using the piccolo with parents of children with a disability

A R T I C L E

USING THE PICCOLO WITH PARENTS OF CHILDREN WITH A DISABILITY

MARK S. INNOCENTI, LORI A. ROGGMAN, AND GINA A. COOKUtah State University

ABSTRACT: All children benefit from positive parenting behaviors that support early child development. For a parent of a child with a disability, thechild’s characteristics and possible limitations can make positive parenting behaviors challenging, and yet, these interactions need to be a focus ofearly intervention to promote optimal family and child development. Family-centered practice, which includes strengthening parenting skills, has beenadvocated by the early intervention field. Although early intervention programs realize the importance of supporting parent–child interaction as part offamily-centered practice, it has not been an emphasis of most early intervention programs. The lack of easy-to-use, psychometrically strong parentingmeasures is an issue in early intervention. The Parenting Interactions with Children: Checklist of Observations Linked to Outcomes (PICCOLO)provides a practical observation measure of parenting with young children. We tested the reliability and validity of this measure with parents of childrenwith an identified disability. Early parenting behaviors predicted cognitive and language outcomes for children with an identified disability up to9 years after the first assessment. The PICCOLO demonstrated strong reliability and both construct and predictive validity, and shows promise as auseful measure for practitioners working with parents who have a child with a disability.

Abstracts translated in Spanish, French, German, and Japanese can be found on the abstract page of each article on Wiley Online Library athttp://wileyonlinelibrary.com/journal/imhj.

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Mark S. Innocenti, Center for Persons with Disabilities, Utah State Uni-versity; Lori A. Roggman, Department of Family, Consumer, and HumanDevelopment, Utah State University; Gina C. Cook, Center for Persons withDisabilities, Utah State University. Most of the observations and measuresused were based on research conducted as part of the national Early Head StartResearch and Evaluation Project funded by the Administration of Childrenand Families (ACF), U.S. Department of Health and Human Services underContracts 105-95-1936, 282-98-0021, and 233-02-0086 to MathematicaPolicy Research, Princeton, NJ, and Columbia University’s Center forChildren and Families, Teachers College, in conjunction with the Early HeadStart Research Consortium. The Consortium consists of representatives from17 programs participating in the evaluation, 15 local research teams, theevaluation contractors, and the ACF. Research institutions in the Consortium(and principal researchers for conducting this research through 36 months ofage) include the ACF (Rachel Chazan Cohen, Judith Jerald, Esther Kresh,Helen Raikes, Louisa Tarullo); Catholic University of America (MichaelaFarber, Harriet Liebow, Nancy Taylor, Elizabeth Timberlake, ShavaunWall); Columbia University (Lisa Berlin, Christy Brady-Smith, JeanneBrooks-Gunn, Allison Sidle Fuligni, Anne Martin); Harvard University(Catherine Ayoub, Barbara Alexander Pan, Catherine Snow); Iowa StateUniversity (Dee Draper, Gayle Luze, Susan McBride, Carla Peterson);Mathematica Policy Research (Kimberly Boller, Barbara Lepidus Carlson, JillConstantine, Julie Ingels, Ellen Eliason Kisker, John M. Love, Diane Paulsell,Christine Ross, Peter Schochet, Susan Sprachman, Cheri Vogel, Welmoetvan Kammen, Jerry West); Medical University of South Carolina (RichardFaldowski, Gui-Young Hong, Susan Pickrel); Michigan State University(Holly Brophy-Herb, Hiram Fitzgerald, Tom Reischl, Rachel Schiffman);New York University (Mark Spellmann, Catherine Tamis-LeMonda);University of Arkansas (Robert Bradley, Richard Clubb, Andrea Hart, Lor-raine McKelvey, Mark Swanson, Leanne Whiteside-Mansell); University of

For infants and toddlers at risk for poor developmental out-comes because of environmental factors, a responsive home envi-ronment that includes good parenting and positive parent–child in-teractions is predictive of better developmental outcomes (Bradley,Corwin, Burchinal, McAdoo, & Coll, 2001; Bradley et al., 1994;Love et al., 2005). Similarly, for children with a disability, thesesame home and parent characteristics predict optimal outcomes(Spiker, Boyce, & Boyce, 2002; Spiker, Hebbeler, & Malik, 2005).In a review of the mother–child interaction research with youngchildren with a disability, Spiker et al. (2002) found that severaltypes of parenting behaviors such as warmth, positive affective

California, Los Angeles (Carollee Howes, Claire Hamilton, Alison WishardGuerra); University of Colorado Health Sciences Center (Robert Emde, MaryMaguire Klute, Jon Korfmacher, Jini Puma, JoAnn Robinson, Paul Spicer,Norman Watt); University of Kansas (Jane Atwater, Judith Carta, Jean AnnSummers); University of Missouri-Columbia (Mark Fine, Jean Ispa, KathyThornburg); University of Pittsburgh (Beth Green, Carol McAllister, RobertMcCall); University of Washington School of Education (Eduardo Armijo,Joseph Stowitschek); University of Washington School of Nursing (KathrynBarnard, Susan Spieker), and Utah State University (Lisa Boyce, Gina Cook,Catherine Callow-Heusser, Lori Roggman). We also thank the members ofthe Disability Early Head Start Consortium Working Group. Development ofthe PICCOLO was supported in part by Grant 90YF0050 from the ACF, U.S.Department of Health and Human Services.

Direct correspondence to: Mark S. Innocenti, Center for Persons with Dis-abilities, 6580 Old Main Hill, Utah State University, Logan, UT 84322-6580;e-mail: [email protected].

INFANT MENTAL HEALTH JOURNAL, Vol. 34(4), 307–318 (2013)C© 2013 Michigan Association for Infant Mental HealthView this article online at wileyonlinelibrary.com.DOI: 10.1002/imhj.21394

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308 • M.S. Innocenti, L.A. Roggman, and G.A. Cook

tone, attentiveness to child cues and interests, and input build-ing on child’s cue’s and interests led to more optimal outcomes.These are the behaviors identified and included, among other keyparenting behaviors, in the Parenting Interactions with Children:Checklist of Observations Linked to Outcomes (PICCOLO) mea-sure (Roggman, Cook, Innocenti, Jump Norman, & Christiansen,2013). The PICCOLO showed strong psychometric properties fora large, ethnically diverse sample that included some parents ofchildren with a disability, but the PICCOLO was not tested sepa-rately in that group. It is likely that all children, with or withouta disability, would benefit from these positive parenting behaviors(Guralnick, 2005).

