CHAPTER NINE: SUMMARY AND CONCLUSIONS
The Scottish Government is committed to reducing inequalities in the early years and is therefore anxious to investigate the effectiveness of interventions that address a spectrum of issues, from early sexual activity through to the development of confident, secure, healthy school-age children. This informed the discussions of the Ministerial Task Force on Inequalities, which reported to Cabinet in May 2008 and, subsequently, the Government's Early Years Framework.
This paper has been prepared by the Scottish Government's Health Analytical Services Division to:
- Investigate the relevant evidence base and advise policy colleagues of the known effectiveness of specific interventions
- Coordinate relevant information being gathered by colleagues across the Scottish Government and more widely to support policy development and delivery
There is a large body of evidence to suggest that risk for many chronic conditions is set, at least in part, in foetal life or immediately after birth. Foetal growth and development is influenced by under-nutrition, risk behaviours such as smoking and alcohol and maternal stress and anxiety; and a number of risk factors for children's subsequent behaviour and mental health problems relate to pregnancy.
9.2.1 Pregnancy at a young age
What do we know about averting pregnancy at a young age?
- Evidence supports school-based sex education and community-based education, and contraceptive services
- Campaigns to increase condom use can delay initiation and reduce the frequency of sex
- Programmes which offer educational supports linked to improving job prospects may motivate young people to avoid pregnancy
- Parenting programmes and antenatal care programmes can improve outcomes for both teenage mothers and their infants. However, the most vulnerable groups are least likely to engage with educational systems.
- A promising initiative, not yet evaluated in the UK, is the Baby Think It Over programme, in which a young person is given a computerised model baby to care for. However, indications are that the simulator needs to be included in a wider programme of lessons on relationships and personal development in secondary school
- The popularity of computer games offers opportunities to engage young people in games involving the care of young babies
Where is the evidence base weak?
- There is little evidence relating to the UK in general, and Scotland in particular
- There is inadequate focus on early fatherhood
- Interventions tackling broader 'upstream' issues of poverty and disadvantage are currently lacking
- The methodological quality of many existing studies is poor and/or focused on a range of outcomes, making it difficult to draw meaningful messages about the effectiveness of individual interventions
9.2.2 Maternal nutrition during pregnancy
What do we know about improving maternal nutrition during pregnancy?
- There is strong evidence to suggest that certain dietary supplements ( e.g. calcium) reduce risks in pregnancy and preterm birth.
- Maternal nutritional status at the onset of pregnancy appears to be more critical than nutritional adequacy during pregnancy for foetal growth
- Factors such as stress may have a more pronounced effect on foetal nutrition (and hence birth weight) than has been acknowledged to date
- Providing advice and information alone is not enough to change dietary behaviour. The more intensive and direct the intervention ( e.g. as vouchers, provision of food or provision of supplements) the greater the chance of success in improving nutritional status
- There are significant challenges in engaging young, low income mothers-to-be
Where is the evidence base weak?
- Good quality evidence relevant to Scotland is very limited
- There is very little evidence relating to targeted evaluations focusing on particular socio-economic, ethnic or other vulnerable groups, or those subject to multiple risks from smoking, poor diet and negative psychosocial factors
9.2.3 Smoking cessation during pregnancy
What do we know about helping smoking cessation during pregnancy?
- Evidence indicates that multi-faceted initiatives are more likely to be effective than those offering a single service
- Routine contact with health professionals during the prenatal period offers opportunities for intervention that have been under-utilised to date
- Advice and support for pregnant women may not reach, or be acceptable to, those at highest risk
- Increasing support for smoking cessation during pregnancy and the immediate postnatal period may affect breastfeeding rates, so could be a legitimate part of a breastfeeding support programme
Where is the evidence base weak?
- Evidence relies too heavily on self-reported behaviour and does not take into account the different experiences of heavy and light smokers.
9.2.4 Maternal stress during pregnancy
No study has yet evaluated a programme or service designed to reduce maternal stress during pregnancy. However, the Nurse-Family Partnership, described and evaluated in the US and currently being implemented in ten test sites in England, appears promising.
The programme is offered to young, disadvantaged pregnant women. Support includes: parenting and health education; referrals to other services; employment advice; help forming mutual support networks. In general, the programme is delivered by nurse visitors, but an approach using paraprofessionals (who received the same training and provided the same services as the nurses) has also been tried and evaluated
What do we know about the effectiveness of the Nurse-Family Partnership?
- Evidence from randomised controlled trials shows a major impact on life outcomes for socio-economically deprived mothers and their children. The evidence comes from the programme as typically implemented in a low income community
- Children of nurse-visited mothers were less likely to receive health care for injuries and ingestions in the first two years of life
- Although the programme had no significant effect on children's behavioural problems at age 2, a much lower percentage of children of nurse-visited mothers exhibited severe behavioural problems when followed up at 6 years old
- Children of nurse-visited women followed up at 15 years old had experienced fewer arrests and fewer incidents of child abuse and neglect
- Mothers who had received nurse visits experienced fewer arrests and convictions, spent less time on welfare and had fewer subsequent births
- Visits from trained paraprofessionals did not achieve the same effects as the nurse-visiting programme
- The programme is particularly interesting because outcomes for both mothers and children are most promising for the most disadvantaged groups
- This is important evidence of the potential effectiveness of an intensive, antenatal home visiting programme that offers 'multiple' support - as long as that support is sustained during the first years of life
Where is the evidence base weak?
