1. Parenting intervention for conduct problems - Who benefits, how does it work? Mediators and moderators of effects in a randomized trial of a preventive community parenting intervention in North Wales ‘Sure Start’ services INTRODUCTION Parenting interventions for reducing conduct problems are often tested in ‘efficacy’ trials, under relatively ideal conditions of a specialist research setting. However, in order to take preventive efforts to scale, it is clearly important to test programs in ‘effectiveness’ trials, in real- world settings that reach families at-risk and can be sustained (Dishion et al. 2003; Gardner et al, 2006; 2007; Scott et al, 2001; Webster- Stratton, 1998) A meta-analytic review suggests that families with high levels of distress and disadvantage do less well in parent training (Reyno & McGrath, 2006). However recent studies show more encouraging results for ‘hard-to-reach’ families (Beauchaine et al., 2005; Baydar et al., 2005), arguably due to using a collaborative and group- based model of intervention, with careful attention to training and fidelity. Relatively little is known about mediators of effects in conduct problem intervention (Weersing & Weisz, 2002), although recent studies suggest enhancing positive parenting may be an important mechanism of change (Forgatch & DeGarmo, 1999, Gardner et al., 2006, 2007). Given few parenting interventions have examined predictors of outcome, and none have extended these investigations into ‘real-world’ settings with regular staff, the North Wales Sure Start trial (Hutchings, Bywater, Daley, Gardner et al, 2007) provides a unique opportunity to examine these issues in a multi-site community trial aimed at preventing conduct problems. When translating high-quality programs into normal services, it is vital to establish if the most needy families are helped, and if similar mechanisms underlie change in child outcome. METHODS Participants: (table 1) 153 children from 11 low-income Sure Start areas, aged 3-5 years, at risk of conduct disorder as defined by scoring above clinical cut-off on Eyberg Child Behavior Inventory. Participants were randomized on a 2:1 basis (104 intervention, 49 waiting-list). Intervention: 12-week, group-based Incredible Years BASIC parenting program. Primary outcome: Parent-reported child problem behavior (Eyberg) Analysis: Moderator effects were tested using a series of multiple regressions, examining effect on outcome of the interaction between each predictor variable and treatment status. Predictor variables were entered thus: step 1, predictor plus treatment status; step 2, the interaction term (treatment x predictor). Mediating mechanisms were tested as follows: 1) we examined inter-correlations between predictor variable (treatment status); mediator variable (parenting skill) and outcome (Baron & Kenny, 1986). 2) Multiple regression tested if introducing mediating variable attenuated relationship between treatment and outcome. 3) Sobel test assessed significance of mediation effect.  Figure 1. Mediation model: Positive parenting as mediator of association between intervention and child problem behaviour outcome. Treatment vs control group Change in observed positive parenting Change in child problem behavior (Eyberg problem) r= 20, p =.02 B= 10.1 r =.27, p=.002 B=.10 r =.31, p =.000 B= 5.9 Mediators and moderators of intervention effects in a randomized trial of a community parenting intervention in North Wales ‘Sure Start’ services Frances Gardner DPhil Frances Gardner DPhil University of Oxford Tracey Bywater PhD Judy M Hutchings PhD University of Wales, Bangor With thanks to The Health Foundation for support Frances Gardner DPhil University of Oxford, Department of Social Policy and Social Work Tracey Bywater PhD & Judy M Hutchings DClinPsy Department of Psychology, University of Wales, Bangor Waiting list controls (n = 47) Intervent ion (n = 86) No. (%) boys31 (66)49 (57) Mean child age months (SD) 46.2 (4.2) 46.4 (6.6) Mean child Eyberg conduct problems (SD); clinical cut- off 11 14.8 (7.7) 16.5 (7.0) No. (%) Lone parent 16 (34)38 (44) No. (%) Total weekly income ≤£64/person 42 (89)76 (88) Parent age (yrs) at first born child Mean (SD) 20.5 (4.2) 21.4 (5.0) Table 2 & 3: show descriptive data on association between predictor variables and change in child