Engaging African American Fathers in Behavioral Parent Training: To Adapt or Not Adapt

Abstract

The Positive Parenting Program, Triple P, is an evidence-based parenting program with strong empirical support that increases parenting skills and decreases child behavior problems. Few studies on Triple P include fathers or African American fathers. This study was undertaken to determine if adaptation to Triple P level 4 is necessary to ensure fit with urban African American fathers.

Qualitative focus groups and interviews were conducted with African American fathers. Some received a brief overview of the program before giving feedback (series A) and others received the entire intervention (series B). Inductive thematic analysis was used to analyze transcripts and codebooks were developed through an iterative process. Series B fathers had fewer negative perceptions and a more detailed perspective. Limited exposure to an intervention may cause participants to provide inaccurate data on intervention acceptability. The fathers’ initial perceptions of interventions, regardless of accuracy, will affect recruitment and engagement and must be addressed. One strategy is to tailor program examples and language to reflect the experiences of African American fathers.

Introduction

Child behavioral disorders are a significant public health concern in the United States. Nationally representative data indicate that, among children in the general population, the twelve-month prevalence of behavioral disorders or impulse control disorders (i.e., oppositional defiant disorder, conduct disorder, attention deficit hyperactivity disorder, and intermittent explosive disorder) is 8.9 percent (Kessler, Chiu, Demler, & Walters, 2005). This estimate does not include those children who have behavioral problems that have not yet risen to the threshold of meeting diagnostic criteria but may have begun to cause difficulties for them at home and school. Children of all races and ethnicities may develop these problems, and evidence suggests that the relationship between child behavior, race, poverty, and whether or not the family lives in an urban or rural area is complex (Costello, Keeler, & Angold, 2001). This makes it difficult to disentangle variations in child behavior problem prevalence by race. However, of particular concern is that, even if prevalence is similar for African American and white children, white children and their families are more likely to get services than African American families (Angold et al., 2002).

Behavioral parent training (BPT) interventions are designed to address child behavior problems by improving parenting skills and competence and enhancing parent-children relationships. Several BPTs have strong empirical support demonstrating their effectiveness with multiple populations (Eyberg et al., 2001; Hood & Eyberg, 2003; Sanders, Markie-Dadds, & Turner, 2003; Webster-Stratton & Hammond, 1997). To improve the overall behavioral health of African American children, efforts must be undertaken to include African American mothers and fathers in BPT. African American fathers, particularly those not living in the home with their children and their children’s mother, may be even less likely to access services through traditional systems such as mental health clinics or family support agencies. Hence, increasing access for them may involve providing BPT interventions through nontraditional settings such as father support agencies.

Triple P

The Positive Parenting Program (Triple P) is an empirically supported BPT intervention. Triple P is a continuum of parent support and training that provides parent management training techniques at different levels of intensity ranging from universal prevention (level 1) to indicated treatment in high-risk situations (level 5) (Sanders, Turner, & Markie-Dadds, 2002). The level 4 group version of Triple P (which is the focus of our discussion) is an eight-week group-based BPT intervention that aims to prevent serious behavior problems by intervening to change parenting knowledge and skills and increase parents’ confidence in their parenting abilities (Sanders et al., 2003). It does so by teaching parents to use positive and consistent parent behaviors, intervening to improve the parent-child relationship, and providing support to parents. The core principles of Triple P are (1) creating a safe engaging environment for children, (2) creating a positive learning environment, (3) providing assertive discipline, (4) setting reasonable expectations for children, and (5) improving parental self-care (Sanders et al., 2003). Triple P also emphasizes self-regulation. The parents decide which of their own behaviors and which of their children’s behaviors they would like to change, set personal goals, and choose which parenting techniques they would like to implement. Additionally, parents are encouraged to self-evaluate their progress toward their goals and success with the chosen techniques (Turner, Markie-Dadds, & Sanders, 2002).

