Getting Programmes into Systems? Three replication RCTs of evidence-based programmes in a local authority setting Tracey Bywater, Nick Axford, Michael Little, Louise Morpeth, Sarah Blower & Daniel Perkins The Social Research Unit

Overview Brighter Futures Strategy The programmes are we looking at and why? How do we integrate the programmes into systems and get systems ready for inclusion of programmes? Design Results (TBC)

Brighter Futures For Birmingham places the emotional health of the young population on the same level of importance as literacy and numeracy unemployment is twice the national average four times as many one-parent households 37 per cent of Birmingham’s population are under 25 years old and the average age is continuing to fall. half of children (250,000) are from minority ethnic groups and not getting support needed 27% of 8, year olds agreed with the statement ‘I often feel depressed’

The process to develop the strategy is unique in England It is distinctive in five ways: driven by high-quality evidence on the wellbeing of our children Prepared by a multi-disciplinary leadership team of 35 people, supported by 200 practitioners across the city’s children's organisations Perspectives of stakeholders have been taken seriously Strategic advantage is made of government initiatives (eg Every Child Matters) but future policy is not driven only by Westminster a commitment to evaluating the strategy and measuring impact on our children's wellbeing year-on-year.

Common Language approach four concepts: – Outcomes (epidemiology – 6000 children - & ‘what works’ evidence) – Activities (perspectives of key stakeholders, evaluation planning) – Inputs (Investments) – Outputs (support from key constituencies, national policy)

Childhood Antisocial Behaviour: a growing political issue increasing in numbers, about 10% of children in Britain and USA but as many as 35% in high risk disadvantaged areas resistant to intervention if not treated early if unresolved can predict delinquency, adult mental health problems and/or crime costly to society - health, education & social service costs 6

Recent Government initiatives to support high risk, hard to engage families Sure Start in England 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) Nurse Family Partnership DoH (Olds - 10 Authorities) The National Parenting Academy 7

As part of Brighter Futures Strategy… Birmingham City Council has funded the evaluation by RCT of three evidence-based programmes The purpose of the studies is to establish the impact and cost-effectiveness of these programmes

The Programmes The PATHS Programme (Providing Alternative Thinking Strategies) Incredible YearsTriple P 9

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 and relationship building, praise and rewards must address difficulties in adult relationships or other family problems interventions work best when delivered early 10

The PATHS Programme (Providing Alternative Thinking Strategies) facilitates the development of self-control, emotional awareness, and interpersonal problem-solving skills. enhances the social competence and social understanding of children facilitates educational processes in the classroom. 11

Making programmes ‘system ready’ - Adapting content of PATHS programme - Developing implementation manuals

Making the system ‘programme ready’ - Staff training and ongoing support - Practising for roll-out - Service design training and Brighter Future events - PATHS head teachers reference group - Regular events - Benefit realisation exercise

Components of 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? 14

Evaluation Questions 1.Do the programmes meet the needs and improve outcomes for children and families who participate? 2. Are the programmes implemented efficiently and effectively with fidelity? 3. Do the programmes offer value for money and net benefit to the Council, Government, society, children and families? 15

Design IY = 162, 3-4 year-olds, 2:1 randomisation, parent-child is unit of randomisation, stratified by age & sex, 9 Children Centres, 3 data collection points TP = 144 x 2, 4-6 & 9-11 year-olds, 1:1 randomisation, parent-child is unit of randomisation, stratified by age & sex, 6 areas, 3 data collection points PATHS = 60 schools cluster randomised trial, stratified by size & % FSM, 1:1, Reception & Year 1 classes, 3 data main collection points (Oct, June 2010, June 2011) 16

Measures IY & TP: – SDQ (screening & primary outcome) – social, emotional – ECBI – child behaviour – Arnold & O’Leary – parenting practices – Service use questionnaire – Demographics – Facilitator completed cost diaries & attendance sheets PATHS: – SDQ – child behaviour – Paths Teacher Rating Scale – child behaviour – Teacher background & school climate – Attendance records – teacher & pupils – Academic grades – Observations in class (Oct & April both academic years)

Analyses for behaviour outcomes Parent Programes (see BMJ & BJP papers): – All families will be included in the analysis irrespective of uptake of intervention. We will carry out 2 analyses: an intention to treat analysis and analyses with ‘completers’, ie complete data sets. – We will present the differences between the intervention and control conditions on follow-up scores from analysis of covariance (ANCOVA) of the response, taking account of area, treatment, and baseline response value, age and sex. Effect sizes will be calculated with Cohen’s guidelines – (LT analysis) A linear mixed model command in SPSS was used to perform repeated measures analysis of variance (ANOVA) over time with no assumption of equal variances, using an unstructured covariance matrix, within subjects for time. All time points were compared to scores at follow-up 1 School Based Programme: – Under discussion,

Cost data analysis Parent Programmes (See companion paper in BMJ & BJP) – Using cost (group costs) & clinical data we will compute how much it will cost per point drop on SDQ – Service use frequencies & costs – Modeling to establish any future savings to Birmingham Council School based Programme – Under discussion

Results…. We have none! Hutchings, Bywater, Daley et al., (2007). A Pragmatic Randomised Controlled Trial of a Parenting Intervention in Sure Start Services for Children at Risk of Developing Conduct Disorder, BMJ. doi: /bmj Bywater, Hutchings, 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, BJP. Doi: /bjp.bp Edwards, R.T., Ó Céilleachair, A., Bywater, T., Hughes, D.A., & Hutchings, J. (2007). Parenting Programme for Parents of Children at Risk of Developing Conduct Disorder: Cost-Effective Analysis. BMJ, doi: /bmj Sanders, M. (2008). Triple P-Positive Parenting Program as a Public Health Approach to Strengthening Parenting. Journal of Family Psychology. Berlin, L. J., Ziv, Y., Amaya-Jackson, L. & Greenberg, M. T. (Eds.). (2005). Enhancing early attachments: Theory, research, intervention, and policy. New York: Guilford. Duke Series in Child Development and Public Policy.

Summary To make systems ready for programmes To make Programmes ready for systems To employ RCT with evidenced based programmes to reduce unwanted (risk) behaviour and increase positive (protective) behaviour To inform decision makers To take to scale and support growing numbers of children in Birmingham

What it’s really about…. “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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