1 Update on the activities of the Centre for Evidence Based Early Evidence Supporting Evidence Based Early Intervention Programmes across Wales and beyond. Bangor University 25 th January 2013 Professor Judy Hutchings, OBE Centre for Evidence Based Early Intervention, Bangor University

2 Summary of presentation Completed research activity – -Wales, -Birmingham, -Pathfinder, -Gwynedd, ESCAPE, parenting programme -Literature review on programmes for parents of teenagers Current research projects Wales – -Small group Dina, -IY Baby, -IY School readiness, -KiVa bullying prevention programme, -PREPARE – web based parenting support, -Gwynedd LA evaluation of early intervention services -Waterloo grant – two day training across Wales to support professionals working with children with developmental challenges Current research projects elsewhere – England ADHD trial with Southampton, Parenting trial with Oxford and Cape Town Universities Other activities – WHO Violence Prevention Alliance – parenting subgroup

Current team  Judy – Centre Director  Helen – Centre Co-Director CEBEI, bringing her expertise in work in Jamaica, University PI for the Small Group Dina Project  Eleanor managing the Dina lottery project  Margiad leading on Dina lottery project data input and analysis  Steff (RPSO on lottery project and Master’s student)  Karen (RPSO on Gwynedd evaluation and Masters student)  Nic (PhD student on maternal language)  Laura (PhD student on children’s peer relationships, Lottery project)  Stefanos (PREPARE PhD student commencing 1 st April 2013)  Elin – Admin for the Children’s Early Intervention Trust Charity (CEIT)  Suzy (Master’s student researching the KiVa bullying prevention programme)  Dilys and Kath – Admin for CEBEI  Bridget and Sue IY trainers working for CEIT  (Catrin – IY Baby, Kirstie IY School readiness, just completing PhDs )  Tracey (Honorary Research Fellow now Reader at University of York)

4 Why the Centre: USA and UK – 1990s  USA few publicly funded services but lots of high quality research  UK publicly funded health and education services but little demand for outcome evaluation and little quality research  My goal to bring evidence based services to Wales and beyond 4

CEBEI strategies  An ongoing research programme  Annual conferences  Staff surveys  Service manager fidelity workshops  Evaluation workshops  Newsletters and conferences  Publications  Supervision and support for evidence based practice and service development

IY Parenting Programme: research completed Welsh Sure Start study: short- and long-term outcomes, outcomes for children at risk of adhd, mediators and moderators of change, maternal depression outcomes, key group leader behaviours Pathfinder project: parenting 8 – 13 year olds outcomes Toddler Programme: 1 – 2 yos, outcomes Nursery Staff Programme: outcomes Foster carer study

Sure Start research project; short and longer term outcomes Short term significant effects occurred relative to controls on all measures: For parents: Reduced maternal depression maintained to 18 months Reduced observed negative parenting and increased positive parenting maintained to 18 month PSI - parental stress levels BDI - depression levels (clinical effect size =.59) For target children: ECBI intensity and total problem scores showed significant reductions at 6, 12 and 18 months and 3 and 4 years Kendall SCRS - self-control Conners – hyperactivity Social competence For sibling nearest in age to index child: ECBI problem, ECBI intensity

Other outcomes from the Sure Start study  Signifcant improvements in inattentive and hyperactive behaviour for the 60+% of children in the clinical range for these problems  Leader skills, praise and reflective statements are mirrored in parents behaviour  Improvements in depression mediate child behaviour improvements

Toddler project Nia Griffith PhD  RCT of the IY Toddler programme in Flying Start areas across Wales  Significant improvements at 6 month FU for parental mental well-being, observed negative parenting, and observed child deviance  Significant improvements at 12 month FU for child development, parental mental health, parental stress, and parental competence

Nursery project  Effectiveness of the IY Toddler programme for Nursery workers  Significant improvements child problematic behaviour in nursery, staff levels of stress, and staff sense of competence  Programme effective in out-of-home setting

IY Foster Carer project  More children in foster care and more with challenging behaviour  Children’s behaviour problems contribute to foster placement breakdown  46 foster carers in three counties in Wales participated (2:1 intervention to control)  Results: significant reductions in child behaviour problems and carer stress and depression  Subsequent publication of issues needing to be considered in working with carers using the IY parent programme

Teacher Classroom Management project  RCT of the IY TCM programme in 12 classrooms  Observations of classrooms and target children (high and low problems identified using TSDQ)  Significant reductions in children’s classroom off- task behaviour  Significant reductions in teacher negatives to target children, and reductions in target children’s negatives to teacher and off-task behaviour

Birmingham Brighter Futures project  Birmingham: biggest local authority in Europe  RCT of three programmes (IY, TripleP, PATHS) done by Dartington Social Research Unit  IY - a replication of Welsh Sure Start Study (161 three and four year olds at risk of emotional and behavioural problems)  CEBEI provided training and supervision for the IY leaders  Results - significant improvements in child behaviour on the SDQ and ECBI and a strong and significant improvement in self-reported parenting skills on the O’Leary Parenting Scale

Current situation in Birmingham  An IY administrator for the City  We still provide training and supervision, 15 new staff trained this week  12 certified leaders, 5 people proceeding to peer coach training, mentor plans to bring programme in-house  A 16 area locality model, either 2 or 3 groups per locality per year dependent upon level of need  Currently 20 groups running the 14 week basic programme.

