Evaluating the Enhancing Parenting Skills (EPaS) 2014 programme Margiad Elen Williams

Behaviour Problems Most common childhood mental health disorder (Polanczyk et al., 2015) Increasing levels over the last decade (BMA, 2013; Hutchings et al., 2011) Most common reason for referral to CAMHS (NCCMH, 2013) Predict poor outcomes into adolescence and adulthood (Colman et al., 2009; Reef et al., 2009) Most common are emotional and behavioural adjustment, sleeping, eating, and regulatory problems Poorer outcomes up to 40 years later, including poorer mental health, poorer social and economic outcomes

Parenting Programmes Most effective interventions (NCCMH, 2013) Different formats of delivery Group programmes highly effective (Furlong et al., 2012) Barriers to access for disadvantaged families Many effective programmes in different formats e.g. group, individual, self-directed Group not always accessible for disadvantaged families, i.e. lack of transport, increasing childcare costs

Individually Delivered May be more appropriate (Lundahl et al., 2006) Eliminate barriers Tailored to family needs (Fettig & Ostrosky, 2011) Tailored programmes involve parent in development of strategies; expert on their children and family routines Helpful for disadvantaged families with multiple risk factors

Enhancing Parenting Skills Developed in 1990s Individually delivered Three core components

Structured Assessment Case Analysis Intervention Strategies What do we know about the family? Why does the behaviour occur? What strategies can be used? Structured Assessment Case Analysis Intervention Strategies What types of behaviour problems are evident? What are the possible triggers?

Previous Research Intensive Treatment trial (Hutchings et al., 2002, 2004) Significant improvements compared to standard CAMHS, maintained at 4-years Health visitor trial (Lane & Hutchings, 2002) Significant improvements but small sample and no randomisation Waterloo trial (Hutchings & Williams, 2013) Significant improvements but small sample and no control group

EPaS 2014 trial Aim to address limitations Course re-designed Day 1 – Structured Assessment Day 2 – Case Analysis Day 3 – Intervention Strategies Tailored to support health visitors See Williams & Hutchings (2015)

EPaS 2014 trial design Multi-centre pragmatic randomised controlled trial North West Wales Central North Wales North East Wales Shropshire

EPaS 2014 trial design Health visitors recruit 2 families Families randomised to intervention or TAU Weekly visits for for up to 12 weeks Data collection at baseline and 6-months Child behaviour Parenting skills Parental depression Observation of parent-child interaction

Health visitors 37 attended training Demographics All (N = 37) Age, M (SD) 42.19 (9.26) Female, n (%) 37 (100) Years as a HV, Median (range) 4.00 (0 – 30) Years in area, Median (range) 5.00 (0 – 30)

Families Child Demographics All (N = 58) Child age (months), M (SD) 40.52 (8.78) Boys, n (%) 42 (72.4) Parent Demographics All (N = 58) Parent age, M (SD) 30.55 (8.90) Fathers, n (%) 1 (1.6) Age birth 1st child, M (SD) 21.80 (5.59) Single, n (%) 19 (32.8) Low education, n (%) 45 (77.6) Below poverty threshold, n (%) 53 (91.4) Unemployment, n (%) 29 (50.0)

Baseline Scores Baseline scores (CO) Intervention M (SD) Above CO Control ECBI Intensity (131) 167.62 (30.07) 27 (93.1) 163.07 (27.56) ECBI Problem (15) 20.31 (6.01) 26 (89.7) 20.31 (5.29) Conners (15) 20.90 (5.60) 24 (82.8) 21.47 (4.97) Median (range) BDI (17) 18.00 (3-44) 17 (58.6) 18.00 (0-43) 18 (62.1)

HV Satisfaction Course Feedback n (%) Overall Course 13 (72.2) Written Material 16 (88.9) Continue to use methods 18 (100) Recommend 12 (66.7) “This has been an excellent course to give me and the parents a framework to tackle behavioural problems” “I would have liked more 1:1 sessions … throughout the intervention phase as this was the most difficult period of the intervention to manage”

