Building long-term family resilience through universal prevention:

10-year parent and child outcomes during the COVID-19 Pandemic 2 Building Family Resilience

Abstract

As the COVID-19 pandemic has been highly stressful for parents and children, it is clear that strategies that promote long-term family resilience are needed to protect families in future crises. One such strategy, the Family Foundations program, is focused on promoting supportive coparenting at the transition to parenthood. In a randomized trial, we tested the long-term intervention effects of Family Foundations on parent, child, and family wellbeing one to two months after the imposition of a national shelter-in-place public health intervention in 2020. We used regression models to test intervention impact on outcomes reported on by parents in a standard questionnaire format and a series of 8 days of daily reports. We also tested moderation of intervention impact by parent depression and coparenting relationship quality. Relative to control families, intervention families demonstrated significantly lower levels of individual and family problems (general parent hostility, harsh and aggressive parenting, coparenting conflict, sibling relationship conflict, and children’s negative mood and behavior problems), and higher levels of positive family relationship quality (positive parenting, couple relationship quality, sibling relations, and family cohesion). For some outcomes, including coparenting conflict, harsh parenting, and child behavior problems, intervention effects were larger for more vulnerable families—that is, families with higher pre-pandemic levels of parent depression or lower levels of coparenting relationship quality. We conclude that targeted family prevention programming is able to promote healthy parent and child functioning during unforeseen future periods of acute stress. The long-term benefits of a universal approach to family support at the transition to parenthood indicate the need for greater investment in the dissemination of effective approaches.

Keywords: Prevention, family, mental health, pandemic 3 Building Family Resilience

Introduction

Anecdotal reports, surveys (Spinelli, 2020), and longitudinal research ((Feinberg,

Under review) indicate that stressors accompanying the COVID-19 pandemic have had a substantial detrimental impact on parent and child mental health. These conclusions are consistent with research demonstrating that parental stress and mental health problems increased during other crises--such as the Great Depression and Iowa Family

Farm Crisis-- in turn leading to interparental conflict, harsh and abusive parenting, and increases in children’s mental/behavioral health problems (Conger et al., 1994;

Schneider, 2017).

Supporting the well-being of parents and children during such crises is critical.

However, with the predicted increases in frequency and severity of environmental, social, and economic crises (Banholzer et al., 2012), it is also important to consider preventive approaches that strengthen parent and child resilience before such crises occur. This long-term follow-up study of a randomized trial examined the long-term impact of a universal, family-strengthening, preventive intervention approach, assessing parent and child outcomes during the COVID-19 pandemic. The prevention program,

Family Foundations (FF), was delivered as a series of 9 pre/postnatal classes to randomly assigned couples expecting a first child roughly ten years before the pandemic.

FF focuses on enhancing the coparenting relationship at the beginning of family formation—a period of normative but stressful change, accompanied by moderate increases in parent depression and couple conflict, and decreases in relationship 4 Building Family Resilience satisfaction (Feinberg et al., 2016; Lawrence et al., 2008). The coparenting relationship is defined as the subset of the interparental relationship concerned with how parents support and coordinate with each other regarding childrearing tasks and responsibilities.

This is viewed as a critical foundation of the well-being of all family members and the quality of other family relationships ((Feinberg, 2002, 2003). As new parents are often uncertain and caretaking can be stressful, support from the other adult involved, the coparent, is a key influence on parental self-efficacy, a “final common pathway” toward positive parenting (Teti et al., 1996). On the other hand, given the psychological importance of one’s parenting role, undermining and conflictual coparenting interactions are a key factor leading to parental stress, anxiety, and depression (Feinberg, 2002,

2003). The combination of parents’ adjustment (i.e., self-efficacy, stress, and mental health) predicts levels of warm and harsh parenting, all of which influences children’s mental and behavioral health.

Tests of FF program effectiveness and mediational pathways in earlier waves of this study and other FF trials (Feinberg et al., 2020; Feinberg et al., 2009; Jones et al.,

2018; Solmeyer et al., 2014) support the potential benefits for parents and children of targeting the coparenting relationship in a preventive manner. Moreover, the benefits of enhanced coparenting quality at family formation appear durable; we have reported long-term impacts of FF as far out as 7 years after birth on teacher’s reports of children’s internalizing, externalizing, and academic adjustment (Feinberg et al., 2014).

