Intervention Summary

Parenting Inside Out

Parenting Inside Out (PIO) is a 12-week voluntary parent management training program for incarcerated parents. The program is designed to assist participants in improving their interaction with their child and their child's caregiver. By improving this interaction, PIO aims to provide participants--many of whom have co-occurring substance abuse and mental health problems--with greater capacity to improve their cognitive and behavioral skills, which are relevant to such issues as reducing personal stress and symptoms of depression and, for those participants who will be leaving prison, reducing postrelease substance use-related problems and criminal behaviors.

PIO is grounded in social learning theory and the parent management training model. It has the following core elements: (1) communication and problem solving, (2) positive involvement in the child's life and activities, (3) encouragement of the child's skill development, (4) setting of limits and nonviolent discipline, and (5) appropriate monitoring and supervision. The program emphasizes communication and cooperation with the child's caregiver and other adults; child development; child health and safety; life skills relevant to children and families; and positive parenting from prison through letter writing, phone calls, and prison visits. PIO also helps parents develop and refine their health behaviors, social interactional skills, and citizenship behaviors for use in all aspects of their lives, including guiding their children toward becoming socially competent adults.

PIO consists of 36 classes that are 2.5 hours each and held three times a week for a total of 90 hours. The classes are delivered by a trained parenting coach to groups of 12-15 participants who may have varying sentence lengths, including life sentences or planned release dates that may be months or years away; however, participants with a planned release must begin the program at least 16 weeks before that date. Classes include large and small group discussions of case studies, critical incident analysis, role-play practice, team projects, and collaborative peer review.

In the study reviewed for this summary, all participating parents had less than 9 months remaining in their prison sentence.

Descriptive Information

Areas of Interest	Mental health promotion Co-occurring disorders
Outcomes	1: Parent stress 2: Parent symptoms of depression 3: Parent-child interaction 4: Criminal behaviors 5: Substance use-related problems
Outcome Categories	Alcohol Crime/delinquency Drugs Family/relationships Mental health Social functioning
Ages	18-25 (Young adult) 26-55 (Adult)
Genders	Male Female
Races/Ethnicities	American Indian or Alaska Native Black or African American Hispanic or Latino White Non-U.S. population
Settings	Correctional
Geographic Locations	No geographic locations were identified by the developer.
Implementation History	PIO has been implemented by the Oregon Department of Corrections And the program has been delivered in most correctional institutions within Oregon., PIO became available for implementation outside of Oregon, and it has been implemented in approximately 20 prisons or jails in California, Illinois, Iowa, Kansas, Michigan, Rhode Island, Virginia, and West Virginia, as well as internationally in Australia. In Oregon, approximately 3,600 parents have completed the program, and outside of Oregon, approximately 1,800 parents have completed the program.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: No
Adaptations	PIO has been translated into Spanish and has been adapted as a shorter, 60-hour program; a program for use in the community, which also has been translated into Spanish; and a program for use in jails.
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.

Study 1

Eddy, J. M., Martinez, C. R., Jr., & Burraston, B. A randomized controlled trial of a prison-based parent management training program: Post-release outcomes. Manuscript in preparation.

Eddy, J. M., Martinez, C. R., Jr., & Burraston, B. VI. A randomized controlled trial of a parent management training program for incarcerated parents: Proximal impacts. Monographs of the Society for Research in Child Development, 78(3), 75-93.

Supplementary Materials

Eddy, J. M., Martinez, C. R., Jr., Schiffmann, T., Newton, R., Olin, L., Leve, L., et al. Development of a multisystemic parent management training intervention for incarcerated parents, their children and families. Clinical Psychologist, 12(3), 86-98.

Kjellstrand, J., Cearley, J., Eddy, J. M., Foney, D., & Martinez, C. R., Jr. Characteristics of incarcerated fathers and mothers: Implications for preventive interventions targeting children and families. Children and Youth Services Review, 34(12), 2409-2415.

