Case Study 1: An Evidence-Based Practice Review Report. Theme: Interventions for children with Special Educational Needs

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1 Doctorate in Educational and Child Psychology Rheanne Jalali Case Study 1: An Evidence-Based Practice Review Report Theme: Interventions for children with Special Educational Needs How effective is the Incredible Year s parenting programme at improving parenting behaviour towards children with Conduct Problems/Disorder and/or Oppositional Defiant Disorder? Summary The Incredible Years is a series of parenting programmes designed to encourage positive parenting skills and reduce negative conduct behaviours in children. Depending on intensity and child age, parent training can last up to twelve weeks; using a structured sequence of topics and activities to develop children s social, emotional competence. This literature review aimed to evaluate the effectiveness of the Incredible Years parenting programme at improving parent behaviours towards children with Conduct Problems, Conduct Disorder and/or Oppositional Defiant Disorder. A systematic literature search was conducted using three databases. Five selected studies were analysed using a coding protocol adapted from Kratochwill (2003), with quality of evidence determined by Harden & Gough (2012) criteria. This review found that there was moderate evidence to suggest the effectiveness of the Incredible Years in improving positive parenting, reducing negative parenting and improving social and emotional well-being. Specific methodological limitations are explored and further research has been suggested to strengthen findings within this area.

2 Introduction Description of the Incredible Years Parenting Programme The Incredible Years (IY) is a series of preventative and targeted programmes aimed at reducing challenging behaviour and building social and emotional competence in children who display signs of Conduct problems (CP) and/or Conduct disorder (CD) (Brotman et al., 2003; Brotman et al., 2005; Scott et al., 2010; The Incredible Years, 2013). Originally designed from a videotape modelling intervention, the IY programme has expanded to include multiple levels of intervention (e.g. basic and advanced), age groups (e.g. infancy, pre-school, school age) and training schemes (e.g. parent, teacher and child). Additionally, these programmes target a wide range of behavioural difficulties including Oppositional Defiant Disorder (ODD) and Attention Deficit Hyperactivity Disorder (ADHD) (Linares, Montalto, Li & Oza, 2006; The Incredible Years, 2013). The goal of training is to improve parenting practice by encouraging appropriate discipline, positive reinforcement, social skills training and play interaction, promoting the child s social and emotional competence (defined as cognitive understanding of emotions and social reactions) (Cline & Frederickson, 2009; Goleman, 1996; Kim, Cain & Webster-Stratton, 2008). This aims to prevent the formation of later conduct problems (Posthumus, Raaijmakers, Maassen, van Engeland & Matthys, 2012; Webster-stratton, Reid, & Hammond, 2001). Parent training lasts for up to twelve weeks, consisting of a structured sequence of topics (e.g. positive behaviour and aggression strategies) using a collaborative approach between facilitator and parent (Beauchaine, Webster-Stratton, & Reid, 2005). Facilitators use vignettes and video interaction to encourage modelling, group 1

3 discussion, problem solving and self-management (Gardner, Hutchings, Bywater, & Whitaker, 2010; Webster-stratton et al., 2001; The Incredible Years, 2013). Initially targeted at families of low socio-economic status (increased risk factors), the parenting programmes are culturally and economically sensitive, available internationally and distributed by non-profit voluntary organisations (Gross et al., 2003). Psychological Basis Developmental models postulate an interaction of multiple influences on the development of child conduct problems. One of these influences is negative parenting (Brotman et al., 2009). The IY programme is consistent with social interactional learning models, depicting that behaviour patterns occur within the home from primary socialisers (Brotman et al., 2003; Patterson, 1986). The IY intervention is based on the premise that children s negative behaviours are learnt from parents through reinforcement. This assumption is based on social learning theory and behaviourist psychology principles. Such theories suggest that all behaviours are produced by experiences of response consequences, resulting in learned behaviours over time (Akers, Krohn, Lanza-Kaduce, & Radosevich, 1979; Cline & Frederickson, 2009; Miller, 1994). Conduct problem behaviours establish during early childhood from negative interchanges between parent and child (Brotman et al., 2005; Cunningham & Boyle, 2002). These behavioural difficulties escalate with developmental challenges (e.g. transition to schooling) where the child is unable to cope with social and academic pressures (Campbell, Shaw & Gilliom, 2000; Patterson, 1986). Within school and home environments, children learn to escape pressures by escalating their negative behaviour. As part of the social 2