- The initiative has not been evaluated in the UK to date, and it is not clear whether findings are transferable to countries where health services are provided free at the point of delivery. The services received by mothers in the US comparison groups would also be very different from health visiting services in the UK
9.2.5 Antenatal classes
What do we know about the effectiveness of antenatal provision?
- A key issue is the degree to which parents living in disadvantaged areas are able to access the support that is available and whether they feel it meets their needs
- Educational/informational interventions can improve knowledge, but are less likely to have an impact on behaviour or psychosocial wellbeing
- Providing a range of health education, psycho-social and developmental topics in antenatal clinics, and looking at the stage in pregnancy when parents are likely to be most receptive, appears to be a promising approach
PIPPIN This is a UK-based initiative designed to improve and maintain parents' emotional and psychological wellbeing and help them prepare for parenthood. PIPPIN uses a variety of professionals and volunteers to engage fathers as well as mothers. Support begins during the last 3 months of pregnancy and continues until the infant is 3-5 months old. A single, small sample evaluation indicated that the initiative helped parents to enjoy more positive relationships with their babies and with each other.
PIPPIN has received international commendation as an example of excellence.
Where is the evidence base weak?
- Little research has been carried out on the content of antenatal classes
- Little evidence relates specifically to Scotland, or the rest of the UK
9.3 Birth onwards - nutrition, smoking cessation and safety
What do we know about the effectiveness of initiatives to support breastfeeding?
- The evidence base on the initiation and duration of breastfeeding is fairly comprehensive, although research relating specifically to Scotland is sparse
- Multi-faceted interventions, focused specifically on breastfeeding, appear to be the most effective. Interventions should span the ante and postnatal period and draw on repeated contacts with professionals and/or peer educators
- A review of evaluations to support breastfeeding in neonatal units found considerable support for Kangaroo Mother Care ( KMC), with studies consistently demonstrating advantages for the infant in terms of physiological stability, reduced morbidity and improved breastfeeding rates
- Eight actions were identified by NICE on the basis of evidence from systematic reviews:
- support for the Baby Friendly Initiative in maternity and community services
- a mix of education and/or support programmes routinely delivered by health practitioners and peer supporters
- changes to policy and practice to encourage and promote breastfeeding
- clinical care to support mother-baby contact
- peer or volunteer support for mothers in the early postnatal period
- breastfeeding education and support targeted on women on low income
- one-to-one needs-based education throughout the first year
- local media programmes to target teenagers to improve attitudes to breastfeeding
Where is the evidence base weak?
- Little attention has been given to interventions directed at groups where rates of breastfeeding are low
- There is a lack of information on participants' views of interventions
- Large, good quality, studies are needed to evaluate the ways national media campaigns can be used to shift cultural values, so that breastfeeding can be recognised as a cultural norm
- There is a lack of large scale, high quality, UK-based evaluations of the Baby Friendly Initiative
- There is inadequate evaluation of the effects of non-health sector interventions, such as school programmes targeting girls and boys prior to pregnancy
- Little attention has been paid to clinical and emotional problems associated with breastfeeding
- Studies need to include outcomes related to costs for families, employers and health services
- There are a number of methodological weaknesses in studies carried out to date, such as imprecise definition of terms in relation to breastfeeding, and potential confounders ( e.g. feeding intention) not always taken into account
9.3.2 Smoking cessation in the postnatal period
What do we know about what helps smoking cessation in the postnatal period?
- Supporting parents to achieve a smoke-free home environment appears to work better than focusing on stopping smoking
- Smoking bans with widespread public support are a prerequisite for the adoption of smoking restrictions at home
- Early findings from the evaluation of smoke-free legislation in Scotland indicates that there is no evidence of smoking shifting from public places into the home
Where is the evidence base weak?
- Research to date has relied too heavily on self-reported behaviour and has failed to focus on the impact of factors such as socioeconomic status and the different experiences of heavy and light smokers
9.3.3 Maternal and child nutrition in the post-weaning period
What do we know about what works to address maternal and child nutrition in the early years?
- Broad measures to improve income in disadvantaged households, and improve access to cheap, nutritious food, are more likely to be effective than providing information and education about nutrition
- Breastfeeding should be promoted as an integral part of a wider nutritional agenda
Where is the evidence base weak?
- There is a need to focus research on specific vulnerable groups (such as families on low incomes and minority ethnic families) and to consider nutrition as part of a broader, life course issue
9.3.4 Oral and dental health
What do we know about what works to promote oral and dental health?
- It is likely that a combination of approaches (including information, education, promotion of healthy eating options, practical support and free dental checks) will be most effective in reducing dental decay in young children
- Steps to raise awareness and understanding about nutrition more generally will also be relevant.
- Childsmile (West), which targets children at risk of tooth decay from the earliest stages of infancy, is a promising initiative which will be evaluated during its 3 year pilot period
Where is the evidence base weak?
- Given that the most disadvantaged families are the least likely to engage with relevant public health messages, it would be helpful to target research on what helps to engage them and change behaviours
9.3.5 Accidents and injuries
What do we know about what works to prevent accidents and injuries to young children?
- This is one area where single issue campaigns (such as those focusing on safety equipment in the home) can be effective
- Basic modifications to the environment (such as playground design) can reduce the severity and frequency of accidents
- Relatively low cost initiatives to improve road safety can be effective and benefit the whole community, in addition to those who are particularly vulnerable
- Home visiting programmes can reduce rates of child injury in the home, although it is not clear which components of programmes are effective
- Educational programmes alone have little effect
- Interventions that address issues via a range of modes (such as changes to legislation, education, safety equipment and environmental modification) are the most likely to be successful
Where is the evidence base weak?
