Introduction

The COVID-19 pandemic was declared a public health emergency in the USA on March 13, 2020. A survey conducted by the American Psychological Association (APA) indicated that parents had higher reported stress than those in a non-caregiving role (APA, 2021). In comparison to pre-pandemic functioning, caregivers reported worsening interactions with their child, difficulty with discipline, and increases in aggressive child behavior (Burkhart et al., 2022). In response to the urgent need of parent education and support, a remote implementation manual for the ACT Raising Safe Kids program (ACT-RSK; Silva, 2011) was developed.

The ACT-RSK program, developed by the American Psychological Association’s (APA) Office of Violence Prevention, is a parenting program for parents and caregivers of children from birth to age 10. The program teaches parents positive parenting skills with the goal of creating safe, stable, and nurturing environments and relationships that prevent children’s exposure to violence, abuse, and other adverse experiences. The Centers for Disease Control and Prevention (CDC) named ACT-RSK an effective strategy for enhancing parenting skills to promote healthy child development (Fortson et al., 2016). Furthermore, the ACT Program is endorsed by INSPIRE—Seven Strategies for Ending Violence, which was developed by various organizations, including UNICEF and the WHO.

ACT-RSK was designed on the basis of evidence-supported educational methods for adult learners (Galbraith, 1998). The program teaches parents why and how to limit children’s exposure to violence, set developmentally appropriate expectations, manage anger, use nonviolent discipline and positive conflict resolution strategies, and teach children to use social problem-solving skills. Parental nurturing is promoted in the ACT-RSK program through several methods. For example, parents are taught to frame misbehaviors as expectable mistakes on the basis of children’s development rather than intentional misdeeds. Parents are guided to understand why children become angry and misbehave and how children might perceive situations. Parents engage in activities designed to help them understand what children need and wish for from their caregivers. They also learn how children experience violence and how it can affect them emotionally and behaviorally. The program is conducted through 9, 2-h group sessions conducted by trained professionals (ACT-RSK Facilitators) with experience working with children and families. Group sessions are interactive and didactic, and use modelling and role play to promote improvements in parents’ knowledge and skills. Motivational interviewing strategies (Miller & Rollnick, 2013) are used throughout sessions to facilitate parents’ behavior change and continued use of positive parenting skills, and a motivational interviewing guide promotes its effective use among ACT Facilitators (Fuentes & Da Silva, 2010). The program was developed to be easily implemented in a variety of community-based settings at very low cost. As such, it has been implemented and researched in various parts of the USA and in several different nations, including Brazil, Portugal, Japan, and many other nations, and ACT-RSK materials have been translated into several languages (Howe et al., 2017). It has not been evaluated in all nations, however.

Results of multiple studies have demonstrated positive outcomes for completers of the ACT-RSK program delivered in person. For example, one randomized controlled trial (RCT; Portwood et al., 2011) conducted in the USA showed evidence of increased effective parenting, reduced use of harsh verbal and physical discipline, and an increase in nurturing behavior at post-intervention and 3-month follow-up. Results also demonstrated a positive impact on perceived social support. A second RCT (Knox et al., 2013) conducted in the USA provided evidence of improved nurturing, positive parenting behaviors, and use of nonviolent discipline as well as lower rates of psychologically and physically aggressive behavior toward children. Results of a third RCT (Altafim & Linhares, 2019) conducted in Brazil indicated improved nonviolent, positive parenting practices and decreased child behavior problems following completion of the ACT-RSK program. ACT-RSK has been found to be effective even in samples of parents with high rates of childhood violent victimization histories (Altafim et al., 2021). A recent integrative review of the literature on the ACT program concluded that completers of the program have improved parenting practices, and their children have decreased behavioral problems. (Altafim et al., 2023). A recent systematic review of universal programs addressing parenting and child maltreatment identified the ACT-RSK program as effective in producing positive changes in parenting practices and emphasized the importance of ACT-RSK and similar parenting programs as universal prevention strategies (Branco et al., 2022).

