Parental training in groups: a brief health promotion program

Abstract Objective To propose a brief parenting program offered in the context of health promotion and evaluate the immediate results relating to use of appropriate parenting practices and quality of parent-child interaction. Methods Forty-five parents of school-age children from two non-governmental institutions located in a medium-sized city in the state of Sao Paulo participated in the study. The following assessment tools were used in the pre and post-tests: the Child Behavior Checklist (CBCL), Quality of Family Interaction Scales (EQIFs), and the Brazilian Economic Classification Criteria (CCEB). Only scores of parents who attended 75% of the program were included in the analysis (25 participants). Results Most of the participants who completed the program were grouped in socioeconomic levels B and C (72%) and the complaints reported in the pre-test centered on disobedience and stubbornness (29.6%, each). Regarding parents’ perceptions of their educational practices and interaction with the children, improvements were detected in several of the aspects measured: affective relationship, involvement, model, communication, rules and monitoring, and children’s feelings, besides reduction in use of physical punishment and negative marital atmosphere (p < 0.03). Reductions were detected in aggressive behavior (p = 0.02) and externalizing problems (p = 0.04). Conclusion Despite the small sample and application in a specific community, this quick and affordable intervention seems to have yielded improvements in parent’s monitoring and their affective relationships with their children, in addition to reductions in punishments and children’s aggressive behavior, contributing to better parent-child interaction in the community.


Introduction
The family is the fundamental unit of society responsible for educating and socializing children. It is through interaction with their parents that children begin to establish emotional bonds, create their first cognitive and relational schemes, come into contact with behavioral and language rules and are also gradually introduced to a larger social environment. [1][2][3] Several factors can hinder child development and contribute to the emergence of psychopathologies, including deficits in parental skill repertoire, inconsistent discipline, lack of monitoring, and excessive punishment.
Some other parent-specific problems can also have effects, such as marital conflicts, difficult parental mood, parental emotional adjustment problems, and maternal depression and anxiety. 4,5 Despite the importance of parents in child development, they rarely receive guidance on how to educate their children. Their parenting style is usually based on their experience and trial and error. 6,7 It has been observed that the prevalence of infant social-emotional and behavioral problems is increasing, especially at school age. 8 This situation requires rapid and effective strategies to identify problems and initiate effective treatments, which are more economically viable than late interventions. [1][2][3][4][5][6][7][8][9] A total of 13-20% of children living in the United States experience problems with cognitive, social, and emotional development and receive treatment for clinically significant disorders late. A global epidemiological survey showed that symptoms only improved without any specific treatment in half of children who exhibited significant problems in pre-school and early school ages.
As time passed and responsibilities increase, others tended to face more serious problems, such as truancy and difficulties with family and with peers, in addition to increased risk of substance abuse in adolescence and adulthood, with a considerable impact on their families and on society, as well as higher treatment costs, which are not affordable for all families. 9 In Brazil, an epidemiological survey 10 estimated rates of child and adolescent mental disorders at around 10-20%. Among problems diagnosed, the highest prevalence rate was 4.4-7% for externalizing defiant disorder and conduct disorder. It has been hypothesized that disorders at subclinical levels could significantly increase these percentages. 11,12 Due to the early influence of parents on child development and socialization, some interventions have been designed to help parents develop optimum strategies for coping with their children's emotional behavior. Parental training is the most common behavioral intervention with efficacy for treatment and prevention of various psychological problems in children. [13][14][15] The results suggest improvement in children's behavior, acquisition of social skills, and increased treatment effectiveness in cases with concomitant interventions.
There are several evidence-based parental training programs available in the literature. 16,17 Most of these programs target families that need to manage problems with children's behavior. In recent decades, some support has been given to preventive family interventions as well as programs aimed at promoting family health, focusing on better interactions between parents and children. 1 These health promotion programs are also intended to prevent emotional and behavioral problems in children.
Their application has yielded positive results in educational practices and family interaction. [18][19][20]  In an attempt to include families with lower socioeconomic levels 24  The aim of this study is to report on the implementation and results of the preliminary program for parents of

Method Participants
The study sample comprised 25 parents of schoolage children who had at least one child aged between The study protocol was approved by the research ethics committee of the university (USP). The samples were selected by convenience.

