Professor Lynn McDonald, Middlesex University

Evidence Based Parent ing Programmes and Soc ia l Inc lus ion Conference at Middlesex Univers i ty

September 20 , 2012

LYNN MCDONALD, MSW, PHDPROFESSOR OF SOCIAL WORK RESEARCHMIDDLESEX UNIVERSITY, LONDON

Professional Best Practice is Knowing Three Evidence-

Based Parenting Programmes

United Nations: Rights to Child Well-Being

United Nations: International Rights of All Children2007 UNICEF publishes 40 indicators of child well-

being in table of 21 economically advanced countries

UK ranked at the bottom as number 21; US was 20th

UK children were unhappiest in industrialized worldParents spent more time ‘just talking’ with their child

and building a positive relationships outside of UK (UK parent talks average 36 minutes a day to child)

2010 UN publishes 23 best family skills programs which have RCT evidence and can be disseminated

2

Risks to Child Development: High and Sustained Stresses (Cortisol levels)

War and destruction; famine and disease;Poverty in a nation with large wealth disparitiesBeing black or ethnic minority in a racist country Toxic environments, lead poisoning, smogNeighbourhoods/countries with crime and drugsImmigration or high mobility-socially disconnectedPoor schools and poorly resourced educationDistant, disengaged family (addicts?)--neglect Family using physical violence to resolve conflict

Child Abuse and Neglect in UK

One in ten UK children is ‘neglected or abused’

UK estimates that only 1 in 250 who were physically abused were actually referred to child protection

Of those investigated in UK and placed on a child protection plan: 44% are neglected 23% psychologically abused 15% physically abused 10% multiple forms of abuse 7% sexually abused

Social Work, Stress and Child Protection

Stressed and isolated families> neglectChildren from poverty more likely to be

neglected: If family lives under $15,000 versus over $30,000, There is 44X times the likelihood the child will be

neglectedNeglect causes high levels of cortisol (stress) Neglect is correlated with problems of

emotional self-regulation and with increases in child aggression

Poverty is correlated with domestic violence, mental health problems, depression, substance abuse and more extended family conflict with no social support

Education: Disparities, Poverty, Social Exclusion and Low Academic Achievement

High stress puts children into survival mode: they cannot learn mathematics, reading or writing

Sustained stress changes the brain and alters neuro-transmitters related to violence/learning

Stress can change gene expression-permanentIf high stress (high cortisol) is sustained over

time it damages a child’s brain for learningHigh stress can cause low immune systems in

which children miss more school from illness, and adults get sick more for compromised parenting

Health: Child Abuse and Neglect Matters

for Poor Outcomes of Child and Adult Health

ACE (Adverse Child Events) research into adulthood

Correlated with more health problems as adults Behavioural Health: substance abuse Mental health: depression, suicide, eating disorders,

anxiety Physical health: cardiovascular, cancer, hypertension

Medical service utilization for adults with child abuse Emergency rooms, outpatient hospital, pharmacy,

primary care, specialty care, (3353 women, age 47)Social support and caring relationships can

mitigate the impact of ACE (child abuse and neglect)

Relationships Can Buffer the Cortisol/ Reduce Stress on a Child’s Development

Caring relationships can buffer the cortisol damage of high sustained stress on a child’s development in health, education and social care

15 minutes of one to one responsive play reduces stressHigh stress levels can be managed with a responsive

parent who shows their love (the opposite of neglect) Notices child’s emotions and is tuned in to the child Is available to the child under stress Asks questions and listens Is physically soothing and touches the child Plays responsively with no bossing, and follows the child’s lead

(Sue Gerhardt, 2002,Why Love Matters)

Maternal hardship Food insecurity Episodic homelessness, residential instability Inadequate medical and dental care Trapped in a dangerous neighborhood Trapped in a dangerous relationship Physically demanding, low wage job Inadequate transportation Daily experience of stigma and social exclusion

Affects hope and mood, irritability, coercive, anger, frustration?

