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After Deployment, Adaptive Parenting Tools: 1-Year Outcomes of an Evidence-Based Parenting Program for Military Families Following Deployment

Abigail H. Gewirtz1 & David S. DeGarmo2 & Osnat Zamir3

Published online: 15 September 2017 # Society for Prevention Research 2017

Abstract Despite significant stressors facing military families over the past 15 years of wars in Iraq and Afghanistan, no parenting programs adapted or developed for military families with school-aged children have been rigorously tested. We present outcome data from the first randomized controlled trial of a behavioral parent training program for families with a parent deployed to Iraq or Afghanistan. In the present study, 336 primarily National Guard and Reserve families with 4–12- year-old children were recruited from a Midwestern state. At least one parent in each family had deployed to the recent con- flicts: Operations Iraqi or Enduring Freedom, or New Dawn (OIF/OEF/OND). Families were randomized to a group-based parenting program (After Deployment, Adaptive Parenting Tools (ADAPT)) or web and print resources-as-usual. Using a social interaction learning framework, we hypothesized an in- direct effects model: that the intervention would improve par- enting, which, in turn, would be associated with improvements in child outcomes. Applying intent-to-treat analyses, we exam- ined the program’s effect on observed parenting, and children’s adjustment at 12-months post baseline. Controlling for demo- graphic (marital status, length, child gender), deployment vari- ables (number of deployments), and baseline values, families randomized to the ADAPT intervention showed significantly improved observed parenting compared to those in the compar- ison group. Observed parenting, in turn, was associated with significant improvements in child adjustment. These findings

present the first evidence for the effectiveness of a parenting program for deployed military families with school-aged children.

Keywords Parenting .Military . Parental deployment . Child adjustment . Prevention

Introduction

Since September 11, 2001, over 2.6 million Americans have deployed to the wars in Afghanistan and Iraq (National Center for Veterans Analysis and Statistics 2016). Almost half of these service members are partnered and parenting, resulting in more than two million children affected by the deployment to war of a parent (Department of Defense 2009). Families of service members in the National Guard and Reserves (NG/R) have been disproportionately affected by the recent conflicts. Unlike families of Active Duty service members who live on or near military installations, most NG/R families live civilian lives in civilian communities, with few of the supports of the military installation. Prior to September 11, 2001, few NG/R service members had deployed to war; since then, these ser- vice members have constituted a key fighting force for the US military (Griffith 2009).

Most military families are resilient. Indeed, data indicate that military children are as well-adjusted as their civilian peers (Park 2011). However, increasing evidence indicates that a parent’s deployment to war is associated with risks to child and partner adjustment (Kelley and Jouriles 2011). Deployment of a parent is associated with parenting chal- lenges for both the deployed and the non-deployed parents (Creech et al. 2014) and increased rates of anxiety, depression, and substance use in youth (Sullivan et al. 2015).

* Abigail H. Gewirtz [email protected]

1 University of Minnesota, Minneapolis, MN, USA 2 University of Oregon, Eugene, OR, USA 3 Hebrew University of Jerusalem, Jerusalem, Israel

Prev Sci (2018) 19:589–599 DOI 10.1007/s11121-017-0839-4

Conceptually, deployment may be viewed as a family stressor, both because of the prolonged absence of a parent service member during deployment and because of the danger to the service member and accompanying potential for stress and anxiety for the family. Family stress models (e.g., Conger et al. 2002) propose that stressful family contexts indirectly impair children’s adjustment via their detrimental impact on parents and parenting. Most of this research has focused on marital transitions and socioeconomic challenges as sources of family stress. In those contexts, parents affected by eco- nomic insecurity, divorce, single parenting, or related risks confer their stress on children via impaired parenting behav- iors. For military families, salient parental stressors include those related to deployment (e.g., length and number of de- ployments; posttraumatic stress symptoms from war experi- ences) and these are associated with impaired parenting prac- tices and, in turn, with poorer child adjustment (Davis et al. 2015; Gewirtz et al. 2017).

