School of Psychology, Bangor University Incredible Years: Evidenced based interventions for promoting social and emotional wellbeing in children and families BANGOR UNIVERSITY in partnership with COLEG LLANDRILLO CYMRU Health and Wellbeing Public Lecture Series One Venue Cymru, Llandudno 5th October 2010 Dr Tracey Bywater School of Psychology, Bangor University t.bywater@bangor.ac.uk

Overview Anti-social behaviour in youngsters Contributing factors of conduct problem onset Social/emotional competence, & interventions How do the interventions work? Research in Wales Parent programmes School based programmes Costs: effectiveness, benefits, delivery

Conduct Problems: Symptoms or Behaviors Bullying or threatening other children Little empathy for others and a lack of appropriate feelings of guilt and remorse Low self-esteem masked by bravado Lying to peers, parents or teachers Stealing from peers, parents, or the school Inattentivity Hyperactivity Physical or verbal aggression Destruction of property Poor attendance record or chronic truancy in older children History of frequent suspension

What factors contribute to onset of conduct problems????

Risk factors for conduct disorder Parenting factors Harsh and ineffective Poor monitoring Low stimulation School factors Classroom aggression Deviant peers Poor teacher response Peer rejection Child factors Poor conflict control Impulsivity, ADHD Learning delays Poor social skills Conduct Problems . Contextual factors Poverty Parental crime, substance abuse or mental illness Life stressors

Conduct problems can lead to… Diagnosed conduct disorder Attachment problems Mental health issues Increased use of health, social and education services Attendance problems at school joblessness Criminal activities Drug taking Poor academic achievement Teenage parenthood Marital problems

Prevalence of conduct disorder in UK BOYS % GIRLS % ALL CHILDREN % Age 5-10 (ONS Survey, Green et al., 2005) 6.9 2.8 4.9 Age 11-16 8.1 5.1 6.6 All ages 7.5 3.9 5.8 Disadvantaged areas (Attride-Stirling, et al., 2000) 20 Looked after children (Tapsfield & Collier, 2005) 37

Office of National Statistics 2007 Approx 70 million people in UK, 3 million in Wales (5% of UK population) 11.9 million children aged under 16 in UK, approx 595,000 in Wales 59,500 = CD (10%), which is equivalent to…..

Childhood Conduct Problems: a growing political issue Resistant to intervention if not treated early Conduct disorder (diagnosed) increasing in numbers, 5-10% of children in Britain and USA but as many as 35% in high risk disadvantaged areas If unresolved can predict delinquency, adult mental health problems and/or crime Costly to society - health, education & social service costs). By the age of 28, those seriously antisocial individuals were costing public services at least 10 times as much as those without problems) 50% of parents show signs of depression

DVD puppet clip

IY programmes are based on: Social Learning/Social Cognitive Theory (Bandura 1960’s onwards) “Most human behavior is learned observationally through modeling: from observing others, one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action. personality as an interaction between three components: the environment, behavior, and one’s psychological processes Social learning theory has sometimes been called a bridge between behaviorist and cognitive learning theories because it encompasses attention, memory, and motivation

Wellbeing Definition by NICE (http://www. nice. org emotional wellbeing: happiness and confidence, and the opposite of depression psychological wellbeing: autonomy, problem solving, resilience, attentiveness/involvement social wellbeing: good relationships with others, and the opposite of conduct disorder, delinquency, interpersonal violence and bullying

Incredible Years Series Short Term Objectives To prevent, reduce and treat aggression and behavior problems in young children. To promote social, emotional and academic competence in young children. Long Term Objectives To prevent and reduce the occurrence of aggressive and oppositional behavior, thus reducing the chance of developing later delinquent behaviors and possible mental health or relationship problems.

Key specific components of effective parenting interventions new parenting skills must be modelled and rehearsed home-based practice or ‘homework’ parenting programmes should should be collaborative & emphasise principles rather than prescribe techniques (non-violent) sanctions for negative behaviour relationship building, praise, fun & play, rewards, reinforcement must address difficulties in adult relationships or other family problems

Parenting Programme research in Wales Welsh Sure Start Basic programme evaluation (The Health Foundation & NWW NHS Trust R&D) Toddler Programme (WAG funded) Nursery Project (funded by NW NHS Trust R&D) LiLAC – foster Carer trial (funded by WORD) Baby Programme (KESS & IY Cymru funded PhD) School Readiness Prog (School of Psyh & IYC PhD) Pathfinders (LA funded)

PARENT PROG DVD CLIPS

How do we know the Programmes work? Randomised Controlled Trials are the ‘gold standard’ in trial design: what are they? What are the benefits? What are the limitations?