But Contextual Stressors on the Parent

Compromises Positive Parenting

Court Ordered Parenting Classes

In US, 448,000 parents attend parenting classes ordered by courts and child welfare each year

Parenting problems of caregivers are only 1 in 12 about excessive discipline. Neglect is over 50%

Parenting programmes focus on alternatives to excessive discipline

Agencies prefer to offer brief, low cost, groups, with trainers having no advanced degree, and easy concepts

Programmes are untested and have no evidence

‘Insular Parents’ (Wahler, 1979)

A classic study was conducted on parenting groups with parents referred by the child protection workers due to referrals for child abuse and neglect

Prof Robert Wahler taught behavior modification techniques with success to improve parenting

Six months later he assessed their use of new skills

If they had no friends or positive extended family social support, i.e. socially isolated, then they did not use the parenting skills they had already learned

Social capital and Stress and Child Neglect

Chronic stress and social isolation increase child neglect: the parents’ mental health problems reduce their ability to be responsive and to parent positively

Social capital reduces stress o Social ties and inclusion buffer stress and enhances adults’

coping mechanisms leading to better mental health, less irritability & anger

Social capital

Reduces Stress

Reduces Child

Neglect

Parents are the Best Prevention Agents

To moderate impact of stress of daily living, parents should be provided extra support and information

Parents can intervene and soothe their child’s high cortisol levels better than any other person

Research over the past 25 years has rigorously tested a range of approaches to improved parenting to result in improved child well-being outcomes

Evidence based parenting accepted as achievement

10, 20, 30 governments are now investing in them

Lists vary from 10 to 23 or 45 EBPs of best evidence

Some Government Lists of Evidence-based Parenting Programmes

UN United Nations Office of Drugs and Crime (2010) Family skills Programmes (23 recommended on

evidence)UK National Academy of Parenting

Practitioners EBP parenting programs for training workforce (2008,

09, 10)US government lists for evidence based

practice Child abuse and neglect prevention (ACYF 2009) Child mental health promotion (CMHS 2008) Substance abuse prevention (NREPP 2009) Juvenile delinquency prevention (OJJDP 2007) Health promotion (universal health care 2012)

2008 National Academy of Parenting Practitioners (NAPP) was established to train 4000 professionals in evidence based parenting

2008 PEIPS funded training of thousands of professionals in parenting EBP

2012 government passed law for universal parenting support with £100 vouchers for all parents of 0-5 kids

England is first country to start a policy of supporting all parents with a voucher for parenting groups

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In UK, Policies and Funds to Promote Evidence based Parenting (EBP)

EBP and Practitioners and Academics

This is a reality now: evidence based parenting has arrived, despite much resistance from some places

Today is the time to start being informed about the variations and themes of the different theories, strategies, and the strengths and weaknesses of the evidence, and the challenges and successes of their quality assurance dissemination capacity

Every practitioner today and every student in health, education, and social work should know about at least 3 and be able to compare and contrast them!

What is the aim of the EBP Parenting

To increase child well-being?To reduce child abuse and neglect?To increase protective factors?To increase relationships of the parent child

bond?To increase parental warmth and discipline?To change parenting attitudes?To increase parents observable talking and

managing of the child’s difficult behaviours?To reduce child’s aggression/conduct

disorder?To increase every child’s health?

19Parents Can Build Protective Factors Against Risks

Strengthening family unit (less conflict)Empowering the parent with skillsPositive parenting approachesImproving Mother-child bondBuilding Parent-to-parent bondsActivated Parent group for supportParent to community/school tiesLow drop out rates are importantWith Repetition of positive exchanges

What is Assessed for the EBP Lists?

Theory underpinning programmes More impact if crosses two domains of

family/school/community and if building positive protective factors

Effective in helping parents be warm & authoritative Practice of responsive play with parent-child Practice giving commands with follow-up

Randomized controlled trial(s) with 1 year follow-up

Demonstrated ability to replicate and ‘scale up’ Retention rates in the field, new settings, and with

socially marginalized, low-income, stressed parents

What Theories Underlie the Parenting EBP

Most common: social learning theory, cognitive behaviour theory, early childhood theory of development

Common: family systems theory, attachment theory

Somewhat common: social ecological theory of child development

Uncommon: social capital, family stress theory, co-production with parents, community organizing, empowering parents in leadership roles, issues of power and social justice

Groups of parents? Parents and children? Multi-family groups? How much time with each?