Instruments
In the pre-test, the main difficulties parents faced concerning their child's upbringing were recorded using a short form. Families' socioeconomic status (SES) was measured using the Brazilian Economic Classification Criterion (CCEB). 28  The intervention schedule is shown in Table 1.
The program consists of six sessions focusing on positive parental educational practices and social skills targeting better parent-child interaction. 27 Although the sessions were structured, there was flexibility for some changes to fit the needs and characteristics of the participants.

Characterization of participants' families and initial complaints
In terms of their family structure characteristics, about their children being "rude," "having no limits," and being "agitated" and "lazy," but these complaints were not mentioned during the pre-test.

Parental educational practices and quality of family interaction
These results are shown in Table 2.

Parents' perceptions of behavioral problems
The six groups were treated together since the Kruskal-Wallis did not detect any differences. The Wilcoxon test (W) was used to compare CBCL scores before and after the intervention.
The results are shown in Table 3. Pre-test and post-test severities were analyzed for the following variables: social competence, internalizing problems, and externalizing problems. The frequencies of each severity classification are shown in Table 4.

Quality in family interaction and educational practices
The post-intervention results were highly significant It is important to note that the participants did not seek the intervention because of clinical complaints, since this was a community sample, and so the initial intervention scores were expected to be reasonable Reduced physical punishment and negative marital atmosphere scores were also significant. Despite using different measurement instruments, other parental training programs have also observed reduced physical punishment, a topic that has been the focus in all programs available in the national and international literature. 23,33 One of the programs that used the same measurement instrument obtained similar behavioral changes, including greater participation and involvement, clarity and consistency in setting rules, use of praise and less use of physical punishment. 23 With similar goals, both programs obtained great results regarding the behavioral measures; the main differences between them were the shorter duration of the PROPAIS II and the cognitive-behavioral approach.

Children's behavior
The pre-test CBCL scores showed various behavioral problems and more children were classified based on their clinical conditions than on normality. Since this was a community sample, this characterization of the children's behavior was a major concern, considering that the scores were similar to those for clinical samples of children undergoing psychological care. 41 These indices corroborate the need for interventions that can identify problems early and help families to cope with them.
After application of PROPAIS II, we observed lower scores for behavioral problems and changes from the clinical to non-clinical category in three variables: social, internalizing, and externalizing problems. There was also improvement in some behavioral problems allocated to the category externalizing problems as a whole, particularly aggressive behavior. The children's behavior was not observed directly. Studies based on parents' perceptions may indicate that children showed improvement in a certain behavior previously considered a problem, but also that parents have begun to interpret their children's behavior differently. 33 These hypotheses are not mutually exclusive. We emphasize that, regardless which of explanation is more likely, in programs that use this type of evaluation, the effect of changes on the daily lives of families tends to be positive: either in terms of lower incidence of child problems or in terms of flexibility of parental perception about the problems and their causes. Since PROPAIS II is a health promotion program, these results are consistent with its goals, which are to promote health and well-being in those communities that, in many cases, do not have access to many interventions.
No changes were detected in children's internalizing behaviors after the PROPAIS II or were described in studies of other preventive parental training programs.
We hypothesize that the internalizing behavioral problems were not only less prevalent in the population, but were also difficult for parents and teachers to detect. Studies have shown that parental training is the best modality for treating disruptive disorders in children. As much as PROPAIS II aims to deal with different complaints,

Final considerations
The results of the initial implementation of PROPAIS II showed significant improvements, mainly related to parental educational practices and parentchild interaction. The greatest difficulty in the study was initial adherence to the program. We tried to directly understand the reasons for loss of interest by the participants who were invited to come to the meeting, but attempts to discover reasons via telephone failed.
The difficulty with attendance may be related to the fact that participants were not necessarily looking for treatment. In Brazil, it is not very common that parents are involved in volunteering activities in schools and other children's institutions. Low parental involvement may be due to excessive work, lack of time, and a shortage of events that include families in institutions, making it difficult for them to appropriate a space that they only recognize as a place for children. Such assumptions may explain the difficulties encountered in this study and in similar programs.
It is important to continue to invest in strategies to maintain participants' attendance, such as publicity on media, direct contact with the institutions, opportunities