report from the first research in practice symposium

Realising the Potential: what works in prevention and family support

held in London and Dartington on 26 February and 15 May 2001

introduction

That prevention is better than cure is an old adage well supported by research evidence. This symposium considers the kinds of work with families and communities that are most likely to maximise the potential of children and young people and to strengthen parenting skills. The morning speakers explored those research messages which inform the assessment and support of parenting abilities - a core element in the new assessment framework.

Ann Buchanan from the University of Oxford focused on research messages about what works in terms of family support for children with emotional and behavioural problems; Moira Doolan , Head of Family Therapy at the South London and Maudsley Trust and project manager of SPOKE programme and Jenny Price , an accredited Webster-Stratton trainer at the Trust, considered what is known about the effectiveness in the British context of the Carolyn Webster-Stratton group approach to parent training; Margy Whalley examined evaluated practice on family support from the Pen Green Research Base and highlighted issues that help to ensure the development of user sensitive services through direct user feedback; and Alan France , from the University of Sheffield, considered methods of engaging with communities to mobilise and maximise support and examined evidence based approaches to community development.

Parents as partners - walking the talk at Pen Green Centre for Under Fives and their Families

Parents make a crucial contribution to children's development, and when professionals treat them as full partners, children have much to gain, as the Pen Green Centre for under fives and their families in Corby, Northants, has shown. Pen Green was one of the first Early Excellence centres identified by the government and offers a wide range of services to young children and their families in an area where, since the steel works closed, most employment has been in low paid factory jobs. It includes a nursery, a creche, a homework club for school aged children, and many groups and courses for adults. Half the children admitted to the nursery are through referrals from social services. Now more than 500 families use the open-access centre every week, and more than 6000 parents have taken part in the centre's pioneering partnership programme over the eighteen years since it opened. The service is jointly funded by social services, education, and health and line managed by social services.

In 1996 Pen Green decided to set up a research base in partnership with parents, staff and researchers at the University of Northampton. Margy Whalley, founding head of the centre, explains  'Research has shown that a large number of parents want to be involved in their children's early school experiences, and also indicates that children gain when their parents are involved in early childhood programmes. But researchers were still unclear about precisely how parental involvement actually benefited children in nursery settings. At Pen Green we wanted to develop a partnership with parents where we could explore this process and come to a clearer understanding of the contribution parents were making.'

The research at Pen Green aims to develop an effective model for working with parents, for developing parents' interest in their children's learning, and for developing a collaborative research partnership with local parents. Key is the centre's style of working with parents - in partnership. Whalley explains

' Our image of the child is rich in potential, strong, powerful, competent and most of all connected to the adults and other children around them. We wanted to build on parents' competencies, not their deficiencies, and recognise the crucial role they play in educating their children.'

From the outset, parents are encouraged to watch for and understand patterns in their children's behaviour which show how the child tries to understand the world. They borrow video cameras to film their children at the centre and at home, and are offered training in what to look for as they observe their children learn. Parents - mothers and fathers - are invited to attend a workshop at the centre on key concepts in child development, followed by long term study groups and a monthly research group. There are 32 parents' groups operating at the centre, run in the morning, afternoon and evening to allow parents working shifts to attend. Individual sessions offer personal support to parents combined with the sharing of information about child development and about the individual child. Parents and staff observe, share information and make decisions together about the next steps for the child.

The centre has found that almost all parents want to help their children learn, and are enthusiastic participants in the research. The centre's approach - of treating the parents as full partners in their children's education and development and of building on their strengths and competencies - has led parents not only to become deeply interested in and committed to their children's welfare and learning but also increased their confidence and interest in their own learning.

helping parents to help children improve their behaviour. A programme that works, and the costs of not using it

Parents' active participation is also key to the Webster-Stratton programme for treating conduct disorder in young children. 'Normal' children fail to comply with their parents' requests about a third of the time, while children with conduct disorder and 'oppositional-defiant' children are non-compliant about two thirds of the time.

Caroline Webster-Stratton's programme, developed and proven to be very effective in the United States, has now been shown through a trial here in Britain to have successfully improved children's behaviour [1] . The Parent Training programme aimed at parents of children under eight developed from an understanding that the most important cause of child conduct problems is the pattern of interaction between parent and child. Research has shown that parents of children with conduct problems show fewer positive behaviours; are more coercive and critical in their use of discipline; are more permissive, erratic and inconsistent; are less likely to monitor or supervise their children's behaviour and are more likely to reinforce inappropriate behaviour and to ignore or punish 'good' or prosocial behaviour. Other factors, such as the child's biological disposition, or the mother's depression, can play a part in establishing patterns of parent child interaction, but the interaction then amplifies and reinforces aggressive and non-compliant behaviour in children.

