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The Effectiveness of Interventions to Address Health Inequalities in the Early Years: A Review of Relevant Literature

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CHAPTER FIVE: PARENTING EDUCATION AND SUPPORT - EARLY YEARS

5.1 Introduction

'Parenting support' is a wide term. What may be supportive to one parent may not be supportive to the next and, within any society, parents are starting off from different places, and will encounter different sets of circumstances that will help or hinder them as they progress through the parenting life course. An additional problem, as noted by Moran et al (2004), is that, while most parenting support initiatives concentrate on parents' knowledge, perceptions of parenthood and their relationship with their child and partner, few are able to tackle directly the background to many parenting problems, such as poor housing, poverty, inadequate education, lack of community integration.

5.2 Child outcomes: emotional and behavioural development

Most of the literature concerning the ways in which parents can be supported in changing emotional and behavioural outcomes for their children focuses on their role in reducing non-compliant or antisocial behaviour (Moran et al, 2004). The early manifestation of behavioural problems (typically beginning at two or three years) is known to be linked to conduct disorder in later life. Studies suggest between 7% and 20% of young children meet the clinical criteria for externalising conduct problems such as Attention Deficit Hyperactivity Disorder. The highest rates are found in families who are:

  • on a low income or unemployed
  • lone-parent
  • without educational qualifications
  • living in social sector housing.

Parenting and family interaction factors are estimated to account for as much as 30-40% of the variation in child antisocial behaviour (Asthana and Halliday, 2006).

5.2.1 Summary of the international evidence base on parenting education and support - behavioural interventions (Asthana and Halliday, 2006 and Moran et al, 2004)

  • Most parent training programmes aimed at parents of very young, pre-school children have been developed as downward extensions of programmes specifically developed for school-age children. Greater consideration needs to be given to influence of developmental or maturational changes when tailoring parenting programmes to younger age groups. However, Webster-Stratton's Incredible Years programme (see below) is appropriately designed for toddlers and preschool children, has been demonstrated empirically to improve children's behaviour and to be cost-effective
  • Group based-programmes can improve the emotional and behavioural adjustment of children under the age of three. However evidence for the maintenance of this improvement over time is not significant, and follow-up data are limited
  • Parent education programmes can improve the behaviour of pre-adolescent children who have behavioural problems. However, interventions have tended to be implemented and evaluated in medical environments, and much of the research has been conducted in the US. Effects are sustained, but not universal - parents who typically continue to experience difficulties are single parents, those suffering from maternal depression, alcoholism or drug misuse and of a low socio-economic status. Similar attributes apply to attrition rates from parenting programmes and are likely to depress initial uptake. This suggests that even when initiatives target people at greatest disadvantage; it remains difficult to engage those in most need. The effects for participants can, however, be quantified in terms of long-term benefits to the individual and society. Evidence indicates a return on investment measured in terms of downstream health costs and (in particular) costs to the criminal justice system, education and welfare services
  • While both individual and group-based programmes are effective, there is some evidence that group-based programmes may be more cost-effective than individual clinic-based training, as well as providing parents with peer support
  • The involvement of both parents and direct work with the child increases efficacy
  • Additional interventions have been included alongside parent training to increase the effectiveness of parent programmes for parents of preschool children. For example, tackling family problems such as marital conflict and parental depression in addition to child behaviour problems has resulted in improved child outcomes, as shown by research using the enhanced Triple P programme (see below).

Summary: what do we know about the impact of parent education and support on child outcomes?

  • Parent education programmes can improve the emotional and behavioural adjustment of young children and the behaviour of pre-adolescent children who have behavioural problems. However, there is currently little evidence that improvements are maintained over time
  • Effects are not universal and the most disadvantaged families are least likely to benefit (because of the problems experienced by parents themselves and/or because they are least likely to become, or to remain, engaged with the programme). This suggests that even when initiatives target people at greatest disadvantage, it remains difficult to engage those in most need
  • There is some evidence that group-based programmes are more cost-effective than individual, clinic-based training, as well as providing parents with peer support
  • The involvement of both the mother and father, and direct work with the child increases efficacy
  • Tackling family problems, in addition to child behaviour problems, has resulted in improved child outcomes
  • However, much of the research to date has been conducted in the US

5.3 Parent outcomes

Parenting skills training is an aspect of parenting support that is relatively well researched, and there are a considerable number of reviews on this topic. This section of the paper summarises Moran et al (2004) in categorising the research evidence around the outcome categories of parenting skills, parenting attitudes, parenting knowledge and parent mental health.

5.3.1 Parenting skills

Interventions typically take the form of a structured course of sessions, are usually between 6 and 12 weeks in length and most take place outside the home setting, often in a community venue. Three sets of skills are commonly targeted by parenting support interventions, since these skills are thought to be associated with better outcomes for children as they develop:

  • Supervision and monitoring - a number of studies have shown that effective supervision acts as a protective factor against the development of antisocial behaviour in young people
  • Boundary setting and discipline - harsh or erratic discipline has been linked with poor short and long-term outcomes for children, including increased aggression, later antisocial behaviour, and poor mental health
  • Communication and negotiation - such skills may help children resist the potentially damaging effects of peer-influence and promote reflective decision making in young people

The known effectiveness of parenting skills programmes

  • Most reviews agree that there is now a relatively extensive body of evidence attesting to the effectiveness of parenting skills programmes and suggesting that boosting specific parenting skills is strongly associated with good outcomes for both parents and children
  • Parents tend to report high satisfaction with having attended a parenting skills intervention, to express a sense of enhanced wellbeing or enjoyment of parenting afterwards and to report they have learned useful things and have implemented changes in the way they interact with their child that has eased pre-existing problems.
  • Parents respond well to being taught specific skills to use in specific situations and receiving practical, take-home tips
  • Where group-based methods are used, parents appear to draw comfort from learning that others face similar situations
  • In the short term, both quantitative and qualitative studies show that parents report general enhancement of skills across a range of dimensions; but most studies collate only short-term impact data from parents
  • The few studies that have collected follow-up data on parent outcomes report sustained improvement in parenting skills for at least one to two years following the programme, although these studies also report high rates of premature dropout
  • Many parents fail to engage with the programme in active ways, and thus cannot reap the full benefits: how the programmes are implemented appears to be critical to their success
  • Up to 40% of parents continue to report substantial difficulties with children after the termination of the programme. Factors that may predict negative outcomes include:
    • Socio-economic situation of the family at referral - poorer families do less well
    • High levels of family dysfunction
    • Severity of child's externalising behaviours at the time of referral

Suggestions for future research (Moran et al, 2004)

  • Children's perceptions of changes in parenting as a result of participation in the programme
  • As ideas about good parenting skills may vary by ethnicity, social class and sex of parent, it would be useful to focus on how well varying types of interventions serve different groups in the community
  • Properly controlled longitudinal studies are required to assess the long-term impact of programmes

5.3.2 Parenting attitudes and beliefs

It is possible to distinguish between interventions (or parts of interventions) aimed at concrete aspects of parenting skills (as above) and those that focus on parenting attitudes - how parents feel and what they believe about their parenting (beliefs about child behaviour and development, perceptions of their own competence and ability to cope, general confidence and enjoyment in parenting).

