Programs that Work
Family Thriving Program
Healthy and Safe Children
Children not experiencing physical, psychological or emotional abuse
Children not experiencing anxiety or mood disorders, such as depression
Children experiencing good physical health
Age of Child
Early Childhood (0-8)
Type of Setting
Type of Service
Type of Outcome Addressed
Child Abuse and Neglect
Evidence Level (What does this mean?)
The Family Thriving Program (FTP) uses cognitive reframing as a method for correcting parents' biased understanding of the relationship between themselves and their children. It has been proposed that a skewed view of the parent-child relationship may contribute to child abuse and neglect. FTP is an enhancement to home visitation models that incorporates cognitive appraisal methods to assist parents in becoming "competent and independent problem solvers." To do this, parents receiving the enhancement are asked by home visitors to review recent parenting problems. Using a series of questions aimed at identifying the problem's cause, the home visitor arrives at a strategy for addressing the problems raised by the parent, and the home visitor follows up on the results of the strategy in subsequent home visits. FTP has been tested as an enhancement to the Healthy Start home visitation program.
Parents of infants receiving home visits
A study of FTP among families with moderate risk for child maltreatment (Bugental, Ellerson, et al., 2002) examined the effect of the Healthy Start home visiting program with the FTP enhancement (HS+) when compared with unenhanced Healthy Start (HS only), and the study also compared with a control condition in which the families received no home visiting. The study was conducted among families expecting the birth of a child that were at moderate risk to become abusive. The study excluded families at high risk of child maltreatment, with the justification that a prevention program such as this one may not have the capacity to provide the appropriate services for very high-risk families. Risk was defined in terms of parent history and circumstances (e.g., unemployment, past history of own abuse, lack of support, unstable housing). Seventy-three parents at moderate risk to become abusive who were also eligible for the Healthy Start home visiting program were randomly assigned either to the control group, the HS only group, or the HS+ group. The three groups were statistically equivalent on all demographic features. Seventy-six percent of families completed the study, and study attrition was statistically equivalent across the three groups.
The study examined two types of measures: those intended to measure harsh parenting and those intended to measure the child's health. Harsh parenting was measured using items from the Conflict Tactics Scale (CTS). The CTS asks for frequency of occurrence of different ways of responding to family conflict, including physical abuse, such as shaking or hitting with a fist, and non-abusive use of force, including spanking and slapping. Parents were notified at intake that home visitors were mandated by law to report instances of child abuse. Child health measures included the following parent-reported statistics: (a) frequency of child injuries, (b) frequency of child illnesses, and (c) frequency of child feeding problems. The health measures were combined into a Child Health Scale score.
In 2009, researchers conducted another study of FTP among families with infants born at medical risk who were recruited into Healthy Start programs (Bugental and Schwartz, 2009). One-hundred and forty-seven infants and their families were referred to Healthy Start by their physicians, social workers, or public health nurses based on the presence of a medical risk factor. Forty-eight of these infants were preterm, 56 had a medical problem, and 40 were referred for other reasons, such as cesarean delivery. Infants were randomly assigned to receive HS only or HS+. The HS only group was statistically similar to the HS+ group, except in the case of maternal education (which was lower in the HS group) and immigration status (there were more immigrant families in the HS only group compared with the HS+ group). The analysts controlled for these variables in the analysis.
The 2009 study examined several measures of parent maltreatment and neglect, including the CTS discussed above; the Framingham Safety Survey, which is focused on household hazards; and the Child Injury Survey, which inquires about the frequency of falls, bruises, etc. Perceived power was also measured using participant (parent and child) drawings of their stature relative to the others in their family.
Most recently, FTP was tested in a study conducted among families referred to Healthy Start from Newborn Intensive Care Units (NICUs) (Bugental, Schwartz, et al., 2010). Thirty-three percent were referred based on preterm birth, 28 percent due to birth complications, and 41 percent due to other medical risks. Families were randomly assigned to the Healthy Start plus FTP enhancement (HS+) group or the Healthy Start only group (HS only), and at baseline there were no significant difference across these two groups in gestational age, intake age, birth weight, maternal age, maternal education, child gender, father present in family, percent Latino, or percent twins. There was a statistically significant difference in responses to the Social Desirability Scale, with the HS only group scoring higher than the HS+ group, indicating that the HS only group was providing answers that were more aligned with social desirability, indicating that they might be less likely to report harsh parenting practices. The analysis of parenting practices as measured by the CTS controlled for this variable.
In addition to the CTS, this study also measured the child's cortisol levels, which were measured 1, 2, and 3 years following the intervention. Cortisol is associated with the body's stress response system, and children exposed to maltreatment or stressors, such as maternal stress or maternal depression, show elevated cortisol levels. Elevated cortisol levels in early life are associated with reduced capacity for learning and memory later in life (Jameison and Dinan, 2001). The study also employed direct child assessments conducted at the 3-year follow up visit, using the McCarthy Scales of Children's Abilities (MSCA). The MSCA was administered in a lab in English or Spanish. Subscales of MSCA include measures related to visual and verbal short-term memory.
