Presentation from the Evidence Based Parenting Programmes and Social Inclusion conference held at Middlesex University, 20th September 2012

1. Professional Best Practice is
Knowing Three Evidence-Based
Parenting Programmes
Evidence Based Parenting Programmes and Social
Inclusion Conference at Middlesex University
September 20, 2012
LYNN MCDONALD, MSW, PHD
PROFESSOR OF SOCIAL WORK RESEARCH
MIDDLESEX UNIVERSITY, LONDON

2. United Nations: Rights to Child Well-Being
2
 United Nations: International Rights of All Children
 2007 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 world
 Parents 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

4. Risks to Child Development: High and
Sustained Stresses (Cortisol levels)
 War and destruction; famine and disease;
 Poverty in a nation with large wealth disparities
 Being black or ethnic minority in a racist country
 Toxic environments, lead poisoning, smog
 Neighbourhoods/countries with crime and drugs
 Immigration or high mobility-socially disconnected
 Poor schools and poorly resourced education
 Distant, disengaged family (addicts?)--neglect
 Family using physical violence to resolve conflict

5. 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

6. Social Work, Stress and Child Protection
Stressed and isolated families> neglect
 Children 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 neglected
 Neglect 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

7. 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-permanent
 If high stress (high cortisol) is sustained over time
it damages a child’s brain for learning
 High stress can cause low immune systems in
which children miss more school from illness,
and adults get sick more for compromised
parenting

8. 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)

9. 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 stress
 High 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)

10. But Contextual Stressors on the Parent
Compromises Positive Parenting
 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?

11. 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

12. ‘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

13. 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
Reduces Reduces Child
Social capital
Stress Neglect
 Social capital reduces stress
o Social ties and inclusion buffer stress and enhances adults’ coping
mechanisms leading to better mental health, less irritability & anger

14. 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

15. 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)

16. In UK, Policies and Funds to Promote
Evidence based 16
Parenting (EBP)
 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

17. 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!

18. 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?

19. Parents Can Build Protective
19
Factors Against Risks
 Strengthening family unit (less conflict)
 Empowering the parent with skills
 Positive parenting approaches
 Improving Mother-child bond
 Building Parent-to-parent bonds
 Activated Parent group for support
 Parent to community/school ties
 Low drop out rates are important
With Repetition of positive exchanges

20. 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

21. 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

22. How is the Parent Group Delivered?
 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

23. Parent ability to do parent-child ‘responsive
play’ activity is included in several EBP
Special Play

24. What is the Evidence: RCTs
What 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

25. Quality Assurance for ‘Scaling up”
 Website and materials for EBP awareness
 Manuals for training the evidence based practice
 Core components and core practices identified
 Training provision capability of high quality
 Capacity developed of numbers of certified Trainers
 Programme integrity checklists for monitoring
implementations; Room for local adaptation?
 Monitoring demographics of parent drop-outs
 Pre and post tests to determine: was there impact
 Sustainability over time: re-certification processes

26. Giving & Receiving Support Between Parents
Reciprocal 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

27. Family Relationships
Family Environment Scale (Moos & Moos, 1981)
N=153
=P<.10(10% change due to chance P<.01 (1% change due to chance)
=p<.05 (5% Change due to chance) P<.001 (0.1% change due to chance)

28. Parents report on Pre and Post FAST on
Child’s Behaviour at home
Strengths & Difficulties Questionnaire (Goodman, 1997)
14
11.75 N=164
12
10 9.35
8.6 8.6
8.17 British Average
7.69
8
6 Pre FAST
4.44
4
4 3.61
2.55 2.38
1.92
2.36
2.01 Post FAST
1.9 1.79
2 1.6 1.4
0.960.82
0.3
0
Pro-social Emotional Conduct Hyperactivity Peer Problems Total Impact
=P<.10(10% change due to chance) P<.01 (1% change due to chance)
=P<.05 (5% change due to chance) P<.001 (0.1% change due to chance)

29. Teachers report on Pre and Post FAST on
Child’s Behaviour at home
Strengths & Difficulties Questionnaire (Goodman, 1997)
N=210
=P<.10(10% change due to chance) P<.01 (1% change due to chance)
P<.001 (0.1% change due to chance)
=P<.05 (5% change due to chance)

30. 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

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

32. RCTs averaged 20% Drop Out Rates for
Low-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

33. Household Income: 77% of Parents were below £20K
33
03/10/2012

34. Drop out rates of Low-Income Parents
 Not monitored usually by the parenting programme
 Data are difficult to find, no central data bank
 Child 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

35. 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

36. 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

37. 2. Strategies for Social Inclusion
to Reduce Drop Out
 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 requests
 Whole 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

38. 3. Strategies for Social Inclusion
to Reduce Drop Out
 ‘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

39. 4. Strategies for Social Inclusion
to Reduce Drop Out
 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

40. 5. Strategies for Social Inclusion
to Reduce Drop Out
 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

41. 6. Strategies for Social Inclusion
to Reduce Drop Out
 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

42. 7. Strategies for Social Inclusion
to Reduce Drop Out
 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

43. 8. Strategies for Social Inclusion
to Reduce Drop Out
 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.

44. 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!