Parent Satisfaction Questions Helpful, n (%) Discussing child’s history 14 (93.3) Describing child’s day in detail 15 (100) Keeping records of problem situations Discussing reasons for child’s behaviour Strategy for teaching new behaviour Tasks to complete between sessions Reading assignments 12 (80) Health visitor Overall process Sufficient info about process Recommend

Analyses Two types of analyses: Complete case – families with baseline and follow-up data (Intervention n = 19; control n = 17) Per-protocol – families who completed all 3 stages of EPaS (Intervention n = 13; control n = 17)

Complete Case F (1, 33) = 5.22, p = .029, d = 0.88

Per-protocol F (1, 27) = 6.83, p = .014, d = 1.30

Conclusions Health visitors working with highly challenged families High levels of satisfaction (HV and parents) Promising results Potentially useful tool for working with disadvantaged families

References British Medical Association [BMA] Board of Science (2013). Growing up in the UK: ensuring a healthy future for our children. Retrieved from: http://www.bma.org.uk/working-for-change/improving-and-protecting-health/child-health/growing-up-in-the-uk Colman, I., Murray, J., Abbott, R.A., Maughan, B., Kuh, D., Croudace, T.J., & Jones, P.B. (2009). Outcomes of conduct problems in adolescence: 40 year follow-up of national cohort. British Medical Journal, 338, a2981-a2989. Fettig, A., & Ostrosky, M.M. (2011). Collaborating with parents in reducing children’s challenging behaviors: Linking functional assessment to intervention. Child Development Research, doi: 10.1155/2011/835941 Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S.M., & Donnelly, M. (2012). Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years (Cochrane review). Cochrane Database for Systematic Reviews, 2, 1-362. doi: 10.1002/14651858.CD008225.pub2 Hutchings, J., & Williams, M.E. (2013). Report on the staff training project to support children with developmental challenges funded by the Waterloo Foundation. Bangor University: Children’s Early Intervention Trust Hutchings, J., Lane, E., & Kelly, J. (2004). Comparison of two treatments for children with severely disruptive behaviours: A four-year follow-up. Behavioural and Cognitive Psychotherapy, 32, 15-30. doi:10.1017/S1352465804001018 Hutchings, J., Williams, M. E., Martin, P., & Pritchard, R. O. (2011). Levels of behavioural difficulties in young welsh school children. Welsh Journal of Education, 15(1), 103-115. Hutchings, J., Appleton, P., Smith, M., Lane, E., & Nash, S. (2002). Evaluation of two treatments for children with severe behaviour problems: Child behaviour and maternal mental health outcomes. Behavioural and Cognitive Psychotherapy, 30, 279-295. doi:10.1017/S1352465802003041 Lane, E., & Hutchings, J. (2002). Benefits of a course in behavioural analysis for health visitors. British Journal of Nursing, 11, 702-714 Lundahl, B., Risser, H.J., & Lovejoy, M.C. (2006). A meta-analysis of parent training: Moderators and follow-up effects. Clinical Psychology Review, 26, 86-104. National Collaborating Centre for Mental Health (2013). Antisocial behaviour and conduct disorders in children and young people: The NICE guideline on recognition, intervention, and management (No. 158). Leicester, UK: RCPsych Publications Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry. Advance online publication. doi:10.1111/jcpp.12381 Reef, J., Diamantopoulou, S., van Meurs, I., Verhulst, F., & van der Ende, J. (2009). Child to adult continuities of psychopathology: a 24-year follow-up. Acta Psychiatrica Scandinavica, 120, 230-238. doi:10.1111/j.1600-0447.2009.01422.x Williams, M. E., & Hutchings, J. (2015). A pilot effectiveness study of the Enhancing Parenting Skills (EPaS) 2014 programme for parents of children with behaviour problems: Study protocol for a randomised controlled trial. Trials, 16, 221-229. doi:10.1186/s13063-015-0741-y

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