Engaging Fathers Recommendations for a Game Change in Parenting Interventions Based on a Systematic Review

Journal of Child Psychology and Psychiatry **:* (2014), pp **–** doi:10.1111/jcpp.12280

Practitioner Review: Engaging fathers – recommendations for a game change in parenting interventions based on a systematic review of the global evidence

Catherine Panter-Brick,1 Adrienne Burgess,2 Mark Eggerman,3 Fiona McAllister,2 Kyle Pruett,4 and James F. Leckman4 1Department of Anthropology & Jackson Institute, Yale University, New Haven, CT, USA; 2Fatherhood Institute, London, UK; 3MacMillan Center for International and Area Studies, Yale University, New Haven, CT, USA; 4Child Study Center, Yale University, New Haven, CT, USA

Background: Despite robust evidence of fathers’ impact on children and mothers, engaging with fathers is one of the least well-explored and articulated aspects of parenting interventions. It is therefore critical to evaluate implicit and explicit biases manifested in current approaches to research, intervention, and policy. Methods: We conducted a systematic database and a thematic hand search of the global literature on parenting interventions. Studies were selected from Medline, Psychinfo, SSCI, and Cochrane databases, and from gray literature on parenting programs, using multiple search terms for parent, father, intervention, and evaluation. We tabulated single programs and undertook systematic quality coding to review the evidence base in terms of the scope and nature of data reporting. Results: After screening 786 nonduplicate records, we identified 199 publications that presented evidence on father participation and impact in parenting interventions. With some notable exceptions, few interventions disaggregate ‘father’ or ‘couple’ effects in their evaluation, being mostly driven by a focus on the mother–child dyad. We identified seven key barriers to engaging fathers in parenting programs, pertaining to cultural, institutional, professional, operational, content, resource, and policy considerations in their design and delivery. Conclusions: Barriers to engaging men as parents work against father inclusion as well as father retention, and undervalue coparenting as contrasted with mothering. Robust evaluations of father participation and father impact on child or family outcomes are stymied by the ways in which parenting interventions are currently designed, delivered, and evaluated. Three key priorities are to engage fathers and coparenting couples successfully, to disaggregate process and impact data by fathers, mothers, and coparents, and to pay greater attention to issues of reach, sustainability, cost, equity, and scale-up. Clarity of purpose with respect to gender-differentiated and coparenting issues in the design, delivery, and evaluation of parenting programs will constitute a game change in this field. Keywords: Research design, coparent, father involvement, child development, violence, prevention, family.

programs worldwide (Naudeau, Kataoka, Valerio, Introduction Neuman, & Elder, 2011). Programmatic approaches Parenting interventions hold great promise for the to early child development have recently called for a promotion of healthy children, healthy families, and paradigm shift in global policy, to foster more effec- healthy societies, in ways that comprehensively tive interventions and systemic approaches to rele- impact the social, physical, and mental dimensions vant health, education, child protection, and of human wellbeing (Olds, Sadler, & Kitzman, 2007; financing agenda (Britto & Ulkuer, 2012). This Panter-Brick & Leckman, 2013). Why then are demands a careful evaluation of how issues of father fathers so marginal to the bulk of parenting inter- participation and impact are articulated in ventions? Issues related to fathers were hardly approaches to (a) research, (b) intervention, and (c) discussed in a recent literature review of early child policy. development programs, which assessed the effec- This review aims to engage with academic tiveness of 15 parenting interventions in low-income researchers who involve themselves in program and middle-income countries and formulated design and/or evaluation, and with stakeholders research priorities and programmatic recommenda- who define the parameters, fund programs, or direct tions (Engle, Fernald, Alderman, Behrman, & Al, the implementation of parenting interventions. Our 2011). Similarly, very few references to engaging purpose is to distill the ingredients that matter for fathers were made in policy documents that reviewed including fathers in a range of settings, in order to the clear economic, health, and education argu- best promote the social, physical, and mental health ments for investing in early child development of children and caregivers. We respond to a need to disseminate evidence, flag problematic issues, and Conflict of interest statement: No conflicts declared. encourage best practice, regarding the effectiveness

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. 2 Catherine Panter-Brick et al. of parenting interventions on family dynamics and the neuroendocrine and neurobiological changes child wellbeing. Globally, we know that father–child associated with specific male and female parental relations vary across time and cultures, and have behaviors (Atzil, Hendler, Zagoory-Sharon, Wine- differential impact on families and children (Cabrera traub, & Feldman, 2012; Kim et al., in press). & Tamis-Lemomda, 2013; Gray & Anderson, 2010; Paternal psychopathology, evidenced in antisocial Hewlett, 2011; Shwalb, Shwalb, & Lamb, 2013). We behavior, substance misuse, and depression, has also know that men’s parenting styles (e.g., demonstrable impacts on child and adolescent func- authoritarian, authoritative, permissive, indifferent, tioning (Phares, Rojas, Thurston, & Hankinson, protective, negligent) are more variable and nuanced 2010). Moreover, fathers are key to coparenting than commonly thought (Selin, 2014), and that interactions that impact family dynamics in ways traditional values pertaining to motherhood and related to, but distinct from, parent–child or fatherhood can exist alongside counter-cultural marital relationships (Fivaz-Depeursinge & Corboz- values that engage men in supporting mothers and Warnery, 1999; McHale & Lindahl, 2011). In sum, children (Solis-Camara, Fung, & Fox, 2014). An an emergent but substantial body of research high- empirical, theoretical, and programmatic lens lights how critical fathers can be to child wellbeing, on gender equity is here needed to move beyond and why it seems good science and good practice to the ‘one-size-fits-all’ parenting programs that essen- involve fathers in preventive interventions to foster tially work to reproduce the social constructs of healthy child development. mother-based childrearing practices. Interventions with fathers Research on why fathers matter The evidence base on parenting interventions that Like mothers, fathers have roles and impacts that exploit these benefits of paternal engagement, how- prove both positive and negative for child wellbeing ever, is quite limited. Specifically, one systematic and family functioning: fatherhood is an important review of early childhood programs identified only 14 aspect of child development (Lamb, 2010; Lamb & intervention studies that included fathers, 11 of Lewis, 2013; Pleck, 2010). Cohort studies have them conducted in the United States (Magill-Evans, revealed the overall protective and positive effect of Harrison, Rempel, & Slater, 2006). In a metaanalysis father involvement on offspring social, educational, of interventions for parents of children with devel- behavioral, and psychological outcomes – through- opmental disabilities, Singer, Ethridge, and Aldana out infancy, childhood, adolescence and adulthood. (2007) identified 17 interventions (again mainly Short- and long-term positive outcomes include those US-based), only three of which included impact data pertaining to psychological health, externalizing and in relation to fathers. A systematic review of Behav- internalizing behavioral problems, substance misuse, ioral Parent Training for attention-deficit/hyperac- criminality or delinquency, economic disadvantage, tivity disorder (ADHD) studies found only 13% capacity for empathy, peer relationships, nontradi- included information on father-related outcomes tional attitudes to earning and child care, satisfaction (Fabiano, 2007). And in a systematic review of with adult sexual partnerships, and self-esteem and fathers’ involvement in programs for the primary life-satisfaction (Fatherhood Institute, 2013b; Feld- prevention of child maltreatment (most of which were man, Bamberger, & Kanat-Maymon, 2013; Flouri, also US-based), only two of the 16 interventions that 2005; Flouri & Buchanan, 2004; Kim, Mayes, Feld- met eligibility criteria reported father-specific data man, Leckman, & Swain, 2013; Martin, Ryan, & (Smith, Duggan, Bair-Merritt, & Cox, 2012). Over- Brooks-Gunn, 2007; Pattnaik & Sriram, 2010; Pleck views that take a global perspective are currently & Masciadrelli, 2004; Sarkadi, Kristiansson, Oberk- confined to the gray literature (i.e., published mate- laid, & Bremberg, 2008). rial that has not undergone formal peer review), Disengaged and remote father–child interactions, namely conference proceedings, databases, pro- as early as the third month of life, have been found to grams implemented by non-governmental organiza- predict externalizing problems in children longitudi- tions and diverse charities worldwide (Burgess, nally (Ramchandani et al., 2013). Fathers’ sensitiv- 2009; McAllister, Burgess, Kato, & Barker, 2012). ity in free play with their 2 year-olds was found to be For example, McAllister et al. (2012) reviewed cur- pivotal to child adjustment at age ten, and more rent issues, discussed best practice, and listed a predictive than early mother–child attachment at age total of 43 international ‘father-focused’ or ‘father-- 16 (Grossman et al., 2002). In one prospective friendly’ programs, detailing case studies with the longitudinal study of 100 families, early-life mater- best evidence base for interventions from the prena- nal and paternal reciprocity were shown to each tal period through the first 8 years of children’s lives. uniquely predict children’s social competence and Their report made three crucial observations regard- aggression in preschool, while father–adolescent and ing the nature and scope of the evidence base. First, mother–adolescent reciprocity each predicted differ- the evidence base is methodologically weak, in the ent aspects of dialogical negotiation (Feldman et al., sense that very few interventions dealing with father 2013). A select body of literature has now evidenced engagement have undergone robust evaluation any-