While ACT-RSK is a well-researched program implemented nationally and internationally, social distancing made necessary by the COVID-19 pandemic effectively shut down ACT-RSK programs. This removed a vital opportunity for parents during a very high-risk period of time for families. For instance, results of a US multi-institutional study (Collings et al., 2022) indicated that during the initial stay-at-home order, incidents of non-accidental child trauma briefly dropped below historical trends and then proceeded to surpass projected rates. Those that were particularly affected included children under 5 years of age, minority children, and children with high scores on the CDC’s Social Vulnerability Index. Additionally, a comparative study (Salt et al., 2021) of healthcare treatment encounters for child abuse and neglect before and after COVID-related school closings in the USA found that the incidence of both sexual abuse and maltreatment-related inpatient encounters increased by 85%. A US study of parenting behaviors conducted in June and July of 2020 found that 77% of parents reported verbal aggression, and 66% reported physical punishment of children (Todorovic et al., 2022). These rates were significantly higher than those collected at the very start of the COVID-19 pandemic (March 2020; Todorovic et al., 2022).

Research to date provides promising evidence of the effectiveness of remote implementation of group parenting programs. A study of the effectiveness of a modified remote version of ACT-RSK with Brazilian mothers indicated an increase in parental sense of competence, improved maternal emotional and behavioral regulation and decreased coercive practices following mothers’ completion of the program. The mothers in the study reported that the remote program was acceptable to them, and the facilitators reported that it was feasible to deliver an online version (Lotto et al., 2022). An integrated data analysis (Day et al., 2021) from 985 parents in 7 published trials of the Triple P Online program found online implementation to be effective for parents from diverse sociodemographic backgrounds. Similarly, a study examining effects of a 4-h self-directed 1–2-3 Magic online training also showed promising results. An RCT (Porzig-Drummond et al., 2015) found that participants of 1–2-3 Magic reported significantly fewer child problem behaviors and significantly less dysfunctional parenting, with results maintained at a 6-month follow-up. Furthermore, a study examining an internet adaptation of a home-visiting program for parents of infants indicated increased positive parenting behavior and reduced child abuse potential among participant parents (Baggett et al., 2017). Increases in parenting knowledge and observed language-supportive parenting behaviors were observed in parents who completed an internet adaptation of the Play and Learning Strategies (PALS) program (Feil et al., 2020). More recently, since the onset of the COVID-19 pandemic, parents in both a hybrid (in-person as well as telehealth) and a fully telehealth-based intervention of the Attachment and Biobehavioral Catch-up (ABC) program demonstrated significant improvements in parental sensitivity from pre- to post-intervention (Schein et al., 2023).

In response to the urgent need to re-start the ACT-RSK program using remote methods, a group of ACT-RSK Master Trainers (professionals with an advanced degree in psychology, counseling, social work, education, and medicine who have longstanding experience in conducting training for professionals and program management, including the ACT-RSK program) worked together to adapt the methods used to deliver the program in order to prepare for remote implementation. They reviewed every activity in the ACT-RSK facilitator manual (Silva, 2011), a document that outlines step-by-step how to deliver each session, and revised each as needed. For example, the manual included recommendations for meeting with participants individually prior to the group sessions to promote rapport and comfort using technology. Facilitators were asked to mail a welcome package to participants that included materials typically provided during in-person groups. Group activities were altered using breakout rooms and interactions that do not require in-person sharing of materials. Information-sharing adaptations included the use of virtual folders, chat boxes, and whiteboards. The suggestions were shared with the broader group of ACT-RSK-trained professionals, feedback was solicited, and edits were made following group consensus. This resulted in the development of the ACT Raising Safe Kids Program Remote Implementation Manual (Rasiah et al., 2021).

This is the first study to evaluate the effectiveness of the ACT-RSK program using the published, standardized remote implementation guide. The study builds upon the only existing investigation of the remote implementation of the ACT program which was completed with a sample of mothers in Brazil (Lotto et al., 2022). This study, conducted in the USA, includes a sample of fathers and other caregivers, as well as mothers. In addition, it evaluates ACT Facilitators’ experiences and feedback regarding the remote version of the program and also measures parental nurturing behavior. Similar to the Lotto et al. (2022) study, this study evaluates parent feedback regarding their experiences with the remote version of the program.

It is hypothesized that there will be improved positive parenting knowledge and behaviors and decreased use of verbal and physical punishment at post-intervention, compared to pre-intervention. Specifically, it is hypothesized that parents’ scores on the Parent Behavior Checklist Discipline and Nurturing subscales, the ACT-RSK About Parenting, Media and Parents’ Behavior subscales will all be improved at post-intervention. It is hypothesized that ACT-RSK Facilitators will report a high degree of fidelity (> 90% of session tasks completed) to the standardized model. Qualitative data are collected to identify benefits, obstacles, and recommendations for adaptations or additions needed for remote implementation. The effects of remote implementation are compared to the effects of in-person implementation as reported in recent evaluation of ACT-RSK.

