Family Check-Up

About the program

Family Check-Up is a brief, motivational intervention that supports parents’ existing strengths, as well as their engagement in additional parent training services when needed. The intervention is based on an ecological assessment of the child and the family. Model-driven, ecological intervention strategies that explicitly target parenting practices have been shown to lead to long-term positive outcomes in children and adolescents. The Family Check-Up assessment captures a comprehensive picture of the various direct and indirect factors that could impose constraints as well as offer windows of intervention in the family system.

A feedback session is tailored to parents’ goals and strengths derived from the assessment. Family Check-Up is delivered over three sessions. Therapists adapt and tailor any additional family interventions by providing a flexible menu of change strategies to choose from to achieve their goals.

Family Check-Up provides a link between home-based preventive intervention services and treatment programs available to parents in other community and service settings. The program provides one annual contact with families at minimum, in order to promote skill maintenance and support adaptive changes over the course of key developmental transitions for the child and family.

Who does it work for?

This program is designed for low-income families and their toddlers at risk for conduct problems.

An RCT was conducted in the USA with a sample of 731 families (Lunkenheimer et al. 2008). Participants were recruited from Women, Infants, and Children (WIC) Nutrition Programs in the metropolitan areas of Pittsburgh, Pennsylvania and Eugene, Oregon; and within and outside the city of Charlottesville, Virginia. Researchers approached families at WIC sites and invited them to participate if they had a child aged between 2 years and 2 years 11 months. Families were screened to ensure  they met the study criteria, including presence of socioeconomic, family, or child risk factors for future behaviour problems. Inclusion risk criteria were grouped by the following three domains:

• Child behaviour problems (e.g., conduct problems, high-conflict relationships with adults)
• Family problems (e.g., maternal depression, daily parenting challenges, substance use problems, teen parent status)
• Sociodemographic risk (e.g., low education achievement and low family income as defined by the WIC criterion)

Children in the sample (49% female, 51% male) had a mean age of 29.9 months at the time of assessment at the age of 2. Across sites, the children were reported to belong to the following racial groups: 50.1% European American, 27.9% African American, 13.1% biracial, and 8.9% other races (e.g., Asian American, Native American, Native Hawaiian). At the time of the first assessment, 36.2% of participating parents were married, 31.6% were single, 19.8% were living together, 7.7% were separated, 4% were divorced, and 0.7% were widowed. Of the families assigned to the intervention condition, 77.9% participated in the Family Check-Up and feedback sessions at child age 2, and 65.4% participated at child age 3.

The review did not identify any evidence that the program has been evaluated in Australia or with First Nations communities.

What outcomes does it contribute to?

Positive outcomes:

Self-regulation, Positive behaviour support: Family Check-Up has shown positive effects for families more likely to have low participation because of their children’s risk of behavioural problems. Lunkenheimer and colleagues (2008) found that the program contributes to an increase in positive behaviour support. Furthermore, the study found that positive parenting and children’s various school readiness skills interact over time during the early childhood years.

The effect size of Family Check-Up on positive parenting practices was small, and the indirect intervention effects on child school readiness were modest, however, these effects remain statistically meaningful due to high stability in parenting and child factors over time.

No effect:

Language development: The program had no effect on children’s language development (Lunkenheimer et al. 2008).

Negative outcomes:

None.

Is the program effective?

Overall, the program had a mixed effect on client outcomes.

How strong is the evidence?

Mixed research evidence (with no adverse effects):

• At least one high-quality RCT/QED study reports statistically significant positive effects for at least one outcome, AND
• An equal number or more RCT/QED studies of similar size and quality show no observed effects than show statistically significant positive effects, AND
• No RCT/QED studies show statistically significant adverse effects

How is it implemented?

Parents or caregivers who agreed to participate in the study were scheduled for a two and a half hour home visit. The assessment began by introducing children to an assortment of age-appropriate toys and having them play for 15 minutes while the parents completed questionnaires.

After this free play an undergraduate videographer approached the family, and each primary caregiver and child participated in a clean-up task (5 minutes) followed by a delay of gratification task (5 minutes), four teaching tasks (3 minutes each, with the last task completed by the alternate caregiver and child), a second free play (4 minutes), a second clean-up task (4 minutes), the presentation of two inhibition-inducing toys (2 minutes each), and a meal preparation and lunch task (20 minutes). The average cumulative length of the parent–child interaction tasks was 1 hour (60.71 minutes) at age 3 and slightly more than 1 hr (72.13 minutes) at age 4.

