Brenda Renz explores the role evidence-based parenting programmes could play in improving outcomes for children and families.
Child development is influenced by many factors. However, a child's relationship with their main care-givers, particularly early in life, is one of the most powerful. We often refer to this influence generally as 'parenting'.
Parenting involves a complicated set of emotions, tasks and skills. For many parents, this is extremely rewarding, if demanding. Their ability to provide their children with the love, security and boundaries that they need to grow into resilient, happy children, should be celebrated, and measures to constantly strengthen this asset are important. Likewise, support, which is relevant and matched to needs, should always be available for families facing greater challenges.
Evidence-based parenting programmes are important because they aim to ensure that support provided to families is based on sound theory, research and experience of what works best. To do this, they start with a clear outcomes focus and mainly draw on studies which track those aspects of a child's development which are most closely related to healthy outcomes. Early-onset behaviour problems are a prime example, and are the focus of several evidence-based parenting programmes, specifically those promoted by the Psychology of Parenting Project (PoPP) set up by NHS Education for Scotland, to make the best of these programmes available to young children and their families.
While it is natural for most young children to display challenging behaviour by being non-co-operative, highly emotional and behaviourally dysregulated*, approximately 10% of young children have a significantly persistent pattern of elevated levels of aggression, non-compliance and emotional distress (Office of National Statistics 1999). This pattern of early-onset behaviour problems is strongly predictive of numerous long- term negative social outcomes, including school disruption, family stress and dysfunction, mental health problems, loss of employment productivity, social isolation, drug and alcohol problems, and crime and antisocial behaviour. Consequently, children experiencing these difficulties incur high economic, social, and personal costs. One study estimated that the financial cost of an individual diagnosed with a conduct disorder at age ten was ten times higher by the time they were 28, than for those without such difficulties (£70,019 vs. £7,423) (Scott et al. 2001a).
Evidence-based parenting programmes can redirect the particularly risk-laden developmental pathways of many children with early-onset behaviour problems. They produce short-terms gains by immediately improving the wellbeing of many children and their parents. They also contribute to intelligently allocating scarce resources by offering long-term positive outcomes and cost savings.
So what does the term 'evidence-based parenting programmes' mean? Technically, the term refers to structured interventions that have been scientifically proven to work. This definition indicates that we can expect programmes of this nature to be founded on robust theories such as those associated with processes of attachment, human ecology and cognitive social learning, and that we can be sure they have undergone rigorous, systematic and objective scientific procedures to test their impact. We can, therefore, be confident that any beneficial effects are linked to the intervention rather than to chance or to other extraneous factors.
Fortunately, although a highly technical area, it is not necessary to be a research expert as several high-quality summaries are available. An excellent example is the Commissioning Toolkit (www.commissioningtoolkit.org) developed by the former UK National Academy of Parenting Practitioners. This rates over 100 parenting programmes on the strength and quality of their evidence; the quality of training and supervision available; the focus of the content; and the quality of the eligibility criteria.
Such summaries generally respect a 'hierarchy of evidence' within which randomised controlled trials (RCTs) assume a position of priority. RCTs are often referred to as the 'gold standard' of research designs. In these, individuals are randomly assigned to one of at least two different conditions. Care is taken early to make sure that the two groups are similar on several measures such as age, social backgrounds and the types and frequency of problems in question. One group receives the intervention while the other does not. Next, the outcomes for each group are compared. Ideally, this comparison is made by observers who do not know which individuals received the intervention and which did not. The findings are analysed statistically to establish whether any differences between the two groups could be expected to occur by chance.
The most effective evidence-based parenting programmes for children with early-onset disruptive behaviour problems are backed by 30 years' worth of quality research, involving multiple randomised control trials. Positive outcomes include meaningful reductions in problematic child behaviour, and also resilience-building improvements in children's emotional and social skills. They also produce improvements in parental depression and self-confidence. Consequently, these parenting programmes are capable of redirecting the developmental pathways of many children whose long-term outcomes are at risk. Indeed, the best are capable of moving two thirds of such children out of the clinical range after a 12-week parent group intervention.
Long-term studies are demonstrating the preventative impact of these programmes with gains being maintained for at least six years (Drugli et al. 2009). The results have been replicated in several countries, including England and Wales, with similar outcomes achieved in real-world settings (Gardner et al. 2006; Hutchings et al. 2007; Scott et al. 2001b). This UK-based outcomes research is now complemented by cost-effectiveness analyses. One such concluded, [this parenting programme] improves child behaviour (...) at a relatively low cost and was cost effective compared with the waiting list control. [It] involves modest costs and demonstrates strong clinical effect, suggesting it would represent good value for money for public spending (Edwards et al. 2007).
Two parenting programmes rank particularly highly. These are 'Incredible Years' developed by Professor Carolyn Webster-Stratton in USA (Webster Stratton 1991) cited above, and Triple P (Sanders et al. 1999) developed by Professor Matt Sanders in Australia. Tests show they are beneficial in other parts of the UK, and internationally, and are particularly potent when run in early childhood and in group format.
Since many parents may find it difficult to attend weekly groups (which now last for up to 18 weeks), these programmes pay particular attention to the process of engagement with families. In line with best therapeutic principles, they emphasise the quality of relationships offered to parents. One way they achieve their results is through the use of manualised materials to ensure that group facilitators offer the same content to all parents. They also systematically use various structured adult-learning strategies such as collaborative problem-solving, video-modelling, role-play and skills rehearsal to foster parents' self-efficacy.
The importance of positive parenting is represented in Scottish Government strategies and policies including 'The Early Years Framework', 'Better Health Better Care' and 'Towards a Mentally Flourishing Scotland'. It also relates to the Healthcare Quality Strategy and 'Achieving our Potential' and is consistent with 'Getting it Right for Every Child'. Most authorities have strategies for their intentions in this area. With a few exceptions, there is little planning for systematically adopting evidence-based programmes or focus on targeting specific outcomes, particularly reducing early-onset conduct problems. By contrast, much of the support for parents has no empirical basis. The time has come for this to change. The Psychology of Parenting Project is, therefore, a welcome development. Its capacity-building implementation plan, which has already started to be adopted in two sites, offers a real opportunity to improve outcomes for children and families.
Brenda Renz has worked as a clinical psychologist for 30 years and has a long-standing interest in early intervention and parenting interventions. She currently holds two part- time positions, one with Lothian CAMHS and one within NHS Education for Scotland, where she co-leads the Psychology of Parenting Project (PoPP). Brenda is authorised to deliver training and supervision in the Incredible Years parenting programme and co- ordinates a national network of group leaders working with this approach. Since its adoption in Scotland, Brenda has also been involved nationally and within Lothian in developing the Family Nurse Partnership programme.
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