Key Evaluation Findings
In the study of families at risk for maltreatment, parents in the Healthy Start plus FTP (HS+) group participated in significantly fewer instances of harsh parenting, and their children experienced significantly improved health related to both of the other two groups, unenhanced Healthy Start (HS only) and the control group (Bugental, Ellerson, et al., 2002). Among the women participating in HS+, 4 percent reported physically abusing their child, compared with 23 percent in the HS only group and 26 percent in the control group. The HS only group was not statistically different from the control group on harsh parenting practices.
The HS+ group yielded the highest score on the Child Health Scale, statistically significantly higher than either the home visitation alone or control conditions, with mean Child Health Scale scores of 0.25 for HS+, -0.05 for HS only, and -0.30 for the control group (Bugental, Ellerson, et al., 2002).
In the study of medically at-risk children, no significant effects were found across HS only and HS+ for CTS measures of physical abuse. Significant improvements were found in HS+ compared with HS only in the area of corporal punishment: 21 percent of parents reported some corporal punishment in HS+, compared with 35 percent in the HS only group. Injury and home safety maintenance were significantly improved in the HS+ group relative to the HS only group. Additionally, in drawings of themselves and their children, mothers in the HS+ group depicted themselves as larger in size relative to their children than mothers in the HS group (average difference of 4 cm), indicating that their sense of self-efficacy in the parent-child relationship was elevated.
In their study of infants referred from the NICU, Bugental, Allen, et al. (2010) found that the HS+ group's cortisol levels were significantly lower than those of the HS only group at the 1- and 3-year assessments. Cortisol levels were not significantly different in year 2. Child verbal short-term memory was significantly improved in the HS+ group relative to the HS only condition (0.48 in HS+ versus -0.10 in HS only); however, child visual short term memory was not significantly different across HS+ and HS only groups. No significant effects were found for the subscale of the CTS concerning harsh parenting practices; however, avoidance tactics were significantly lower among HS+ parents (0.01 in HS+ versus 0.32 in HS only), and there was a significant effect of the intervention on the combined use of both harsh parenting and avoidance tactics, with HS+ parents scoring lower on the combination of these scales than the HS only group.
Organizations already implementing intensive home visitation programs
Services provided within the program were funded by the State of California.
FTP enhancement incorporates all of the features of the home visitation program (in this study Healthy Start), adding an additional component incorporated at the start of each of the home visits. The program protocol states, "In implementing the Family Thriving Program, the basic method involved assistance to parents in the cognitive and motivational re-framing of commonly-occurring caregiving challenges. That is, parents were assisted in rethinking the causes of caregiving challenges, and in becoming their own information seekers and problem solvers... In the [enhanced] condition, better ways of interpreting caregiving problems were suggested to parents, along with the direct provision of information regarding community resources and developmental issues, along with recommendations regarding potential ways to solve existing problems" (Bugental, 2010).
FTP enhancement does not require additional staffing beyond the home visitation staff. Additional training is needed, and training materials are provided on the program developer's website, http://www.psych.ucsb.edu/~bugental/.
Issues to Consider
The Family Thriving Program received a "proven" rating. The initial program evaluation and the two additional replications were randomized controlled trials, and the participants in these trials experienced significant improvement in a range of outcomes in the areas of physical and emotional health. FTP is a home visitation program enhancement and has not been evaluated as, nor is it intended to be, a stand-alone program. Only the initial study of FTP compared the FTP enhancement with Healthy Start alone and with no home visitation services. All subsequent studies evaluated the FTP enhancement to Healthy Start in comparison with Healthy Start alone. FTP has not been evaluated as an enhancement to any other home visitation programs beyond Healthy Start, and the results may differ when the enhancement is applied to other programs.
The program has been implemented as an enhancement to established Healthy Start program sites. FTP was first evaluated among an immigrant population at risk for child maltreatment in Santa Barbara County, California. It has since been tested among populations of medically at-risk infants and their parents.
Daphne B. Bugental
Resources can be found on the program developer's website: http://www.psych.ucsb.edu/~bugental/
Bugental, D. "FTP Program Protocol," 2010.
As of November 22, 2010:
Bugental, D. B., A. Schwartz, et al., "Effects of an Early Family Intervention on Children's Memory: The Mediating Effects of Cortisol Levels," Mind, Brain, and Education, Vol. 4, No. 4, 2010, pp. 159-170.
Bugental, D. B., and A. Schwartz, "A Cognitive Approach to Child Mistreatment Prevention Among Medically At-Risk Infants," Developmental Psychology, Vol. 45, No. 1, 2009, pp. 284-288.
Bugental, D. B., P. C. Ellerson, et al., "A Cognitive Approach to Child Abuse Prevention," Journal of Family Psychology, Vol. 16, No. 3, 2002, pp. 243-258.
Jameison, K., and T. G. Dinan, "Glucocorticoids and Cognitive Function: From Physiology to Pathophysiology," Human Psychopharmacology, Vol. 14, No. 4, 2001, pp. 293-302.