Effectiveness of a Psychoeducational Parenting Group on Child, Parent and Family Behavior: A Pilot Study in a Family Practice Clinic with an Underserved Population

Over the last several decades the medical and mental health fields have worked to create collaborative relationships in order to provide integrated (mind-body) care for adults (Frank, McDaniel, Bray, & Heldring, 2003; Gatchel & Oordt, 2003; Haas, 2004; McDaniel, Hepworth & Doherty, 1992; Moss, McGrady, Davies & Wickramasekera, 2003). Results have suggested that adult integrated primary care: (1) increases communication between doctor and patient, (2) increases management of behavioral health symptoms, (3) increases management of chronic conditions such as diabetes and asthma, and (4) reduces overall visit frequency (Gallo, et al., 2004; Law & Crane, 2000; Law, Crane & Berge, 2003; Mendenhall & Berge, in press; Moss, et. al., 2003). These promising results have suggested the need to look at providing integrated care for children in primary care, but there has been a lack of research in this area outside of specialty care clinics (Bradley, et. al., 1999; Cunningham, et.al., 2008; Kitchiner & Bundred, 1996). Thus, the main purpose of this paper is to report results of a pilot study testing initial feasibility of a parenting psychoeducational group targeting child behavioral problems within a primary care clinic in order to improve integrated care options for children and their families. Parenting/Relational Issues and Primary Care There is a need for more relational interventions housed within primary care clinics. Research on mental health problems in primary care indicate that over 65% of patients who report mental health problems (e.g. depression, anxiety) to primary care doctors report “relationship problems” as one of the main causes of the mental health problem (Kroenke, & Mangelsdorff; 1989). Based on experiential evidence within the clinic where this study was conducted, MD residents and faculty report that over half of the parents that present for primary care visits identify that one of the main reasons for their visit is “problems with their kids,” or “stress because of their family.” Thus, parenting psychoeducational groups may offer a resource for the primary care doctor, the patient, and the child. Psychoeducational groups are not new to primary care clinics, many chronic health conditions (e.g. diabetes, asthma, chronic pain) are being treated with a combination of individual primary care visits and “group visits” (Gatchel & Oordt, 2003). For instance, in treating diabetes many primary care clinics offer group visits to patients where they learn about basic diabetes education, psychosocial symptoms that may co-occur with diabetes, specific management techniques (e.g. lifestyle changes), and receive social support. Research has identified that these types of groups have been effective in decreasing isolation, increasing management behaviors, and in some cases reducing hemoglobin A1c levels in diabetic patients (Crane & Marshall, 2006; Gatchel & Oordt, 2003; Mendenhall & Berge, in press; Moss, et.al., 2003). Similarly, parenting psychoeducational groups could be utilized to manage chronic relational problems between children and their parents as an outlet for integrated care within primary care clinics. Parent Management Training A wide variety of research studies over more than twenty years have shown that children’s behavior reliably improves as a result of training the parents to behaviorally manage and communicate more effectively with their children. Programs have included therapists with individual couples or single parents, therapists working conjointly with parents and the child, and psychoeducational group training programs (O’Dell, 1985). Moreover, there is an abundant developmental literature defining parental styles and their positive or negative outcomes on children. Each parent management training approach typically has overlapping elements, as well as, specific constructs unique to their individual approach. Reviews of the literature (Hart, Newell, & Olsen, 2003; Ladd & Pettit, 2002) identify three major overlapping dimensions across parent management approaches that link parenting practices to confident and competent children. Earlier studies referred to these dimensions as warmth, expectation, and respect for individuality (Baumrind, 1967, 1971; Damon, 1988); later definitions utilized the terms connection, regulation, and autonomy (Hart et al., 2003). The present study uses a parenting curriculum that focuses on these three dimensions of parenting and calls them Love, Limits and Latitude (LLL). Underserved Populations and Primary Care Because underserved populations are typically difficult to reach and have high drop-out rates in research, they are an important population to learn about (Fiscella & Holt, 2007; Miranda, et.al., 2004; Reschovsky, & O’Malley, 2008). Patients who are mostly minority, with low income and low education levels are commonly found within inner city primary care clinics (Fiscella & Holt, 2007; Miranda, Schoenbaum, Sherbourne, Duan, & Wells, 2004; Reschovsky, & O’Malley, 2008). Providing parenting psychoeducational groups to underserved populations within primary care clinics provides a natural avenue to access and engage a population that is typically hard to reach. Using primary care clinics as a research base may allow for: (a) underserved populations to feel less stigmatized because they are comfortable in the primary care setting, (b) increased convenience for research involvement, (c) potential increase in the adherence to research protocol or reduced drop-out rates. Research Questions In order to establish initial feasibility of a parenting psychoeducational program in an underserved population in Minneapolis, a pilot study was conducted to address three main research questions. These questions were primarily chosen based on the needs of the families in the clinic, which were most commonly communicated as “complaints” relayed to their primary care doctors at medical visits (i.e. family functioning problems, child misbehavior and couple relationships problems). The following research questions were addressed in this study: (a) Does self-reported family functioning increase after participation in the LLL parent psychoeducational group? (b) Does self-reported child misbehavior decrease after participation in the LLL parent psychoeducational group? and (c) Does self-reported couple relationship distress decrease after participation in the LLL parent psychoeducational group?