conduct problems. Family social disadvantage did not predict poorer child problem behavior outcome following intervention. On the contrary, in moderator analyses, children whose parents were more distressed at baseline showed greater improvement (p=.03 for Beck depression; p=.05 for Parenting Stress) in problem behavior. There was a trend for children of lone parents to show better outcomes (p=.08). Very low income and teen parenthood did not moderate intervention effects, suggesting families with these disadvantages were equally likely to be helped by intervention. Child risk also did not predict poorer outcome. In moderator analyses, younger (p=.009), and male (p=.02) children, showed greater improvement in problem behavior. Level of ADHD (Conners) or observed child problem behavior at baseline did not predict outcome. RESULTS Change in Eyberg problem score, time 1-2 Categorical risk variable Intervention (n=86) Control (n=47) 1. Lone Parent 8.8-.1 Living with partner 5.11.7 t-test, lone vs nott=-2.0, p=.05 t=.7, NS Moderator effectβ=-.30. p =.08 2. Low income <£200pw 7.91.6 >200 pw5.70.6 t-test <200 vs 200+ t=-1.2, p=.3 t=-.41 NS Moderator effectβ = -.06, NS 3. Teen parent6.6.9 Not7.21.3 t-test teen vs nott=.37 NSt=.17, NS Moderator effectβ =.01, NS 4. Child gender: boy7.9-.7 girl5.94.6 t-test boy vs girlt=-1.3 NSt=2.2, p=.03 Moderator effectβ = -.39, p=.02* Moderators: Table 2. Moderator analyses: associations between change in conduct problems and categorical risk factors Correlation between risk variable at baseline and change in Eyberg score Continuous risk variable Interventn n=86 Control n=47 5. Maternal depression (Beck) r=.20,P=.06 R = -.20, NS moderator effect β =.45, p=.03* 6. Parenting stress (PSI) r=.23, =.04 R= -.14, NS moderator effect β =.79, p=.05* 7. Child age r=.05, NS R=.44 P=.002 moderator effect β = -1.6, p=.009* 8. Child deviant behavior (observed) r=.-06, NS R=.11, NS moderator effect NS Table 3. Moderators: associations between change in conduct problems & continuous risk factors DISCUSSION Moderator analyses show that families who are more distressed or disadvantaged had child outcomes which were as good as, or better than, lower risk families. Maternal depression and stress were significant moderators, with more distressed mothers showing better child behavior outcomes following intervention. Child gender and age also moderated intervention effects, with younger children and boys doing better. The family risk data are somewhat at odds with an older body of trials, and meta-analysis (Reyno & McGrath, 2006), showing that more disadvantaged families do worse on parent- training. However, they are consistent with recent trials of Incredible Years Program, which find good outcomes for low-income parents, and fail to replicate earlier patterns of moderator effects. This may be due to the strong focus of this high quality program on collaborative group work with parents, within the framework of a cognitive-behavioral model, which is likely to help address issues of diversity of background. The present findings extend this work, showing that even in an effectiveness trial in multiple agencies, in areas of high poverty, it is possible to achieve change (or greater change) in conduct problems in the most distressed or disadvantaged families. The mediator analysis is consistent with recent studies showing the importance of teaching positive parenting skill as a mechanism in conduct problem prevention (Forgatch & DeGarmo 1999; Gardner et al. 1999; 2007) and treatment (Gardner et al., 2006). It suggests similar mechanisms are responsible for change in the context of a multi-agency effectiveness trial. KEY POINTS 1. The Incredible Years Program shows robust results in a multi-site RCT – it improves parenting and conduct problem in a high risk sample. Yet few studies have examined predictors of change in effectiveness trials 2. Most importantly, it is effective (or more so) for parents traditionally thought of as ‘hard to reach’, and it appears to work via similar mediating mechanisms as found in efficacy trials - change in positive parenting 3. The findings are novel in showing how it is possible to roll out an evidence- based preventive program into diverse ‘real world’ services, and to reach some of the most disadvantaged families within designated low-income ‘Sure Start’ areas. References: Baron, R., & Kenny, D. