Parenting in the early years: effectiveness of parenting support programs for Indigenous families
Resource sheet no.16 for the Closing the Gap Clearinghouse
Robyn Mildon and Melinda Polimeni
August 2012

Summary
What we know
•	Programs that focus on supporting parenting in the early years aim to influence the behaviours of children, parents or families in order to reduce the risk or ameliorate the effect of less than optimal social and physical environments.
•	This paper focuses on two types of parenting support programs:
–	parenting programs - short-term interventions aimed at helping parents improve their relationship with their child
–	home visiting programs - which include various programs, supports and services delivered to the family by a person visiting the home.
What works
•	There is a body of evidence that demonstrates that parenting programs are key to promoting the wellbeing of children and preventing the development of later problems.
•	There is some evidence that parenting programs may improve some outcomes associated with child abuse and neglect, such as poor parent–child interactions.
•	Although parenting support programs are often used as secondary or tertiary interventions in high-risk families, they may be more effective as universal primary prevention programs. 
•	There is little evidence on parenting education programs developed specifically for Indigenous families in Australia. Preliminary evidence suggests early intervention parenting programs may be effective in reducing problem and risk behaviour among Indigenous children at home and school, and in increasing parental confidence.
•	Home visiting programs benefit young children by improving socioeconomic and cognitive outcomes and reducing the frequency of and potential for abuse. 
•	International evaluations of home visiting programs have shown improvements in parents’ childcare knowledge, and small but positive effects on parenting attitudes and behaviour.
•	There is also little information on the effectiveness of home visiting programs developed specifically for Indigenous families in Australia, but preliminary evidence suggests they may be effective in improving outcomes in Indigenous communities. 
•	Short-term improvements found include more positive parent–child interactions, better quality home environments, reduced postnatal depression scores, and improved perception of the parenting role.
•	Effective parenting support programs for Indigenous families generally include the following:
–	Use of cultural consultants in conjunction with professional parent education facilitators and home visitors.
–	Long-term rather than short-term programs.
–	A focus on the needs of both parents/carers and the child.
–	A supportive approach that focuses on family strengths.
–	Use of structured early intervention program content while also responding flexibly to families.
What doesn’t work
•	Programs that do not provide quality, structured content or sound delivery methods.
•	Adapting ‘mainstream’ (non-Indigenous specific) programs for Indigenous families without community involvement or consultation.
•	Programs that lack a strong focus on communication and relationship building.
•	Failing to link families with other services in the community.
What we don’t know
•	More rigorous research is needed to determine the effectiveness of parenting education and home visiting programs for Indigenous Australian families, and the factors that are related to program success for these families.

Introduction
Families play a critical role in their children’s development and learning. A large body of research provides strong evidence that parents and the home environment are the most influential forces in shaping children’s early learning. The responsiveness of parents to their children, and the manner in which parents talk with and teach their children are important determinants of children’s later wellbeing and development (Landry et al. 2001; Osofsky & Thompson 2000).
Shonkoff and Phillips (2000:226) state that ‘parenting’ is a term used to ‘capture the focused and differentiated relationship that a young child has with the adult (or adults) who is (are) most emotionally invested in and consistently available to him or her’. They argue that who fulfils this role is far less important than the quality of the relationship she or he establishes with the child.
For Indigenous communities, support for parents in their parenting role has a different context from non-Indigenous communities. The responsibility for child rearing and teaching children has traditionally been through an extended family, kin and community and is seen as very much still tied to this cultural norm, even when families and children face isolation from their own Indigenous communities (SNAICC 2004).
In this resource sheet, we examine what we know about programs for Australian Indigenous families that effectively support parenting in the early years. This is not a systematic review of all programs; instead, we present briefly on the evidence for parenting programs generally and then focus specifically on the evidence for such parenting programs in helping Indigenous families.

Programs to support parenting in the early years
Programs that focus on supporting parenting in the early years aim to influence children’s, parents’ or families’ behaviours in order to reduce the risk or ameliorate the effect of less than optimal social and physical environments. These programs aim to not only prevent the development of future problems such as child abuse, emotional and behavioural problems, substance abuse and criminal behaviour, but also to promote the necessary conditions for a child’s healthy development in all areas (Watson et al. 2005).
Current thinking about prevention and early intervention accepts the premise that early childhood experience strongly affects health and wellbeing and the attainment of competences (such as social and academic skills) at later ages, and that investment in the early years will be reflected in improved education, employment and even national productivity (Keating & Hertzman 2000). Evidence that early intervention can counteract biological and environmental disadvantage and set children on a more positive developmental trajectory continues to build (Brooks-Gunn et al. 2000).
