parental monitoring intervention - NCBI - NIH

PARENTAL MONITORING INTERVENTION: PRACTICE MAKES PERFECT Xiaoming Li, PhD, Bonita Stanton, MD, Jennifer Galbraith, MA, James Burns, MD, Lesley Cottrell, MA, and Robert Pack, PhD Morgantown, West Virginia, and Baltimore, Maryland

Data from a randomized, controlled longitudinal study of African-American parent-adolescent dyads were analyzed to assess the impact of a parental monitoring intervention on (a) the similarity of parent and adolescent reporting of adolescent involvement in risk and protective activities, and (b) the reported rates of risk involvement by youth. Self-reported and parental perception of youth risk and protective activities were collected at baseline and 1 2 months postintervention. There was no significant difference between self-report and parent perception of youth activities among intervention dyads at follow-up. By contrast, parents in the control dyads significantly underestimated youth protective and risk activities. There was no evidence of a direct intervention effect on self-reported risk behaviors. These data confirm earlier findings that a culturally-tailored parental monitoring intervention can increase agreement of youth risk involvement among youth and their parents and provide evidence that this effect endures over time. The data argue for the need to consider intervention strategies that address both parents and youth. (J Natl Med Assoc. 2002;94:364-370.)

Key words: adolescents * African American * parental monitoring * risk behaviors Substantial literature confirms what generations of parents around the world have intuitively believed and acted upon-that they can purposively influence the activities and aspirations of their adolescent children.'-4 Among the component activities involved in the broader realm of parenting that appear to be © 2002. From the Departments of Pediatrics, Psychology, and Community Medicine, West Virginia University, Morgantown, West Virginia, and the Department of Pediatrics, University of Maryland, Baltimore, Maryland. Requests for reprints should be addressed to Xiaoming Li, PhD, Department of Pediatrics, West Virginia University, P.O. Box 9214, Morgantown, WV 26506-9214. 364

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especially important in influencing adolescent risk and protective behaviors are "supervision" (knowing the whereabouts, activities, and companions of the adolescent) and "communication," involving both form (open, warm, but demanding) and content (addressing the behaviors of interest) .5,6 Although a vast research effort has been devoted to evaluating direct attempts to influence adolescent risk and protective behaviors (e.g., school-based and community-based youth interventions7'8), there has been comparatively little research evaluating the impact of intervention efforts designed to increase or improve parental supervision and communication on parental monitoring and/or adolescent behavior.9-'2 In an earlier report,'3 we described the VOL. 94, NO. 5, MAY 2002

PARENTAL MONITORING INTERVENTION

short-term (2 and 6 months postintervention) results from a randomized, controlled trial of a program seeking to increase parental monitoring among African-American parents of adolescents residing in low income urban housing. Overall at baseline and at both postintervention assessments, parents underestimated youth involvement in risk behavior. However, at the 2- and 6-month follow-up, the intervention dyads had more concordance than did the control dyads.13 A concurrent area of interest to human immunodeficiency virus preventioni researchers has been the sustainability of intervention effect over time.8 Although a handful of studies have addressed this issue among risk reduction interventions directly targeting adolescents,'4 to the best of our knowledge no study has examined the long-term impact (1 year or longer) among interventions primarily targeting parents on parent supervision and communication and/or of adolescent risk behavior. Accordingly, in this brief report, we examine, through a randomized controlled study, the impact of a parental monitoring intervention 1 year postintervention on (a) the similarity of parent and adolescent reporting of adolescent involvement in risk and protective activities, and (b) the reported rates of risk involvement by youth according to intervention status. Therefore, we are assessing the long-term direct effect of the intervention (on parent-youth similarity of risk reporting as a proxy for parental supervision and communication) and a long-term indirect effect of the intervention (on adolescent risk involvement).

MATERIALS AND METHODS Participants The effect of the intervention program "Informed Parents and Children Together" (ImPACT) on parental monitoring and supervision was assessed through a randomized, controlled longitudinal evaluation involving 237 dyads (a parent or guardian and one of their children ages 12 through 16 years of age). JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

Dyads were identified and recruited by a local resident serving as a project facilitator from each of eight public housing developments during the summer of 1997. Virtually all residents in the public housing communities lived at or below the poverty line and were African American. For a dyad to be eligible, the youth had to spend at least 50% of his/her time with the parent (defined as a biological parent, other relative, legal guardian, or other guardian), and the child had to be 12 to 16 years of age at the time of enrollment (summer of 1997). Only one child and one parent per household were eligible for inclusion in the study. The youth and parent were required to complete baseline measures. Only the parents, as the targeted audience of the intervention, were required to partake in the intervention, although in fact all of the youth did participate.

