Patching in Children With Unilateral Congenital Cataract and Child Functioning and Parenting Stress.

Importance: Parents may be concerned about the adverse outcomes of occlusion therapy in children treated for unilateral congenital cataract (UCC). Objective: To determine whether occlusion therapy in children treated for UCC with poor visual outcomes is negatively associated with poorer child and/or family functioning. Design, Setting, and Participants: This cohort study was conducted in 2023 using data collected between 2006 and 2016 in the Infant Aphakia Treatment Study (IATS). IATS participants with a visual acuity (VA) of 20/200 or worse were included. Statistical analysis was performed from July 2022 to October 2023. Exposure: Caregivers reported the mean daily minutes of patching during the 12 months prior to the VA assessment at 4.5 years of age. Patching was categorized as minimal (<15 minutes per day), moderate (15 to <120 minutes per day), or extensive (≥120 minutes per day). Main Outcome Measures: At 4.25 and 10.5 years of age, caregivers reported stress associated with the parenting role using the Parenting Stress Index and the Ocular Treatment Index and child behavior problems using the Achenbach Child Behavior Checklist. Motor skills were assessed at age 54 months using the Movement Assessment Battery for Children-Second Edition. Children completed the Harter Self-Perception Profile for Children at age 10.5 years. One-way analysis of variance and χ2 tests were used to compare outcomes by amount of patching. Results: Patching data were available for 47 of 53 children (88.7%) with a VA of 20/200 or worse. Among these 47 children with patching data included in the study, 20 (42.5%) were female, 27 (57.5%) were male, 12 (25.5%) were reported to have been patched fewer than 15 minutes per day, 11 (23.4%) were patched 16 to 119 minutes per day, and 24 (51.1%) were patched at least 120 minutes per day. Parenting stress, child behavior problems, motor functioning, and child self-perception were similar in all groups. For example, after adjusting for gender and insurance status, there was a nonsignificant difference between mean stress scores of 11.0 (95% CI, -4.5 to 26.5) points for parents who reported minimal patching vs parents who reported patching at least 120 minutes per day, and there was no significant difference in children's report of their global self-worth (0.0 [95% CI, -0.4 to 0.3] points). Conclusions and Relevance: Occlusion therapy was not negatively associated with family or child functioning. Although the sample size was limited, these results do not support changes to the current practice guidelines.

Parenting Stress and Adherence to Occlusion Therapy in the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial.

PURPOSE: Using data from the Infant Aphakia Treatment Study, we examined the relationship between adherence to patching and parenting stress. METHODS: Caregivers completed the Parenting Stress Index 3 months after surgery (n = 106), after a visual acuity assessment at 12 months of age (n = 97), and at 4.25 (n = 96) years of age. Patching was reported in quarterly telephone interviews and annual 7-day patching diaries, and averaged across all assessments prior to and in the 6 months following the first stress assessment, and for 6 months before and after the other two stress assessments. The association was assessed using linear regression. RESULTS: Caregivers reporting the highest stress levels 3 months after surgery (i.e., 75th percentile) subsequently reported approximately three-quarters (0.87, 95% confidence interval -1.3 to -0.34) of an hour a day less patching than caregivers reporting the least stress (i.e., the 25th percentile) after controlling for prior patching and other confounders. The association was in the same direction, but not statistically significant, after the second stress assessment and was not apparent at 4.25 years of age. In contrast to our hypothesis, we did not find evidence that higher levels of patching were associated with subsequent increases in parenting stress. CONCLUSIONS: Three months after surgery, higher levels of parenting stress are associated with poorer adherence to patching, and thus stress may contribute to early adherence to patching. TRANSLATIONAL RELEVANCE: Clinicians may wish to provide support to caregivers exhibiting high levels of stress since it may impact their ability to adhere to prescribed patching.

Predictors of Treatment Completion for Families Referred to Trauma-Focused Cognitive Behavioral Therapy After Child Abuse.