A wealth of evidence demonstrates the effectiveness of Triple P at changing parenting knowledge and skills and decreasing child behavior problems (de Graaf, Speetjens, Smit, de Wolff, & Tavecchio, 2008; Nowak & Heinrichs, 2008; Sanders, 2012; Sanders et al., 2003; Thomas & Zimmer-Gembeck, 2007). Studies indicate that Triple P is effective with a wide range of applications including parents at risk of maltreating their children, parents of children with early onset conduct disorders, and families experiencing marital conflict (Sanders, Markie-Dadds, Tully, & Bor, 2000).

Multiple meta-analyses of level 4 Triple P have been conducted and report similar findings, although with some variation in the effect magnitude. Thomas and Zimmer-Gembeck (2007) found a medium sized effect (d = −.67) on child behavior problems in favor of group Triple P versus the control group. Alternatively, Nowak and Heinrichs (2008) found small to medium size effects. Across studies, participants made greater gains when entering the study with higher levels of difficulties. A third meta-analysis of the effectiveness of Triple P on parenting behaviors found positive effects for parenting across multiple domains (e.g., reducing dysfunctional parenting and increasing parenting competency), and it found that gains were maintained over time (de Graaf et al., 2008). Furthermore, the positive effects were found across diverse samples. Although limitations are evident in some of the studies, overall the body of evidence suggests that Triple P is well supported by the empirical literature.

Triple P and Fathers

Despite the robust evidence supporting Triple P, the picture is much less clear for African American fathers. More mothers than fathers participate in Triple P, as evidenced by fathers’ absence from or small sample size in Triple P research (Fletcher, Freeman, & Matthey, 2011; Thomas & Zimmer-Gembeck, 2007). Although the parenting behaviors of fathers improved overall, fathers reported less improvement than mothers (Fletcher et al., 2011; Nowak & Heinrichs, 2008). The race or ethnicities of the fathers in the studies were not reported. Given that many of the samples were non-U.S. samples, generalizing these findings to African American fathers is problematic. This suggests that efforts are needed to recruit African American fathers into Triple P, determine whether or not modifications should be made to improve the parenting outcomes of fathers, and test its effectiveness with this population.

Triple P is a well-defined intervention. Any modifications or adaptations that are made to meet the unique circumstances of a manualized empirically supported intervention (ESI) such as Triple P must balance fidelity and adaption (Becker, 2002). This is vital because maintaining fidelity to the core components of an ESI is associated with intervention effectiveness—even when it is necessary to increase cultural relevance (Martinez & Eddy, 2005; McKleroy et al., 2006). Although Triple P requires adherence to specific manualized content, the process of delivery is flexible (Sanders, 2013; Turner et al., 2002). Specifically, the facilitator may use clinical judgment to make decisions, such as how to tailor examples and pace service delivery, based on group composition and the needs of group members. This flexibility, within adherence to core components, makes Triple P an ideal candidate for use with urban African American fathers.

Fathers and Other Behavioral Parent Training

Efforts to engage urban African American fathers in Triple P can be informed by father participation in other empirically supported BPTs. Prior studies providing BPT to fathers only (Fabiano et al., 2012) or to both fathers and mothers (Reid, Webster-Stratton, & Hammond, 2004; Webster-Stratton, 1990; Webster-Stratton & Hammond, 1997; Webster-Stratton, Reid, & Hammond, 2004) have been successful at engaging fathers in parenting interventions. Providing a parent training program (Coaching Our Acting-Out Children: Heightening Essential Skills, or COACHES) to predominantly white fathers (89%) of children between the ages of six and twelve with attention deficit hyperactivity disorder, Fabiano et al. (2012) obtained strong levels of father engagement. This was evidenced by high attendance and completion rates, low tardiness to sessions, and high father-reported satisfaction with the intervention. Variation in these process outcomes was not reported by race; therefore, it is unknown whether the African American fathers (11%) in the study had similar or different experiences.

Similar positive outcomes for fathers have been seen when mothers and fathers attend the group intervention together. In a series of studies providing the Incredible Years intervention to both fathers and mothers of children with behavior problems (Reid et al., 2003; Webster-Stratton, 1990; Webster-Stratton & Hammond, 1997; Webster-Stratton et al., 2004), Webster-Stratton and colleagues were successful at improving parent and child outcomes and maintaining gains over time. As with the COACHES intervention, however, when the race of participants was reported, the vast majority (90%) of fathers in their studies were white. It is promising that intervention recruitment rates, retention rates, and consumer satisfaction were high among fathers participating in the Incredible Years (Webster-Stratton & Hammond, 1997). However, given the very low participation by African American fathers, it is unknown whether these findings would translate to urban African American fathers.

