Parenting Interventions: Effectiveness Across Contexts and Cultures

Transcription

1 Parenting Interventions: Effectiveness Across Contexts and Cultures Frances Gardner Professor of Child and Family Psychology Centre for Evidence-Based Intervention Department of Social Policy & Intervention University of Oxford, UK

2 Collaborators: Acknowledgements: UK: Profs Judy Hutchings, Paul Montgomery, Paul Ramchandani, Wendy Knerr, Lucie Cluver Sweden: Knut Sundell USA: Early Steps team: Tom Dishion, Danny Shaw, Melvin Wilson. Funders of parenting trials and reviews: Oak Foundation - MRC South Africa, Swedish Board of Health and Welfare, NIH - NIDA, NIMH Esme Fairbairn Foundation, Nuffield Foundation; Health Foundation,

3 Parenting interventions: Examining the evidencebase across families, contexts and cultures Outline: Why parenting? What interventions? Basic evidence on effectiveness. To what extent does this evidence apply across contexts? Do they work in the real world? Randomised trials in UK, mechanisms of change For which children & families, what kinds of problems? Are they adaptable to different service settings, cultures, countries? Factors affecting transportability

4 Parenting interventions: What are they?

5 Essential components of effective parenting programmes Specific, core factors eg social learning theory, attachment theory provide core principles underpinning intervention General factors eg relationship & counselling skills; respecting parents goals & values Effective programmes tend to share general & specific principles eg Triple P (Sanders) Incredible Years (IY) (Webster Stratton) Parent Management Training (PMTO) (Forgatch) Parent-Child Interaction Therapy (PCIT) (Eyberg) Family Check Up (FCU) (Dishion et al., 2008)

6 Specific components / ingredients of effective parenting interventions - Emphasise principles rather than prescribe techniques -Active problem solving by parents around own family needs - Using social learning principles: eg importance of parent child interaction, reinforcement, clarity, consistency. - - Start with relationship building, praise and rewards, - - Later move onto discipline strategies, reducing conflict, harsh parenting - - Parents apply principles to own situation, to change parenting behaviour

7 Common components/ingredients of effective parenting interventions (eg Incredible Years, Triple P) Collaborative leader/ therapist style, start with parents needs & goals Parents use active problem-solving to apply principles to own situation. Not didactic. Focus on behavior change: video, discussion, role-play practice; home practice with child Materials to support program: tip sheets, books, CDs etc Group programmes: parents receive weekly feedback; between session support from group leaders Groups must be accessible for parents (time, place, language, food, child care)

8 Parenting interventions: how do we know they work?

9 What constitutes good evidence? Randomised controlled trial (RCT): Considered gold standard for minimising bias in evaluation Well-worked out methods for complex interventions; parents views central to evaluation Good quality research is expensive, but so is ineffective or untested practice - even more so Well-meaning interventions may do no good - and worse, may do harm (ethical obligation). Many examples of well-liked interventions doing harm Systematic Review: Summarise findings of trials - rigorous, transparent, replicable, up to date. Very useful for policy

10 Effective parenting interventions: What is the evidence base? Assuming we know what constitutes good evidence- Over 100 randomised trials, many good systematic reviews (Barlow Cochrane, Campbell reviews, NICE guidance) Show effectiveness of parenting interventions based on social learning theory for: Reducing child problem behaviour Improving positive and harsh parenting; reducing parent depression, child maltreatment Early and middle childhood, and teens Replications by independent teams, different places. All this evidence - why use one without an evidence-base? Need to ask: in what contexts was it gathered? Is this evidence applicable to a wide range of families, children, contexts, countries?