Pathfinder Early Intervention project  Six Authorities England delivering IY School Aged programme with 8-13 yr olds  First trial of programme with children in older age range  Training and supervision co-ordinated by CEBEI (Judy, Bridget, Sue)  18 session programme (IY School Age Basic + Advanced adult relationship programmes)  Significant improvements in child behaviour, parental depression, parenting skills at 6- month FU

Additional analyses  Mediator – improvements in parenting skills mediated improvements in child behaviour  Moderator – all of the normal risk factors, teenage parent, family history of drug/alcohol use, parental depression, single parenthood or poverty moderated outcome, they all did equally well  Only family history of crime moderated outcome with these families demonstrating poorer outcomes

Gwynedd ESCAPE evaluation undertaken by Ceri Ellis Escape is:  A six-session parent programme for parents of conduct problem teenagers (10-18 yrs)  Programme aims: to increase school attendance and reduce offending behaviour  One topic each session :- empathy; current issues at home; division of parental control and responsibilities; how to approach situations; how to be positive; how to empower their child

Gwynedd evaluation  Gwynedd Families First Deliveries Plan included multi-agency support for parents of high challenge teenagers  Escape programme selected  No previous good evidence of efficacy  Gwynedd funded evaluation but after commencement of the programme  Evaluation of outcomes from 3 groups, 2 in Bangor, 1 in Porthmadog (N=21)

Sample and measures  32 referred 21 recruited (66%)  Retention (pre-post data from 14 parents (67%), qualitative interviews with 11 parents (53%)  fathers represented one third of parents  71% of teenagers were male  38% of parents were single  Measures of child behaviour, parental mental health, ‘Family Grid’, parent (11) and leader (4) qualitative feedback

results  Significant improvements in conduct and pro- social scores on SDQ but remained within clinical range  Significant improvement in parent self- esteem and an unvalidated measure  Data for parental mental health was incomplete at post-group  Parents enjoyed the programme but too short and did not address specific issues/needs

conclusions  Gwynedd recognised the need for evaluation  Difficult to generalise findings, pre-post measures collected by leaders and a small sample, etc.  Significant improvements but still in clinical range so prospects of maintenance of gains limited  Leaders were highly skilled with additional training (e.g. IY) and made additions to programme  Effective programmes with this target population are longer and involve both parents and adolescents  Should be emphasis on providing families with effective interventions that yield sustained results

Literature review of programmes for parents of teenagers with challenging behaviour  Gwynedd Council commissioned a review of evidence-based parent programmes for parents of high challenge teenagers  Undertaken by Suzy Clarkson  Ten programmes reviewed, Multi-systemic Therapy*, Functional Family Therapy* Strengthening Families Programme 10-14*, Parents Plus Adolescents Programme, Incredible Years (8 -13 years), Standard Teen Triple P, Take 3, STOP, Living with Teenagers, ESCAPE * Blueprint programmes with evidence for this population

 In general, across the age range, parenting programmes for conduct disorder show greatest impact compared to other interventions but results decrease with child age  Limited number of evidence-based programmes with this age range  Effective programmes for this age range (MST; FFT; SPT 10-14) are all Blueprints for Violence Prevention  Effective programmes work with the whole family (both parents and teenagers) – more sustainable and have significant impact on adolescent emotion regulation and behaviour

Conclusions  Effective programmes are longer  Effective programmes include parents and adolescents and are Blueprints  Fidelity has a significant relationship with positive outcomes  Barriers to attendance require addressing (transport, childcare, etc.) to ensure retention  Although costly in the short-term, costs are minimal in the long-term when considering the cost of antisocial behaviour for society

Current Studies IY Therapeutic Dino School for high risk young children – extra coaching for high risk children already receiving classroom Dina and with TCM trained teachers IY School Readiness Programme for parents of children as they enrol in school delivered by school staff to build the home-school link IY Baby Programme for parents and babies during their first year of life delivered by health care staff KiVa bullying prevention programme

Small Group Dina project BIG Lottery funded project RCT of the 18-session IY Small Group Dina programme 22 schools in Gwynedd, Powys, and Anglesey  Phase 1 (2010/11) – 9 schools  Phase 2 (2011/12) – 13 schools