4 interactional learning model, Patterson labels this a coercive process (Patterson, Reid & Dishion, 1992). Intervention primarily involves changing social discourses in the family environment (Webster-Stratton, 1984; Webster-Stratton, Kolpacoff & Hollinsworth, 1988). As primary socialisers, parent training aims to change children s behavioural difficulties within the family context (Miller, 1994). Parents learn social-learning principles whereby appropriate behaviours are positively reinforced and inappropriate behaviours discouraged. Many studies have confirmed the effectiveness of the behavioural parent training method (McCart, Priester, Davies, & Azen, 2006). The specific methods used in the IY are equally supported by psychological theory. Within the IY programme, parents watch video clips of child-adult interactions facilitating group discussion, problem solving and the sharing of ideas. The origins of videotape modelling relate to Attachment Theory principles in which the goal is to illuminate the affective nature of parent-child interactions. Video tape modelling can support changes in parenting behaviour by providing opportunities to observe affective, nurturing interactions and identify the responses that produce positive outcomes. In the IY programme, parents experiment initiations with their own child through a scaffolding approach, fostering the development of warm and positive relationships (Bowlby, 2008; The Incredible Years, 2013; Webster-Stratton & Hammond, 1997; Wood, Bruner & Ross, 1976). Research has indicated the effectiveness of video tape modelling methods (Webster-Stratton, 1984; Webster- Stratton et al, 1988; Webster-stratton, 1992; Webster-Stratton & Hammond, 1997; Webster-Stratton, 1998). 3

5 Rationale The incidence of child conduct problems is an issue shown to be increasing internationally (Posthumus et al., 2012; Webster-Stratton et al., 2001; Websterstratton, Reid & Hammond, 2004). As aggressive behaviours become increasingly resistant to change, longitudinal studies suggest that intervention should occur at the earliest point possible. Furthermore, without early intervention, behavioural difficulties such as ODD and CP/CD result in entrenched patterns by eight years of age, leading to later difficulties (e.g. peer rejection, academic failure and criminality) (Eron, 1990; Fossum, Mørch, Handegård, Drugli, & Larsson, 2009; Miller, 1994; Snyder, 2001). In the UK, such outcomes highlight the importance of preventive and targeted intervention to children displaying conduct difficulties. Government strategies have focused on early intervention for children since the introduction of the Every Child Matters agenda (DfES, 2003). Typically, Educational Psychologist (EP) involvement will occur when the child is presenting behavioural difficulties within school. When considering the psychological development of conduct difficulties, one could suggest that such involvement is too late to eradicate all negative behaviours. However, research suggests that parenting interactions are one of the most important protective/ risk factors for early onset conduct behavioural problems, with parent training a key mechanism for change (Miller, 1994; Webster-stratton et al., 2004). This gives insights into the ways that EPs can support the child and reverse the impact of some behavioural difficulties, promoting long lasting change. A meta-analysis of the IY by Menting, Orobio de Castro & Matthys (2013) demonstrated the effectiveness of the parent training in 4

6 improving child CP/CD and/or ODD behaviours. However, as noted by the authors a premise of the IY is that the child s behaviour is ultimately influenced by the parent s. In considering the potential benefits of parent training, analysing specific improvements in parental behaviours and well-being is an area yet to be explored. By targeting and modifying parental practices at the source, it is expected that there will be longer lasting improvements in the child, particularly for later school life (Menting et al., 2013). With this in mind, this systematic literature review provides an appraisal of the evidence base for the effectiveness of the IY parenting programme in improving parental behaviours towards children with CP/CD and/or ODD. Review Question How effective is the Incredible Year s Parenting Program at improving parenting behaviour towards children with conduct problems/disorder and/or oppositional defiant disorder? Critical Review of the Evidence Base A comprehensive literature search was carried out on the 30 th December 2013, to locate all studies relevant to the research question. A search was undertaken in three databases (ERIC, Medline and PsycINFO) using the search terms outlined in Table 1. Table 1 Search Terms Applied Database Search Term 5

