Centre for Evidence Based Early Intervention COPING Parent Programme: The Confident Parent Internet Guide: Strategies for all parents Evaluation of an online universal parenting programme: A pilot randomised controlled trial Dawn Owen 3rd year PhD Student Centre for Evidence Based Early Intervention

Background Parenting in the 21st century has become more demanding Effects of divorce and relationship breakdown on children’s social competence (Amato, 2000) Impact of work stress on parent-child interactions on child behaviour (Repetti & Wood, 1997) Effects of maternal mental health on child behaviour (Elgar et al., 2004; Gao et al., 2007) Negative impact of the growth in technology (e.g. smartphone and tablet use by children) on child behaviour and mental health (Palmer, 2006) Could also briefly mention cyber bullying, effects of social media etc on child mental health Exposure to more negativity i.e. news coverage

Importance of parenting Good parenting is essential in the prevention of child mental health problems and the promotion of child health and well-being (Ulfsdotter et al., 2012). Children learn new behaviours through direct experience or by observing the behaviour of others in their environment (Social Learning Theory: Bandura, 1977), and for young children, parents are their most important role models Parenting plays a key role in the emergence and maintenance of problematic child behaviour (Furlong et al., 2012; Hutchings et al, 2007; McMahon & Forehand, 2005) Important to promote positive parenting even in the face of challenges! Changing the behaviour of the parent is key in changing the behaviour of the child

Parenting programmes Good evidence for parenting programmes that teach parents core social learning theory principles (Hutchings et al., 2007) and include relationship building, play, praise, reward and positive role modelling and non-violent discipline strategies (Furlong et al., 2012) However, these programmes mostly target clinical levels of conduct problems (Hutchings et al., 2007), or target parents living in high risk areas (e.g. Flying Start areas) Many parents not accessing support at all (Sanders, 2008) Less evidence for universal parenting programmes (Ulfsdotter et al., 2014) Many parents not accessing support, buy may need it for minor child problem behaviours. As parents are now facing more challenges it is important to provide them with support and strategies on how to encourage positive child behaviour and strengthen relations.

Health visitors Increased workload and difficulty in providing adequate support to all families (Wilson et al., 2008; Williams & Hutchings, 2017) Services do not have the resources to provide universal programmes targeting health promotion and well-being to all parents (Lindberg et al., 2013). An alternative mode of delivery is needed to ensure that all parents have access to evidence based advice. This could potentially reduce health service burden and avoid the low-level child behaviour problems that occur in many children from progressing to more challenging ones Services overcome with demands, and so support not available to all. If no support is provided, small problems may progress and end up being more of a burden on our services.

Role of technology Technology has the potential to reach more families The internet allows access to evidence based advice for all parents without seeking referral from health care professionals This could allow professionals more time and resources to target clinical (or identified at-risk) populations with individualised interventions Potential to reduce cost burden Opportunity to promote positive parenting strategies Evidence for web-based interventions include weight loss, reducing alcohol consumption and some parenting ones too Parents can access advice at home in their own time

COPING Parent universal programme Trials conducted by Judy Hutchings and colleagues during the 1990s (Hutchings et al., 2002; Lane & Hutchings 2002; Hutchings, Lane & Kelly 2004) with parents and health visitors demonstrated good outcomes from parents being taught effective behavioural strategies As part of these trials help sheets were provided and subsequently published as ‘The Little Parent Handbook’, (Hutchings, 2013) This formed the basis of online universal programme

Outline of the programme 10 chapters Parents complete one chapter each week Each chapter focuses on different parenting skills Log in and read through information Watch video examples of positive parenting Answer questions based on the videos and receive feedback Complete multiple-choice quiz and receive feedback Suggested activities and time given to practice the skills 8 content chapters and 2 revision chapters Chapters include special time, praise, reward, instructions giving and language development Video example short (30seconds – 1 minute) Answer questions based on the video in an attempt to train parents to look out for the positive behaviour (observational skills) Suggested activities include spend 10m playing with your child everyday and praise positive behaviour

Example page Optional audio button LifeGuide software used All pages follow similar layout Information presented in bullet point format and in small chunks Key points highlighted in a different colour Back and next buttons so that parents can go back to review previous points Short videos to illustrate key parenting strategies Instructions on how to make the videos full screen

Pilot randomised controlled trial Recruitment methods: Word of mouth, health visitors, school nurses & recruitment posters distributed to local nurseries and primary schools Inclusion criteria: Parent/guardian of a child aged between 3-8 years Good understanding of English Access to internet on a PC, laptop, or tablet HVs and school nurses approached parents on their caseloads LifeGuide software does not yet support smartphones so parents unable to access the programme on their mobile

Procedure Recruited 56 parents of children aged 3-8 years Randomised parents on a 2:1 ratio to either intervention (n=38) or 3-month wait-list control group (n=18) Baseline visits conducted April – July 2016 3 month follow-up visits conducted July – December 2016 6 month follow-up visits for intervention group only conducted in December 2016, January & February 2017 Hvs/school nurses recruited 19 participants Word of mouth also recruited 19 participants Recruitment posters recruited 18 participants