Number of parents served: 8; 15; 21-51 whole families

Group facilitators: one, two, or team of 4 partners

Training of facilitators: professional; non-professionals; parent/service users with professionals

Form of delivery: all didactic; mix of lecture, role play and video tapes; only experiential learning

Weekly meetings (number of sessions varies: 4, 6, or 8, 10, 12, or 16; with 22 boosters or less or without)

Where and when: Clinic settings, or informal church, community settings or schools; day, evening, weekend

How is the Parent Group Delivered?

Parent ability to do parent-child ‘responsive play’ activity is included in

several EBP

Special Play

What is the Evidence: RCTsWhat gets you on the EBP List?

Randomized controlled trials (RCT) Rigour: size, attrition, results, effect sizes, negative

outcomes ITT intent to treat analyses? Standardized

instruments? Independent RCT or by the programme developer

There may be 20 government or private lists of EBP and they are now being compared and critiqued;

UNODC list is in order of how many RCTs each of evidence-based family skills programmes had 1) Triple P—listed with 45, but recently learned they

have 65 2)Incredible Years— … 11) FAST— four RCTs completed with one year

follow-up

Website and materials for EBP awarenessManuals for training the evidence based

practiceCore components and core practices

identifiedTraining provision capability of high qualityCapacity developed of numbers of certified

TrainersProgramme integrity checklists for

monitoring implementations; Room for local adaptation?

Monitoring demographics of parent drop-outsPre and post tests to determine: was there

impactSustainability over time: re-certification

processes

Quality Assurance for ‘Scaling up”

Giving & Receiving Support Between ParentsReciprocal Parent Support (McDonald & Moberg, 2002)

=P<.10(10% change due to chance =P<.001 (1% change due to chance=P<.05(5% change due to chance =P<.001 (1% change due to chance

Family RelationshipsFamily Environment Scale (Moos & Moos, 1981)

=P<.10(10% change due to chance

=p<.05 (5% Change due to chance)

P<.01 (1% change due to chance)

P<.001 (0.1% change due to chance)

N=153

Parents report on Pre and Post FAST on Child’s Behaviour at home

Strengths & Difficulties Questionnaire (Goodman, 1997)

Pro-so

cial

Emot

iona

l

Condu

ct

Hyp

erac

tivity

Peer P

robl

ems

Total

Impa

ct

0

2

4

6

8

10

12

14

8.6

1.9 1.6

4

1.4

8.6

0.3

7.69

2.55 2.36

4.44

2.38

11.75

0.960000000000001

8.17

1.92 1.79

3.61

2.01

9.35000000000001

0.820000000000001

British Av-erage

Pre FAST

Post FAST

N=164

=P<.10(10% change due to chance)

=P<.05 (5% change due to chance)



Teachers report on Pre and Post FAST on Child’s Behaviour at home

Strengths & Difficulties Questionnaire (Goodman, 1997)

=P<.10(10% change due to chance)

=P<.05 (5% change due to chance)


N=210


Quality Assurance for Scale Up of EBP Parenting for Child Well-Being

Teams are made up of local parents and multi-agency professionals from health, education, social care: parents help to run FAST at every level

Teams must be culturally representative of race, class, religion, language of students at local school

Middlesex University does Quality Assurance Certifies FAST Trainers and Supervisors Training (2 days) Supervision (3 Days) & Evaluation (1

day) Evaluation of pre and post SDQ, Moos and Moos,

social capital Monitoring retention rates and demographics of

poverty Capacity Building and sustainability and planning

Retention Rates of 83% across 15 Local Authorities (UK)

RCTs averaged 20% Drop Out Rates forLow-Income Parents: Could That be Replicated?

Retention rates: if a family comes once, about 80% will complete 6 or more of 8 weekly FAST meetings & graduate to parent-led monthly groups (4 RCTs): 72% inner city, low income, single parent, African American

families with emotionally disturbed children in New Orleans 80% rural, Native American reservations, low-income families

with universal recruitment of all children in Wisconsin 85% urban, Mexican American immigrants, low income,

universal recruitment of all children in Milwaukee, Wisconsin 90% risk for special education with behaviour problems, low-

income, mixed cultural backgrounds in Madison,WI

Household Income: 77% of Parents were below £20K

12/04/2023

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Drop out rates of Low-Income Parents

Not monitored usually by the parenting programme

Data are difficult to find, no central data bankChild mental health clinics: if you come once,

40-60% will drop out prior to treatment completion

Child clinics: if parent is low-income, lone parent, black or ethnic minority, over 60% drop out early

Voluntary Parenting groups: drop out rates for low-income, socially marginalized parents are 75-95%

This must be monitored and addressed

How is Parent Retention Managed?