Small Group Dina project Children identified using the teacher version of the Strengths and Difficulties questionnaire (Goodman 1997) Participants randomised on a 1:1 basis to intervention or wait-list control Final sample N = 224 children

Small Group Dina project Measures include :-  Demographics (parent & teacher)  Child behaviour (parent & teacher)  Parental mental health  Parenting skills  Wally problem solving task  Lego task (observation)  Classroom observation (phase 2 only)

Small Group Dina project Child characteristics SDQ total difficulties borderline 14 and 17 Abnormal Child demographicsControl (n=109)Intervention (n=115) Mean age, months (SD)65.24 (10.84)65.57 (12.01) % male % Welsh Mean no. SGD sessions (SD) attended /14.63 (3.80) Mean TSDQ total score* (SD) (4.71)18.24 (4.46)

Small Group Dina project Parent characteristics Parent demographicsControl (n=109)Intervention (n=115) Mean age, years (SD)33.44 (6.41)33.21 (8.04) % female % single parents % below poverty threshold % left school at 16 yrs

Small Group Dina project Teacher characteristics Teacher demographicsAll (N=54) Mean age, years (SD)39.44 (10.51) % female96.4 Mean no. yrs teaching15.43 (9.91) Mean no. yrs current school11.42 (8.56) Mean no. schools taught2.09 (1.11) % teaching multi-year class42.9

Small Group Dina project Next steps  Finish data inputting & checking  Conduct data analysis  Write-up results We hope to have results to report by the conference in Cardiff

KiVa Anti-bullying programme Developed by Prof Christina Salmivalli University of Turku, Finland Funded by Finnish Government RCT trial National roll out since 2009 Approved for WG funding

34 defenders of the victim outsiders assistants of the bully victim reinforcers of the bully 12% 8% 20% 7% 17% 24% bully  Participant roles in bullying (Salmivalli et al., 1996) Background of KiVa: The social architecture of bullying

35 In order to reduce bullying...  We do not necessarily need to change the victims, making them ”less vulnerable” UNIVERSAL  Influencing the behavior of classmates can reduce the rewards gained by the bullies and consequently, their motivation to bully in the first place INDICATED However, the victims need to feel that they are heard and helped by the adults at school The bullies need to be confronted for their unacceptable behavior

36  Repeating & testing of what has been learnt – ”I KNOW”  Learning to take action – ”I CAN”  Motivation – ”I DO” KiVa games and KiVa Street are closely connected to student lessons

37 RCT: Success of the indicated actions  The proportion of cases handled by the school team in which bullying...  Stopped completely79.4%  Decreased18.5%  Remained the same 1.9%  Increased 0.3% Garandeau et al., Tackling acute cases of bullying: Comparison of two methods in the context of the KiVa antibullying program. 37

38 Scaling up  2009: 1450 schools  2010: schools  2011: schools + Åland Island  82% of comprehensive schools in the country have adopted KIVa  About teachers and other school personnel trained face-to-face 38

39 Main conclusions (broad rollout)  Effects weaker than in RCT, but still significant (for victimization, OR= 1.21, 95% CI= ), with much variation across grade levels  Again, strongest effects in grade 4 and weakest in secondary school (grades 7-9)  Generalized to Finnish population of 500,000 students, the effects of this size would mean a reduction of victims and 8000 bullies after nine months of KiVa implementation 39

40 Current pilot in Wales  Small scale KESS funded evaluation, CEBEI – Suzy Clarkson Mres  7 schools in North Wales, 3 schools in Cheshire, 7 schools in South Wales  Trained by Christina in May 2012, Unit 2 curriculum in English 9 – 11 yos  The 17 schools completed baseline survey and are implementing programme, now on lessons 3 to 4 of Unit 2 and very enthusiastic about the lessons  Only one bullying incident so far 40

41 RCT funding from March 2013 Welsh Big Lottery Funding Project Partners, Dartington social Research Unit & CEBEI 20 primary schools (from across Wales) To implement and evaluate the entire KiVa primary school curriculum (Units 1 and 2) (all of KS2, years 3 - 6) Randomised allocation of schools 10 schools to implement 2013 and 20 schools to implement in 2014 Meetings in March to identify interested schools 41

42 Aims and outcomes 42 Reduce bullying, measured by pupil self- report – online survey Reduce victimisation, measured by pupil self-report – online survey Improved mental well-being, measured by Teacher Strengths and Difficulties Questionnaire Improved school attendance, measured in terms of half day sessions missed

PREPARE  A newly funded study  Funded by a former student at Bangor  To develop a web based parent programme using evidence based principles to support children’s school readiness  Funding for a PhD student, Stefanos, and for web consultancy and associated costs to trial the programme  Commencing 1 st April

Possible PREPARE components  Play  Read  Encourage  Praise  Attend  Reward  Educate