There have been a number of reviews of the efficacy of cognitively based approaches, mostly coming from the US; in particular Parent Effectiveness Training ( PET) and Systematic Training for Effective Parenting ( STEP). Both these programmes rely heavily on verbal and written methods of training, usually in a classroom style format, with 'teaching' led by a trained facilitator intermixed with less formal discussion amongst group participants.

Known effectiveness of cognitively based programmes

  • In general, research indicates that these programmes do have benefits for parents (measured by parent self-report)
  • Meta analysis of 26 PET programmes suggests that effects can persist for up to six months, although the number of studies employing follow-up measures was relatively few.
  • Although both PET and STEP have been implemented with socially and economically disadvantaged families (in the US) there does not appear to be any specific evidence that these programmes are effective for the most deprived populations
  • As the programmes focus on thinking and talking rather than 'doing,' they do not seem especially appropriate for parents who themselves have high levels of family problems, or whose children are displaying more serious behaviour problems
  • Conclusions of effectiveness are limited by a paucity of well-designed studies that meet rigorous scientific criteria
  • Greater exploration is required of alternative formats or approaches that could work effectively with higher risk families to alter parenting attitudes and, ultimately, impact on child outcomes

5.3.3 Parenting knowledge

This third group consists of interventions focused on improving or extending parents' understanding and knowledge about child development, child care and child health. This type of approach may form a distinct part of a wider programme of parenting education/support, or may operate as a discrete intervention in its own right.

These approaches assume that improving parents' understanding of how children think, grow and develop will enable parents to tailor their own responses and behaviours towards their children more appropriately. They may then be better equipped to care for their children's physical needs (for example, protecting them from injury and health problems) or better informed about aspects of children's emotional, psychological and social development.

Moran et al (2004) note that research among parents themselves (including specific studies among families in deprived areas) shows that many parents express a need for both factual information and advice about a diversity of issues that arise in the course of normal family life.

Knowledge-based parenting programmes have been widely offered in many countries both as universal and targeted services. Frequently they have been targeted at particular need groups, especially adolescent mothers. The structure and intensity of these interventions ranges widely, from audio-visual materials made available in public places, to short information sessions and other low-level, time-limited programmes for groups of parents, to more intensive, formal services offered to groups or single individuals over a standardised time frame and working to a set curriculum.

Known effectiveness of knowledge-based parenting programmes

  • Factual knowledge and understanding of child development and child care issues can certainly be enhanced in the short to medium term through services of this kind, for parents of all types and ages, and some 'less complex' parent behaviours may also be influenced
  • Most studies that use a pre- and post-test methodology show statistically significant gains in knowledge following the intervention, and some show self-reported changes in behaviours
  • Few studies were able to make robust measures of actual changes in behaviour, and almost all rely on self-report rather than independently verified observations, but there are some indications that interventions like these can change behaviours
  • Although all types of parents have been shown to benefit, the more 'marginalised' the group, the greater the gains
  • Men and boys may benefit less from these kinds of intervention than women and girls.

Suggestions for future research

  • The extent to which gains in knowledge translate into measurable change in both parenting and child behaviours
  • Whether promising low-level interventions can achieve the same results more cost-effectively than longer, more intensive designs
  • Possible differences in effectiveness for men and boys as compared to women and girls, and the mode of intervention best suited to each sex
  • The extent to which benefits persist in the medium to long term
  • Whether follow up programmes and booster sessions could enhance effectiveness
  • Whether programmes like this can achieve measurable change in outcomes for children
  • The extent to which these types of approach 'add value' in integrative interventions combining information giving with other types of parenting support

5.3.4 Parenting mental health

Though the prevalence of mental health problems amongst the general population of parents is unknown, a systematic review of large scale epidemiological studies confirms that common ('neurotic') mental disorders are significantly more frequent in socially disadvantaged populations (Fryers et al, 2003). Scotland's own national ' Well? What do you think?' survey highlights strong links between mental disorder and level of income, ease of managing on income, and whether or not people live in a deprived area (Braunholtz et al, 2007) Work by Gould (2006) to estimate the prevalence of mental disorders among parents in England and Wales, notes the particular vulnerability of lone parents and people who are dependent for their income on social security transfers.

There is now a clear body of evidence indicating that parents with poor mental or emotional health often cope less well with the demands of parenting, and that this can have measurable adverse effects on children's wellbeing. Poor maternal health has been shown to adversely affect children's attachment (Stein et al, 1991), and long-term emotional and mental health (Rutter, 1972). More recently, it has been shown to be predictive of the persistence of children's mental health difficulties (Meltzer et al, 2003; Buchanan and Ten Brinke, 1997), and is associated with high levels of both physical and behavioural problems in children (Ghate and Hazel, 2002).

Most programmes are medium duration (eight to twelve weeks) and the content varies enormously, from discussion groups to formal educational training, including structured training in specific therapeutic techniques such as rational emotive therapy.

In summarising the evidence on programmes with a primary focus on the general emotional wellbeing of parents, Moran et al note that they do not include programmes that specifically aim to treat mothers with post-natal depression, or interventions for promoting better mental health among adults generally, some of whom will be parents.