Is attendance monitored? Follow up if missing?

Are there rewards for attendance? Prizes? Payment?

Meals for participants? Who cooks?Free transportation?Free child care?Ethnic matching of facilitator and group?Increased interactive learning style vs.

lectures?Are parents given manuals? Home work?Is time for socializing made possible?Are there strategies for showing poor parents

respect

1. Strategies for Social Inclusion to Reduce Drop Out

Parents are required partners on the team at every level of program: in planning, training, adaptation, delivery

Parents are part of a team which also has professionals from health, education, social work

Teams are required to be culturally representative of the participating families Religion, language, ethnicity, social class, race,

geography, immigrant status You see someone like yourself co-leading the groups


Family systems approach supports hierarchy of executive sub-system: respecting parents always Only the parents are spoken to, not the children Parents are coached and supported to lead activities for

their own children Parents are coached and supported to give children

multiple imbedded compliance requestsWhole family invited (serves 20-60 families at a

time)Universal recruitment of all children at an age

level especially in schools serving high-needs communities Persistent outreach for ‘hard to reach’ families Parent partners (matched on SES and ethnicity) do

outreach


‘Please, just come try it once’ Low risk: business psychology strategy to ‘try it

once’ Systematically reinforce attendance once it

happens Bring your family with you: easier for the parent Link onto ‘natural and ecological’ positive

interests of parents Parents have interest in their child’s well-being and their

child doing well in school: Parents have an interest in meeting other parents of

children in the same year group at a school Parents recognize ‘transition of starting school’ as

stressful for their child


Reciprocal exchanges model social inclusion- Universal cultural practice of receiving

and giving back visible for children to see

Each family wins a big basket of gifts: FAIR

When they win the lottery, parent is given a cook pot and grocery tokens to prepare a meal

Each family is expected to give back to FAST

Families sign ‘thank you’ note and respect the weekly cook with public thanks presentation


Flexible ‘manualized’ multi-family group programme for ‘deep’ cultural adaptation: Core components 40%; programme integrity is

monitored with 3 sites visits in 8 weeks Local adaptation by the team of 60% of its group

processes is encouraged to fit with local priorities:

Local teams adapt the program including professionals from health, education and social care in partnerships with parents from the school;

Local adaptation and flexibility respects different kinds of cultural, religious knowledge


Positive programme for child well-being Positive setting of the school (rather than a potentially

stigmatised child mental health clinic ) Positive name (Families and Schools Together) Positive activities for experiential learning with

weekly repetitions Structured and sequenced family activities interrupt

family conflict and boredom Positive experience of mastery of repeated activities

and routines Strengths based: values are that ‘every parent loves

their child’ Positive energy with people singing, drawing, crafts,

laughing, talking and playing together


Strengthening relationships in social ecology of the child: building protective factors against stress Parent child bond Family unity (reduced family conflict) Parent to parent bond Parent connection to 4-5 other parents at that

school (social capital) Parent connection to the school teachers and staff Parent connection to the local community Parent self-referrals to health, education, social

care resources as needed


After 8 weekly parenting group meetings, what happens? Does it just end! What about having 22 monthly booster sessions to maintain gains a graduation ceremony is held in recognition of the

progress that has been made. Parents in the parent group have made many

relationships of trust; 86% report they continue to see friends they met in 8 weekly meetings 4 years later

Affirmation: Parents are given by the team positive parenting observations made over the 8 weekly groups

Parent graduates host 22 monthly booster sessions to maintain gains with school support.

Good Luck Today Learning about Three EBP

Thank you for coming to Middlesex Univ today

Thank you for being interested in children and families in the UK and considering EBP

Thank you for coming to learn about three distinct best EBP practice parenting programmes today

Thank you for being committed to Social Inclusion Best Practices for UK Parenting groups

Good luck!

Professor Lynn McDonald, Middlesex University

Education

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