‘Putting children first’: the role of psychology in applied youth mental health research – The ‘Incredible Years Ireland’ Study

Dr Sinéad McGilloway, Department of Psychology , NUI Maynooth

OverviewPART ONE• Background/context: youth mental health and emotional and

behavioural difficulties

• The Incredible Years program: theory, practice and research

• Supporting ‘at-risk’ families: the international policy context -------------------------

PART TWO• The NUIM-led National Evaluation of Incredible Years: - the research team - research objectives - research design and methodology • Conclusion

Youth mental health: why worry? • “Society…has a choice whether or not to acknowledge the

importance of mental health of its children [and young people] and invest in it appropriately or not…if we are to change things, action is needed now.” (Mental Health Foundation, 1999)

• Mental health problems amongst young people have increased substantially in almost all developed countries since World War II

• Approximately one in five children and adolescents have mental ill health but….the majority rarely reach specialist services

• Problems range from: *emotional and conduct disorders; anxiety; depression; substance abuse; self harm; eating disorders; and psychotic illnesses

The Irish context: a legacy of vulnerability

• Increase in juvenile offending (typically high levels of mental ill health and EBD amongst offenders)

continuing high school drop-out rates

• Increasing numbers of 15 to 17 yr-olds detained in adult prisons • Increase in the use of adult inpatient care by teenagers (and the

lack of appropriate facilities) • Suicide: more young people (15-34yrs) in Ireland die from suicide

than in any other EU member state

• Impact of bullying on school children

• Emotional and behavioural difficulties (EBD)include:

- withdrawn or disruptive behaviour - marked and persistent concentration difficulties - poor social interaction - poorly developed life/social skills • Approximately 10% of children in UK and US

(higher in boys); as many as 35% in areas of high social deprivation

• Children with EBD often rejected by peers -> unhappiness, low self-esteem, difficulty in forming friendships

EBD: a source of growing concern

• Conduct difficulties are detectable, preventable and treatable but…

• Resistant to intervention if not treated early; 75% treatment success rate for <10s; 25% for adolescents

• Predictive of: juvenile delinquency; low levels of educational attainment; school drop-out; entry into the Criminal Justice System; and adult mental health problems

• Considerable long-term costs -> health, education, social services and CJS

• “Preventing, reducing and halting aggressive behaviour at school entry…is a beneficial and cost-effective means of interrupting the progression from early conduct problems to later delinquency and academic failure.” (Webster-Stratton & Reid, 2004)

The good news…• Behaviourally based (early)interventions have

been shown to be very effective in addressing problem parenting and promoting social competence

• Behavioural disorders can be detected at an early age due to well known risk factors:

- low income/poor living conditions - disadvantaged neighbourhoods - young and/or lone parent households - parental mental health problems - low parental educational levels/criminal history - large families

Risk factors related to conduct problems

Parenting Factors

Contextual/family Factors

School and Peer Factors

ChildFactors

Early Onset Conduct Problems

The Incredible Years Parent,Teacher and Child Training Series

• The Incredible Years program comprises three linked programmes aimed at addressing parent and child behaviours whilst also helping teachers to better manage problem behaviour

• Developed and refined by Professor Carolyn Webster-Stratton, University of Washington, Seattle over a 30-year period

• Two long-term goals: (1) to develop comprehensive treatment programmes for young children with early onset conduct problems;(2) to develop cost-effective, community-based prevention programmes for families and teachers to promote social, emotional and academic competence

Teacher Programme

Child Dinosaur Programme Treatment

Child Dinosaur ProgrammeClassroom

Infant ToddlerParent Programme1-2 yrs

School

Readiness

Programme

2-4 yrs

School Aged BASIC Parent Programme6 – 8 yrs9-12 yrs

ADVANCED Parent Programme

BASIC Parent Programme

3-6 yrs

The Incredible Years Programmes

The BASIC Parent Training Intervention

• Focuses on strengthening parenting skills to prevent, reduce and treat conduct problems among children aged 3 - 6 years and to increase their social competence

• 12-14 weekly sessions -> collaborative approach and skill development through group discussion, videotape/DVD modelling, role play, and practice/rehearsal

Key components of IY parent training

• New parenting skills must be modelled and rehearsed

• Sanctions (non-violent) for negative behaviour, relationship building, praise and rewards

• Home based ‘practice’ or homework• Collaborative ethos – emphasising principles

rather than prescribing techniques• Address difficulties in adult relationships/other

family problems• Must be delivered early

The theoretical framework of the Incredible Years

• Based on the psychological principle that behaviour is learned through social interaction

• Underpinned by Bandura’s Social Learning Theory (1978) -> reciprocal determinism

P

B E

• Social interaction reinforces ways of thinking and behaving

• Bandura emphasised the process of learning through observation (ie. most human behaviour is learned by following a model)

• Modelling influenced by: (1) characteristics of the model; (2) observer attributes; and (3) reward consequences

• Aim of Incredible Years: “…to increase positive behaviours

through a variety of rewards whilst reducing unwanted behaviours through response cost or other strategies, resulting in their disappearance.” (Hutchings and Webster-Stratton, 2004)

The logic model of the Incredible Years

Leads to: Lowered capacity to engagewith others &Poor decisionmaking

Leads to: Anti-social BehaviourandEmotional Difficulties

Leads to:Poor Perform.Inschool

PTImproved Parenting

skills

CTImproved

Social Skills

TT Improved Classroom

Management

Parenting which is:

HarshInconsistentCoercive

Incredible Years: the empirical context

• Based on approx.20 years of research and development (mainly in the US) using rigorous methodologies (eg. RCTs) and including longer-term follow-ups