Applying a social interaction learning (SIL)model, Patterson and colleagues proposed how parenting in stressful family con- texts affects children’s adjustment, by increasing the frequency and rate of coercive or inept (e.g., harsh or non-contingent) dis- cipline in parent-child interactions (Patterson 1982, 2005). The model relies on coded observations of parent-child interactions that form the basis for the measurement of parenting practices. The SILmodel undergirds the family of interventions known as ParentManagement Training-OregonModel (PMTO) (Dishion et al. 2015; Forgatch and Patterson 2010). PMTO targets the reduction of coercion by improving positive parenting (i.e., skill encouragement, problem solving, positive involvement, effec- tive discipline, and monitoring). The PMTO model has been widely tested in randomized trials and found to be efficacious and effective with diverse families in the USA and Northern Europe (Forgatch and Patterson 2010). However, the model has never been tested inmilitary populations or for those affected by traumatic stressors such as war (Gewirtz et al. 2008).

Few evidence-based prevention and treatment interven- tions have been specifically developed or modified for mili- tary families, despite the extraordinary and somewhat unique stressors faced by families with a parent deployed to war. While several resources are available to military families seek- ing help with parenting, especially for young children (Gewirtz and Youssef 2016), to our knowledge, no parenting interventions for military families with school-aged children have been evaluated in randomized trials. The current study therefore represents the first large-scale RCT of a parenting intervention for military families after deployment.

The After Deployment, Adaptive Parenting Tools Intervention The After Deployment, Adaptive Parenting Tools (ADAPT) intervention is a 14-week parenting program delivered in sessions of 2 h per week tomulti-family groups of six to 15 parents per group. Topics address six core parenting

skills: teaching through encouragement, discipline, problem solving, monitoring, positive involvement with children, and emotion socialization. Material was delivered using active teaching techniques and according to PMTO implementation (training and fidelity) guidelines (Forgatch et al. 2013). In developing ADAPT, we extended the PMTO model by pro- viding material specific to military families and the deploy- ment context (e.g., discussion and role play of deployment- specific family scenarios), and by adding material to enhance parent emotion regulation (with mindfulness exercises) and emotion coaching skills (Gewirtz et al. 2014). Facilitators were military (National Guard and veterans) and non- military human service providers (e.g., school guidance coun- selors, social workers) who received 11 days of workshop training and biweekly ongoing coaching from the PI and other staff certified in the PMTO model.

Effectiveness Hypotheses

The SIL preventive intervention model (Forgatch and Patterson 2010) posits that change in proximal targeted out- comes, i.e., parenting practices, leads to changes in distal child adjustment outcomes. Child adjustment factors are considered distal because the intervention is provided directly to parents and not to children; therefore, intervention effects on child adjustment should operate indirectly through the putative par- enting mechanisms and processes. Evaluations of randomized trials support this approach (Forehand et al. 2014). Based on these findings, we formulated the following intent-to-treat (ITT) effectiveness hypotheses:

H1: Parents in the ADAPT intervention group will show greater 1-year pre-post change in the proximal outcome of effective parenting practices relative to the control condition.

H2: Pre-post change in effective parenting will be associated with improvements in child adjustment at 1 year.1

We also explored baseline by treatment intervention effects to understand whether parents demonstrating poorer baseline parenting might benefit more from the ADAPT intervention, as prevention interventions commonly benefit those families at greater baseline risk for deficient parenting or child adjust- ment (Brown et al. 2008; Flay et al. 2005). Finally, in addition

1 We hypothesize indirect effects of change in parenting to improvements in child adjustment, rather than mediating effects because mediation is more robustly tested with the mediator as a temporal antecedent to a distal outcome. We also expected and tested replication of PMTO findings from Forgatch and DeGarmo (1999) who found that parenting, as target of the intervention, showed preliminary sensitivity to change with indirect associations to child outcomes at 12-month post baseline, demonstrating full mediation at later follow-ups.

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to intent-to-treat, we examined final models using complier average causal effects (CACE) to examine impact of engage- ment in the intervention.

Method

The current sample included 336 military families comprising 314 mothers, 294 fathers, and 336 children, residing in a Midwestern state. Participants consented and completed a baseline assessment for a prevention study evaluating the ef- fectiveness of a parenting program (ADAPT). Families were eligible to participate in the study if at least one parent had deployed to recent conflicts (i.e., Operation Iraqi Freedom or Operation Enduring Freedom, OIF/OEF) and at least one child between the ages of 4 and 12 was living in the home.

