Reaching those who need it most

Judy Hutchings and Eleanor Lane on how to engage the high-risk families.
The government is finally recognising the large and growing problem of pathways to criminality, and is seeking solutions. Money has been pumped into programmes such as Sure Start, to support families of preschool children in designated high-risk areas. But despite its popularity, a large-scale evaluation of Sure Start in England has failed to demonstrate any consistent effects from the services provided, particularly for the most disadvantaged families whose children are most at risk (Abrams, 2005; NESS 2005). This is sadly just a reflection of the broader picture: although children at high risk of developing antisocial behaviour can be accurately identified at a young age, most families do not receive properly ‘evidence-based’ help.

The government is finally recognising the large and growing problem of pathways
to criminality, and is seeking solutions. Money has been pumped into programmes such as Sure Start, to support families of preschool children in designated high-risk areas. But despite its popularity, a large-scale evaluation of Sure Start in England has failed to demonstrate any consistent effects from the services provided, particularly for the most disadvantaged families whose children are most at risk (Abrams, 2005; NESS 2005). This is sadly just a reflection of the broader picture: although children at high risk of developing antisocial behaviour can be accurately identified at a young age, most families do not receive properly ‘evidence-based’ help.
Even when families do get such help, it is often not effective in service settings (Scott et al., 2005). Until recently interventions were mainly successful with children with less severe problems and whose families were relatively less disadvantaged (Dumas & Wahler, 1983). The public health model of universal and brief interventions described by Sanders and Morawska in the previous article has an important part to play in providing widespread services, but helping the families whose children are most at risk
of severe problems has been much harder – we have only recently learned how to engage and retain such families (Hartman et al., 2003; Scott et al., submitted 2005; Webster-Stratton, 1998).
This article discusses how to make programmes work in practice, and what has been learned about engaging and retaining the high-risk families that may have seemed beyond help in the past.

The essential components

There have been a number of systematic reviews of parenting programmes. Good examples of such reviews are the good practice lists reviewed by Brestan and Eyberg (1998) for the American Psychological Association, the Cochrane reviews (Barlow et al., 2002), and the Blueprint series.
The Blueprint series acts as a resource to help planners to select effective programmes and implement them with a high degree of integrity (see www.colorado.edu/cspv/blueprints). The criteria for programme inclusion are rigorous, and, following a review of more than 600 programmes, only 11 have achieved ‘Blueprint’ status. Those that have been selected are supported by evidence of long-term beneficial effects in reducing violence and by independent replication in both research and service settings; they also have detailed implementation protocols and training procedures that enable others to deliver them in the same way and instruments
for monitoring them that ensure implementation quality. The Olds programme (described by Sutton and colleagues in the first article) and the Incredible Years programme are both identified in almost all systematic reviews, and are both Blueprint programmes (see www.incredibleyears.com).
Taylor et al. (2002) identified 11 lists of best practice programmes and listed 21 family-based schemes that were identified on at least three lists, suggesting that there was consensus about the evidence for them. Based on such reviews, the components that make some parenting programmes more effective than others have been identified (Hutchings et al., 2004; Taylor & Biglan, 1998):
l    New parenting skills must be actively rehearsed through role-play or other forms of rehearsal, or giving parents videotape feedback of their own performance (Hutchings et al., 2004).
l    Parenting programmes must teach behavioural principles rather than techniques. When parents learn principles, they acquire the tools to decide what works best for them and to respond positively and appropriately in new situations (McMahon & Forehand 2003). This also enables parents to plan their own strategies and to set
and achieve their own goals (Webster-Stratton & Hancock, 1998).
l    Parents must implement new parenting behaviour, learned in the group, at home (Patterson, 1982). Programmes which set home assignments for parents and give feedback on these home activities are more effective.
l    Programmes must include both non-violent sanctions for negative behaviour and strategies to build positive relationships through play and praise. Early behavioural parenting programmes focused on the management of problem behaviour but, often, initial gains were not maintained. Similarly, programmes that only focused on relationship building, without helping parents to develop a consistent discipline plan, also often failed to demonstrate long term effectiveness (Hobbs et al., 1990).
l    Difficulties in adult relationships and other family problems must be addressed. For example, Dadds et al. (1987) found that although a behavioural family intervention benefited parents and their children, when parents also had relationship difficulties a ‘partner support’ programme was needed to achieve sustained improvements.

