Promotion of Parental Responsivity: Implications for Population-Level Implementation and Impact

Parental responsivity, including back and forth interactions aligned with children’s social and verbal cues, improves children’s social-emotional, cognitive, and language development^1,2  and is even associated with long-term indicators of health and well-being.^3–5  Much work is underway to develop and test interventions designed to promote caregiver responsivity. In the current issue of Pediatrics, Sokolovic et al⁶  performed a meta-analysis of programs targeting parent responsivity to identify the impact of programs and the program characteristics associated with success. The analysis included 120 studies of randomized trials and found that, although these programs were diverse in how they operated, they were effective across a wide range of populations.

The authors have made a major contribution to the literature in finding that such programs generally work and have effect sizes (ESs) at a level large enough to inform policies supporting implementation. These findings indicate a clinically meaningful impact that was observed across many family characteristics, platforms, and strategies especially relevant to pediatric practice, including for low-income families (ES 0.55), home visiting (ES 0.51), both group (ES 0.57) and individual (ES 0.60) format, use of didactics (ES 0.58) and video feedback (ES 0.61), and delivery by professionals, including pediatricians (ES 0.53). Most relevant to early childhood stakeholders, the findings provide broad support for interventions focused on enhancing responsive caregiving and strongly suggest the need for scaling of diverse interventions across platforms.

In this review, the authors also focused on determining which components of programs seemed to add value. In particular, increased impact was found for programs that provided didactic teaching, opportunities for parents to observe models of responsive behavior and practice responsive skills, receipt of feedback, and opportunity for self-reflection. At the same time, the authors suggested that many other factors did not necessarily result in increased impact. These factors include delivery through home visiting, use of video feedback, and whether programs took place individually or in groups, for which ESs were comparable, regardless of whether these platforms or strategies were used. The authors further suggested that pediatricians may be less able to provide targeted guidance on parental responsivity because they address “multiple aspects of child and family well-being.”⁶ 

However, there are threats to generalizability that lead to caution in the interpretation of analyses examining use of specific platforms, strategies, and program providers. First, the majority of the studies did not include many families from racial and ethnic minority groups (74% had >50% white participants or did not report race), and nearly two-thirds (63%) of families participating in those studies were not low income. As a result, findings are not generalizable for populations most likely to benefit from many of the strategies under study. Second, analyses comparing average effects for program characteristics (eg, video recording, home visiting) across programs using differing strategies and targeting populations with different types of risks (ie, prevention of disparities related to income and race or ethnicity versus support for parents of children with neurodevelopmental disorders or with already present challenges related to discipline in response to perceived behavior problems) are not straightforward to interpret. For example, comparison of the Parents as Teachers (PAT) model,⁷  delivered using a didactic approach by a nonclinician through home visiting in a population at risk for disparities, with the Preschool Autism Communication Trial (PACT)⁸  curriculum, which also uses a didactic approach but is delivered by speech and language therapists trained in health care for families with children with autism spectrum disorder, would not provide useful information about the added value of home visiting. As such, estimation of added value of program characteristics would likely require other analytic or design approaches that may not have been possible here (eg, comparison of otherwise similar subgroups) or experimental designs. Third, even if there were not these limitations, it is not clear that the added-value questions addressed in this meta-analysis are especially relevant. For example, the rationale for delivering interventions in a specific platform (eg, home visiting or pediatric well-child care) is likely less related to whether that platform is associated with greater impacts and more related to the potential for successful program delivery in the context of community and family needs.^9–11 

In short, we believe that the findings as reported in this study support implementation and study of a wide variety of programs that seek to reduce disparities through promotion of parent responsivity, both within pediatric primary care (both by pediatricians and colocated staff)⁹  and through home visiting.¹⁰  Although we agree that careful consideration of cost is critical, the large existing research base documenting both engagement and impact in populations at risk for disparities underscores the need for such programs, in alignment with American Academy of Pediatrics policies related to child poverty,¹²  racism¹³  and toxic stress.¹⁴  In particular, clear and consistent impacts have been shown for programs in pediatric primary care targeting early literacy (Reach Out and Read),^15,16  programs using video feedback (Video Interaction Project)¹⁷  and broadly supporting parenting (HealthySteps),¹⁸  programs using home visiting (eg, Nurse Family Partnership, Family Check Up),^19,20  and programs integrated across health care and home (eg, Smart Beginnings).^21,22  Finally, population-level reduction of disparities will require funding for both individual programs and integrated community-level initiatives (eg, The Pittsburgh Study, City’s First Readers, Together Growing Strong, Get Ready Guilford, 3-2-1 IMPACT, etc),^11,23–28  beginning in early childhood to support lifelong resilience.

ES

effect size