Of the 336 families participating in the study, 272 families had two parents participating in the study and 64 families had one parent participating. Among the two-parent families, 258 couples were married to each other, 12 couples were not mar- ried to each other, and 2 did not indicate marital status. Of the 64 parents participating in the study without a partner, 41 were mothers and 23 were fathers. Parents participating alone re- ported being married (but husband declined study participa- tion; n = 23), divorced (18), single (10), separated (9), or widowed (1). The rest did not indicate marital status (n = 3). Length of marriage to current partner ranged from 1 to 28 years, with mean length of marriage 9.75 years (SD = 5.3) for fathers and 9.4 years (SD = 5.3) for mothers. Number of children in a household ranged from one to six with a mean of 2.34 children in a family (SD = 0.96).

Participants were predominantly White (88.4% of fathers and 92.7% of mothers). Mothers’ ages ranged from 23 to 51 (M = 35.67, SD = 5.89), and fathers’ ages ranged from 23 to 58 (M = 37.75, SD = 6.54). About half of participants (47.7% of fathers and 51.9% of mothers) reported completing at least a bachelor’s degree. Household incomes ranged from $39,999 or less (13.8%) to $120,000 or more (14.5%), with most fam- ilies reporting income between $40,000 to $79,999 (43.5%) or $80,000 to $119,999 (28.2%).Most fathers (84.3%) and about half of mothers (48.4%) were employed full-time.

In 86.7% of participating families, one parent was de- ployed to recent conflicts; and in the remaining 13.3% of families, both parents were deployed to recent conflict. In 18.2% of families, the mother was deployed; in 95% of the families, the father was deployed. Most parents deployed with the ArmyNational Guard (59%); others deployed with the Air National Guard (10.7%), the Army (12.9%), Navy (6.6%), Air Force (2.8%), or Marine Reserves (0.3%). During these oper- ations, 51.2% of deployed parents were deployed more than once for an average of 1.73 deployments (SD = 1.16). In 58.3% of these deployments, parents were deployed for more than 12 months.

Of the 314 mothers and 294 fathers who completed the baseline assessment, 255 (81%) mothers and 226 (76.8%) fa- thers completed the 12-month/ Time 3 (T3) assessment (see Fig. 1, CONSORT chart). An immediate posttest data point, Time 2 (6-month post baseline), involved only adult self- report data, and thus, data from that time point are not included in this report. There were no significant differences in most demographics (i.e., race, income, age, marital status, number of children) betweenmothers and fathers who completed the T3 assessment and those who dropped out. However, mothers who completed the T3 assessment (M = 2.27, SD = 0.59) had more children on average than mothers who dropped out (M = 2.54, SD = 1.21) as measured at baseline (t(307) = − 2.05, p < .05).

Measures

Effective Parenting Practices Scores on parenting practices were obtained from direct observation of parent-child interac- tions during structured family interaction tasks (FITs). These were a series of 5-min tasks in which parents and children (moth- er-child, father-child, mother-father-child) were asked to (i) iden- tify and then solve a source of everyday conflict (e.g., bedtime, cleaning bedrooms, homework; Prinz et al. 1979); (ii) discuss deployment-related concerns (e.g., missing a child’s birthday); and (iii) plan a fun family activity. Other tasks assessed teaching: games in which parents were told to provide children with the help they needed; and monitoring: children told of a time when parents were not present; parents were instructed to gather infor- mation from the child (adapted from Dishion et al. 2007).

Parenting practices were measured with five previously vali- dated SIL indicators: (1) problem-solving outcome, (2) harsh discipline, (3) positive involvement, (4) skill encouragement, and (5) monitoring. In prior observational studies of parent- child relationships in families with children aged 4 to 12, FIT codes demonstrated ecological validity, construct validity, and sensitivity to change with at-risk families (Forgatch and DeGarmo 1999; Gewirtz et al. 2009, 2015). Immediately after reviewing video footage of each task, trained coders scored FITs using a Coder Impressions system (Forgatch et al. 1992). Observers were trained for 60 h and underwent biweekly recali- bration meetings to minimize observer drift and continue train- ing. Inter-rater reliabilitywas assessedwith intraclass correlation coefficients (ICCs) for randomly selected coder teams.

