PolicyLab

Recognizing the untapped potential of the pediatric primary care setting for addressing children’s behavioral problems, our team, alongside colleagues from Safe Place: The Center for Child Protection and Health and the Department of Child and Adolescent Psychiatry and Behavioral Sciences at Children’s Hospital of Philadelphia (CHOP), modified an existing intervention called Child–Adult Relationship Enhancement (CARE) from the Mayerson Center for Safe and Healthy Children. Together, we developed PriCARE, a trauma-informed group-training program hosted in the primary care setting that teaches caregivers techniques to support the social and emotional growth of their children. As a group-training program for parents, PriCARE is designed to improve child behavior, strengthen parent-child relationships and decrease parental stress. 

In the first study of its kind, our team tested the effectiveness of PriCARE through a randomized controlled trial (RCT) at CHOP’s primary care facility in South Philadelphia. We enrolled 120 families and found that children whose parents participated in PriCARE had significant short-term improvements in behavioral symptoms. Additionally, after attending the PriCARE intervention, parents reported improvements in several common parenting behaviors that can influence child behavior. These include decreased belief in use of corporal punishment and increased empathy toward their children. Academic Pediatrics, a premier medical journal, published the findings of this research trial.  

Encouraged by the positive findings from the initial PriCARE evaluation, our team expanded the capacity of PriCARE to reach more families. Currently, we offer PriCARE to caregivers of children ages 2 to 6 at seven CHOP primary care network sites (Karabots, Cobbs Creek, Main Campus, Drexel Hill and South Philadelphia, Chestnut Hill and Roxborough). To date, more than 800 mothers, fathers, grandparents, foster parents and other caregivers of approximately 1,000 children from CHOP primary care practices have attended PriCARE.

In 2016 our team enrolled approximately 180 parent-child pairs in a second, larger PriCARE evaluation. Utilizing direct observation methods, we conducted video observations of children's behaviors on a subset of participants and conducted qualitative interviews with parents to inform program improvement efforts. Impactful feedback emerged from the qualitative interviews describing caregivers’ experiences and perceived impact of participating in PriCARE:

• “The trainers were awesome. They seemed to be really knowledgeable, but also kind and understanding so you felt like you could be honest with a bunch of people who are having trouble with their kids. So, it was nice to feel like you were in a safe space where you could be honest and you weren’t gonna get judged for it and that they were understanding.
• “I’m not as worried as if I’m a bad mom or I don’t know what I’m doing. I feel more confident.”
• “I’m not always frustrated or worried that if we are in public or if she’s going to really act up and throw a hissy fit. So, it’s like I’m more calm and relaxed.”
• “I encourage her to do positive things…she changed a lot, not just at home but as well as in school…her behavior is much better.”

Next, we enrolled 174 caregivers in a third RCT examining outcomes of parenting stress, disruptive child behaviors and parenting attitudes. Our results showed that parents who received PriCARE had decreased parenting stress and had improved parental perceptions of the severity of child behaviors.

We also developed, piloted and evaluated new technological advances—such as a text messaging platform and demonstration videos—designed to increase engagement with parents and reinforce key skills between weekly, in-person sessions. Participants reported that receiving the texts and video clips helped them remember how to practice the skills in between sessions, clarified class content and reminded them about upcoming sessions. Additionally, receiving the messages made caregivers feel supported, motivated, calm and connected to a community. One parent stated, “the texts made me feel like even when I’m not in class, the help and support was still there.” 

Our fourth RCT examined if this text message system enhanced our prior findings on decreasing child behavior concerns and parenting stress; we are currently finalizing and publishing our results.

Additionally, we have made several adaptations to PriCARE in the past several years to meet the needs of families. Dr. Samantha Schilling, a former CHOP fellow, led the effort to implement and evaluate English and Spanish PriCARE in North Carolina; Dr. Erica Messer, one of the developers of the original CARE intervention, piloted PriCARE in Cincinnati Children’s Hospital suburban primary care practices. We also now offer PriCARE virtually, which started during the COVID-19 pandemic but continued due to caregivers’ positive feedback and to increase accessibility. The evaluation of these new initiatives shows promise that PriCARE is effective across caregiver groups in strengthening the child-caregiver relationship and providing caregivers the skills to nurture positive child behavior.

Lastly, Clinical Futures and PolicyLab awarded our team a grant through a joint pilot grant program to implement and assess a PriCARE module focused on positive discipline techniques and appropriate timeout procedures. You can read more about that project here.