There are a number of approaches to supporting parenting in the early years. For the purposes of this resource sheet, programs have been grouped according to their primary focus: parenting programs and home visiting programs. The evidence base for both types of service is examined, with a particular focus on findings and recommendations relevant to Indigenous families. 
It is important to note that, generally, these services are not provided in isolation but rather in combination with other services. Therefore, it can be difficult to attribute positive results solely to a parenting program, for example, as other services may also contribute to improved outcomes for parents and children.
Parenting programs
Parenting programs are typically focused, short-term interventions aimed at helping parents improve their relationship with their child and preventing or treating a range of problems including emotional and behavioural problems (Barlow & Parsons 2003). Parenting programs are based on the premise that interventions that promote caring, consistent and positive parenting are central to creating safe and supportive environments for children (Sanders & Cann 2002). Research has documented that the risk of child maltreatment is heightened when parents lack necessary child-rearing skills, social supports and knowledge of child development (Tomison 1998). Thus, parenting programs are often designed to increase parental knowledge of child development; assist parents in developing parenting skills; and normalise the challenges and difficulties inherent in parenting (Sanders et al. 2000).
Parenting programs often involve the use of a standardised, manualised program or curriculum and are underpinned by a number of theoretical approaches. A range of techniques are often used in such programs including discussion, role play and practice of skills in the home (Barlow et al. 2011).
Parenting programs are now being offered in a variety of settings such as clinics, community-based settings and in the home; and in a number of formats including groups and individual one-on-one programs.
A number of recent systematic reviews, published by the Cochrane Database of Systematic Reviews, suggest that parenting programs are moderately effective in the short term in improving maternal psychosocial health (Barlow et al. 2002), and the emotional and behavioural adjustment of infants and toddlers (Barlow & Parsons 2003) and older children (Barlow & Stewart-Brown 2000). There is also evidence to suggest that they are effective in improving outcomes for both teenage mothers and their children (Barlow et al. 2011). 
The body of research examining the effectiveness of parenting programs since the 1960s demonstrates a consensus that parenting programs focusing on early parenting to improve parent–child interaction in particular, and parenting practices more generally, are key to promoting the wellbeing of children and preventing the development of later problems (Barlow et al. 2010). However, a recent review found there is insufficient evidence that parenting programs are effective in reducing child abuse and neglect, but some evidence exists that parenting programs may improve some outcomes associated with child abuse and neglect such as poor parent–child interactions (Barlow et al. 2008).
Although parenting programs are often used as secondary or tertiary interventions in high-risk families, such programs may be more effective as universal primary prevention programs (Barlow et al. 2010).
The effectiveness of group parent programs for Australian Indigenous families
There is little information available regarding parenting education programs developed specifically for Indigenous families in Australia. Although many programs have been designed to improve Indigenous maternal and childhood health, most have not been rigorously evaluated for their effect on child health and wellbeing (SNAICC 2004). 
A search of the literature identified only three articles focusing on parenting education for Indigenous families. One case study described the development and evaluation of The Boomerangs Aboriginal Circle of Security Parenting Camp Program (Lee et al. 2010), and two reported on the effects and cultural appropriateness of parenting programs that were tailored for Indigenous families. The first is an adaptation of the evidence-based Group Triple P – Positive Parenting Program (Turner et al. 2007). The second is an adaptation of the evidence-based Exploring Together program, as part of a preventive strategy in response to serious social problems affecting young Tiwi people, their parents and families (Robinson & Tyler 2008).
Lee and colleagues (2010) used case studies to describe the development and evaluation of The Boomerangs Aboriginal Circle of Security Parenting Camp Program, an intervention based on an attachment framework using the Circle of Security and Marte Meo programs as a base and drawing on traditional Indigenous culture. Circle of Security is an early intervention group program based on attachment theory, which aims to improve parents’ caregiving behaviours and prevent child mental health problems (Hoffman et al. 2006). Marte Meo is a program which aims to help parents use ordinary interactions to support their child’s development (Aarts 2000).

The study involved three Indigenous Australian mothers with preschool-aged children who attended the 20-session Boomerangs Program. The 20 sessions included two 3-day camps, one at sessions 3–7 and the second at sessions 17–20.  The aim of the camps was to provide a safe and nurturing environment for the Indigenous parents to reconnect with themselves and with their children in a natural setting. Various activities were undertaken during the camps, such as parent–child interaction guidance, family games, mothering business and parental self-care. Mothers gave positive feedback on the program in increasing the awareness, sensitivity and responsiveness of their interactions with their children, and this was reflected in the results of the questionnaires and observation of the mother–child interactions during play. However, the research design (case study without a comparison group) and small sample size prohibits any definitive conclusions being drawn about the effectiveness of the program.