Despite advances in the dissemination of evidence-based therapy for abuse-related traumatic stress, many referred children fail to complete treatment. Using archival data from a sample of children participating in trauma-focused cognitive behavioral therapy (TF-CBT) at a hospital-based child advocacy center, analyses explored the impact of baseline child traumatic stress symptoms, a second (nonprimary) caregiver's treatment attendance, and the number of assessment sessions on treatment completion while controlling for demographic variables. We conducted analyses separately for the total sample (n = 77) and for a subsample of children 6 years of age or older (n = 65) who completed measures of traumatic stress. Families who completed TF-CBT had fewer pretreatment assessment sessions, odds ratio (OR) = 0.41, 95% CI [0.19, 0.88], and greater nonprimary caregiver session attendance, OR = 1.30, 95% CI [1.03, 1.64], than families who did not complete treatment. Child age, race, and insurance status did not predict treatment completion. Among children at least 6 years of age, treatment completion was related to younger child age, OR = 0.76, 95% CI [0.59, 0.98], and fewer diagnostic evaluation sessions, OR = 0.29, 95% CI [0.11, 0.74], but not to baseline traumatic stress symptoms. Findings may suggest benefits of shortening the assessment period and including a second caregiver in TF-CBT.

Assessment of Adherence to Visual Correction and Occlusion Therapy in the Infant Aphakia Treatment Study.

Occlusion therapy throughout early childhood is believed to be efficacious in treating deprivation amblyopia but has not been rigorously assessed in clinical trials. Further, tools to assess adherence to such therapy over an extended period of time are lacking. Using data from the Infant Aphakia Treatment Study, a randomized clinical trial of treatment for unilateral congenital cataract, we examined the use of quarterly 48-hour recall interviews and annual 7-day prospective diaries to assess reported hours of patching in 114 children throughout the first 5 years of life. Consistency of data reported was assessed using correlation coefficients and intraclass correlation coefficients. Both interview and diary data showed excellent consistency with Cronbach's Alpha's ranging from 0.69 to 0.88 for hours of patching and 0.60 to 0.73 for hours of sleep. However, caregivers reported somewhat more adherence in prospective diaries than retrospective interviews. Completion rates, on the other hand, were substantially higher for telephone interviews than prospective diaries. For example, after four years of surgery response rates to telephone interviews exceeded 75% versus completion rates of only 54% for diaries. In situations where occlusion dose monitors cannot be used for assessing adherence to occlusion therapy, such as in infants or over an extended period of time, quantitative assessments of occlusion therapy can be obtained by parental report, either as a series of prospective diaries or a series of recall interviews.

Behaviors of children with unilateral vision impairment in the Infant Aphakia Treatment Study.

PURPOSE: To determine whether behavioral functioning of 4.5-year-olds differs between two treatments for unilateral cataract and whether behavioral functioning is predicted by visual acuity in the treated eye. METHODS: The Infant Aphakia Treatment Study is a multicenter clinical trial in which 114 infants with unilateral congenital cataracts were randomized to undergo cataract extraction with contact lens correction or implantation of an intraocular lens. Patching data were collected during the year preceding a visit at age 4.5 years, when both visual acuity and caregiver-reported behavioral functioning were assessed for 109 participants. Caregiver stress was assessed with the Parenting Stress Index at 4.25 years. RESULTS: There were no treatment group differences in behavioral functioning as measured by the Child Behavior Checklist. Poorer visual acuity was associated with more externalizing behavior problems (attention problems and aggressive behavior) and total behavior problems in regression models that did not include caregiver stress. Both caregiver stress and dichotomized visual acuity significantly predicted externalizing problems. CONCLUSIONS: Treatment assignment did not affect caregiver-reported behavior. Poor visual acuity may confer risk for problems with attention and aggressive behavior in preschoolers treated for unilateral cataract.

Association Between Occlusion Therapy and Optotype Visual Acuity in Children Using Data From the Infant Aphakia Treatment Study: A Secondary Analysis of a Randomized Clinical Trial.