The clinical trial undertaken by Dr Stephen Scott and colleagues found that anti-social behaviour among children of parents at the end of the parent training programme had fallen very significantly compared to children on the waiting list who had received no intervention, and that even a year later the level of improvement remained the same. They found that the programme was effective for highly antisocial children, and worked equally well with disadvantaged families, ethnic minority families and lone parents.

The researchers emphasise that the improvement in the child's behaviour occurs as a result of changed parenting behaviour, not just changed attitudes or mood. They also stress that the specific content of the programme is very important to its effectiveness, and those trained as therapists need ongoing supervision. Moira Doolan, Head of Family Therapy, South London and Maudsley Trust, and Jenny Price, research therapist, Kings College London, are currently involved in a second preventive trial led by Dr Stephen Scott and Professor Kathy Sylva that is evaluating the effectiveness of the Webster-Stratton school age programme in conjunction with a reading support programme (Sylva and Crook), in helping reception class children to settle into school.  Data are not yet available from this trial but evaluations by parents who have been involved in the programme are very positive.

The basic parent training programme, as outlined by Webster-Stratton [1] has the following stages:

• Play skills: with therapists discussing the importance of play with parents and presenting effective ways of playing with their children.
  
• Praise: therapists teach parents to identify the behaviour they want to promote, to look for those behaviours, and to praise them.
  
• Incentives: for some children, incentives or rewards are also needed to motivate the child to change their behaviour.
  
• Limit setting: all children test limits as part of their learning, and consistent limits with predictable consequences give children a sense of security.
  
• Ignoring skills: children's behaviour is reinforced by the attention it receives - even critical attention. So, when misbehaviour is ignored the child will eventually stop what they are doing.
  
• Time-out skills: violence or destructive behaviour may call for a more extreme form of ignoring - removing the child for a brief period from parental attention. It also models for the child the parent's use of self-control, and a non-violent response to conflict.
  
• Natural and logical consequences: as long as the child will be safe, the parent allows them to learn from the consequence of their action rather than protect them from it. So, rather than force the child to put their coat on, the parent explains that if they don't, they will feel cold outside. If the child chooses not to put on their coat, they get to feel cold.

The costs of not intervening effectively when children have behaviour problems has been illustrated by a study by Stephen Scott and colleagues at the Institute of Psychiatry in London [2] . They  followed up a large cohort of people aged twenty seven who at age ten had been screened for behaviour problems in inner London schools. One in four had been identified by their teacher as having behaviour problems, including one in twenty who were also diagnosed with conduct disorder. Those with behaviour problems had more accidents, more teenage pregnancies,  and a shorter lifespan. They were more likely to have been divorced or separated, more likely to have behaved violently to their partner and children, more likely to have children in local authority care, had fewer friends and were also more likely to have been diagnosed with antisocial personality disorder. While 18 per cent of those with no behaviour problems had a criminal record at age 27, the proportion grew to 31 per cent for those with conduct problems and to 56 per cent for those with conduct disorder. The researchers calculated that the overall cost to the public for each person who at 10 was diagnosed with conduct disorder was over £70,000 by the time they reached 27, compared to about £7,500 per person for those with no behaviour problems at age 10.

experts or gofers?

The Pen Green and Webster-Stratton programmes, although dissimilar in many ways, both succeed by engaging parents in programmes to help and support their own children's individual development.  Engaging a community of parents as partners in promoting the safety of the community's children presents a different sort of challenge.

Alan France at the University of Sheffield is evaluating [3] the Communities that Care programme, a strategy developed in the United States for mobilising communities to reduce crime and drug abuse among young people. The programme has been used across the United States and is now being piloted in Britain with funding from the Joseph Rowntree Foundation [4] .

France points out that to evaluate the effectiveness of any model which aims to change people's behaviour, research needs to be done over a period of years. Communities that Care is built on evidence that there are both risk factors and protective factors which together impact on young people's behaviour, and that communities can both reduce the risk and strengthen protective factors.

To be effective, 'community' must in this context include the key strategic leaders including, for example, the social services director, and key leaders in the voluntary sector - people who have the capacity to 'unblock blockages' and to implement proposals emerging from consultations.

Key lessons from the evaluation so far include the value of constructing real partnerships between professionals and local people through working together. This led to information being shared and concerns being raised which changed the perspective of professionals and parents. In one case for example a survey found that 85 per cent of young people said their parents always knew where they were at night. Although this seemed reassuring to the professionals, parents in the community were alarmed that 15 per cent of young teenagers were out at night unsupervised.

