Transcript Birmingham Brighter Futures Intervention evaluations Data

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
[email protected]
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Overview
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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
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Conduct Problems: Symptoms or
Behaviors
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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
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What factors contribute to
onset of conduct
problems????
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Risk factors for conduct disorder
Parenting factors
•Harsh and ineffective
•Poor monitoring
•Low stimulation
Child factors
•Poor conflict control
•Impulsivity, ADHD
•Learning delays
•Poor social skills
School factors
•Classroom aggression
•Deviant peers
•Poor teacher response
•Peer rejection
Conduct
Problems
Contextual factors
•Poverty
•Parental crime, substance
abuse or mental illness
•Life stressors
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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
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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
(ONS Survey, Green et al., 2005)
8.1
5.1
6.6
All ages
(ONS Survey, Green et al., 2005)
7.5
3.9
5.8
Disadvantaged areas
(Attride-Stirling, et al., 2000)
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Looked after children
(Tapsfield & Collier, 2005)
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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…..
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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
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DVD puppet clip
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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
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Wellbeing
Definition by NICE (http://www.nice.org.uk/Guidance/PH12/Guidance/pdf/English)
• 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
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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.
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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
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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)
PARENT PROG DVD CLIPS
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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?
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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)
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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 followups, all 6 months apart
• Saw control families at baseline and follow-up 1
then offered the intervention
• Measures were administered at each time point
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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?
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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?
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What should we measure?
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Measures
1. Personal Data and Health Questionnaire (PDHQ, Hutchings, 1996)
2. Socio-economic disadvantage (SED 6; Hutchings, 1996)
3. Index of Major Life Events (Oxford University)
4. Beck Depression Inventory (BDI; Beck et al., 1961)
5. Parenting Stress Index/Short Form (PSI/SF; Abidin, 1990)
6. Eyberg Child Behavior Inventory (ECBI; Eyberg & Ross, 1978; Eyberg, 1980)
7. Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997)
8. Conners Abbreviated Parent/Teacher Rating Scale (Conners, 1994)
9. Kendall Self Control Rating Scale (SCRS; Kendall & Wilcox, 1979)
10.Social Competence Scale – Parent (Fast Track Project)
11.British Picture Vocabulary Scale (BPVS-II; Dunn, et al.,1997)
12.The Parenting Scale (Arnold, O’Leary, Wolff & Acker, 1993)
13.Service Utilisation Questionnaire (Chisholm et al., 2000; Beecham, 1995)
14.EQ-5D Health-Related Quality of Life Questionnaire (Kind et al.,1995)
15.Dyadic Parent-Child Interaction Coding System (DPICS; Eyberg & Robinson, 2000)
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DPICS
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Me a n fre que ncy s core s
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Co n d it io n
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in t erv en t io n
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c ont r o l
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Tim e
Figure 1. Observed Positive Parenting in 30 minutes
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DPICS
Positive pa re nting me a n fre que ncy
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T IME
Figure 3. Observed positive parenting behaviours in 30 minutes
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Eyberg
Figure 2. Eyberg Child Behaviour Problem Scores
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Long term Sure Start data
Summary of Main Outcomes
Observational findings:
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Intervention parents use more positive parenting, less critical
parenting
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Children are better behaved
Parent report findings:
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Parents perceive their child as having fewer problem behaviours
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Child behaviours are less intense
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Reduction in parental depression & stress,
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Increase in parent skills/comptency
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Reduction in child hyperactivity, conduct problems, increased social
competence and self control, sibling improvements
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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”
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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, 678 - 682.
• 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, 318-324.
• 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.
Toddler Programme Research
• Aim: To evaluate the
effectiveness of the 12-week
Toddler Parenting Programme
with a group of parents with
Toddlers aged 12-36 months
• Participants: 103 families
randomised on a 2:1 basis; 70
Intervention and 33 Control
• Service staff were health
visitors and child care
practitioners
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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
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One family – 10 years on…
• Pre
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Terrorised family
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Controlled the family
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Ran away constantly
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Wouldn’t get on school bus –
Swearing, shouting, lying –
School work terrible
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Threatened sister with knife
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Burnt his sister
Tried to set fire to school
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
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DVD of effective parenting
strategies – praise & shaping
behaviour
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Foster Carer Trial
• 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
Funded by WORD, collaborating with CEPhI & 3 LA Children Services, supported
by NWORTH
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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).
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The Carer Satisfaction Questionnaire
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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”
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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:10.1111/j.1365-2214.2010.01155.x
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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
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
School DVD clip
cooperation
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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
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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).
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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
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Outcome Measures – 3 time points
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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
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Teacher completed:
– Teacher Stress Inventory
– Teacher background
– Teacher SDQ (screening tool & primary outcome measure)
– Attendance levels (plus attendance for teacher)
– Academic Attainment
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Child:
– Wally Problem Solving Task
– Observation of behaviour relating to core programme components
– Programme satisfaction ‘questionnaire’
– Friendship levels
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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
Implementation Fidelity
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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?
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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
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• 100 children = £1, 700 000/year
Recent Government initiatives to
support families & children
• 2001 - 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
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Why WAG have chosen to develop IY in Wales
1. They have an evidence base in Wales.
2. 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.
3. They teach social skills and problem solving alongside strategies
to reduce problem behaviours.
4. The programmes have demonstrated long-term outcomes
5. The programmes are for parents, children and teachers so enable
co-ordination across agencies
6. Tackle barriers to access
7. Fidelity – IY has checklists, training, accreditation processes
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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
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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
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Lessons Learned to inform Policy & Practice
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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
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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!
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Diolch yn Fawr and thanks for listening!
For further information on the research please contact me on
01248 383845
[email protected]
For information on training, conferences, availability on parent
programmes please contact Dilys Williams on 01248 383758
[email protected]
Or access
http://www.incredibleyearswales.co.uk