11 Data from RCTs suggests effective for a range of families: Low income and average families Families with complex, multiple needs (eg maternal mental illness, high poverty, those with incarcerated sibs (eg Scott; Webster-Stratton; Gardner). Need to remove barriers. Child problems range from severe conduct disorder/ offending, to mild problems or none; children with multiple problems (eg ADHD, learning disability) Families in child protection system Much evidence is from US & Australia - do they work in UK? Our UK trials: i) examined effectiveness ii) asked if intervention is more or less effective for more severe or disadvantaged subgroups (moderator analyses)

12 Examples of randomised trials of parenting interventions: Do they work in UK real world settings?

13 Randomised trials in real-world UK services Treatment trials - referred for moderate-severe conduct problems London, CAMHS (Scott et al., 2001): age 3-8 Oxford, community-based in voluntary sector (Gardner et al., 2006): age 2-9 Prevention trials - targeting those with emerging conduct problems North Wales Sure Start: (Hutchings et al 2007; Gardner et al, 2010). In multiple Sure Start services, age 3-5. London, Primary Schools: two trials (Scott et al 2010 a b). Parents of 5-6yr olds. Incredible years plus parent reading

14 Oxford parenting trial in voluntary sector: Family Nurturing Network (Gardner et al. 2006, JCPP) 76 children age 2-9, referred for mod-severe conduct problems Randomised to Incredible Years groups in 5 sites, vs wait-list. Found strong intervention effects (ES.5 -.8) on: - child conduct problems; and siblings - - positive and negative parenting skill - - by parent report & direct observation in home; Intention-to-Treat analyses Effects maintained to 18 month follow up. High consumer satisfaction. Real world service? Testing real practice, small NGO, local venues, low paid, non-clinically-trained staff. Hutchings North Wales trial, more so, similar effects or better, high risk prevention, age 3-5.

15 Mediators of change in parenting interventions: these ask: how do they work, or what are the active ingredients of intervention?

16 Why investigate mediators of change in parenting trials? 1. Clinical questions: Is the intervention working in the way we think it is? What are key active ingredients that we need to emphasise? 2. Scientific questions: Can test theories of intervention change, and, combined with longitudinal studies, test theories of developmental change (Rutter, 2005). For example: Positive parenting shows up as predictor of natural change in child problem behaviour does it also work as mediator of intervention change? (Dishion et al 2008; Gardner et al 1999; 2003, 2006, 2007, 2010). If so, powerful evidence for a causal role...

17 Could we identify mediators of change in our UK parenting trials? - Oxford trial: found change in observed positive parenting in the home predicted change in child problem behaviour. Replicated in Wales & US trial of the Family Check Up (Gardner et al. 2006, 2007; 2010; Dishion et al 2008) - - Oxford trial: also tested competing mediation models, asking which is more important in driving intervention change? is it change in parents confidence about parenting; or change in positive, or in harsh parenting? - although all these outcomes were improved by intervention, only change in positive parenting skill appeared to be driving change in child behaviour (Gardner et al. 2006) -- change in maternal depression also mediated change in child outcome in Wales, and US studies (Shaw et al., 2010)

18 Moderators of change in parenting interventions: for whom do they work? look for differential effects - do they work better for some than others?

19 Moderator analyses: Can parenting interventions help diverse families, or those that are very troubled or marginalised? 1. Which families? Socio-demographic, ethnicity, parent factors, eg mental illness 2. Which children? Age, gender, complex needseg severe conduct problems; co-morbid problems - ADHD, anxiety; children who show callous traits; in child protection system.

20 Why investigate moderators of change in parenting trials? Clinically: Identifying groups for whom intervention is suitable; subgroups which might need extra therapeutic effort, or where might do harm. May challenge beliefs about suitability of client groups for interventions (eg Ollendick et al. 2008). Theoretically: Identifying subgroups that are differentially responsive to intervention - and thus distinct causal mechanisms? Mediated moderation cf. Bakermans-Kranenburg

21 Moderator effects: definition In intervention trials, moderator analyses ask whether intervention effects are conditional on initial characteristics of the sample - or- does one sub group have better or worse outcomes than the other, compared to the equivalent subgroup in the control group. moderators distinct from predictors of outcomeassociated with outcome only in the treatment group

22 Recent studies of moderators - many earlier predictor studies found worse outcomes in more troubled families (Lundahl et al., 2006, n=63 Reyno & McGrath, 2006 n=31) - However, moderator analyses in large US Incredible Years trials reached quite different conclusions (Beauchaine et al. 2005; Baydar et al. 2003) - What is known about moderator effects in UK trials?

