Parenting interventions for child problem behaviour: For whom, where and why do they work? Frances Gardner Professor of Child & Family Psychology Centre For Evidence-Based Intervention Department of Social Policy & Intervention University of Oxford

Outline Introduction: why parenting? what interventions? Evidence on effectiveness, applicability and mechanisms of change, including egs of UK randomised trials Wider applications of parenting interventions - Do they work in ‘real world’ services? Are they transportable to different cultures and countries? Can they be delivered to the wider population? Useful for ‘high need’ families – where there is abuse, severe delinquency?

Why parenting interventions? 1. Parenting skill is one of the strongest predictors of good outcomes for children - longitudinal studies from many countries show positive, consistent, supportive parenting predicts low levels of child problem behaviour & child abuse; enhanced cognitive development Conversely, harsh, inconsistent parenting is predictive of poor youth outcomes: problem behaviour, child abuse & neglect, delinquency, drug use, school failure; poor health & mental health; partner violence (Hoeve et al, 2010).

Why parenting interventions? 2. What about other factors that contribute to youth problems? - such as parent stress, family poverty, low education or bad neighborhoods.... Of course, these are all important – but studies suggest that parenting is the mechanism or ‘common pathway’ through which these contextual factors impinge on children (Rutter). Good parenting appears to be able to protect children in the face of these stresses.

Why parenting interventions? 3. There’s a lot of knowledge about effective parenting interventions, as we shall see.... Many systematic reviews of Randomised Controlled Trials- (RCTs), eg by Cochrane, Campbell Collaborations

Parenting interventions: What are they?

Essential components of effective parenting programmes Specific factors: based on Social learning theory principles to change parent & child behaviour Attachment - building warm, close parent-child relations Cognitive-behavioral principles to deal with parent stress, anger General factors: Effective practitioners - work in a way compatible with clients’ beliefs and values. encourage clients to focus on present & future possibilities, not past problems are empathic, accepting, warm Effective programmes share general & specific principles eg Triple P Incredible Years Parent-Child Interaction Therapy (PCIT) Parent Management Training (PMTO) Family Check Up

Specific components of effective parenting interventions -emphasise principles rather than prescribe techniques - active problem solving by parents around own family needs & values - using ‘social learning’ principles: eg importance of parent child interaction, reinforcement, clarity, consistency, small steps. -Start with relationship building, praise and rewards, -How to reduce conflict & harsh, punitive strategies -Later - sanctions (non-violent) for problem behaviour -Parents apply principles to own situation, to change parenting behaviour - using discussion, role play, modelling, problem solving, practice, homework etc

One example: the Incredible Years parenting intervention (Webster Stratton) Group based parent programme (also: teacher, child) Strong evidence base Effective as both clinical and preventive programmes Evidence for applicability across cultures within USA Identified and adopted by a number of governments as effective programme eg: - UK: NHS- NICE guidelines; National Academy of Parenting Research as effective program; - US: Office of Juvenile Justice & Delinquency Prevention as model “Blueprint” programme for violence prevention

The Incredible Years Basic program- principles and components two hour sessions, weekly Emphasis on shared problem solving in group Collaborative (not didactic) leader style, start with parents needs & values Emphasis on parents learning principles not techniques, on changing behaviour Viewing & discussing video clips of parents Role-play in group; home practice with child

Components of Incredible Years parenting program Materials to support programme: books, CDs, leaflets. Parents receive weekly feedback & between session support from group leaders Groups must be accessible, especially for hard-to- reach & busy parents (time, place, language, childcare…) Content pyramid - stresses first relationship building, then discipline strategies

Parenting interventions: how do we know they work?

What constitutes good evidence? Randomised controlled trial (RCT): Considered ‘gold standard’ for minimising bias in evaluation Well-worked out methods for complex interventions; parents’ views central to evaluation Good quality research is expensive, but so is ineffective or untested practice - even more so Well-meaning interventions may do no good - and worse, may do harm (ethical obligation). Many examples of well-liked interventions doing harm Systematic Review: Summarise findings of trials - rigorous, transparent, replicable, up to date. Very useful for policy

Effective parenting interventions: What is the evidence base? Many randomised controlled trials (RCTs) demonstrating effectiveness of structured, cognitive-behavioural interventions for: Reducing child conduct problems, ADHD. Improving parenting skill & confidence; child & parent mental health Not just young children; good results with antisocial teens Many good systematic reviews (Cochrane/ Campbell reviews, eg Barlow 2012, Furlong et al 2012; Piquero, 2009; NICE guidance) Many replications by independent teams, UK, US, some other European countries. Why use interventions without an evidence base? Not cost effective, maybe not ethical?

