Research has shown that strong evidence based parenting intervention programmes with pre-school children have demonstrated good outcomes in the random controlled trials (RCTs) but these programmes have not always given the same results in real life settings. This submission describes the author's work in delivering, researching and supporting the dissemination of the strong evidence-based 'Incredible years' parent, child and teacher programmes across Wales, through services such as Sure Start, with the help of the Welsh Government. It sets out the reasons for choosing the programmes, the steps taken to test their effectiveness in service setting across Wales and lessons learned. The programmes are relevant to QS59 statement 4 Parents or carers of children with a conduct disorder aged 3 to 11 years are offered a referral for group or individual parent training programmes.
Aims and objectives
The aim of this case study is to show how the incredible years parent programme was successfully implemented by the Sure start services across North and Mid Wales. This evidence based programme had proved effective in service settings for both the prevention and treatment of conduct disorder problems in several countries in different continents. It has been trialled in Wales as a CAMHS based treatment for parents of children with conduct disorder and related difficulties and the evidence from this trail showed that the programme also functioned as an early preventive intervention.
These results showed that the programme met the UK government's criteria that publicly funded early years intervention services must use evidence based programmes, thus providing the opportunity to use the programme to deliver the sure start services across mid & North Wales.
The 'Incredible years programme', developed by Webster-Stratton at the University of Washington, Seattle, has over 30 years of research behind it and is considered to be one of the best evidence based programmes in the world for both the prevention and treatment of conduct disorder and related difficulties. The programme, which has components for parents, children and teachers covers a wide age range from birth to 12 years old, has proven to be effective when delivered in everyday service settings.
Reasons for implementing your project
Research has shown that early intervention for parents with young children who are at risk of long-term conduct disorder and antisocial behaviour can reduce this risk. However, research also shows that whilst programmes worked well in randomly controlled trials conducted by their developers, these programmes did not always work as well in real life settings. This presented those running projects with the dilemma of what programme to choose; will that programme work in a service setting.
The author Judy Hutchings, with her joint appointment as the consultant clinical psychologist in NW Wales Child and adolescent mental health services (CAMHS) with responsibility for children with conduct disorder and as Director of a research team in Bangor University trialled the Incredible years parent programme as a CAMHS based treatment for parents with children with conduct disorder and related difficulties. The trial proved successful and was established as a treatment intervention programme within the CAMHS. The evidence also shows that the programme worked well as an early prevention intervention.
Everybody's business: Child and adolescent mental health services (National Assembly for Wales 2001) expanded the role of the CAMHS staff to include supporting primary staff in the prevention of children's mental health problems. The change allowed the author to support sure start services in North and Mid Wales along with her work with children with severely challenging behaviour. 11 sure start services in North and Mid Wales delivered the programme, whilst in England and the rest of Wales the sure start initiative was delivered using a plethora of different programmes.
As part of the programme sure start staff in Wales were given basic leader training and were running the programme. This provided an ideal opportunity to research how the incredible years' parent programme had worked in a real life setting. As the service was new the sure staff managers were receptive to advice on how to deliver an effective service and how to seek evidence of outcomes achieved. They were willing to commit the levels of staff time and resources needed to deliver the programme effectively and to participate in the RCT. As an evidence-based programme, it met the criteria for obtaining funding from the health foundation to conduct an RCT evaluation with identified high risk three and four year old children living in these communities.
How did you implement the project
The author obtained programme leader accreditation from the incredible years programme developers and progressed to mentor status enabling her to undertake training and supervision of parent leader leaders. She was then able to deliver a basic leaders training to sure start staff. She was also a part of the research team in Bangor University which had expertise in conducting RCT and with the increase in early intervention provision, and the demand for evidence, the research met the conditions for making a successful grant application to the Health Foundation. This was made by the author and the participating services.
All the fidelity components of the programme were incorporated in programme, including basic leader training, on-going weekly supervision of leaders, provision of all the materials. A peer support group was established to support programme delivery.
The research team included a health visitor who worked with local health visitors, training them in collaborative, non-judgemental recruitment strategies. This enabled the health visitors to help parents recognise that their child presented challenges that made parenting more difficult and inform them that intervention could help them support their child. The health visitor's role was crucial in targeting the right families and ensuring a high take up rate of 93% of eligible families signing up for the trial. Parents were supported with transport and crèche facilities where needed; meals were provided at each group session. Leaders followed up parents that missed sessions and phoned all participants weekly. Parents completed a weekly session evaluations that guided delivery. As a result 83% of participants attended 7 or more of the 12 sessions. An impressive result with identified high levels of social disadvantaged risk families.
Short and long term outcomes include:
Significant improvements in child and parenting behaviour, parental stress and depression; replicating those achieved by the programme developer, including similarly high retention rates and good outcomes with the most disadvantaged and hard to engaged families (Hutchings, Bywater, Daley, Gardner et al. 2007; Bywater et al. 2009).
In a study of a sub sample of children at risk of ADHD, independent improvements were found in child hyperactivity and inattentivity (Jones et.al 2008).
Research found that there was a correlation between the level of leaders praise and observed reflective behaviour and changes in the parents' behaviour in the home. "The more the leaders praised the parents in the groups the more likely parents were to praise their children in the home". (Eames et al. 2010).
Cost effective analysis showed that 'compared to the children on the waiting list the Incredible Years basic parenting programme improved children's behaviour at a cost of £1344 per child'. Thus showing the programme had achieved significant benefits at reasonable cost. (Edwards et al 2007). The Welsh government monitored the study and as a result of the positive outcomes incorporated funding to develop the parent programme into their Parenting Action Plan for Wales (Dept. for training & Education 2005), providing funded parent group leader training for staff across the 22 Welsh local authorities.
Key learning points
- Having an in-house or locally available trainer to deliver the basic leader training proved cost effective and more efficient. In this case the training was delivered to sure start staff across Wales & to peer - support group by the author who was a member of the research team and an experience psychologist.
- As the Sure Start services were new in Wales the Managers were open to advice on how to deliver effective services and seeking evidence of outcomes achieved.
- Helpful that the sure start staffs were already trained and enthusiastic about the research trial - Establishing a peer group to support the programme
- Ensure that the evidence based programme has proved effective in a service setting and not just in the RCT trial.
- It was proved crucial to have a health visitor on the research team who could train the local health visitors in collaborative non-judgemental recruitment strategies, so they could help identify families who could benefit from the intervention programme.
- The research benefitted from having an experienced psychologist on the research team.
- Providing transport, meals at each session & crèche facilities reduced the barriers for parents attending the sessions.
- Weekly phone calls to all participants. Follow up of parents who missed sessions.
- Parents completed weekly session evaluations that guided delivery.
- Leaders working with the parents were encouraged & supported through weekly supervision that included viewing videotapes of sessions and the leaders completed a checklist detailing the components delivered during each session.