In a more rigorous study, a randomised repeated measures trial was used to assess the effects and cultural appropriateness of a group-based parenting program tailored for Indigenous families (Turner et al. 2007). Child health and Indigenous health workers in Queensland delivered an 8-session group parenting program adapted from the evidence-based Group Triple P—Positive Parenting Program. This program is a preventively oriented, early intervention program incorporating consultation, print and video materials that aim to promote positive, caring relationships between parents and their children, and to help parents develop effective management strategies for dealing with a variety of common behaviour problems and developmental issues.
Importantly, extensive community consultation occurred in the adaptation phase in terms of the appropriateness of program content, resources and delivery format. The program content was seen as appropriate, but changes were made to the language and images used in program resources, and the examples used to depict parenting strategies (e.g. a culturally tailored video, workbook and presentation aids) were developed. The structure of group sessions was also altered to allow more time to develop trust, slow the pace of presentation, share personal stories and discuss the social and political context for parenting.
The study, although limited by a relatively small sample size (n=20), showed some empirical support for the effectiveness of the culturally tailored parenting program. Parents who attended the Group Triple P reported a significant decrease in rates of problem child behaviour and less reliance on some problematic parenting practices following the intervention in comparison to families who were on a waitlist for this program. Participants in this sample were randomly assigned to receive Group Triple P immediately or after a period of time on the waitlist. The program also led to parent reports of improvements in child behaviour. Effects were primarily maintained at 6-month follow-up. Qualitative data showed generally positive responses to the program resources, content and process.
Recently Robinson and Tyler (2008) reported on preliminary findings from a trial to implement the Exploring Together Preschool Program for Indigenous and other parents and children in the Tiwi Island communities in the Northern Territory. The Exploring Together Preschool Program is a structured program that aims to improve parenting and children’s social-emotional learning (Littlefield et al. 2000). Children showing some indication of behavioural and/or emotional difficulties are referred to the program by teachers, family members or others. The child attends with their parents in groups of six parent–child pairs over 9–10 weeks. Five to seven children participated in a program, each with a parent, attending one weekly 2-hour group session in which the first hour was given over to parent–child interaction and the second hour to separate parents’ and children’s groups.
In contrast to what was done to adapt Group Triple P, some content of the program was redeveloped to ensure adequate recognition of important themes in Tiwi parenting and family life while retaining the key elements of structure and content. Importantly, the basic framework and much content were retained, but adjusted to take into account literacy levels. For example, the program’s emphasis on written homework was not maintained and facilitators used drawing activities as a way to elicit conversation in many sessions.
The limitations of the evaluation research design, specifically the absence of randomisation and a control group, meant that definitive attribution of outcomes was not possible. In general, however, both quantitative and qualitative analyses of responses to the program were positive, some strongly positive. These included statistically significant reductions in problem and risk behaviour among participating children at both home and school. The capacity of the program to support child development by promoting responsive parenting and increasing parental confidence was indicated by strongly significant reductions in parental distress as measured by the K6 instrument. The K6 is a brief measure of psychological distress and is widely used as a screening tool and for program evaluation (Kessler et al. 2003).
In summary, the researchers note that the adapted Exploring Together Preschool Program—Ngaripirliga’ajirri—showed many highly promising outcomes and, within the limits of the research design, indicated that a structured early intervention program may be effective in remote Australian Indigenous contexts.
Home visiting programs
Home visiting does not refer to a specific service, program or intervention, but refers to the manner in which a service, program or intervention is delivered (Gomby 2007; Higgins et al. 2006; Sweet & Applebaum 2004). Home visiting programs may deliver various programs, supports and services; however, the common feature of these programs is that they are delivered to the family by a person visiting the home. Therefore, the most important characteristic of home visiting programs is how the content of a program or intervention is delivered, rather than the content itself.
There is great variation in the content, the processes used to deliver content, and the length and intensity of service in home visiting programs; most have not yet been rigorously evaluated (Sweet & Applebaum 2004). This can make it difficult to compare programs in terms of their effectiveness and outcomes for families. Further, many published reports of home visiting programs lack detail regarding the theoretical framework that underpins the program, the processes used within the program, and what happens during home visits (Vimpani 2000).