IMPORTANCE: Patching has been a mainstay in treating unilateral congenital cataract. However, its efficacy has not been rigorously assessed. OBJECTIVE: To examine the association between patching and visual acuity in a cohort of children treated for unilateral congenital cataract. DESIGN, SETTING, AND PARTICIPANTS: This study was a secondary analysis of a randomized clinical trial (Infant Aphakia Treatment Study) of infants born from August 1, 2004, through December 31, 2008, who were treated with 1 of 2 treatments for unilateral congenital cataract and followed up to 5 years of age. Data analysis was performed from March 1, 2013, to March 1, 2016. INTERVENTIONS: Cataract extraction and randomization to receipt of an intraocular lens vs being left aphakic for the first 5 years of life. MAIN OUTCOMES AND MEASURES: Caregivers reported patching in the previous 48 hours in quarterly semistructured telephone interviews. The mean number of hours of patching per day was calculated from surgery to the first birthday (n = 92) and between 12 and 48 months of age (n = 102). Monocular optotype acuity was assessed at 4½ years of age by a traveling examiner using the Aphakia Treatment Study HOTV protocol. RESULTS: The Infant Aphakia Treatment Study enrolled 114 children; 57 were randomized to each treatment group. At 4½ years of age, optotype visual acuity was assessed in 112 children. The current analyses exclude an additional 3 children (2 who had adverse events that limited visual potential and 1 who had Stickler syndrome), leaving 109 total children analyzed (59 female [54.1%] and 92 white [84.4%]). Caregivers reported patching their children a mean (SD) of 3.73 (1.47) hours per day in the first year of life and 3.43 (2.04) hours per day thereafter. An association between reported patching and treatment was not identified (mean difference in first year, -0.29 hours per day; 95% CI, -0.90 to 0.33 hours per day; mean difference between 12 and 48 months of age, -0.40 hours per day; 95% CI, -1.20 to 0.40 hours per day). Visual acuity was associated with reported hours of patching in the first year of life (r = -0.32; 95% CI, -0.49 to -0.13) and between 12 and 48 months of age (r = -0.36; 95% CI, -0.52 to -0.18). However, patching accounted for less than 15% of the variance in logMAR acuity at 4½ years of age. CONCLUSIONS AND RELEVANCE: These results support the association of occlusion throughout the preschool years with improved visual acuity in infants treated for unilateral congenital cataract. However, similar visual outcomes were achieved with varying amounts of patching. These conclusions should be interpreted in the context of limitations related to generalizability from incomplete data collected in a clinical trial. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00212134.

Motor skills of children with unilateral visual impairment in the Infant Aphakia Treatment Study.

AIM: To assess motor functioning in children aged 4 years 6 months enrolled in the Infant Aphakia Treatment Study, and to determine contributions of visual acuity and stereopsis to measured motor skills. METHOD: One hundred and four children (53% female) with unilateral aphakia randomized to intraocular lens or contact lens treatment were evaluated at 4 years 6 months (age range 4y 6mo-4y 11mo) for monocular recognition visual acuity, motor skills, and stereopsis by a traveling examiner masked to treatment condition. Motor skills were assessed with the Movement Assessment Battery for Children--Second Edition (MABC-2). Visual acuity was operationalized as log10 of the minimum angle of resolution (logMAR) value for treated eye, best logMAR value for either eye, and intraocular logMAR difference. RESULTS: Student's t-tests showed no significant differences in MABC-2 scores between the intraocular lens and contact lens groups. The mean total score was low (6.43; 18th centile) compared with the normative reference group. Motor functioning was not related to visual acuity in the treated eye or to intraocular logMAR difference, but was predicted in a regression model by the better visual acuity of either eye (usually the fellow eye), even after accounting for the influence of age at surgery, examiner, orthotropic ocular alignment, and stereopsis. INTERPRETATION: Children with unilateral congenital cataract may have delayed motor functioning at 4 years 6 months, which may adversely affect their social and academic functioning.

Can Preoperative Psychological Assessment Predict Outcomes After Temporomandibular Joint Arthroscopy?

PURPOSE: Psychological assessment has been used successfully to predict patient outcomes after cardiothoracic and bariatric surgery. The purpose of this study was to determine whether preoperative psychological assessment could be used to predict patient outcomes after temporomandibular joint arthroscopy. MATERIALS AND METHODS: Consecutive patients with temporomandibular dysfunction (TMD) who could benefit from arthroscopy were enrolled in a prospective cohort study. All patients completed the Millon Behavior Medicine Diagnostic survey before surgery. The primary predictor variable was the preoperative psychological scores. The primary outcome variable was the difference in pain between the pre- and postoperative periods. The Spearman rank correlation coefficient and the Pearson product-moment correlation were used to determine the association between psychological factors and change in pain. Univariable and multivariable analyses were performed using a mixed-effects linear model and multiple linear regression. A P value of .05 was considered significant. RESULTS: Eighty-six patients were enrolled in the study. Seventy-five patients completed the study and were included in the final analyses. The mean change in visual analog scale (VAS) pain score 1 month after arthroscopy was -15.4 points (95% confidence interval, -6.0 to -24.7; P < .001). Jaw function also improved after surgery (P < .001). No association between change in VAS pain score and each of the 5 preoperative psychological factors was identified with univariable correlation analyses. Multivariable analyses identified that a greater pain decrease was associated with a longer duration of preoperative symptoms (P = .054) and lower chronic anxiety (P = .064). CONCLUSIONS: This study has identified a weak association between chronic anxiety and the magnitude of pain decrease after arthroscopy for TMD. Further studies are needed to clarify the role of chronic anxiety in the outcome after surgical procedures for the treatment of TMD.

