Intervention Summary

Nurturing Parenting Programs

The Nurturing Parenting Programs (NPP) are family-based programs for the prevention and treatment of child abuse and neglect. The programs were developed to help families who have been identified by child welfare agencies for past child abuse and neglect or who are at high risk for child abuse and neglect. The goals of NPP are to:

Increase parents' sense of self-worth, personal empowerment, empathy, bonding, and attachment.
Increase the use of alternative strategies to harsh and abusive disciplinary practices.
Increase parents' knowledge of age-appropriate developmental expectations.
Reduce abuse and neglect rates.

NPP instruction is based on psychoeducational and cognitive-behavioral approaches to learning and focuses on "re-parenting," or helping parents learn new patterns of parenting to replace their existing, learned, abusive patterns. By completing questionnaires and participating in discussion, role-play, and audiovisual exercises, participants learn how to nurture themselves as individuals and in turn build their nurturing family and parenting skills as dads, moms, sons, and daughters. Participants develop their awareness, knowledge, and skills in five areas: (1) age-appropriate expectations; (2) empathy, bonding, and attachment; (3) nonviolent nurturing discipline; (4) self-awareness and self-worth; and (5) empowerment, autonomy, and healthy independence. Participating families attend sessions either at home or in a group format with other families. Group sessions combine concurrent separate experiences for parents and children with shared "family nurturing time." In home-based sessions, parents and children meet separately and jointly during a 90-minute lesson once per week for 15 weeks.

Two group facilitators are recommended for every seven adults participating in the program. Two additional group facilitators are recommended for every 10 children participating. NPP can be implemented by professionals or paraprofessionals in fields such as social work, education, recreation, and psychology who have undergone NPP facilitator training and have related experience.

Multiple NPPs have been developed for various age groups and family circumstances (see the Adaptations section below for more information). The studies reviewed for this summary involved the NPPs designed for (1) parents and their children 0-5 years and (2) parents and their school-age children 5-12 years.

Descriptive Information

Areas of Interest	Mental health promotion Mental health treatment Substance use disorder prevention
Outcomes	1: Parenting attitudes, knowledge, beliefs, and behaviors 2: Recidivism of child abuse and neglect 3: Children's behavior and attitudes toward parenting 4: Family interaction
Outcome Categories	Family/relationships Social functioning Trauma/injuries
Ages	6-12 (Childhood) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Black or African American Hispanic or Latino White Race/ethnicity unspecified
Settings	Home Other community settings
Geographic Locations	Urban Suburban Rural and/or frontier
Implementation History	Initial research and development for the Nurturing Parenting Programs occurred. Over the past 30 years, about 14,000 agencies have implemented NPP worldwide, reaching an estimated 1.1 million families. Approximately 30 studies have been published or described in evaluation reports. NPPs are currently being implemented in all 50 States plus Australia, Belgium, Bermuda, Canada, Chile, England, France, Greenland, Guam, Iceland, Ireland, Italy, Jamaica, Japan, New Zealand, Norway, the Philippines, Portugal, Scotland, Singapore, Taiwan, Thailand, the Virgin Islands, and the West Indies.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	NPP materials have been translated into Arabic, Hmong, Kreyol (Haitian), and Spanish. Adaptations of NPP include: Nurturing Program for Parents and Their Adolescents Nurturing Program for Parents and Their Children with Health Challenges Nurturing Program for Families in Substance Abuse Treatment and Recovery Nurturing Program for Prenatal Families Nurturing Program for Teen Parents and Their Young Children Nurturing Skills for Families Nurturing Skills for Teen Parents ABC's School-Based Program for Parents and Their Children 5 to 8 Years Community-Based Education in Nurturing Parenting Family Nurturing Camp Weekend Experience Nurturing America's Military Families Nurturing Fathers Program Nurturing God's Way, a parenting program for Christian families
Adverse Effects	No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories	Selective Indicated