Intervention Design Intervention Program. Informed by previous literature 12,15 the research team developed the 60- to 90-min-long home-based intervention "ImPACT," utilizing a culturally-tailored video and follow-up discussion. Development of the parental monitoring video was based on an intensive qualitative research phase, including focus group discussions and individual interviews conducted among parents and youth. The interviews explored parental concepts of risk involvement, risk prevention, the role and meaning of "parenting" and "monitoring" and how they change by age and gender of the child, and the optimum setting and arrangements for meeting with parents to deliver an intervention. All discussions and interviews were audiotaped, transcribed, and entered into ETHNOGRAPH.16 Transcripts were coded for theme identification. Based on this information, a professional video production team, "Video Press," produced a 22-min video, which includes portions of individual interviews, parent-youth conversations, and youth-youth discussions regarding the importance of parental monitoring and adolescent risk and protective behaviors. The video contains a condom demVOL. 94, NO. 5, MAY 2002

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onstration and examples of negotiation and six main messages directed to parents of adolescents: (a) monitor your children; (b) talk with your children about sex before they begin to have sex or engage in other risk behaviors; (c) know basic facts about AIDS; (d) know how to use a condom; (e) emphasize self protection including abstinence and/or the use of both condoms and some other form of contraceptives; and (f) emphasize that drug or alcohol use poses risks and, if combined with sex, may lead to risky sexual behaviors. After viewing the video, the parents were asked if they had any questions, after which they were asked to role play a gender-specific vignette (with prompts). After a review of the main points of the video, the parent and youth were asked to reverse roles in the vignette and again role play the scenario. Finally, the parents were given their own copy of the video and corresponding literature. Thus, the intervention consists of a single session of approximately 60 to 90 minutes' duration. Control Program. Employing a comparable qualitative research methodology, the research team prepared an alternative (control) intervention, the "Goal for IT!!" (GFT) program. The GFT program consists of a 22-min video entitled "Goal for it: A guide for adolescents and parents on education and career training," also produced by the researchers with the local community. The parent and child randomized to the control group watched the video with a health educator. The video presents a four-step guide in planning for education and career training. The first step is interests and identifying careers that you would enjoy or at which you would excel. The second step is setting goals, both short-term and long-term results or achievements. The third step is creating an action plan that includes a step-by-step process used to obtain the goal. The final step is a progress check monitoring how close you are to your goals by looking at your milestones and benchmarks. After watching the video, both parent and child were given a "Goal for It" workbook in which they were encouraged to 366


follow the steps in achieving a long-term goal for themselves. The health educator guided both parent and child through the four-step process and encouraged them to record the process in their workbooks. The entire interview took approximately 60 min, 20 min for the video, and 40 min for the workbooks. Thus, the duration and formats of the GFT and ImPACT interventions are equivalent. However, unlike the ImPACT curriculum, in the GFT program there is no discussion of monitoring and communication, no discussion of HIV risk and prevention, and no skills training with regard to communication and/or condom-use. Intervention Administration. A team consisting of an interviewer (to administer baseline questionnaires, vide infra) and the interventionist with a portable video player went to each household at a prearranged time. The interventionists had been trained in the delivery of both interventions during a 4-day training course conducted prior to the start of the process. After providing informed, written consent, parents and youth completed baseline measures in separate rooms in their apartment. Subsequently, the dyad was randomly assigned in a blinded fashion through a random numbers table to the intervention (ImPACT) or control (GFT) condition. The interventionist then delivered the appropriate program (GFT or ImPACT depending on the randomization assignment) to the parent and, optionally, the targeted adolescent child. The randomized trial was approved by the Institutional Review Board at the University of Maryland, Baltimore, Maryland.

Measures and Statistical Analysis Measures were presented to the parent and youth aurally and visually by a "talking" Macintosh computer.17 Briefly, the research team developed a Parent-Adolescent Risk Behavior Concordance Scale, derived from the risk assessment portion of the Youth-Health Risk Behavioral Inventory.'8 The scale independently asks youth and their parents whether the youth VOL. 94, NO. 5, MAY 2002


had engaged in several risk and protective behaviors over the previous 6 months. In an earlier study, we found a strong inverse correlation between parent-child concordance and youth involvement in risk behaviors and a strong positive correlation between concordance and involvement in protective behaviors.13 Prevalence of self-reported and parental perception of youth protective and risk behaviors were determined at baseline, 2, 6, and 12 months postintervention. Because we have previously reported the 2- and 6-month postintervention data, only the baseline and 12-month data are reported in the current study. Intervention impact on the concordance between parent and youth reporting for each of the behavioral measures was examined using paired Student's t-test. A smaller magnitude of t-values indicates a higher concordance (or smaller discrepancy) between the responses from parents and youths in each dyad. Only dyads in which both the parents and youth provided responses were included in these analyses. For baseline data, the analysis was initially conducted among only the dyads who completed 12 months of follow-up (i.e., n = 179), then was repeated among all dyads who had data available at baseline (i.e., n = 237). Intervention impact on self-reports of risk reports of risk and protective behaviors among the targeted adolescents was assessed by chisquare test. Because of the known association of male gender and advancing age with most risk behaviors,'9'20 age and gender were further controlled in these analyses using analysis of covariance.