For parents of a child with a disability, the practice of thesepositive parenting behaviors can become challenging because ofthe disability. Children with various disability conditions, as com-pared to typically developing children, may have less predictable orsalient cues, be less responsive, or respond in unpredictable waysto their parents’ behaviors. Differences from typical developmentmay occur in emotional expressiveness, joint attention, social refer-encing, initiation of social interaction, and responsiveness to socialand physical cues, all of which may contribute to the recognizeddifficulty with communication and atypical interaction behaviorsof many children with a disability (Biringen, Fidler, Barrett, &Kubicek, 2005; Spiker et al., 2002, 2005).

In addition to these disability characteristics, many parents car-ing for infants and toddlers with a disability report high levels ofstress (Al-Qaisy, 2012; Bailey, Golden, Roberts, & Ford, 2007) andlower levels of marital satisfaction (Brobst, Clopton, & Hendrick,2009). The time required to do everyday caretaking increases forsome parents of children with a disability and can affect the healthand well-being of parents (Raina et al., 2005). Adding to thesepotential mental and physical health concerns, studies of childrenwho receive early intervention for children with a disability (Earlyintervention will be used in this article to refer to interventionprograms for parents with children with a disability, also knownas Part C programs.) have found a sizeable proportion of fami-lies facing significant environmental risks (Spiker et al., 2005).It seems clear that these factors—disability characteristics, highstress levels, poor mental health, marital conflict, environmentalrisk—when combined, can interfere with parents’ ability to pro-vide the rich, responsive caregiving so important to their children’sgrowth and development (Biringen et al., 2005; Dilworth-Bart,Kurshid, & Vendell, 2007; Grych, Fincham, Jouriles, & McDon-ald, 2000; Spiker et al., 2002, 2005).

Not all parents of children with disabilities will engage in lessthan optimal parenting. There is great variability in the populationof families who have a child with a disability (Spiker et al., 2005),including variability in parenting styles. Studies have acknowl-edged the stresses and strains associated with parenting a childwith a disability, but they also have explored the ways that par-ents enjoy and are rewarded by raising their child with a disability(Hastings & Taunt, 2002; Van Riper, Ryff, & Pridham, 1992; Yau& Li-Tsang, 1999). Mothers who find their relationship with theirchild with a disability emotionally reinforcing, as compared with

mothers who do not, experience less parenting stress and perceivethemselves as more effective parents (Glenn, Cunningham, Poole,Reeves, & Weindling, 2008).

The potential barriers to optimal parenting need to be consid-ered in models of early intervention for children with disabilities.The transactional model (Sameroff & Fiese, 2000), although notspecifically targeted to disability intervention, is relevant. Thismodel posits that development occurs in a dynamic process thatcontinually changes over time. The behaviors of the parent andchild change in response to interactions, causing continued changeas each others’ behaviors change. The implication for parenting isthat negative parenting interactions can cascade in such a way thatthe parent and child each behave in ways not optimal to the re-lationship, and these nonoptimal behaviors evolve and strengthenover time. Positive parenting interactions, conversely, can lead toevolving behaviors that optimize the relationship in support ofcontinuing positive interactions.

The developmental systems approach has been posited toguide the practice of early intervention for children with a disability(Guralnick, 2005, 2011). Parent–child interactions, or transactions,are a key aspect of this approach, which emphasizes three levelsthat connect and influence each other and have implications for thework of early interventionists. The first level focuses on individualdevelopment and guides understanding of how children use theirgrowing developmental resources and organizational processes toexpand their social and cognitive competence. The second level fo-cuses on the immediate relationship contexts of development andguides attention to environmental influences, governed throughfamily interactions, which influence children’s development. Thetransactional nature of family dynamics is recognized specificallythrough the family factors of parent–child interactions, family ex-periences, and child health and safety. The third level focuses onthe context outside of the family and guides the identification ofresources available to families to support optimal family patternsof interaction. Establishing or restoring optimal family function-ing, including parent–child interactions, should be a key activity ofearly intervention in any program for vulnerable children guidedby this approach.

Family-centered practice has been accepted by the early in-tervention field for over 20 years and has been evolving as a prac-tice. This set of practices, based primarily on the family systemsmodel, emphasizes family strengths, family choice, and collabo-ration between families and professionals, with a focus on howintervention is delivered (Dunst & Trivette, 2009; Dunst, Trivette,& Deal, 1988, 1994; Trivette, Dunst, & Hamby, 2010). The com-ponents of family-centered practice include understanding fam-ily needs (concerns and priorities) and strengths, using families’existing capabilities (strengths), and providing capacity-building,help-giving practices that build on and further enhance informalsocial supports and resources. Dunst and colleagues (Dunst &Trivette, 2009; Dunst, Trivette, & Hamby, 2006; Trivette et al.,2010) completed meta-analyses that were focused on identifyingand supporting the components of the model. Two recent meta-analyses have suggested that family-centered, help-giving practices

Infant Mental Health Journal DOI 10.1002/imhj. Published on behalf of the Michigan Association for Infant Mental Health.

Using the PICCOLO with Parents of Children with a Disability • 309

had effects on parent, family, and child behavior and function-ing either directly, indirectly (mediated by self-efficacy beliefs),or both (Dunst & Trivette, 2009; Trivette et al., 2010). Relevantto our focus on parent–child interaction, early interventions havedemonstrated clear benefits for both parent–child interactions andchildren’s development when using the family-centered approach(Trivette et al., 2010).