7 ERIC Medline PsycINFO Contains intervention (all fields) AND conduct (all fields) AND parent* (all fields) Contains intervention (all fields) OR incredible years (all fields) AND conduct (all fields) AND parent* (all fields) Contains intervention (title) OR incredible years (abstract) AND parent* (abstract) AND conduct (title) OR conduct problem* (title) This review aimed to develop a research area suggested by Menting et al. (2013). The searches were limited so that only studies in peer-reviewed journals (to control for research quality) and written in English (translation resources were not available) were included in search results. Studies containing group-based Incredible Years parenting interventions, pre-post data and the use of an intervention and control group were necessary for their appropriateness to the research question. This is in line with evidence hierarchies (Guyatt et al., 1995). However in considering the availability of studies, it was decided that randomisation need not be necessary. Removing duplicates, the relevant search pages were screened for appropriate studies, initially via title and then by abstract. A flow diagram of the study selection process is illustrated below. Reasons for exclusion are outlined in Appendix 1. Of the 5 studies chosen, 3 were identified by Medline, 1 by PsycINFO and 1 by ERIC although there was overlap in presence across databases. The 5 studies that met the inclusion criteria for critical analysis are presented in Table 3 below. Diagram 1 Flow Diagram of Full Literature Search 6

8 Papers identified from search terms (PsycINFO, ERIC & Medline) n = 620 Excluded based on Title n Abstracts Assessed n = 20 Excluded based on Abstract (Using Inclusion Criteria) n - 2 Full Text Assessed n = 18 Excluded based on Inclusion Criteria n - 13 Studies included in synthesis n = 5 7

9 Table 2 Inclusion & Exclusion Criteria Inclusion Criteria Exclusion Criteria Type of Article Language Type of data Intervention Measures Design The article is in a peer reviewed journal. As these studies are assessed using a stringent criteria, methodological rigour is ensured. The study is written in English. This is due to a lack of resources for translation. The study must contain primary empirical data. This ensures originality of findings. The study contains a condition whereby the parent IY training is solely implemented as part of the study. Children within this condition receive no additional intervention alongside their parents. This ensures accuracy of findings. The study measures (internal/external) improvements in parenting behaviour. The study is a controlled design with pre and post (and/or follow up) intervention measures of parenting behaviour. This can ensure accurate detection of improvements in parenting behaviour from the IY training. The article is not in a peer-reviewed journal. The study is not written in English. The study does not contain primary empirical data e.g. Meta-analyses. The study does not contain a condition whereby the parent IY training is solely implemented as part of the study. Children within this condition receive additional interventions alongside their parents. The study does not measure improvements in parenting behaviour. The study is not a controlled design with pre and post (and/or follow up) measures of parenting behaviour. 8

10 Control Group Participants Children Parents Analysis Year of Publication The study uses a wait list control group. In comparing the findings of the effects of the IY training to the comparison group, this type of control ensures a greater accuracy, as participants will have similar characteristics, but receiving no additional intervention (as of yet). The study s participants are children aged 2 9. This targets a wide range of negative behaviours before they become potentially entrenched. The study uses participants who have been labelled as having CP/CD and/or ODD. The study includes parent(s) that are mother, father or both; biological, foster and/or step parents. The study reports quantitative analysis. This allows confounding variables to be separated out and ensures a focus on improvements in parenting behaviour. The study uses the intervention called the Incredible Years. The study does not use a wait list control group. The study uses an alternative intervention as its only control measure. The study uses children older than 9 years and/or without a label of CP/CD and/or ODD. The study does not include parents. The study does not report quantitative analysis in reference to improvements in parenting behaviour. The study uses an older version of IY known as the Videotape Modelling Programme (VMP). 9