Methods

Sample

The sample included only parents or caregivers who live with and regularly care for their children ages 1–10 years. Forty-three parents/caregivers consented to participate in the study. Of these, 35 completed the pre-intervention questionnaires. Of the 35 individuals who completed the pre-intervention questionnaires, 14 failed to complete the program or the post-intervention measures, leaving a final sample of 21 participants whose pre and post-test scores were included in the final analyses. The small sample size in this study mirrors the sample size used in the previous study by Lotto et al., 2022. Such a sample size was deemed adequate for observing changes in this previous study. Given that both are feasibility and pilot studies, the relatively small number of participants is justified.

The 35 pre-intervention participants included 24 mothers, 6 fathers, 1 grandmother, 2 aunts, 1 adoptive mother, and 1 who identified as “other.” The majority of participants were White (75%), non-Hispanic (90.1%), and single mothers (60%) with a high school education/GED (60%) earning an annual income of $30,000 or less (77.15%). The mean age of caregivers was 33.86 (SD = 9.31). Caregivers represented 9 female and 26 male children, aged 1–10 years (with one parent/caregiver not reporting the age of their child) with a mean age of 4.59 (SD = 2.85). Groups were conducted through seven organizations including one Head Start program, one community mental health center, three social service centers, and two academic medical centers in the Midwest region of the United States. Caregivers met inclusion criteria if they received services from one of the seven organizations, lived with and regularly cared for a newborn to 10-year-old child, and had reliable internet access. There were no child characteristics other than child age used to determine eligibility. See Tables 1 and 2 for additional sample demographics.

Table 1 Caregiver demographics
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Table 2 Means and standard deviations for pre and post-test outcome variables
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Measures

The Parent Behavior Checklist (PBC; Fox, 1994) was used to assess parents’ nurturing behaviors. The PBC is well-established and has been reported to have high internal consistency and test–retest reliability (Fox, 1994). The PBC was used in several past studies on the ACT-RSK program (e.g., Knox & Burkhart, 2014; Knox et al., 2013; Portwood et al., 2011). The Discipline (30 items) and Nurturing (20 items) subscales were used. Items on the Nurturing subscale include statements such as, “I praise my child for learning new things” and, “My child and I play together on the floor.” Higher scores on this scale indicate more/better parental nurturing behaviors. Items on the Discipline subscale include statements such as, “I spank my child at least once a week” and, “I yell at my child for whining.” Lower scores on this scale indicate less use of verbal and physical punishment by parents. Item responses are made on a 4-point Likert scale ranging from never (1) to almost always/always (4). The PBC also has a “not applicable” option for each item. In accordance with the PBC Manual instructions (Fox, 1994), when less than 10% of a participant’s subscale items were missing, the scores were pro-rated on the basis of the other completed items. Although participants in this study were asked to complete every item, many chose “not applicable” for more than 10% of the items, and their scores were therefore considered not valid and not included in the analyses. The internal consistency of the PBC in the present study was Cronbach’s alpha = 0.90.

Caregivers self-reported about their parenting behaviors and knowledge using the ACT-RSK Evaluation (Silva, 2011). The scale includes an 11-item subscale (“About Parenting”) addressing parents’ responses to children’s misbehaviors. The scale has items such as, “When my child misbehaves, I raise my voice or yell,” and “When my child misbehaves, I spank, slap, grab or hit my child.” Response choices range on a 5-point Likert scale. The internal consistency of the ACT-RSK About Parenting scale in the present study was Cronbach’s alpha = 0.77.

The ACT-RSK Evaluation has a second subscale (“Media”) assessing parents’ limiting and monitoring of children’s media use. The subscale has 9 items such as, “How often do you switch channels from inappropriate programs?” and “How often do you limit the time your child plays video games?” Response choices range from never (1) to always (4). The internal consistency of the ACT-RSK Media scale in the present study was Cronbach’s alpha = 0.77.

The third subscale (“Parents’ Behavior”) of the ACT-RSK Evaluation used in this study includes 10 items about parents’ behaviors related to the content addressed in the ACT-RSK program. Items include, for example, “I praise my children when they behave well and do good things,” and “I control my anger when I have difficulties with my children.” Response choices range on a 5-point Likert-type scale from “Never” to “Always.” Higher scores on all ACT subscales indicate improved parental behavior. The internal consistency of the ACT Parents’ Behavior scale in the present study was Cronbach’s alpha = 0.82.