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182. Baydar, N., Reid, M. J., & Webster-Stratton, C. (2003). The role of mental health factors and program engagement in the effectiveness of a preventive parenting program for Head Start mothers. Child Development, 74, 1433-1453. Beauchaine, T., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and predictors of one-year outcomes among children treated for early-onset conduct problems: A latent growth curve analysis Journal of Consulting and Clinical Psychology, 73, 371-388. Dishion, T. J., Nelson, S., & Kavanagh, K. (2003). The Family Check-Up With High-Risk Young Adolescents: Preventing Early-Onset Substance Use by Parent Monitoring Behavior Therapy, 34, 553-571. Eyberg, S., & Ross, A. (1978). Assessment of child behavior problems: The validation of a new inventory. Journal of Clinical Child Psychology, 7, 113-116. Forgatch, M., & DeGarmo, D. (1999). Parenting through change: An effective parenting training program for single mothers. Journal of Consulting and Clinical Psychology, 67, 711-724. Gardner, F., Burton, J., & Klimes, I. (2006). Randomised controlled trial of a parenting intervention in the voluntary sector for reducing child conduct problems: outcomes and mechanisms of change. Journal of Child Psychology and Psychiatry, 47, 1123-1132. Gardner, F., Shaw, D., Dishion, T., Burton, J., & Supplee, L. (2007). Randomized prevention trial for early conduct problems: effects on proactive parenting and links to toddler disruptive behavior. Journal of Family Psychology, in press. Hinshaw, S. P. (2002). Intervention research, theoretical mechanisms, and causal processes related to externalizing behavior patterns. Development and Psychopathology, 14, 789-818 Hutchings, J., Bywater, T., Daley, D., Gardner, F., Whitaker, C., Jones, K., et al. (2007). Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomised controlled trial. BMJ, 334, 678. Reyno, S., & McGrath, P. (2006). Predictors of parent training efficacy for child externalizing behavior problems - a meta-analytic review. Journal of Child Psychology and Psychiatry, 47, 99-111. Scott, S., Spender, Q., Doolan, M., Jacobs, B., & Aspland, H. (2001). Multicentre controlled trial of parenting groups for childhood antisocial behavior in clinical practice. BMJ, 323, 194-203. Webster-Stratton, C. (1998). Preventing conduct problems in Head Start children: strengthening parenting competencies. Journal of Consulting and Clinical Psychology, 66, 715-730. Weersing, V. & Weisz, J. (2002). Mechanisms of action in youth psychotherapy. Journal of Child Psychology& Psychiatry 43, 3-29 AIMS To examine moderators and mediators of intervention effects (as defined by Hinshaw, 2002) in an RCT of a parenting intervention for preventing conduct problems, implemented across multiple ‘Sure Start’ services for low- income families in North Wales, an impoverished region, mostly rural and bilingual. We found robust intervention effects on multiple outcomes (Hutchings et al., 2007), including child conduct problems and parenting, measured by parent-report and direct observation. We examine the following questions: 1. Moderators - for whom does it work?: Do Family risk factors - low income, lone or teen parent, maternal depression, parenting stress, and Child risk factors - child problem behavior, ADHD, age & gender, differentially predict child response to intervention? 2. Mediators - what are the active ingredients of change?: Does change in positive and negative parenting skill mediate change in child problem behavior? To avoid method overlap, we examine observed parenting skill as a predictor of parent-reported child behavior. Table 1. Sample characteristics at baseline Mediators: We tested whether observed positive parenting mediates treatment change. All 3 variables were inter-correlated (fig 1). Hierarchical multiple regression was used, with change in conduct problems as DV. IVs were entered thus: Step 1, effect of treatment on conduct problems; Step 2, showed this effect is attenuated when positive parenting is introduced as a mediator. There was a significant partial mediation effect (Sobel test, p<.014). Change in negative parenting did not predict treatment change, nor qualify as a mediator.