- The evidence base is dominated by literature from the US and, in general, reports do not provide adequate information to indicate whether findings might be transferable to Scotland
- When considering the effectiveness of initiatives, research needs to focus on the attitudes and habits that underlie many risky behaviours
9.4 Birth onwards - Home visiting programmes
Home visiting has been identified as an important intervention for tackling health inequalities from an intergenerational perspective, and is capable of producing improvements in parenting, child behavioural problems, cognitive developments in high-risk groups, a reduction in accidental injuries to children and improved detection and management of postnatal depression. However, the evidence base includes a number of different approaches, and not all evaluations are positive. This section focuses primarily on individual models operating in Scotland and elsewhere, to highlight the known strengths and weaknesses of each approach.
Sure Start Scotland
This is the main programme in Scotland which supports vulnerable families with very young children. The objectives of the initiative are to: improve children's social and emotional development; improve children's health; improve children's ability to learn; strengthen families and communities. The initiative aims to change and enhance existing services, rather than providing a specific service
What do we know about the effectiveness of Sure Start Scotland?
- The impact of Sure Start has yet to be evaluated in Scotland, but a mapping exercise carried out in 2004/05 found that some Sure Start services had formal evaluations in place and the majority of local authorities carried out formal consultations. Benefits of Sure Start funding include:
- capacity building (in terms of staff and premises) has helped staff to work with harder to reach families as well as improving service quality
- recruitment of local people as volunteers for services
- improvements in joint working between professional groups
- services aiming to serve the hardest to reach groups reported some success (self report only)
- improved child behaviour and development and increased self-esteem of the parent
- The following concerns have been raised:
- demand for Sure Start services outweighs supply
- how to ensure provision of support beyond age three?
- how to balance the needs of the highest priority families with preventative work with other vulnerable families
- support may become intrusive
- In England, a programme of evaluation has found that, where Sure Start is implemented as intended, there is some evidence of effectiveness, but that it is too early to see the expected long-term benefits. To date, the initiative has experienced difficulties reaching and engaging the most disadvantaged families.
This initiative began as a national health demonstration project in Glasgow, focusing on intensive home-visiting support and the provision of a strengthened network of community-based services in two deprived communities. The initiative was implemented through health visitor-led skill mix teams. After the initial phase, the service moved to a targeted approach for those most likely to gain from the interventions. It has now devolved across Glasgow.
What do we know about the effectiveness of 'Starting Well'?
- The first phase of the service has been evaluated, but findings are difficult to interpret, not least because the initiative was implemented differently in the two intervention sites, and the approach was diluted to some extent
- The intensive visiting programme encouraged mothers to trust services
- Better quality information on needs and life circumstances helped in putting together individualised care packages
- Variations in process and outcomes depended on the receptivity of mothers to the service, and health visitor caseload pressures
The Child Development Programme ( CDP) and the Community Mothers Programme ( CMP)
The CDP programme operates throughout the UK and internationally. It offers monthly visits to parents by specially trained health visitors, starting antenatally and continuing for the first year of the child's life. The programme focuses on health, language, cognition, socialisation, nutrition and early education. It aims to develop the potential of the parents, rather than making them dependent on the health visitor.
The CMP programme evolved from CDP and uses volunteer 'community mothers,' who receive training to support recipients of the programme
What do we know about the effectiveness of the Child Development Programme and the Community Mothers Programme?
- Evaluation of the CDP in the UK indicated that empowering parents to take control of the health and development of their children and fostering their parenting skills are fundamental for the success of the programme
- A longitudinal study of the effectiveness of the First Parent Visitor Programme (a variant of the CDP) in the UK was unable to demonstrate an overall advantage over conventional health visiting
- Evaluation of the Comprehensive Child Development Programme in the US found that children's health, ability to concentrate and social behaviour were better, compared with those who received conventional postnatal care, and that they were more likely to have story books at home.
- An evaluation of the CMP in the Irish Republic found that visits from community mothers had beneficial effects on parenting skills and maternal self-esteem, which were sustained over time. The effects also carried through to subsequent children born to mothers, who were more likely to have received immunisation and to have been breastfed.
- In general, it is not clear from the evidence whether outcomes were better or worse for particular groups of families within the communities participating in evaluations of the CDP or CMP and, therefore, it is hard to tell whether the initiatives are effective for the most disadvantaged families
- The CMP is not a costly or intensive intervention and offers benefits to the community volunteers and, potentially, to the wider community as well as to the mothers visited
This is a UK-based volunteer home visiting programme which offers support, friendship and practical help to young families under stress, in their own homes. All volunteers must have experience of being a parent.
What do we know about the effectiveness of Home-Start?
- There is little information about the effectiveness of the intervention in Scotland - an evaluation of the 18 schemes operating in 1998 appears to have relied on survey information and self-reported health improvements
- The volunteers who delivered the scheme were valued as friends who offered practical support
- An evaluation of the costs and outcomes of Home-Start support in Northern Ireland and the south of England found that mothers valued the service, exhibited fewer depressive symptoms at follow-up and were experiencing less parenting stress. However, much of the change appeared to be due to the passage of time and greater experience of parenthood. At follow-up, there were no significant differences in formal service costs between the study and comparison groups, although the receipt of Home-Start services pushed costs for the study group higher than costs for the comparison group.