However, it is unclear if the beneficial outcomes of a limited dosage, universal preventive intervention would be swamped by the multi-layered combination of social, economic, and health stressors that often arise in the face of severe crises. Infectious 5 Building Family Resilience disease epidemics such as COVID-19, economic crises such as the Great Recession, and environmental disasters such as floods, fires, or storms, often present an array of acute difficulties that may cumulatively overwhelm parents’ and children’s ability to cope.

The durability of the long-term outcomes observed in prior Family Foundations studies holds promise for the hypothesis that such beneficial outcomes persist even during unforeseen, extended crises such as COVID-19. In fact, it may be that FF’s proximal aim of enhancing supportive coparenting relations serves as a critical protective factor in the context of future adversity. As depicted in the conceptual (not analytic) model in Figure 1, which is an adaptation of the ecological coparenting model

(Blinded), we posit positive and effective coparenting relationship functioning as a key factor in how families cope with and adapt to new crises. A supportive coparenting relationship which facilitates sharing of information, emotional support, problem-solving, and joint decision-making would support parents’ ability to cope with unforeseen, new crises. In this regard, it is notable that some pandemic-related challenges and stressors are coincidentally similar to those that arise at the transition to parenthood: Parents have been faced with major changes in daily routines; increased caretaking responsibilities; a need for increased coordination around work and minding children; demands by children for increased emotional support; and a need to acquire, process, and make decisions about new information related to health risks (Power, 2020;

Russell, 2020).

In this study we test the hypothesis that families randomly assigned to FF ten years ago demonstrated better parent and child adjustment and higher quality family 6 Building Family Resilience relationships in the early phase of the pandemic compared to control families.

Moreover, given gender differences in the impact of the pandemic on parents (Alon,

2020; Power, 2020) as well as prior gender differences in FF outcome research, we explore program impacts by parent gender.

We also explore whether pre-pandemic parent depression or coparenting quality moderate program outcomes. A general finding in the prevention literature is that the impact of family-focused prevention (Jones et al., 2018) is often accentuated among families with higher levels of risk factors. On the one hand, the benefits of preventive intervention are especially salient for these families; on the other hand, it is often more difficult to detect intervention effects among families at low levels of risk as there is less potential for intervention to improve outcomes. For both of these reasons, we hypothesize that the effects of FF would be accentuated among families with higher levels of risk pre-pandemic. We operationalize risk here by assessing pre-pandemic levels of parent depression and (low) coparenting quality: These two factors are important factors supporting the ability of parents to cope with and adjust to stressors

(blinded; Council, 2009) while promoting healthy family relationships and child well- being.

Methods

Participants in the current study were drawn from a parent study--a randomized trial of FF (Feinberg et al., 2016; Feinberg, Roettger, et al., 2015; Jones et al., 2018).

Participants were recruited primarily from central Pennsylvania, as well as Delaware and Texas, between 2008 and 2012. Couples were eligible if they were expecting a first 7 Building Family Resilience child, at least 18 years of age, and resided together. 399 primiparous mother and father dyads enrolled. Those randomized to the intervention condition were invited to participate in FF, consisting of nine classes before and after birth. Four waves of data were collected between pregnancy and 4 years postpartum. When children were in first or second grade, wave 5 data collection was initiated for the first cohorts of the study.

Wave 5 data began to be collected two years before the pandemic onset, and included parent and teacher reports of children’s adjustment.

When the COVID-19 pandemic began, we paused wave 5 data collection. At that point, of the overall sample, 208 (52%) families had participated, 161 (41%) families had not yet been contacted or had not scheduled a home visit, and 30 (7%) families had declined to participate in wave 5, withdrawn from the study, or become ineligible for further follow-up. Analyses of participating wave 5 families indicated no systematic or differential attrition across conditions based on 6 demographic variables (parent gender, child gender, parent education, parent age, household income, marital status) and 12 other variables representing physical, mental, and behavior health and couple relationship quality.