Whilst these specific components are essential, they not sufficient to help multi-stressed, severely disadvantaged families. The way in which programmes are delivered also affects outcomes, and recent research has identified the factors common to successful interventions across a range of fields including health, education and industry (Hubble et al., 1999; Lambert, 1992); these factors include:
l    building a collaborative alliance with parents (Webster-Stratton & Herbert, 1994);
l    mobilising parents’ resources and working in a way that is compatible with their beliefs and values;
l    accepting parents’ goals at face value, tailoring tasks and suggestions to them and collaborating in exploring material that is relevant to the them;
l    conveying an attitude of hope and possibility without minimising the problem or the pain that accompanies it: encouraging parents to focus on present and future possibilities instead of past problems.

These factors are particularly important in engaging multi-stressed, hard-to-reach families, who have many other difficulties in their lives and feel blamed for their children’s problems and abandoned by the authorities.

Making programmes work in practice
Having established that there are effective evidence-based interventions, the important question is how to get them delivered effectively in real-life service settings. In such environments attempts to replicate positive results often fail because a programme has been adapted or diluted, due to lack of resources or skills, in ways that prevent it from achieving the same outcomes (Mihalic et al., 2002).
What we need are strategies to ensure the quality and fidelity of implementation, and this is an important and developing area of research. Five main components have been identified (see box). A number of studies show a positive connection between ‘fidelity’ and the level of success (e.g. Domitrovich & Greenberg, 2000). The Blueprint data on the Bullying Prevention Programme, evaluated in Norway and the UK, shows that the biggest improvements were achieved in those classes that had participated most actively and extensively in delivering the programme (Olweus
& Alasker, 1991). Also, a study of delinquency prevention in American schools found that due to lack of resources or skills many school-based prevention activities were of poor quality and were not being implemented with sufficient strength to produce the desired positive outcomes (Gottfredson et al., 2000).

Engaging high-risk families
Even if implementation fidelity is spot on, it can still be hard to engage some high-risk families. Often the families themselves are blamed for the failure. As Webster-Stratton (1998, p.184) puts it:
Such families have been described as unmotivated, resistant, unreliable, disengaged, chaotic, in denial, disorganised, uncaring, dysfunctional and unlikely candidates for this kind of treatment – in short, unreachable. However, these families might well describe traditional clinic-based programs as ‘unreachable’. Clinical programs may be too far away from home, too expensive, insensitive, distant, inflexible in terms of scheduling or content, foreign in terms of language (literally or figuratively), blaming or critical of their lifestyle. A cost benefit analysis would, in all likelihood, reveal that the costs to these clients of receiving treatment far outweigh the potential benefits even though they do genuinely want to do what is best for their children. Perhaps this population has been ‘unreachable’ not because of their own characteristics, but because of the characteristics of the interventions they have been offered.
The Webster-Stratton Incredible Years (IY) programme (Webster-Stratton et al., 2001) provides an excellent example of how to both recruit and retain these families. The programme is made accessible through the provision of transport, daycare, meals and flexible course times. Once recruited, the programme is delivered in a way designed to ensure an effective, collaborative, client–practitioner relationship.
In addition to the basic parent programme, the advanced IY programme focuses on adult relationship skills and problem solving with adults and children (another of the factors identified as needing to be addressed to ensure long-term maintenance: Dadds et al., 1987). There is also a programme to help the child to do their best in school that encourages home–school links and helping children with school assignments. By including programmes for parents, children and teachers, the scheme covers several important protective factors. The child and teacher programmes improve outcomes for highly challenging children, demonstrating improved peer relationships, problem solving and academic engagement in children and increased teacher praise and reduced teacher criticism.
The IY programmes have proved to be practicable, cost-effective and transportable. Evidence from England (Scott,2005; Scott et al., 2001), Wales (Hutchings et al., 2006), Norway and Canada confirms the effectiveness of these programmes. But what is even more impressive is that Webster-Stratton has achieved good outcomes with families who, in other studies, have dropped out or failed to make progress.
Webster-Stratton’s starting point is that non-attendance is a problem in the programme, not in the participants. When this approach is taken, factors such as social and economic disadvantage and maternal mental health cease to be related to levels of engagement or positive outcomes with the programme (e.g. Baydar et al., 2003). Although working with very disadvantaged communities in Seattle, Webster-Stratton has demonstrated higher levels of take-up and retention and better long-term outcomes than most other programmes on this field. For example 88 per cent of high-risk, enrolled ‘Head Start’ families were retained in the programme, completing more than two thirds of the sessions (Webster-Stratton, 1998). Children from low-income families who qualify for the Head Start preschool education programme are exposed to multiple risk factors for subsequent conduct problems and later offending. Yet studies examining the efficacy of the IY programme with Head Start families (Reid & Webster-Stratton, 2001) have found no adverse connection between parents’ socio-economic status or ethnicity on uptake, satisfaction with the programme, or outcome. As Hartman et al. (2003, p.396) have noted, ‘as mothers are given opportunities to acquire further positive parenting skills, levels of economic disadvantage become less important in predicting treatment success or failure’.
In contrast to the Sure Start experience in England, the first author has worked with 11 Sure Start services in North and Mid Wales, supporting the delivery (by Sure Start staff) of the IY basic parenting programme to parents of high-risk three- and four-year-olds. With very careful attention to implementation fidelity the results demonstrate good evidence of both short- and longer-term effectiveness. There are significant changes, including increases in positive parenting, reductions in harsh parenting and improved child behaviour.