Measures Primary measure – researcher observed parent and child engaging in child-led play for 30 minutes. The play was coded using the DPICS coding system (Robinson & Eyberg, 1981). 20% of visits double coded. Secondary measures – self-report questionnaires: Eyberg Child Behaviour Inventory Arnold O’Leary Parenting Scale Parental Sense of Competence General Health Questionnaire Demographic information also collected Direct observation was selected as the primary measures as direct observational methods provide a more precise account of behaviour defined by the researcher and not the parent Discuss the DPICS coding categories

Results - Demographics 19 families (33.9%) were recruited by health visitors and school nurses, 21 (37.5%) by recruitment posters and 16 (28.6%) via other referral The mean age of the children was 57.38months (SD=19.12) with over 70% boys Over 80% of the sample were in employment and over 85% either married or in a relationship Sixteen (28.6%) parents had previously attended a parenting course prior to completing baseline questionnaires There were no significant differences between the intervention and control families in terms of demographic characteristics at baseline Parenting course - (15 attended an ‘Incredible Years’ parenting group and 1 completed the ‘Enhancing Parenting Skills 2014 Programme’ with a health visitor).

Results – Behavioural Observation Per-protocol analysis found a significant difference between intervention and control parents on the primary measure Parents in the intervention group demonstrated significantly less use of indirect commands and significantly more use of praise compared with control parents Direct command: F (1,25) = 0.45, p=.507 Praise: F (1,25) = 5.56, p=.026 (*) Indirect command: F (1,25) = 4,71, p=.040 (*) Questions: F (1,25) = 2.10, p=.160 Negative Parenting: F (1,25) = 1.20, p= .282 Explain quickly why per-protocol A lot of parents in the intervention condition not logging in at all (*) significant

Results – Behavioural Observation Pre and post scores for intervention and control conditions for praise and indirect command categories Praise Indirect Command Discuss that the control group has improved also … but the main difference is the intervention group is praising more. F (1,25) = 5.56, p=.026 F (1,25) = 4,71, p=.040

Results – Behavioural Observation Intervention parents praising significantly more in comparison with control parents

Results – Secondary Measures Over 40% of children scored above the cut-off on the ECBI intensity scale Over 45% scored above the cut-off on the ECBI problem scale Over 40% of parents scored above the clinical cut off on the General Health Questionnaire Comparison of the scores for the Parenting Scale subscales with the mean clinical group scores from Arnold et al. (1993), showed that the sample was reporting problematic levels of parenting No significant results found on any of the secondary measures Mention that although this was a universal programme, children in the sample still scored highly on the ECBI and parents still displayed problematic levels of parenting. Possible justification for the need of universal parenting programmes ?

Results – Secondary Measures However, there was a reduction on both of the sub-scales of the Eyberg Child Behaviour Inventory for the intervention parents Outcomes Intervention Control Baseline (n=38) M (SD) F-up (n=25) (n=18) (n=11) ECBI Intensity (131) 130.76 (30.20) 118.64 (31.01) 140.33 (29.70) 124.73 (33.39) ECBI Problem (15) 13.11 (7.74) 9.20 (8.62) 13.06 (8.50) 13.36 (9.56) Mention that although this was a universal programme, children in the sample still scored highly on the ECBI and parents still displayed problematic levels of parenting. Possible justification for the need of universal parenting programmes ?

Results – Secondary Measures Over 40% of children scored above the cut-off on the ECBI intensity scale Over 45% scored above the cut-off on the ECBI problem scale Over 40% of parents scored above the clinical cut off on the General Health Questionnaire Comparison of the scores for the Parenting Scale subscales with the mean clinical group scores from Arnold et al. (1993), showed that the sample was reporting problematic levels of parenting Interesting find that a relatively advantaged population reported significant levels of problems in terms of parenting, child behaviour and mental health … Mention that although this was a universal programme, children in the sample still scored highly on the ECBI and parents still displayed problematic levels of parenting. Possible justification for the need of universal parenting programmes ?

Strengths & Limitations This was a randomised controlled trial with a wait-list control condition The behavioural observations incorporated inter-rater reliability component Data collectors remained blind to group allocation Once randomised, intervention parents could start the online programme immediately thus reducing the amount of time spent waiting for the intervention Programme was universal Limitations: Issues with the LifeGuide software Parents not engaging with the programme weekly Due to time and funding constraints only a small sample was recruited and was not based on a power calculation

Where to next? School-based support staff project (Anwen Rhys Jones) The project is currently adapting this web-based programme in order to make it more relevant to school based support staff, particularly increasing the content associated with praise, teaching new behaviour and language development This project has the potential to contribute to improvements in the level of skills obtained by school based support staff by providing them with the positive behaviour change strategies, which could potentially improve child outcomes Please contact Anwen for more information on the school based programme seu84e@bangor.ac.uk Introduce Anwen’s project and mention that she has a poster at the conference if anyone would like any more information to contact Anwen

Thank you very much Any questions? dawn.a.owen@bangor.ac.uk