- The researchers who carried out the costs and outcomes study suggested that the benefits of a community-based initiative, which does not aim to provide a structured, intensive programme, might only be apparent after a number of years
9.5 Parenting education and support - early years
Parenting education and support is a diffuse subject area and it is not easy for policy makers to extract clear messages from the evidence base. Overviews do not tend to isolate effectiveness specifically for the infant or preschool child and confounding dimensions such as gender, ethnicity, family status and race are often neglected. Studies also often fail to discriminate between the contribution of different programme elements such as format, method of intervention, group support or therapists'/facilitators' skills.
What do we know about the impact of parenting 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
Where is the evidence base weak?
- Much of the research to date has been conducted in the US
- Good quality longitudinal research is required to explore whether improvements are sustained over time
- Research needs to focus on engaging and meeting the needs of parents in the most disadvantaged circumstances
What do we know about the impact of parent education and support on parent outcomes?
- 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
- 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
9.5.1 The National Audit of Parent Antenatal and Postnatal Education Provision in Scotland, 2005
What do we know about parent education provision in Scotland?
- 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. They wanted 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
9.5.2 Evidence relating to particular parenting programmes
Three major parenting programmes that have been the subject of evaluation are considered below. All have been shown to be effective, although each has areas of weakness. In addition, it should be noted that the people responsible for developing Triple P, Incredible Years and Mellow Parenting have all been closely involved in the evaluation of the programmes to date, possibly compromising the objectivity of the findings.
The Positive Parenting Programme (Triple P)
Triple P is a Behavioural Family Intervention programme based on social learning principles. Originally developed in Australia, 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). 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
What do we know about the effectiveness of Triple P?
- Studies have reported improvements in a range of behaviours and relationship problems for up to two years after intervention
- Triple P has been found 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 Programme
The programme was developed in Canada and is aimed at parents of children aged 1-10 who are at high risk of developing conduct disorder. It is a behavioural-humanistic programme addressing child behaviour and the parent-child relationship. The initiative comprises a number of different interventions involving parents, teachers and children.
What do we know about the effectiveness of the Incredible Years Programme?
- The intervention has been demonstrated 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
- The programme worked equally well across all participating Sure Start areas, regardless of differing crime levels
- The programme 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 intervention 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. It is particularly interesting because it was developed for use in deprived communities in Scotland and has been adapted to meet varying needs (such as Mellow Fathers and Parenting in Prison)
What do we know about the effectiveness of the Mellow Parenting Programme?
- The intervention improves parent-child interaction, child centredness, mother's mental health and child behaviour problems
- The programme would profit from more rigorous scrutiny, using research design incorporating a control condition and longer term follow up
9.5.3 Initiatives to promote positive parenting in Scotland
Parenting Across Scotland ( PAS)
This is a multi-agency partnership project which aims to research the concerns and issues affecting parents and the support available, by bringing together organisations and knowledge to share good practice and represent the views of parents in policy. PAS promotes a positive image of parenting, in recognition of the commitment that families show in raising children.
OK to Ask
This 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)
Piloted in 2006 through PAS, PIPs were single two-hour sessions in schools which provided:
- 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
One of the five PIPs focused on a pre-school project. The pilot was evaluated and reported in February 2007.
What do we know about the effectiveness of PIPs?
- Although parents and agencies through that PIP was a good idea, it proved difficult to attract parents to attend PIPs
- Parents who attended all said they would recommend the PIP to a friend. Some had already passed information they had received on to others
- The marketplace was the most successful aspect of the PIP format (receiving endorsement from all parents who attended)
- Almost all parents who attended said they felt better informed about the support services available to families
A model for parenting services in Glasgow (draft)
An unpublished draft discussion paper provides an evidence-based model for parenting services in Glasgow. The paper highlights a number of considerations that are likely to be more widely applicable, and chimes with the findings of earlier chapters of this paper. The paper recommends:
Low cost universal interventions: baby buggies and carriers designed to bring babies into close contact with parents' faces and bodies; baby massage to improve sleep and contentment; use of mass media programmes to deliver infant mental health messages; open access parenting classes delivered to large numbers of families.
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 one year instead of 8 weeks and 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: robust methods for additional, structured 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: the Triple P programme for children under 3 years; the Incredible Years programme (for children between 3 and 5 years); a more intensive intervention for families with additional needs - possibly Mellow Parenting, although further evaluation is required; support to enable vulnerable families with additional needs to use these programmes (child care, transport, accessible venues).
9.6 Three to eight years - early years education and childcare
Although there is an extensive evidence base in relation to early years education and childcare, it is often difficult to isolate the effects of non-parental day care from parental training and education. In addition, with a complex mosaic of provision, it is difficult to establish what works, for whom, in what circumstances.
9.6.1 Pre-school education ( EPPE)
The Effective Provision of Pre-School Education ( EPPE) project
This is the first major European longitudinal study of a national sample of young children's development between the ages of 3 and 7 years (beginning in 1997). A wide range of information has been collected on 3,000 children. The study also looks at background characteristics relating to parents, home environment, and pre-school settings children attended. Settings were drawn from a range of providers. All settings were in England. A sample of 'home' children (who had no or minimal pre-school experience) were recruited to the study at entry to school for comparison with the pre-school group.
As part of the wider study, the EPPE team conducted an investigation into children who might be 'at risk' of special educational needs ( SEN). The Early Years Transition and Special Educational Needs ( EYTSEN) project was a sub-study within EPPE. Focusing on children from ages 3-6, the study used a range of information to identify children 'at risk' of developing SEN.
What do we know about the effectiveness of pre-school education from the EPPE project (and EYTSEN subsample)?