11 Table 3 List of Included Studies Included Studies 1. Gardner, F., Burton, J., & Klimes, I. (2006). Randomised controlled trial of a parenting intervention in the voluntary sector for reducing child conduct problems: outcomes and mechanisms of change. Journal of Child Psychology and Psychiatry, 47(11), Hutchings, J., Bywater, T., Daley, D., Gardner, F., Whitaker, C., Jones, K., Eames, C., & Edwards, R. T. (2007). Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomised controlled trial. BMJ: British Medical Journal, 334(7595), Larsson, B., Fossum, S., Clifford, G., Drugli, M. B., Handegård, B. H., & Mørch, W. T. (2009). Treatment of oppositional defiant and conduct problems in young Norwegian children. European Child & Adolescent Psychiatry, 18(1), Letarte, M. J., Normandeau, S., & Allard, J. (2010). Effectiveness of a parent training program Incredible Years in a child protection service. Child Abuse & Neglect, 34(4), Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: Intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33(1), Comparison of Selected Studies The five studies were summarised (Appendix 2) and compared on methodological features. Of the selected studies, 4 were randomised controlled trials (Gardner, Burton & Klimes, 2006; Hutchings et al., 2007; Larsson et al., 2009; Webster- Stratton et al., 2004) and one used a controlled design without random assignment to conditions (Letarte, Normandeau & Allard, 2010). 10

12 The critical appraisal for quality and relevance framework, (Weight of Evidence, WoE) developed by Harden & Gough (2012) is designed to guide evaluation by weighting three aspects of each chosen study; Methodological Quality (WoE A), Methodological Relevance (WoE B) and Topic Evidence (WoE C). Within this review, weightings were numerically rated and averaged to create an Overall Weight of Evidence (WoE D) (Gough, 2004). This framework permits an objective judgement in determining each studies value and appropriateness to the review question. The WoE framework is shown in Table 4. The WoE for each study is shown in Table 5. To assess the quality of methodology (WoE A), the UCL Educational Psychology Literature Review Coding Protocol (adapted from APA Task Force on Evidence Based Interventions in School Psychology was used) (Kratochwill, 2003). These coding guidelines contain clear and extensive criteria, designed specifically for the type of studies included in this review. Within these guidelines, the quality of measures, comparison group and statistical analyses were examined. Completed coding protocols can be found in Appendix 3. Further information about the WoE framework is in Appendix 4. 11

13 Table 4 Framework for Weight of Evidence (Harden & Gough, 2012) Weight of Evidence A Weight of Evidence B Weight of Evidence C Weight of Evidence D Quality of execution of the study in relation to quality standards for studies of that type (Methodological Quality) Appropriateness of research design for addressing Review Question (Methodological Relevance) Appropriateness of focus of study to Review Question (Topic Relevance) Considering A, B & C to rate the overall degree to which the study contributes in answering the Review Question (Overall weight of evidence) Table 5 Weight of Evidence for each Study Studies Methodological Quality A Weighting Score Methodological Relevance B Topic Relevance C Overall Weight of Evidence D Gardner, Burton & Klimes (2006) Hutchings et al (2007) Larsson et al (2009) Letarte, Normandeau & Allard (2010) Webster-Stratton, Reid & Hammond (2004) Medium High High High Medium High Medium Medium Medium Medium Medium Medium Low Low Medium Low Medium Medium Medium Medium 12

14 Critical Review Outcome measures. Improvements in parenting behaviour were defined as increased positive parenting, reduced negative parenting and increased parent emotional wellbeing. Reported effect sizes used Cohen s d and Eta-squared (n 2 ) (calculated to 2dp), judged according to relevant criterion (Cohen, 1988; Ferguson, 2009). See appendix 2 for full outcome measures. Improvements in positive parenting behaviour. Positive parenting can be defined as nurturing and supportive behaviours that encourage children s social and emotional development. Such behaviours include praise, boundary setting, appropriate discipline and positive affect (Webster-Stratton, 1989; Webster-Stratton, 1998). Although measured differently, all studies reported statistically significant differences in positive parenting at post intervention (see table 6). Of the five studies, three achieved a medium weighting and one a high weighting for overall quality (Gardner et al., 2006; Hutchings et al., 2007; Larsson et al., 2009 & Webster-Stratton et al., 2014).. Effect sizes varied from small to high with one medium weighted study reporting sustained effectiveness at six months follow up (Hutchings et al., 2007). In the higher weighted study, smaller effect sizes were reported at post intervention (Gardner et al., 2006). This was similarly reported by Letarte et al. (2010). However due to this study s low rating for methodological quality/relevance, less weighting should be given to findings. Studies by Webster-Stratton et al. (2004), Hutchings et al. (2007) and Gardner et al. (2006) scored medium methodological quality and medium to high 13

