Project Summary/Abstract Child maltreatment (CM) is a pervasive public health problem and there is a critical need for brief, effective, scalable prevention interventions. Problematic parent-child relationships lie at the heart of CM. Parents who maltreat their children are more likely to have punitive parenting styles characterized by high rates of negative interaction and ineffective discipline strategies with over-reliance on punishment. Harsh, reactive parenting can contribute to the development of child behavioral problems which, in turn, can increase parental stress and lead to escalation of negative parenting behaviors, including abusive and neglectful parenting. Thus, parenting interventions that strengthen parent-child relationships, teach positive discipline techniques, decrease harsh parenting, and decrease child behavioral problems hold promise as CM prevention strategies. Challenges in engaging parents, particularly low-income and minority parents, and a lack of knowledge regarding effective implementation strategies, however, have greatly limited the reach and impact of parenting interventions. To address these challenges, our interdisciplinary team from the University of North Carolina and Children’s Hospital of Philadelphia collaborated in implementing and evaluating, Child Adult Relationship Enhancement in Primary Care (PriCARE)/Criando Niños con Cariño. PriCARE/Cariño is distinct from other programs because it was (1) developed and iteratively adapted with input from racially and ethnically diverse families, including low- income families and (2) designed specifically for implementation in primary care with inclusion of strategies to align with usual-care work flow to increase uptake and retention. In randomized controlled trials (RCTs), PriCARE has demonstrated success in engaging parents, promoting positive parenting, reducing parent stress, and improving child behaviors. The objective of this project “Child-Adult Relationship Enhancement in Primary Care: Effectiveness Trial of a Primary Care Based Parenting Intervention to Prevent Child Maltreatment” is to conduct a multi-site RCT of PriCARE/Cariño plus Usual Care vs. Usual Care among 1932 parents and their 2- 6-year-old children with Medicaid/CHIP/no insurance from 6 clinics. We will examine the effectiveness of PriCARE/Cariño on reducing suspected CM, in addition to reducing proximal CM related outcomes (child behavior problems, parent stress, harsh/neglectful parenting). By testing proximal outcomes in addition to the more distal outcome of CM, this study will help to elucidate the mechanisms of change and advance the science of CM prevention. Finally, in this study we will also identify PriCARE/Cariño implementation determinants and examine their relationship to implementation outcomes. If successful, results will be used to seek funding from state agencies and payers to sustain PriCARE/Cariño in primary care, while continuing to refine and study implementation and dissem...