RESULTS

Sample Characteristics Ninety-six percent (228) of the parent respondents were female. The median age of the youth was 13.6 years, and 51% were male at baseline. One-year follow-up data were obtained from both the parent and the youth from 76% (179) of the dyads (50% control and 50% of intervention dyads) and from at least JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

the parent or the youth for 81% (191) of the dyads. Median age of the youth who participated in the 12-month follow-up assessment was 14.4 years (SD = 1.41) overall, including a mean age of 14.52 years (SD = 1.41) among intervention youth and 14.28 (SD = 1.41) among control youth. Forty-nine percent of the youth in the 12-month follow-up were male, including 53% males among intervention youth and 47% among control youth.

Perceptions of Youth Behaviors At baseline, overall, parents perceived their youth as less involved in positive and risky activities than reported by the youth (Table 1). Intervention youth reported significantly higher rates of academic honors and involvement in three sets of risk behaviors (weapon carrying, alcohol, and marijuana use) than their parents perceived them to have had. Likewise, among control dyads, youth reported significantly higher levels of involvement in four risk behaviors (staying out all night, using alcohol, selling drugs, and having sex) than their parents perceived them to have had. Not shown in the table, a similar response pattern was revealed between intervention and control dyads for those who were followed at the 12month postintervention (n = 179). At 12-month follow-up, overall, parents continued to perceive their youth as less involved in honors and risk behaviors than were reported by the youth (Table 2). However, among intervention dyads, there were no significant differences in this regard (i.e., the level of parent-youth concordance was higher at the 12-month postintervention than at baseline). By contrast, in control dyads, parents significantly underestimated honors and four risk behaviors (weapon carrying, staying out all night, consuming alcohol, and using marijuana).

Self-reported Behaviors Actual risk behaviors of youth were assessed pre- and postintervention. Several of the risk behaviors demonstrated a modest increase in prevalence over the course of the year of folVOL. 94, NO. 5, MAY 2002

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Table 1. Self-Report and Parent Perception of Youth Protective/Risk Involvement Among 237 Urban African-American Parent-Youth Dyads at Baseline Control Dyads Intervention Dyads Parents Youth t-statistic Youth Parents t-statistic 1.14 0.61 0.69 (0.46) 0.53 (0.50) 0.71 (0.46) Received an honor 3.461 (0.49) 0.11 0.41 (0.49) 0.34 (0.48) 1.68 0.27 (0.45) 0.35 (0.48) Engaged in a fight 1.15 0.11 (0.32) 0.16 (0.36) 3.56* 0.07 (0.26) Carried a weapon 0.21 (0.41) 0.09 (0.29) 0.19 (0.39) 1.00 0.12 (0.32) 0.16 (0.37) Stayed out all night 2.15t 1.16 0.08 (0.28) 0.12 (0.33) 1.39 0.06 (0.23) 0.10 (0.30) Smoked cigarette 0.08 (0.27) 0.17 (0.38) 0.07 (0.26) Drank alcohol 0.15 (0.36) 2.34t 2.20t 0.47 0.09 (0.28) 0.10 (0.31) Used marijuana 0.12 (0.33) 0.06 (0.23) 2.35t 0.03 (0.16) 0.15 (0.36) 0.06 (0.23) 1.07 3.45* Sold drugs 0.09 (0.29) 3.59: 0.23 (0.42) 0.37 (0.49) 1.90 0.33 (0.47) 0.40 (0.49) Had sex (ever) Note: Proportion (standard deviation) of youth/parents reporting a particular behavior was presented in each cell. Behaviors during previous 6 months were assessed unless indicated otherwise. A smaller magnitude of t-statistic indicates a higher concordance (or smaller discrepancy) between the responses from parent-youth dyads. *P< 0.001. tP < 0.05. 1P < 0.0001. Table 2. Self-Report and Parent Perception of Youth Protective/Risk Involvement Among 179 Urban African-American Parent-Youth Dyads at 12-Month Post-intervention

Youth 0.56 (0.50) 0.26 (0.44) 0.19 (0.39) 0.22 (0.42) 0.13 (0.34)

Intervention Dyads Parent

Control Dyads t-statistic

Youth 0.67 (0.47) 0.27 (0.45) 0.22 (0.42) 0.26 (0.44) 0.16 (0.37)

