Jenny Burton Frances Gardner University of Oxford

1. Benefits of community based parenting groups for hard-to-manage children: Findings from the Family Nurturing Network Trial Jenny Burton Frances Gardner University of Oxford Centre for Evidence Based InterventionFunded by the Esmee Fairbairn Foundation

2. Anti-social behaviour in young children • Starts young • Persistent • Poor outcomes- high risk for: school failure; criminality; drug abuse; mental illness; poor health / employment • Costly to society • Effective parenting interventions exist – many RCT’s and meta-analyses

3. Using and developing this evidence base in practice • FNN chose intervention with a strong evidence base: Webster-Stratton ‘Incredible Years’ • Systematically collected practitioner evaluation data, pre-post intervention - wished to be open to scrutiny • Used this to develop and argue for RCT funding by independent researchers.

4. Questions for the trial: Is the Webster-Stratton parenting programme effective in a UK voluntary sector, community setting, ‘non-specialist’ therapists: • For improving parenting skills and reducing conduct problems ? • For improving maternal well-being and family relationships? Process questions: What predicts outcome? Does change in parenting predict change in child behaviour?

5. Principles and content of the Webster-Stratton ‘Incredible Years’ parenting intervention www.incredibleyears.com • FNN offer a 14 week group intervention. • 2 hours per week. • 2 group leaders. • 10-14 parents, partners, grandparents.

6. Overcoming barriers • Referral and self-referral • Local community venues (16-18 groups a year) • Food, Child care • Daytime and evening groups • Free • Active recruiting of fathers • Provide transport • Home assessment visits before group starts

7. Engagement and collaboration with families • Individual goals in the group • Collaborative not didactic process • Builds on parents’ strengths and expertise • Video clips – cognitive behavioural principles • Role-plays to find solutions + practice skills • Home practice + diaries + individual feedback • Weekly feedback from parents on sessions • Phone calls between sessions if needed

8. Building positive and nurturing relationships • Parenting behaviours – play, praise, nurturing, communication, incentives, limit setting, handling misbehaviour, problem solving. • Cognitions - seeing child’s viewpoint, attributions re child’s negative behaviour, understanding normal development; temperamental differences between children • Affect – coping with emotions, stress, feeling competent, gaining social support

9. Intervention Summary • CBT-based • Community setting • Skills focussed • Multi-component group based parenting intervention for parents of children aged 2-9 years • Mostly mothers • 14 sessions

10. Design of randomised controlled trial 76 families randomly allocated to either : InterventionGroup: ‘Incredible Years’ parenting group (n = 44) or Control Group: Delayed intervention - 6 months later (n = 32)

11. Recruitment procedure • Referral then routine home assessment by FNN group leader, project explained. Information left. • Researcher visits to discuss, request consent, carry out assessments • Randomisation after first assessment • Families who decline go on normal FNN wait-list

12. Inclusion criteria Child: • Referred for help with problem behaviour; causing most concern to parent • Above clinical cut off on Eyberg Child Behaviour Inventory (parent report of conduct problems) • Aged 2 – 9

13. Summary of assessment procedures and measures • All families assessed at home on 3 occasions • Time 1: Pre-intervention • Time 2: ‘Post-intervention’, 6 months later • Time 3: Follow up, 18 months after time 1 • Researchers blind to group allocation • Standardised, validated measures: • parent interview, questionnaires • systematic direct observations in the home; good levels of inter-observer reliability achieved

14. Settings for home observation Aim- to sample parent & child behaviour in a range of everyday situations • Child watches brief video, has to switch it off • Child & parent play with toys • Parent gets child to clear up toys • Child play skittles game • Parent gets child to clear up skittles • Parent busy filling in questionnaires

15. Outcome measures:i) child problem behaviour • Parent questionnaire (to main carer): Eyberg Child Behavior Inventory (ECBI; Robinson et al,1980) • Direct observationof behaviour in everyday situations, e.g. non-compliance, negative & aggressive behaviour, independent play (Gardner, 1987,1989; 2000). • Semi-structured interviewre conduct & hyperactivity: Parent Account of Child Symptoms (PACS; Taylor et al,1986)

16. ii) Parenting skill, confidence & well-being Direct observation at home: • Parent-child conflict • Parent negative behaviour; negative commands • Parent- child positive interactions (joint play, talk, praise, positive discipline; Gardner,1994;1999; 2002). Parent questionnaires • Parenting Scale- (discipline style & techniques; Arnold, O’Leary et al, 1993) • Parent Sense of Competence (PSOC; Johnston & Mash, 1989) • Beck Depression Inventory (Beck, 1972)

17. iii) Effect on family relationships Parent questionnaires: • Sibling behaviour problems: Eyberg Child Behavior Inventory (parent report on sibling causing most concern) • Effect on relationship with partner: Dyadic Adjustment Scale (DAS; Spanier, 1976)

18. iv) Parents' satisfaction with intervention Therapy Attitude Inventory, TAI (Brestan, Eyberg et al, 1999). 10 items: How much liked the intervention How much change in child’s behaviour Satisfaction with skills learned

19. Analysis strategy • To compare the two randomised groups, Intervention & Control, at ‘post intervention’ (time 2), controlling for time 1 differences in variables one way ANCOVA; non-parametric t-test on change scores for skewed variables; (regression models of change using standardised residuals) • Intention-to-treat design - include all families allocated to intervention, irrespective of uptake. • At 18m follow up (time 3), randomised comparison is no longer possible, as both groups, have been offered intervention by then.