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. Engaging fathers 3 where in the world. Second, in evaluation, very few reproductive and productive tasks, such as Turkey ‘parenting’ interventions disaggregate findings by and Pakistan, impetus for involving men in both gender, and most are limited to short-term impacts parenting programs and violence prevention pro- on family lives and self-reported beliefs and behav- grams has come from women themselves (ACß EV, iors. Taking this step would allow sound conclusions 2009; Bhandari & Karkara, 2006), as well as from to be drawn regarding the relative effectiveness of international organizations. Some UNICEF programs mothering, fathering, or coparenting interventions. have begun with the premise that men have limited Third, on a global scale, the evidence base on knowledge of child health and development, while parenting roles and parenting interventions is heav- fathers, being prime decision-makers in the home and ily tilted toward fathers, mothers, and children living community, are crucial to improved maternal-child in the global north. In the global south, there exists health outcomes. While engaging fathers in such some evidence regarding interventions with men to contexts presents challenges, the demand by women promote reproductive health and prevent gen- for father engagement is apparent. der-based violence or HIV transmission, but little More holistic parenting interventions have addressed evaluation conducted with fathers in their role as wider aspects of coparenting and family life known to caregivers for promoting child health and develop- impact child health and development (Feinberg, ment. Kan, & Goslin, 2009; Hawkins, Lovejoy, Holmes, Father-focused interventions encompass programs Blanchard, & Fawcett, 2008). Thus Cowan, Cowan, commonly set to increase the quantity and improve Pruett, Pruett, and Wong (2009) identified five the quality of fathers’ involvement with their children. aspects of family life relevant to father engagement: In this respect, parenting is considered a core medi- caregiver mental health, the quality of relationships ator in the design of many interventions, given its between parents, the quality of father–child or putative influence on a wide range of child outcomes mother–child relationships, the pattern of care- (Olds et al., 2007; p. 357). An increased quantity of giver–child relationships transmitted across genera- the time men spend interacting with their children tions, and the balance of stressors and social thus serves as an important proxy for positive child supports outside the immediate family. Because outcomes. Exemplars of interventions which pay parental mental health and the social architecture attention to fathers’ time commitments include, in of family life can be important predictors of child the United States, a range of Early Years father–child health, the design and evaluation of some parenting activity programs, such as in Head Start (Fagan & interventions have sought to address those wider Iglesias, 1999) and Early Head Start (Vogel et al., dimensions. Indeed, a US program such as Family 2011) and, in Peru, Proyecto Papa in Accion (McAllister Foundations has strategically focused on the copar- et al., 2012). Of course, the time that fathers spend in enting relationship of couples expecting their first parenting activities varies considerably worldwide – child, in order to prevent the kind of stresses and both in absolute terms, and relative to mothers early parenting difficulties that may lead to a nega- (Miranda, 2011). Based on OECD data, Scandinavian tive developmental cascade in children (Brown, countries emerge as the most gender-equal in time Feinberg, & Kan, 2011; Feinberg, Jones, Kan and spent on child care (Fatherhood Institute, 2010). In Goslin, 2010; Feinberg & Kan, 2008). This approach middle- and low-income countries, father-inclusive is in stark contrast to the Nurse-Family Partnership programs have often explicitly or implicitly encour- (NFP) program, in place for more than three decades, aged increased male involvement in child care and but targeted at first-time mothers (Donelan-McCall, domestic labor as part of a wider promotion of gender Eckenrode, & Olds, 2009). In the United Kingdom, equality (Bhandari & Karkara, 2006; Barker, where this program is known as the Family Nurse Dog˘ruo¨z, & Rogow, 2009; McAllister et al., 2012). Partnership (FNP), relatively more attention has The quality of father–child interaction is commonly been paid to engaging with fathers alongside vulner- addressed in programs by focusing on fathers’ under- able teenage mothers, providing early professional standing of child development and/or their skills in help at a time when new parents redefine themselves child-behavior management. For example in Turkey, as caregivers and as a couple (Ferguson & Gates, the community-based Father Support Program aims 2013). to enhance awareness in fathers regarding their There are substantial weaknesses in program importance in child care and child development, and evaluation related to coparents, namely program to reduce harsh parenting (Barker et al., 2009). Such engagement with two parents rather than one. Few types of father-focused interventions are promoted in studies have sought to examine whether fathers are a wide range of settings, including jails, centers effective ‘change agents’ (Elder et al., 2011), or as fostering early child development, and centers for effective as mothers in implementing change (Adesso child and adolescent mental health, where fathers, as & Lipson, 1981; Cia, Barham, & Fontaine, 2010). target participants, are often not well acquainted with Some studies indicate that, even where only one parenting literature, receive little social support, or parent participates in the intervention, gains in have little experience as primary caregivers. Interest- family functioning are greater or better maintained ingly, in cultures that favor a gender division of when there is another parent in the home (Bagner &

Eyberg, 2003; Hahlweg, Heinrichs, Kuschel, holistically and synergistically geared to improving Bertram, & Naumann, 2010; Webster-Stratton, family level caregiving environments. In the global 1985). Another-parent-in-the-home also seems to north, such policies are most often found in the be protective against program drop-out (Bagner, design of paternity and parental leave systems and 2013). But is delivery more effective when both in the allocation of parenting time after divorce or parents participate? May et al. (2013) found this to separation. In the global south, most of the funding be the case, as did Lundahl, Tollefson, Risser, and to engage men in programmatic interventions has Lovejoy (2008) and Bakermans-Kranenburg, van been in the areas of intimate partner violence, sexual Ijzendoorn, and Juffer (2003) in metaanalyses. The and reproductive health, and HIV prevention, quality of evidence to-date, however, is highly vari- including Prevention of Mother to Child Transmis- able: thus while Bakermans-Kranenburg et al. sion. Even there, engagement with men may be (2003) found three interventions with fathers to be limited or even counter-productive (Sherr & Croome, ‘significantly more effective’ than interventions with 2012). mothers alone, the studies involved only 81 fathers, Policies on parenting tend to reflect and perpet- and were not randomized. Without randomization, uate, implicitly or explicitly, the gender biases that we cannot be sure whether positive effects have more prevail in cultural stereotypes and mainstream to do with the nature of families in which both parenting practices. In the realm of social welfare parents participate, than with fathers’ participation policies, conditional cash transfers or other income per se. The very few studies that have randomized support programs for low-income families have participants to test this important proposition have often excluded men, on the grounds that women found that engaging with both parents, rather than devolve more of their income to the household than one, may indeed deliver benefits (Besnard, Capuano, do men. Recent critiques of income support pro- Verlaan, Poulin, & Vitaro, 2009; Cia et al., 2010; grams are instructive: to focus exclusively on Cowan et al., 2009; May et al., 2013; Rienks, Wads- women may inadvertently contribute to a gender worth, Markman, Einhorn, & Etter, 2011). divide, in which women are viewed as caregivers In sum, most parenting evaluations have not been and responsible, while men are seen as inherently gender-disaggregated, nor has the impact of deliver- derelict in their capacity for family support. ing a program to both parents vs. one individual Similarly, strong gendering biases in parenting parent been measured. Most global overviews have policies tend to reproduce a mothering rather focused attention on identifying ‘strategic entry than fathering cultural model of childrearing: these points’ for early child development investments, to tilt programmatic interventions toward mothers, include center-based programs, home-based pro- rather than toward both fathers and mothers as grams, and media campaigns (Naudeau et al., coparents. 2011). Moreover, concern is rarely expressed regard- Indeed, policy frameworks underpinning fam- ing the potential for couple participation to ‘skew’ ily-based interventions are often predicated on a findings. For instance, if a significant percentage of father deficit model, one that sees fathers as inef- the parents attending are couples, and if couple fective or neglectful in the arena of child health and participation enhances outcomes, does a positive development (Hawkins & Dollahite, 1997; Maxwell, evaluation stem from program design and delivery, Scourfield, Featherstone, Holland, & Tolman, 2012). or from the fact that many parents attended a deux? Such a deficit model of father involvement is wide- Similarly, given that fathers do not seem to benefit as spread in the social construction of parenting inter- much as mothers from program participation (argu- ventions in countries such as the United Kingdom ably due to program design, rather than father and the United States, but also in the global south. deficits), are findings skewed by participant gender, A more productive framework would espouse a even when parents attend solo? In their review of socioecological model that focuses attention on the parenting interventions targeting competencies rele- social, economic, and political environments that vant to child health and development, Olds et al. shape the quality or quantity of father engagement (2007) emphasized that the evidence base on par- with their children and their commitment to coparenting interventions will only be improved if research enting (Cowan et al., 2009; Sunar et al., 2013). projects adhere to the highest standards of randomization in controlled trials, and in particular, to the Gaps in the global evidence base CONSORT standards for reporting evidence. Without robust evidence, the considerable promise of par- In sum, there is little evidence of a virtuous cycle in enting programs for improving the life course of the evidence base, given the gender biases that are children will remain undocumented. often manifested in policy frameworks, parenting interventions, and even basic research. We know that gaps in the evidence base are best addressed by Policy frameworks on parenting grounding parenting interventions in theory, as well Policies relevant to men as fathers are often focused as in epidemiology and developmental research. on specific social or health outcomes, rather than As highlighted by Olds et al. (2007; p. 357), this