Qualitative data were obtained from caregivers and ACT-RSK Facilitators. Caregivers were asked to complete the ACT-RSK Feedback Questionnaire, which asked participants to provide information on what they liked and disliked about the program, as well as recommendations for future implementation. To measure the dosage of the intervention, ACT-RSK Facilitators completed the ACT-RSK Fidelity Checklist, which is a standardized checklist completed after every session (Silva, 2011, p. 10–13). The scale lists every activity and task described in the ACT-RSK Facilitator manual and requires respondents to check off which they completed. Facilitators also completed the ACT-RSK Feasibility Scale developed by the authors of this study. The Feasibility Scale asked facilitators to identify obstacles encountered in preparation for remote implementation, while conducting the program, and after the program, as well as benefits of the remote program and recommendations for the future. A focus group was conducted with ACT-RSK Facilitators after completion of all groups.

Procedure

The Institutional Review Board at the investigators’ universities approved the study protocol. Informed consent was gathered from all participants (caregivers and ACT-RSK facilitators). A HIPAA-compliant telehealth platform (Zoom) was used to deliver the program. Recruitment for the study targeted only parents or caregivers who live with and regularly care for their children ages 1–10 years. Referrals were made by staff (e.g., physicians, teachers, and social workers), and fliers were placed at each of the 7 centers for self-referrals. Data were collected over a 6-month period from January 2021 to June 2021 during the COVID-19 pandemic via Research Electronic Data Capture (REDCap; Harris et al., 2009). This allows participants to complete anonymized questionnaires online with real-time data entry and validation. All sessions were delivered by certified ACT-RSK Facilitators. Seven groups were facilitated by 10 ACT-RSK facilitators who worked in pairs. Groups comprised of 3–6 parents.

All remote ACT-RSK programs started with an introductory meeting in which a research assistant explained the study to all potential program participants including both caregivers and facilitators. Informed consent was individually obtained. Each caregiver was sent electronically through REDCap three questionnaires (demographics questionnaire, Parent Behavior Checklist, and ACT-RSK Evaluation) and instructed to answer all child-related study questions about only one of his/her children aged 10 years or younger. Questionnaires were completed prior to the start of the remote ACT-RSK program. At post-intervention, caregivers completed the Parent Behavior Checklist, ACT-RSK Evaluation, and ACT-RSK Feedback Questionnaire. Facilitators completed the ACT-RSK Fidelity Checklist after each session and the ACT-RSK Feasibility Scale at post-intervention. Both questionnaires were sent to facilitators via REDCap. Upon completion of the program at all centers, facilitators were invited to participate in a focus group to discuss their experiences with virtual delivery of the program. A total of 10 facilitators consented and completed the surveys and participated in the focus group. Caregivers received a $10 gift card for completing pre-intervention questionnaires and a $15 gift card for completing post-questionnaires.

Analysis

The Kolmogorov–Smirnov test of normality was used to test the normality of the data obtained via the ACT-RSK and PBC scales. Paired samples t-tests were used to compare the sample’s pre-intervention and post-intervention scores on each ACT-RSK Evaluation subscale. Paired samples t-tests also were used to compare the sample’s pre-intervention scores to their post-intervention scores on each PBC subscale. Independent samples t-tests (parent age, child age, ACT and PBC pre-test scores) and chi-square analyses (child gender, relationship of caregiver to child, parent ethnicity, parental education) were completed on demographic variables to examine whether completers differed from non-completers (identified as those who did not complete post-intervention measures). Qualitative results from the caregivers’ reports on the ACT-RSK Feedback Questionnaire and Facilitators’ reports on the ACT-RSK Feasibility Scale were organized by identifying the three most frequently reported answers in each category. Two members from the research team reviewed focus group transcripts and their accompanying field notes. Reviewers independently developed codes to organize the data to capture themes. Consensus was achieved through discussion. Total rates of completion of the activities listed on the ACT-RSK Fidelity Checklist were calculated and reported.

Results

Of the 43 individuals who consented to participate, 21 completed the program and post-tests, suggesting a 51% dropout rate. None of the analyses on the demographic variables indicated statistically significant differences between these two groups, suggesting no identifiable pattern of attrition.