A meta-analytic review of home visiting programs was conducted by Sweet and Applebaum (2004). This meta-analysis examined 60 studies on home visiting programs for young children conducted since 1965 in the United States. Almost all programs included in the review reported parent education (97%) and child development (85%) as the primary goals of the program. Parent education goals included improvement of parenting skills, behaviour, attitudes, and parent–child interaction skills, while the child development goals included attempts to improve children’s development or wellbeing in any way. As part of services directed toward parents, programs provided information on child development (92%), parent–child together activities (58%), supplied material goods to families (28%), provided home-based early childhood education (20%), and provided centre-based early childhood education (15%). A third of programs reported providing case management services and provided child health or developmental screening of some sort. Over half of the programs provided referrals to social and health services and about a quarter provided direct provision of health care to the parent and child.

The review concluded that, in general, home visiting was beneficial for young children compared to control groups, with children receiving home visiting having improved socioeconomic and cognitive outcomes. The frequency of and potential for abuse was reduced in families who received home visiting. Home visiting programs also had a positive effect on parenting factors such as parenting attitudes and behaviour. However, these changes were mostly small, indicating that the degree of positive change that occurs in families as a result of home visiting programs may be modest.
Since the meta-analysis conducted by Sweet and Applebaum, a number of systematic reviews of the research literature have been conducted. A search of the Cochrane Database of Systematic Reviews revealed that two systematic reviews on home visiting were recently withdrawn from the database. Both reviewed a specific home visiting program, the Nurse Family Partnership (NFP) (for more details, see below). One applied the NFP to benefit teenage mothers (Macdonald et al. 2007 Withdrawn) and the other reviewed evidence for effectiveness of the NFP with vulnerable adult mothers (Bennett et al. 2008 Withdrawn). These reviews both concluded that there is only limited evidence that home visiting programs are effective for teenage mothers, and no evidence that they are effective for vulnerable adult mothers. Both reviews were withdrawn following a submission from David Olds (20 September 2007), arguing that these conclusions were flawed because the authors reviewed evidence from a wide variety of programs that differed on important features, such as program length, target populations, goals and structure. He also argued that the reviews failed to meet basic methodological standards, which may have led to inaccurate conclusions. This highlights the difficulties involved in examining this literature and the limitations of the existing evidence base.
Another recent review conducted by Holzer and colleagues (2006) examined findings of meta-analyses, literature reviews, and original well-controlled studies of home visiting programs for preventing child maltreatment. This review examined evidence from eight home visiting programs—one program from Australia: the Community Child Health Nurse home visiting program for newborns, and seven programs developed in the United States: the Nurse Home Visiting Program; the Healthy Start Program; Healthy Families America; the Head Start Program; Parents as Teachers; the Home Instruction Program for Preschool Youngsters; and the Comprehensive Child Development Program. The review examined results from home visiting programs that were longer term programs providing regular home visiting from birth to 2 years of age.
The interventions in this review were directed at low-income families, young mothers and families considered at-risk for child maltreatment, with the majority of programs targeting pregnant women or mothers with young children. The majority of home visiting programs used non-professional volunteers as home visitors who were able to access support from professionals, such as nurses. Holzer and colleagues concluded that the evidence for the effectiveness of home visiting programs for at-risk families is mixed. Programs generally report some degree of success, however none of the programs included in the review met all of the program goals. Studies reported improvements in: parental knowledge and skills, and children’s cognitive and social development; fewer incidents of child maltreatment; and increased linking of parents to health and family support services. Two of the programs included in the review were found to be not effective at all.

Papers on home visiting programs published since these key reviews of the literature have also reported similar findings. For example, a series of papers reporting on the outcomes of a randomised controlled trial of the Healthy Families Alaska home visiting programs showed mixed results. Gessner (2008) found that there was little evidence that this program had an effect on child maltreatment. Reductions in child physical abuse referrals to child protection services were seen in both the program group and the control group. 
Duggan and colleagues (2007) similarly reported that there was no change in maltreatment reports or measures of potential maltreatment for families receiving the Healthy Families Alaska home visiting program in their study. Intervention and control groups were similar after program delivery in their use of severe physical discipline and parent risks such as mental health problems, substance use, and domestic violence. It was also found that home visitors often failed to address parental risks and to link families to community resources. 
Caldera and colleagues (2007) examined parent and child outcomes for the Healthy Families Alaska home visiting program and found that children in the group who received the program had better developmental and behavioural outcomes compared to control children, however there was no overall effect on child health. Parents who received the program were found to have improved parenting self-efficacy, and made improvements in the quality of the home environment. However, this improvement was not as great for parents who had higher stress levels.