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. Engaging fathers 5 includes a theory of program engagement, with a Methods clear understanding of what drives beliefs and We conducted a systematic search of standard literature behavior, including the fundamental question of databases and a thematic hand search of the global literature ‘why would parents want to spend their time partic- on parenting interventions, to include studies that offered data ipating in [a given] program.’ Olds et al. (2007) did on father participation and impact. This search strategy not highlight issues pertaining to father or couple enabled us to identify the most widely used and best- documented parenting programs world-wide, and to include involvement. However, such issues lie at the heart of studies of programs in the global south that would not have biases implicitly or explicitly embedded in most been captured by systematic searches of peer-reviewed jour- parenting interventions. nals. We identified both single studies and reviews that Program engagement is certainly a critical element indicated successful strategies in father engagement and that of successful implementation. Yet there is scant evidenced links between fathers’ program participation and child outcomes. The term ‘father’ designated all men who are research relating how participant engagement socially significant to children or assume actual fatherly roles relates to program outcomes (Daniel et al., 2011; in taking care of children, whether or not the birth father, Scourfield, Cheung, & Macdonald 2014). A growing married to the mother, or coresident with the child. number of studies are adopting more proactive For the systematic database search, we targeted articles approaches to engaging fathers, spurring a deeper from Medline, PsychInfo, SSCI, and the Cochrane Library. Using the appropriate proximity operators and (un)limited reflection on how best to engage with men in truncation characters for each respective database, our search programmatic interventions (Holmes, Galovan, strategy was as follows. In step 1, our search terms were: Yoshida, & Hawkins, 2010; Maxwell, Scourfield, parent* with (program or intervention or engage or evaluation), Holland, Featherstone, & Lee, 2012; Palm & Fagan, father* with (program or intervention or engage or inclusion), 2008). In sum, when it comes to fathers, our men* with intervention, gender, partner, or coparent. In step 2, we narrowed the pool of results to necessarily include one knowledge on the empirical associations between search term designated by steps (a–c), as follows: we combined fathers’ involvement in raising children and the step 1 and (2a) father and (2b) (intervention or program) and health or educational outcomes of children is quite (2c) (parent or coparent) and (2d) (evaluation or review). Thus consistent – fathers have a substantial impact on results from step 1 were narrowed such that the final set of child development and wellbeing. What is missing is results necessarily included at least one search term from Step 2a, one search term from Step 2b, and so on. We imposed no a systematic evaluation of the global evidence base date or language limits on our database searches, which were regarding fathers’ impact on child wellbeing out- finalized in October 2013. comes via the interventions which involve or could We supplemented the above searches with a thematic hand involve them. search of the gray literature on parenting programs, such as those conducted by UNICEF worldwide and available databases on the topic of fatherhood and child neglect. We also Objectives of this review examined books on fatherhood or parenting, conference proceedings from voluntary organizations, research networks This paper offers a systematic review of father-inclu- such as Childwatch, and the websites of OECD, the Global sive parenting and coparenting interventions under- Child Development Network, the African Child Policy Forum, taken across the world. It asked two specific WHO, the World Bank, Fatherhood.gov, and ACF/OPRE. Finally, we contacted authors of sourced articles, and fathers’ research questions. First, how are fathers currently and men’s organizations worldwide. involved in parenting interventions worldwide? This Two authors removed duplicate records obtained from step identifies the main obstacles to their inclusion systematic database and thematic searches, then screened and engagement, in terms of existing programs as all papers on the basis of their abstracts and/or full-length well as everyday parenting activities. Second, what text. Three coauthors independently assessed all papers with respect to three exclusion criteria, to exclude material that (a) improvements can be made in the design, imple- provided insufficient gender-disaggregation in program evalu- mentation, and evaluation of parenting programs to ation, (b) duplicated information presented elsewhere, or (c) effectively engage with fathers and assess related did not include process evaluation or impact evaluation of impacts? This step identifies improvements that family dynamics or child wellbeing. Two coauthors reviewed a would constitute a game change in this field. We subsample of publications to ensure inter-rater reliability. The remaining papers constituted the final set of full-text docu- considered preventive programs related to prenatal ments selected for this review. health and sexual health; harm-reduction programs To evaluate quality and scope within this literature, we then that addressed child maltreatment, domestic vio- identified a small number of studies on the basis of their lence, or alcohol abuse; behavioral training pro- empirical and/or thematic contribution to father-inclusive grams, such as those for teenage parents, first-time parenting interventions. We searched for exemplars of diverse settings, target group, mode of program delivery, and outcome parents, and parents of children with developmental indicators, in order to characterize, on a global scale, current or medical conditions; programs that engaged men efforts to engage with fathers and evaluate their impact on in settings such as jails or early years’ centers; and child and family wellbeing. Four authors, working in pairs, programs that involved men in child care and independently assessed all papers selected for review, with promoting gender equality. Father/men-only respect to three inclusion criteria, to capture studies (a) situated in the global south as well as the global north, (b) programs are not necessarily the best programmatic including both process data on father participation and strategy, but they are often the only place in which outcome data on father or child impact, and (c) exemplifying to find evidence on father participation or effective- diverse modes of program delivery and target populations. ness. Where several potential exemplars existed of a given program,

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. 6 Catherine Panter-Brick et al. we selected the parenting intervention that had benefited from best of our knowledge, we identified the best-known the most comprehensive and high-quality evaluation. parenting interventions or studies that included Our review thus focused attention on research design and some evidence of father inclusion or father impact evaluation, rather than findings per se. On a global scale, the = lack of gender-differentiated data essentially precluded a on child or family outcomes (n 199 publications). useful metaanalysis based on actual findings. Metaanalyses, We categorized the results of our final search however, are not the sole form of systematic reviews (Gough, according to whether this material consisted of Oliver, & Thomas, 2012; Petticrew & Roberts, 2006; Uman, (a) publications (n = 113) assessing a given 2011). We systematically assessed the scope and quality of father-inclusive parenting program, or (b) reviews, extant literature. First, we comprehensively identified all the studies relevant to answering two specific research questions commentaries, book chapters, and working papers (on engaging fathers in parenting interventions worldwide, and (n = 86) potentially useful for thematic discussion. evaluating the soundness of program design and implementa- We present a global overview of the evidence base tion). Second, we tabulated single programs and created a in Table 1 and online supplementary Table S1. coding scheme to explicitly assess the evidence base with Table 1 focuses on 34 exemplars (n = 52 publica- respect to caregiver demographics, sample size, group comparison, and measures on family and child outcomes. tions) to capture the diverse range of father- inclusive parenting interventions, in order to draw thematic conclusions on the nature of the evidence Results base regarding gender-disaggregated parenting interventions. It includes 14 exemplars from the The evidence base United States, and 20 from other countries. Table Figure 1 shows the steps of our literature searches. S1 reviews an additional 58 programs (n = 61 From a total 31,586 articles that mentioned fathers, evaluations), including 36 US-based programs (39 we identified 868 articles that engaged with fathers publications) and 22 programs from other countries. in parenting or coparenting interventions and men- Upon examination, these were programs with smal- tioned program evaluation or review, and an addi- ler sample sizes, less rigorous evaluation of father tional 153 publications from hand searches of the participation or father impact, and/or interventions gray literature, many of which concerned the global highly similar to chosen exemplars. In selecting our south. In total, we screened 786 nonduplicate exemplars, we sought to achieve global representa- records. We then excluded 472 records on the basis tion as well provide comparative perspective. Given of abstracts and 115 papers on the basis of full-text the state of the evidence base, programs from the articles, following our three exclusion criteria. To the global south were often less rigorously evaluated