In what service contexts? Settings for parenting RCTs: Wide range of families, settings, modes of delivery: Prevention (general & high risk) AND Treatment studies. Range of service settings: health services - primary care & specialist, schools, child protection services, community groups, voluntary or NGO sector, ‘Head Start’ nurseries, day care, workplace Flexible range of delivery methods: Individual vs group; home vs centre; phone, media-based, reality TV, internet (Triple P TV trials) - So can adapt to family need & preference, service & cultural context. Many more settings in practice - these are just the randomised trials. Critical questions: Do they work in ‘real world’, everyday services? Can they make a difference across the population, be taken ‘to scale’? Less evidence on this so far.

Data from RCTs suggests effective for a range of families: Low income and average families Families with complex, multiple needs including maternal mental health problems, history of maternal abuse, high poverty, those with incarcerated sibs (eg Scott; Webster- Stratton; Sanders; Gardner). Need to remove barriers. Range of child disorders/ problems Families who maltreat their children/ involved in the child protection system We tested in our UK trials - if intervention more or less effective for these subgroups (moderator analyses)

Examples of trials of parenting interventions in UK services: How do they work? (mediators) For whom do they work (moderators)

Transporting a US program to UK real-world services: 2 randomised trials Incredible Years parenting with low-income UK families – many social problems... Training, fidelity, adaptation to local family needs Oxford trial: Children with severe behaviour problems, referred for treatment, in community settings, in voluntary / nonprofit sector, age 2-9 (Gardner et al., 2006). North Wales trial: Targeted prevention in multiple ‘Sure Start’ services, age 3-5. (Hutchings et al 2007; Gardner et al, 2010)

Overcoming barriers to engagement – practical & process Local community venues (respond to parent views) Build relations with families,referrers, staff in community Food, child care Daytime and evening groups –offer choices Active recruiting of fathers Home assessment visits before group starts Collaborative not didactic process; builds on parents’ strengths and wishes; Individual goals Phone calls between sessions if needed North Wales: offer Welsh-language groups & materials

Oxford trial in voluntary sector: Family Nurturing Network ( Gardner et al. 2006, Jnl Child Psychology & Psychiatry) 76 families, randomised to intervention vs wait-list. Children 2-9, referred for severe conduct problems. ‘Incredible Years’ parenting groups Clear intervention effects on child problem behaviour, positive and negative parenting skill, - by both parent report and direct observation in home. Good effect sizes, in Intention-to-Treat analyses, ES Effects maintained to 18 month follow up. High consumer satisfaction. Very much a ‘real world’ service: - testing real practice, in voluntary sector, local venues, low paid staff; developer not involved in trial (but well trained & supervised; dedicated focus on IY program)

North Wales Incredible Years trial Hutchings, Bywater, Daley, Gardner et al., BMJ 2007 Children age 3-5 years in 11 ‘Sure Start’ areas, screened by health visitors for risk for conduct problems 133 families, randomised to intervention vs wait-list ‘Incredible Years’ parenting groups. Clear intervention effects on child problem behaviour (ES.9), positive and negative parenting skill (ES.6 -.9), by both parent report and direct observation in home. Effects on parent depression (ES.5) & stress. Effects maintained for 1.5 years Effect Sizes impressive – (NB, from Intention-to-Treat analyses) First truly ‘real world’ study in multiple services to get these effects ?? Low income, bilingual areas, high unemployment

1. Observed Positive parenting: ( sum of praise, affectionate, positive affect, problem-solving) Evidence-Based Intervention Group, Department of Social Policy & Social Work University of Oxford

2. Observed Negative parenting (sum of critical statements; negative commands, physical negative) Evidence-Based Intervention Group, Department of Social Policy & Social Work University of Oxford

3. Observed Child negative aggressive behaviour ( sum of cry/ whine/ yell; physical aggression; smart talk; destructive) Evidence-Based Intervention Group, Department of Social Policy & Social Work University of Oxford