Key to both the developmental systems approach and family-centered practice is a focus on working with the family system topromote optimal development. Both approaches include a focus onparenting and parent–child interaction. Family-centered practices,while not excluding child-focused activities, have suggested thatthe central focus of early intervention should be on parent–childinteraction (Dunst & Trivette, 2009; Dunst et al., 2006). Never-theless, the field of early intervention continues to be primarilychild-focused (Campbell & Halbert, 2002; Harbin, McWillian, &Gallagher, 2000). For example, Scarborough et al. (2004) found,based on practitioner reports, that 44% of early intervention homevisits were focused solely on the child rather than on both the childand family. In direct observations of early intervention practition-ers during home visits, Peterson, Luze, Eshbaugh, Jeon, and Kantz(2007) found that 66% of the practitioners’ time was spent directlywith the child, with 51% of their time spent directly teaching thechild and 33% of their time spent engaging in adult interactions;very little time was focused directly on enhancing parenting be-haviors via coaching parent–child interactions or modeling. Thesechild-focused practices continue despite the fact that, nationally,most families receive less than 2 hr of early intervention per week(Scarborough et al., 2004), a small quantity if practitioners viewthemselves as the primary change agents of early intervention.

This is not to imply that parent–child interaction is an ignoredcomponent of early interventions for parents of children with adisability. Warren and Brady (2007) reviewed the role of maternalresponsivity for children with a disability and highlighted severalinterventions that have demonstrated links between positive im-pacts on maternal responsivity and better developmental outcomesfor children. Mahoney and Perales (2003, 2005) reported positiveoutcomes of a relationship-focused intervention model for childrenwith a disability. These studies have demonstrated that a focus onparent–child interaction does occur in some interventions, but thisfocus is not widely implemented in practice (Peterson et al., 2007;Scarborough et al., 2004).

We advocate for directly including a focus on parent–child in-teraction within the family-centered model. This parenting-focusedapproach works through the parent–child relationship to sup-port the parent in the role of promoting the child’s development(Roggman, Boyce, & Innocenti, 2008). The parenting-focused ap-proach includes the direct evaluation and monitoring of parent-ing. Positive developmentally supportive parenting behaviors arenoted and used in practice to provide feedback and encouragementto parents. Positive parenting behaviors can serve to bridge andstrengthen additional positive parenting behaviors that may notbe occurring as often. The parenting-focused model emphasizesmore types of parenting behaviors than just maternal responsive-

ness. It is clear that multiple parenting behaviors contribute tooptimal outcomes for children (Guralnick, 2005; Roggman et al.,2008; Roggman et al., 2013; Spiker et al., 2002). As Roggmanet al. (2013) noted, multiple parenting behavior domains predictmore than one kind of developmental outcome in children (mul-tifinality), just as any particular child developmental outcome ispredicted by parenting in more than one domain (multicausality;Cicchetti & Rogosch, 1996; Masten, 2006). A parenting-focusedapproach would be a component of early intervention practice thatis consistent with both the developmental systems approach andthe family-centered model.

A parenting-focused approach requires a tool to measure theuse and quality of specific parenting behaviors during parent–childinteraction. Almost 20 years ago, Greenspan and Meisels (1994)called for a closer examination of developmental assessments forinfants and young children. One recommendation was the needfor psychometrically sound measures of parent–child interaction.Mahoney, Spiker, and Boyce (1996) found no psychometricallysound measures to assess parent–child interaction. Mahoney et al.(1996) also observed that a measure would need to be practical tobe used by practitioners. In the intervening period, many measuresof parent–child interaction have been developed, but a psychome-trically sound measure for observing parenting of children withdisabilities that also is easy to use and practical for use in earlyintervention has not been developed.

The PICCOLO (Roggman et al., 2013) has demonstratedstrong psychometric properties in a large, diverse sample, but notspecifically for those parents who have a child with a disability.This study examined the psychometric properties of the PICCOLOwhen used to observe parenting behaviors in interactions with chil-dren with a disability. PICCOLO reliability and construct validitywere examined. Predictive validity was examined in relation tochildren’s developmental outcomes when they were 3 years ofage, just before kindergarten entry, and in the Grade 5, and exam-ined further in models that accounted for community and familycharacteristics.

METHOD

Data Sources

Data used for this study were from parenting observations and childdevelopment data available from the video and data archive of theEarly Head Start Research and Evaluation Project (EHSREP; Ad-ministration for Children and Families, 2002; Faldowski, Chazan-Cohen, Love, & Vogel, 2013; Love et al., 2005; Vogel, Yange,Moiduddin, Kisker, & Carlson, 2010). As part of the EHSREP,17 sites collected video observations of mother–child interaction,when children were approximately 14, 24, and 36 months (re-ferred to here as 1 year, 2 years, and 3 years). The selectioncriteria imposed for the development of the original PICCOLO(Roggman et al., 2013) included only European American, AfricanAmerican, and Latino American families for whom a parent–childinteraction session had been videorecorded and who spoke either



English or Spanish. The non-EHSREP observations and data usedin the Roggman et al. study (2013) were excluded from the presentstudy because of lack of information on disability status.

Peterson et al. (2004) examined the data for children in theEHSREP sample with disability indicators. Overall, the incidencefor indicators of potential disability was extremely high, 87% ofchildren, but few (4.7%) were receiving Part C early interventionservices for children with a disability (Individuals with DisabilitiesEducation Improvement Act of 2008). They identified four cate-gories based on disability indicators. The first two categories aremost salient for this study. Peterson et al. (2004) found that 14.4%of children either received Part C services or had a diagnosed con-dition which should have made them eligible for Part C services.Children from these two categories were included in this study;they are referred to herein as children with an identified disability.

PICCOLO scores for children with an identified disabilitywere available for the current study from the combined EHSREPand PICCOLO datasets. We examined the PICCOLO data to esti-mate reliability and validity of the measure with this subsample ofparents. The most up to date version of the EHSREP dataset wasused. Data were examined to identify children who met the criteriafor the first two categories defined by Peterson et al. (2004). Weidentified 309 children (10.1% of the total sample) who were in oneor both of these nonmutually exclusive categories: receiving PartC services or having a diagnosis that would qualify them for thoseservices. This is lower than the number identified in the Petersonet al. (2004) article, but we attribute this to the use of a more recentEHSREP dataset.