African American fathers have been excluded from the BPT research, and there are clear gaps in our knowledge about parenting and child behavior outcomes, as well as about recruitment and attendance outcomes for this population. Further complicating the story is that it is likely that many, if not most, fathers included in this research were men residing in the same home as their children. However, almost two-thirds of African American children do not live with their biological fathers (U.S. Department of Commerce, 2011). The experiences of nonresident fathers with BPT may be different from those of fathers in intact families, but this has not been explored.

Service Context

Although in many circumstances mothers and fathers may attend a parenting intervention together, this may not be an option for some fathers, particularly those not living in the same home as their children and their children’s mother. In these instances, parenting interventions are often provided by social service agencies working specifically with fathers either as a stand-alone intervention or as part of a larger continuum of services.

Father support agencies typically provide comprehensive programs to promote responsible fatherhood with a particular emphasis on the service needs of low-income fathers. The range of services can include, but is not limited to, job training, apprenticeships, GED classes, legal services, and reentry programs for fathers exiting prison. They may also provide programs to increase positive involvement of fathers in their children’s lives and to promote positive parenting behaviors. Although parenting interventions developed specifically for fathers are available and very appropriate for this service delivery context, their focus is on the role of fathers in the lives of children and child development for first time fathers or fathers of young children or infants (Cornille, Barlow, & Cleveland, 2005; Cowan, Cowan, Pruett, Pruett, & Wong, 2009). They do not address the treatment of child behavior problems among older children. Given the prevalence of disruptive behavior problems discussed above, the absence of BPT within this service context is a noticeable gap.

To Adapt or Not Adapt

Empirically supported interventions are often—intentionally or unintentionally—adapted in an attempt to better fit the groups for which practitioners or researchers intend to use them (Becker, 2002; Chen, Reid, Parker, & Pillemer, 2012). The intent of the adaptation is presumably to increase participation and engagement by the targeted population, and in the case of BPT interventions, to achieve better parenting and child behavior outcomes than can be achieved with the unadapted intervention. However, Lau (2006) cautions about adapting an intervention without empirical support demonstrating that the existing ESI is less effective with culturally diverse minority populations. In her approach to the selective adaptation of ESIs, she suggests that adaptations may be necessary when there is distinctive sociocultural context. A target population may have unique vulnerabilities and/or be situated in a community that may not easily engage with the original intervention. The highly segregated, disadvantaged urban communities in which African American fathers must parent their children present very difficult circumstances such as high crime rates, drugs, gang violence, and few resources. These communities are very different from the communities in which middle class white families are living, and, as asserted by Forehand and Kotchick (1996), much of what we know about the effectiveness of BPTs is based primarily on intervention implementation with middle class white families. Additionally, much of Triple P research has been conducted with families of middle or high socioeconomic status (Thomas & Zimmer-Gembeck, 2007). Since the early 1990s, however, the diversity of mothers in the research has increased somewhat, but not enough. This is not the case for African American fathers. They remain almost completely absent.

Another sociocultural vulnerability that should be considered when recruiting for and implementing BPT with African American fathers is individual or family level poverty. For nonresident fathers the absence of financial resources may, first and foremost, impede their ability to remain involved in their children’s lives. Secondly, financial strain, such as anxiety over financial circumstances, challenges associated with paying child support, and difficulty finding and maintaining employment, may also keep fathers from participating in BPT (Threlfall, Seay, & Kohl, 2013).

Lau’s approach (2006) also suggests that those contemplating adaptation of ESIs should consider the social validity of the existing intervention. Social validity is the acceptability of the intervention by the target population and includes three dimensions: treatment goals, procedures, and outcomes (Foster & Mash, 1999). Essentially, is the intervention a good fit?