Mediators of change in Wales & Oxford trials Or - How does it work; is it working in the way we think it is? What are the active ingredients -can refine, emphasise key components We found in Wales & Oxford trials that: - change in positive parenting skill was best predictor of change in child problem behaviour, after intervention. Whereas: - change in parents’ confidence about parenting; - change in harsh parenting (altho’ both much improved) Did not seem to be driving in change in the child behaviour. (UK & US: Gardner et al. 2006, 2007, 2010; Dishion et al. 2008)

Moderators of change in Wales & Oxford trials: Or: for whom did it work? Did it work better or worse with very high risk families? Mothers who were depressed, children with more behaviour problems - they did better in intervention Improvements in the intervention group were NOT related to: single parent - poverty level of family – child age – family size. So: the more disadvantaged families did just as well – often better Other studies have found the same: Very similar pattern in Oxford trial; In our US trial of Family Check up; mirrors US Webster-Stratton findings on families in child protection system; and her trials in Head Start nurseries. Gardner et al (2010) Journal of Clinical Child & Adolescent Psychology

Wider benefits & applications of parenting interventions: what are some key questions for research and practice? Work in real world services? Work across wide range of cultures & countries? How to take to scale - widespread dissemination? Cost, capacity, can they be briefer, cheaper? Worth offering to all families? - primary prevention: improving parent child relationships across population? Or work better with higher risk families? High need families/ children? Child protection system, school exclusions, young offenders? Yes- promising interventions

Applying parenting interventions more widely Real world services? Best examples of real world trials are North Wales Sure Start & Birmingham IY These both tested IY parenting and achieved very good results in stringent RCT in multiple real world services, run by multiple agencies; mix of high skill and regular service staff. But careful attention to fidelity is vital....

Applying parenting interventions more widely Wide range of cultures? USA: Large Webster-Stratton study based on pooled data from 3 RCTs with 650 diverse low income families in HeadStart nurseries (Reid et al. 2003; 19% African American, 11% Hispanic, 12% Asian, 50% Caucasian) - found no ethnic differences in any child & parent outcomes, by parent report or direct observation; nor in engagement, attendance, parent satisfaction UK: Scott’s RCT in London schools, also no effect of ethnicity on outcomes satisfaction, attendance (Scott et al 2010, PALS trial). Studies of other interventions have often found similar results- PCIT, FCU

Applying parenting interventions more widely? Wide range of countries? Our systematic review found parenting interventions ‘transport’ well across countries (Gardner et al, 2013): In 17 trials of EB parenting programs in 10 ‘new’ countries, effect sizes were just as high as they were in ‘origin’ countries. The effects were not related to how similar or dissimilar the countries were in cultural values, resources, or family policy regimes (eg family-friendly vs not). Surprising trends toward higher effect sizes in ‘non- western’ countries. Parenting in South Africa- Judy

PCIT Triple PPMTO Puerto Rico Hong Kong Iceland Iran NorwayCanada Sweden Incredible Years Transportability of parenting interventions across countries: A systematic review 17 trials - which programmes in which countries? Ireland UK NL

Applying parenting interventions more widely Taking to scale - widespread dissemination? Cost, capacity, can they be briefer, cheaper? - lot of issues here, but one possibility is using e-technology: Evidence base is more preliminary- but some promising trials of interventions delivered via TV, internet, self help booklets & videos. Examples: Triple P on TV, internet Also possibilities for more modern technology- eg text prompts, reminders to practice etc (worked well with adolescent depression CBT, Merry et al, 2012, BMJ) Review: Jones, Forehand et al 2013; Montgomery et al Cochrane review

Applying parenting interventions more widely Worth offering to every family? -Primary prevention: improving parent child relationships across population? -Sounds a good thing- however evidence unclear for universal programmes for any families- some have shown good effects, some have not (eg Triple P). -What outcomes would you expect to change - child behaviour or only parenting?

Applying parenting interventions more widely High need families/ children? eg Families in child protection system, school exclusions, young offenders? Yes- promising interventions for families where there is physical abuse: Incredible Years, PCIT, although RCTs are smaller & fewer than for child problem behaviour (Barlow et al 2006; Chaffin et al 2011) Teen offenders: mixed evidence about effects of well-known US programs when transported elsewhere (eg MST didnt work in Canada, Sweden, modest effects in UK); FFT in UK

Webster Stratton (2010), ‘Adapting Incredible Years (with fidelity) for families in child welfare system’ Analysis of Head Start preschool randomised trial data, using IY basic parenting programme (n=630) 20% of kids in child protection system their problems were worse But intervention just as effective for these families - ie improved parenting & child problem behaviour Conclude: this regular, high quality programme, was just as effective with the most high risk parents Families in Head Start who have had contact with child protection system