Figure 1 Literature search PRISMA diagram

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. Engaging fathers 7 than those from the global north; nonetheless, they taken behavior-change programs due to their use of were included to provide geographical spread. In all, violence, while others are universal programs such we list 92 programs (n = 113 publications) from 20 as the Leksand Models in Sweden, a maternity different countries – Australia (n = 9), Brazil (n = 1), services-based intervention (Hoskings & Walsh, Canada (n = 5), China (n = 1), Finland (n = 1), 2010; Johansson, 2012). Germany (n = 1), Iran (n = 1), Israel (n = 1), Jordan We found noteworthy exemplars of parenting inter- (n = 1), Mexico (n = 2), Niger (n = 1), the Netherlands ventions offering relatively good designs as well as (n = 1), New Zealand (n = 1), Pakistan (n = 1), promising outcomes from addressing or including Peru (n = 1), Sweden (n = 2), Turkey (n = 2), Ukraine fathers (Table 1). Thus the Supporting Father Involve- (n = 1), United Kingdom (n = 7), and USA (n = 52). ment program in the United States focuses explicitly While Table S1 details, by country, the types of on fathers’ roles and coparenting: remarkably, this program, their settings, target group, father sample intervention tested whether men-only or coparent size, and data availability on father participation and groups were the most effective means of supporting impact, Table 1 provides detailed information on fathers’ participation in the lives of their children process and impact data, in addition to information (Cowan, Cowan, Kline Pruett, Pruett, & Gillette, 2014; on program type, mode of delivery, and target group. Knox, Cowan, Cowan, & Bildner, 2011). Other Most program evaluations are situated in the initiatives have been developed to support positive global north – parenting interventions in the global coparenting, taking this as a leverage point for the south are rarely captured by systematic database enhancement of family functioning and child out- searches, while parenting interventions captured by comes (Feinberg & Kan, 2008). Also from the United thematic hand searches rarely involve fathers. Most States, Head Start exemplifies the type of intervention interventions are designed with a view to harm- that focuses explicitly on the father-preschooler dyad, reduction or primary prevention. These include looking to improve child behavior, social skills, and programs targeting vulnerable families ‘at risk’ of school readiness by increasing fathers’ engagement various negative outcomes (e.g., programs such as with their children and enhancing their support and Head Start in the USA, directed at low-income childrearing skills (Fagan & Iglesias, 1999). In Niger, parents to mitigate the effects of poverty on parent- Ecole des Maris characterizes a community-based ing and child outcomes). They also include programs program that encourages men to advocate for and specifically targeting men with a history of violent help develop health services to be accessed by moth- behavior, or fathers of vulnerable children (e.g., born ers and children. This program, funded by the United prematurely, with disabilities or conduct disorders), Nations Population Fund (UNFPA), is based on the for prevention of future harm and/or improvement of theoretical premise that traditional male social power parenting skills and child and family outcomes. Few can act as a brake on rates of improvement in programs aim to strengthen family-level resilience to maternal and child health. Because men in Niger enhance better-quality parenting. dominate household and community decision- making, the program explicitly involved men to transform attitudes and behaviors of whole commu- How are fathers currently engaged? nities, training ‘model husbands’ to enhance women’s Regarding our first question (how fathers are cur- access to local health services, especially assisted rently involved in parenting interventions), posed to childbirth. Similarly in Turkey, the Father Support evaluate the extent to which fathers are targeted for Program (FSP) run by the Anne Cß ocuk Egitim Vakfi inclusion, the cases in Table 1 and Table S1 (ACß EV) or Mother Child Education Foundation, was demonstrate a wide range of program design – established when the Foundation realized that fathers and relatively low coherence overall. Some inter- would benefit from the kind of support that had ventions target just one parent, most often the hitherto focused on the mothers of preschool chil- mother by default, as does, for example the Positive dren; indeed, the mothers enrolled in ACß EV’s Mother Parenting Program (Triple P) developed in Australia Support Program had reported that their husbands (Fletcher, Freeman, & Matthey, 2011). Others are were ‘obstacles’ in supporting what women were designed to engage with mothers and fathers in learning to foster positive child development (Barker, separate groups, such as the Proyecto Papa in Dogru oz,€ & Rogow, 2009, p.8). The sessions targeted Accion in Peru, aiming to increase the quantity of at fathers were thus designed to foster family-level father–child engagement and fathers’ sensitivity to communication and move beyond authoritarian mod- understanding child health and development issues els of fatherhood. (McAllister et al., 2012). Still others, such as the Fatherhood Relationship and Marriage Education Of what quality are the evaluations? intervention (FRAME) work only with couples (Rienks et al., 2011; Wadsworth et al., 2011). Some Unsurprisingly, there exist few randomized-control programmatic interventions are designed for trials and quasi-experimental evaluations of parenting high-risk families – such as the Australian Dads programs that have included fathers. Among the 34 on Board intervention with fathers who have under- programs in Table 1, eleven (eight of them in the

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. 8 © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014 ahrn atrBike al. et Panter-Brick Catherine Table 1 Global overview of parenting programs that evaluated father impact and participation (34 exemplars)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Australia Burleigh 1 9 1-hr home visit session, Mother and fathers (couples) RCT (n = 15 intervention, Process: time and activities Scholz and Samuels (1992), Relaxation showing a video and giving and their 4-week-old infants n = 15 controls). sheets for parents to ﬁll out; and Samuels, Scholz, & Baby Bath both parents hands-on Measures: self-completion time collected 8 weeks later, at Edmundson (1992) and Massage experience of the techniques diaries; observations of father which time observations –child interaction and family carried out by two observers. dynamics; Kansas Marital Impact: (a) parents: father/ Satisfaction Scale, CES-D mother infant bathing scale, Rosenberg Self-esteem frequency, massage scale frequency, infant caretaking, interaction quality, self-esteem, depression, marital satisfaction, and (b) infants: responses/overtures to mother/father Dads on Board Weekly 2-hr therapeutic Fathers who had already Progress of seven Process: pre/post test (parent Bunston (2013) groupwork sessions over participated in father-participants and their report) plus facilitator 8 weeks plus ‘therapeutic behavior-change programs as partners (if attending), observation and report. newsletter’ (reporting on each a result of their use of violence monitored and reported. Impact: father/infant and – © session) for parents between plus their babies/toddlers. Measure: Maternal/Paternal mother/infant attachment;

04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 sessions. Mothers can attend but focus Postnatal Attachment Scale fathers’ behavior and Two facilitators (male & female), is on father–child dyad understanding (read infant closely supervised cues; develop curiosity/ respect for infant; understand concept of ‘holding’; understand impact of own behavior on infant) Healthy Dads, 8 9 1.5 hr weekly face-to-face Overweight and obese fathers RCT (n = 27 intervention, Process: data collected at Burrows et al. (2012), and Healthy Kids sessions for 3 months: 5 and their primary school-aged n = 26 wait-list control) baseline, and at 3- and Morgan et al. (2011) Program sessions for fathers only, 3 children 6-month follow-up: physical activity sessions for observation and self-report. fathers and children Impact: (a) fathers: weight status; waist circumference; systolic blood pressure; physical activity; dietary intake, physical activity, and (b) children: dietary intake; weight status © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014

Table 1 (continued)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Positive Exemplar of a widely-endorsed Focus on dyadic parent–child Metaanalysis of 28 studies Process: (mainly) pre- and Fletcher et al. (2011), and Parenting behavioral parent training interaction: 26% of attendees reporting father engagement post- self-report (mothers and Fabiano (2007) Program (BPT) program, delivered in are single mothers and 21% in Triple P (a tiny proportion of fathers); attendance & (Triple P) various formats – the most fathers [likely to be the program delivery, since data homework completion effective with fathers being partners of participating are rarely (facilitator report); up to Stepping Stones (10 sessions, mothers] gender-disaggregated and 2 year follow-up. for parents of a child with a never disaggregated by Impact: (a) fathers: compliance disability) and Pathways (14 individual v. couple with program; impact on sessions, including 4 on anger participation). fathers relative to mothers, management) Measure: The Parenting Scale and (b) children: behavior Canada Caring Dads 17-week group parenting Men who have maltreated Assessment of 98 men who Process: Pre- and post (fathers’ Scott and Lishak (2012) intervention; systematic (including neglected) their completed the course and had self-report). outreach to mothers to ensure children and/or exposed pre and post assessments. Impact – fathers: aggression/ safety and freedom from them to intimate partner Measures: Buss-Perry hostility/laxness; parenting; coercion; ongoing, violence Aggression Questionnaire; The coparenting collaborative Parenting Scale; The Parenting case-management of fathers Alliance Measure with referrers and other © professionals involved with 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 their families Home-visiting Parent education in the home First-time fathers of RCT (n = 81 intervention, Process: Data collected at Benzies et al. (2008), and intervention during two visits by a home 5-month-olds n = 81 control). baseline and 3 months Magill-Evans, Harrison, (no formal visitor Measures: Nursing Child postintervention (child Benzies, Gierl, and Kimak name given to Assessment Teaching Scale; 8 month old): observation; (2007) this Parenting Sense of father self-report. intervention) Competence Scale Impact – fathers: skills in fostering cognitive growth, sensitivity to infant cues China Early Parent education and support Fathers of neonates less than Quasi-experimental design – Process: pre/post intervention Lee, Wang, Lin, and Kao (2013) intervention in a neo-natal intensive care 37 weeks gestation in a historical comparison study: (fathers’ reports). for fathers of unit: booklet plus 5 sessions neo-natal intensive care unit n = 35 intervention fathers, Impact: parenting stress; premature of 1:1 guidance by nurses n = 34 controls) fathering ability; perceived