15 methodological/topic relevance. Given their overall quality (WoE D), greater consideration should be given to their findings. From this, evidence suggests a small to moderate effect of the IY programme in improving positive parenting behaviour. Table 6 Effect sizes for Positive Parenting Study Outcome* Effect sizes Overall Quality Pre-Post Descriptor Pre-Follow Up Descriptor Gardner, Burton & Klimes (2006) Observed Positive Parenting Self-reported Parenting Skill Cohen s d =.38 Cohen s d =.65 small moderate No effect sizes reported High Hutchings et al (2007) Observed & Self- Reported Positive Parenting Cohen s d =.57 moderate Cohen s d =.62 moderate Medium Larsson et al (2009) Self-Reported Positive Parenting Mother: Cohen s d = 1.44 high high Parental behaviour not assessed Medium Father: Cohen s d = 2.24 Letarte, Normande au & Allard (2010) Self-Reported Praise & Incentives. Self-Reported Appropriate n 2 =.03 n 2 =.08 small small No follow up Low 14

16 Study Outcome* Effect sizes Overall Quality Pre-Post Descriptor Pre-Follow Up Descriptor Discipline small Self-Reported Behaviour Monitoring n 2 =.07 smallmoderate Self-Reported Positive Verbal Discipline n 2 =.18 Webster- Stratton, Reid & Hammond (2004) Observed & Self- Reported Positive Parenting Mother: Cohen s d =.51 moderate small No effect sizes reported Medium Father: Cohen s d =.35 *see appendices for references Reductions in negative parenting behaviour. Negative parenting can be described as the parenting behaviours that may contribute to a child s behavioural difficulties. Negative parenting behaviours may include the use of harsh or inconsistent discipline, physical punishment, verbal criticism and laxness (Arnold, O'Leary, Wolff & Acker, 1993; Gardner et al., 2006; Webster-stratton et al., 2004). Four out of five studies reported statistically significant differences in parent negative behaviours after the IY programme (see table 7). In comparing results between negative and positive parenting, it appears that there are larger effects of the IY intervention in reducing negative parent behaviours. Studies by Gardner et al. (2006) and Webster-Stratton et al. (2004) reported moderately 15

17 larger effect sizes than in positive parenting. Interestingly, the study by Hutchings et al. (2007) reported a non-significant effect at post intervention but a significant, moderate effect size at follow up. Significance differences may be due to the different type of statistical analyses used at post intervention and follow up. In placing more weighting on the studies that scored higher in overall quality (WoE D); there is moderate evidence to suggest that the IY is effective in reducing parent s negative behaviours. There are a number of possible reasons why reported effect sizes for negative parenting behaviour appear larger than positive parenting. Research indicates that child conduct behaviours arise from negative parental interchanges (Brotman et al., 2005; Cunningham & Boyle, 2002), implying that during intervention, parents may have an increased awareness of their negative behaviours rather than positive. Subsequently, a reduction in negative behaviours would more likely be reported. Table 7 Effect Sizes for Negative Parenting Study Outcome* Effect sizes Overall Quality Pre-Post Descriptor Pre-Follow Up Descriptor Gardner, Burton & Klimes (2006) Observed & Self- Reported Reduced Negative Parenting Cohen s d =.74 moderatelarge No effect sizes reported High Hutchings et al (2007) Observed & Self- Reported Reduced Negative Parenting Not significant Cohen s d =.32 small Significant Cohen s d =.58 moderate Medium 16