IY Welsh Sure Start trial Funded by the Health Foundation Collaborators: CEPhI Bangor University Oxford University National Health Service (Health Visitors) The developer of IY, Carolyn Delivery staff Sure Start services Children & family services Statistical support Chris Whitaker (now NWORTH)

Trial Design Children of 3-4 years ‘at possible risk’ of CD Randomly allocated families to intervention or waiting list control using 2:1 ratio Saw intervention families at baseline and 3 follow-ups, all 6 months apart Saw control families at baseline and follow-up 1 then offered the intervention Measures were administered at each time point

Evaluation Questions The evaluation answers the following three questions: Do the programmes meet the needs and improve outcomes for children and families who participate? Are the programmes implemented efficiently and effectively with fidelity? Do the programmes offer value for money and net benefit to the Council, Government, society, children and families?

Specific Questions…. For which children and families are the interventions effective? What are the environmental/contextual circumstances that improve the likelihood of success? Does the duration of time participating in an intervention affect likelihood of success, that is, is there a dosage affect? What are the costs of implementing the interventions? What are the longer term costs and benefits of intervention?

What should we measure?

Measures Personal Data and Health Questionnaire (PDHQ, Hutchings, 1996) Socio-economic disadvantage (SED 6; Hutchings, 1996) Index of Major Life Events (Oxford University) Beck Depression Inventory (BDI; Beck et al., 1961) Parenting Stress Index/Short Form (PSI/SF; Abidin, 1990) Eyberg Child Behavior Inventory (ECBI; Eyberg & Ross, 1978; Eyberg, 1980) Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) Conners Abbreviated Parent/Teacher Rating Scale (Conners, 1994) Kendall Self Control Rating Scale (SCRS; Kendall & Wilcox, 1979) Social Competence Scale – Parent (Fast Track Project) British Picture Vocabulary Scale (BPVS-II; Dunn, et al.,1997) The Parenting Scale (Arnold, O’Leary, Wolff & Acker, 1993) Service Utilisation Questionnaire (Chisholm et al., 2000; Beecham, 1995) EQ-5D Health-Related Quality of Life Questionnaire (Kind et al.,1995) Dyadic Parent-Child Interaction Coding System (DPICS; Eyberg & Robinson, 2000)

DPICS

Figure 3. Observed positive parenting behaviours in 30 minutes DPICS Figure 3. Observed positive parenting behaviours in 30 minutes

Eyberg Figure 2. Eyberg Child Behaviour Problem Scores

Long term Sure Start data

Summary of Main Outcomes Observational findings: Intervention parents use more positive parenting, less critical parenting Children are better behaved Parent report findings: Parents perceive their child as having fewer problem behaviours Child behaviours are less intense Reduction in parental depression & stress, Increase in parent skills/comptency Reduction in child hyperactivity, conduct problems, increased social competence and self control, sibling improvements

Praise Indeed! “I wanted to write to you two to say thankyou, you have taughet me to appriciat my little girl and the time we have together Since doing this course + working with Zoe her speach has come on She knows and rembers things I think that’s were praise come,s in. I love and respect my daughter more thankyou for all your help, your support and your praise It makes me feel Im Finaly doing a good Job Thankyou”

References Hutchings, J., Bywater, T., Daley, D., et al., (2007). A Pragmatic Randomised Controlled Trial of a Parenting Intervention in Sure Start Services for Children at Risk of Developing Conduct Disorder, British Medical Journal, 334, 678 - 682. Bywater, T., Hutchings, J., Daley, et al., (2009). Long-Term Effectiveness of a Parenting Intervention in Sure Start Services in Wales for Children at Risk of Developing Conduct Disorder, British Journal of Psychiatry, 195, 318-324. Edwards, R.T., Ó Céilleachair, A., Bywater, T., et al., (2007). Parenting Programme for Parents of Children at Risk of Developing Conduct Disorder: Cost-Effective Analysis. British Medical Journal. Gardner, F., Hutchings, J., Bywater, T. &Whitaker, C. (2010). Who Benefits and How Does It Work? Moderators and Mediators of Outcome in an Effectiveness Trial of a Parenting Intervention. Journal of Clinical Child & Adolescent Psychology, 39(4), 1–13.

Toddler Programme Research Aim: To evaluate the effectiveness of the 12-week Toddler Parenting Programme with a group of parents with Toddlers aged 12-36 months Participants: 103 families randomised on a 2:1 basis; 70 Intervention and 33 Control Service staff were health visitors and child care practitioners Outcome Measures: Demographics, Beck Depression Inventory Parent Stress Index Parenting Sense of Competence Warwick-Edinburgh Mental Wellbeing Scale HOME inventory Ages and Stages Questionnaire Schedule of Growing Skills Direct Observation of interaction funded by WAG, supported by CRC Cymru & NWORTH, 2 PhD students – Welsh Language medium scholarship & CEPhI

Parent mental wellbeing Baseline scores were taken into account by ancova Results being written for publication Results thus far: Analysis of the data set is ongoing, however so far we have found several significant findings from baseline to follow up 1; a reduction in negative parenting, specifically reduced physical negative parenting, and a significant increase in parental wellbeing.