After pausing the parent study, we invited participation in an optional substudy in

April/May 2020. This optional substudy examined adjustment during the pandemic, assessed through parent report on an online questionnaire. After completing the questionnaire, parents were asked to complete an 8-day burst of brief daily reports to facilitate understanding of daily fluctuation of family dynamics during the pandemic

(blinded). As daily reports reduce demand for retrospective recall, daily report data may 8 Building Family Resilience differ in levels of scores or degree of bias from medium-term recall in standard questionnaires (Bolger et al., 2003), we utilized both standard questionnaire and daily report scores of a construct where available; daily report measures assessed the same

(e.g. daily behavior problems vs. externalizing problems) or related constructs (e.g., daily child mood vs. internalizing problems). We invited parents from the 330 families who had not previously withdrawn from the study and for whom we had current contact information, indicating to them that this substudy was optional as we did not want to increase their stress during the difficult early period of the pandemic. 158 (48%) mothers and 118 (35%) fathers from 174 (53%) families completed the online questionnaire. Of these, parents from 156 (89%) families participated in the daily report burst: 149 (94%) mothers and 103 (87%) fathers completed an average of 6.6 and 6.8 days of reports, respectively. This optional wave of data collected in April/May 2020, including the online questionnaire and daily reports, is the focus of this study.

The 174 families participating in the pandemic-period survey had an average 2.3 children (SD=1.0; range=1-5). As had been the case in all prior waves, the target child for purposes of parent report was the oldest child in each family (47% female), who was an average of 9.5 years old (SD=1.2). Mothers and fathers were on average 38.8

(SD=4.5) and 40.5 years (SD=5.3), respectively. At pretest, parents had completed an average of 15.4 years of education (SD=1.7), and median annual household income was $87,500 (SD=38,807; range = $$2,500-$162,500). 165 couples (95% of families participating in the pandemic-period survey) were still living with the same partner with whom began the study, and all but 4 were married. Of the 9 couples no longer living together, 3 were never married, 5 were divorced, 1 was married but separated. 9 Building Family Resilience Reflecting the original recruitment area, 95% of parents were non-Hispanic White, 3% were non-Hispanic Black, and 2% were Asian. No significant differences were found in attrition from wave 5 to the optional pandemic survey by intervention condition, education or income. However, pandemic-period survey participants were more likely to be White non-Hispanic than non-participants. No significant differences in differential attrition were found for education, income, or race.

Intervention

Family Foundations was delivered to intervention couples through a series of five prenatal and four postnatal classes. The classes were led by two trained group leaders

(one male/one female). Lessons focused on coparental conflict resolution and problem solving, communication and mutual support strategies, and parental expectations of the postpartum experience and expectations of each other. In order to enhance participant interest and reduce burden, the prenatal classes also included standard childbirth education material so that participants did not have to attend a separate class series for childbirth preparation. Engagement was very high: Over half of intervention couples attended at least 8 of the 9 classes. Average attendance was 6.7 classes (4.4 prenatal classes and 2.3 postnatal classes. One prenatal and one postnatal class for each cohort were videotaped and rated by a trained, reliable observer for implementation quality; percent of content delivered and quality of delivery was judged to be high (blinded).

Families assigned to the control group received mailed written materials on selecting quality childcare and the stages of child development.

Measures 10 Building Family Resilience Unless noted explicitly as part of the daily report assessments, all measures were implemented in the standard questionnaire administered before parents undertook the daily report burst. Daily report measures were created for this project, loosely based on

Parent Adjustment

Parents reported on their levels of Hostility using four items from the Symptoms

Checklist-90-Revised (SCL-90-R) (Kaplan, 1998), including “feeling easily annoyed or irritated” and “getting into frequent arguments”. Higher scores indicated higher levels of hostility (alpha = .78). Parents reported how often they had felt Depressive Symptoms during the last week using 20 items (alpha = .89) from the CES-D Scale (Radloff, 1977), including “feel lonely” and “feel that your life has been a failure”. Higher scores indicated higher levels of depression.

Family Relationships

Parents reported on overall Coparenting Relationship Quality over the past month using the brief version of the Coparenting Relationship Scale (14 items) supplemented with 3 additional items relevant to the pandemic (Feinberg, Brown, et al.,

2012). Example items included “I believe my partner is a good parent” and “my partner and I have the same goals for our child”. Higher scores indicate better coparenting relationship quality (alpha = .89). On the daily report measure, parents reported on

Coparenting Tension or conflict: Parents were asked “how much tension or disagreement was there between you and your partner today regarding the following topics?” 7 topics were presented (alpha = .93), including “sharing parenting duties” and

“money, financial issues.” Parents reported on Relationship Satisfaction using the Love 11 Building Family Resilience and Relationship Scale (Braiker & Kelley, 1979), a 14-item measure that asks parents about their relationship during the past month. 5 items were used, including “to what extent do you love your partner at this stage?” and “How close do you feel toward your partners?”. Higher scores indicate greater relationship satisfaction.