Known effectiveness of interventions addressing parents' emotional and mental health

  • Much of the evidence cited by Moran et al is based on individual studies relating to a variety of types of intervention, so it is difficult to take messages about their effectiveness
  • Although feedback from participating parents may indicate 'feeling helped' by an intervention, this does not necessarily result in a measurable improvement in other types of outcome
  • A systematic review of RCTs, assessing the effectiveness of parenting programmes aimed at improving maternal psychosocial health, concluded that a number of different approaches have been shown to be effective, although many focused on interventions for parents of children with severe behaviour or health difficulties. However, a diverse array of parenting programmes were found to be successful, indicating that perhaps common 'process' factors in the delivery of programmes may be a more important factor influencing effectiveness than any one theoretical approach
  • Newpin is the best known UK example of interventions that offer support for parents with young children who are experiencing emotional difficulties. Newpin offers an initial home visit, followed by attendance at local centres, where befriending by volunteers as well as therapy and training are on offer. On the basis of available evidence, Newpin appears to make a significant difference to the mental health of some clients, but more rigorous evaluation, using matched comparison groups, is required. (At present, Newpin does not operate in Scotland)

Suggestions for future research

  • Work to address the precise components of service delivery that influence the success of the diverse range of programmes on offer
  • Further exploration of interventions that reduce risk for postnatal depression
  • Work to address the mental health needs of fathers, parents from different ethnic groups and deprived social backgrounds, and how to support them
  • Focus on long-term outcomes

Summary: what do we know about the impact of parent education and support on parent outcomes?

Parenting skills

  • Programmes have been shown to be effective: boosting specific parenting skills is strongly associated with good outcomes for both parents and children
  • Parents report enhanced wellbeing and enjoyment of parenting following the intervention
  • Parents appreciate a practical approach to learning specific skills
  • Parents draw comfort and support from their peers in group programmes
  • How programmes are implemented appears to be critical to their success: it is important that parents engage actively in order to reap the benefits
  • The most disadvantaged parents tend to experience the most negative outcomes
  • Few studies have collected follow-up data on parent outcomes, although there is some evidence of improvements being sustained for up to two years
  • Specific gaps in the evidence base are:
    • children's perceptions of changes in parenting as a result of the programme
    • how well varying types of intervention serve different groups in the community
    • assessment of the long-term impact of programmes

Parenting attitudes and beliefs

  • Research indicates that programmes have benefits for parents (measured by self-report)
  • Few studies have collected follow-up data, but effects have been shown to persist for up to 6 months
  • There is no evidence that the major cognitively based programmes are effective for the most deprived populations, and they may not be appropriate for parents in the most distressed circumstances
  • Alternative approaches of working effectively with higher risk families to alter parenting attitudes should be explored

Parenting knowledge

  • Factual knowledge and understanding of child development and child care can be enhanced in the short or medium term, for parents of all types and ages
  • Studies show significant gains in knowledge following the intervention, and some show self-reported changes in behaviours
  • Few studies were able to make robust measures of changes in behaviour, but there are indications that interventions can change behaviours
  • The most disadvantaged groups made the greatest gains
  • Women and girls are likely to benefit more from these kinds of intervention than men and boys
  • Future research could usefully focus on:
    • the mode of intervention best suited to each sex
    • better measurement of change in parenting and child behaviours
    • whether low-level interventions can achieve the same results as more intensive designs
    • whether benefits persist in the medium to long term
    • whether follow up programmes and booster sessions enhance effectiveness

Parenting mental health

  • A number of different approaches have been shown to be effective: it appears that common 'process' factors in the delivery of programmes may be more important in influencing effectiveness than any one theoretical approach
  • Future research could usefully focus on:
    • the precise components of service delivery that that influence success
    • interventions that reduce risk for postnatal depression
    • the mental health needs of fathers, parents from different ethnic groups and deprived social backgrounds
    • long-term outcomes

5.4 The National Audit of Parent Antenatal and Postnatal Education Provision in Scotland, 2005

The purpose of the national audit, carried out in 2005, was to explore the nature and pattern of antenatal and postnatal education in Scotland and to make recommendations with a view to promoting the uptake of parent education opportunities. 'Parent education' was broadly defined as 'an intervention delivered with the aim of improving parents' capacity to care for their child …. activities that are offered over and above routine care and support to parents in addition to routine antenatal/postnatal services' (McInnes, 2005).

5.4.1 Literature review

A systematic review of literature published between 1992 and 2003 was conducted to establish the evidence base for interventions, beyond routine care, which aim to change or improve parenting skills (literature relating to interventions delivered in the antenatal period only is discussed in Chapter Two). In 2006, an update of the literature review was undertaken. This sought to include papers published between 2003 and 2006 and included 21 new papers that reported on 16 additional interventions.

The findings relating to post antenatal interventions are summarised here, although it should be borne in mind that much of the literature is likely to have been included in the Asthana and Halliday review.

Interventions delivered in infancy

  • A total of 29 studies were found. Studies were located in a number of countries including England (eight) and Scotland (one) and targeted a range of vulnerable groups ( e.g. teenage mothers, preterm babies, drug users, low income families)
  • Studies addressed a range of outcomes, including knowledge, attitudes, psychological wellbeing, parenting behaviour and coping skills
  • Home visiting had a mixed impact on diverse parenting issues, but education and individualised sleep management planning helped parents cope with unsettled infants
  • A number of interventions targeted mothers who had postnatal depression, or who were at risk of developing it:
    • Community midwives providing individualised care, sleep management planning, counselling and interpersonal psychotherapy appeared to be the most effective techniques
    • Early postnatal debriefing was not successful in reducing postnatal depression

Interventions delivered in both the antenatal period and infancy

  • Fourteen interventions met the review criteria, three of which was based in the UK
  • Most of the studies targeted women at high risk of poor pregnancy outcomes, although two studies in the updated review recruited a relatively advantaged sample and a further two studies involved the partner
  • Outcomes for all the studies varied widely and included smoking cessation, baby walker use, hospitalisation rates, immunisation rates, parenting behaviour, parental mental health and childhood injuries
  • The most effective interventions appeared to be home visiting programmes, although further research is required to identify the specific context in which this can be most effectively employed
  • Telephone support was effective in reducing stress and depression while increasing self-esteem and coping powers
  • An educational package delivered by health visitors and midwives had an n positive impact on the use of baby walkers
  • Leaflets had no effects on the outcomes measured

As noted in Chapter Two, the authors of both literature reviews acknowledged that most of the research was conducted out with the social and cultural context of the UK, and thus generalisability to populations in Scotland may be limited. There were other limitations to the studies, such as measuring a diverse range of outcomes, using assorted methods to deliver the interventions and a lack of evidence for the more vulnerable or excluded groups such as low-income or teenage parents.