23 What did we find in Wales? Moderator effects in Incredible Years trial -Gardner, Hutchings et al,2010 What primary outcome? - change in parent-reported conduct problems What family predictor variables?.. Found: No family risk factors were associated with poorer treatment outcome - low income, lone parent, teen parent just as likely to do well But, some were associated with better outcomes - mother depression, parenting stress. Similar pattern of moderators in Oxford trial; in Family Check Up RCT in US (Gardner et al, 2009, 2010)

24 Family Check Up (FCU): Intervention effects on Child Problem behaviour by parent education level (Gardner, Dishion et al 2009 JCCP)

25 Moderators, or for whom do they work? Child characteristics as moderators Clinically, what kinds of kids those with more severe conduct problems, or comorbid problems- ADHD, anxiety, callous traits? At what age is it better to intervene?

26 Children with severe conduct problems and comorbid problems Children who were boys, had high ADHD, high conduct problems did better in Wales trial (Gardner et al, 2010; Jones, Hutchings et al.2009 ) Ollendick review (2008) showed co-morbid kids did not do worse in interventions for conduct problems (nor for anxiety, depression) Moderators in Triple P trials?

27 Parenting interventions with children who show Callous-Unemotional behaviours Callous unemotional children thought to be hard to treat -low anxiety, guilt, unresponsive to socialisation, esp. punishment Is there any evidence that kids with high levels of CU are less responsive to parenting interventions? Very few studies addressing this question: Hawes & Dadds (2003) Yes. Kids 4-8 with conduct problems showed poorer treatment outcome if also had high CU traits. Predictor study only- don t know if might have been same for control group CU kids. Hyde, Shaw, Gardner, Dishion. (2011) No. Toddlers at risk for conduct problems showed similar outcomes in Family Check Up intervention, if had high or low CU traits. Moderator design Teen delinquents with CU - did as well with CBT in US study

28 Conclusions on moderators: are parenting interventions applicable to a wide range of families, or are there differential effects? Recent trials show no moderator effects for most family risk variables - contrast with older predictor literature. No evidence more troubled families / kids respond less well Outcomes as good or better if mother depressed, very poor, low education, teen parent, high ADHD. Callous traits - unclear What might be common factors in interventions (IY, FCU) that reach more troubled families? To varying degrees, both use tailored, individualised approach In IY, collaborative group process In Dishion s Family Check Up, Motivational Interviewing techniques to enhance parent engagement, desire for change

29 Does age of the child matter? Surely early intervention is better?

30 Source1: Parenting interventions: comparing effects by age group between meta-analyses. Fill in the blanks: what mean effects would you expect? Age of children 0 3 Mean effect size (WMD)? Primary outcome Parent reported behaviour problems Author Barlow et al Cochrane review 3 11? Parent reported conduct problems Dretzke et al., 2009 NICE/ HTA 10 17? Arrest rates Woolfenden et al Cochrane review

31 Source1: Parenting interventions: comparing effects by age group between meta-analyses. Mean effects based on Cochrane / HTA reviews Age of children Mean effect size (WMD) Primary outcome Author Parent reported behaviour problems Parent reported conduct problems Barlow et al Cochrane review Dretzke et al., 2009 NICE/ HTA Arrest rates Woolfenden et al Cochrane review

32 Source 2: Comparing effects by age group within meta-analyses Age covered Interventions What age effects Authors 1 17 All interventions for conduct, anxiety depression 2 16 parent training for conduct problems more effective with older kids No interactions by type of problem more effective with older kids. Corrn r=.69 age & effect size Weisz et al (1995) Serketich & Dumas (1995) 2 5 yrs vs 6 12 parent training for conduct problems. No age effects Lundahl et al (2006)

33 How well do parenting interventions transport across service contexts, countries & cultures?

34 In what service contexts have parenting interventions been tested? Settings for these randomised trials: Many countries; wide range of targets: Universal and targeted prevention, and treatment studies. Range of service settings: health services primary and specialist, schools, child protection services, community groups, voluntary sector/ NGOs, Head Start nurseries, day care, workplace, prisons Range of delivery methods: Individual vs group; home vs centre-based; phone. Media-based, eg computer-programs; TV, reality TV (Triple P) Thus can be flexible according to family need, preference, context. Many more settings in practice- these are just the trials!