The Kolmogorov–Smirnov test of normality was used to test the normality of the data obtained via the ACT-RSK and PBC scales, and results indicated that all the variables follow normal distributions. Results of the t-tests indicate significant pre/post improvements in scores on the ACT-RSK About Parenting subscale t (12) =  − 2.18, 95% CI [− 9.84, − 0.01], p = 0.049, d = 0.61 (medium effect) and the ACT-RSK Parents’ Behaviors subscale, t (19) =  − 2.50, 95% CI [− 5.15, − 0.45], p = 0.02, d = 0.56 (medium effect). There was not a significant pre/post difference on the ACT-RSK Media subscale, t (19) =  − 0.23, 95% CI [− 4.07, 3.27], p = 0.82, d = 0.05. Results indicate significant pre/post improvements in scores on the PBC Discipline subscale t (8) = 2.58, 95% CI [0.68, 12.40], p = 0.03, d = 0.86 (large effect). There was not a significant pre/post difference on the PBC Nurturing subscale, t(9) =  − 0.94, 95% CI [− 7.95, 3.35], p = 0.37, d = 0.37. See Table 2 for means and standard deviations for key study variables.

Of the total sample of ACT-RSK participants, 21 provided qualitative feedback via questionnaire about remote implementation on the ACT-RSK Feedback Questionnaire. Caregivers were asked about likes/benefits and dislikes/obstacles to participation in remote implementation of the program and recommendations for future implementation. The 3 most frequent responses were extracted. The 3 most liked aspects of the program included, in order of most often reported to least often reported, learning about discipline, gaining the knowledge that families go through the same things, and learning how to manage parental stress/anger. The 3 most cited dislikes of the program included, in order, nothing, not in person, and low number of parents in the group. The 3 most cited recommendations for the program included, in order, nothing, having more parents per group, and changing the time of the group. Table 3 provides details of the qualitative feedback provided by caregivers on the ACT caregiver questionnaire.

Table 3 Qualitative caregiver feedback from the ACT-RSK Feedback Questionnaire (N = 21)
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Ten ACT-RSK facilitators completed the ACT-RSK Fidelity Checklist, Feasibility Scale, and participated in the focus group. The ACT-RSK Fidelity Checklist lists every activity in the ACT-RSK program manual. Results indicate that Facilitators completed a total of 99.89% of the activities. The most frequently cited responses to items on the ACT Feasibility Scale regarding benefits of the remote program was the removal of transportation-related barriers (n = 6). The most frequently mentioned barriers/obstacles were related to caregivers having difficulty managing distractions and children in the vicinity (n = 7). The recommendation most often cited was to make a guide for online etiquette for participants taking part in remote sessions (n = 5). The 3 most frequent themes reported in the facilitator focus group related to identified differences between in-person and online facilitation, recommended adaptations, and recommended populations. Subthemes are provided in Table 4. Seven of the 10 facilitators planned to offer virtual groups in the future. The remaining facilitators reported that they were going to return to in-person groups on the basis of the preference of their organization.

Table 4 Most frequent themes reported in the facilitator focus group
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Discussion

The ACT-RSK program has been recommended by the World Health Organization as a low-cost, effective method to prevent violence against children (World Health Organization, 2019). Research has clearly demonstrated its effectiveness in improving parenting knowledge and behavior and reducing physical and psychological aggression toward children (Knox et al., 2013; Portwood et al., 2011). As such, the program is implemented broadly, in various parts of the USA and in several different nations (Howe et al., 2017). This broad-scale implementation was virtually brought to a halt when the COVID-19 pandemic hit, leaving families across the globe without this important resource. For this reason, it was vital that a remote version of the program be developed. This study examines the effectiveness of the remote version of the ACT-RSK program in the USA and provides evidence about feasibility and fidelity of remote implementation.