No studies explored the views and needs of parents, including vulnerable or hard to reach groups who do not routinely attend antenatal education classes. The author noted that this might reflect the search strategy, designed to identify high quality interventions, but it is likely that research into parents' perspectives has received inadequate attention to date.

Therefore, the conclusion of the author of the updated review highlights the fact that, even taking into account more recent evidence, it is still not possible to improve parenting outcomes by identifying reliable strategies of intervention.

5.4.2 Mapping parent education provision in Scotland

Following the literature review, parent education service provision in Scotland was mapped and the views of professionals involved in the planning, management and delivery of these services was explored. A survey of a random sample of parents was also carried out, to include the views of those at whom services were targeted, and focus groups were conducted with representatives of parents who may not access routine services.

Parent education provision

  • A range of parent education initiatives outwith routine services were available in Scotland (although the majority of service provider respondents were from the central belt)
  • The major focus of parenting intervention was knowledge acquisition, particularly in relation to nutrition, child development, play and relaxation
  • Most of the services offered some sort of peer or social group support and around half provided stress management and assisted parents in accessing other services and benefits
  • Topics were delivered by a variety of methods, with the most popular being group work/workshops, followed by one-to-one interventions, written information and drop in sessions
  • Postnatal services were offered most frequently in the first few months after birth, declining gradually throughout the first year
  • Parent education services were most frequently delivered by health visitors, followed by parents and midwives.
  • A number of providers collaborated with other organisations in the delivery of their services
  • The majority of senior management reported involving users/parents in service planning, although fewer had been involved in decision making or the day to day running of services
  • Parenting services targeted a range of individuals, including mothers, teenage parents, fathers, parents from ethnic minorities, parents with a range of health and lifestyle challenges. Most providers believed they reached some of the target group
  • Only a small number of services had completed any formal evaluation, and those that had were likely to be part of Sure Start Scotland or Starting Well

Views of providers and users on parent education

  • Format of services - service providers offered parent education in different locations, targeted at different people and offered different topics delivered by a variety of methods
    • The majority of mothers found the information they had received at antenatal classes useful, although less than half had received all the information they felt they needed ( e.g. dealing with problems or complications). Those who felt they had been involved in determining content were more likely to be satisfied with how the classes had been run
    • Mothers attending postnatal classes had been more involved in deciding content. Main reasons given for attending were to meet other mothers, get advice on feeding, emotional support and practical aspects of baby care
    • Providers stated that they usually catered for parents' wishes, and recognised that informational support was usually what was required. They believed that emotional support was generally provided by the peer group. Providers expressed some concern that services aimed to promote healthy behaviours, such as breastfeeding, rather than support the parent's decision
    • Providers felt that the most common methods of delivering parent education were also thought to be the most effective ( i.e. group work/workshops, followed by one-to-one sessions and drop-in services)
    • The majority of mothers had received postnatal advice or information, usually as part of routine postnatal care delivered by midwives and health visitors
    • Most parenting services were provided at regular intervals, with a smaller proportion provided on demand. Some were provided as a short course - e.g. six-week block. The need for regular sessions was highlighted as a means of providing security and belonging, keeping clients engaged, building relationships and addressing problematical areas
    • Providers had differing views about who was the 'right' person to deliver the service ( e.g. a person with similar experiences to the client, volunteers or other parents either independently or in co-facilitation with a professional person). Health professionals were not always seen to be the right people, due to different background, potential lack of empathy and different life experiences
    • Parents felt that a lack of uniforms made groups more accessible, although some felt it was important to have professional input and structure to the group.
  • Accessibility of services - because most respondents were based in urban areas, important issues to do with remote or rural accessibility may not have been covered
    • Providers suggested that childcare problems, transportation, timing of services, location, cost of attending, parents' perceptions of services in relation to themselves and other lifestyle pressures could affect participation
    • Providers also noted that lack of motivation, apathy and a lack of understanding of the need for parent education could reduce uptake of parent education services
    • Providers suggested that facilities such as crèche provision, a café and space to take time out might improve attendance
    • Providers felt it was useful to discuss issues in the environment where most of the parenting would take place, and where clients were most relaxed, and thus supported service delivery within the client's home

Weblink to summary report: http://157.203.43.151/uploads/documents/Section1.pdf

Summary: what do we know about parent education provision in Scotland?

Provision

  • A range of parent education initiatives is available across Scotland, although the central belt may be better served than more rural and remote areas
  • Topics are delivered by a variety of methods: group work/workshops are the most common
  • Services are delivered by a range of different professional groups and volunteers (including health visitors, midwives and parents)
  • Users/parents are often included in service planning, although involvement in decision making and the day to day running of services is less common
  • Services target parents facing a range of health and lifestyle challenges and most providers believe they reach some of their target group

Views of providers and users

  • Mothers found both antenatal and postnatal classes useful for practical advice and emotional support, including from other mothers. A need was expressed for more information about dealing with problems
  • Mothers who had been involved in determining the content of classes were more likely to express satisfaction
  • Providers usually catered for parents' wishes and believed that emotional support was generally provided by the peer group
  • Providers expressed some concern that the focus of the education was on promoting healthy behaviours ( e.g. breastfeeding) rather than supporting the individual parent's decision
  • Regular sessions were felt to be important to provide security, keep people engaged and to build relationships
  • Providers had differing views about who should deliver a service and the relative importance of personal experience and professional skills

Accessibility of services

  • Providers felt that a range of issues around accessibility, motivation and understanding could affect participation in classes
  • Providers supported service delivery within the client's home, the environment where parenting is taking place

5.5 Parenting programmes in Scotland

An unpublished literature review carried out by a team from Greater Glasgow Health Board in 2004 aimed to identify and compare the effectiveness of the major parenting education programmes employed in Glasgow (Hacker et al, 2005) The review claims that the five major programmes in operation in the UK are:

  • Triple P
  • Incredible Years
  • Mellow Parenting
  • Veritas/Family Caring Trust
  • NCH

Thirty-eight articles met the review's inclusion criteria, although only two articles related to Mellow Parenting, two to NCH programme and two to Veritas/Family Caring Trust programme. While the majority of studies evaluating the Incredible Years programme and the Triple P programme were considered by the authors to meet a high research standard, no controlled trial design was employed in assessing the effectiveness of Mellow Parenting, the NCH programme or the Veritas/Family Caring Trust programme. Because of this, the review was unable to meet its aim to compare the effectiveness of the individual programmes and, consequently, is less useful than it might have been. In addition, although several of the papers reviewed specified that the intervention was targeted on parents of children with disruptive behaviour, there is no specific reference to the socio-economic circumstances of families included in the studies.