- Duration of attendance is important: an early start (under age 3) is linked to better intellectual development. It does not appear to be important whether children attend full-time or part-time
- High quality pre-schooling is related to better intellectual and social/behavioural development for children
- Settings where staff have higher qualifications have higher quality scores, and children make more progress
- Disadvantaged children benefit significantly from good quality pre-school experiences, especially where they mix with children from different social backgrounds
- Integrated centres (combining education and care) and nursery classes are more effective than other types of provision in promoting positive child outcomes
- The quality of the home learning environment is more important for intellectual and social development than parental occupation, education and income
- The number of months a child attended pre-school continued to have an effect on their progress throughout Key Stage 1
- High quality pre-school provision, combined with longer duration, had the strongest effect on child development
- Those children who had no pre-school experience were more likely to be 'at risk' of Special Educational Needs, even taking into account this group's higher level of multiple disadvantage
- The form of pre-school provision may be important. Children 'at risk' of poor cognitive development benefited from integrated centres and nursery schools; children 'at risk' in terms of poor social behaviour benefited from integrated centres, nursery classes and playgroups
9.6.2 The High/Scope Perry Pre-school Study and other evidence from the US
The High/Scope Perry Pre-school Study
The study, which began in 1962, examined the lives of 123 African Americans born in poverty in a disadvantaged area of Michigan, and at high risk of failing in school. At ages 3 and 4, children were randomly divided into a programme group and a no-programme group, who received no preschool programme. The curriculum for the programme group included five key groups of experience (creative representation; language and literacy; initiative and social relations; movement and music; logical reasoning). Children followed the programme for two years and received intensive input from highly trained workers.
What do we know about the effectiveness of pre-school education from the Perry Study and similar initiatives from the US?
- The High/Scope Perry Pre-school Program is the best known and most influential of all preventative programmes. It has been the subject of high quality evaluation and is unique in following up child participants, not only to adulthood, but to middle age
- The programme evaluated successfully (in the short- and long-term) and its success is likely to be due to the broad focus of the curriculum
- The programme has been shown to cost-effective: the major cost is the initial investment, while the major benefits are reduced costs of education, increased earnings, and decreased costs of welfare assistance and crime
- Other US studies which have received rigorous evaluation have found positive effects on school and college attainment. Although there were variations in the implementation of key aspects of the interventions, over time participants' motivation and social skills reduced the impact on criminal justice services and improved health and job market performance
- Evaluation of the Seattle Social Development Project, which combined training to improve children's social competence and thinking skills with a parenting programme and classroom management programme for teachers (with promising long-term outcomes) highlighted the finding that a 'late intervention' programme did not produce the significant long-term effects achieved by the full intervention
Where is the evidence base weak?
- It is not clear whether outcomes for the most disadvantaged children matched those with fewer risk factors
- Since all the evidence comes from the US, it is not known whether these programmes would be transferable to the Scottish context
9.6.3 Systematic review of day care
A systematic review of day care for pre-school children in disadvantaged populations reported positive effects on mothers' education, employment and interaction with children (as well as an increase in children's IQ and beneficial effects on behavioural development and school achievement. Long-term follow up demonstrated increased employment, lower teenage pregnancy rates, higher socio-economic status and decreased criminal behaviour.
However, most of the trials combined non-parental day care with some element of parent training or education (mostly targeted at mothers) and failed to disentangle the possible effects of these two interventions, among other methodological weaknesses. In addition, all the contributory studies were conducted in the US, so the transferability of findings to the Scottish context is uncertain.
9.7 The effectiveness of initiatives targeting vulnerable groups
Families facing the disadvantages associated with poor housing conditions, low income, unemployment or/and a lack of supportive relationships are vulnerable to a range of additional stresses, such as homelessness, and alcohol and drugs misuse. This is not intended to be a comprehensive investigation of all such groups, but to flag up some examples and indicate what is known, or where work is in progress. The actual groups included were suggested by colleagues who contributed to the paper. The review of services below provides a broader perspective of the circumstances of families from additional risk groups, although it has not been possible to separate out individual experiences.
9.7.1 A review of services for vulnerable families with very young children
A review of local authority and health services to support vulnerable families with children aged 0-3 years was carried out in Scotland in 2000-2001. The review examined the case records of 147 families with children aged 3 and under in touch with social work services. The majority of families were experiencing profound and acute stresses (such as mental illness, drug dependency, alcohol misuse or domestic abuse).
Although the review is now several years old, findings are still likely to be relevant. An extensive range of services was found to be offering practical help, information, parenting education and advice, and emotional support to parents in difficulty:
- The bulk of antenatal care and support was provided by midwives, most of whom perceived themselves as offering the same service to all new parents, regardless of specific risk factors
- The health visitor was the key contact with health services. Most families had a designated health visitor, although levels of contact varied widely from weekly to very limited contact. Health visitors did not have a clear sense of their responsibilities towards vulnerable families, and practice varied widely
- Most contact with other health services centred around diagnosis and treatment of the individual patient. Services rarely considered the family's wider circumstances, unless there was evidence of immediate risk to a child
- Most of the families had an allocated social worker, who carried out assessments of families' situations and made referrals to other services. Local authorities also provided families with material and financial help
- Family support workers offered practical advice and support to parents and sometimes offered respite by looking after children. These staff also played a part in monitoring children's development
- Out of hours or emergency services played a key part in dealing with crisis referrals. Out of hours staff were skilled and experienced and gathered a great deal of information and offered good professional insights into the supports needed. This contact was important in setting the context for families' further contact with daytime services
- Family centres brought together a range of practical, material and emotional supports for parents, usually underpinned by some form of child care
- Voluntary sector support included home visiting services; parents' support groups; child care and play sessions; advice, advocacy and emotional support for young homeless people or people leaving local authority care; and specialist assessment of families with complex needs for the local authority
What does the review tell us about local authority and health services supporting vulnerable families?