The PICCOLO

Development of the PICCOLO is well-described in Roggman et al.(this issue). Briefly, the 29 most consistently reliable and validitems describing positive parenting behavior were selected from89 possible items tested from over 4,500 videorecorded observa-tions of parent–child interaction in over 2,000 low-income familiesfrom the EHSREP and other research. The observation context forthe parent–child interactions used to develop the PICCOLO in-volved the parent and child playing together in a semistructuredsituation in which parents were asked to play with their childrenfor about 10 minutes using toys provided in a sequence of bags,beginning with the first bag and dividing the time however theywished (Berlin, Brady-Smith, & Brooks-Gunn, 2002; Fuligni &Brooks-Gunn, 2013; National Institute of Child Health and HumanDevelopment Early Child Care Research Network, 1999; Vandell,1979). The first bag contained a book, the second bag included toysfor pretend play, and the third bag (included only in the EHSREPobservations) contained other age-appropriate, manipulative toys.

For the original PICCOLO tool (Roggman et al., this issue), in-terrater agreement was tested for each item, and scale internal con-sistency and single-factor structure were tested within each of fourdomains: affection, responsiveness, encouragement, and teaching.Item-level interrater-reliability correlations between pairs of ob-servers averaged .77, and absolute agreement between observers

averaged 75% across all items and domains. Internal consistencyα across the four domains averaged .78 (range = .75–.80). Factorloadings for each item on a single factor for each domain weregreater than an acceptable minimum of .40 (M = .65).

Validity was tested, overall and within ethnic groups, us-ing concurrent parenting measures and later child developmentmeasures at 3 and 5 years of age. To estimate construct validity,PICCOLO domain and total scores were correlated with indepen-dent ratings of observed parenting behavior from the EHSREPdata archive. These independent ratings were based on 7-pointscales for maternal sensitivity, cognitive stimulation, and positiveregard (Berlin et al., 2002; Fuligni & Brooks-Gunn, 2013), whichwere combined into a single score of supportiveness (α = .82–.83; Fuligni & Brooks-Gunn, 2013). Averaged over all three agepoints, the original PICCOLO was correlated with supportiveness,r = .62, p < .0001, demonstrating strong construct validity (Rog-gman et al., this issue). Predictive validity was evident in sta-tistically significant correlations between the original PICCOLOscores and multiple measures of children’s cognitive-language andsocioemotional development at ages 3 and 5, obtained from theEHSREP dataset.

Analysis of the PICCOLO with Parents of Childrenwith a Disability

To test scale reliability of the PICCOLO for parents of childrenwith an identified disability, the internal consistency of each do-main scale was assessed using Cronbach’s α. To assess the single-factor structure of items within each domain for the parents ofchildren with an identified disability, confirmatory factor analysiswas used with scores averaged across child ages. For the PICCOLOfor parents of children with an identified disability, construct valid-ity was estimated by correlating total PICCOLO scores with scoresfrom the EHSREP Parent Supportiveness scale rated from the sameobservations. To examine PICCOLO predictive validity for chil-dren with an identified disability, scores were examined in rela-tion to child language, cognitive, and academic outcomes tested at36 months (3 years old), prekindergarten (5 years old), and Grade 5,using measures from the EHSREP dataset (ACF, 2002; Faldowskiet al., 2013; Vogel et al., 2010). All child outcome measures wereadministered by trained individuals according to protocol devel-oped for the EHSREP (ACF, 2002; Faldowski et al., 2013; Vogelet al., 2010).

Predictive Validity Measures

Child receptive language vocabulary was measured at child age3 years, 5 years, and Grade 5 with the Peabody Picture VocabularyTest-III (PPVT-III; Dunn, Dunn, & Dunn, 1997). Internal consis-tency for the PPVT-III, as reported by the authors, is indicatedby Cronbach’s α of .92, and test-retest reliability is .91, similar tothe α of .96 in the EHSREP sample at 5 years of age. Among10-year-olds in the national norming sample for the PPVT-III



(n = 100), the internal consistency α was .96, split-half reliabilitywas .94, and test-retest reliability was .88 (Dunn et al., 1997).

At 3 years of age, children’s scores on the Bayley Scales ofInfant Development (BSID-II) Mental Development Index (MDI;Bayley, 1993) were used to examine associations with children’scognitive development. Coefficient α for the MDI has been re-ported at .92 (Bayley, 1993).

At 5 years of age, children’s cognitive skills were measuredusing the Woodcock–Johnson Psycho-Educational Test Battery-Revised (WJ-R) Applied Problem Solving (WJ-AP) and Letter–Word Identification (WJ-LW) subtests (Woodcock & Johnson,1990). Reading ability or decoding was measured with the WJ-LW, the Letter–Word Identification subtest of the WJ-R subtest,and general cognitive development with the WJ-AP subtest. Thesebatteries can be used for a wide age range, are well suited to testingboth reading ability and achievement, and have established relia-bility and validity on a normative sample, with Cronbach’s αs of.84 to .94 (Woodcock & Johnson, 1990).

At Grade 5, two measures from the Early Childhood Longi-tudinal Study-K (ECLS-K) were used (Vogel et al., 2010). Thelanguage/literacy assessment measured children’s reading skills,including vocabulary, comprehension, and meaning-making, andthereby provided an estimate of children’s overall reading skills.The ECLS-K math assessment measured children’s ability in sev-eral domains of problem-solving, including simple multiplicationand division, understanding of place value, and using ratios andfractions. The ECLS-K measures are psychometrically sound (Pol-lack, Atkins-Burnett, Najarian, & Rock, 2005). Internal consis-tency coefficients were calculated across the six rounds of readingassessment completed as part of the ECLS-K, with αs ranging from.69 to .93 for the reading assessment and from .58 to .88 for themathematics assessment (Pollack et al., 2005).

The Matrix Reasoning subscale of the Wechsler IntelligenceScale for Children, Fourth Edition (Wechsler, 2003), a direct as-sessment of children’s cognitive abilities, also was used at Grade 5.The Matrix Reasoning subscale measures visual processing and ab-stract, spatial perception. Matrix Reasoning tasks are related to gen-eral intellectual ability and are considered relatively language-fairand culture-free (Raven, Raven, & Court, 1998; William, Weiss,& Rolfhus, 2003). Internal consistency split-half reliability wasreported as .89 and test-retest reliability as .85 for the publishedmeasure.

