Improving Parent Competence with a Community-Based Group Parent Training Program

Connection between Co-occupations and Competence

There is a bi-directional relationship between co- occupations and parenting competence. In Larson’s (2000) study of the mothering role [2], co-occupations were both impacted by the child’s needs and impactful to the mother’s competence. Other studies show that changing parent behaviors through coaching interventions not only changes the parent’s performance but also the co-occupational performance and behaviors of the child [9, 10]. When the child’s behaviors and performance are altered, the impact on the parent’s competence is also altered. Price and Stephenson’s (2009) examination of co-occupations of a mother and child identified that successful co-occupations increased the occupational, social, and emotional development of the mother and the child and increased the parent’s sense of competence. With greater competence and performance satisfaction, parents increase their engagement in co- occupations [4]. In this way, co-occupational interactions impact parent’s sense of competence and parenting competence impacts co-occupational performance.

Impact of Goal Setting and Individual Coaching

Studies show that the general developmental information that parents receive from health and social service agencies does not have as great of an impact on many child and parent outcomes as information with the addition of individualized coaching [11, 12]. Parents’ awareness of needs and ability to identify concerns is enhanced with individual developmental questionaires and reflective interventions [13]. Generalization of interventions to other co-occupational areas and contexts is enhanced by parents setting their own goals and receiving coaching to develop their own intervention strategies [9, 14]. Although short term gains have been evident with instructional parenting programs [15], long term improvments have been found with programs that included individual feedback or coaching [3, 9, 16, 17]. Brief programs, with four to ten sessions, were also found to be effective when they included coaching strategies for parents to become independent problem solvers [8, 9, 10, 17]. Programs that educate and provide individual coaching empower parents to use the new information beyond the scope of the program for maximum potential benefits across all areas of life.

Perception of Child Behavior and Competence

Studies have also shown that a parent’s sense of competence is more closely correlated with a parent’s perception of their child’s behavior than with a clinical evaluation of the child’s behavior [18]. This phenomenon can be explained in several ways. Children may not behave the same way with a clinician present as they do in their typical co-occupations with their parents. Also, the brief evaluation may not capture the range of behaviors that the parent experiences. The parent’s perception is a more accurate interpretation of the daily co-occupational interactions that are taking place. In order to have the greatest influence on a parent’s sense of competence, their perception of co-occupational performance must be used to set goals and develop interventions. This connection lends more support to the need for parents to be active participants in parenting programs.

Information Needs of Parents

Parent training programs that focus on a specific skill or parenting need have been shown to impact psychosocial well-being, competence, and stress [3, 6, 10, 11, 13]. Studies have shown that the majority of parents want support and guidance with co-occupations that occur in the home such as bathing, dressing, grooming, and feeding. Parents feel a higher level of competence when they are able to apply strategies to challenging co-occupations to achieve their goal of improved performance. Sleep and relaxation strategies that decrease fatigue and increase a parent’s ability to cope with challenges have also been shown to be valuable to parents and correlate with an increase in competence [3, 9, 16]. By focusing on the topics that parents want and need, group parent training programs can be appropriate for a wide range of parents in the commuity.

Successful Parent Training Programs

Parent training has been used to support the parenting role and has been shown to be an effective intervention for increasing parents’ sense of competence [8, 9, 16]. A systematic review of 48 randomized controlled trials demonstrated that the intervention is effective in multiple settings and cultures [15]. When parents set goals and implement strategies, the intervention is family-centered and supports the individual ways that families function [8, 9]. Individual feedback within a group training experience helps parents connect the information to their co-occupational routines and contexts [16]. Parents’ successful attempts to modify co-occupations with their children result in more satisfaction with their parenting role and an increase in parenting competence.

A systems approach that addresses the transaction of the parent, child, and the context is used as a foundation to influence the parent-child co-occupations. The key features of the intervention are emotional support for the parent, an exchange of information, and a structured problem solving process [8, 9, 16]. Emotional support for the parent often comes from the practitioner, but group parent trainings can offer additional support from other parents that may be experiencing similar challenges with their children [16]. Educating parents about child development addresses any knowledge gaps the parents may have and has the ability to change the parents’ perspective about their perceived co-occupational challenges. Practitioners must then help parents identify the desired outcomes of challenging co-occupations and explore ways to achieve the desired performance. Following up with parents after their independent attempts at making co-occupational changes is beneficial to provide feedback and support any further problem solving that may be needed. This process empowers parents and creates the potential for parents to generalize their problem solving skills to other co-occupations and contexts with their children, thus impacting the well- being of the family [9].

Theoretical Framework

Lifestyle Redesign is an occupational therapy model that focuses on preventative health care. Participants adapt to daily challenges by setting health and quality of life goals that impact physical and psychosocial well-being [19, 20]. The Lifestyle Redesign model has two key assumptions. The first assumption is that occupations are transformative [20]. Transformations occur when occupational participation changes the individual, the environment, or the sociocultural context [19, 21]. Small occupational changes have the ability to make larger long- term transformations. The second assumption is that meaningful occupations are essential for health [20]. When occupations are meaningful to the individual, the transformative effect is increased [19]. Using these assumptions, the Lifestyle Redesign model guides the development and implementation of customized plans for health related activities.

Lifestyle Redesign was used to guide the development of this parent training program. The model’s combination of group educational presentations, peer exchange, individual reflection, and facilitated goal setting were used to transform the meaningful co-occupations of parents and children. Educational components of the project focused on the health related development of co- occupations. Parents then recognized patterns in their own co-occupations that were impacting the health and well-being of their family. Through the Lifestyle Redesign model, participants changed co-occupational patterns in order to incorporate meaningful and healthy routines for their current and future well-being.