The Centers for Disease Control and Prevention’s Map of the Adaptation Process (MAP) provides a five-step formula for adaptation (McKleroy et al., 2006). The first step in the process is directly applicable to the question of social validity. First, it is necessary to assess for fit between the target population (in our case, urban African American fathers) and the intervention and between the intervention and the service setting. It is essential that practitioners or researchers considering the adaptation of an ESI to a new culturally diverse population do not make assumptions about how the target population views the intervention or about the fit between the population and the ESI. The voices of the target population, as well as those of other key stakeholders such as those providing services to the population, must be heard in this process (McKleroy et al., 2006). Secondly, what was learned during the assessment in the first step needs to inform the determination of whether to implement the intervention with or without adaptation. Thirdly, any changes deemed to be necessary to meet the unique characteristics of the target population should be made. Fourthly, the adapted intervention should be pilot tested and finally it should be implemented. The Engaging Fathers in Positive Parenting mixed methods study reported in this article was guided by the first three MAP steps. The next section reports on step 1: what the authors learned about the fit between the evidence-based practice Triple P and African American fathers.

Methods

Engaging Fathers in Positive Parenting Study

The Engaging Fathers study was carried out in response to the call for proposals by the National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, to adapt evidence-based parenting interventions to engage fathers in child maltreatment prevention. Given the paucity of data supporting the effectiveness of Triple P with urban African American fathers, this study was undertaken: (1) to determine if adaptations to level 4 Triple P were necessary to ensure fit with this diverse understudied population and (2) to develop a strategy to engage them in Triple P. This formative research was conducted to assess the acceptability of Triple P to African American fathers.

Four qualitative methods were used to help determine if adaptation was necessary and to inform the development of the engagement strategy. Findings from two methods are reported briefly here. This project was carried out by a partnership between a university and a community-based father support agency. All study protocols were approved by the institutional review board of the university, and all participants went through informed consent.

Sample and Procedures

First, five focus groups were conducted in February and March 2010 with twenty-nine African American fathers of children between the ages of four and twelve (the target child age of Triple P). For ease of discussion, these focus groups will be called series A. The focus group participants were, on average, 37.5 years old (SD = 5.3). Over half (51.7%) were single, whereas13.8 percent were married and living with a partner and 34.5 percent were divorced or separated. Nearly two-thirds (62.1%) were unemployed, 20.7 percent did not complete high school, 51.7 percent had a high school degree, and 27.6 percent had some college or a college degree. The fathers were recruited via flyers distributed at businesses and social service agencies located in neighborhoods surrounding the partner agency. The interview guide for the focus groups was designed to elicit information in response to the study aims and consisted of five domains: (1) opinions about parenting programs, (2) elements that inhibit participation in parenting programs, (3) elements that facilitate participation in parenting programs, (4) opinions about the Triple P materials, and (5) ways to engage fathers in Triple P. Participants provided feedback about Triple P materials by responding to questions after watching a short clip from a Triple P DVD and reviewing a program marketing brochure and participant manual (Turner et al., 2002). The focus groups, which were audiotaped, were facilitated by an African American female trained in focus group facilitation.

Secondly, using convenience sampling, eleven African American fathers known to the community partner were invited to participate in the Triple P group intervention between April and June 2011. At the completion of each session, an African American male conducted brief focus groups (fifteen minutes) to obtain information from the fathers about their perceptions of the Triple P intervention with a particular emphasis on the content, examples used by the facilitator to illustrate concepts and ideas, and teaching techniques. These focus groups will be called series B. The groups were conducted by a facilitator trained and accredited in the level 4 group Triple P. The average age of the fathers participating in these groups was 34.2 (SD = 9.4) years. Most were single (63.6%) or divorced/separated (27.3%). The sample was largely unemployed (72.3%). About one in five (18.2%) had some high school, 45.5 percent had a high school diploma or GED, 27.3 percent had attended some college, and 9.1 percent held a college degree.