RESULTS

The PICCOLO demonstrated strong reliability and validity whenused with parents of children with an identified disability. Resultsof analyses demonstrating these findings are presented next.

Descriptives

Using Peterson et al.’s (2004) disability-indicator criteria, 309 chil-dren with disabilities were identified in the dataset as having re-ceived Part C services or having a diagnosed condition that would

have made them eligible for Part C services; these children will bereferred to as the children with identified disability (CID) group.The remaining children were those without these disability indica-tors in Peterson et al.’s (2004) criteria; these children will be re-ferred to as the children with no identified disability (CNID) group.Peterson et al. (2004) identified many of these Head Start childrenas having biological risks (61%) or suspected delays (64%), theirLevels 3 and 4, but these children will not be included in the CIDgroup.

Table 1 presents information, collected at entry into EHSREP,on a variety of demographic characteristics of the children andtheir mothers in the CID and CNID groups. These include motherage, defined as mother younger or older than 20 years at child’sbirth; mother education; whether there was an adult male in thehousehold; child gender and ethnicity; primary language spokenat home; and maternal risk group, which was based on a count ofidentified risks that includes single mother, teen mother, motherwithout a high-school diploma, mother neither working nor inschool, or family receiving public assistance (Admiknistration forChildren and Families, 2002; Faldowski et al., 2013; Love et al.,2005). On all characteristics examined, except adult male in house-hold and risk group, there were statistically significant differencesbetween the groups. Mothers in the CID group were older whenthe child was born, had more education, and were more likely to beEuropean American. Children in the CID group were more likelyto be male and to have English as their primary language.

Not all children in the CID group had been scored on thePICCOLO. Of the 309 children identified in this group, 236 chil-dren and mothers had been observed and scored using the PIC-COLO. Roggman et al. (this issue) identified a number of PIC-COLO exclusion criteria that would have led to this smaller sam-ple, including poor video quality, a language other than Englishor Spanish, or ethnicity other than the three major groups tested.Demographic and comparative information on children in the CIDgroup who were and were not observed with the PICCOLO alsoare presented in Table 1. Statistically significant differences werefound between these two CID subgroups on the variables of anadult male in the household, child gender, ethnicity, and primarylanguage of English. Families with PICCOLO observations weremore likely to have an adult male in the home, to speak Englishat home, and for the child to be male. In the families withoutPICCOLO observations, there were more families who were ofethnicity who did not meet the inclusion criteria for PICCOLO(∼15%); after removing those cases, however, there were no eth-nicity differences.

The remaining analyses include only mother–child pairs withPICCOLO scores. Domain scores at each age for the two groups(CID and CNID) were compared using one-way analysis of vari-ance, and only three statistically significant differences were found:Affection when children were 3 years old, F(1, 1364) = 3.93, p =.05, encouragement when they were 3 years old, F(1, 1364) =4.75, p = .03, and teaching when they were 2 years old, F(1,1493) = 8.59, p < .00. Scores for the CID group were higher in theaffection and encouragement domain at 3 years of age while CID



TABLE 1. Demographic Characteristics of the Parents and Children with (CID) and without (CNID) an Identified Disability and, among Childrenwith an Identified Disability, Those with and without PICCOLO Observations

All children Only CID group

CID (%) CNID (%) With PICCOLO (%) No PICCOLO (%)Variable (n = 276–309) (n = 2400–2686) (n = 233–236) (n = 65–70)

Mother age (∗, n.s.)a

Mother younger than 20 40.8 43.4 25.7 23.2Mother education (∗∗, n.s.)

<Grade 12 41.9 48.3 38.5 53.7Grade 12 or GED 30.2 28.5 35.5 11.9>Grade 12 27.9 23.2 26.0 34.3

Adult male in household (n.s., ∗∗) 38.7 38.5 42.8 24.6Child is male (∗, ∗∗) 61.8 49.9 64.8 51.4Ethnicity (∗, ∗)

White 49.7 35.7 51.1 47.7Hispanic 19.0 24.1 16.7 12.3African American 27.5 35.5 31.8 24.6

Primary language (∗∗, ∗)English 83.7 78.2 87.7 70.1

Risk group (n.s., n.s.)<3 risks 47.4 41.8 50.5 37.13 risks 28.3 31.5 27.1 32.3>3 risks 24.2 26.7 22.4 30.6

n.s. = not statistically significant.aStatistical significance is presented in parentheses: first for the CID and CNID groups, then for those in the CID group with and without PICCOLO assessments.∗Significant at the .01 level. ∗∗Significant at the .05 level.

group scores for the teaching domain were lower at 2 years of age.Total PICCOLO scores when children were 1, 2, or 3 years of ageare presented in Table 2 for the CID and the CNID groups. Nostatistically significant differences were found between groups onthe total scores.

Reliability. Reliability was assessed for the PICCOLO scores onlyfor parents of children with an identified disability, the CID group.Scale reliability was assessed by testing the internal consistency ofeach domain scale. Coefficient α was examined for each domainto ensure that it exceeded an acceptable minimum of .65. Inter-nal consistency α across the four domains averaged .80. Withineach domain, internal consistency of the scale was indicated bycoefficient αs of .79 for the affection domain, .79 for the respon-

TABLE 2. Total PICCOLO Scores for Parents of Children with andwithout an Identified Disability at Each Observation

CIDa (n = 174–195) CNIDa (n = 1,157–1,381)

PICCOLO M SD M SD

1 year 38.15 8.23 38.14 7.562 years 40.52 8.33 41.16 7.723 years 40.77 7.80 40.47 7.68

aCID = group of parents of children with an identified disability; CNID = groupof parents of children with no identified disability.

siveness domain, .81 for the encouragement domain, and .80 forthe teaching domain.