- A wide range of services was offering support to families, but support was poorly coordinated unless there was an inter-agency child protection plan or supervision plan in place. Children with physical or learning disabilities or sensory impairments were particularly poorly managed. The impact of the disability on the family as a whole was not taken into account in planning, and carers' needs were not consistently assessed
- The health professionals providing the bulk of antenatal care and support either did not have a clear sense of their responsibilities to vulnerable families, or perceived themselves as offering the same service to all new parents, regardless of risk factors
- Families and professionals feared that social work departments would permanently remove children from their parents' care, although this was not reflected in reality
- Negative perceptions of field social workers hindered families from seeking early help from social work services, but families with experience of support were more objective and realistic
- Parents valued health professionals who took time to discuss problems and were honest about the help they could offer - health visitors were particularly appreciated for the practical support and advice they provided
- Few parents had a consistent relationship with a named GP and contacts with GPs were described as hurried. Parents felt that GPs were too ready to prescribe tablets and unwilling to take time to listen to their problems and worries
- Parents were very positive about the support they received from family centres, particularly valuing respite, emotional support and advice and social support from peers
- Family centres provided safe environments for parents to acquire skills, build trusting relationships with staff and watch staff interacting with children. Parents wanted better information on a range of topics, specific provision for fathers, and additional support at evenings and weekends
9.7.2 People who are homeless, or at risk of becoming homeless
Many people at risk of homelessness lack the knowledge and skills required to manage a tenancy and the self-confidence and interpersonal skills necessary to communicate with agencies and develop social networks. Young people, care leavers, ex-offenders, ex-service personnel, people with low educational achievement and literacy problems are particularly vulnerable. However, at present the evidence base appears to be thin.
Research in 2001 to identify the range of life skills training provision available in Scotland found there was limited knowledge on the resettlement needs of many people ( e.g. families, people from black and minority ethnic groups, women). Although life skills training appeared to be well embedded in homelessness provision, there were wide variations in the length of time that the training was provided to clients.
None of the projects surveyed submitted details of formal service evaluations. Consequently, there is very little evidence of the effectiveness of life skills training as part of the resettlement and tenancy sustainment process.
The Dundee Families Project
Run by NCH Action for Children Scotland, the project provides services for families who are, or who are at risk of, becoming homeless due to anti-social behaviour. A range of services are offered through: individual and couple counselling, family support and group work. The three main service types are:
- Outreach: a preventive service offered to families in their existing homes
- Dispersed tenancies
- Core: accommodation offered to the most needy families in a residential block for up to four families
What do we know about the effectiveness of the Dundee Families Project?
- The project worked with 126 families in 4 years (1996-2000), about half of all referrals to the project. Information on closed cases showed that the majority of families made good progress, particularly regarding housing issues; however, many still had serious childcare problems.
- Parents and young people were very positive about the service. Adults identified substantive changes in their housing situation, facilities for children, positive changes in family relationships and behaviour. Children and young people thought the staff were helpful and their housing situation improved. They identified improvements both in their own behaviour at home and school and in their parents'.
- Evidence suggests that the project generates cost savings, through stabilising families' housing situation, avoiding costs associated with eviction, homelessness administration and rehousing and, in some cases, preventing the need for children to be placed in foster or residential care
- Crucial ingredients of the service were: good management, stable staff, shared ownership by other agencies, a repertoire of challenging methods and a holistic approach.
9.7.3 Misuse of alcohol and other drugs
There is growing concern about the potential impact of adult problem drug and alcohol use upon children, the potentially high numbers of children involved and the need to ensure that child protection measures are in place when required.
What do we know about the effectiveness of interventions to address parental substance misuse?
- A range of services for children and families is developing, but there is a need for a continued expansion of such responses, and for their rigorous evaluation
- Studies which were able to demonstrate their effectiveness at improving children's risk and protective factors and behaviours were not able to clarify which resilience factors determine positive outcomes
Where is the evidence base weak?
- Research to date has failed to focus on children's views
- There is a need to view parental substance misuse as part of a far wider, multi-dimensional picture
9.7.4 Children at risk of neglect or acting beyond the role of their parents
Risk and protective factors for potential neglect are known to be similar to risk factors for potential disruptive behaviour, although evidence on the precise mechanisms of the inter-relationship is limited. Effective approaches to family service provision are highlighted in other sections of this paper, so the focus here is on compulsory mechanisms for parents.
Parenting Orders were introduced in Scotland in 2005, but have attracted harsh criticism and have been little used. Findings from England and Wales, where Parenting Orders have been established since 2000, indicate a degree of success in terms of attendance, but that families had histories of unsatisfactory contact with support agencies prior to referral for a Parenting Order. This raises questions as to whether, if such families had had access to such support before, they would have required the compulsory measure at all.
9.7.5 Looked after children
There is a gap in the evidence about effective interventions to support looked after children, both during childhood and early adulthood, when they are particularly vulnerable to early and unplanned parenthood. However, it is known that:
- Placement stability and encouragement of carers is important for achieving educational success.
- Education and employment prospects after the age of 16 can be improved by careful assessment of each young person's capabilities and by working with them to increase their employability
In Scotland, these messages are reinforced by findings from a recent major review and a qualitative research project
Many of the initiatives to avert pregnancy at a young age will be particularly relevant to young people who are, or have been, in the care system.