The review did not specifically report the results of using the programmes in Glasgow, and there are also studies from the remainder of the UK that have not been included. Below I have summarised findings from the review, with additional information as relevant. (I have tried to make it quite clear what comes from the review, what does not, and (if appropriate) where I am commenting on the review findings. If possible, I have also included more of an introduction to each of the programmes than appeared in the review.

5.5.1 Triple P programme

The Positive Parenting Programme ('Triple P') is a Behavioural Family Intervention programme based on social learning principles. Originally developed in Australia in the 1970s, and used widely in a range of countries and situations, it is a programme with standardised training and accreditation processes. Delivered to parents and not to children, it works at five levels (from community based to a narrow targeted focus):

  • Level 1: population level for all interested parents of children 0-16 years (promotion of parenting style through media, parenting tip sheets etc)
  • Level 2: brief early intervention strategy for parents of children with mild behavioural/developmental issues. Delivered through primary care services (1-2 consultation sessions, tip sheets, videotaped programmes)
  • Level 3: more intensive early intervention strategy, targeting parents of children with mild to moderate behavioural/developmental difficulties (involves four sessions providing active skills training for parents)
  • Level 4: group or self-directed parent training programme for parents of children with more severe behavioural/developmental difficulties (involves 8-10 sessions of intensive work with parents, offered as three separate delivery approaches)
  • Level 5: enhanced programme, individually tailored. Aimed at whole families with persistent childhood behavioural problems and where other sources of parental family stress are present

The programme is based on five core parenting principles:

  • Ensuring a safe and engaging environment for children
  • Creating a positive learning environment for children
  • Using assertive discipline
  • Having realistic expectations, assumptions and beliefs about the causes of children's behaviour
  • The importance of parental self-care

Triple P is of particular interest because of its adoption as part of the Starting Well Health Demonstration Project in Glasgow (see Chapter Four, Section 4.4). From a policy-making perspective, and particularly in relation to inequalities, the division of 'Triple P' into five delivery levels of increasing intensity is key.

The review included 23 effectiveness studies assessing Triple P, of which 19 were classified as RCTs.

  • The studies reported improvements in children's disruptive behaviour, parent-child interaction, parenting conflicts, relationship satisfaction and communication.
  • Improvements in disruptive behaviour were maintained for up to two years after intervention
  • The intervention was described as effective within a range of settings (standard, self-directed, telephone-assisted, group and enhanced intervention) and with several different family types
  • One factor limiting the quality of the research is the fact that Sanders (who devised the programme) collaborated with most of the reported effectiveness studies, raising questions as to their objectivity.

The review was carried out too early to capture an evaluation of Triple P within the Starting Well Demonstration Project (Cunningham Burley et al, 2006). This work was particularly important because it set out to evaluate the use of Triple P in a Scottish context, as well as its acceptability to staff and parents as one part of the broad Starting Well intervention. However, the focus of the evaluation was on process rather than outcomes. The central research questions were:

  • Is Triple P being consistently and appropriately used with all families within the Starting Well Project?
  • Do Project workers have an understanding of the programme and a belief in its value and efficacy?
  • Do Project workers feel adequately and appropriately supported to deliver Triple P?

Data collection involved interviews and focus groups with a range of Starting Well staff and with parents.

Main findings:

  • There was overall support for Triple P from providers; however -
    • because parent education programmes are not yet 'normalised' within the community, staff felt they had to be careful not to stigmatise families by suggesting Triple P
    • practitioners felt that materials were too Australian and focused on overly affluent families. Materials required adaptation for the Glasgow and Starting Well context
    • practitioners felt that cultural differences between Australia and deprived parts of Glasgow might be stumbling blocks for families and staff
    • delivery of Triple P was affected by health professionals' perceptions of the relative priorities of families and their readiness or ability to receive Triple P
    • there was a view that the families that could most effectively be offered Triple P were those whose lives were more ordered and where there was good relationship between health care worker and parent - i.e. not targeting the most deprived families
    • confidence to deliver Triple P and a strong personal belief in the model were essential determinants of staff commitment to Triple P and influenced whether and how staff delivered the programme
  • Parents who had participated in Triple P groups were generally supportive of the programme, appreciated spending time with like-minded people experiencing the same kind of life difficulties (not just parenting), and were enthusiastic recruiters of other parents to Triple P. However -
    • there was some reluctance to be involved in groups, because of concerns that they would be labelled as 'bad parents' and their perceptions of other group participants as being different from themselves
    • Triple P materials were seen as discrete packets of advice, rather than as part of a different approach to parenting
    • the relative affluence of the parents depicted in the visual materials were more of an issue than the 'Australianess' of the materials

The evaluation concluded that the 'social support' element may be important as a way of encouraging parents to engage with parent education programmes, and to maintain their participation. Parents' discomfort within some group settings may be a production of professionals' scepticism about Triple P and a lack of confidence to work proactively in complex social settings. Training and support for professionals was highlighted as the most pressing task for Starting Well, to ensure staff are confident and enthusiastic providers of Triple P.

5.5.2 Incredible Years Programme

The programme was developed in the 1980s by Carolyn Webster-Stratton, a Canadian educational psychologist with a public health nursing background. The programme is aimed at parents of children aged 1-10 who have early indications of conduct disorder, or are at high risk of developing conduct disorder. It is a behavioural-humanistic programme addressing child behaviour and the parent-child relationship. It was used in the US Head Start programme and has been used in various Sure Start initiatives in Wales. The initiative comprises a number of different interventions involving parents, teachers and children:

  • BASIC Parent Training Program, targeting parenting skills and delivered in the home
  • ADVANCE Parent Training Program, targeting interpersonal skills for parents, delivered in the home
  • EDUCATION Parent Training Program, targeting academic skills for parents, delivered in home and school
  • Teacher Training Program, targeting classroom management skills and delivered in schools
  • Child Training Program, targeting social skills, problem solving and classroom behaviour, delivered in home and school.