Outcomes

Outcome 1: Parent stress
Description of Measures	Parent stress was measured using 12 items from the 14-item Perceived Stress Scale. Participants responded to questions that asked about their feelings of stress in the past month (e.g., "How often have you felt that you were unable to control the important things in your life?" and "How often have you felt confident about your ability to handle your personal problems?").
Key Findings	A study was conducted with incarcerated parents who had at least one minor child, a role in parenting his or her child, and less than 9 months before the end of his or her prison sentence. Participants were randomly assigned to the intervention group, which received PIO, or the comparison group, which received parenting services as usual (i.e., a nonstandardized parenting program that varied widely in scope and approach, depending on the location). Participants were assessed before and immediately after the intervention, but prior to release from prison. At the postintervention assessment, participants in the intervention group had less stress than participants in the comparison group (p = .03), after controlling for preintervention stress ratings, inmate gender and age, and total family contacts in prison.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 2: Parent symptoms of depression
Description of Measures	Parent symptoms of depression were measured using the 20-item Center for Epidemiologic Studies Depression scale. Participants responded to items regarding the frequency of various symptoms of depression experienced in the past week (e.g., "I felt depressed," "I thought my life had been a failure").
Key Findings	A study was conducted with incarcerated parents who had at least one minor child, a role in parenting his or her child, and less than 9 months before the end of his or her prison sentence. Participants were randomly assigned to the intervention group, which received PIO, or the comparison group, which received parenting services as usual (i.e., a nonstandardized parenting program that varied widely in scope and approach, depending on the location). Participants were assessed before and immediately after the intervention, but prior to release from prison. At the postintervention assessment, participants in the intervention group had fewer symptoms of depression than participants in the comparison group (p = .02), after controlling for preintervention mood, inmate gender and age, and total family contacts in prison.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 3: Parent-child interaction
Description of Measures	Parent-child interaction was assessed using two scales: A 3-item scale measuring the participant's perceptions about whether contact with his or her child had a positive, negative, or neutral influence on the child's behavior A 4-item scale measuring the participant's perceptions of his or her child's behavior after parental contact (e.g., "After contact was the child happy?") Scores for each scale were averaged, standardized, and combined to produce an overall measure of parent-child interaction.
Key Findings	A study was conducted with incarcerated parents who had at least one minor child, a role in parenting his or her child, and less than 9 months before the end of his or her prison sentence. Participants were randomly assigned to the intervention group, which received PIO, or the comparison group, which received parenting services as usual (i.e., a nonstandardized parenting program that varied widely in scope and approach, depending on the location). Participants were assessed before and immediately after the intervention, but prior to release from prison. At the postintervention assessment, participants in the intervention group had a more positive parent-child interaction than participants in the comparison group (p = .02), after controlling for preintervention parent-child interaction, inmate gender and age, and total family contacts in prison.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.6 (0.0-4.0 scale)

Outcome 4: Criminal behaviors
Description of Measures	Criminal behaviors were assessed using the following: The Elliot Delinquency Scale. The Elliott Delinquency Scale is a 45-item, self-report questionnaire used to measure criminal behaviors. Participants were asked to report how many times in the past 12 months they had participated in a variety of antisocial and criminal behaviors, including theft (e.g., "steal someone's purse or wallet or pick someone's pocket"), violent behavior (e.g., "hit or threaten to hit one of your parents"), and illegal drug sales (e.g., "sell hard drugs such as meth, heroin, cocaine, LSD or any other hard drugs"). Participants were assessed in prison (in regard to the period before incarceration) and 6 months after release from prison. Cumulative official records of police arrests. Official records of police arrests were collected for participants from age 18 to the incarceration at the time of the study, as well as at 1 year after release from prison. Data were collected via OJIN OnLine, a Web-based, paid subscription data access system for court case information from all 36 circuit courts in Oregon, as well as tax and appellate courts. The system provides information from civil, small claims, tax, domestic, and criminal (including misdemeanor and felony) cases.
Key Findings	A study was conducted with incarcerated parents who had at least one minor child, a role in parenting his or her child, and less than 9 months remaining before the end of his or her prison sentence. Participants were randomly assigned to the intervention group, which received PIO, or the comparison group, which received parenting services as usual (i.e., a nonstandardized parenting program that varied widely in scope and approach, depending on the location). Findings included the following: At 6 months after release from prison, data from the Elliot Delinquency Scale indicated that participants in the intervention group were more likely than those in the comparison group to have no postrelease criminal behaviors or abstain from criminal behavior (p < .05), after controlling for prior criminal behavior and gender. At 1 year after release from prison, data from the cumulative official records of police arrests indicated that participants in the intervention group had fewer arrests than participants in the comparison group (p < .05), after controlling for prior arrests, gender, and time in prison.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 5: Substance use-related problems
Description of Measures	Substance use-related problems were measured by 8 items that addressed behavior problems associated with substance use: Using 0 (no) or 1 (yes), participants rated their agreement with 5 items (e.g., "had to use more drugs or alcohol to get the same effect," "drove or used equipment while using drugs or alcohol," "desire to use drugs or alcohol so strong you couldn't keep from using"). Using a 7-point scale ranging from 0 (never) to 6 (daily), participants reported "how often substance use interfered with job or home" and "how often used larger amounts of drugs or alcohol." Using a 10-point scale ranging from 0 (no problems) to 10 (many problems), participants reported "how much has drug or alcohol use caused problems."
Key Findings	A study was conducted with incarcerated parents who had at least one minor child, a role in parenting his or her child, and less than 9 months remaining before the end of his or her prison sentence. Participants were randomly assigned to the intervention group, which received PIO, or the comparison group, which received parenting services as usual (i.e., a nonstandardized parenting program that varied widely in scope and approach, depending on the location). Participants were assessed before the intervention, at the midpoint of the intervention, after the intervention, and at 6 months after release from prison. At 6 months after release from prison, participants in the intervention group were more likely than those in the comparison group to have no postrelease substance use-related problems (p < .001), after controlling for prior substance abuse and gender.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	2.7 (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	18-25 (Young adult) 26-55 (Adult)	55% Female 45% Male	59% White 13% Black or African American 12% Non-U.S. population 8% American Indian or Alaska Native 8% Hispanic or Latino