Rationale for the Current Study

When parents have adequate resources to provide care, foster development, and manage their child’s behaviors, they have high levels of competence and self- efficacy in their parent role [4]. Under best practice, pediatricians should be addressing age appropriate topics at well-child visits that include “feeding and nutrition, sleeping, nurturing, injury prevention, growth, learning, behavior, discipline, communication, language development, and toileting” [22]. However, there are disparities between the recommendations of the American Academy of Pediatrics and what information parents actually receive [23]. A national survey in the United States showed that only 10.8% of parents received information in all of the recommended age appropriate topics [23]. It appears that relying on anticipatory guidance from pediatricians does not provide parents with the variety and depth of knowledge required to understand and support their child’s developmental needs, especially when co-occupations are challenging.

Parents would benefit from a trusted source of professional information related to their child’s development and coaching to identify a co-occupational dysfunction. Parents of children with a variety of diagnoses and parents of children without any diagnoses have all demonstrated improvements with co- occupational interventions. Receiving information and identifying a goal has even been shown to increase parent satisfaction before any intervention has taken place [9]. The importance of understanding their child’s behavior and having new strategies to support co-occupational change have a greater impact on parents’ sense of efficacy than the outcome of the strategies. This pilot study addressed the gap in preventative community services by providing access to developmental information and individual coaching by an occupational therapist for any parent regardless of concerns.

Setting and Participants

The pilot study took place in a suburban housing community in a small Virginia town. The group educational components were scheduled to take place in the community building, and participants were recruited through weekly community emails. Eight parents attended the first educational session, but only five of the original participants completed the entire study. Scheduling conflicts and weather related interruptions were given as reasons for withdrawal from the study. An additional parent that was unable to attend the first session was added in the second week of the study. She received the information from the first session online.

All of the participants were mothers who lived in the housing community. To be considered for the pilot study, participants needed to be a parent or primary caregiver of a child between the ages of 0-18 years. Four of the mothers had two children each, one mother had one child, and one mother had three children under the age of 18. The children ranged in age from 2 to 14 years old. Participants were asked to attend all three of the educational sessions, participate in follow-up coaching between sessions, and complete the outcome measures pre- and post-implementation.

Outcome Measures

The Parenting Sense of Competence scale is a 16 item Likert scale questionnaire that is commonly used to measure competence in the parental role [18]. It has been proven a reliable and valid measure with subfactors of satisfaction and efficacy [18]. The Parenting Sense of Competence scale was used in this pilot study as a pre- and post-test to determine the effect of the co- occupational intervention on parents’ sense of competence.

Parent coaching programs conducted by occupational therapists have also used the Canadian Occupational Performance Measure to assist parents in identifying co- occupational needs, setting individual goals, and monitoring performance progress and satisfaction [8, 9]. The Canadian Occupational Performance Measure was modified for this pilot study to include categories for the three educational topic areas of behavior, feeding, and sleep in order to focus participants’ attention to those areas. Participants were asked to reflect on the information from the educational presentations, identify areas of concern, and create goals that they would like to work towards with their child. They then rated their satisfaction and perceived level of performance for each goal on a Likert scale. After rating these areas again at the end of the study, the Canadian Occupational Performance Measure was used to determine the effectiveness of the intervention on the co-occupations of parents and children.

Co-occupational Goals

In this study, participants were able to create individual goals related to the three topic areas addressed in the education portion – social emotional behavior, feeding and nutrition, and sleep. The intervention differed from previous studies in that topic areas were chosen on the basis of parent needs and included co-occupations that span all age ranges of children. The six participants had more concerns about feeding and nutrition as evidenced by their creation of nine feeding and nutrition goals – almost half of the 19 total goals for the project. Although the majority of parenting programs outside of occupational therapy target behaviors related to social emotional development and management [15], there exists a need for education and coaching on other co- occupational parenting activities such as feeding. Occupational therapists are well qualified to address this need and can provide a new co-occupational perspective to traditional parenting program structures.

The intervention in this study focused on the match between the parent’s expectations and behavior and the child’s developmental abilities. Parents often view their child’s behavior as the source of the problem and miss the impact of the parent-child interaction. Instead of attempting to fix the child when parents have little control over making changes, the intervention in this study encouraged parents to make changes in their own behavior which they do control. By matching their expectations and beahvior to their child’s abilities, parents are able to shape co-occupations and promote child development. Through the structured goal setting process, participants also learned how to identify co- occupational concerns by reflecting on the developmental information presented. Because recruitment of participants in this study was not based on existing concerns or daignoses, participants created goals to address concerns that were unique and meaningful to them. In many cases, this allowed participants to create goals that addressed a small manageable concern before any health related consequences had occurred. Repeating the structured goal setting process throughout the study with each topic also increased the opportunity for participants to generalize the concept to other parenting areas. Participants can then use the structured process with other sources of information to set future goals for co-occupational change as their children grow. As in this study, client-centered programs with broad access have the potential to be an effective means of family health prevention.

Program Length

The length of the intervention also differed from previous research studies. Similar parent training programs had 12 weeks of group education [16], or offered 8-10 coaching sessions [8, 9]. This 6-week pilot study included three educational sessions and three opportunities for individual coaching. Through the process of increasing parent’s awareness of typical development and providing a structure to identify concerns and set goals, parents were able to become more competent in making co-occupational changes on their own. The results of the project contribute to the evidence that short-term interventions that empower parents can make a significant impact on parents’ health and well- being [10, 11, 17].