Parenting stress in the infant aphakia treatment study.

OBJECTIVE: To evaluate parenting stress following infants' cataract extraction surgery, and to determine if levels of stress differ between 2 treatments for unilateral congenital cataract in a randomized clinical trial. METHODS: At surgery, an intraocular lens (IOL) was implanted or children were left aphakic, treated with contact lens (CL). Stress measures were administered 3 months after surgery and at the first visit after the visual acuity (VA) assessment done at 12 months of age. RESULTS: Caregivers in the IOL group reported higher levels of stress than those in the CL group 3 months after surgery, but there were no group differences in stress scores at the post-VA assessment. Stress scores did not change differentially for participants assigned to IOL versus CL treatments. CONCLUSIONS: Treatment assignment did not have a significant impact on caregiver stress during infancy or on the change in stress during the child's first 2 years of life.

Predictors of adherence to occlusion therapy 3 months after cataract extraction in the Infant Aphakia Treatment Study.

BACKGROUND: Little information is available on factors that predict adherence to patching in infants. We evaluated data from the Infant Aphakia Treatment Study, a randomized clinical trial of treatment for infants with unilateral congenital cataracts, to investigate factors associated with successful adherence to patching protocols. METHODS: In the Infant Aphakia Treatment Study, patching was prescribed 1 hour daily per month of age until 8 months of age and 50% of waking hours thereafter. A centrally located staff member inquired about the patient's adherence to patching in a phone interview with the primary caregiver. Analyses used χ(2) tests of independence and logistic regression to identify predictors of reported adherence and of achieving adherence rates of at least 75% ("good") and 90% ("excellent"). RESULTS: A total of 104 caregivers provided data on patching 3 months after surgery, at which time 60% reported patching at least 75% of the prescribed time. Reported adherence was not associated with the type of treatment (P = 0.73) but was better in children with private insurance (P = 0.01) and for children with mothers reporting lower levels of parenting stress (P = 0.03). CONCLUSIONS: Most caregivers reported being able to adhere to prescribed patching shortly after extraction of a unilateral congenital cataract. The type of correction (intraocular lens vs contact lens) was not associated with the amount of patching achieved, whereas family socioeconomic status and maternal stress appeared to play a role.

Adherence to occlusion therapy in the first six months of follow-up and visual acuity among participants in the Infant Aphakia Treatment Study (IATS).

PURPOSE: Achieving good vision in infants born with a unilateral cataract is believed to require early surgery and consistent occlusion of the fellow eye. This article examines the relationship between adherence to patching and grating acuity. METHODS: Data came from the Infant Aphakia Treatment Study, a randomized clinical trial of treatment for unilateral congenital cataract. Infants were either left aphakic (n = 53) or had an intraocular lens implanted (n = 55). Patching was prescribed 1 hour per day per month of age until 8 months of age and 50% of waking hours thereafter. Adherence was measured as the mean percentage of prescribed patching reported in a 7-day diary completed 2 months after surgery, and 48-hour recall interviews conducted 3 and 6 months after surgery. Grating visual acuity was measured within 1 month of the infant's first birthday (n = 108) using Teller Acuity Cards by a tester masked to treatment. Nonparametric correlations were used to examine the relationship with grating acuity. RESULTS: On average, caregivers reported patching 84.3% (SD = 31.2%) of prescribed time and adherence did not differ by treatment (t = -1.40, df = 106, p = 0.16). Adherence was associated with grating acuity (r(Spearman) = -0.27, p < 0.01), but more so among pseudophakic (r(Spearman) = -0.41, p < 0.01) than aphakic infants (r(Spearman) = -0.10, p = 0.49). CONCLUSIONS: This study empirically has shown that adherence to patching during the first 6 months after surgery is associated with better grating visual acuity at 12 months of age after treatment for unilateral cataract and that implanting an intraocular lens is not associated with adherence. (ClinicalTrials.gov number, NCT00212134.).

