Building on Proven Practice on conduct disorder research in last week’s Community Care, Celia Atherton presents research on parenting intervention programmes in Wales carried out by the Incredible Years Wales Centre among others
This article summarises two strands of research on a parenting intervention programme delivered through Sure Start Wales for parents with children at risk of developing conduct disorder: a randomised controlled trial to measure the effectiveness of the parenting programme on child behaviour and parenting skills, and a cost effectiveness analysis. The research was carried out between January 2003 and March 2005.
Authors: Judy Hutchings, Tracey Bywater, Dave Daley, Frances Gardner, Chris Whitaker, Karen Jones, Catrin Eames, Rhiannon T Edwards.
Institution: The research was carried out by a team based at the Incredible Years Wales Centre at Bangor University. The randomised controlled trial was led by Judy Hutchings of the School of Psychology and the cost-effectiveness analysis by Rhiannon T Edwards of the Centre for the Economics of Health, Institute of Medical and Social Care Research. The training and supervision of staff delivering the programme was also carried out by the centre, and led by Judy Hutchings.
The research evaluates the effectiveness of the Webster-Stratton Incredible Years basic parenting programme. The primary outcome measure used was the Eyberg child behaviour inventory, a standardised instrument for measuring problem behaviour in children. A number of other well-validated measures were used to assess, for example, parental stress, depression and parent-child interaction.
The researchers gathered data on child behaviour and parenting skills by direct observation in participants’ homes and through questionnaires completed by parents. As families were recruited to the study, baseline data was recorded: families were followed up at six, 12 and 18 months after the intervention.
Cost-effectiveness was measured in terms of incremental cost per unit of improvement on the intensity score of the Eyberg child behaviour inventory.
The Webster-Stratton Incredible Years basic parenting programme incorporates all the factors identified as improving parent training outcomes. Thirty years of research, including randomised trials in the UK, have shown the programme to be effective. Incredible Years (IY) is one of only two programmes identified by the National Institute for Health and Clinical Excellence as effective for treatment of conduct disorder (the other is the Triple P – Positive Parenting Programme developed in Australia, see link below). Importantly, the IY programme materials include tools to help ensure that the programme model is successfully replicated in real world settings.
Incredible Years has proved more effective than other programmes at engaging and retaining high risk and hard to reach families.
Eleven Sure Start services in Wales have been using the IY programme since 2001, which provided the opportunity for this service-testing based trial of the programme.
Some 153 socially disadvantaged families with a high risk child aged between the ages of three and four took part in the trial. The families were identified by health visitors, who administered the Eyberg child behaviour inventory.
Families were eligible if the child scored above the clinical cut off point on the Eyberg scales. 104 of the families participated in the parenting programme, while the control group of 49 families were put on a six-month waiting list and received no intervention over that period. The allocation of families to the intervention or the control group was done using rigorous randomisation methods and the control group were offered the programme after the six-month follow-up.
The parenting programme consisted of 12 two-hour sessions delivered weekly with a maximum of 12 parents in each session. The programme was delivered by trained and experienced leaders who received three hours supervision each week at the Incredible Years Centre in Bangor by a certified IY trainer. The group leaders came from a range of professional backgrounds – social workers, health visitors, psychologists, family support workers. The programme uses a collaborative approach to promote positive parenting, and the programme content is clearly laid out and firmly adheres to the Incredible Years model. Parents’ overall mean attendance was 9.28 sessions out of 12 sessions provided, and 83.5% of participants attended six or more sessions.
The intervention and control groups had very similar scores when assessed before the intervention. A follow-up comparison of the two groups showed significant differences in the intervention group in terms of both child and parent measures, indicating that the programme had a positive effect on the behaviour of both.
● Researchers observed parents in the intervention group using more positive, less critical parenting and better behaved children.
● Children in the intervention group had significantly reduced antisocial and hyperactive behaviour and increased self-control compared with children in the control group.
● Parents perceived their child as having fewer and less intense problem behaviour than before the intervention.
● Improvements in parent skills and competencies, reductions in negative child behaviour and reductions in parental stress and depression had all been maintained at the follow-up 18 months after the intervention.
● The parents who were more depressed or who were lone parents tended to show greater improvement in children’s problem behaviour and in parenting.