Data Analysis

Audio recordings of the focus groups were transcribed for data analysis. Analyses followed an inductive approach (see Krueger, 1998). The codebooks were developed using an iterative process. That is, the transcripts and notes from one focus group were reviewed by the authors, a research assistant, and a professional social worker employed by the community partner. Each team member identified and recorded emerging themes, which were presented and discussed at a team meeting. A similar process was used for a second transcript. The team then developed a preliminary codebook that defined each theme. During the readings of subsequent transcripts, each team member evaluated the utility of the codebook by constantly comparing it with newly emerging themes (Glaser & Strauss, 1967). This process was repeated until the codebook was finalized. Transcripts were then coded by a single team member using NVivo. Themes were compared among participants within a focus group and across focus groups.

Findings

Although the qualitative data provided a rich understanding of urban African American fathers’ perceptions about parenting, fatherhood, and parenting interventions, the discussion of findings will be limited to the fit between Triple P and African American fathers. Themes that emerged under the domain opinions about the Triple P materials are reported here. Overall, perceptions can be classified into two overarching areas: (1) negative perceptions or things participants did not like or understand or wanted to change; and (2) positive perceptions or things that participants liked and felt could be beneficial to themselves, their children, or fathers like themselves.

Negative Perceptions

After watching a snippet of the Triple P DVD, several fathers across all five focus groups in series A felt that they could not identify with several aspects of the intervention, particularly the non-urban setting and the absence of men and African Americans. These sentiments were shared by several participants. One father said, “When an urban neighborhood has a big crime rate, your kids don’t come home like that. Your mom ain’t cooking at home like that… . If you look at this program, you’d be like it’s not like that in this environment… . It’s a different environment.” Another father was clearly annoyed by the lack of fathers in the DVD, particularly because the authors were targeting African American fathers in their research. He captured the position of many fathers when he articulated this: “If you can show a woman, you can show a father as well. A man as well. Instead of just saying at the end you see her because she’s the one doing all the support to the child. So if you are going to do this, at least say ‘If it’s a parent, show both.’”

Another said, “And most programs support the woman, but this program here is saying it’s for a parent. But if you are just looking at the pictures, I don’t see no father figure at all.” For these fathers, gender was as important an issue as race, which was also viewed as a problem due to the absence of African Americans. Many fathers in both series A and series B wanted to see more African Americans in the DVD and other program materials. A father who participated in series B said, “Need to make sure the context is relatable to the black community—the wording.” This highlighted the need to use examples and content that the fathers could connect with.

Although it was not a primary observation of any of the focus groups in either series A or series B, a few fathers felt that positive parenting techniques were too passive for parenting in disadvantaged communities. In support of continued use of physical discipline, one father shared his view that he is a better man today because of the beatings he received from his father:

My father, he whopped me with anything he could grab, and we looked at it as beating, but I haven’t been to jail. I ain’t been standing on no corner. I ain’t really broke no laws. I don’t have no record for real. None of that. Some of these kids, especially in the neighborhoods that we are raising our kids in now, this light-hearted approach would not work all the time.

His very real fear, shared by others in the series A focus groups, was apparent: Children in these communities would not learn what they need to survive without physical discipline.

Fathers who participated in the series B focus groups (and hence were exposed to Triple P in its entirety) reported very few negative perceptions. Things that they would like to see changed involved getting more in depth with the content. For instance, one father said:

This positive parenting, they touch on it a couple of times but I think it needs to be really more vital or touched on more about it; you can’t do positive parenting without positive parents, you know, some type of… . Because without self, then I think the parent themselves really need to work on yourself and be in a peaceful and stable like state because you don’t need to be on drugs or nothing, but if you are mad and angry and stuff all the time… . Like I say, the book do touch on it but I think they need to emphasize the parent bettering themselves and being peaceful and stable, you know? I think that is real vital for the success.

He saw value in positive parenting but wanted more content on self-care, which is one of the core principles of Triple P (Sanders et al., 2003).

Positive Perceptions

Even fathers in series A who viewed only a very small proportion of the materials saw some benefit. One father commented, “Oh, it’s just everyday life. I mean it just got right to the point. I mean it’s stuff in there that pertains to everybody, I mean, in the household, in a real life household. It’s good.” Another saw Triple P as differentiated from other parenting interventions. He stated, “It caught my attention and made it seem like it wasn’t just the same old program as they normally have out there. Then, after reading it, it was good to know that it’s not no new program either. It’s been around, and it’s been tested.”