Flexibility - eg more sessions for groups that need them; spend longer on: basic relationship building through play; parent attributions, developmental expectations; anger management and hitting (similar components to other ‘high-need’ interventions - eg Dawes ‘Parents Under Pressure’, for drug using, abusing parents, Triple P level 5) home visits; collaborate with case workers Case series of 136 families in child protective services suggests strong effects on parenting & child outcomes, in pre-post design. What adaptations for families in child protection system (Webster Stratton 2010):

Systematic reviews of interventions for children who have been physically maltreated Montgomery, Gardner, Ramchandani & Bjornstad 2009, for UK DCSF: parenting; family-therapy, child focussed. Found: 7 RCT’s of Parenting Interventions – compared to ‘treatment as usual’ Most small & modest quality, a few had maltreatment outcomes Some evidence for reducing maltreatment Better evidence for improving parenting skills and child mental health outcomes Promising ? - especially as consistent with: i)evidence from trials of same interventions with other high risk groups, for reducing harsh parenting / conflict; and ii)with findings of Triple P population-level maltreatment prevention trial

Conclusions 1: What do we know about effective parenting interventions? Parenting interventions work - strikingly strong evidence base from randomised trials. If they are delivered well, with fidelity, they are able to improve parenting skill, child behaviour, parent mental health, & reduce child abuse For reducing problem behaviour, they appear to be as effective in families with multiple problems, as for more average families Mechanisms of action- or key ingredients appear to be change in parenting skill

Conclusions 2: What do we know about effective parenting interventions? Much evidence that transportable across diverse range of services, families, cultures, in many countries Why transportation across countries so successful, when parenting is so culturally patterned? Many further questions, challenges: To have widespread impact on children (take ‘to scale’), need to pay attention to systems of training, supervision, high support for staff to carry out new, skilled, often difficult work. Should we be offering universal prevention? Is it effective, feasible, scalable? Can new technologies help?

Thank you!

Some references Knerr, W., Gardner, F., & Cluver, L. (2012). Reducing harsh and abusive parenting and increasing positive parenting in low- and middle-income countries: a systematic review. In press, Prevention Science. Gardner, F., Hutchings, J. & Bywater, T, Whitaker, C. (2010). Who benefits and how does it work? Moderators and mediators of outcomes in a randomised trial of parenting interventions in multiple ‘Sure Start’ services. Journal of Clinical Child and Adolescent Psychology, 39, Gardner, F, Connell, A, Trentacosta C, Shaw, D., Dishion, T, Wilson, M. (2009). Moderators of outcome in a brief family-centred intervention for preventing early problem behaviour. Journal of Consulting and Clinical Psychology, 77, Montgomery P, Gardner F, Bjornstad G, Ramchandani P. (2009). Systematic reviews of interventions following physical abuse: Final report to DCSF. Dishion, T., Shaw, D., Connell, A., Gardner, F. et al, (2008). The Family Check-Up with high-risk indigent families: preventing problem behavior by increasing parents’ positive behavior support in early childhood. Child Development, 79, Hutchings, J., Bywater, T., Daley, D., Gardner, F., Jones, K. et al (2007). Pragmatic randomised controlled trial of a parenting intervention in ‘Sure Start’ services for children at risk of developing conduct disorder. British Medical Journal, 334, Gardner, F., Burton, J. Klimes, I. (2006) RCT of a parenting intervention in the voluntary sector for reducing child conduct problems: outcomes and mechanisms of change. Journal of Child Psychology & Psychiatry, 47, parenting-intervention-06.pdfhttp:// parenting-intervention-06.pdf

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Finally, taking interventions to scale Step beyond mere real-world services- How to embed them in service systems so as to reach a larger % of families that might benefit? Will they still be effective? Fidelity one of big challenges Two examples: - South Carolina, USA: Triple P trial - England: central government initiative National Academy of Parenting Practitioners

National Academy of Parenting Practitioners - rationale: Many effective parenting programs- however……. £££m’s spent on bottom up, home grown programs w/ little success - Sure Start evaluation. Many staff working with parents had little training for parenting work Government Dept Children Schools & Families set up academy in Nov 2007 to address these issues, via training and research. Partnership between voluntary (NGO/ non-profit /third) sector, government & university- Kings College London Getting research into practice - rolling out in UK