Home-based family intervention for low-income children with asthma: a randomized controlled pilot study.

Low-income African American children have disproportionately higher asthma morbidity and mortality. Education alone may not address barriers to asthma management due to psychosocial stress. This study evaluated the efficacy of a home-based family intervention integrating asthma education and strategies to address stress using a community-based participatory research model. Children age 8 to 13 with poorly controlled asthma and their caregivers were recruited from an urban hospital and an asthma camp. Caregivers with elevated scores on a stress measure were enrolled. Forty-three families were randomized to the 4- to 6-session Home Based Family Intervention (HBFI) or the single session of Enhanced Treatment as Usual (ETAU). All families received an asthma action plan and dust mite covers; children performed spirometry and demonstrated MDI/spacer technique at each home visit. The HBFI addressed family-selected goals targeting asthma management and stressors. Asthma management, morbidity, family functioning, and caregiver stress were assessed at baseline, postintervention, and 6 months after the intervention. ED visits and hospitalizations were ascertained by medical record review for a year after intervention completion. Only one child (5%) in HBFI had an asthma-related hospitalization compared to 7 patients (35%) in ETAU in the year following intervention. Participants in both groups demonstrated improved asthma management and family functioning, and reduced ED visits, symptom days, missed school days, and caregiver stress, but there were no differential treatment effects. The results suggest that a home-based intervention addressing medical and psychosocial needs may prevent hospitalizations for children with poorly controlled asthma and caregivers under stress.

Validity of the Family Asthma Management System Scale with an urban African-American sample.

OBJECTIVE: To examine the reliability and validity of the Family Asthma Management System Scale for low-income African-American children with poor asthma control and caregivers under stress. The FAMSS assesses eight aspects of asthma management from a family systems perspective. METHODS: Forty-three children, ages 8-13, and caregivers were interviewed with the FAMSS; caregivers completed measures of primary care quality, family functioning, parenting stress, and psychological distress. Children rated their relatedness with the caregiver, and demonstrated inhaler technique. Medical records were reviewed for dates of outpatient visits for asthma. RESULTS: The FAMSS demonstrated good internal consistency. Higher scores were associated with adequate inhaler technique, recent outpatient care, less parenting stress and better family functioning. Higher scores on the Collaborative Relationship with Provider subscale were associated with greater perceived primary care quality. CONCLUSIONS: The FAMSS demonstrated relevant associations with asthma management criteria and family functioning for a low-income, African-American sample.

Treatment adherence among low-income, African American children with persistent asthma.

OBJECTIVE: The study aims to assess medication adherence and asthma management behaviors and their modifiable predictors in low-income children with persistent asthma. METHODS: The authors conducted a cohort study of 143 children ages 6 to 11 prescribed a daily inhaled controller medicine that could be electronically monitored. Children were recruited from clinics or the emergency department of an urban children's hospital. Data were collected at baseline (T1) and 1 year later (T2). Outcome measures were adherence to controller medications as measured by electronic monitoring devices, observed metered-dose inhaler and spacer technique, exposure to environmental tobacco smoke, and attendance at appointments with primary health care provider. RESULTS: Medication adherence rates varied across medications, with higher rates for montelukast than for fluticasone. Eleven percent to 15% of children demonstrated metered dose inhaler and spacer technique suggesting no drug delivery, and few (5% to 6%) evidenced significant exposure to environmental tobacco smoke. Less than half of recommended health care visits were attended over the study interval. Few psychosocial variables were associated with adherence at T1 or in the longitudinal analyses. Fluticasone adherence at T2 was predicted by caregiver asthma knowledge. CONCLUSIONS: A substantial number of low-income children with persistent asthma receive less than half of their prescribed inhaled controller agent. Patients without Medicaid, with low levels of caregiver asthma knowledge, or with caregivers who began childrearing at a young age may be at highest risk for poor medication adherence.

A competency-based approach to couple and family therapy supervision.