Conclusion
Conduct disorder is a large and growing problem that can be prevented or treated using parenting programmes based on psychological principles. It is important
for psychologists to take a lead in discussions about antisocial behaviour since the most effective interventions have been derived from psychological theory and psychologists have been in the forefront of developing them.
There is a place for both universal preventive approaches and more intensive targeted approaches for children at the highest risk of severe long-term problems. The important point is that those delivering programmes need to take responsibility for making them accessible and relevant: only then can they be effective even with the high-risk, disadvantaged children who, in the past, often had poor outcomes. Good outcomes in preventive and clinical settings also involve addressing the issue of implementation fidelity to ensure that research findings are replicated faithfully in service settings.
The government are spending vast sums of money to support families, but it is sometimes using ineffective programmes or delivering evidence-based programmes ineffectively. Effective programme delivery can be achieved, as we have demonstrated using the IY programme with high-risk children living in Sure Start areas in Wales. The government must take the lead in prescribing the use of such programmes, through training initiatives and through ensuring that staff are given sufficient time and resources to implement with fidelity. Children and families in the UK deserve nothing less.

- Judy Hutchings is at the University of Bangor. E-mail: [email protected].
- Eleanor Lane was research officer at the University of Bangor until 2005.

BOX: Getting programmes right‘

Implementation fidelity’ is the degree of fit between the original programme and its application in a given service setting. Five main components are identified in the Blueprint series:

l    Adherence: Is the programme being delivered as designed, with all the core components,to the appropriate population, with staff trained to the appropriate standard, with the right protocols, techniques and material and in the right contexts?
l    Exposure: Does the treatment ‘dose’ (e.g. the number of parenting sessions in a course, and their frequency and length) match the original programme?
l    Quality of programme delivery: Are the leaders skilled in using the techniques, or methods, enthusiastic and prepared?
l    Participant responsiveness: Is the participant involved in the activities and content of the programme?
l    Programme differentiation: Are all of the unique features of the programmes identifiable and present (e.g. role-play practice and home assignments)? 

Weblinks
Incredible Years Wales: www.incredibleyearswales.co.uk
Center for the Study and Prevention of Violence: www.colorado.edu/cspv/blueprints

Discuss and debate
Should clinical psychologists focus more on early prevention rather than more severe problems for which outcomes are less effective?
How can psychologists take the lead in ensuring public money is spent on effective, evidence-based programmes?
Have your say on these or other issues this article raises. E-mail ‘Letters’ on [email protected] or contribute to our forum via www.thepsychologist.org.uk.

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