Parents rated their Positive and Negative Parenting on 6 items from the Child’s

Report of Parenting Behavior (CRPBI) (Schwarz et al., 1985) asking how they behaved towards their oldest child during the past month, with 3 positive (alpha = .76) and 3 negative (alpha = .60) items. Example items included “I spoke to my oldest child in a warm and friendly voice” and “I lost my temper with my oldest child”. Higher scores indicated more positive and more negative parenting, respectively. In the daily report measure, parents reported on Positive Parental Discipline and Aggression with items adapted from the Parent-Child Conflict Tactics Scale. Positive Parental discipline was measured with 2 items (r = .36, p < .01): “In the last 24 hours, did you take any of these actions towards your oldest child?”: “Set clear limits” and “Give a time out or consequence”. Daily level of Parenting Aggression was assessed with 6 items (alpha

= .81) using the same question stem; example items include “say something sarcastic or mean” and “threaten to spank or hit”.

Parents with more than one child reported on their oldest child’s behavior with his or her younger sibling(s) over the past week using 5-items from the Sibling Interaction

Relationship measure (Stocker & McHale, 1992). 2 items reflected positive relations (r =

.86, p < .01) and 3 items reflected negative relations (alpha = .77). Example items included “talked with his/her siblings in a nice and friendly way” and “got mad or angry 12 Building Family Resilience at his/her siblings”. Higher scores indicated more positive and more negative sibling relationships, respectively. Parents reported on Family Cohesion with four items (alpha

= .74) from the Family Environment Scale (Moos, 1974), asking about their family over the past month. Example items included “family members feel very close to each other” and “family members like to spend their free time with each other” . Higher scores indicated greater family cohesion.

Child Behavior

Parents reported on target children’s Externalizing and Internalizing behavior problems during the past month using eight (alpha = .60) and six items (alpha = .67), respectively, from the Strengths and Difficulties Questionnaire (Goodman et al., 1998). Example items included “often loses his/her temper” and “has many worries or often seems worried”. Higher scores indicated more externalizing and internalizing problems. In the daily report, parents reported on children’s Behavior Problems with five items asking how much time over the past 24 hours their child behaved in a variety of negative ways towards either parent. The 5 items (alpha = .89), including “refuse to cooperate” and

“throw or break things”, were created based on topics and behaviors addressed in standard questionnaire measures. In the daily report measures, parents also reported on how much of the time that day their oldest child seemed in a Positive Mood with one item: “happy”. Children’s Negative Mood was assessed with 4 items (alpha = .89), including “worried or anxious” and “tense or irritable”.

Control Variables 13 Building Family Resilience Pre-pandemic (wave 5) levels of total family income (reported in categories ranging from under $5,000 to $150,000), parent education, and relationship satisfaction from wave 5 were used as control variables. When not utilized as a moderator, Parent depression from wave 5 was used as a control variable in all analyses. Given that all outcome measures were reported on by parents, we also included parent report of social desirability (Crowne & Marlowe, 1960) at pretest as a control variable.

Analyses

Daily report measures were averaged across days. We assessed intervention impact for all questionnaire and daily report measures with hierarchical linear regression models (SAS proc mixed); parent scores were nested within family and intervention condition was entered as a fixed effect. Missing data was accommodated with maximum likelihood techniques. Each outcome was assessed in a separate model We assessed moderation of intervention effects by testing, in separate models, interaction terms comprised of intervention condition (0=control, 1=intervention) and parent gender

(1 = male, 2 = female), pre-pandemic parent depression, and coparenting relationship quality. Continuous variables were grand mean centered to aid in interpretation.

Adjusted means were calculated using the LSMEANS command to compute effect sizes for significant differences (Cohen’s d).