One of the most well-researched and successful home visiting programs is the Nurse Family Partnership (NFP) program, developed in the United States by David Olds and colleagues (Olds 2006; Olds et al. 2007). The NFP was designed to improve the health of mothers during and after pregnancy to improve child health and development, and also to improve the course of parents’ lives by helping parents plan for future pregnancies, education, and their own personal work goals (Olds 2006). Research on the NFP started almost three decades ago and three randomised controlled trials of the program have been conducted with different populations in different contexts. The program has produced positive outcomes for both mothers (reductions in subsequent pregnancies, participation in work and education, decreased use of public assistance) and children, including fewer child injuries and improved child emotional and language development (Olds 2006). The program targets families from socioeconomically disadvantaged communities. Long-term follow up for this program has also found favourable results for families who have participated (Olds et al. 2007).

The effectiveness of home visiting programs for Australian Indigenous families
Similar to parenting education programs, there is little information available regarding home visiting programs developed specifically for Indigenous families in Australia. A search of the literature identified only four articles on home visiting programs for Indigenous families: two studies reporting on the use of a mainstream home visiting program that included Indigenous families as participants, one review article, and the findings of one pilot study.
Herceg (2005) conducted a review of the evidence for home visiting programs for Indigenous mothers, babies and young children. No published studies were identified that reported on home visiting specifically for Indigenous families. However, two Australian studies that included Indigenous families as participants were identified. Although these studies did not report outcomes for Indigenous families separately, they have been included in this section due to the significant proportion of Indigenous families that participated. 
Quinlivan and colleagues (2003) conducted a randomised controlled trial in Western Australia with first-time teenage mothers. Nurses delivered this program and 30% of mothers who received the home visiting program and 18% of mothers in the control group were Indigenous. The aim was to reduce the frequency of adverse neonatal outcomes and improve knowledge of contraception, breastfeeding and infant vaccination. The program consisted of five postnatal home visits conducted 1 week, 2 weeks, 1 month, 2 months and 4 months after the birth of the child, with each visit lasting 1–4 hours. Topics covered in home visits included breastfeeding and bottle feeding, parent–child bonding skills, contraception, child vaccination, maternal mood, and alcohol and drug consumption. 
Results at the 6-month follow-up found that postnatal home visits were associated with reductions in infant death, non‐accidental injury and non‐voluntary foster care, and significant increases were seen in maternal contraception knowledge; however, no significant increases were observed in knowledge of breastfeeding or infant vaccination. There were no significant differences between the home visiting group and the control group on infant vaccination or breastfeeding rates.
In one of the most rigorous studies examining an Australian home visiting program, child health nurses in Brisbane were used as home visitors in a randomised repeated measures trial of 181 families. Of participants, 6% in the intervention group and 9% in the control group were Indigenous. The aim of this study was to reduce risk factors associated with child maltreatment and neglect. The program consisted of weekly visits for the first 6 weeks after birth, fortnightly until 3 months of age, then monthly until the child was 12 months of age. A minimum of 18 home visits were provided to each family. At 6 weeks, the group participating in the home visiting program showed:
•	a reduction in postnatal depression scores
•	improvements in the perception of their parenting role
•	more positive parent–child interactions
•	better quality of the home environment related to child development (Armstrong et al. 1999).
However, these early promising results were not maintained 12 months later, with no significant differences found between the intervention and control groups.

Recently, Sivak and colleagues (2008) reported on preliminary findings from a home visiting program for Indigenous families—the Family Home Visiting Program (FHVP)—being delivered by the Children, Youth and Women’s Health Service in South Australia. The FHVP has been adapted from the Nurse Family Partnership (NFP) program described above. The Australian Government is rolling out the Australian Nurse-Family Partnership Program (www.anfpp.com.au), which is based on the NFP program, in five Indigenous-controlled health services. The aim is to support women pregnant with an Indigenous child and their families.
The FHVP has been trialled with Indigenous families in four sites across South Australia. The goals of the program were to enhance the mental, physical and social wellbeing of children and their families; to help families provide a safe and supportive environment for their children; and to better link families to available resources and networks in the community. Unlike the NFP, the FHVP does not include an antenatal care component, and professional Indigenous cultural consultants work alongside professional nurse home visitors to deliver the program. Nurse home visitors are also supported by a multidisciplinary team of psychologists, social workers and Aboriginal health workers. All families across South Australia receive one home visit after their child is born (before 3 months of age). Families identified as having additional support needs (based on universal criteria and maternal risk factors) are offered the ongoing FHVP until the child turns 2 years of age. A total of 34 visits are received by families, with weekly visits for the first 6 weeks, fortnightly visits for the next 6 months, and then monthly visits for the final 16 months.
