with scholarship from Foundation of University of São Paulo (FUSP) with partnership with Maria Cecília Souto Vidigal Foundation (FMCSV). The Foundation for Support of Research in the State of São Paulo, Brazil (FAPESP) (grants #2012/25293-8; #2015/21721-3; #2013/24655-6). The National Council of Science and Technology Development (CNPq) supported one of the authors (grant

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    Research manuscript was performed by Elisa Rachel Pisani Altafim, Maria Eduarda André Pedro and Maria Beatriz Martins Linhares, University of São Paulo, Ribeirão Preto Medical School, Department of Neurosciences and Behavior and Ribeirão Preto Philosophy, Sciences and Literature School.

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