Results

Descriptive statistics and results of tests of intervention main effects are provided in Table 1. Only significant effects are discussed (see Table 1 for non-significant 14 Building Family Resilience results). For the questionnaire measures, tests of main effects of the intervention condition indicated more positive and less negative adjustment for the intervention condition relative to the control condition for parent general hostility (b = -0.18, p < .05), positive (b = 0.32, p < .001) and negative (b = -0.21, p < .05) parenting quality, couple relationship satisfaction (b = 0.37, p < .05), negative (b = -0.35, p < .05) and positive sibling relationship quality (b = 0.40, p < .05), family cohesion (b = 0.20, p < .01), and a trend for coparenting relationship quality (b = 0.16, p < .10). For the daily report variables, tests of main effects of the intervention condition indicated better adjustment for the intervention condition relative to the control condition for coparenting tension (b =

-0.36, p < .001), parent aggression (b = -0.03, p < .001), child positive (b = 0.23, p

< .05) and negative mood (b = -0.36, p < .001), and child behavior problems (b = -0.13, p < .001).

Parent gender did not significantly moderate intervention effects on any outcome measures (all ps > .10). We found significant moderation by parental depressive symptoms on the survey report of family cohesion (b = 0.61, p < .05), and for the daily reports of coparenting tension (b = -1.90, p < .001), parent discipline (b = -.26, p < .001). parenting aggression (b = -0.15, p < .001), child positive (b = 0.74, p < .05) and negative mood (b = -0.91, p < .01), as well as a trend for positive parenting (b = 0.55, p < .10). In all cases except parent discipline, intervention effects were larger when parents reported higher levels of depressive symptoms (Figure 2).

We also found significant moderation by coparenting relationship quality on the daily reports of family cohesion (b = -0.34, p < .001), parent discipline (b = 0.16, p 15 Building Family Resilience < .001), parenting aggression (b = 0.07, p < .001), and child behavior problems (b =

0.14, p < .001). For all of these except parent discipline, intervention effects were larger for families experiencing lower levels of coparenting relationship quality.

For parent discipline, intervention effects in both sets of moderation models were larger among families at lower risk. In other words, among families who reported lower levels of depression or higher levels of coparenting quality, intervention parents reported using more positive discipline than control parents.

Discussion

In earlier work, we found that parent, child, and family well-being declined from levels assessed before the onset of the COVID-19 pandemic to the early phase of the pandemic (Feinberg, Under review). The magnitude of the deterioration in well-being was surprisingly large. In this report, we examined whether a universal, preventive program for expectant couples implemented ten years ago would demonstrate long- term protective effects for families—reducing the degree of deterioration in well-being— during the highly-stressful first phase of the COVID-19 pandemic. In prior waves of data collection with this sample when children were infants and toddlers, we had found robust intervention effects and thus hypothesized that intervention impacts would continue and benefit families during the early phase of the pandemic.. Overall, we found robust evidence in this long-term follow-up study that the acute stress of the pandemic did not swamp the benefits of the intervention, and that intervention families continued to show higher levels of individual and family well-being compared to control families. Moreover, we found positive intervention effects on some domains that had not 16 Building Family Resilience been targeted by the intervention or assessed in prior waves.

As the proximal target of Family Foundations (FF) is the coparenting relationship, based on the we hypothesis that coparenting is a foundation of all family members’ well- being and of positive family relationships (Feinberg, 2002, 2003), we were especially interested to understand program impacts on coparenting. We found significant intervention effects on the average level of parents’ daily reports of coparenting tension and conflict, but a trend towards significance on a questionnaire measure asking parents to report retrospectively on coparenting over the past month. It is possible that daily reports of coparenting were more sensitive during this time period relative to a standard questionnaire regarding coparenting. It may be that parents’ long-term experience and evaluation of their coparenting relationship influenced their reporting more strongly on the more general questionnaire measure. We also found significant program impact on couple relationship satisfaction, a related but distinct construct from coparenting relationship quality. Although we view coparenting as a more salient causal influence on family member well-being and family relationships than couple relationship quality in early childhood, couple relationship quality may become increasingly important as children grow older and the intensity of hands-on, daily parenting tasks and hassles decline.

In prior research, we have found that FF participation has been linked to reduced parent depression; however, we did not find main effects of the intervention on depression during the pandemic. It’s possible that the stress of the pandemic led to very high levels of depressive symptoms that swamped intervention effects. Indeed, we 17 Building Family Resilience previously found that levels of parent depressive symptoms showed large increases from the pre-pandemic period to May 2020 (Feinberg, Under review).