35 Can parenting interventions translate well across countries and cultures? Will a program effective in US transport to Sweden? Aust- UK? Will a program effective with white families in US & NZ work for Maori families in New Zealand? What factors affect whether such transportation is possible? When we move countries, this may mean big shifts in service context as well as culture (US Sweden). Vital questions to answer with so much international enthusiasm for dissemination Much evidence on transported interventions, will give some examples But- there is no systematic coverage - so will also tell you about a new systematic review underway.

36 Can parenting interventions translate well across cultures? Cultural factors (Incredible Years, Triple P; many other examples too): Diverse families in many RCTs (Scott -London; Gross- Chicago; Miller- NY Bronx; Webster Stratton- Seattle) Consumer testing in some countries and cultures (eg Panama, Greece, Japan, Manchester, indigenous people in NZ, Australia; Triple P & IY), to help guide implementation

37 Incredible Years parenting in different cultural groups - evidence from trials Large Webster-Stratton (n=650) study based on pooled data from 3 RCTs with diverse low income families in HeadStart nurseries (Reid et al., 2003) 19% African American, 11% Hispanic, 12% Asian, 50% Caucasian - found no ethnic differences in any child & parent outcomes, by parent report or direct observation; nor in engagement, attendance, parent satisfaction Scott s trial in London schools, also no effect of ethnicity on outcomes satisfaction, attendance (Scott et al 2010, PALS trial). Studies of other interventions have found similar results- PCIT, FCU - no differences in outcome by ethnicity.

38 Can parenting interventions translate well across countries? Many successful examples Randomised trials of Incredible Years, Triple P in: UK, US, Ireland, Canada, Australia, Norway, Hong Kong, New Zealand, Germany, Holland, Iran.. Implementations in many more: Russia, Thailand, Denmark, Japan, Portugal, France.. What counter examples? MST didn t work in Sweden (Sundell, 2008), nor Canada. Triple P in Zurich; Strengthening Families in Sweden. Why not? Publication bias? -investigators less likely to write up unsuccessful interventions / trials (eg poor service context fit for parenting groups in Jamaica; led to IY teacher focus, Baker-Henningham, 2010)

39 What about parenting interventions in low and middle income countries? Much concern in low & middle income countries about youth violence & problem behaviour, family violence, child abuse (WHO, 2002; UNODC, 2009). Much enthusiasm for EB dissemination. Would parenting interventions help? One recent systematic review (Knerr, Gardner, Cluver, 2012):

40 Findings of systematic review of parenting interventions in low and middle income countries (Knerr, Gardner, Cluver, 2011): Conducted according to Cochrane Guidelines Found 12 RCTs of parenting programmes some transported from other countries all worked to improve parenting skills - but most RCTs very poor quality; 2 trials of high methodological quality/ low risk of bias - Rahman, Pakistan; Cooper, South Africa. Striking that none were programmes with a prior evidence-base

41 Systematic review of transportability... Many examples to pick- but no systematic evidence. Questions for systematic review: Q1. How effective are parenting interventions when transported to countries different from those in which they were developed and tested? Q2. Using these data, what factors appear to influence successful transportation or otherwise, across countries? Initial focus: parenting interventions for children 3-10, with identified conduct problems Gardner F, Montgomery P, Knerr, W (Oxford) in collaboration with Knut Sundell (Swedish Board of Health and Welfare)

42 Methods for review Q1: effectiveness of transported parenting interventions for conduct problems Stage 1: search systematic reviews to identify evidencebased (EB) parenting programs for reducing conduct problems in 3-10 yr olds. (100+ reviews!) Stage 2: global lit search*, based on stage1 list of EB programs, to identify programs developed & tested in Country 1 (origin), then transported and tested in Country 2 (RCT/ quasi-rct). 3. Apply inclusion criteria, appraise study quality, examine heterogeneity, conduct meta-analysis. * search grey literature, non-english databases, author contacts... So far finding large