The review included nine evaluation studies, of which seven were classified as RCTs.

  • The parenting intervention has been demonstrated to enhance parenting skills (use of praise, limit setting etc) and parental self-confidence
  • The teacher programme has demonstrated an increase of peer- and teacher-child interaction, bonding with parents, and proactive classroom management strategies
  • In relation to children, studies demonstrated an increased use of appropriate cognitive problem-solving strategies and more pro-social conflict management strategies with peers. Children were also reported to be more socially competent and demonstrated a reduction in conduct problems at home as well as in school
  • A limiting factor with this research is that Webster-Stratton (who devised the programme) has collaborated with the majority of the research studies, and therefore that objectivity may have been affected
  • Further research is required to demonstrate that the intervention is effective in targeting a range of children's behavioural problems across settings

The Incredible Years Basic Parent Programme was evaluated in 11 Sure Start areas in Wales, with parents of pre-school children at risk of developing conduct disorder. The evaluation began in 2002. Participating families were randomised to intervention and waiting-list control condition. (This evaluation was not included in the review above. I presume there was some reason why it did not meet the inclusion criteria, but it is a useful piece of work, nonetheless.)

Every attempt was made to ensure fidelity of programme content and delivery. In addition, the Sure Start areas paid attention to issues of access, child care and provision of a family meal. (The Incredible Years programme addresses these issues to encourage high-risk families to engage with services.) The main findings are as follows:

  • At the six-month follow-up, significant improvement in parenting and child problem behaviour was seen on the vast majority of measures for the intervention group only
  • Behaviour changes were robust and maintained up to the 18-month follow up
  • The programme worked equally well across all participating Sure Start areas, regardless of differing crime levels
  • A bolt-on study of cost-effectiveness showed that the parent programme represented good value for money (see Chapter Eight for more detail)

The authors concluded that parent programmes can be effective in disadvantaged Sure Start areas when those who need help most are targeted effectively by knowledgeable health visitors; programmes are implemented with fidelity; group leaders are supervised and accredited; barriers to attendance are addressed (Hutchings et al, 2007).

5.5.3 Mellow Parenting

Mellow Parenting is a 14 week, one day a week group designed to support families with relationship problems with their infants and young children. It combines personal support for parents with direct work with parents and children on their own parenting problems, and has proved effective in recruiting and engaging families with a variety of severe problems.

Mellow Parenting was devised to meet the needs of 'hard to reach' families, particularly where behavioural problems are compounded by family difficulties such as parental mental illness, social isolation, domestic violence, parental literacy problems. It is, in part, a way of working rather than a tightly prescribed curriculum, and variants of Mellow Parenting have been devised to meet varying needs (such as Mellow Fathers, Parenting in Prison, Mellow Babies for Infants at Risk).

Two studies evaluating the Mellow Parenting programme were included in the review. Results indicated that:

  • Intervention improves parent-child interaction, child centredness, mother's mental health and child behaviour problems
  • Programme would profit from more rigorous scrutiny, using research design incorporating a control condition and longer term follow up

The review does not note that Christine Puckering, lead author on both studies, is responsible for developing the programme, so the programme currently lacks independent evaluation. However, the Mellow Parenting programme has the advantage of being developed and applied in deprived populations in Scotland.

5.5.4 Veritas/Family Caring Trust programme

The review gives no details of what this programme involves, and the Family Caring Trust website indicates that it endorses no one model. Two research articles reported that the intervention increased parenting confidence and increased parents' self-esteem, but sample sizes in both studies were small and it is not clear whether the studies evaluated the same intervention. Without more information it is not possible to investigate the approach further.

5.5.5 NCH programme

Again, the review gives no details of what this programme involves, and I have been unable to find any information about it. Two research articles suggested that the intervention improved mothers' attitudes towards their children, and knowledge of behavioural principles. It was not clear whether the described positive outcomes can be maintained over time, as no long-term follow-up study had taken place.

5.5.6 Audit report

An audit report was carried out in tandem with the literature review described above, to establish the range of parenting education programmes in the City of Glasgow by Health, Education, Social Work and Voluntary Sector providers. The report also set out to identify basic demographic features of parents/carers attending the programmes (Hacker et al, 2004). However, the audit's response rate was low (20%) so these results are unlikely to summarise all courses available in Glasgow, or a reliable profile of parents/carers using them. Therefore this is not a comprehensive picture of parenting programme provision in Glasgow, and findings should be treated with caution.

The audit questionnaire required respondents to specify whether they were using one of the five interventions described above or 'other' (for purposes of analysis, a category comprising: a combination of standard approaches, tailor-made interventions, and programmes that were not further specified). I am not sure whether the five interventions are the only standardised parenting programmes whose effectiveness has been measured, and (because of the compressed 'other' category) it is not possible to tell from the audit report whether other such programmes were found. It is unfortunate that the category was compressed, because 'other' was the most frequently employed approach to parenting (54% of responses). Consequently, it is difficult to take useful messages about provision from the responses as reported.

The questionnaire did not specifically ask providers how they targeted the programme/s they were using, although the report includes a summary of to whom parenting programmes are offered (based on questions on ethnicity and involvement of individual family members). The main issues thought to be preventing parents/carers from attending sessions were 'lack of understanding of the reasons for parenting group' and 'lack of interest,' both of which seem to be highly relevant to people in disadvantaged circumstances.

Several of the findings are important, despite the low response rate. At the time of the audit, there was a broad range of standardised and non-standardised parenting education programmes in use in Glasgow. These programmes reflected a variety of theoretical perspectives on child management, including behavioural management training, parenting skill training, cognitive behavioural problem-solving approaches. However, parenting education provision was, largely, both idiosyncratic and non-evidence based, and fewer than half the providers were accredited in the programme they were using. Most programmes were offered exclusively on weekdays in the daytime, making it difficult for working parents to attend sessions. The authors also suggest that lack of interest or understanding of parenting programmes emphasise the importance of destigmatising parenting education. However, as only providers' views were considered, this could not be investigated.