infants Measures: Parental stressor support by nurse fathers Engaging scale (NICU); Fathering ability scale (NICU); Nurse-parent support tool (NICU); demographic and control variables; booklet evaluation 9 10 © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014 ahrn atrBike al. et Panter-Brick Catherine Table 1 (continued)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Iran Anger 79 weekly group workshops Mothers and fathers 13 fathers and 8 mothers Process: Pre/post intervention Yekta, Zamani, Parand, and management Measures: State-Trait Anger survey (parent self-report). Zardkhaneh (2011) training Expression Inventory; Parental Impact: anger intensity; anger Anger Evaluation expression; anger control Questionnaire Israel Nonviolent 50 min once-weekly sessions Mothers and fathers (couples) Quasi-experimental: 46 Process: Pre/post (6 weeks Lavi-Levavi, Shachar, and resistance with both parents for 4– of children (age under 18) mothers and 43 fathers, with after intervention) Omer (2013) (NVR) Parent 10 weeks plus 29 with acute behavior problems wait-list control. questionnaires (parent Training intersession phone support Measures: The Parental self-report). calls Helplessness Questionnaire; Impact: parental helplessness, an Escalation Questionnaire; power struggles, negative Demographic Questionnaire feelings, parental submission, father’s family-participation Jordan UNICEF Better 16 hr delivered via different Mothers, fathers (whether In Jordan only – Process: Data collected at Al-Hassan (2009), and Parenting schedules – e.g., consecutive together as a couple or in quasi-experimental design: baseline and immediately Al-Hassan and Lansford Program (BPP) days, weekly, monthly single-sex groups is not intervention (n = 336 postintervention (parent (2011) © known) participants, only 18 of them, self-report). 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 i.e., 6%, fathers), and a Impact: knowledge of child control group development; parenting skills (reduction of harsh discipline, use of explanation during discipline, perception of behaviors that constitute child neglect; time with children playing and reading) Niger Ecoles des UNFPA-funded schools for Men in the community via Observation/report data Process: Postintervention UNFPA (2011) Maris ‘model husbands,’ in Zinder married husbands of good monitoring reporting and self-report; pre– region, twice-monthly character as advocates/early post data comparison. meetings adopters Impact: rates of prenatal care, assisted and safe deliveries, infant mortality; community actions (e.g., new facilities for women and midwives); men’s attitudes and behavior © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014

Table 1 (continued)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Pakistan Aangan, Rozan Regional capacity building Whole community, including Reporting Process: postintervention Bhandari and Karkara (2006) workshops on men, caring fathers and men, religious reporting and fatherhood, to address leaders, police, teachers and Impact: establishing of local child sexual abuse health professionals committee; attendance by men at couples’ and fathers’ groups; participation by religious leaders in child sexual abuse training and referral Peru Proyecto Papa Five workshops covering the Mothers and fathers (single Participants: n = 500, Process: Postintervention McAllister et al. (2012) in Accion basics of positive parenting parents and partnered including 125 men survey: father self-report and and the importance of visual/ parents) some partner report. verbal stimulation/reading to Impact – fathers: family young children; support involvement; respect for session for fathers facing family members; connection particular difﬁculties with children; use of violence;

04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 caregiving work Sweden Internet-based 7 9 1.5 hr sessions delivered Mothers and fathers of 104 Quasi-experimental design: Process: Baseline face-to-face Enebrink, Hogstrom, Forster, Parent over 10 weeks via the internet children aged 3–12 exhibiting intervention parents evaluation of children for and Ghaderi (2012) Management (text, illustrations, videos of conduct disorders compared with wait-list psychiatric disorders. Pre/ Training parent/child interactions, controls. post (and 6 month follow-up) (PMT) parenting discussion forums) Sixty-nine percent of parent reports. Attendance Homework. Online feedback participants were couples. records. Couple and individual parent Impact: child behavior; participation measured, also parenting strategies; cost impact by child gender and dose–response rates. Measures included: Early Assessment Risk List-20B/

21G; Eyberg Child Behavior fathers Engaging Inventory; Strengths and Difﬁculties Questionnaire; Parenting Practices Interview 11 12 © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014 ahrn atrBike al. et Panter-Brick Catherine

Table 1 (continued)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Leksand Model 16–18 group sessions prenatal Expectant mothers and fathers Quasi-experimental design: Process: surveys (self-report), Johansson (2012), and to 12 months postpartum. recruited via maternity families of babies born in interviews, attendance Hoskings and Walsh (2010) Topics include child services, with fathers 2000, followed to 2006. records development, bonding, couple specifically invited to the first Leksand groups compared with Impact: (a) mothers & fathers: relationship, new roles, antenatal appointment and controls who received satisfaction with staff and parental leave there personally invited to traditional parent-preparation program; mother/father participate in Leksand and fewer sessions attendance; fathers’ parental leave uptake; program cost, and (b) children: collected, but not reported in English language publications Turkey Father Support 13-session weekly program Fathers only Surveys Process: Pre/post surveys Barker et al. (2009) Program (fathers’ self-report). (FSP), ACEV Impact: parenting skills and behavior; communication; gender relations United Kingdom © Celebrating Activities included: training for Fathers and male carers; local Report Process: Pre/post data Bath & North East Somerset 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 Fatherhood: a professionals; a photographic service providers; policy comparison (2011–12 vs. Council (2013) year long exhibition, a film, a website, a makers 2012–13). campaign celebration event, and Impact: numbers of fathers 2012–13 ‘Fathers’ Fridays’ using Children’s Centres, attending ‘Fathers’ Fridays’, SEN (Special Educational Needs) meetings, etc.; local media coverage about fathers Family Nurse 30-month intensive Highly vulnerable teenage (a) Survey of 54 fathers Process: father self-report; Ferguson and Gates (2013), Partnership home-visiting support for mothers, fathers frequently currently in the program, (b) professionals’ reports; Barnes et al. (2011), and (FNP) mothers (program on Licence engaged also interviews with 24 fathers and national data analysis Fatherhood Institute (2013) and developed from the US professionals: (c) Data and Impact: fathers’ program Nurse Family-Partnership information in National participation; couple Program) Evaluations communication and relationship; coparenting; parenting © Table 1 (continued) 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Strength to Assessment followed by c. 10 Fathers who have perpetrated Mainly process evaluation: (a) Process: interviews during/ Stanley, Graham-Kevan, and Change individual sessions followed domestic violence project throughput data (32 post intervention (no Borthwick (2012) by a 1 year group program men, 11 women) over baseline); data analysis. 18 months, (b) 47 interviews Impact: fathers’ motivation to (21 men, 13 partners), and (c) complete program and change 10 interviews with project behavior; actual behavior staff & steering group change; awareness of impact members. of violence on children Measure: Bespoke data collection tool recording individual’s and partner’s history, service use, social and family context, patterns of abuse and risks Ukraine UNICEF Papa Between 7 and 9 2-hr men-only Expectant fathers Regional data (no comparison Process: Baseline and McAllister et al. (2012) Schools peer mentoring sessions regions) and UNICEF postintervention surveys; across the transition to evaluation of the whole data analysis fatherhood. One element in a program Impact: fathers’ birth multifaceted program to attendance and knowledge improve early childhood and understanding of infant/

© health and development child development; 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 breastfeeding rates, infant mortality, child trauma United States Creating A 4-phase Families of preterm infants in RCT: 258 mothers (147 in the Process: analysis of hospital Melnyk et al. (2006) Opportunities educational-behavioral intensive care units COPE group, 113 in the data and demographic for Parent intervention program relating comparison group) and 154 information; parent Empowerment to the care of premature fathers (81 in the COPE group self-report and parent-infant (COPE) infants (audio-taped/written and 73 in the comparison interaction observation. Data information plus activity group). collected at baseline and at 5 sheets) Measures: State-Trait Anxiety other time points, including at Inventory; Beck Depression 2 months’ corrected infant Inventory; Parental Stressor age Scale-Neonatal Intensive Care Impact: (i) mothers and Unit; Index of Parental fathers: parental stress and

Behavior in the NICU; Parental mood; parental beliefs; fathers Engaging Belief Scale-NICU; Clinical parenting behavior; parental Risk Index for Babies (CRIB); sensitivity; involvement in Infant NICU LOS (length of infant care, and (ii) infant: hospital stay); demographic length of hospital stay and information; infant associated costs gestational age 13 Table 1 (continued) 14 ©

04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014 Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference al. et Panter-Brick Catherine

Early Head Fathers’ participation in EHS Low-income fathers of RCT: 74 fathers, 47% randomly Process: data collection at 10, Roggman et al. (2004) Start (EHS) activities preschoolers in a rural area assigned to EHS support 14, 24,and 36 months. Measures: Coded Observation at 24 months. Observational Measures; Impact: (a) fathers: Bayley Scales of Infant father-toddler social toy play, Development; Center for (b) toddlers: development at Epidemiological Studies 24 and 36 months Depression Scale; Parenting Stress Index; Dyadic Adjustment Scale Family Psycho-educational sessions, 8 Expectant ﬁrst-time parent RCT: 5-waves of follow-up; Process: pre–post surveys Feinberg, Roettger, Jones, Foundations classes over 6 months couples second wave involved n = 147 (parent self-report); Paul, and Kan (in Press), (FF) delivered through existing mothers (71 control, 76 observation. Brown, Feinberg, and Kan childbirth education intervention group). Follow-up Impact: (a) mothers and (2011), Feinberg, Jones, Kan, departments to 7 years in some instances fathers: includes individual and Goslin (2010), Feinberg, and family functioning Kan, and Goslin (2009), (stress, depression, quality of Feinberg and Kan (2008) couple and coparenting relationship), and (b) children: child adjustment Flint Fathers Fifteen 2-to-3 hr sessions Nonresident African American Quasi-experimental design – Process: pre/post test surveys Ellis, Caldwell, Assari, and De and Sons (fathers with sons) conducted fathers and their 158 intervention and 129 (self-report) Loney (2014), and Caldwell