The ratio of change in costs to change in effects through the intervention was estimated at £73 per one point improvement on the intensity score of the Eyberg child behaviour inventory. By this measure, it would cost £5,486 to bring a child with the highest possible intensity score to below the clinical cut-off point, and £1,344 to bring the average child in the intervention group to the same position. There was an 83.9% chance of the intervention being cost-effective.
The average cost for each child was £1934, including start-up costs for training and materials. Once group leaders had been trained to deliver the programme the cost decreased to £60 per one point improvement on the Eyberg intervention score.
An analysis of the sample subdivided by children’s intensity score showed that the intervention “became more cost effective in children at greater risk of developing conduct disorder”.
This trial shows that the Webster Stratton Incredible Years basic parenting programme can reduce key risk factors for the development of conduct disorder. The excellent short-term and promising long-term results contrast with the early indications from the ongoing national evaluation of Sure Start in England which found no significant effect in preventing or reducing conduct disorder however, the national evaluation will provide stronger grounds for drawing definitive conclusions when published in 2008. The results of the Welsh research study show that by delivering a parenting programme that evidence has shown to be effective, and crucially, by making sure that the programme is delivered with fidelity, remarkable outcomes can be achieved with high risk children from hard to reach families.
The Incredible Years basic parenting programme in Wales was delivered through Sure Start services and these results indicate that a robust programme can provide value for money when done in this way. The economic implications of failing to address conduct disorder in childhood are serious: the costs of services to those aged 28 who exhibited conduct disorder in childhood have been estimated to be 10 times higher than for those with no problems.
● Conduct disorder affects 5-10% of children aged between five and 15 in the UK.
● Behaviour problems in the early years (3-5) are strong predictors of persistent problems – antisocial and criminal behaviour and the associated poor prospects for employment, relationship breakdown, and substance misuse.
● Effective parenting is key to reducing children’s behaviour problems and parenting programmes are more effective with younger children when problems are less entrenched and parents’ can more easily influence their children’s behaviour.
National Evaluation of Sure Start
● Since 2001, £3,100m has been invested in Sure Start.
● The preliminary findings of the national evaluation of Sure Start in England found no significant effect in preventing or reducing conduct disorder.
Evidence Based Interventions
● In the first years of Sure Start, there has been no government requirement that Sure Start services should deliver evidence-based programmes. Across the country, Sure Start has provided a wide variety of services and programmes, with a variety of approaches to crucial issues such as staff training, supervision and provision training materials.
● The Welsh Assembly government has now stated that only evidence-based early intervention programmes will be funded.
● In England the new, large-scale Pathfinder trial has funded the Incredible Years programme in six authorities as one of three evidence-based programmes being delivered and evaluated.
● Fidelity of implementation refers to the extent to which the real life application of a programme in a service setting matches the original programme as it was designed.
● Evidence based programmes can only work well if delivered with fidelity. In many cases, programmes are delivered in ways that do not replicate the model and cannot therefore be considered the same programme or expected to have the same results as the model.
● Strategic planning must see that a programme is delivered as designed:
* With all the core components
* With fully trained staff
* To the right population in the right context.
● These promising results are the outcome of targeting an evidence-based programme at a population – the parents of younger children – with whom this intervention is known to be most effective.
Councils Implementing the Programme
● From April 2006 the Welsh Assembly has been funding the training of staff across Wales and the supply of appropriate programme materials. In the first year, 160 staff from 15 of the 22 Welsh local authorities received Incredible Years training.
● In November 2006, Carolyn Webster-Stratton and a colleague visited London to train mentors and consult with local authorities supporting the DfES Pathfinders initiative. Local authorities in the scheme will roll out parenting classes targeting the 8-12 age group. Each authority will have two mentors/trainers who will train group leaders and provide supervision. Judy Hutchings, director of Incredible Years Wales and lead researcher on this project will be the programme manager.
Links and Resources
● Full text of articles in British Medical Journal (BMJ):
● National Institute for Clinical Excellence (Nice) guidance on Conduct disorder in children/parent-training/education programmes
● Webster-Stratton Incredible Years
● Incredible Years Wales
● Triple P positive parenting programme
● Research in practice research review: Conduct Disorder in Older Children and Young People: Research messages for practice problems (Joughin and Morley 2007)
Celia Atherton is director of Research in Practice, providing a range of services supporting evidence-informed practice with children and charities at www.rip.org.ukThis article appeared in the 17 May issue under the headline “The Incredibles”