A qualitative evaluation of the first 12 months of this program was conducted using focus groups and interviews with 60 parents and extended family members (Sivak et al. 2008). Participants were all actively involved with or completed the FHVP. The aim of this study was to examine what is working well for families who are participating in the program. The evaluation indicated that families valued the cross‐cultural partnership of the FHVP nurses and Indigenous workers, and the in‐home delivery and flexibility of the program was thought to encourage engagement in the program. The most important feature was reported to be the qualities of the staff, including honesty, friendliness, warmth, non‐judgmental attitudes and listening skills, and the relationships they built with the families. The flexible and whole-family approach to the program was also highly valued by families. The cultural consultants were thought to be especially crucial for engaging families in the program. 
These findings support previous studies that have found that including extended family members, being adaptable and responsive to family needs (McGuigan et al. 2003), and developing good relationships between workers and families (Kirkpatrick et al. 2007; Krysik et al. 2008) are key factors for successful home visiting programs. The importance of workers being from a similar cultural background has also been found to be a factor related to recruitment into home visiting programs. Daro and colleagues (2003) found that rates of engagement in Healthy Families America programs were higher where families were matched with a worker of the same racial background (Hispanic or African American).

A limitation to the FHVP identified by Sivak and colleagues (2008) was related to the perceptions of the program among families. Many families believed the program was related to child protection services surveillance or that they were enrolled in the program because of their child’s low birthweight. Some families were also not aware that the FHVP was voluntary. As this study only included people who were actively involved in or completed the program, no information is yet available regarding the experiences of families who did not take part or withdrew. Therefore, the barriers to engaging and retaining families in the program were not explored in this study. At present, no information is available on whether the positive experiences of families in the program translated to improved outcomes for children. However, outcome evaluation of this program will be available in the future.
Evidence from home visiting programs for indigenous families in other countries other than Australia
Little international evidence exists regarding the effectiveness of home visiting programs for indigenous families. Only two studies, conducted in the United States, have shown that a home visiting program delivered to indigenous families by indigenous paraprofessionals demonstrates some effectiveness. 
A research group at the Johns Hopkins Centre for American Indian Health in the United States conducted two separate trials of a home visiting program developed specifically for American Indian mothers. The primary aims of this program were to improve mothers’ childcare knowledge, skills and involvement. The program was delivered by paraprofessionals who were bilingual American Indian women with experience in tribal health and human services. Paraprofessionals were used due to the shortage of qualified nurses who work on American Indian reservations. Workers received 500 hours of training and were tested to ensure mastery of necessary skills. The workers also received daily supervision and ongoing training every 3 months. As this program was based on the Healthy Families America model of home visiting, cultural adaptations to the program were made in consultation with the communities participating in the home visiting program.
Barlow and colleagues (2006) examined the short-term effectiveness of this home visiting program (called the Family Spirit Program [FSP]) in a randomised controlled trial with 53 pregnant American Indian adolescents. Of these, 28 mothers received FSP and 25 received a breastfeeding education program as a control. The FSP consists of 25 home visits from 28 weeks gestation until the child is 6 months of age. 
The results of this trial showed that mothers receiving the FSP program, when compared to those receiving the breastfeeding education program, had improved knowledge of child care at 2-month and 6-month follow-up. Improvements were also observed in the mothers’ childcare skills; however, the improvements were not significant and were not maintained 2 months and 6 months after the program concluded. Parent involvement scores were found to be significantly higher at 2 months after the program, but not at 6 months. There was a decrease in maternal depression scores after the program but this difference did not reach statistical significance. These findings support those of Armstrong and colleagues (1999), who also found that initial decreases in maternal depression scores, and other improvements in parent and child outcomes, were not maintained 12 months later.

A follow-up to this study was recently conducted by Walkup and colleagues (2009). The study randomly allocated 167 young American Indian expectant mothers to FSP or a control group. In this study, data were also collected on infant outcomes through direct observation by workers. Data were collected at 28 weeks gestation and at 2, 6 and 12 months postpartum on maternal self‐reports of parenting knowledge, involvement and psychosocial factors. The results from this study are promising, with child activity levels, impulsiveness, aggression, and separation distress reported by mothers to be lower in the FSP group compared to the control group. Positive parent outcomes included higher parenting knowledge for the FSP group compared to the control group at all time points. This supports the findings of Barlow and colleagues (2006), that improvements in parent knowledge are maintained over time. However, no differences were found between the FSP and control groups at any time point for parenting involvement, maternal social support, depressive symptoms, substance abuse or parenting stress.