This home visit assessment protocol was repeated at ages 3 and 4 for both the control and intervention groups. The randomisation sequence was computer generated by a member of the staff who was not involved with recruitment. Randomisation was balanced by gender to ensure an equal number of boys and girls in the control and intervention subsamples. To ensure a double-blind research design, the examiner opened a sealed envelope to reveal the family’s group assignment only after the assessment was completed and then shared this information with the family. Examiners carrying out follow-up assessments were not informed of the family’s randomly assigned condition.

Families randomly assigned to the intervention condition were then scheduled to meet with a parent consultant for two or more sessions, depending on the family’s preference. Typically, the three meetings include an initial contact session, an assessment session, and a feedback session. However, to optimise the internal validity of the study (i.e., to prevent differential dropout for intervention and control conditions), the assessments were completed before random assignment results were known to either the research staff or the family.

The initial meeting was an assessment conducted with research staff, during which the family engaged in a variety of video-recorded in-home tasks of parent–child interaction and caregivers completed several questionnaires about their own, their child’s, and their family’s functioning. During this home assessment, staff also completed ratings of parent involvement and supervision. The second session was a “get to know you” meeting during which the parent consultant explored parent concerns, focusing on family issues that were currently the most critical to the child’s wellbeing. The third meeting involved a feedback session during which the parent consultant used motivational interviewing strategies to summarise the results of the assessment.

An essential objective of the feedback session was to explore the parent’s willingness to change problematic parenting practices, to support existing parenting strengths, and to identify services appropriate to the family’s needs. The parent consultant offered the parent the choice to engage in follow-up sessions that were focused on parenting practices, other family management issues (e.g., co-parenting), and contextual issues (e.g., childcare resources, marital adjustment, housing, and vocational training). Although parent consultants offered appropriate community service referrals according to the particular needs of the family, follow-up sessions most often consisted of ongoing in-person or phone sessions with the parent consultant.

Parent consultants were initially trained for 2.5-3 months in a combination of strategies that included didactic instruction, role play, and ongoing video-recorded supervision of intervention activity. Certified lead parent consultants at each site certified new parent consultants before they started work with study families. Certification was achieved by review and assessment of competence and fidelity to program protocol via videotapes of feedback and follow-up intervention sessions.

Parent consultants were re-certified yearly as part of their ongoing professional development, and to reduce drift from the intervention model. This followed Forgatch, Patterson, and DeGarmo (2005), who found that direct observations of therapist fidelity to parent management training predicted change in parenting practices and child behaviour. In addition, cross-site case videoconferences were convened weekly to further enhance fidelity. Finally, annual parent consultant meetings were held to update training, discuss possible changes in the intervention model, and address special intervention issues reflected by the needs of families across sites.

How much does it cost?

Information not provided

What else should I consider?

Given the modest, indirect effects of the Family Check-Up on children’s inhibitory control and language skill, questions arise as to whether the Family Check-Up could be revised to be more sensitive to these aspects of child development in early childhood. Parent consultants working with families randomly assigned to the intervention noted anecdotally that many of the caregivers seemed depressed and disengaged from their young child, which could make it challenging for these parents to engage in proactive behaviours that would promote their children’s language development and inhibitory control. Although efforts were made in this intervention to promote positive parenting in general, future versions of the Family Check-Up could be refined to specifically target parenting behaviours known to influence children’s school readiness competencies, as well as to target maternal depression.

Where does the evidence come from?  

RCT conducted in the USA with a sample of 731 families (Lunkenheimer et al. 2008).

Further resources

• https://www.nwpreventionscience.org/
• Lunkenheimer, E.S., Dishion, T.J., Shaw, D.S., Connell, A.M., Gardner, F., Wilson, M.N., and Skuban, E.M. 2008. Collateral Benefits of the Family Check-Up on Early Childhood School Readiness: Indirect Effects of Parents’ Positive Behaviour Support. Developmental Psychology, 44(6), 1737-1752.