Family Thriving Program
Protocol Outline
This outline provides guidelines and examples to be employed in implementing the methods used in the Family Thriving Program (see References for citations). The program represents methods that can be added to existing home visitation programs (rather than as a free-standing program employed to replace other programs). Within the Family Thriving Program, home visitors were initially trained in methods used within Healthy Start programs. These methods involve parent education, assistance in establishing connections with relevant community agencies, and establishing potential sources of social support).
In implementing the Family Thriving Program, the basic method involved assistance to parents in the cognitive and motivational re-framing of commonly-occurring caregiving challenges. That is, parents were assisted in rethinking the causes of caregiving challenges, and in becoming their own information seekers and problem solvers. In evaluating the effectiveness of the cognitive-motivational condition, the ultimate outcomes (e.g., reduced child maltreatment), were compared the outcomes of a home visitation condition focused on direct assistance to parents. In the direct assistance condition, better ways of interpreting caregiving problems were suggested to parents, along with the direct provision of information regarding community resources and developmental issues, along with recommendations regarding potential ways to solve existing problems.
The difference between conditions focused on facilitation of the parents’ own efforts in resolving caregiving and other family issues, in contrast with the provision of direct guidance in resolving caregiving and other family issues. The effectiveness of the program was also compared with the outcomes of families referred to existing community agencies.
The population employed in the initial implementation of the program involved referrals from physicians and public health agencies prior to the birth of a child. Referrals were based on the risk factors present in the family that predict the possibility of future maltreatment (as described in Bugental et al., 2002).
TRAINING
Part 1 Intervention Protocol
Begin training home visitors by reviewing this document, followed by role playing and viewing training videos.
Part 2 Timeline for Interventions
Review this guideline with home visitors
Part 3 Making contacts with families
Once a referral has been made, a home visitor is assigned to the family. This home visitor contacts the family by phone to set up an initial visit in the home. At that visit, the home visitor will explain the program and ask the family if they are interested in participating. If the family agrees to participate, a Consent to Participate form is signed and as much of the Client Information form is completed as possible at this time. The home visitor then schedules the next visit (initial assessment).
Part 4 Timeline Checklist (form)
Home visitors can keep one of these in each client’s chart and update as appropriate.
Part 5 Client Information (form)
Home visitors can take this with them on the initial visit and update this data in client’s chart as additional information becomes available
Part 6 Progress and Fidelity Notes for Interventions (form)
Notes are recorded at every home visit recording
Intervention Protocol
Family Thriving Program
Information for Home Visitors
All families will participate in a standard home visitation program (e.g., Health Families Program), altered to make use of a cognitive-motivational approach that involves both the reframing of problems and initiation of resolution strategies. This primarily involves the introduction of a brief conversation at the start of each visit. This conversation involves figuring out the reasons for, and potential ways of resolving a recent caregiving problem. However, if other problems are identified later during the visit, the same approach is employed.
WHAT ARE THE GOALS OF PROBLEM-SOLVING DISCUSSIONS?
Problem-solving discussions are designed to empower parents to manage the everyday events of caregiving. The first goal is to assist parents in identifying recent caregiving challenges they have experienced, and then considering the possible causes of those problems. After identifying a recent problem (either at the start of the visit, or as the problem is mentioned during the course of the visit), the parent is asked for their view of the reasons for the problem. They are encouraged to think of a variety of reasons -- in search of a potential reason that does not involve blame (of self or others) and that is amenable to potential resolution efforts. As soon as the parent identifies a “resolvable” type of cause, the home visitors shifts the topic to consideration of potential resolutions.
The second goal is to assist parents in generating possible solutions for “difficult” caregiving experiences. By coming up with their own ideas—and then testing them out—parents gain experience in an effective problem-solving process. That is, they gain practice in coming up with ideas about the child’s feelings and motives, and acquire a sense of mastery and competence as a result of reaching resolutions. After a potential problem is decided, the parent implements and then reports back during future home visits regarding its success (or lack of success). In many cases, the potential resolution requires “fine-tuning.” In other cases, a new approach will be considered and attempted. Parents are reminded at future visits of their own resolutions when a similar problem arises in the future.
As a means of accomplishing either goal, parents are assisted in “cue detection” or “baby reading.” That is, they are assisted in finding a way of figuring out alternative causes of problems (e.g., shifting away from assuming that a fussy child is being stubborn, to considering all the possible factors that might make a child fussy and what they might look for in direct observation). In addition, they are assisted in considering how they would know if a potential problem-solving resolution is successful (e.g., does the child now show more instances of positive behavior and what are the range of responses that a child could show that indeed reflect a positive state). In short, they are assisted in ways of observing their children and figuring out what the child may be experiencing. This might involve a search for the cues that the child is interested in interacting with others, or that he or she is interested in exploring the physical world around them (by sight, touch, or movement). At other times, this will involve cues that a child does not want to interact with others or explore the world. At still other times, this might involve cues that a child is distressed, for example, that he or she is fearful or wary, experiencing pain or discomfort, frustrated, overwhelmed, hungry, tired, or bored. This information will then be used in helping parents to generate hypotheses about their children’s motives, and why at times children themselves and the caregiving experience is temporarily “difficult” and what kind of changes might be found that are indicative of a reduced problem.