Taken together, these two studies indicate that this program, delivered by Native American paraprofessionals to young Native American mothers, can improve childcare knowledge. However, the findings showed that the program may not be as successful for improving parental involvement with the child and other childcare skills. The studies also demonstrate that American Indian home visitors who are members of the local community and speak the native language can be used to deliver a home visiting program to young American Indian mothers, but it is unclear whether the program itself or the method of delivery limited findings of effectiveness. However, it was noted that the capacity of the workers to speak the native language helped with completing assessments in the home. These studies did not examine outcomes through the delivery of the FSP by professionals (indigenous or non-indigenous), therefore it is not known whether better outcomes would be achieved if professionals were used in conjunction with the American Indian paraprofessionals.
Secretariat of National Aboriginal and Islander Child Care promising practices and recommendations
Promising practices for parenting support programs
Based on the literature reviewed above regarding parenting education and home visiting programs for Indigenous families, a number of promising practices have been identified in a consultation paper published by the SNAICC (SNAICC 2004). Future programs for Indigenous populations should endeavour to incorporate and further evaluate the effectiveness of these practices.
Use cultural consultants in conjunction with professional parent education facilitators and home visitors
The available Australian evidence suggests that parenting education and home visiting programs for Indigenous families should use cultural consultants to work alongside non-Indigenous practitioners. The cultural consultant may be especially important in engaging and recruiting families into programs. This is supported by research conducted with indigenous families overseas that has shown that indigenous paraprofessionals can deliver effective home visiting programs, to good effect, when they receive substantial training and supervision (Barlow et al. 2006).
Use long-term home visiting programs rather than short-term programs
The available evidence suggests that programs for disadvantaged families that are longer term achieve better outcomes (Holzer et al. 2006). It has also been suggested that parenting education and home visiting programs that include antenatal visits may be more effective, particularly for engaging Indigenous parents (SNAICC 2004).
Focus on the needs of both the primary caregiver and child
The existing evidence suggests that parenting education and home visiting programs that focus on the needs of both mother and child achieve better outcomes (Holzer et al. 2006). Specifically, home visiting programs that addressed maternal issues such as employment and family planning, as well as focusing on reducing the risk of child maltreatment, showed greater improvements for both primary caregivers and children.
As extended family, relatives and community are typically involved in raising Indigenous children, programs supporting early parenting should consider focusing on the needs of both extended kin networks and children (SNAICC 2004). 
Promote parenting and home visiting programs as being supportive to parents and families, and focus on family strengths within the program
It appears that parenting programs and home visiting are acceptable when the intervention is perceived by the parents to be supportive, rather than a form of parental surveillance (Armstrong et al. 1999). There may often be distrust of welfare services among disadvantaged families. It has been suggested that commencing parenting education and home visitation before the child is born may help engage parents, as there is a greater perception that the services are about supporting the family, rather than ‘checking up’ once the child is born. Parenting education and home visiting programs may also need to improve communication to families and communities regarding the purposes of the program to distinguish it from other child welfare or child protection services. Programs should also focus on family strengths, highlight what families are doing well, and build on the competencies that already exist within families. Programs with a ‘strengths‐based’ approach are more effective (Holzer et al. 2006; SNAICC 2004).
Use structured program content while also responding flexibly to families
One of the most important features of parenting education and home visiting programs is the program content and the processes used to deliver content; that is, what is actually done during program sessions. Content delivery by practitioners that matches the goals of the program, is standardised, and is delivered using effective teaching and behaviour change processes will be more effective in achieving the program aims. It is clear from the literature that family participation in a program is not enough to improve outcomes. What is important is what is done during group sessions or home visits. Programs also need to be flexible enough to accommodate the needs of families and work within the context of the family. Therefore, practitioners also need to link families with other services where appropriate, and be able to adapt the program to the circumstances of the family.
Recommendations for delivering programs
The SNAICC made a series of recommendations for the delivery of early childhood and parenting services to Indigenous families (SNAICC 2004). In addition to the promising practices listed above, this section summarises the Secretariat’s recommendations that may have particular relevance for the delivery of programs that aim to support Indigenous families with parenting in the early years. These recommendations focus on features of services that are likely to be related to successful uptake and effectiveness of parenting education and home visiting programs for Indigenous families.

Programs must take into account the cultural norm in Indigenous communities of extended family, relatives and community being involved in raising children
Programs based on mainstream parenting practices that typically involve the mother and father may be too narrow for the context of Indigenous parenting. Differences in child‐rearing approaches in Indigenous communities must also be considered (for example, approaches to sleeping, feeding and discipline). Programs supporting early parenting should consider the inclusion of other family and community members who are involved in raising children.