Problem-solving outcome was scored with a nine-item scale evaluating the quality of the parent and child solution, extent of resolution, apparent satisfaction at the outcome of the discussion, and likelihood the family would put this solu- tion to use (α = .87–.89; ICC = .88–.94). Items were rated based on the problem-solving interactions using a 5-point Likert scale ranging from 1 (untrue) to 5 (very true). Harsh discipline was measured by an eight-item scale assessing overly strict, authoritarian, erratic, inconsistent, or haphazard

Prev Sci (2018) 19:589–599 591

parenting practices (α = .75; ICC = .58–.78). Items were rated based on the entire interaction on a 6-point Likert scale rang- ing from 1 (never) to 6 (always). Positive involvement was derived from a ten-item scale evaluating parent’s warmth, em- pathy, encouragement, and affection (α = .75–.76;

ICC = .76–.84). Items were rated based on the entire interac- tion on a 6-point Likert scale ranging from 1 (never) to 6 (always). Skill encouragement was assessed using an eight- item scale reflecting parent’s ability to promote children’s skill development through encouragement and scaffolding

Fig. 1 CONSORT flow chart of ADAPT randomized control trial and 12-month data in present report

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strategies (α = .76–.83; ICC = .72–.76). Items were rated based on teaching tasks on a 5-point Likert scale ranging from 1 (untrue) to 5 (very true). Monitoring was measured by a four-item scale assessing parents’ supervision and knowledge of their child’s daily activities (α = .60–.71; ICC = .74–.64). Items were rated on a 5-point Likert scale ranging from 1 (untrue) to 5 (very true). All scales were averaged to create summary scores, such that higher scores indicate higher pos- itive communication. The final mother and father parenting scores were composites of the five SIL indicators scaled 1 to 5.

Child Adjustment Construct A multiple-indicator latent construct was defined to evaluate the distal outcome of child adjustment, using child-, teacher-, and parent-reported scale scores. Scores were selected from a set of indicators previous- ly employed to evaluate the baseline theoretical model that specified indicators demonstrating factor convergence in a higher-order confirmatory factor model using all three data sources (Gewirtz et al. 2017). The following indicators dem- onstrated pre-post factor convergence and acceptable fit in a confirmatory factor analysis model.

Self-Report of Child Adjustment

The child report scales included the school problems compos- ite T score from the Behavioral Assessment Scale for Children (BASC-2; Reynolds and Kamphaus 2004) and the loneliness and social dissatisfaction scale (Asher and Wheeler 1985). The BASC-2 has established construct validity, and conver- gent validity with other scales such as the Child Behavior Checklist (Achenbach and Rescorla 2001), good internal con- sistency, and test-retest reliability (Reynolds and Kamphaus 2004). Self-report data were collected using age- and gender- normed instruments for children aged 5–7, 8–11, and 12–18. Symptom items were rated on a Likert-type scale from 1 (never) to 4 (almost always). Internal consistency across age groups, time, and subscales was good. The school problems composite included two BASC scales for younger children: the poor attitudes toward school and poor attitudes toward teachers, as well as the sensation-seeking scale score for ado- lescents. Negative attitudes toward school was a seven-item scale (α range = .79–.86), negative attitudes toward teachers was a nine-item scale (α range = .75–.77), and sensation seeking was a nine-item scale (α range = .73–.79).

The second child report indicator assessed internalizing symptomsmeasured with the loneliness and social dissatisfac- tion scale (Asher and Wheeler 1985), a 24-item scale of lone- liness and dissatisfaction with peer relations rated on a 3-point scale. Items were scored to indicate increasing loneliness. Sample items were have nobody to talk to in class, lonely in

school, don’t have any friends in school, and feel left out (α range = .72–.87).

Adult Report of Child Adjustment

Parent and teacher reports of the adaptive skills compositeTscore from the Behavioral Assessment Scale for Children (BASC-2; Reynolds and Kamphaus 2004) were used to assess behavioral problems in children (ages 6 to 11) and adolescents (ages 12 to 21). Parents and teachers rated BASC items on a 4-point scale ranging from 0 (never) to 3 (almost always). The adaptive skills composite demonstrated good internal consistency across re- porters, age groups, and time (α range = .78–.94). The teacher- reported adaptive skills composite assesses functional communi- cation, adaptability, social skills, leadership, and study skills and is composed of 39 items in the child and adolescent version. The parent report adaptive skill composite included four subscales: adaptability, social skills, activities of daily living, and functional communication. Parent scores were the average of available mother and father reports. Analyses controlled for marital status and years married.