Although we did not find an intervention effect on parent depressive symptoms in this study, we did find an effect on parents’ feelings of general hostility and anger relative to control parents. These findings are consistent with the FF conceptual model in which coparenting is associated with better parent adjustment, which leads to more positive parenting quality (blinded). In addition to reporting lower levels of coparenting conflict and parent general hostility relative to control parents, intervention parents also reported lower levels of aggressive and negative parenting, and higher levels of warm parenting towards children. Again, these results were obtained during a period—the early stage of the COVID-19 pandemic--when parenting quality had deteriorated substantially among many families (blinded).

Consistent with our conceptual model, along with intervention impacts on coparenting, parent adjustment, and parenting quality, we found intervention effects on children’s adjustment. We did not observe significant differences by condition on retrospective questionnaire measures of children’s externalizing and internalizing behavior, but intervention parents did report lower levels of children’s negative mood and behavior problems and higher levels of positive mood relative to control parents in daily report data. As with coparenting, it may be that parents’ daily reporting was more sensitive to actual behaviors and events than was the retrospective reporting on questionnaire measures. 18 Building Family Resilience Although sibling relations strongly influence children’s mental and behavioral health, educational attainment, and peer and romantic relationships throughout the lifetime (Feinberg, Solmeyer, Hostetler, et al., 2012; Feinberg, Solmeyer, & McHale,

2012), most family researchers and practitioners neglect assessing or intervening on sibling relations. Sibling relations are often the longest-lived relationship in one’s life, involve issues of competition and triangulation with parents, and have a high level of emotional intensity with both high levels of conflict and warmth. Yet few preventive interventions have been developed to promote sibling relationships, and even fewer have been rigorously tested. Moreover, the generally high levels of physical aggression in sibling relationships (Tucker et al., 2013) were potentially highly problematic during pandemic phases when families were confined to households (Perkins et al., 2021). In this context, it is notable that FF appears to have yielded positive benefits for both negative and positive dimensions of sibling relationships in this wave of long-term follow-up data assessed during the pandemic. As research indicates that sibling relationship quality is linked with the quality of other family relationships (Reese-Weber

& Kahn, 2005) (i.e., couple relationship and parent-child relations) (Feinberg, Solmeyer,

& McHale, 2012), and we found intervention effects on these other relationships, it should not be surprising that we detected beneficial intervention effects on positive and negative dimensions of sibling relations. Moreover, as children’s sibling conflict and warmth predict future mental health, delinquency, aggression, substance use, academic functioning, and romantic and peer relations (blinded), the impact of FF on sibling relationship quality may lead to even longer-term benefits into adolescence and adulthood. 19 Building Family Resilience Finally, given that intervention parents reported less negative and more warm dyadic relationships in the family, it is not surprising that we also found a significant intervention effect on parents’ reports of family cohesion—the overall quality of family relationships. Family cohesion itself is an important dimension of family functioning which has been linked to adolescent internalizing and externalizing problems and subjective well-being (Fosco, 2020).

We did not find that parent gender moderated these results, indicating that the intervention’s focus on coparenting had equivalent long-term benefits for mothers and fathers. Moreover, the lack of gender moderation suggests that mothers and fathers reported similarly regarding family relationships and child adjustment. In contrast, we found that the magnitude of intervention effects varied based on pre-pandemic levels of parent depression and coparenting quality. We found significant moderation effects in a total of 10 out of 34 tests (~30%), which exceeds the rate of 5% that would be expected by chance.

Plots revealed that for control families, higher pre-pandemic levels of parent depression predicted poorer adjustment in terms of coparenting conflict, aggressive parenting, and family cohesion. However, these associations were smaller or not present for intervention families, indicating a protective effect of the intervention in relation to the risk posed by parent depression for family relationships during at least the early phase of the pandemic. Similarly, we found that random assignment to FF protected family functioning and child adjustment from the potential effects of low coparenting quality. Thurs, for some outcomes, assignment to the Family Foundations 20 Building Family Resilience condition ten years before reduced or eliminated the risk posed to family functioning or child adjustment by prior parent depression or low-quality coparenting.