18 Larsson et al (2009) Self-Reported Reduced Harsh Discipline Mother: Cohen s d =.61 moderate Parental behaviour not assessed Medium Father: Cohen s d =.82 high Self-Reported Reduced Inconsistent Discipline Mother: Cohen s d = 1.05 Father: Cohen s d =.67 high high Letarte, Normande au & Allard (2010) Self-Reported Reduced Harsh Discipline. Self-Reported Reduced Physical Punishment n 2 =.04 n 2 =.01 small small No follow up Low Webster- Stratton, Reid & Hammond (2004) Observed & Self- Reported Reduced Negative Parenting Mother: Cohen s d =.81 Father: Cohen s d =.51 high moderate No effect sizes reported Medium *see appendices for references Increased emotional well-being. Studies also detected changes in parents emotional wellbeing (table 8), defined as stress levels, feelings of depression and perceived competence (Gardner et al., 2006; Hutchings et al., 2007). Stress. 17

19 Using the Parenting Stress Index (Abidin, 1990) two studies measured stress levels. Both studies reported significantly moderate to high effect sizes in the reduction of parent s stress with the study by Hutchings et al. (2007) reporting moderate to large effects at follow up. The study by Larsson et al. (2009) reports sex differences between parents in perceived stress. Study findings by Hutchings et al. (2007) should be given greater consideration due to the diverse nature of measures used. In considering this, it appears that only one study gives a reliable indication of the effectiveness of the IY in improving parent stress levels. In terms of generalisation, findings should be treated with caution. Depression. Using the Beck Depression Inventory (Beck, Ward, Mendelson, Mock & Erbaugh, 1961) two studies measured parent s feelings of depression. One study reported a non-significant effect of the IY (Gardner et al., 2006) the other study reporting small to moderate effects at post intervention and follow up (Hutchings et al., 2007). Although both studies obtained medium to high WoE D, the mix of significant and non-significant findings (within the same measure) suggest limited evidence in the effectiveness of the IY in improving depression. Competence. One study used the term self-efficacy (relating to parental confidence) and reported non-significant findings (Letarte et al., 2010). Across studies, competence was measured using different instruments, raising concerns regarding construct validity levels. Two studies measured competence, reporting small to large effect sizes (Gardner et al., 2006; Hutchings et al., 2007). Despite a medium/high overall quality 18

20 (WoE D), differences in effect sizes suggest insufficient evidence to report the effectiveness of the IY in improving sense of competence. Table 8. Effect Sizes for Emotional Well-being Study Relevant Measures* Post Effect sizes Follow Up Overall Quality Gardner, Burton & Klimes (2006) Beck Depression Inventory Parenting Scale Parent Sense of Competence Competence Cohen s d =.4 (small-moderate) Depression Not Significant Cohen s d =.35 (small) No effect sizes reported High Hutchings et al (2007) Parenting Scale Parenting Stress Index Beck Depression Inventory Stress Cohen s d =.66 (moderate) Depression Cohen s d =.48 (small-moderate) Competence Cohen s d =.95 (high) Stress Cohen s d =.79 (moderatelarge) Depression Cohen s d =.51 (moderate) Competence Cohen s d= 1.18 (high) Medium Larsson et al (2009) Parenting Practices Interview (PPI) Parent Stress Index Stress Mother: Cohen s d =.67 (moderate) Father Cohen s d =.86 (high) Parental behaviour not assessed Medium Letarte, Normandea u & Allard (2010) Parenting Practices Interview (PPI) Parenting Selfefficacy Measure; Parenting Self- Self-efficacy Not significant n 2 =.02 (small) No follow up Low 19