We have found that this cognitive-motivational approach buffers against parental feelings of helplessness or hopelessness in coping with early relationships with a newborn child. “Potential problems” are turned into “positive possibilities.” When this happens, we have found reductions in mothers’ depressive symptoms (as measured by the Beck Depression Inventory), and long-term changes in the tactics they use in managing conflict in their family interactions (as measured by reduced use of physically harsh tactics or emotionally avoidant tactics).
HOW WILL YOU PREPARE TO CONDUCT PROBLEM-SOLVING DISCUSSIONS?
In preparing to conduct problem-solving discussions with parents, you will start by role playing such interactions with your supervisor and other trainees. You will take turns playing the part of a parent or the home visitor. You will start by making a list of the kinds of some of the positive and negative experiences one might have with a young infant, e.g.:
The infant looks away or turns away from the caregiver when spoken to.
The infant produces a sudden loud cry and turns rigid when his diaper or clothes are being changed.
The infant cries and cries, and nothing seems to help.
The infant pulls away or stiffens when picked up.
The person playing home visitor will start by asking, “So how has everything been since I visited last?” The person playing the parent will then come up with a “problem”. The home visitor then redirects that problem to focus on cues from the child (e.g., if a mother says, “Johnny didn’t seem to want to be picked up”), the home visitor will follow this up with questions about the cues used in deciding what Johnny wanted. The home visitor also asks for times when Johnny seemed to want to be held, and what the cues were in deciding this.
If the parent provides no accounts of negative interactions, the home visitor will solicit such observations with the question, “Think of a time when things were not going particularly well with the baby. What was happening?” (if it does not come up, the home visitor will ask what the baby was doing and what they appeared to be feeling during this time).
If the parent provides no accounts of positive interaction, the home visitor will solicit such observations with the question, “Think of a time when things were going well with the baby. What was happening?” (if it does not come up, the home visitor will ask what the baby was doing and what they appeared to be feeling during this time).
The home visitor will then restate parents’ accounts of caregiving events to make a connection between what the infant did and what conclusion parents drew about the child’s motives/feelings. For example, if the parent states that they knew the child was mad at them because the child frowned (or looked away), the home visitor would ask them what other reasons there might be for a child to frown (or look away). If parents have trouble coming up with something, the home visitor asks them if they are always mad if they frown or look away during an interaction (and asks for other reasons they might have for frowning or looking away). Whenever a parent comes up with a blame-oriented explanation, the home visitor will pursue other possible causes of children’s negative reactions until a “benign” explanation is offered.
Next, the home visitor will ask, “If you wanted just one thing to be different – either something good to happen, or something bad to stop – what would it be?” After the parent comes up with something, the home visitor follows through with a question asking the parent to think about what they might do to reach this goal. For example, If they say, “Just to get the baby to sleep through the night”, the home visitor follows up with the question, “What are some of the things you have heard about or thought about that might help?” After the parent comes up with a list, the home visitor asks them what they would like to try in the next week or so. They are also encouraged to observe other changes, e.g., how quickly the child falls asleep, what happened before they fell asleep. She then winds up by saying that the parent can report back next time as to how it all worked out.
WHAT WILL YOU ACTUALLY DO?
Problem-solving discussion
For all your visits to the family (after your first introductory visit), you should
start with the problem-solving discussion. This discussion should follow the same format shown above. That is, first focus on what has been going on (positive and negative); in doing so, always be sure to get some information from them on what child cues they use to decide what a child wants or doesn’t want. Second, have them set a goal for the next time period, and decide what means they would like to try for reaching that goal.
On return visits, always begin with a discussion of how their problem-solving efforts worked out (be sure to check your notes to see what it was they were going to try). If they feel they are making headway on the issue, this should be recognized, e.g., “It sounds like you and Johnny are getting there.” Then move on to questions regarding other issues that have come up that need attention. If they feel they have not been making progress, go back to a discussion of cues from the child, and what those cues might mean; then wind up with a discussion as to how they would like to shift to try something different (or, if they prefer, try a little longer with the approach they are using).
Sample Scenario (this example is similar to the one provided on the training tape video shown on Bugental’s web page. It only focuses on the most basic aspects and does not explore the “cue detection” issues)
Home visitor: So how has everything been with you and Johnny this last week (or time period since last visit)?
Mother: It’s been tough. He just cries and cries during the night and nothing I do seems to help. I am just so tired.
HV: What do think is going on? Why do you think he cries so much?
MO: I don’t know. He just cries. I don’t know why.
HV: What do you try doing?
MO: Well, I feed him.
HV: So you think he cries because he’s hungry. Does it work?
MO: Sometimes he cries right away after I feed him. I try to burp him but that doesn’t help.