9.8 Investment in the early years - longer-term impacts
9.8.1 Costs and outcomes in services for children in need
A long-term approach to decisions on spending and service planning needs to be taken if resources are to be shifted towards intervention earlier in life and earlier in the development of problems for children who are at high risk. On the evidence of a programme of 14 studies carried out in England, each of which included an economic component that attempted to describe the way resources were used, or to link costs to the results achieved, the authors concluded that the most rational approach to decision-making is likely to depend on:
- Understanding the current position - including variations in how local authorities and partner agencies uses resources
- Planning and designing services - shifting resources from 'heavy end' higher-cost services to earlier, more preventative services
- Linking costs and outcomes - developing the kind of services that have the best chance of success, such as those targeting high risk children who are at a turning point or transition in their lives
- Improving information about what works - supporting research and evaluation and improving monitoring data
What do we know about the costs and outcomes of services for children in need?
- Tightly controlled interventions with a clear rationale tend to have better outcomes than less strictly controlled 'standard' interventions
- It is easier to improve outcomes for younger children than with older ones
- The evidence base is stronger for specialist programmes (usually targeted work with vulnerable families - such as intensive home visiting) than on universal family support services (such as Home-Start) but universal services that have been evaluated appear to be both relatively low cost and very well received
9.8.2 0-3: How Small Children Make a Big Difference
This paper, published in January 2007, takes a broad focus on the long-term impacts of addressing issues of parenting and care in the early years. The recommendations made by the paper are sweeping and do not seem to be particularly helpful, but the main, evidence-based messages are useful:
- Early engagement pays a very high rate of return. Growth modelling on early years investment by the Brooking Institute led to the conclusion that, in the USA 'using reasonable assumptions, we project that GDP would be $988 billion larger within 60 years' although, as yet, no one has modelled the dynamic and complex factors that would affect growth in the UK.
- If they receive sensitive care in the first 3 years, children will feel better in themselves, be more resilient and appreciate other people's feelings
- Costs should rise for screening and support during pregnancy, through to parenting and enrichment for children from 0 to 5, and again at 16-18 as more young people stay on at school. However, outcomes would start improving from primary year one, with children arriving at school with better behaviour, motivation and language skills
- Families and not schools are the major contributors to inequality in student performance
- Investment promotes economic growth by creating a more able workforce and reduces the costs borne by criminal justice, health and welfare system
- Remedial work for young people from an impoverished environment becomes progressively more costly the later it is attempted
- In the US a series of studies targeted at higher risk families followed up over time have estimated a payback of between 3 and 7 times the original investment by the time the young person reaches the age of 21. The most well known is the Perry Pre-School project, where groups have been followed up regularly, most recently at 40 years old.
9.8.3 The costs and benefits of early intervention
- Early engagement pays a high rate of return. High quality longitudinal research of an innovative initiative from the US (the Perry Pre-School Project) indicates major benefits to the criminal justice system, health, education, employment and income levels and a return of $17 dollars for every dollar spent by the time participants reached the age of 40
- However, it is risky to extrapolate from studies conducted 20 or 30 years ago (and outwith the UK). The problems of the children served are likely to be more severe and the definition of particular outcomes may have changed over time
- No one has yet modelled the dynamic and complex factors that would affect growth in the UK if greater investment was made in the early years.
- Evidence on the effectiveness of parenting interventions which focus on improving educational outcomes for children is inconclusive and further complicated by lack of rigorous evaluation of many interventions, and few examinations of costs and benefits. However interventions in this area may be low cost and so the benefit-cost ratio is likely to be positive
- Home visitation interventions show some benefits, although effects across a range of child outcomes are likely to be modest. Cost-benefit analyses of the Nurse-Family Partnership indicate that the programme is most effective when serving high-risk individuals, but would be cost-effective even if aimed only at low-risk families
- Evidence relating to the effectiveness of parenting interventions which focus on improving educational outcomes for children is inconclusive, and further complicated by lack of rigorous evaluation of many interventions
- There is strong evidence that parent training produces positive results in addressing child conduct disorder, although it is difficult to identify the key elements of programmes which achieve better outcomes for children
- Several studies (including recent evaluations of the Incredible Years programme in the UK) indicate that parent training can have positive impacts on both parents and children
- The cost of parent training is relatively low and the long-term benefits of parenting programmes need only be small to justify the investment
9.8.4 Creating and fostering non-violence in society
The WAVE Trust (Worldwide Alternatives to Violence) was formed to identify and disseminate best practices for creating and fostering non-violence in society, through a soundly-researched understanding of the root causes of violence. In 2005, the Trust published results from an eight year study of the root causes of violence. Main findings:
- Violence costs the UK more than £21 billion per annum. A tiny fraction of this is spent on prevention, and most of that on the least effective age groups ( e.g. 5-15). Early interventions (0-3) are fruitful and cost effective. Negative cycles can be transformed and children given the opportunity to grow into contributing, personally fulfilled adults (and future parents)
- Violence is triggered in high-propensity people by social factors such as unemployment, poor housing, overcrowding, economic inequality, declining moral values and stress.
- Alcohol plays a significant role in the timing of violence
- Since these factors reflect long-term cultural trends that are difficult to reverse, investment in reducing the number of people with propensity to violence is a strategic imperative
- The structure of the developing infant human brain is a crucial factor in the creation (or not) of violent tendencies
- Empathy is the single greatest inhibitor of the development of propensity to violence. Empathy fails to develop when prime carers fail to attune with their infants
- Parent training has evaluated as highly cost-effective for preventing serious crime: £4,000 per serious crime prevented, compared with £9,000 for both teenage supervision and prison. Training carried out before children reach the age of five may be expected to compare still more favourably.