To test for single-factor structure of items within each domainfor the CID group, confirmatory factor analysis was used withscores averaged across child ages. A single-factor structure wassupported in each domain. Factor loadings for the CID samplewere in the moderate to high range (M = .59). All items on themeasure had factor loadings above the recommended minimum of.40 for this sample, with the exception of “close physical prox-imity” (.23) in the affection domain and “presents activities in asequence of steps” (.38) in the teaching domain. The proximityitem had low variability in this sample, which may account forthe low factor loading. The sequencing item had a low rate ofincidence that could account for the low factor loadings in thispopulation.

Construct validity. To test construct validity, the PICCOLO scorefor the CID group was correlated with the supportiveness scorefrom the EHSREP video observations of parenting (Berlin et al.,2002; Fuligni & Brooks-Gunn, 2013). The supportiveness con-struct from this observation included the domains of maternalsensitivity, cognitive stimulation, and positive regard. Significantcorrelations (range = .53–.64) were found between supportivenessand the PICCOLO at all ages. These correlations were .54 at age 1,p < .00, n = 188, .65 at age 2, p < .00, n = 192, and .53 at age 3,p < .00, n = 172.



TABLE 3. Correlations Between Outcome Measures at 3 and 5 Years ofAge and Grade 5 and PICCOLO Scores for Children with an IdentifiedDisability

PICCOLO

Outcome Measure 1 year 2 years 3 years

3 yearsPPVT (n = 138–149) .25∗ .20∗ .19∗

BSID MDI (n = 135–150) .24∗∗ .31∗∗ .24∗∗

5 yearsPPVT (n = 131–139) .41∗∗ .39∗∗ .40∗∗

WJ Applied Problems (n = 137–145) .26∗ .29∗ .30∗∗

WJ Letter/Word ID (n = 117–121) .24∗∗ .23∗ .29∗∗

Grade 5ECLS-K math (n = 97–103) .29∗∗ .32∗∗ .31∗∗

ECLS-K lang/lit (n = 98–108) .33∗∗ .34∗∗ .39∗∗

Matrix Reasoning (n = 98–109) .29∗∗ .31∗∗ .34∗∗

PPVT (n = 97–108) .33∗∗ .40∗∗ .36∗∗

PPVT = Peabody Picture Vocabulary Test 3; BSID MDI = Bayley Scales of In-fant Development, Mental Development Index; WJ = Woodcock–Johnson Psycho-Educational Test Battery-Revised; ECLS-K math = Early Childhood LongitudinalStudy-Kindergarten cohort, Math scale; ECLS-K lang/lit = Early Childhood Longi-tudinal Study-Kindergarten cohort, Language and Literacy scale; Matrix ReasoningTest = Wechsler Intelligence Scale for Children matrix reasoning test.∗Correlation is significant at the .05 level (two-tailed). ∗∗Correlation is significantat the .01 level (two-tailed).

Predictive validity. To test predictive validity, PICCOLO totalscores for the CID group at each age were correlated with childdevelopment measures from assessments at child ages 3 years,5 years, and at Grade 5. Each of these developmental outcomemeasures had been selected for the EHSREP study because ofstrong psychometric properties and appropriateness for the pop-ulation being assessed. Correlations with the PICCOLO reflectedstrong medium to large effect sizes (.19–.41) and were statisticallysignificant at all ages (Table 3).

To better understand the relation between parenting as mea-sured by the PICCOLO and cognitive and language outcomes, aseries of multiple regression models were tested within both groups(CID and CNID). To facilitate analysis and interpretation, PIC-COLO scores were averaged over time, and standardized outcomescores at each age level were collapsed into a single compositevariable. An overall PICCOLO score was obtained by computingz-scores for PICCOLO scores at each age (1, 2, and 3 years). Thesescores were averaged over time, providing each mother and childwith a single PICCOLO score. Similarly, a z-score transforma-tion of each outcome variable at each age was computed. A meanacross outcomes at each age was computed, and Cronbach αs wereobtained for these constructed outcome indices for children in theCID and CNID groups. These αs were strong: For 3-year-old out-comes (PPVT and BSID MDI), αs were .75 for the CID groupand .72 for the CNID group; αs for 5-year-old outcomes (PPVT,WJ-AP, and WJ-LW) were .77 and .73, respectively; and αs forGrade 5 outcomes (PPVT, matrix reasoning, ECLS-K reading, andECLS-K math) were .89 and .84, respectively.

TABLE 4. Multiple Regression Results for Analysis of Covariates and thePICCOLO on Dependent Variable at Each Age for Children without andwith an Identified Disability

Dependent Variable Model F∗ Adjusted R2 Change R2a β PICCOLO∗

Outcome: 3 yearsCNID 15.87 0.28 0.04 0.23CID 6.31 0.53 0.20 0.48

Outcome: 5 yearsCNID 11.29 0.21 0.05 0.26CID 2.08 0.27 0.19 0.48

Outcome: Grade 5CNID 13.67 0.23 0.05 0.24CID 2.94 0.29 0.08 0.34

aChange from Step 2 to Step 3.∗p ≤ .001 for all outcomes.

A series of three-step multiple regression models were used topredict children’s developmental outcomes, as the dependent vari-ables at each age. Steps 1 and 2 included covariates to control forcommunity and family characteristics. Covariates were includedbecause the CID group included children with variable character-istics that may have influenced parenting behavior and children’sdevelopmental outcomes, so it was important to control for othersources of variation. Step 1 included the site at which the childreceived services to control for variations in community resources.To control for additional variations in family and community char-acteristics, Step 2 included entries of ethnicity, child gender, familyrisk group, and (at Grade 5 only) school poverty as indicated by thepercent of students receiving free or reduced lunch at the child’sschool. The full model was statistically significant at each age(Table 4). Table 4 contains the F for each multiple regressionmodel, the adjusted R2, the change in R2 from Step 2 to Step 3, andthe adjusted β for the PICCOLO variable, entered alone in Step 3.