21 Study Relevant Measures* Post Effect sizes Follow Up Overall Quality Agency Measure & Maternal Confidence in Toddlerhood Webster- Stratton, Reid & Hammond (2004) Composite scores: Parenting Practices Interview (PPI) Parent Discipline Inventory (DDI) Calculated via composite scores No follow up Medium *see appendices for references Participants. The studies were carried out in different countries; United Kingdom (UK), Canada, United States of America and Norway. Studies that were conducted within the UK were given medium/ high weightings for topic relevance. Additionally, these studies had sufficient sample sizes, strengthening the reliability of findings. In judging effect sizes, there is evidence to suggest that the IY is effective in improving UK parental behaviour (Gardner et al., 2006; Hutchings et al., 2007). Three non UK studies had insufficient samples sizes (Larsson et al., 2009; Letarte et al., 2010; Webster- Stratton et al., 2004), scoring lower on statistical analyses (WoE A) and methodological quality (WoE B). This may limit the reliability of effect sizes reported. All participants were referred as having CP/CD and/or ODD. One study included children with learning difficulties and ADHD as well participants with CP (Letarte et al., 2010). Due to differences in sample, this study obtained a low weighting for topic relevance, posing difficulties in generalising the effectiveness of the IY program to all children with CP/CD and/or ODD. 20

22 As stated in inclusion criteria, participants ranged from 2-9 years of age with only one study using a concentrated age range of 3-4 years (Hutchings et al., 2007). This indicates that the intervention was carried out for children in different developmental stages. Research has highlighted that conduct behaviours can become entrenched through age, introducing additional difficulties such as peer rejection (Eron, 1990; Miller, 1994; Snyder, 2001). These may influence the level of intervention and parent behaviours, meaning that improvements may not be consistent across all ages. The study by Hutchings et al. (2007) focused on pre-school children and reported relatively moderate effect sizes. As the study obtained a medium quality weighting, one could suggest the IY parenting programme is more effective for improving parent behaviour with younger age groups. With studies that recruited wider age ranges, it is uncertain whether the effectiveness of the IY can be generalised as improving behaviours in all parents. The referral process for the IY differed across studies. Recruitment of children and parents were based upon referral by professionals (Gardner et al., 2006; Larsson et al., 2009; Letarte et al., 2010), parent requests (Webster-Stratton et al., 2004), and clinical scores (Hutchings et al., 2007). It could be considered that referral by professional judgement is the most objective way of selecting children with CP/CD and/or ODD for treatment. This was one of many aspects in the study by Gardner et al. (2006) that obtained a high weighting for WoE C. Studies that relied on parental request could introduce confounding variables meaning that reported improvements could be exaggerated. Such differences affected studies weighting of topic relevance (WoE C) (Webster-Stratton et al., 2004). In four out of five studies, the IY parenting intervention was aimed at treating children. In comparing effect sizes of the medium/higher weighted studies it appears 21

23 that the IY intervention is effective as a targeted treatment particularly in reducing negative parenting. However, is this finding due to the nature of targeted treatments? One could suggest that targeted interventions are remedial in correcting existing behaviours, whilst preventative interventions aim to enhance positive environments. Only one study used the IY intervention as a preventative measure (Hutchings et al., 2007). The effect sizes given within this study support this assumption, reporting a non-significant reduction in negative parenting but a moderate improvement in positive parenting. Further research would need to be conducted to verify this. The use of the IY as a preventative measure affected the study s WoE C, scoring at a medium level. Research Design. Four out of the five studies randomly assigned participants to conditions. Evidence derived from randomised controlled trials has been identified as having greater reliability (Guyatt et al., 1995). This strengthens the accuracy of findings, particularly with medium to higher weighted studies (Gardner et al., 2006; Hutchings et al., 2007; Larsson et al., 2009; Webster-stratton et al., 2004). In one study (Letarte et al., 2010) random assignment was not used as participants had to register interest. This may have impacted on participant motivation, contributing to the lower weighting given for methodological relevance, (WoE B). Control Group. Examining effectiveness by a wait list control meant that all participants would be equally eligible for intervention, sharing similar behavioural characteristics. This enabled a fairer starting point at pre intervention, ensuring greater accuracy in comparing scores. However the nature of a wait list control may have also influenced 22