Results are currently being written for publication so watch this space

One family – 10 years on… Pre Post Terrorised family Controlled the family Ran away constantly Wouldn’t get on school bus Swearing, shouting, lying School work terrible Threatened sister with knife Burnt his sister Tried to set fire to school Post Everything changed Behaviour stabilised Became sociable Worked hard with love of music Home schooled Completed a 2-yr performing arts course Opened own performing arts company for children in the community 6 is now 100 in last 2yrs Lots friends & stable relationship Letter received last week from a Mum, Melanie, who was at end of tether 10 yrs ago and took part in an early trial of the IY parent prog Son was 11/12 10 years ago. Her daughter is also doing brilliantly at coleg Llandrillo So – lets watch a couple of techniques used to encourage child behaviour

DVD of effective parenting strategies – praise & shaping behaviour Disc 4 of 9 – parent prog Vignette 9 – training when on phone – end at high 5 Vignette 22 – proximal praise, end at ‘I hate peas’

Foster Carer Trial Outcome Measures: Aim: Is the programme effective in supporting carers, increasing the toolkits they have to deal with certain behaviours, and improving child behaviour and outcomes for Looked After Children ? Participants: 46 foster carers, 29 Intervention and 17 Control. Children ranged from 2-18 years Outcome Measures: Demographics Eyberg Child Behaviour Inventory (ECBI) SDQ (Carer & Teacher) Service Use Questionnaire Health EQ5 Arnold O’Leary Parenting Scale Becks Depression Inventory Programme Satisfaction 3 NW authorities CD – 5-10% in general population 20-25% in disadvantaged areas 35-40% in lac expensive Funded by WORD, collaborating with CEPhI & 3 LA Children Services, supported by NWORTH

Results Significant reductions for Intervention in comparison to control across : ECBI intensity subscale SDQ hyperactivity levels Depression levels for foster carers Foster carers found the programme useful and supportive The carers regarded the course as professional training and hence were serious about attending (9 sessions ave).

The Carer Satisfaction Questionnaire Which two parts of the parenting programme were most helpful to you? Given this list. Carers also stated that group support, group discussion and mid week support call from buddy/leader was very helpful indeed

Foster Carer feedback “Excellent to be able to discuss and trouble-shoot specific child problems with other carers, great to get updates and reminders.” “Some reward systems don’t work for particular problem” “I would welcome more course content on attachment issues and a longer programme” Facilitators echoed the feedback on lengthening the prog for this population, and the devloper – Carolyn WS also advocates this.

Published findings available at ‘Wiley Online Library’: Bywater, T., Hutchings, J., Linck, P., Whitaker, C.J., Daley, D., Yeo, S.T., Edwards, R. T. Incredible Years Parent Training Support for Foster Carers in Wales: A Multi-Centre Feasibility Study.  Child Care Health and Development. Doi:10.1111/j.1365-2214.2010.01155.x Available online -

School-Based IY Research in Wales Teacher Classroom Management Classroom Dina - child programme Small Group Dina - Promoting social and emotional wellbeing in Primary School Children, a pilot study and large RCT

Dinosaur School Curriculum How to do your best in school How to become a feelings detective How to solve problems How to manage anger How to make and keep friends Dinosaur School, is a comprehensive social skills and problem-solving curriculum that teaches positive social and communication skills, conflict resolution and anger management, emotional and academic literacy, and appropriate school behaviours. It also aims to promote positive self-esteem. The Therapeutic Dina Programme (Webster-Stratton, 1990) is delivered for two hours per week for a period of 18 - 20 weeks to groups of six children. Sessions involve: homework review, introducing new material through discussion and by watching video-clips, role play practice, small group fun games and activities and homework activities

School DVD clip cooperation

Small Group Dina Research Building social and emotional competence in young school children in North Wales: pragmatic randomised controlled trial of a school based intervention Lottery funded – 3 year project to 2013 IY Cymru partnered with Gwynedd Education & Bangor University Supported by NWORTH and NISCHR Ethical approval by NW REC & School of Psychology Registered the trial on two public databases – NISCHR & ISCRTN Aim: To evaluate the effectiveness of the Small-Group Therapeutic DINA programme with school children who may benefit from more intense sessions (in schools already delivering classroom Dina).