As hypothesized, results of the present study indicated a decrease in parental use of verbal and physical punishment of children after participation in the remote ACT-RSK program. Also as hypothesized, results indicated improvements in parents’ responses to children’s misbehaviors as well as parents’ behaviors related to the content taught in the ACT-RSK program. However, contrary to the hypotheses, there were no significant improvements in parents’ nurturing behavior nor parents’ limiting and monitoring of children’s media use. This is in contrast to previous research on the in-person version of the program that showed improvements on these variables (Knox et al., 2013; Lotto et al., 2022). It is possible that these nonsignificant findings could be related to the very small (N = 21) sample size. Consistent with Lotto et al.’s (2022) findings, ACT Facilitators found implementation to be feasible and acceptable to parents and facilitators. Facilitators were able to implement the program with near-perfect rates of fidelity to the standardized in-person model. However, the 51% dropout rate resulted in a very small sample size. This rate of attrition is slightly higher than that found in a systematic review of research with in-person ACT-RSK program outcomes (ranging from 14 to 47%; Pontes et al., 2019). The attrition in this study also compares unfavorably to that reported in the only other published study on the remote implementation of the ACT-RSK program (Lotto et al., 2022). In that study, conducted in Brazil during the COVID-19 pandemic, the rate of attrition was 33%. Differences between the two studies, including shorter group time (60–90 min versus 2 h in the present study) and mothers’ only groups in the Brazilian study, may have accounted for some of the difference in attrition. It may be that remote ACT-RSK programs in the US should anticipate and prepare for significant attrition. Since parents in this study reported concerns about the small number of parents in the groups, it is possible that small group size may have contributed to attrition. Future studies on remote implementation are needed to clarify. Benefits to remote implementation were identified including decreased transportation barriers to caregiver participation and the opportunity to learn effective discipline strategies. Drawbacks of remote implementation identified in the present study include perceived increased difficulty managing distractions and low numbers of parents in the remote groups. Recommendations included involving children at the end of each session (e.g., for a brief story or activity), creating template presentations and sharing them on-screen, delivering materials to participants’ homes to build rapport, and developing a guide for participant etiquette during online group sessions.

We compared the results of remote implementation obtained in this study to recent findings obtained in a study conducted in Brazil by Pedro et al. (2017) and another conducted in the US by Portwood et al. (2011). The medium effect sizes found in this study for the ACT-RSK About Parenting (d = 0.61) and ACT-RSK Parents’ Behaviors (d = 0.56) subscales were smaller than the large effect sizes found when the group was implemented in-person (Pedro et al., 2017). In addition, the non-significance of the changes of scores on the Media subscale compares unfavorably to the large effect size identified by the same authors. The large effect size for the PBC Discipline scale (d = 0.86), however, compares favorably to the medium effect identified by Portwood et al (2011) in an investigation of in-person implementation of ACT-RSK. However, the lack of significant change for the PBC Nurturing subscale is in contrast to the medium effect found by Portwood and colleagues (2011).

There are several limitations to the present study. First, the sample size (N = 21) is very small, and this may have undermined the internal and external validity of the study’s results. The dosage and fidelity data were self-reported by facilitators and may have been affected by social desirability bias or related factors. In future studies, the use of trained observers to complete the fidelity checklists would improve on this weakness. In addition, on the basis of how some participants endorsed items (frequent use of the “not applicable” response option), some PBC scores were invalid and could not be included in analyses. Another limitation of this study is the use of a pre-post design as opposed to a randomized control trial design. Random assignment to treatment/control or in-person/remote groups was not used, and results at long-term follow-up were not collected or examined. In keeping with these limitations, a larger sample size is needed as is a RCT with random assignment to groups. The utilization of more rigorous study designs may provide better evidence of causality. It is recommended that 3-month (at minimum) follow-up data be obtained to determine whether gains are maintained. The remote program should be studied outside the pandemic period in order to determine whether the outcomes identified were related to pandemic-specific factors. Furthermore, similar to the diverse evidence base that has been established on in-person implementation of ACT-RSK, the remote program should be studied in other cultures and nations in order to examine its effectiveness in those contexts.

Implications

This study suggests that remote implementation of the ACT-RSK program has benefits to families, specifically in terms of promoting positive parental behaviors and discipline and decreasing parental use of verbal and physical punishment. However, remote implementation may not improve parental nurturing, media monitoring, and limit-setting. Since this finding diverges from outcomes of studies of the in-person ACT program, more research addressing these variables is needed to clarify whether this finding is replicable. It should be noted that children’s media use increased during the pandemic for many reasons, such as parents’ need to occupy children while managing home, family, and work tasks simultaneously during lockdown and also the fact that children were often required to use media to complete schooling. Given these factors, parents may not have been able or prone to limiting and monitoring children’s media. Lastly, though there was significant attrition, both caregivers who completed the program and facilitators did find the remote implementation to have benefits, and facilitators were able to conduct the program with fidelity. It is suggested that facilitator recommendations be considered when conducting future studies to determine whether these enhancements (e.g., shared screen of template presentations, delivering materials to caregivers’ homes to increase rapport, and involving children at the end of the sessions if they are present in the home) strengthen/improve outcomes. Future research is needed to evaluate outcomes of remote implementation in both non-pandemic times and in other cultures.