24 effect sizes. The use of a wait list control may introduce additional moderator variables e.g. expectancy effects (participants may behave worse to receive the intervention quicker) (Baker-Henningham, 2011; Barker, Pistrang & Elliott, 2003). This could question the reliability of effects sizes. Furthermore, expectancy effects may have contributed to the lack of strong evidence in increased positive parenting. Measures. The studies all used a range of measurements to ascertain improvements in parenting behaviour. Although some measures overlapped between studies, there appeared to be no relationship between measures and effect sizes. As stated in the Kratochwill s coding protocol (WoE A) (see appendix 3) studies were given greater weighting if they used a range of measurements from a range of sources. Similarly stated in WoE B and C criteria studies were allocated higher weightings if they used multiple, diverse measures of parent behaviour. The use of observation was significant in meeting high weighting criteria as it enables a direct objective measure that reduces bias (p.6 Hutchings et al., 2007). Some studies met this criterion, scoring high for methodological relevance (Gardner et al., 2006; Hutchings et al., 2007.) One study used observation but obtained medium weighting due to the number of intervention groups (Webster-Stratton et al., 2004). As well using observation, studies given medium/high weightings also used a range of selfreport measures. Two studies used pure self-report methods to measure improvements, with one study relying upon self-report measures from one source (Larsson et al., 2009; Letarte et al., 2010). These were therefore allocated low weightings (Letarte et al., 2010). Although self-report reliability statistics were reported as medium to strong, the accuracy and credibility of self-report methods can be criticised. This is due to the subjective nature of participant response as there can 23

25 be a wish to please the researcher as well as self-enhancement purposes (Barker et al., 2003; Delroy, Vazire & Vazire, 2007). Whilst all studies used some form of selfreport method (particularly for measuring emotional well-being) studies that triangulated these measures gained increased accuracy in detecting behavioural improvements. Studies that relied on self-report lacked credibility checks. Although parental behaviours were the only interest in this review, it should be considered that a lack of multi-method and multi-source data collection leads to a single dimension conceptualisation of outcomes. Thus, caution should be placed in generalising these study results. Conclusion & Recommendations Conclusion Four out of five studies reviewed suggest that the IY parenting programme is moderately effective in improving positive parent behaviour, reducing negative behaviour and improving emotional well-being. Specifically, effect sizes indicate that the IY is more effective in reducing negative parenting behaviour than other behavioural domains. Three studies reviewed support these findings through the use of objective measures (Gardner et al., 2006; Hutchings et al., 2007; Websterstratton et al., 2004). Overall three studies obtained medium for overall quality (Hutchings et al., 2007; Larsson et al., 2009; Webster-stratton et al., 2004) with one obtaining a high weighting (Gardner et al., 2006). Although the study by Hutchings et al. (2007) was given high weighting for methodological relevance, the overall medium weighting (WoE D) derived from limitations in WoE A and C. A number of methodological issues have been discussed within this critical review, influencing the reliability of findings. Firstly, due to the diverse age range of 24

26 participants, it is uncertain whether the IY s effectiveness can be generalised to children of all ages. Although wait list control groups are well grounded in ethical responsibility, the difficulties in controlling confounding variables limit accuracy levels. These difficulties also exist in relying upon self-report measures. Such confounding variables may have contributed to the apparent stronger effects of the IY on negative parenting. Additionally, only one study made the statistical relation that improvements in parenting behaviour produce improvements in child behaviour. Achieving a higher quality weighting, this study supports the hypotheses made by Menting et al. (2013), reinforcing the effectiveness of parent training methods (Hutchings, Lane & Gardner, 2004). Recommendations Based on a review of the findings there is evidence to suggest that the IY parenting programme is effective in reducing negative parenting behaviours as well as improving some aspects of parent emotional well-being. As most of the studies reviewed used the IY programme to treat conduct difficulties (rather than prevent), recommendations for this programme are as a targeted intervention for younger age groups, as according to research, negative behaviours are not yet entrenched at this stage (Snyder, 2001). Although there was some evidence to suggest positive preventative effects, further research comparing targeted versus preventative intervention would need to be conducted (particularly in measuring negative parenting behaviours). Additionally, future reviews would benefit focusing on particular age categories, discovering if there is a critical time for child and parent behaviour improvement. Such findings may impact upon the setting the intervention is delivered in. In considering the 25

27 relationship between parent and child interchanges, studies need to make more statistical links between parent and child improvements. This would be highly useful for strengthening the effectiveness of the IY in promoting whole family improvement. 26

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