These PICCOLO models at each age explained a statisticallysignificant amount of variance. The change in adjusted R2 fromStep 2 to Step 3 is notable. At all ages, entry of the PICCOLOin the models added statistically significant prediction of develop-mental outcomes. For the CID group, more variance in children’sdevelopmental outcomes was explained by the PICCOLO parent-ing behavior variable than that in the models for the CNID group.Betas for the PICCOLO, in all models at all ages in both groups,were statistically significant, but at all ages, βs were higher for theCID group than for the CNID group. An examination of the βs aseffect size estimates suggests that the effect of early parenting, asmeasured by the PICCOLO, on children’s later developmental out-comes was two to four times greater in the CID group than it was inthe CNID group. For each whole unit increase in the independentvariable, β describes the increase in the dependent variable. So forthese standardized variables, an increase of 1 SD in the PICCOLOscore (7–8 points or any four additional parenting behavior itemsfrom the PICCOLO) would predict better outcomes for childrenwith an identified disability by almost a 1/2 SD at ages 3 and



5 years and by 1/3 SD at Grade 5. The βs for PICCOLO in the CIDgroup would be considered medium to large effect sizes, larger at 3and 5 years of age; βs for the PICCOLO in the CNID group wouldbe considered medium (Cohen, 1988).

DISCUSSION

The goal of this study was to determine if the PICCOLO is ap-propriate for use with parents of children with a disability. ThePICCOLO is a psychometrically sound measure of parent–childinteractions. For this study, we obtained the same dataset used totest PICCOLO psychometrics, a large sample of ethnically diverseparents and children from low-income families (Roggman et al.,this issue), and children with disability indicators in the datasetwere identified using an established procedure (Peterson et al.,2004).

The PICCOLO demonstrated strong reliability, as well as con-struct and predictive validity, for parents of children with an iden-tified disability. These results not only suggest the usefulness ofthe measure for practitioners and researchers in the field of earlychildhood disabilities but also provide strong support for the con-tention that early parenting is important for children with disabili-ties (Spiker et al., 2002, 2005), as emphasized in existing modelsfor early intervention (Dunst & Trivette, 2009; Guralnick, 2011).In this study, early parenting behaviors predicted cognitive and lan-guage outcomes up to 10 years after the first PICCOLO assessment.Early parenting appears even more important, based on our results,in relation to later outcomes for children with a disability than forchildren without a disability. This is consistent with the differentialsusceptibility hypothesis (Belsky, Bakermans-Kranenburg, & vanIJzendoorn, 2007), in which environmental impacts are greater formore vulnerable individuals. Our results show that the impacts ofthe parenting environment are greater for children who are moredevelopmentally vulnerable because of a disability.

The importance of parenting for children with a disabilityis not surprising. Positive parenting and parent–child interactionsplay a role in the major models used to understand and guidethe process of early intervention (Guralnick, 2011; Trivette et al.,2010.). Intervention approaches focus on increasing specific par-enting skills. Parenting, however, is typically considered a meansto the end goal of improved developmental outcomes for childrenwith a disability (Peterson et al., 2007; Warren & Brady, 2007).Rarely in early intervention programs do we see parenting as afocus of intervention solely for the sake of improving parenting.Although we would not recommend a sole focus on parenting, ourfindings suggest that including a focus on parenting increases theeffectiveness of early intervention. Trivette et al. (2010) demon-strated impacts of parenting on family and child functioning, aswould be expected in a systems model. Parenting also appears toplay a mediator role for child outcomes in Early Head Start (Ad-ministration for Children and Families, 2002). The indirect effectsof mediation models suggest that interventions that influence par-enting show not just additive effects but also multiplicative effects,with an increase in parenting resulting in a larger increase in child

outcomes (and an unknown increase in family functioning). Lim-iting the focus on parenting to only a small set of specific skillsintended to, for example, increase language skills misses the largergoal of intervention: durable, long-term improvements in familyand child functioning. Recent research on preschool interventionfor children with a disability has raised some questions about amodel solely focused on child skill acquisition (Sullivan & Field,2013), questions that should be applied to models of early inter-vention for children under age 3 years, such as those included inthis study.

Practitioners have sometimes suggested to us that parents can-not provide the support needed by children with a disability, thatthe children’s disability interferes with positive parenting, or thatthe kinds of developmentally supportive parenting provided byparents of typically developing children will not be adequate fora child with a disability. Our results show that these statementsare not true for this sample of children. Positive, developmentallysupportive parenting behaviors, used to some extent by all parentsin the EHSREP as measured by the PICCOLO (Roggman et al.,this issue), were even more predictive of positive longitudinal out-comes for children with a disability than for children without adisability. These results suggest that parents who have a child witha disability similar to those in the EHSREP sample (Scarboroughet al., 2004, suggest that the majority in Part C are similar to thissample.) do not necessarily need to change the quality of theseidentified behaviors: PICCOLO scores did not differ between theCID and CNID groups, but those within each group who did moreof these behaviors had children with better outcomes. This doesnot imply that there are not some parents who have a child withmultiple disabilities or a more severe disability who may need par-enting behaviors not included in the PICCOLO. Nevertheless, thefindings of multifinality and multicausality in the PICCOLO study(Roggman et al., this issue) suggest that although there may beother positive parenting behaviors that are important, the parent-ing behavior identified by the PICCOLO across multiple domainsshould help lead to positive child outcomes. The findings of thepresent study suggest that parenting across multiple domains cansupport the cognitive and language development of children witha disability.

Parenting as measured by the PICCOLO was designed to mea-sure positive parenting behaviors predictive of good child devel-opmental outcomes. Programs for parents at risk, such as home-visiting programs for families in poverty, typically focus directlyon parenting as an outcome equal in status to other outcomes. Earlyintervention Part C programs often consider parenting as an addi-tional intervention variable that can be modified to help improvechild outcomes. This distinction is subtle, but meaningful, althougheach has parenting in a causal chain. Early intervention programsdo not typically assess parenting to better understand existing par-enting skills and use them to guide intervention. This philosophicaldifference, expressed in differences in the practices and process ofearly intervention services, may be counterproductive to improvedlong-term child outcomes and to the goals of positive family func-tioning. The developmental systems approach (Guralnick, 2011)



and family-centered practice models (Dunst et al., 2006) speak tothe importance of parenting as a central goal, albeit not the onlygoal, that contributes to the maximization of functioning of thefamily as a unit and to the well-being of members of the family(Trivette et al., 2010). Research on families of children with adisability has provided evidence that the parent–child relationshipmay be disrupted by behaviors the child exhibits that are char-acteristic of the disability or by the impact that these behaviorshave on parent mental health (Biringen et al., 2005; Dilworth-Bartet al., 2007; Spiker et al., 2005). Given the models that guide earlyintervention and our knowledge about the impacts of disability onparent–child interaction, it seems clear that the field has not beenclearly focused on an important outcome.