Covariates

Impact of the ITT effect was coded 1 for assignment to the ADAPT condition and 0 for controls. Deployments was the combined number of months the military parent(s) were de- ployed. Married was a dichotomous indicator representing two- parent versus single-parent status coded 0 for single and 1 for married. Years married was the average of husband and wife reports of years married to current spouse. Gender was coded 1 for girl and 0 for boy.

Analytic Strategy

Results were examined using intent-to-treat (ITT) analysis. The main effectiveness hypotheses and indirect effects analy- ses were tested with structural equation path modeling (SEM) using Mplus 7.4 (Muthén and Muthén 1998–2015). SEM is a latent variable regression technique that simultaneously com- bines factor analyses with path analyses under the assump- tions of multivariate normality. Model fit was evaluated using recommended fit indices (Byrne 2013; McDonald and Ho 2002) of a chi-square minimization p value above .05, a com- parative fit index (CFI) above .95, a chi-square ratio (χ2/df) less than 2.0, and a root mean square error of approximation (RMSEA) below .08.

Data for observed parenting practices and parent, teacher, and child reports were collected at baseline/pre-intervention at Time 1 (T1) and post intervention T3, 12 months later. For the two-wave data, SEM models were specified as auto-

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regressive change models, a pre-post intervention analysis of covariance approach. We specified across time error covari- ances for pre-post indicators as recommended for repeated measures and correlated error (Byrne 2013).

Analysis of Indirect Effects on Child Adjustment Outcomes

Effectiveness hypotheses were tested using an indirect effects modeling approach to examine the impact of the intervention on child adjustment outcomes via change in parenting (Shrout and Bolger 2002). To estimate indirect effects, bias-corrected bootstrapped standard errors and confidence intervals are rec- ommended to address the asymptotic distribution of the mul- tiplicative indirect term. We also examined direct effects in order to explore whether indirect effects might be mediated (MacKinnon 2008). Mediation requires a direct intervention effect on the distal child adjustment outcome as well as on the proximal target of the intervention, parenting practices. Change in parenting is required to be associated with change in child adjustment, and also required to render the direct effect on child adjustment nonsignificant. Finally, since the ADAPTstudy was a preventive intervention, we also explored whether there were baseline by treatment (i.e., moderated) intervention effects.

Missing Data and Attrition Analyses

Data were modeled using full-information maximum likeli- hood (FIML), which uses all available information from the observed data in handling missing data. FIML estimates are computed by maximizing the likelihood of a missing value based on observed values in the data. Compared to mean- imputation, list-wise, or pair-wise models, FIML provides more statistically reliable standard errors. Individuals who have baseline data only and no follow-up data contribute noth- ing to the likelihood of estimates and are effectively excluded from change analyses.

CACE Complier Analyses

Finally, we specified complier average causal effects analyses (CACE) where treatment effects are examined taking into ac- count intervention compliance observed in the intervention group and estimated in controls. CACE mixture modeling matches intervention Bnoncompliers^ (observed class) with the control Bnoncompliers^ (not observed) according to their measured characteristics. Once control noncompliers are iden- tified, a control complier class can be identified. Using this subgroup from the control condition, unbiased intervention impact effects can be calculated (Jo 2002; Little and Yau 1998). Compliance status was defined as either parent engag- ing in seven or more treatment sessions. Among intervention

mothers, 54% attended seven or more sessions, while 44% of fathers did so.

Results

Hypothesis 1: Proximal Impact

Means and standard deviations for the pre-post indicator scale scores used in the SEMeffectiveness evaluation are presented in Table1bysourceofdatacollectionandgroupcondition.Thefirst step of the primary effectiveness evaluation tested hypothesis 1 focusing on the impact of the ADAPT intervention on change in observed parenting practices. Findings supported hypothesis 1. Results are presented in Fig. 2 in the form of standardi

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