Fathers who received the complete intervention were very positive about it. They articulated many examples of how they recognized themselves in the material and how they applied the material to their lives and saw a difference. One father stated, “I used to be more aggressive with them but now I am just calming down.” Another commented,

I have been through all these situations with my kids. So, that’s like I’m just like wow, it’s so head on. Then it’s like when visitors arrive or different things like that, so it’s almost like they just took a script out of my life and just put it in this book. That’s what it’s like to me. I can relate to the home situations and the community situations.

After recognizing his role in his child’s behavior for the first time, another said,

After that session last week, I just went home and I just thought about everything that was going on, and I came to the conclusion that it wasn’t really so much as my kids that were giving me the problem—it was really myself that was causing all the problems.

That is a very powerful statement given that the parent is the change agent in BPT interventions. It is through changing the parent’s behavior that children’s behavior improves.

Discussion

Short exposure to Triple P provided some initial glimpses into urban African American fathers’ perception of one ESI; however, their trepidation about an intervention that does not have African American and father friendly materials was paramount. Fathers participating in these focus groups viewed Triple P much less favorably than fathers who received the complete intervention. As one would expect, comments made in the focus groups that received Triple P were much more detailed and personal. Although fathers participating in series A and series B had similar demographics, they clearly viewed the intervention differently.

This highlights two key points. First, adaptation frameworks such as MAP stress the need to get feedback from the target population. Limited exposure to the intervention is an inadequate way to gather this information. In fact, it may do more harm than good because participants are unable to gain full insight into all aspects of the intervention. Secondly, recruitment and initial engagement with the intervention are critical. The perceptions that fathers hold about a program may create a barrier to getting them to an agency providing the intervention and keeping them participating. Thoughtful strategies will need to be introduced to help overcome these barriers.

Limitations of this study should be noted. Fathers were recruited from one geographic region. Although there are likely similarities between fathers in this study and those living in other disadvantaged urban neighborhoods blighted by high crime, drugs, gang violence, and few resources, fathers in this study may not be representative of all urban African American fathers. Further, fathers self-selected into study participation; therefore, findings should not be generalized to fathers mandated to attend parenting interventions. Additionally, the sample size was small. Given that the objective of the study was to explore the fit between Triple P and urban African American fathers and not to determine the effectiveness of the intervention with this population, the authors believe that the sample size was adequate. Notwithstanding these limitations, this study makes important contributions to the evidence supporting Triple P and to the decision making process related to adapting Triple P or other empirically supported interventions.

Conclusion

Despite the growing availability of empirically supported BPTs, African American fathers still rarely participate. It is through positive parenting behaviors and the promotion of positive parent-child relationships that Triple P and other BPTs affect child behaviors. Children who experience positive relationships with their father, whether or not he lives in the same home, have fewer behavior problems and are less likely to engage in risky or antisocial behaviors than children who experience negative father-child relationships (Black, Dubowitz, & Starr, 1999). Father involvement is also associated with a reduction in behavior problems among youth with disruptive behaviors reported at baseline (Coley & Medeiros, 2007). Outcomes are better if fathers are involved. Hence, more efforts are needed to understand the transportability of Triple P to African American fathers and to further explore the acceptability of Triple P by nontraditional service settings, such as father support agencies.

Much of the research on parenting interventions has been carried out with middle class white families (Forehand & Kotchick, 1996). The service needs of urban African American fathers are likely very different from those of this majority population. However, in the process of carrying out this study the authors learned that, despite the differences, Triple P likely fits well with this population. Because of the small sample size, consisting of fathers from a small geographic region in one city, and potential selection bias (fathers in this study may or may not have been more motivated to be involved in their children’s lives than fathers who elected not to respond to the recruitment materials), it is necessary to be cautious about overgeneralizing. The authors are optimistic, however. Although more research is warranted to test the effectiveness of Triple P with this population, practitioners should not be hesitant to use Triple P with African American fathers. For fathers who were exposed to the complete intervention, it appears to be a socially valid intervention. However, when Triple P is used with this population, it is important to tailor examples to the circumstances of culturally diverse groups and to use language with which urban African American fathers relate.