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Outcomes

Outcome 1: Parenting attitudes, knowledge, beliefs, and behaviors
Description of Measures	Parenting attitudes, knowledge, beliefs, and behaviors were assessed using the following self-report measures: Adult Adolescent Parenting Inventory (AAPI), which assesses five constructs or aspects of parenting: (1) empathy toward children's needs, (2) belief in the use of corporal punishment, (3) parent-child role reversal (i.e., parent behaves as if helpless and needy and looks to his or her own children as though they were adults who could provide parental care and comfort), (4) expectations of children's developmental capabilities, and (5) attitudes toward children's power and independence (i.e., beliefs about the importance of obedience versus autonomy in children). Items in the AAPI have a 5-point Likert response category format, from strongly disagree to strongly agree. Personality Factor (16PF), a standardized, norm-referenced inventory that assesses 16 factors of personality. Nurturing Quiz, a multiple choice, criterion-referenced inventory designed to measure a parent's understanding of parenting techniques and strategies presented in NPP.
Key Findings	In one study, participating families were referred to NPP by the State child welfare agency because of allegations of child abuse and/or neglect. The study found significant positive changes in parental attitudes in the following areas, as measured by the AAPI: Parents developed more appropriate expectations of children's development (p < .00); the effect size for this finding was small (Cohen's d = 0.45). Parents' empathic awareness of their children's needs increased (p < .00); the effect size for this finding was medium (Cohen's d = 0.71). Parents became less supportive of using corporal punishment (p < .00); the effect size for this finding was medium (Cohen's d = 0.67). Attitudes reflecting parent-child role reversal decreased (p < .00); the effect size for this finding was small (Cohen's d = 0.20). Parents' attitudes toward children's power and independence improved (p < .00); the effect size for this finding was small (Cohen's d = 0.29). In another study, participating families were referred to NPP by the State social services agency or Parents Anonymous groups because of abusive parent-child interactions. The study found significant changes from pre- to posttest in the following areas: Data from the AAPI showed significant positive changes in parenting and child-rearing attitudes and behaviors. Specifically, parents participating in the NPP developed more appropriate developmental expectations of children, an increased empathic awareness of children's needs, more appropriate attitudes toward the use of corporal punishment, and a decrease in parent-child role reversal behaviors (all p values < .05). The improvement in empathic attitudes toward children's needs and differentiation of appropriate parent-child roles was maintained through 1-year follow-up. Further, attitudes toward the use of corporal punishment and inappropriate developmental expectations of children significantly improved from posttest to 1-year follow-up (p < .01). Data from the 16PF showed significant increases in parents' enthusiasm (p < .01), social boldness (p < .01), and self-assuredness (p < .05) and significant decreases in radicalism (p < .05), anxiety (p < .02), and tough demeanor (i.e., insensitivity to other people; p < .05). Data from the Nurturing Quiz indicated a significant increase in acquired knowledge related to behavior management concepts and techniques (p < .05). In a third study, participating families were referred to NPP by the State social services agency or nonprofit social services organizations because of child neglect or neglect and abuse. Some were court-ordered to attend a parenting program based on their long-standing inability to change their neglecting parenting pattern. The study found significant changes from pre- to posttest in the following areas, as measured by the AAPI: Parenting and child-rearing attitudes significantly improved, such that parents had more appropriate expectations of children, had more empathic awareness of children's needs, were less supportive of using corporal punishment, and developed a more appropriate view of the role of children and parents in a family (p values < .001). Parents' knowledge of parenting and child-rearing techniques improved significantly (p < .001). No significant changes in parents' personality, as measured by the 16PF, were seen over the course of the study.
Studies Measuring Outcome	Study 1, Study 2, Study 3
Study Designs	Preexperimental
Quality of Research Rating	3.1 (0.0-4.0 scale)

Outcome 2: Recidivism of child abuse and neglect
Description of Measures	Recidivism was identified by determining whether participants were involved in any abuse and neglect incidents after completing the NPP treatment program. Data on incidents were obtained from the State administrative data system used to capture information on caregivers who are or have been the subject of investigations of alleged child abuse or neglect.
Key Findings	In one study, participating families were referred to NPP by the State child welfare agency because of allegations of child abuse and/or neglect. The study found that a high dosage of treatment (at least 14 sessions of NPP) reduced child abuse and neglect recidivism by 73%, a significant improvement compared with results for lower levels of attendance (p < .05). In another study, participating families were referred to NPP by the State social services agency or Parents Anonymous groups because of abusive parent-child interactions. The recidivism rate in this study was 7.36%; only 7 of the 95 adults who completed the program were charged with additional counts of child abuse and neglect after participation in the program.
Studies Measuring Outcome	Study 1, Study 2
Study Designs	Preexperimental
Quality of Research Rating	2.9 (0.0-4.0 scale)