20. Initial family demographic data • Boys 74 % • Single parent 47% • On benefits 64% • Manual job / no job 66% • Poor neighbourhood 65% • Parent depression 69% • Mod-severe depression 45% • Mean age of child 6 years • Mean child problem score 22 (cutoff 11; norm 5-7) No significant differences between intervention and control groups on these measures

21. Research numbers • 76 families recruited • 44 in Intervention and 32 in Control group • 93 % retention after 6 months • 90 % retention after 18 months (similar in group I & C) • Observational data available on 93 % • Slight variation in numbers for some measures Group attendance numbers - Intervention group 73 % attended at least 7 sessions of 14 15 % attended 1-6 sessions 12 % attended none

22. Findings 1:Child problem behaviour Found significant intervention effects on: • Parent report of child problem behaviour • Observed child non-compliance and negative / aggressive behaviour • Observed child independent play • Interview measure of child hyperactivity But – no effect on interview measures of conduct problems

23. Significance level p = .01Effect Size 0.48 (medium)

24. Significance level p = .006Effect Size 0.71 (large)

25. Significance level p = .06Effect Size 0.46 (medium)

26. Findings 2: Parenting skill, confidence & well-being Found significant intervention effects on: • Parent sense of competence – especially ‘efficacy’ • Parent-reported parenting skills • Observed parenting skills (parent-child conflict, negative commands, vague commands) • Observed positive parent- child interactions (joint play, talk, praise, positive discipline) • Some effects on harsh parenting But- parent depression did not improve significantly

27. Significance level p = .026Effect Size 0.62 (large)

28. Significance level p = .01Effect Size 0.45 (medium)

29. Significance level p = .009Effect Size 0.73 (large)

30. Significance level p = .04Effect Size 0.50 (medium)

31. Findings 3: Effect on family relationships Found intervention effect on worst sibling’s behaviour problems (Eyberg) p = .026, Effect size 0.53 (medium) But no effect on relationship with partner (Dyadic Adjustment Scale) NB Numbers much smaller in both cases.

32. Predictors of change 1 (For whom?) These analyses are highly speculative as the Ns are small. Do any kinds of families respond particularly well or badly to the intervention? (multiple regression models) NO - all appear to be equally likely to do well • Lone parents • Parents on benefits • Families with younger vs older kids • Families with more difficult kids - these factors do not predict outcome

33. Predictors of change 2: very preliminary data on process measures Does change in parenting predict change in child behaviour? (from time 1 – time 2, intervention group only; all) Found: Increase in observed positive parenting predicted improvement in child non-compliance; r =.34, p = .04 Change in negative parenting was a less strong predictor of outcome. Parents sense of confidence did not predict outcome- suggests that change in skill more important. Cautious re small sample.

34. Consumer satisfaction: scores on Therapy Attitude Inventory, TAI Intervention group Appraisal of group 91% liked group Behaviour change 75 % felt behaviour problems had improved 97 % felt they had learned useful skills Effects on family 88 % felt group helped with other family problems

35. Parents' qualitative comments: "Is there anything else you would like to to tell us about your experience of the parenting groups?” • Good to hear other parents' problems, how dealt with them, felt not alone • Other parents a support • Staff very good, encouraging, approachable • Enjoyed it • Behaviour improved

36. Some quotes • My life with my children is so much better I wish I would have done it years ago! • I found I could relate to other people's problems, & not feel alone. We all got on well with each other as a team. • It helped me have a much better relationship with my child and also learnt me how to do things better. • Having suffered from depression since my teens these groups give a lifeline to parents to know that we are doing a great job & there is no set standard to being a parent. • I found them quite refreshing, knowing that I wasn’t the only one with problems. And it made mine less of one! Leaders were so nice and approachable. I do feel I have benefited and more confident, in my dealings with my children!! Although far from perfect!!.

37. Summary Intervention appears to improve many important aspects of parent child relationship: • Child behaviour problems; sibling behaviour • Child independent play • Parenting skill and confidence about their parenting - including conflict, negative and positive parenting; style of instructions (but - little effect on depression) • Change in child problem behaviour predicted by changes in positive and negative parenting Important to note that improvements: • Maintain at 18 month follow up • Apply across whole range of families • Found not just from parent report, but from assessment by independent observers.

38. Some policy implications Findings of FNN trial suggest that possible to provide high quality evidence-based interventions for children showing antisocial behaviour problems: • In voluntary sector • In local community settings • With non-specialist staff - well-trained & supervised • For families with high level of need Evidence from US settings appears to be applicable here Families, funders, taxpayers deserve interventions that ‘work’

39. Challenges for good quality, Evidence-Based practice • How to train and disseminate more widely yet maintain quality? • Funding for high quality work • Why so much evidence and so little use of it? • Threat to established practice • Limited understanding of what is good quality evidence