Perhaps one of the reasons that the early intervention field hasnot focused as directly on parenting as on children’s developmentas a targeted outcome is that children’s developmental outcomesare easier to measure than are parenting outcomes. There are manypsychometrically sound tools for measuring developmental out-comes, especially those directly related to academic success. Manyof these developmental measurement tools are easy to use and pro-vide a clear metric for the impact of our practices. The same cannotbe said of most tools designed to measure parenting.

Some time ago, Mahoney et al. (1996) outlined three criteriathat would facilitate the assessment of parent–child interaction: (a)The measure must be reliable and valid, (b) it must be implementedin a sensitive and equitable way for all parents, and (c) interven-tionists must have a compelling reason for measuring parent–childinteraction. We believe that the PICCOLO tool meets these crite-ria: The PICCOLO is reliable and valid, is easy to learn to use, andall parents are assessed in the same way. The behaviors measuredby the PICCOLO appear appropriate for different ethnicities, forparents of children with a disability, and perhaps even for othercountries (Bayoglu, Unal, Elibol, Darabulut, & Innocenti, this is-sue). The PICCOLO is useful for practitioners (Wheeler et al., thisissue). The results of this study, along with the models that guideour practice, clearly demonstrate the importance of measuring par-enting behaviors in early intervention because they lead to betterfamily and child outcomes. By measuring parenting behaviors,practitioners will be better able to provide interventions that fo-cus on strengthening positive parenting behaviors. The PICCOLOprovides a tool for measurement, intervention, and evaluation ofparenting behaviors.

This is not to imply that the focus of practitioners workingwith families of children with disabilities will change quickly.During the last 20 years of discussing family-centered practice andmaking some positive improvements in this direction (Campbell& Halbert, 2002; Salisbury, Woods, & Copeland, 2010), practi-tioners have often shown resistance, and observations of practicehave shown that family-centered practices are still implemented inlimited fashion (Campbell & Sawyer, 2007; Peterson et al., 2007).Clearly, more research is needed on the process of interventions inthe home that can increase the kind of parenting that leads to im-proved child outcomes. We believe that effective early interventioninvolves identifying positive parenting behaviors, providing feed-

back to parents on how these behaviors are likely to support chil-dren’s development, and helping parents find more opportunitiesto use these behaviors. We hope that the PICCOLO can facilitateresearch to test specific strategies for increasing developmentallysupportive parenting in a variety of settings.

Limitations

There are limitations to the current study. The sample is not anationally representative sample, although it does represent di-verse geographic areas. The parents are mostly from low-incomefamilies. These families may face more challenges in parenting achild with a disability, but a high level of challenge is not atyp-ical for many parents of children with a disability (Spiker et al.,2005). We know that income level does make a difference in lan-guage development (Hart & Risley, 1995) and may with parentingas well. Although the items tested for the development of thePICCOLO came from existing measures, which generally havebeen developed for middle-class, European American parentsand may reflect parenting practices of middle-class parents, thePICCOLO was tested on parents in poverty. We need to moreclearly understand the parenting of families with more secure in-comes as well as those in poverty.

The children in this sample were not children with severeor multiple disabilities. Clearly, parenting is important for thesechildren with more involved disabilities, but do the same types ofparenting lead to better outcomes for children with more severedisabilities? Research has focused on parenting a child with severemultiple disabilities (Chen, Klein, & Haney, 2007; Janssen, Riksen-Walraven, van Dijk, & Ruijssenaars, 2010) because the nature ofthese disabilities are disruptive to the parent–child relationshipand because the importance of parenting is readily recognized. Re-search is needed to further examine the impact of other parentingbehaviors on children with severe disabilities or with a variety ofdifferent disability conditions that may affect parent–child inter-actions in different ways (e.g., autism, cerebral palsy, deafblind-ness). Usefulness of the PICCOLO for this purpose needs to beexamined. The PICCOLO includes a finite set of indicators of par-enting behaviors that occur during parent–child interaction. Morethan likely, there are other parenting behaviors that are unique toparents of children with multiple disabilities or a more severe dis-ability. Similarly, there may be parenting behaviors that are uniqueto other cultures. The PICCOLO provides a beginning point foradding other parenting behaviors to test, using an approach similarto that used to test the PICCOLO for fathers (Anderson, Roggman,Innocenti, & Cook, this issue), to identify specific additional be-haviors that may be important in certain relationships, cultures,and circumstances.

Conclusion

The PICCOLO measure is an appropriate, reliable, and valid mea-sure of parenting interactions with children with a disability as wellas parenting interactions with typically developing children. Earlyintervention practitioners can use PICCOLO to better understand



a parent’s parenting skills and to build on those behaviors thatparents are already using and value. The PICCOLO lends itselfto a strengths-based parenting approach (Roggman et al., 2008).It is an easily used tool that helps practitioners evaluate parentingbehaviors, encourage developmentally supportive parenting, andprovide information on parenting that can be used in intervention(Wheeler et al., 2013).

The association between parenting and child outcomes hasbeen a topic of discussion for many years, in relation to bothtypically developing children and those with disabilities (Brooks-Gunn & Lewis, 1984; Mahoney, Finger, & Powell, 1985). The lackof strong tools to assess parenting has been a long-standing issuein the early intervention field. Perhaps the PICCOLO will helpaddress this issue and assist more programs to focus more directlyon parenting as an intervention component and as an outcome. Wehope that the PICCOLO will provide another tool for practitionersthat will facilitate research and intervention on parenting as a keyaspect of family-centered practice.

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using the piccolo with parents of children with a disability

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