1. 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

2. 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

3. 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

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

5. 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

6. 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

7. 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

8. 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…..

9. 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

10. DVD puppet clip

11. 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

12. 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

13. 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.

14. 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

15. 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)

16. PARENT PROG DVD CLIPS

17. 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?

18. 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)

19. 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

20. 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?

21. 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?

22. What should we measure?

23. 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)

24. DPICS

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

26. Eyberg
Figure 2. Eyberg Child Behaviour Problem Scores

27. Long term Sure Start data

28. 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

29. 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”

30. 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,
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,
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.

31. Toddler Programme Research
Aim: To evaluate the effectiveness of the 12-week Toddler Parenting Programme with a group of parents with Toddlers aged 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

32. 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.

33. Results are currently being written for publication so watch this space

34. 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

35. 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’

36. 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

37. 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).

38. 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

39. 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.

40. 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: /j x
Available online -

41. 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

42. 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 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

43. School DVD clip cooperation

44. 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).

45. 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

46. 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

47. 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

48. 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?

49. 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, /year

50. Recent Government initiatives to support families & children
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

51. 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

52. 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

53. 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

54. 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

55. 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!

56. Diolch yn Fawr - and thanks for listening!
For further information on the research please contact me on
For information on training, conferences, availability on parent programmes please contact Dilys Williams on
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