Outcome 3: Children's behavior and attitudes toward parenting
Description of Measures	Children's behavior and attitudes toward parenting were assessed using the following self-report measures: Children's Parenting Inventory (CPI), an inventory based on the AAPI and designed for use with young children. Like the AAPI, the tool assesses views and attitudes toward parenting styles and behaviors. The children respond to parenting examples with "I agree," "I'm not sure," or "I disagree." Early School Personality Questionnaire (ESPQ) or Children's Personality Questionnaire (CPQ), based on the 16PF personality inventory. The questionnaires are designed to assess primary personality traits in children that are useful in understanding and evaluating personal, social, and academic development, as well as creativity, emotional stability, self-concept, excitability, and apprehension.
Key Findings	Participating families were referred to NPP by the State social services agency or Parents Anonymous groups because of abusive parent-child interactions. Significant changes from pre- to posttest were found in the following areas: Data from the CPI showed a significant increase in children's self-awareness and an improvement in parent-child role reversal (p values < .05). Significant improvements in self-awareness were also seen from posttest to 1-year follow-up (p < .01); children also became less supportive of corporal punishment from posttest to 1-year follow-up (p < .01). Data from the personality questionnaire indicated significant increases in children's assertiveness (p < .05) and enthusiasm (p < .01) and a significant decrease in tough demeanor (i.e., insensitivity to other people; p < .03).
Studies Measuring Outcome	Study 2
Study Designs	Preexperimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 4: Family interaction
Description of Measures	Family interaction was assessed using the following measures: Family Environment Scale (FES), a 90-item self-report inventory that examines the social and environmental characteristics of a family, focusing on three areas: relationships, personal growth, and system maintenance. Observational Data Collection Form, used to collect data during 1-year follow-up, in-home observations of family interactions. Two observers were assigned to conduct each in-home observation. One observer recorded data, and the other facilitated family activities as part of the intervention. Each observation period lasted 2 hours and entailed structured and unstructured family activities. All family members and interactions were coded. Observers were trained to identify verbal and nonverbal patterns of behavior (e.g., disinterest/coldness, interest/warmth, expression of feelings/needs).
Key Findings	In one study, participating families were referred to NPP by the State social services agency or Parents Anonymous groups because of abusive parent-child interactions. The combination of self-reported data from the FES and observational data from in-home visits revealed significant pre- to posttest improvements in family cohesion (p < .03), family expressiveness (p < .03), and family independence (p < .01), while family conflict decreased significantly (p < .01). From posttest to 1-year follow-up, significant increases were found in family cohesion (p < .05), family expressiveness (p < .04), and family organization (p < .02), while family conflict decreased significantly (p < .05). In another study, participating families were referred to NPP by the State social services agency or nonprofit social services organizations because of child neglect or neglect and abuse. Some were court-ordered to attend a parenting program based on their long-standing inability to change their neglecting parenting pattern. Self-reported data from the FES showed significant positive changes in family interaction patterns from pretest to posttest. Family cohesion, expressiveness, organization, independence, achievement, reaction, and cultural and moral interactions increased, while family conflict and control decreased (p values < .001).
Studies Measuring Outcome	Study 2, Study 3
Study Designs	Preexperimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	Data not reported/available	75% Female 25% Male	58% White 42% Race/ethnicity unspecified
Study 2	6-12 (Childhood) 26-55 (Adult)	54% Female 46% Male	90% White 6% Black or African American 2% American Indian or Alaska Native 1% Hispanic or Latino 1% Race/ethnicity unspecified
Study 3	26-55 (Adult)	73% Female 27% Male	89% White 8% Hispanic or Latino 3% American Indian or Alaska Native 1% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Parenting attitudes, knowledge, beliefs, and behaviors	4.0	4.0	2.6	2.7	1.9	3.4	3.1
2: Recidivism of child abuse and neglect	3.5	3.5	2.4	2.8	1.9	3.4	2.9
3: Children's behavior and attitudes toward parenting	3.3	3.3	3.3	3.0	2.0	3.5	3.0
4: Family interaction	3.9	4.0	3.3	2.9	2.0	3.5	3.2

Study Strengths

The instruments used in the studies have adequate to very good psychometric properties. Information was provided about the methods and procedures used to design and implement the intervention and evaluate it in multiple sites. The intervention and its key components were grounded in theory and well structured. In all the studies, the interventionists were trained and supervised. Efforts made to minimize attrition and missing data were successful. The analyses used were appropriate.

Study Weaknesses

The one-group pretest-posttest design selected for the study, while appropriate for evaluating programs in the early stage of development, is inherently limited in that it does not control for many threats to internal validity. The authors reported that monitoring intervention fidelity across sites was challenging, and many sites likely did not fully adhere to the intervention model.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
4.0	4.0	4.0	4.0

Dissemination Strengths

Implementation is supported by a wealth of extremely well-designed, high-quality, and easy-to-understand materials and resources. The Program Implementation Manual and Resource Guide functions as a comprehensive, step-by-step roadmap to implementation. Further, treatment materials are well developed and age- and parent-appropriate. The program Web site has readily accessible information, including free information to educate interested parties about the program to assist with decisions on which elements of the program to implement. The facilitator training and Training for Trainers program provide multiple opportunities to implement the program successfully. Many training sessions are taught by the principal developer, but the Web site also includes a list of certified trainers. Training materials are very good: Easy reader editions are provided for parents in a respectful way, and materials for children are simple and meet the child's educational and maturity level. The developer has set very high standards with a detailed collection of materials to support and maintain implementation with fidelity. The various high-quality assessment tools and inventories provide objective data for ongoing quality assessment and improvement activities.

Dissemination Weaknesses

No weaknesses were identified by reviewers.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Materials set (includes all materials needed for implementation and quality assurance)	$300-$2,000 depending on the program selected	Yes
3-day, on- or off-site facilitator training	$250-$325 per participant	Yes
4-day, on-or off-site training of trainers	$350-$400 per participant	No
Phone or email technical assistance	Free	No
On-site technical assistance	About $500-$750 per day plus travel expenses	No

Additional Information

The cost of running a high-quality NPP varies based on the program format and number of sessions provided. The initial set of materials can be used to implement the program to approximately 15 families. The majority of program materials are reusable.