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: Parent stress	4.0	4.0	2.5	3.0	2.5	3.5	3.3
2: Parent symptoms of depression	4.0	4.0	2.5	3.0	2.5	3.5	3.3
3: Parent-child interaction	2.5	1.5	2.5	3.0	2.5	3.5	2.6
4: Criminal behaviors	3.8	2.5	2.5	3.0	2.5	3.5	3.0
5: Substance use-related problems	2.5	2.0	2.5	3.0	2.5	3.5	2.7

Study Strengths

The Perceived Stress Scale, the Center for Epidemiologic Studies Depression scale, and the Elliot Delinquency Scale have well-established, acceptable reliability and validity levels. The training of coaches was extensive: they received 3 days of training in the intervention and additional training in procedures and protocols related to working in prison; coaches met or spoke weekly with their supervisor; and the coaching team met once per month with the supervisor and the principal investigator for group supervision and continuing education. The study's retention rates were very high at assessment points. The study used a randomized controlled design. Appropriate analyses were used, including intent to treat, multiple imputation of missing data, and examination of each outcome for nesting.

Study Weaknesses

The measures used for two outcomes--parent-child interaction and substance use-related problems--were not supported by evidence of established forms of validity beyond face validity, and no reliability data from independent studies were presented. Reliability and validity of the fidelity assessment instruments are unknown. Participants missed one-third of the intervention sessions, but no analyses controlled for this, nor is there much discussion of the implications of these missed sessions.

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.

Children's Justice Alliance & Oregon Social Learning Center. Parenting Inside Out: PIO trainer materials [CD-ROM]. Portland, OR: Author.

Children's Justice Alliance & Oregon Social Learning Center. Parenting Inside Out: Coach CD: Prison version [CD-ROM]. Portland, OR: Author.

Children's Justice Alliance & Oregon Social Learning Center. Parenting Inside Out: PIO as an outcomes-based program [CD-ROM]. Portland, OR: Author.

Children's Justice Alliance & Oregon Social Learning Center. Parenting Inside Out: PIO child-centered play [CD-ROM]. Portland, OR: Author.

National Center on Shaken Baby Syndrome. Infant crying [CD]. Farmington, UT: Author.

Schiffmann, T., Eddy, J. M., & Johnson, M. Parenting Inside Out: Coach manual: Version 3.1: Prison, community, and jail. Portland, OR: Author.

Schiffmann, T., Eddy, J. M., Martinez, C. R., Jr., Leve, L., & Newton, R. Parenting Inside Out: Parent management training. Portland, OR: Children's Justice Alliance and Oregon Social Learning Center.

Schiffmann, T., Johnson, M. T., & Eddy, J. M. Parenting Inside Out: Trainer's manual. Portland, OR: Children's Justice Alliance and Oregon Social Learning Center.

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

The dissemination package includes materials for supervisors, parenting coaches, and participants. The program content is consistent throughout the package and easy to follow. Each session is outlined and detailed for coaches. The curriculum includes a wide variety of handouts, tools, exercises, worksheets, and other materials designed to engage participants. A 3-day certification program is required for coaches and is offered as an on- or off-site training. Master trainers are available to provide consultation and technical assistance as needed. Supervisors are trained to oversee coaches throughout the implementation process, providing feedback via a series of forms and tools that strengthen overall fidelity. A parent survey is available to support outcome monitoring.

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
Curriculum licensing fee (includes quality assurance materials and permission to copy student workbook)	$2,000-$4,000 per year per site, depending on number of annual program participants	Yes
Curriculum manual (includes coach manual)	$500 each	Yes
3-day, on-site coach training	$5,000 for up to 10 participants, plus travel expenses	Yes, one coach training is required
3-day coach training at regional facility	$990 per participant	Yes, one coach training is required
Multisession Web-based coach training	$775 per participant	Yes, one coach training is required
4-hour, on- or off-site supervisor training (includes all materials)	$250 per participant, plus travel expenses if necessary	No
Consultation and technical assistance with master trainers	Free for first 3 hours; $50 for each additional hour	No