Breaking the Cycle: PriCARE Supports Parents During Early Childhood Challenges

PriCARE helps parents and guardians build stronger relationships with their children through positive parenting techniques like labeled praise for appropriate behavior and child-led play.

Editor's Note: Where Discovery Leads is a multimedia storytelling project that delves into key research themes at Children's Hospital of Philadelphia Research Institute. This is part two of a five-part series that focuses on scientific studies aimed at addressing behavioral and mental health.

Complementing these stories is a brief video featuring Tami Benton, MD, Psychiatrist-in-Chief, where she highlights CHOP's behavioral health lifespan research, which is moving treatment closer to personalized medicine.

As children learn to walk, talk, and make decisions, they may also display more challenging behaviors — whining, throwing tantrums, hitting, biting, and screaming. These outbursts, while not uncommon, can leave parents stressed and perplexed.

"Toddlers don't come with instruction manuals," said Joanne Wood, MD, MSHP, a PolicyLab faculty member and Section Chief of Safe Place: Center for Child Protection and Health at Children's Hospital of Philadelphia. "When I started studying and implementing positive parenting programs 15 years ago, I had a toddler, and even being a pediatrician, I found there were so many simple rules of positive parenting that I didn't know or wasn't doing correctly."

The Positive Parenting Program to Improve Problem Behaviors in Preschool-age Children (PriCARE) at CHOP is a six-week, group-based intervention that supports parents and guardians as they navigate this critical — and often turbulent — time in a child's life.

Over the past decade, the PriCARE team has conducted four randomized controlled trials to measure the success of their model. Parents and guardians who have gone through the program reported more empathy, less reliance on corporal punishment, decreased parenting stress, and noticeable positive changes in their child's behavior, according to findings published in Academic Pediatrics in 2017, 2020, and 2021.

"I feel more confident in the decisions I make," one participant said.

Another reported, "I'm not as stressed when I'm with my son. I don't take my stress out on him."

Dr. Wood founded PriCARE alongside former CHOP physician Samantha Schilling, MD, and collaborators at Cincinnati Children's Hospital. Since its inception in 2014 the program has helped more than 800 mothers, fathers, grandparents, foster parents, and other caregivers of approximately 1,000 children from CHOP's Primary Care practices.

PriCARE supports parents and guardians by building stronger relationships with their children through positive parenting techniques like labeled praise for appropriate behavior and child-led play. Group sessions are held virtually in the evenings, led by mental health professionals. The program includes role-playing, weekly assignments, and feedback on short videos of play sessions between caregivers and their children.

Caregivers are taught to follow their child's lead and avoid questions, commands and negative statements during 1-on-1 play sessions with their child.

"It's not a type of play that all parents are typically engaged in with their child. It can be different and uncomfortable at first," Dr. Wood said. "Often, parents bombard kids with questions and want to teach them. But the foundation of positive parenting is to shift toward following the child's lead during play."

PriCARE is open to all parents and guardians — regardless of whether their child has behavioral issues — but it's designed to reduce parenting stress and help prevent more serious behavior problems down the line.

These study findings appear in Academic Pediatrics.

"One of the things we see is that parents unintentionally ignore their child when they are well-behaved and provide attention when their child is acting out. That attention, even if it is negative attention, can unintentionally reinforce the problematic behaviors," Dr. Wood said. "Worsening child behaviors can increase parenting stress, which can lead to harsh parenting and may cause a child to act out even more."

Breaking that cycle is critical for both parents and children. Early behavior problems if not addressed can impact school readiness and contribute to academic, emotional, and social struggles, as well as increase a child's risk of maltreatment and abuse, according to Dr. Wood.

The program was developed with input and feedback from families including families from diverse backgrounds and is continuously being evaluated and tailored for different populations, including young parents, foster caregivers, and Spanish-speaking families (Criando Niños con CARIÑO). CHOP researchers are also piloting a new, five-week Positive Discipline Module to build on PriCARE's foundational tools, like praising appropriate behavior, strategic ignoring, and giving good commands.

To further expand PriCARE's reach and impact, CHOP researchers, in partnership with the University of North Carolina, received a five-year R01 grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development to evaluate PriCARE's impact on child maltreatment. The study will enroll 2,000 Medicaid-covered caregivers and evaluate whether PriCARE reduces child maltreatment reports to Philadelphia's Department of Human Services and North Carolina Child protective services.

Behavioral Health Lifespan Research: Moving Closer to Personalized Medicine. Access the video transcript.