The report acknowledged several limitations to the study, including:

  • lack of focus on the perspectives of the users/potential users of parenting programmes
  • analyses of data were restricted by the questionnaire design
  • the (relatively) low programme drop-out rates (22%) were based on provider self-report only
  • it had not been possible to investigate the 'other' category of provision
  • study did not investigate local pre/post programme measures

One final point in relation to the audit report: respondent identity was protected, and the authors claimed that this prevented individual follow-up of providers. Any measures that might have boosted response rates would have been useful, and it is not clear why confidentiality was an issue, since the intended respondents were professionals answering questions about the programmes they provided. No information was requested that would breach the confidentiality of individuals attending those courses.

An unpublished paper prepared by Rona Dougall of NHS Greater Glasgow and Clyde contains a useful summary of the range of parenting initiatives operating across the UK. It includes an overview of the features of Triple P, Incredible Years and Mellow Parenting and indicates the ways in which these programmes have been evaluated. It is particularly helpful because it indicates that all three are aimed at and/or evaluated with parents of children in areas of high deprivation, and because it focuses specifically on evidence from the implementation of the programmes in the UK. The paper draws heavily on Hacker et al, but does not focus on the limitations of the data. It provides a very helpful summary table, which is reproduced here (with Rona's permission). When it appeared in Rona Dougall's paper, the table included notes linking to various sections of the paper, which I have removed because I have not reproduced the paper. I hope that all relevant issues have been covered in the paragraphs above.

Table 5.1: summary of parenting programmes (Rona Dougall, GGC)

Criteria/feature

Triple P

Webster-Stratton

Mellow Parenting

Comments

Evidence based

Used successfully internationally
e.g.

v

v
Head Start ( USA)

Used in UK
e.g.

Starting Well

Sure Start (Wales)

Community sites, (Scotland)

Published evaluations (positive)

v

v

In progress

RCT evaluations

v

v

Meets NICE guidelines 9 re social learning theory

v

v

v

Includes relationship enhancing strategies

v

Uses humanistic theory

v

Uses family systems theories

v

Population level approach

v

Multi-level

v

Group based

v

v

v

Uptake generally good

v

v

v

Has adaptations for specific situations/groups

v

v

v

Delivered to parents (other family carers)

v

v

v

Includes delivery element to children

v

v

Enables parental self-direction

v

v

Covers 0-16 years

v

v

Covers early years

v

v

v

Evaluated with early years age

v

Addresses families with complex problems

v

v

v

Aimed at/evaluated with parents of children:

with diagnosed conduct disorder ( CD)

v

with high risk of developing CD

v

v

v

in areas of high deprivation

v

v

v

Benefit to siblings shown

v

Follow-up evaluation

v

v

v

6-18months

Personnel

Can be delivered by HVs

v

v

v

Clinical supervision required

Home visits incorporated

v

Can be

Involvement of school teachers

v

Uses video modelling

v

v

v

Uptake good / drop out rates low

v

v

Summary: what do we know about the effectiveness of parenting programmes?

  • Group-based programmes can improve the emotional and behavioural adjustment of young children, although there is limited evidence for the maintenance of this improvement over time
  • Parenting programmes can make a significant difference to the short-term psycho-social health of mothers, although it is not clear that these results are maintained over time
  • Even when initiatives target people at greatest disadvantage, it remains difficult to engage those in most need
  • The effectiveness of two of the five standardised parenting programmes operating in the UK (Triple P and Incredible Years) has been evaluated using a controlled trial design:
    • Triple P (which involves five delivery levels of increasing intensity) was reported to improve a range of behaviours and relationship problems for up to two years after intervention, to be effective in a range of settings and with several different family types.
      • In Scotland, providers felt that Triple P was more effective for those whose lives were more ordered - i.e. not the most deprived families.
      • The possible stigma of attending a parenting programme was an issue for both providers and parents
      • The relative affluence of parents in visual materials was more of an issue for participants than the 'Australianess' of the materials
    • Incredible Years (which comprises a number of interventions and target groups) was reported to enhance parenting skills and parenting self-confidence, along with a range of other positive effects.
      • Evaluated across Sure Start areas in Wales, improvements in child problem behaviour were maintained up to the 18-month follow up
      • Authors concluded that parent programmes can be effective when those who need help most are targeted by knowledgeable health visitors, programmes are implemented with fidelity, group leaders are supervised and accredited and barriers to attendance are addressed
  • The Mellow Parenting programme (which is more a way of working with a variety of needs than following a prescribed curriculum) was developed for and applied in deprived populations in Scotland. Evaluation data is available, and indications are positive, but more rigorous scrutiny and follow up are required
  • It is difficult to extract clear messages from such a diffuse subject area. Evaluations relating to the application of parenting programmes in the UK - and specifically in Scotland - are few, and it is not clear whether findings from countries with different health and social care systems are transferable to Scotland
  • The people responsible for developing Triple P, Incredible Years and Mellow Parenting have been closely involved in the evaluations of the programmes to date, possibly compromising the objectivity of the findings

5.6 Initiatives to promote positive parenting in Scotland

5.6.1 Parenting Across Scotland ( PAS)

PAS is a multi-agency partnership project, funded by the Scottish Government, which aims to:

  • Research the concerns and issues affecting parents and families in Scotland
  • Co-ordinate and improve the information and support available
  • Gain greater recognition for the job parents and families do in bringing up Scotland's children
  • Represent the views of parents in policy

PAS partners support families through the provision of a wide range of services including parenting projects; family centres; family conferencing; relationship support, counselling and mediation.

5.6.2 OK to Ask Gateway Telephone Helpline

The gateway comprises a single entry point through the 'Parentline Scotland' number, which provides an initial 'listening ear' with direct and indirect referrals between participating partners. The pilot ran from April 2006 to March 2007 and was externally evaluated by SMCI Associates. I was unable to access a full evaluation report, but key findings are reported on the PAS website:

  • The peak call month for partners was May 2006 when OK to Ask was launched to coincide with the Family Law (Scotland) Bill
  • Callers, call-takers, helpline managers and strategic staff all thought the gateway was a good idea
  • There was a general lack of clarity over the nature and purpose of the gateway
  • A lack of clear and established protocols led to a degree of mistrust among partners
  • The different opening hours of the partner agencies were identified as problematic

The evaluation made a number of recommendations including:

  • Developing a shared vision for the gateway
  • Reviewing the gateway partnership
  • Facilitating user involvement

PAS identifies the further development of the OK to Ask parent information initiative in the plan of future work (2007-10).