04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 Measures;: Parental Monitoring monitoring; father–child 2014) Index; questions from some communications; validated scales coalesced into communication about sex new scales; demographic and and risky behavior extent; control variables intentions to communicate; race-related socialization; parenting skills; satisfaction, and (b) sons: paternal monitoring; father–child communications; communication about sex and risky behavior extent/ efﬁcacy; race-related socialization; intentions to avoid violence; physical ﬁghting; intentions to exercise © Table 1 (continued) 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Fatherhood 14 workshop hours over five Low-income, high-risk couples RCT: data collected from 112 Process: pre–post surveys Rienks et al. (2011), and Relationship group sessions, addressing with children fathers out of 137 couples (parent self-report); analysis Wadsworth et al. (2011) and Marriage issues known to affect the randomly assigned to couple, of demographic and control Education quality of couple male-only, or female-only variables. (FRAME) relationships: control. Impact: amount of father communication, coping, Measures: Demographic and involvement problem solving; parenting control variables including skills relationship with child (birth. v. social father); Brief Symptom Inventory-18 (anxiety & depression); 8-item Danger Signs scale (communication); Coping Efficacy Scale (modified); Inventory of Father Involvement; Communication Skills Test; Parenting Alliance Inventory; Dyadic Adjustment Scale (Relationship Adjustment Head Start Class-room volunteering; Fathers & father-figures of Quasi-experimental research Process: Pre/post fathers’ Fagan and Iglesias (1999)

© Fathers’ Day activities; 3-to-5 year olds design (146 intervention self-report; interviews; 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 fathers’ support groups; fathers/father-ﬁgures vs. 55 teacher report; observation father–child activity sessions. comparison group) in four Impact: (a) father: accessibility Father-sensitivity training for Head Start sites vs. four & engagement with child; staff control sites. support for learning; Measures: Parenting child-rearing behaviors; Dimensions Inventory dose-effect; father’s Parent/Caregiver Involvement residential status; child Scale gender, and (b) child: Woodcock-Johnson Tests of behavior; social skills; Achievement (revised) Social academic readiness skills Skills Rating System In-home A 12-week twice-weekly Fathers and mothers of 19 Surveys and observation. Process: pre/post surveys Bendixen et al. (2011), Elder training of in-home training for fathers in children with autism, Measures: ADI–R, ADOS, and (parent self-report); video et al. (2011), Elder et al. fathers of following the child’s lead, 3-to-8 year old the Vineland Adaptive observation. (2005)

children with imitation with animation, Behavior Scales; Parenting Impact: (a) fathers and fathers Engaging autism commenting on the child, and Stress Index–Short Form; mothers: parenting stress; expectant waiting Fathers also Family Adaptability and parenting behavior; trained to train mothers Cohesion Evaluation Scales II parent-to-parent knowledge/ skills transmission, and (b) child: behavior 15 16 © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014 ahrn atrBike al. et Panter-Brick Catherine

Table 1 (continued)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Inside Out 12 weekly group sessions in a Incarcerated fathers Quasi-experimental (n = 307) Process: Pre/post surveys Rutgers University-Newark Dads small group format with at and control (n = 104) groups (father self-report); Economic Development least one peer leader per in three correction facilities; postintervention interviews; Research Group (2011) group semistructured interviews data analysis. with program participants Impact: infractions; coping; (n = 27) and stakeholders conﬁdence in receiving (n = 6); within-facility support from staff; parenting comparison of infraction data knowledge; parenting collected for 90 days before behavior; parenting attitudes; program entry, during family relationships; views on program participation and for fatherhood; program content 90 days after program exit. and delivery Measures: Inside Out Dad Survey, plus Coping Self-Efﬁcacy Scale, Fathers’ Parental Attitude Research

© Instrument 9 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 Keep A Clear 4 weekly in-school lessons for Teenagers and their mothers RCT: 1022 parents and 511 Process: pre/post test student Werch et al. (1991) Mind (KACM) students, each followed by ﬁve and fathers teenagers assigned to and parent surveys drug use parent/child homework intervention and wait-list (self-report); teacher survey. prevention activities control. Impact: (a) fathers: program Measures: (a) for students, drug-related parent–child standardized and validated communication; parental developed by authors for beliefs; program compliance, previous studies, and (b) for satisfaction and perceived fathers and mothers, new but effectiveness; drug-related pretested knowledge; motivation to help children avoid drugs, and (b) children: alcohol, tobacco, and marijuana use, intentions, beliefs, and knowledge; program compliance and satisfaction © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014 Table 1 (continued)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Minnesota 5 9 90-min group sessions Expectant young African RCT: coparenting intervention Process: pre/post intervention Fagan (2008) Early held once a week for 5 American and Hispanic (n = 44, experimental group) questionnaires (mothers and Learning consecutive weeks fathers and their adolescent and childbirth/baby care fathers); weekly Design partners intervention (n = 46, questionnaires (fathers). Coparenting comparison group) plus Impact: coparenting; parenting and ‘strong’ quasi-experimental competence Childbirth design (n = 64, control group) curricula Measures: Fathers’ prenatal communication and involvement; Parenting Alliance; Fathers’ support of mother; Fathers’ engagement with infant; Parenting sense of competence; Demographic measures; Measure of fathers’ subjective experiences with the Intervention Oregon model Manual provides material for Stepfathers; stepchildren RCT: 110 recently married Process: Extensive DeGarmo and Forgatch (2007) of Parent 13 sessions families with an multiple-method data Management early-elementary-school-aged obtained from questionnaires, © Training focal child: experimental interviews, and direct 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 (PMTO) condition (61%) and control observation during four (39%) assessed over 2 years. center visits, plus The mean number of sessions preintervention baseline and attended by the intervention three postintervention group was 11.71 over an follow-ups. average of 27.42 weeks Impact: (a) stepfathers: involvement; engagement; parenting behavior, and (b) stepchildren: compliance; mood Shaken Baby Leaﬂets, posters, a video and Expectant and new mothers Quasi-experimental design Process: Post intervention Dias et al. (2005) Syndrome signed parental undertakings and fathers comparing abusive head survey; data collection; data Prevention in an 8-county region of trauma rates in 1–3 year olds comparison; Program western New York State over 5 years with Impact: rates of abusive head naigfathers Engaging preintervention rates in the trauma; parents’ recall of same region and state-wide video and leaﬂet content at rates during the intervention 7 month follow-up, extent of period commitment contract signature 17 18 © 04TeAtos ora fCidPyhlg n Psychiatry. and Psychology Child of Journal Authors. The 2014 ahrn atrBike al. et Panter-Brick Catherine

Table 1 (continued)

Parenting Target group and extent of Nature and rigor of the program Delivery father involvement evaluation Process and impact outcomes Reference

Siempre Papa Twelve 2-hr sessions Latino fathers, including in a 211 fathers participating in the Process: Pre–post father McAllister et al. (2012) (the 24/7 Dad implemented in groups or with correctional facility intervention 2006–2011 in self-report. Curriculum; individuals plus mental Maryland; plus headline Impact: fathers’ parenting Spanish health & case-management ﬁndings from other skills and knowledge; time edition, support evaluations spent with children; attitudes delivered toward partners and gender across the roles; communication with United States) partners and children

Supporting 32-hr curriculum over 14– Mainly low-income Mexican 3-arm RCT with 900+ couples. Process: baseline and Knox et al. (2011), Cowan Father 16 weeks by male/female American and African Men-primarily groups postintervention self-report et al. (2014), Cowan et al. Involvement coleaders including couple American families compared with and independent rating, with (2009), and Cowan et al. communication, parenting, couples-groups and controls. video observation and (2007) family behavior patterns. Case Measures include: video follow-up at 18 months.