Generalizations from this study are limited for a number of reasons, including the sample which, reflecting the characteristics of the region from which the majority of the sample was recruited, was largely white. Although the sample exhibited a wide range of income, the median family income ($87,000) of this sample (average 2.3 children/family) was somewhat, but not severely, higher than the U.S. national median income for a family of four ($78,500) (Office of Policy Development and Research,

2020). Pursuant to eligibility requirements for entry into the study as approved by the funding sponsor, the sample was limited to heterosexual couples. Additionally, although we tested and did not find evidence of differential attrition, just over half the sample decided to participate in this optional data collection during the pandemic. Strengths of the study include the use of multiple methods (questionnaire and brief daily reports), rigorous analytic methods including maximum likelihood to accommodate missing data, assessment of differential attrition, and a randomized design. Finally, we included several control variables, including parents’ pretest scores on social desirability as a control variable to account for bias that may have been introduced by utilizing parent report measures.

Public Health Implications

This study found evidence that effective, early preventive intervention for families may not only have long-term effects for all family members, but may also serve a protective function during unforeseen periods of stress and anxiety such as the early 21 Building Family Resilience phase of the COVID-19 pandemic. These results add to a growing body of evidence for the efficacy of FF’s strategic focus on enhancing coparenting; this evidence now extends across multiple delivery modalities, including in-person and videoconference classes, an online self-study e-version (Feinberg et al., 2020), home visiting with low- income parents (Ammerman, Under review), and school-based classes for adolescent parents. Evidence of program effects also comes from pre/post evaluations of the FF program adapted for parents who already have children; one study was conducted with a parent peer mentoring version of FF for parents of young children with Autism

Spectrum Disorder (Hock et al., under review), and another home-visit version adapted for Australian parents at risk for family violence (Giallo et al., under review).

More broadly, these findings underline that the benefits of universal family-focused prevention can extend to non-targeted domains-- such as sibling relations. Previous FF trial results have also revealed intervention effects on outcomes extending beyond our original hypotheses, such as adverse birth outcomes (Feinberg, Jones, et al., 2015;

Feinberg, Roettger, et al., 2015) and family violence (Feinberg et al., 2016).

In addition to the critical role that children’s mood and behavior problems, along with family conflict plays in the development of children’s future mental and behavioral health

(Bai et al., 2020; Streit et al., 2021), these factors—along with mental and behavioral health—influence long-term physical health outcomes (Miller et al., 2011; Repetti et al.,

2002). In addition, we speculate that, in this case, the intervention’s beneficial impact on negative mood and family conflict may have helped reduce individuals’ exposure and susceptibility to COVID--19, and severity of the disease when exposed. The general hypothesis that psychosocial preventive intervention effects on stress and family conflict 22 Building Family Resilience can lead to positive effects on physical health is supported by findings of FF intervention effects at the prior, pre-pandemic wave of data collected when children were 7-8 years old. We had hypothesized that intervention-associated reductions on stress and family conflict over a period of years would lead to lower levels of inflammatory biomarkers that are risk factors for cardiovascular risk (Schreier, In preparation). We found such effects for levels of parent inflammatory biomarkers, but not children’s levels. We hypothesize similar impacts on susceptibility to COVID-19 as stress and interpersonal conflict are associated with reduced immune functioning, likely via dysregulated inflammatory responses to virus exposure (Cohen, 2020). Notably, dysregulated inflammatory processes are a factor in severe COVID-19 cases (Yu, 2020). We also note that our recent work in the context of the pandemic with another sample demonstrates that reduced stress, conflict, and mental health problems facilitate a family’s capacity to sustain protective health behaviors such as social distancing

(blinded). Although speculative, we plan to examine these issues further in future work.

In sum, the findings here suggest that strategically targeted, universal, early family prevention may help parents and children develop resilient attitudes, behaviors, and relationships that provide protection in a range of unforeseen future contexts. One implication of this finding is that the cost-benefit calculations that influence policy decisions and funding of prevention may under-estimate the long-term protective benefits of effective early prevention programming. In prior work, we found that the conservatively-estimated benefits of FF outweighed implementation costs by a factor of

5. As we continue to examine the long-term benefits of FF, in normative and crisis- period contexts, the recognized monetized benefits of the intervention may continue to 23 Building Family Resilience increase. Such findings suggest that we our cost-benefit data has led us to underfund investments in prevention and public health programs aimed at enhancing family functioning and resilience and thus children’s lifelong health and development. 24 Building Family Resilience