The competency-based movement continues to guide professional psychology. This has been highlighted through the establishment of essential foundational and functional competencies. The current paper focuses on the intervention competency domain and delineates its relevance within the field of couple and family therapy (CFT). We begin by providing an overview of 8 essential components of CFT: developing a systemic formulation, forging a systemic therapeutic alliance, understanding family-of-origin issues, reframing, managing negative interactions, building cohesion/intimacy/communication, restructuring/parenting, and understanding and applying evidence-based CFT models. We then provide a brief illustration of foundational and functional competencies essential to CFT. We conclude by addressing the CFT competency within an integrative approach to supervision and provide a case illustration that depicts this process. The relevance of establishing unique, evidence-based, theory-specific competency components is highlighted.

Barriers to asthma management among urban families: caregiver and child perspectives.

OBJECTIVE: Asthma is one of the most common chronic diseases of childhood. Those particularly affected are young, poor, African American children. Moreover, rates of emergency department visits, hospitalizations, and mortality are substantially higher for black children. Despite the ample published research on asthma prevalence and asthma management interventions, there is little research available on barriers to asthma care among urban, low-income families as perceived by children with asthma and their caregivers. METHODS: This qualitative study analyzed data from five focus groups conducted with 28 participants in metropolitan Atlanta. RESULTS: This study found caregiver and child health beliefs and perceptions concerning the use of daily controller medications to be a significant barrier to asthma care and proper self-management at home and at school. Barriers to environmental control consisted mostly of financial constraints, which made residential environmental remediation activities difficult to implement. Psychological distress was prevalent among both children and caregivers, which demonstrated the burden associated with managing a chronic illness. CONCLUSION: Families in urban, low-income communities require asthma management interventions tailored to their specific characteristics, barriers, and challenges. Our findings can be used to inform and enhance asthma management interventions for urban families with children with asthma.

Caregiver depressive symptoms and observed family interaction in low-income children with persistent asthma.

This study examined the relationship between caregiver depressive symptoms and observed parenting behaviors and family processes during interactions among 101 urban, low-income Africtan American families with children with persistent asthma. Caregivers (primarily female) were assessed on four dimensions (i.e., warmth/ involvement, hostility, consistent discipline, relationship quality) in three videotaped interaction tasks (loss, conflict, cohesion). The results indicated that increased depressive symptoms were significantly associated with lower warmth/involvement and synchrony scores and greater hostility scores during the loss and conflict tasks. In the total sample, the highest levels of hostility and the lowest levels of warmth/involvement were found for the conflict task; nevertheless, caregivers with moderate/severe depressive symptoms showed a significantly greater increase in hostility from the loss to the conflict task than caregivers with minimal/mild depressive symptoms. The findings highlight the salience of considering task content in family observational process research to expand our understanding of depressed and nondepressed caregivers abilities to modulate appropriately their behaviors and affect across various family interactions. Implications for improving asthma management for low-income children with persistent asthma are discussed, including the utility of multidisciplinary interventions that combine asthma education with family therapy.

Family processes in pediatric asthma.

PURPOSE OF REVIEW: Family processes are best conceptualized within an integrated, dynamic biopsychosocial model of pediatric asthma. We reviewed the literature on specific family processes proposed to influence asthma outcomes, the mechanisms of influence, and family-focused interventions to improve asthma control. RECENT FINDINGS: Family characteristics associated with asthma outcomes include caregiver psychological functioning, parenting, and whole-family processes. These characteristics influence asthma outcomes via asthma management behaviors and/or disease-related psychophysiologic pathways. Family-focused interventions designed to promote asthma control include psychoeducation and family therapy, although alternative models have also been proposed. SUMMARY: Despite the increasing evidence that family processes contribute to asthma outcomes, few theory-based family interventions have been developed for children with asthma. Systemic consultation models and biobehavioral family interventions, in conjunction with pediatric care, appear to hold the most promise for helping families of children with poorly controlled asthma.

Training in family psychology: a competencies-based approach.

After providing an overview of the family psychology landscape and the competencies-based movement in professional psychology, attention is paid to eight family-specific competencies in the following areas: the application of scientific knowledge to practice, psychological assessment, psychological intervention, consultation and interprofessional collaboration, supervision, professional development, ethics and legal issues, and individual and cultural diversity. Effective strategies for providing family-focused education and training to psychology trainees at the doctoral, internship, and postdoctoral levels and to psychologists through continuing professional education in these core competency domains are provided.