© management and support observation; ‘The Pie’; ‘Who Impact: (a) fathers: 04AscainfrCidadAoecn etlHealth. Mental Adolescent and Child for Association 2014 provided does What’ Questionnaire; involvement and engagement, Father–child Relationship parenting stress and Scale; Parenting Stress Index; behavior, couple satisfaction, Parenting style attitudes (b) couples: relationship questionnaire; Quality of satisfaction, decreased stress, Marriage Index; Couple couple violence, harsh Communication parenting and family income, Questionnaire; Child Adaptive (c) children: behavior Behavior Inventory (hyperactivity) and adjustment, and (d) institutions: increased father-friendliness

Global programs are designated to a speciﬁc country where impact evaluation took place. RCT, randomized controlled trial. Process data describe the extent to which fathers were included in the deliverables of the intervention; impact data describe outcomes related to effectiveness. Engaging fathers 19

United States) benefited from a randomized con- ent-focused and child-focused variables, many of the trolled trial evaluation, and nine (four of them in the interventions in Table 1 include only parent-focused United States) from quasi-experimental evaluation. variables, rather than comprehensive measures of Even among these robustly evidenced programs, family functioning and child developmental out- sample sizes can be tiny: for example just 27 inter- comes. As for research methods, only eight of the vention and 26 control fathers were included in the interventions (e.g., the Home Visiting Program in Australian child obesity program (Healthy Dads, Canada) include observation, rather than just paren- Healthy Kids), while others (e.g., Supporting Father tal reports, to capture the quality of parent–child Involvement and Family Foundations, both United interactions. Few assessment periods extend to States) were couple interventions. Among 14 of our 6 months postintervention, although exemplar tabulated programs, evaluations took the form of cohort studies with several-wave data such as Family simple pre/post surveys, based on interviews with Foundations, the Leksand model and the Oregon mixed groups of participants, while in some cases model of Parent Management Training (Stepfathers) (e.g., Proyecto Papa in Accion , Peru), the evaluation are able to shed light on longer-term birth outcomes was a cross-sectional survey, postintervention. and school or family functioning. Few studies have Evaluations of programs from the global south included measures of mental health in their evalu- tend to be among the least rigorous. For example, in ation; the Family Foundations program is one exam- Jordan, while 93% of participants reported that the ple of couple-based prevention program that UNICEF-led Better Parenting Program was highly explicitly examined the protective or buffering effects useful in conveying the role of fathers in children’s on stress and maternal depression (Feinberg, Jones, lives, the evaluation survey data contained only 18 Kan, and Goslin, 2010). Some interventions have fathers out of a total 336 participants – so fathers’ focused specifically on violence prevention, including views are essentially missing (Al-Hassan & Lansford, reduced harsh parenting by fathers (examples 2011). And while the Turkish Mother Support Pro- include Triple P and Dads on Board in Australia, gram (ACß EV) is internationally renowned because of and UNICEF’s Better Parenting Program in Jordan). its long-term evaluation (yielding key evidence of And while outcomes in Table 1 encompass both lifetime effects and multilevel benefits), the associ- father impact and father participation, some parent- ated Turkish Fathers Support Program has received ing interventions (e.g., Celebrating Fatherhood in the limited evaluation, namely a pre- and postcourse United Kingdom and Aangan in Pakistan) were attitude survey to parenting roles, behavior, and designed principally to increase fathers’ engagement communication (Barker et al., 2009). with local services, rather than to assess the impact In looking at the evidence from Table 1, which of this on family or child wellbeing. Well-evaluated includes some of the best-known and best-evaluated parenting interventions (e.g., Incredible Years, Tri- programs for ‘parents’ in which fathers are known to ple-P, Family Nurse Partnership) typically report have participated, it is striking to find that (a) the moderate effects on parent and child outcomes, evidence relating to fathers, where presented, is including parents’ knowledge acquisition, health commonly secondary to the evidence pertaining to behaviors and children’s externalizing behavior. mothers, and that (b) the evidence relating to couple However, ‘father effects’ may remain elusive where v. individual participants is, with one exception, reporting is not gender-disaggregated, where sample missing altogether. Indeed, the CONSORT standards sizes of mothers or fathers are not equivalent, or designed to provide a systematic and explicit frame- when different procedures are used for fathers and work for reporting quasi-experimental or experimen- mothers in data collection. tal data are far from attentively adhered to.

Discussion and recommendations What outcomes are reported? Our evidence base shows that systematic evaluation We indicate in Table 1 and Table S1 a range of of ‘father engagement’ and ‘father effectiveness’ is process and impact outcomes. The ‘process data’ stymied by the way parenting interventions are describe the activities, schedules, and deliverables of designed and delivered. We turn to the second the intervention, while the ‘impact data’ describe question guiding this review: what improvements outcomes related to effectiveness per se. In most can be made? Thus far, our results show that an cases, the lack of robust evaluation makes it difficult overhaul of program design and delivery is required to evaluate ‘findings’ and substantiate the claims to obtain the necessary good-quality data on father that programs have made for positive outcomes of and couple participation and impact. In both father engagement; for this reason, we do not tabu- research and community-based practice, a game late empirical findings. change in this field would consist in engaging The evidence base on fathers is both patchy and unequivocally with coparents – rather than include limited, reflecting the fragmented nature of data just mothers and explicitly or implicitly marginalize collection and program design. While relevant out- fathers and other coparents, as in the bulk of comes of parenting interventions include both par- parenting interventions implemented to-date.

Table 2 offers a guide to best practice to help rethink and family functioning, either positive or negative, is issues of (a) design, (b) delivery, and (c) evaluation on a incontrovertible, it is short-sighted to sideline fathers, global or local scale. We identified, from our reading of or indeed other coparents, and to ignore their contri- the literature, key issues at each of these three stages butions by focusing only on mothers. Asking the of parenting interventions; specifically, our research question ‘how to make parenting interventions cul- and clinical experience led us to highlight issues that turally compelling to both fathers and mothers as present themselves as programmatically related to coparents?’ is a good starting point. The next funda- engaging coparents. First, with respect to design, we mental requirement for a game change in parenting identified seven major issues in terms of cultural, interventions would be to pay attention to the neces- institutional, professional, operational, content, sity of gender-disaggregated data collection and data resources, and policy biases that work to marginalize reporting – namely, exactly how many fathers, moth- fathers from the outset. We have already raised some ers, and coparents participated in a given program – to of the gender biases in cultural, institutional, and render analyses by subgroup possible. professional practices predicated on a deficit model Second, with respect to delivery, we highlight key that sees fathers as ineffective or neglectful as par- programmatic and logistic issues that can work to ents. Because the impact of fathers on child wellbeing systematically disengage fathers from parenting

Table 2 A guide to best practice for building the evidence base of coparenting interventions

Design Delivery Evaluation

Cultural biases: How When, where, and how: Does the timing, Reach: Inclusion and engagement of culturally-compelling are parenting the place, and the medium of program significant caregivers, including fathers interventions, in terms of making delivery work to include fathers as well as and other individuals in addition to themselves relevant and attractive to mothers? Are sufficient resources mothers. coparents? committed to ensure reaching them both? What are the advantages and disadvantages of individual home visits vs. group-based programs, and those of programs that engage with single parents vs. coparents? Institutional biases: How father-friendly Training: Are facilitators ready and Process: Data on recruitment of is the organization in terms of policies, skilled to work with coparents, fathers as participants, delivery of program, recruitment, support, and monitoring? well as mothers or other caregivers? Are monitoring of attendance, participation, How responsive are parenting their approaches sensitive to and referrals, pre/post institutional interventions to gender-related gender-specific concerns? practices, and participant attitudinal differences in parenting goals? changes; observation and monitoring beyond self-reports. Professional biases: Do staff capabilities Communication: Are both mothers and Impact: Prevention and reduction of and attitudes toward parents exclude fathers explicitly informed and problematic outcomes related to quality fathers? individually reminded about the of parenting and family functioning; child importance of program participation, and outcomes in health, education, benefits to children? Are both parents psychosocial development, and followed up in cases of nonattendance? maltreatment. Are nonparticipating partners explicitly contacted? Operational biases: Is data collection on Activities: Are homework expected of all Sustainability: Commitment to policies, parents disaggregated by sex? Does it coparents? Is participation monitored for resources, and activities; outcomes identify coparents among mixed groups one or both parents? lasting beyond a program’s timeframe. of participants? Content biases: Is the content of the Holistic support: Are the needs of fathers Cost: Demonstrable cost-benefit for intervention relevant to fathers, as well as well as mothers recognized? Where children, families, and societies; as mothers? support is needed, are male as well as estimated cost of failing to engage with female caregivers directed to relevant coparents. health, education, and other social services? Resource biases: Are sufficient resources Equity: Better outcomes for those most committed to enable an organization to disadvantaged. audit current practices and implement change? Policy biases: Are vision, needs Scale-up: Provision for replication in other assessment, partnerships, action plans, settings; dissemination of findings to and strategies endorsed and integrated, strengthen the evidence base; advocacy with clear attention given to gender and for a policy agenda on child wellbeing. coparenting issues?