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Control Intervention Intervention Effects Mean SD Mean SD Beta 95% C.I. d Parent Adjustment Hostility 0.81 0.64 0.66 0.55 -0.18* (-0.34, -0.02) 0.35 Depression 0.69 0.43 0.64 0.47 -0.06 (-0.17, 0.05) Family Relationships Relationship Satisfaction 7.41 1.75 7.77 1.38 0.37* (0.03, 0.73) 0.34 Coparenting Rel. Quality 4.87 0.92 4.99 0.89 0.17+ (-0.03, 0.36) 0.26

Coparenting Tension 2.51 1.41 2.22 1.24 -0.36** (-0.57, -0.16) 0.25 Parent Discipline 1.73 0.33 1.80 0.41 0.05 (-0.01, 0.10) Parenting Aggression 1.08 0.14 1.05 0.09 -0.34** (-0.04, 0.01) 0.22 Positive Parenting 4.13 0.64 4.31 0.59 0.32** (0.14, 0.50) 0.55 Negative Parenting 1.79 0.52 1.68 0.57 -0.21* (-0.38, -0.05) 0.41 Negative Sibling 2.78 0.94 2.54 .080 -0.35* (-0.65, -0.05) 0.41

Relations Positive Sibling Relations 4.21 1.12 4.34 0.99 0.40* (0.05, 0.74) 0.39 Family Cohesion 4.17 0.65 4.33 0.54 0.20** (0.05, 0.35) 0.42 Child Adjustment Internalizing 1.43 0.39 1.40 0.33 -0.01 (-0.12, 0.10) Externalizing 1.73 0.32 1.70 0.33 -0.06 (-0.19, 0.06) Positive Mood 7.84 1.29 7.86 1.23 0.23* (0.04, 0.43) 0.15 Negative Mood 2.76 1.08 2.54 1.09 -0.36** (-0.56, -0.17) 0.25 Behavior Problems 1.34 0.26 1.25 0.24 -0.13** (-0.17, -0.01) 0.48

Notes: Due to a lack of gender differences, mother and father values were aggregated; +p<0.10; *p<0.05; **p<0.01. d = Cohen’s d. 95% C.I. = 95% confidence interval. 32 Building Family Resilience 33 Building Family Resilience Table 2: Results of intervention by depression and coparenting moderation analyses

Intervention x Depression Intervention x Coparenting Beta 95% C.I. d Beta 95% C.I. d Parent Adjustment Hostility -0.30 (-0.80, 0.21) 0.05 (-0.17, 0.27) Family Relationships Relationship Satisfaction -0.06 (-1.16, 1.04) -0.08 (-0.57, 0.40) Coparenting Tension -1.9** (-2.58, -1.22) 0.75 0.22+ (-0.06, 0.51) 0.13 Parent Discipline -0.25** (-0.45, -0.06) 0.11 0.16** (0.08, 0.24) 1.66 Parenting Aggression -0.15* (-0.20, -0.10) 1.31 0.07** (0.05, 0.09) 0.64 Positive Parenting 0.55+ (-0.01, 1.12) 0.27 -0.20 (-0.45, 0.05) Negative Parenting -0.23 (-0.75, 0.29) 0.15 (-0.07, 0.37) Negative Sibling Relations -0.02 (-1.08, 1.04) -0.01 (-0.45, 0.44) Positive Sibling Relations -0.11 (-1.36, 1.13) -0.16 (-0.67, 0.36) Family Cohesion 0.61** (0.14, 1.08) 0.93 -0.34** (-0.54, -0.14) 0.12 Child Adjustment Internalizing -0.26 (-0.60, 0.08) 0.09 (-0.06, 0.24) Externalizing 0.09 (-0.31, 0.49) 0.02 (-0.16, 0.19) Positive Mood 0.74* (0.09, 1.38) 0.15 0.01 (-0.27, 0.28) Negative Mood -0.91** (-1.56, -0.26) 0.25 -0.04 (-0.31, 0.23) Behavior Problems 0.07 (-0.19, 0.04) 0.14** (0.09, 0.19) 0.07

Notes: Due to a lack of gender differences, mother and father values were aggregated; +p<0.10; *p<0.05; **p<0.01. d = Cohen’s d. 95% C.I. = 95% confidence interval. 34 Building Family Resilience Figure 1 Conceptual Model 35 Building Family Resilience Figure 2. Illustrative plots of moderation by depressive symptoms and coparenting relationship quality using model-based estimates. 36 Building Family Resilience 37 Building Family Resilience