Programs for Indigenous families are likely to be more successful when there is community involvement
Community involvement may include community consultation in the development of programs and services, employment of local Indigenous workers, and involvement of community mentors and elders. Community-based, owned, and controlled services have been identified as having higher success rates in Indigenous communities (Herceg 2005; SNAICC 2004).
There should be a strong focus on communication and relationship building
Successful services and programs with Indigenous families depend largely on the relationships that families have with workers and services. Therefore, family interventions should place a strong focus on developing good relationships with families, and facilitate effective communication. It has been suggested that good communication and relationships may be facilitated by workers who are from a similar background to the family and are Indigenous. As mentioned previously, the use of Indigenous staff where possible or using partnered approaches, where cultural consultants work in conjunction with non-Indigenous professionals, can be important factors in promoting communication and building relationships with families (Sivak et al. 2008).
There should be a focus on linking families with other services in the community
Programs and services that can address the holistic needs of families will be more successful. Linking families with and integrating other services (such as housing, employment, education, and health) in a timely fashion when they are needed is imperative, as it is unlikely that a single service or program will be able to address all needs that may arise. Connecting families with community-based services also promotes ongoing links with the community and enables families to become familiar with services that they may use again in the future. It has also been suggested that existing community hubs (such as health services and schools), which are familiar to and used by community members, should be used as places where families can access support.
The use of mainstream programs may not be appropriate for Indigenous communities
It has been highlighted that the use of mainstream programs for Indigenous families may not be appropriate due to factors outlined in the first recommendation above. Mainstream programs may be adapted for Indigenous communities; however, community consultation, support and involvement should be sought. Programs or services that do not engage the Indigenous community are unlikely to be effective.

Conclusion
The existing evidence regarding the effectiveness of parenting education and home visiting programs for Indigenous families is weak. Few well-controlled studies have been conducted and little research is available on programs specifically for Indigenous families. However, a number of program characteristics are associated with improved outcomes for families. The effectiveness of parenting education and home visiting programs appears dependent on features related to the intensity and duration of the program, content delivered, teaching strategies, target group, and worker characteristics.
Future research needs to further examine what factors contribute to the effectiveness of programs, particularly in the area of the processes used to deliver content to families, which has been largely overlooked. Parenting education and home visiting programs require formal evaluation to determine which content and process elements are related to improved outcomes for families. This is particularly important for Indigenous communities, as factors related to program success are very likely to be different from those of non-Indigenous communities. 
Programs for Indigenous families also need to consider: cultural practices associated with raising children; the need for community involvement and consultation; that mainstream parenting education and home visiting programs may not be appropriate for Indigenous communities; the use of Indigenous workers and cultural consultants to work alongside non-Indigenous workers; and a strong focus on relationship building and communication. In conclusion, parenting education and home visiting programs are promising interventions for disadvantaged families, and have shown some effectiveness for improving outcomes in Indigenous families. However, further research is required to identify the factors related to success and improved outcomes for families. In particular, those factors that may be related to effective parenting education and home visiting programs in Indigenous communities should be identified.

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Acknowledgments
This review was prepared by Dr Robyn Mildon (Director of Knowledge Exchange and Implementation, Parenting Research Centre) and Dr Melinda Polimeni (Senior Manager, Implementation, Parenting Research Centre).  We would like to acknowledge the very valuable feedback from members of the Closing the Gap Clearinghouse Board and Scientific Reference Group and Associate Professor Aron Shlonsky, University of Toronto.
Abbreviations
FHVP		Family Home Visiting Program
NFP		Nurse Family Partnership
SNAICC	Secretariat of National Aboriginal and Islander Child Care
Terminology
Indigenous: ‘Aboriginal and Torres Strait Islander’ and ‘Indigenous’ are used interchangeably to refer to Australian Aboriginal and/or Torres Strait Islander people. The Closing the Gap Clearinghouse uses the term ‘Indigenous Australians’ to refer to Australia’s first people.
Funding
The Closing the Gap Clearinghouse is a Council of Australian Governments initiative jointly funded by all Australian governments. It is being delivered by the Australian Institute of Health and Welfare in collaboration with the Australian Institute of Family Studies.
Suggested citation
Mildon R & Polimeni M 2012. Parenting in the early years: effectiveness of parenting education and home visiting programs for Indigenous families. Resource sheet no. 16. Produced for the Closing the Gap Clearinghouse. Canberra: Australian Institute of Health and Welfare & Melbourne: Australian Institute of Family Studies.
Cat. no.: IHW 77	ISBN: 978-1-74249-335-0