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. Engaging fathers 21 interventions. For example the timing and the loca- nisms and scale-up of initiatives with demonstrable tion of program delivery can be obvious deterrents to short- and long-term benefits. For example in their fathers, and to working parents generally. The case of review, Olds et al. (2007; p. 372 and p. 381) cited Family Foundations presents a good example of a estimates from The Washington State Institute for method of delivering a program to first-time parents in Public Policy showing that two programs – Parents a nonstigmatizing way, with 8-week sessions pro- as Teachers (home visits and 3-year parent-group vided through an existing institutional niche, namely meetings) and the Nurse-Family Partnership program a hospital’s childbirth education department (Brown, (tested in three separate randomized controlled Feinberg & Kan, 2011). Involving fathers early on, trials, RCTs) – respectively produced a offering flexible hours or visiting at home, being $800-per-family and a $17,000-per-family return persistent in communicating the positive gains to on investment. Importantly, Heckman and col- children of father involvement, being explicit in wel- leagues have argued that traditional ‘equity-effi- coming them personally to participate (not simply ciency tradeoffs’ are not pertinent to interventions through the mothers), are all essential steps that delivered to disadvantaged children in the early remove barriers to father engagement (Maxwell, years of life: early child development programs offer Scourfield, Featherstone, et al., 2012). Some key both a cost-efficient way to produce a capable questions – with respect to ‘how’ programs are best workforce and an equity-gain in helping those at implemented – still remain unanswered: depending greatest disadvantage (Heckman, 2009; Heckman & on cultural norms, risk profiles, financing and flexi- Masterov, 2007; Campbell et al., 2014). From a bility, programs might work best when targeting policy point of view, ‘it is not enough to know that mothers and fathers during home visits or when early-life conditions matter. It is important to know delivering group-based parenting programs in health, the costs and benefits of remediating early-life def- community or employment settings, and might be icits at different stages of the life cycle’ (Conti & most effective when reaching out to an individual Heckman, 2013), as well as the longer-term benefits parent or to two or more family members involved in of enhancing the capabilities of children. coparenting. Finally, with respect to evaluation, key issues include moving beyond the evaluation of process Conclusions data (for example how many fathers or mothers This review has fore-grounded discussion of parent- participated in program activities and how and when ing interventions that include fathers as significant impacts were measured). What is needed is more actors in the lives of children. It makes a threefold robust and longer-term evaluation of outcome data, contribution to the extant literature: we provide a to include parenting quality, coparenting quality, global and comparative overview of the evidence family functioning, parental stress/depression, as base, highlight why there are weaknesses in this well as child outcomes in relation to health, educa- field, and offer recommendations on father inclusion tion, psycho-social development and maltreatment. and engagement. At best, this evidence is provided through random- First of all, our review demonstrates a current lack ized controlled trials, cohort studies, observations, of synthesis and coherence in the global evidence or third-party reports. We highlight here issues of base. To-date the literature on father engagement is reach and sustainability, rather than just effective- highly fragmented across education, gender, social ness or impact. These are important components of work, and health-related fields, with patchy synthe- programmatic ‘success’ that raise issues regarding sis therein. It lacks a comparative perspective as well possible tradeoffs between effectiveness, efficiency, as global representation, which makes it difficult to and equity. For example they raise questions as to extrapolate relevant data from the experience of whether the needs of harder-to-reach fathers are practitioners and participants in the high-income served in parenting interventions, and whether psy- north, and from the initiatives emerging from the cho-education programs targeting behavior change, global south. in the absence of structural interventions to benefit Second, our review highlights a number of reasons vulnerable families, benefit mostly those who are why the evidence base on parenting interventions already advantaged. that have included fathers is often of poor quality. One of the most neglected aspects of evaluation There are few exemplars using an overarching the- relates to economic arguments, in terms of compar- oretical model or an integrated operational strategy ing the benefits of targeted versus holistic interven- from design through to evaluation. Most reviews tions or engaging with one parent versus coparents. to-date have included studies in which the small A comprehensive framework would include numbers of participating fathers were excluded from cost-effectiveness analyses, evaluating alternative analysis, in which ‘parents’ were undifferentiated by yet comparable programs, and cost-benefit analyses, gender, and in which the participation of couples weighing tradeoffs of alternative investments for versus individual parents was not accounted for. ‘maximum social gain’ (Naudeau et al., 2011; pp. Our understanding of fathers’ participation and 160–2), to allow better financing allocation mecha- impact in parenting interventions is therefore still

© 2014 The Authors. Journal of Child Psychology and Psychiatry. © 2014 Association for Child and Adolescent Mental Health. 22 Catherine Panter-Brick et al. in its infancy, and the generalizability of findings far tance of grandmothers, mothers-in-law, and other weaker for fathers than for mothers. relatives in the global south. The gendered and social Third, we make recommendations on father inclu- nature of parenting means that fathers, mothers, and sion and engagement in parenting programs, but other caregivers arrive with distinct expectations, caution that these must be respectful of cultural assets, constraints, and experiences: these cannot values and consonant with structural constraints be homogenized or overlooked. In lower-income coun- that shape everyday behavior. Some of the evidence tries, women (e.g., in the ACß EV-led initiatives in presented in this review comes from father-only Turkey, Aangan in Pakistan) and professionals (e.g., programs, with only a few focused more comprehen- healthcare and development workers in Niger, sively on coparenting relationships. While this evi- Jordan, Ukraine) have actively sought methods of dence is important, one must not be drawn into engaging men in family issues. They work to mobilize thinking that father-only programs are the best way men’s interest and to engage men in private and public forward – some noteworthy research suggests that spaces, in order to enhance interpersonal communi- they are not (Cowan et al., 2009; Spaulding, Gross- cation, family-level care, community action, and child man, & Wallace, 2009; Wadsworth et al., 2011). outcomes. Indeed, many men are extremely unwilling to attend Parenting interventions thus need to be compelling men/father-only groups (Russell et al., 1999), while to all stakeholders and decision-makers, namely from a programmatic point of view, men-only services fathers and other significant caregivers as well as are often an add-on to other programs, deemed mothers, program directors, and funders. More spe- unsustainable when resources are short. Further- cifically, resources can be unnecessarily wasted more, behavioral change within families seems unli- where there is no effective engagement with fathers kely to be sustained when only one parent, whether in their roles as caregivers, because this may the mother or father, is the sole target of a parenting undermine a range of existing parenting activities intervention. We need to comprehensively under- and negate additive or synergistic impacts in the stand the community of care provided to children, lives of children. Whether absent or present, fathers and the sensitivity of children to a range of caregiving have an impact on children, mothers, and family contexts. A body of cross-cultural research thus dynamics, for better and for worse. Marginalizing reminds us of the significance of alloparents (includ- such important players amounts to poor profes- ing grandparents, other blood relatives, and commu- sional practice and poor evaluation. It may also nity neighbors) as alternative caregivers with a stake undermine practitioners’ and policy makers’ duty of in the everyday responsibilities of parenting, beyond care, in failing to assess risk, enhance resilience, and sole consideration of the mother or biological parent optimize the positive impacts on family and child (Bentley, 2009). In fact, children may be raised by wellbeing that are aspired to in parenting interven- several generations of female relatives, as in Mexico tions. Key priorities are to engage fathers and (Solis-Camara et al., 2014), or placed under the care coparenting couples successfully, to disaggregate of different relatives in response to changing socio- process and impact data by fathers, mothers, and economic demands, as in Afghanistan (Panter-Brick, coparents, and to pay greater attention to issues of Goodman, Tol, & Eggerman, 2011). This raises ques- reach, sustainability, cost, equity, and scale-up. tions regarding which program modalities are the most compelling in which contexts, focusing attention on the means of program delivery (group-based Supporting information vs. home visits, universal v. targeted, mother-only, Additional Supporting Information may be found in the father-only, or coparents), above and beyond atten- online version of this article: tion to program content. Recent advances in the field Table S1 Global overview of parenting programs that of child health and development have also reminded evaluated father impact and participation. us that we need to rethink interventions in terms of the best leverage points to build family-level resilience, not just minimize risk to children (Panter-Brick Acknowledgements & Leckman, 2013). They also challenge us to rethink The authors received no specific funding to undertake ß the kind of evidence needed to detect ‘differential this systematic review. They thank the Yale-ACEV partnership, The Fatherhood Institute, and the Bernard susceptibility to context,’ regarding both adverse and van Leer Foundation for their collaboration, and beneficial effects of parenting (Pluess & Belsky, William Hodges for generating the initial set of refer- 2010). ences to be reviewed. Understanding the fundamental dimension of gender in parenting programs is as significant as current efforts to target the different subgroups of Correspondence mothers (lone parent, teenage mothers, low-income Catherine Panter-Brick, Department of Anthropology & mothers, minority-group mothers, substance-abusing Jackson Institute, Yale University, 10 Sachem Street, mothers, and/or incarcerated mothers) in the global New Haven, CT 06511, USA; Email: Catherine.panter- north, or indeed to recognize the caregiving impor- [email protected]

Key points • Fathers have substantial impact on child development, wellbeing, and family functioning, yet parenting interventions rarely target men, or make a dedicated effort to include them. • Our review of the global evidence on parenting interventions that have included men as parents or coparents shows that insufﬁcient attention is given to reporting father participation and impact. • A fundamental change in the design and delivery of parenting interventions is required to overcome pervasive gender biases and to generate robust evidence on outcomes, differentiated by gender and by couple effects in evaluation.

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