Gwynedd evaluation of early intervention services A collaborative project between CEBEI, the Children’s Early Intervention Trust, and Gwynedd Council Builds on the Escape and Literature review partnership 1 st Feb 2013 – 31 st March 2014 Karen Jones, CEBEI appointed as RPSO to undertake this work

Gwynedd evaluation early intervention services Project will involve :-  Developing ‘Distance Travelled Toolkit’ to be used by Gwynedd’s Team Around the Family to measure/monitor impact of its work on improving outcomes for families  Developing appropriate measures to evaluate/monitor impact of four, newly commissioned, early intervention services working with families  Undertaking independent evaluation with sample of families receiving interventions/services through the programme

Waterloo foundation grant  £10,000 to deliver training in one to one work with families with children with developmental problems across Wales  To deal with the problems/behaviours that might be amenable to change  Builds on the earlier Intensive Treatment Programme research and the Enhancing Parenting Skills programme  Support from Children in Wales

The plan  Two days training, February and April  Five locations in Wales: Bangor, Flint, Cardiff, Swansea and Newtown  15 participants in each Centre  Day one – introducing a structured assessment and case formulation process  Day two focused on intervention  A manual developed to support assessment, case analysis and intervention skills  A parenting booklet to teach parenting skills and principles of reinforcement being published  Participants collect data for evaluation

The ADHD trial in England Partnered with Southampton University in a head to head trial of IY and New Forest parenting programme with young children aged 2 – 5 at risk of ADHD -Locations: Nottingham, Stoke and Southampton CEBEI trained IY group leaders and are supporting through supervision (Judy, Sue, Bridget, Linda - Poole) Each Centre running one trial group and 5 research groups Jan 2012 – Dec 2013 Results 2014 Challenges so far include loss of group leaders, recruitment and retention difficulties

Parenting trial with Oxford & Cape Town Universities Urgent need for affordable parenting programmes in low/middle income countries The core components of effective parent programmes are known Sinovuyo is a programme that incorporates - african values –respect for families, elders - african culture, stories and songs recognises the many challenges facing in severly disadvantaged circumstances, families, bereavement, intimate partner violence, HIV and aids etc..

SINOVUYO CARING FAMILIES PROJECT Development and Evaluation of an Evidence-Based Early Childhood Development Parenting Programme for Vulnerable Families in South Africa

YEAR 1: INTEVENTION DEVELOPMENT -Community-based participatory approach with stakeholders -Parents, Service Providers, Expert Consultations -Policy meetings with relevant government agencies -Qualitative research in community: May – June Focus groups and In-depth Interviews -97 Parents, 24 Service providers -Experiences of parenting children with behavior problems -Applicability of acceptability of evidence-based parenting progs -Feasibility of implementing parenting programmes -Programme develop and manualization -Illustrated story vignettes, role-play, storytelling -Home practice

YEAR TWO: PILOT EVALUATION STUDY -Randomised controlled trial: Feb to May N = 60 parents in Khayelitsha (a township outside Cape Town -Wait-list control (3 months) -Parents/caregivers of children ages 3 to 8 -Assessments at baseline and post-study -Outcome Evaluation -Child Behavior Problems (self-report and observational) -Parenting Behavior (self-report and observational) -Parental Mental Health (depression and parenting stress) -Process Evaluation -Programme fidelity, Exposure/Adherence, Participant satisfaction

WHO Violence Prevention Alliance  dedicated to the prevention of interpersonal violence through the implementation of evidence-informed strategies.  Parenting project sub-group – to reduce violence against children through increasing effective parenting by increasing the evidence-base for parenting programmes applicable to low- and middle-income countries (LMIC) given the dearth of evidence of effectiveness in such countries.  Developing a guidance document on conducting outcome evaluations of parenting progs to prevent violence in LMIC. funded by the UBS Optimus Foundation, work began in 2012 and will be completed in June 2013

First meeting Zurich Dec 2012  Two further priority projects identified: -Identify the core principles/essential ingredients that make programmes effective and synthesize results to provide guidance on how to choose a good parenting programme; Judy Hutchings and Chris Mikton (WHO) co- lead on seeking funds for this project  Review the evidence for mass media campaigns and edutainment interventions;

Development of the IY programmes in Wales Welsh Government funded support for training across Wales for the programmes from 2006 – Authorities have partnered in our RCTs 3 Authorities have mentors, six have peer coaches, 30 certified or part certified leaders across Wales 56

57  Welsh Government continuing to fund training across Wales in parent programmes for a seventh year, until March 2013  All 22 Authorities in Wales delivering the parent programme  Baby and toddler parent programmes seen as highly relevant to early intervention projects  School readiness parent programme becoming established

Thank you For further information please visit our websites ales.co.ukhttp:// ales.co.uk Research website: research.bangor.ac.ukhttp://incredible-years-wales research.bangor.ac.uk