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 Intervention Funded by the Esmee Fairbairn Foundation

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

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.

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?

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

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

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

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

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

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

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

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

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

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

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

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)

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)

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

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.

Initial family demographic data  Boys74 %  Single parent 47%  On benefits64%  Manual job/ no job66%  Poor neighbourhood65%  Parent depression 69%  Mod-severe depression45%  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

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 % attended 1-6 sessions 12 % attended none

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

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

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

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

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

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

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

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

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

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.

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

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.

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

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

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!!.

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.

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’

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