Parent

t-statistic

2.54* 0.51 (0.50) 1.10 0.49 (0.50) Received an honor 0.41 0.25 (0.43) -0.19 0.27 (0.44) Engaged in a fight 0.11 (0.32) 1.62 0.04 (0.21) Carried a weapon 4.09t 1.72 0.09 (0.29) 0.14 (0.35) Stayed out all night 3.47t 1.65 0.12 (0.33) 0.11 (0.32) 0.28 Smoked cigarette 0.07 (0.25) 1.81 0.21 (0.41) 0.17 (0.37) Drank alcohol 0.26 (0.44) 2.96t 0.90 0.18 (0.39) 0.04 (0.21) Used marijuana 0.12 (0.33) 0.09 (0.29) 3.39t 0.33 0.07 (0.25) 1.72 0.08 (0.27) Sold drugs 0.18 (0.38) 0.10 (0.30) 0.57 0.68 (0.48) 0.30 0.75 (0.44) 0.71 (0.46) Had sex 0.74 (0.45) Note: Proportion (standard deviation) of youth/parents reporting a particular behavior was presented in each cell. Behaviors during previous 6 months were assessed. A smaller magnitude of -statistic indicates a higher concordance (or smaller discrepancy) between the responses from parent-youth dyads.

*p < 0.05. tp < 0.0001. tp < 0.001. low-up. For example, weapon carrying increased from 19% at baseline to 21% at 12month follow-up; staying out all night increased from 17% to 24%; smoking cigarettes from 11% to 15%; alcohol consumption from 16% to 23%; marijuana use from 11% to 15%; and drug selling from 12% to 13%. At baseline there were no differences on the basis 368


of intervention status. At the 12-month postintervention, risk behaviors did not differ on the basis of intervention status. Drug trafficking was higher among intervention compared with control youth (18% vs. 8%, p = .048), but the difference became nonsignificant (p = .076) after controlling for the gender and age of the youth in the two conditions. VOL. 94, NO. 5, MAY 2002


DISCUSSION These data confirm and extend earlier findings that a culturally-tailored parental monitoring intervention can increase agreement of reports of youth risk involvement among youth and their parents. At the same time, consistent with our earlier study, there is no evidence of a direct intervention effect on actual youth risk involvement. The apparent paradoxical increase of drug trafficking among intervention youth at 12 months was explainable by the marginally increased age and increased number of male adolescents among the intervention dyads compared to the control dyads. As we reported earlier,j3 risk involvement was by the report of the youth and not through any objective measure. This study sample was a convenience sample and thus the highest risk families may not have participated, although clearly these families are at risk. Finally, these families live in one cultural and geographic niche; these data may or may not be applicable in other settings. The duration of this intervention effect is an encouraging finding, suggesting that brief interventions can have a lasting impact. Although this study was not designed to address why the intervention effects remain robust, we can speculate that practicing parental supervision and effective parent-adolescent communication may have been mutually reinforcing. If this mechanism does explain the effect, it might argue for the importance of the initial postvideo "practice" session, followed by a review of main messages and repeat practice session. In fact, after reviewing our data, we found suggestive evidence of an interesting intervention effect over time. To further explore this possibility, we examined the difference in parent-child concordance between intervention dyads and control dyads over time, speculating that if "practice" were in fact a significant factor, we might see an increase in "intervention" effect over time, rather than a waning or flat effect. Therefore, we examined the magnitude of difference between youth self-report and parent JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION

perception on the nine behavioral measures (i.e., one protective and eight risk behaviors) as a concordance measure (i.e., a smaller difference represents a higher concordance, and vice versa). The youth-parent difference between intervention dyads and control dyads did not differ at baseline (.73 for intervention dyads vs. .54 for control dyads), at 2 months (.78 vs. .96), or at 6 months (.67 vs. .91). However, the difference was significantly larger among control dyads compared to intervention dyads at 12 months postintervention (.43 vs. 1.03, p = .042). These data suggested that, over the passage of time, concordance among intervention dyads increased while control parents and youth remain discrepant, such that intervention vs. control concordance scores are significantly different at 12 months postintervention. The difference remained significant (p = .019) after controlling for age, gender, and baseline difference. The absence of an intervention effect on risk involvement of the youths themselves is not necessarily surprising. The parental monitoring intervention targeted parental monitoring behaviors and not specifically adolescent risk involvement. The current adolescent risk reduction literature provides evidence for the need to include several intervention components in adolescent risk reduction intervention which were not present in the parenting intervention (e.g., enhancing the self-efficacy of the youth is risk avoidance, practice in negotiating and other skills enhancement, etc).21'22 These data instead argue for the need to consider intervention strategies, which address both parents and youths in adolescent risk reduction efforts.

ACKNOWLEDGMENTS This work was supported by the National Institute of Mental Health (4RO1-MH54983). We thank the other members of the ImPACT team and the many community members who helped us prepare and pilot-test this study. We appreciate the fine work done by Video Press in the production of the video "Protect your child from AIDS." We thank Mary Bane for help in preparing the manuscript. VOL. 94, NO. 5, MAY 2002

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