Another example of the benefits of working together were that social services staff were able to explain how the child protection register works - that a rise or fall in the number of registered children was as likely to be the result of a policy change or an increase in family support work as a rise or fall in the level of child maltreatment or neglect in that community.

But there were also risks, and in particular the problems arising when the process becomes dominated by either the professionals or the local people. Sometimes a group of local people can themselves become '"experts"', picking up the language and knowledge which then makes it difficult for new people to get involved.

France's work suggests that capacity building in communities is an important prerequisite to establishing partnerships. Without the preparation work, including training and support, it's likely that it will be largely the seasoned activists who will get involved.

Perhaps the most significant finding so far in the evaluation concerns the expectations and experiences of volunteer community members in this programme. France reports that the pressure on communities to participate does not always take into account the social and economic realities of their lives by providing for example, free child care and taxis. 'The model local people found most useful was where they were consultants rather than participants. It was more effective for the professionals to do the running around rather than leaving the leg work to local people who are sometimes expected to do it with very little reward.'

a cure for every ill?

Returning to the theme of interventions to help individual children, Dr Ann Buchanan of the University of Oxford has identified many initiatives which have been shown to be effective. Her research summary for Barnardos, 'What works for troubled children' [5] uses the same 'ecological' model as Communities that Care - children's lives are subject to risk factors and protective factors, and strengthening or increasing the protective factors can mitigate the impact of risk factors. This doesn't mean particular circumstances cause or prevent adverse results - only that they are associated with them but where it is possible to strengthen or increase the protective factors in a child's environment, risk may be reduced.

For example, the longitudinal National Child Development Study found that having a mother who smoked before her pregnancy was a risk factor in respect of behavioural problems for children at 7, 11 and 16 but in respect of emotional problems only at age 7. Having a father who reads to the child at age 7 was not significant in respect of emotional problems but was protective in respect of behavioural problems at age 7, 11 and 16. Conflict within the family increases the risk of both emotional and behavioural problems for children at all three ages, while outings with dad at age 7 is protective of emotional problems at 7 and 16, and protective of behavioural problems at all three ages. There is also evidence that some children seem to be more resilient than others in that they survive severely negative experiences intact. Buchanan quotes Rutter and colleagues' [6] hypothesis, having reviewed all the literature, that it might be possible to promote young people's resilience by:

• Reducing sensitivity to risk by giving young people opportunities to succeed in challenging activities
  
• Reducing the impact of the risk by parental supervision; positive peer group experiences; avoiding being drawn into parental conflict and having opportunities to distance oneself from an abusive parent
  
• Reducing negative chain effects, e.g. drug and alcohol abuse arising from suspension from school
  
• Increasing positive chain effects by mobilising support for the young person from, for example someone who might help get them a job
  
• Compensatory experiences, such as positive models of non-violent men in the life of a child who has witnessed domestic violence
  
• Opening up of positive opportunities, such as educational or career opportunities
  
• Teaching coping strategies and skills including constructive ways of viewing negative experiences.

Buchanan describes a number of strategies parents can adopt in order to manage behavioural problems in young (primary age) children such as sleep problems, truancy, wetting and soiling and stealing. She also outlines some effective ways of tackling common emotional and behavioural problems in adolescents including depression, anger and post-traumatic stress.

She emphasises that to keep faith with children, young people and families, it is important that professionals are competent and are guided by their own ethical code of practice. They should be aware of what tasks they are and are not competent to undertake, and should have enough understanding of the range and application of different interventions as well as the services provided by each agency to be able to refer on appropriately.

conclusion

Among the key messages from the symposium were the importance to children's welfare and development of engaging family members - including fathers - as partners; mobilising their huge allegiance to their children; utilising their expertise about their own children; working with parents' strengths and competencies; but at the same time taking into account the real difficulties they face and offering them appropriate support.

[1] Scott, S., Spender Q., Doolan M., Jacobs B. & Aspland  H. (in press) Multi-centre controlled trial of parenting groups for child anti-social behaviour in clinical practice . British Medical Journal

[2] Scott, S., Knapp, M., Henderson, J. & Maughan B. (in press) Long-term costs of social exclusion:  follow-up study of anti-social children into adulthood . British Medical Journal

[3] France, A. & Crow, I. (2001) CT C: The Story So Far . JRF

[4] Utting, D. (ed.) (1999) A Guide to Promising Approaches. Communities that Care (020 7837 5900)

[5] Buchanan, A.  (1999) What works for troubled children? Family support for children with emotional and behavioural problems . Barnardos

[6] Rutter, M., Giller, H. & Hagell, A. (1998) Antisocial Behavior by Young People. University of Cambridge Press prevention and family support