Weblink to report of work undertaken and future plans: http://parentingacrossscotland.org/publications/PAS05-07.pdf

5.6.3 Parent Information Points

In 2006, PAS, with the support of the Scottish Executive, piloted Parent Information Points ( PIPs). The key aim of the PIPs was to 'deliver a universal service, accessed quickly and easily, ensuring that the sessions werepackaged in a user-friendly, non-stigmatising, non-threatening way'. They did this by providing a single two-hour session in a school which focused on one of the three transitional stages. Parents were given an open invitation to attend.

The main features of a PIP session were:

  • a marketplace of representatives of local support agencies;
  • a 'ten top tips' presentation about child development at the relevant transitional stage
  • presentations or workshops from other agencies on subjects relevant to the age group.

The pilot ran from May to November 2006 and the evaluation was completed in February 2007. Four of the five PIPs focused on High Schools, but one focused on a pre-school project.

Key findings:

  • It was difficult to attract parents to Parent Information Points, particularly the parents of teenagers
  • Parents and agencies thought that PIP was a good idea, although having little idea what the session would entail
  • The market place was the most successful aspect of the PIP format, with 100% of parents finding it helpful. Some parents thought that the market place was more useful to their teenage children than to themselves.
  • The workshops were the second most successful aspect of the PIPs for parents, with two thirds (66%) finding them helpful and enjoyable
  • Just over a tenth (13%) of parents said that the best thing about the PIP was meeting other parents.
  • 100% of parents who attended said they would recommend the PIP to a friend. Some parents had already passed information gathered at the PIP onto friends.
  • Participants in general (parents, agencies, pupil helpers) thought there was a good range of information (78%), with 60% saying that the PIP was 'useful', 55% saying that it was helpful and 48% saying that they would come again.
  • 86% felt better informed about support services available to families, with 70% saying that they were likely to use services they found out about at the PIP and 78% of participants in general also felt better informed about the teenage years, with 66% saying that they felt more confident about parenting.

Weblink to summary of evaluation findings: http://www.parentingacrossscotland.org/publications/200707_PIPSPASSUMMARY.pdf

5.6.4 A model for parenting services for Glasgow (draft)

An unpublished draft discussion paper (quoted with permission from lead author Phil Wilson) provides an evidence-based model for parenting services in Glasgow. Naturally, it is outwith the remit of this work to comment on the model, and the document relates closely to the report of the Expert Working Group on Infant Mental Health, (HeadsUpScotland, 2007) but the paper highlights a number of considerations that are likely to be more widely applicable, and chime with the findings of earlier chapters of this paper. The model comprises a number of different levels which span the various age groups (0-3, 3-5, 5-12 and 13-18). Naturally, the approaches within the levels vary between the age groups: here initiatives relevant to the first two age groups are included.

Low cost universal interventions

  • Baby carriers and backward-facing buggies that bring babies into close contact with parents' faces and bodies
  • Baby massage (shown to improve babies' sleep and contentment, as well as lift the mood of depressed mothers)
  • Using opportunities to deliver infant mental health messages using mass media programmes
  • Open access parenting classes delivered to large numbers of families

Active filtering

  • Early intervention to maximise chances of success, because younger, pre-symptomatic children are more likely to be amenable to change than children with entrenched pathology and damaged social relationships - a possible intervention is Mellow Babies (a version of Mellow Parenting aimed at very vulnerable families with infants aged under one year) although more rigorous evaluation is required
  • Health visitor training in the field of evaluating parent-child relationships
  • Routine health visitor contact with families to continue for one year (instead of 8 weeks)
  • Further need for contact from health visitors with all families when the child is in the third year of life (telephone or questionnaire), since early language delay is a powerful indicator of child psychopathology
  • Health visitors to be kept informed about any concerns that GPs or other service professionals have about the child

Additional assessments

  • Robust methods for additional assessments of children and families who give cause for concern to either the families themselves or to the health visitor
  • Structured assessment to include a number of measures focusing on the child, the parent, the relationship and the family (and the possibility of a further battery of measures)
  • A small number of health visitors (perhaps one per Community Health and Care Partnership) to receive 6 months' training to become proficient in using all the tools

Interventions

  • The Incredible Years programme (where the child is between 3 and 5 years)
  • The Triple P programme for children under 3 years (at least until the Incredible Years initiative is modified for use in younger children
  • For families with additional needs, a more intensive intervention may be needed. The Mellow Parenting programme is one such approach, although further evaluation of the programme is required
  • Support may be necessary to enable vulnerable families with additional needs to use these programmes (child care, transport, accessible venues)

Summary: promoting positive parenting in Scotland

  • Parenting Across Scotland ( PAS) is an example of a multi-agency partnership project which aims to research the concerns and issues affecting parents, and the support available, to share good practice, represent the views of parents in policy and promote a positive image of parenting.
  • OK to Ask provides a gateway approach to parent helplines. Evaluation of a pilot in 2006-07 indicated that the gateway was welcomed by all stakeholders, but there was a general lack of clarity about its nature and purpose.
  • Parent Information Points ( PIPs) are single 2 hour sessions in schools designed to provide a marketplace of representatives from local support agencies, a presentation about child development and presentations/workshops from other agencies on subjects relevant to the age group. Evaluation indicates that parents are satisfied with the information they have received from PIPs, but there has been difficulty getting parents to attend
  • A model for parenting services in Glasgow (draft) provides an evidence-based model for parenting services. The model comprises a number of levels:
    • Universal interventions: baby buggy design to bring babies into close contact with their parents' faces and bodies; baby massage; using mass media to deliver infant mental health messages; open access parenting classes
    • Active filtering: early intervention to maximise chances of success; health visitor training in the field of evaluating parent-child relationships; routine health visitor contact to continue for the first year of life; further health visitor contact with all families when the child is in the 3 rd year of life; health visitors to be kept informed about any concerns that GPs or other service professionals have about the child
    • Additional assessments: additional assessments of children and families who give cause for concern (including a wide range of measures); health visitors to receive 6 months' training to become proficient in using the tools
    • Interventions: Triple P programme (children under 3 years); Incredible Years programme (for children between 3 and 5 years); a more intensive intervention for families with additional needs (possibly Mellow Parenting); support to enable vulnerable families with additional needs to use the programmes