The WAVE Trust examined over 400 interventions that might reduce violence, or the root causes of violence. It identified 4 programmes as being of particular interest because of their focus on addressing core issues of empathy; intervening before the birth of the child; research evidence to support their effectiveness. Two of the programmes (the Nurse-Family Partnership and PIPPIN) have been discussed above. The other two are The Circle of Security and Roots of Empathy
The Circle of Security
This is a 20-week, group-based, parent educational and psychotherapeutic intervention designed to shift patterns of care-giving interactions in high-risk, caregiver-child pairs. High-risk families are identified and assessed by a university-based assessment team and Circle of Security therapists.
What do we know about the effectiveness of the Circle of Security?
- It appears from the references in the WAVE report that the programme is relatively recent, and it seems to be confined to the US at present.
- Early findings suggest that the intervention has:
- Increased ordered child and caregiver strategies
- Increased secure caregiver strategies
- Increased secure child attachment
- Increased caregiver affection, sensitivity, delight and support for exploration
- Decreased caregiver rejection, neglect, flat affect and role reversal
Roots of Empathy ( ROE)
This is a widely applied parenting programme for children aged 3-14 (not yet delivered within the UK). Its goal is to break the intergenerational cycle of violence and poor parenting. The WAVE research was particularly interested in ROE because of the ways in which it prepared schoolchildren for parenthood. It emphasises, models and provides literal hands-on experience of how to handle and interact with a real-life baby.
Children share in regular visits with a neighbourhood parent, infant, and trained ROE instructor. Over an 8 month period, students learn understand how babies develop. They become attached to 'their' baby, learning about its needs and interacting with it. The programme also links to the school academic curriculum: students use maths skills to measure, weigh and chart the development of the baby, and write and read stories and poems that tap and help them relate to their own emotions.
What do we know about the effectiveness of the Roots of Empathy programme?
- A number of projects have evaluated the ROE programme. Findings indicate that ROE children (relative to comparison children) demonstrated significant improvements from pre-test to post-test in the following areas:
- Increased emotional knowledge
- Increased social understanding
- Increased pro-social behaviour with peers
- Decreased aggression with peers
- Decreased proactive aggression ( e.g. bullying)
WAVE carried out an in-depth review of ROE and was highly impressed with the findings. The report does not discuss issues of transferability, although the Canadian-based initiative is now being piloted in Australia and Japan.
The evidence base on the effectiveness of interventions aimed at parents and children in the early years is extensive and, since it is children from the most disadvantaged sections of society who are most affected by these issues, there are important lessons for policy and practice. However, it is difficult to extract meaningful messages from the evaluation of initiatives which have focused on a range of outcomes and to ascertain whether findings are relevant to the most disadvantaged families.
Evaluation of interventions aimed at improving parenting and maximising the early development of the child indicate that outcomes tend to be less positive for the most disadvantaged families. Initiatives which aim to target all families in deprived areas, so as to avoid stigmatising families with the greatest number of risk factors, may not be reaching the most disadvantaged families (or, at least, are not reporting whether and how they are engaging the most disadvantaged families).
There is good evidence to show that home visiting programmes during pregnancy and the first year of life allow a range of issues to be addressed, support provided and, if appropriate, referrals and access to other services to be facilitated. However, families who are hard to reach by traditional services may feel more comfortable with volunteers from their own community. Initiatives which engage mothers within the community and train them as 'experts' help to build capacity within the community, in addition to supporting other mothers. Mothers targeted by the intervention may find it easier to trust their peers. However, not all evaluations of the use of volunteers have been positive, and it is important that volunteers receive appropriate training and support in their role.
Parent education programmes have been shown to have positive child outcomes, although effects are not universal and the most disadvantaged families are least likely to benefit. However, programmes have been effective in boosting parenting skills, increasing knowledge and improving parents' mental health. Evidence of effectiveness relating to three specific parenting programmes is building, although further, good quality, independent evaluation of the Triple P, Incredible Years and Mellow Parenting programmes would be helpful.
Looking beyond services to support parents and children, the evidence indicates the importance of using mass media programmes to promote positive images of parenting, as well as individual issues such as breastfeeding. Universal low cost approaches that help to build the bond between parent and child (such as baby massage and improvements to baby buggy design) are non-stigmatising ways of improving outcomes for the most disadvantaged groups.
Provision of adequate education on sex and contraception has been shown to be effective in averting pregnancy at a young age but, again, the most vulnerable groups are least likely to engage with educational systems. Tapping into the popularity of computer games may be a way of engaging young people in games which involve the care of young babies. An initiative involving a computerised model baby appears promising, when included as part of a curriculum of lessons on relationships and personal development. However, it has yet to be evaluated in the UK.
There is clearly a major economic imperative to address issues of parenting and care as early in life as possible. The evidence suggests that investment in screening and support during pregnancy, and parenting and care until children are 5 years old pays off almost immediately as children are better prepared when they arrive at school. Subsequently they are likely to achieve better qualifications and to gain and sustain employment, with savings to the health, welfare and criminal justice systems.
However, most of the evidence relating to long term impacts of investment in the early years comes from the US, and findings are unlikely to be transferable. There is a need for good quality, longitudinal studies based in Scotland.
Despite a number of weaknesses and gaps in the evidence base, there is increasing evidence that investing in the early years (and focusing on young people while they are at school to promote sexual health and prevent early pregnancy) can have long term benefits and, ultimately, play a significant role in reducing health inequalities.