Participants 20 schools in Gwynedd 10 to deliver small group in the 1st year (phase 1) 10 to deliver in the 2nd year (Phase 2) 40 teachers/classroom assistants to deliver 240 children 120 intervention 120 wait-list control 240 parents of participating children Teachers of participating children

Outcome Measures – 3 time points Parent completed: Demographics Becks Depression Inventory (BDI) Arnold O’Leary Parenting Scale Warwick Edinburgh Mental Well-being Scale (WEMBS) Parent Strengths and Difficulties Questionnaire (SDQ) Eyberg Child Behaviour Inventory (ECBI) Dina Questionnaire Teacher completed: Teacher Stress Inventory Teacher background Teacher SDQ (screening tool & primary outcome measure) Attendance levels (plus attendance for teacher) Academic Attainment Child: Wally Problem Solving Task Observation of behaviour relating to core programme components Programme satisfaction ‘questionnaire’ Friendship levels

What makes this trial important This will be the first rigorous trial of the IY Small Group Dina Programme for young children who are already receiving the classroom curriculum It has been made possible by the lottery funding but also because of the innovative approach in Gwynedd to establish the classroom curriculum county-wide We are assessing academic attainment, attendance levels and effects on teachers

Implementation Fidelity is the programme delivered as designed? are all the core components present? to the right population? with appropriately trained staff? using the right protocols, techniques & materials? in the right context?

Parent Programme Costs Edwards et al., (2007); Bywater et al., (2010) Mean cost of delivering parent group = £1934 per child for 8 children, £1289 for 12 children, = approx £14,000 total SS sample (high levels of conduct problems possibly progressing to CD) = approx £1,400/year in service use Looked After Children = £26,000/year/child in service use costs Scott et al., (2001) £17,000/year, or £1mill over a lifetime for CD kids = for every 10 children we prevent or reduce CD = a saving of minimum £170,000/year 100 children = £1, 700 000/year

Recent Government initiatives to support families & children 2001 - Sure Start in England, then in Wales The Welsh Assembly Government Parenting Action Plan (2005), Flying Start, Genesis Reaching Out: the Action Plan on Social Exclusion published Sept 2006 The Respect Agenda The Pathfinder project (DfES) 18 services to deliver and evaluate three parent programmes The Family Intervention Project DfES (50 Authorities) Family Nurse Partnership DoH (Olds - 10 Authorities) The National Parenting Academy

Why WAG have chosen to develop IY in Wales They have an evidence base in Wales. They are collaborative programmes in which the parent, child or teacher is encouraged to recognise their own expertise and to engage in shared problem solving, enhancing self esteem and ownership of skills taught. They teach social skills and problem solving alongside strategies to reduce problem behaviours. The programmes have demonstrated long-term outcomes The programmes are for parents, children and teachers so enable co-ordination across agencies Tackle barriers to access Fidelity – IY has checklists, training, accreditation processes

IY Training Across Wales WAG are continuing to fund training across Wales in parent, child, and teacher programmes for a fifth year, until March 2011 All 22 Authorities in Wales delivering the parent programme Staff from 21 Authorities trained in TCM and 19 Authorities in Classroom Dino

CONCLUSIONS IY is gathering momentum across Wales Positive results for children, their families, teachers and schools: improves social and emotional well being reduces child problem behaviours reduces parental depression and stress reduces teacher stress Supports teachers and parents to positively influence child behaviour by encouraging pro-social behaviour For best chance of success include all key carers Can be used as preventative intervention and as treatment CONCLUSIONS

Lessons Learned to inform Policy & Practice Programmes can be effective (even in disadvantaged Sure Start areas) when core research principles are adhered to: Know what outcomes/change are required Select an evidence-based programme for the target population Develop a strategy for recruiting the target population Address relevant service access issues Ensure implementation fidelity Evaluate the programme delivery and outcomes

Acknowledgments Huge thank you to all participating parents, children, teaching staff, Foster Carers, Schools, service delivery staff, IY supervisors and trainers, Service Managers in all LAs, all support staff – without you the research would not be possible! Also we wish to acknowledge all collaborators and support received throughout various projects, to include NWORTH, CRC Cymru, NISCHR, CEPhI, Gwynedd Education, Oxford University. And of course thank you to the funders of our various projects for enabling the research to happen. Finally – ‘The Team’, for working tirelessly and getting the job done!

Diolch yn Fawr - and thanks for listening! For further information on the research please contact me on 01248 383845 t.bywater@bangor.ac.uk For information on training, conferences, availability on parent programmes please contact Dilys Williams on 01248 383758 d.williams@bangor.ac.uk Or access http://www.incredibleyearswales.co.uk