43 Methods for Q2: factors affecting transportability of parenting interventions 2 strategies - 1.cautiously quantitative; 2. narrative synthesis 1. Subgroup analyses within meta-analysis: - do effect sizes vary by characteristics of intervention, or context, in country 2? - will code trials by factors such as: country type, level of alternative services, theory-base, type of intervention. 2. Search for contextual & cultural literature associated with EB interventions included in review; narrative review of factors identified in literature

44 Ways of classifying cultural & service context factors that may affect transportability. (Sundell & Ferrer-Wreder, 2011) Country service context: for example, how did this differ for MST in Sweden vs in Missouri, US? (Sundell et al., 2008) Cultural i: classify factors at whole country level (Sussman et al 2008); will success depend on cultural distance between country 1 and 2? (eg individual vs collectivist societies; gender roles) Cultural ii: in more micro sense of fit between intervention and recipients- has it been specially adapted? Or does it build in cultural flexibility?

45 What is needed for transportability? Cultural adaptation, or flexibility with fidelity...? Essential that programs are culturally sensitive, respect families values But should they be adapted for specific groups? If so, must do this with fidelity- ie retain core ingredients that make it effective Or should be sufficiently flexible not to need multiple versions? Limited evidence on this issue US trials show poor or equal results for adapted versions (Kumpfer et al 2002; McCabe & Yeh 2009) Many programs allow or encourage adaptation with fidelity eg Incredible Years - good results with minority families for flexible approach; eg SafeCare study: practitioners valued flexibility & fidelity, did not see need for specific adaptations (Self-Brown et al. 2011)

46 Instead of adaptation (with fidelity?) - Maximise flexibility in first place? Enhance flexibility by building it in from outset - thus adaptation happens at the level of every family, rather than adapted for the cultural group or country, whilst keeping fidelity to core principles: eg Incredible Years: although topics laid out, parents define own goals, generate & test own solutions; staff training rewards adaptation to clients situation This approach brings advantage of embedding in natural communities, fostering tolerance (eg school, nursery) rather than culturally segregated groups, as result from culturespecific adaptations. May need many surface adaptations: videos, acting, location, social norms (Lau, 2006; Kumpfer, 2002; Webster Stratton, 2010)

47 What do we know? Some conclusions Effective parenting interventions Strikingly strong evidence base. Know something about mechanisms Can engage & help a wide range of families Effectiveness evidence appears to transfer across diverse cultures & service settings in many countries but not in all contexts.. Much written, but little systematic evidence about the extent of transportability across countries, and the factors affecting its success or otherwise Promising evidence of applicability in developing countries; need trials of EB programs.

48 Some references Gardner, F., Hutchings, J. & Bywater, T, Whitaker, C. (2010). Who benefits and how does it work? Moderators and mediators of outcomes in a randomised trial of parenting interventions in multiple Sure Start services. Journal of Clinical Child and Adolescent Psychology, 39, Gardner, F, Connell, A, Trentacosta C, Shaw, D., Dishion, T, Wilson, M. (2009). Moderators of outcome in a brief family-centred intervention for preventing early problem behaviour. Journal of Consulting and Clinical Psychology, 77, Montgomery P, Gardner F, Bjornstad G, Ramchandani P. (2009). Systematic reviews of interventions following physical abuse: Final report to DCSF. Cochrane reviews in prep. Dishion, T., Shaw, D., Connell, A., Gardner, F. et al, (2008). The Family Check-Up with high-risk indigent families: preventing problem behavior by increasing parents positive behavior support in early childhood. Child Development, 79, Hutchings, J., Bywater, T., Daley, D., Gardner, F., Jones, K. et al (2007). Pragmatic randomised controlled trial of a parenting intervention in Sure Start services for children at risk of developing conduct disorder. British Medical Journal, 334, Gardner, F., Burton, J. Klimes, I. (2006) RCT of a parenting intervention in the voluntary sector for reducing child conduct problems: outcomes and mechanisms of change. Journal of Child Psychology & Psychiatry, 47, pdf

49 Thank you!

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