• The findings have shown Incredible Years to be highly effective in reducing child aggression and other behaviour problems whilst increasing social competence at home and at school

• For example, BASIC PT programme has been strongly supported through 9 published RCTs

• - based on parent reports and direct observation of child behaviour and parenting style

The Welsh Surestart Study

• Three RCTs of the parent (PT) and teacher (TT) programmes

Parent Training• 46% reduction in conduct problems and negative child

behaviour in the intervention group versus 7% in the control group

• Reduction in violent incidents and significant improvements in parenting skills and parental mental health

• Longer term findings show maintenance of all gains in the intervention group

Teacher Training • Intervention teachers gave clearer instructions to children

than in the control group and allowed more time for compliance before repeating instructions;

• Pupils in intervention classes more compliant with more socially positive behaviour

• Teachers reported satisfaction with the programme and believed that the strategies taught were effective and improved pupils’ behaviour

Supporting high risk families: the policy context

• Several recent UK government initiatives: - Surestart program in England (2001) - Welsh Assembly Government Parenting Action Plan (2005) - ‘Reaching Out’: the Action Plan on Social Exclusion (2006) - National Academy for Parenting Practitioners (NAPP) (2007) - NICE guidelines

• Norway: – extensive government funding to implement the Incredible Years programme on a national basis

(The programme has also been implemented in Canada, Australia, New Zealand, Scandinavia, Germany, Portugal)

• US: – “blueprint” and “model” programme for violence and substance abuse prevention (US Office of Juvenile Justice and Delinquency Prevention; the Centre for Substance Abuse Prevention)

Part Two

The Incredible Years Ireland Research Study

The Research Team NUI Maynooth

• Dr Sinead McGilloway (Psychology)• Dr Anne Lodge (Education)• Dr Catherine Comiskey (Maths)• Dr Yvonne Barnes-Holmes (Psychology)• Professor Donal O’Neill (Economics)

Bangor University, Wales

• Dr Tracey Bywater (Psychology and Incredible Years Wales Centre)

Queen’s University Belfast

• Dr Michael Donnelly (Public Health & Epidemiology)

University of Washington

• Collaborative support from Professor Carolyn Webster-Stratton

Our role?

• To undertake and complete to the highest possible standards, a three-year national evaluation of the Incredible Years programme in Ireland

• To act as the objective, honest ‘broker’ when conducting the research and when disseminating findings

• To work collaboratively with Archways and others (eg. schools/teachers) in executing the research and to promote a sense of ownership amongst all key stakeholders

Research objectives 1. To assess the effectiveness of the parent training

programme on child and parent behaviour

2. To consider the impact of the teacher training programme on child behaviour

3. To assess some combination of parent, teacher and/or child training on behaviour

4. To examine the cost-effectiveness of the programme

5. To monitor and appraise all aspects of implementation fidelity

Key research questions

• To what extent does the Incredible Years programme lead to improvements in the behaviour of young Irish children(2-7yrs)?

• How effective is the programme in improving parental well being and parental and teacher skills and competencies?

• Are improvements maintained over time?

• Do some programme elements work better than others?

• How cost-effective is the programme?

• How do the results compare with work undertaken elsewhere?

• What are the experiences of key stakeholders and what factors facilitate or inhibit the effective implementation of the programme?

• Are there any problems or issues in delivering the programme that are peculiar to an Irish context?

• A largely experimental evaluation based on a pragmatic Randomised Control Trial (RCT) design

1. Multi-site longitudinal follow-up study involving three RCTS on: (a) parent training (PT); (b) teacher training(TT); and (3) a combination of parent, teacher and child training(PT/TT/CT)

2. A smaller implementation sub-study on the process of implementing the Incredible Years programme (including aspects of fidelity)

3. An economic evaluation based on a cost-effectiveness analysis for each trial

Research Design

Methodology

• Participants randomly allocated to intervention or waiting list control group on basis of inclusion criteria

• Six sites: four in Dublin (PT); one in Limerick (TT) and one in Cork (PT/TT/CT)

• Participants in the RCTs will be assessed at baseline and 6 and 12 months later (approx. 2 visits at each data collection point)

• Study based on mixed methods including questionnaire-based assessments, some observational work and interviews (1:1 or group-based) with key stakeholders

Principal outcomes: (1) RCTs

• Child conduct problems • Child social and problem solving skills • Parent competencies • Parent psychological well being/mental health • Teacher competencies (classroom management)• Changes in parent-child and teacher-child

interaction (behavioural observation)

(2) Implementation study

(2) Implementation sub-study

• Stakeholder views

• Qualitative interviews and brief self-report measures) (including parent and teacher satisfaction)

• Implementation fidelity (eg. quality of programme delivery, participant responsiveness)

(3) Economic Evaluation

• Routinely available costs (eg. materials, training)

• Costs of health, education and social services used by parents, children and teachers during study period

• Incredible Years Group Leader cost diaries

• Overall outcome -> incremental costs of intervention relative to other interventions

Developing the evidence base

• Increasing recognition that health and social care policies and practices need to be informed by robust evidence derived from high quality research

• Such research informs process of service delivery and the formulation of key government policies

• Evidence-based programmes are more likely to have an impact because they tend:

- to be taken more seriously - to be more likely to influence service providers and policy makers - to receive funding - to make a difference

Conclusion • The need to address emotional and behavioural

problems in our children is a social and political imperative

• Incredible Years Ireland Study (IYIS) – will be one of the largest evaluations outside the US

• One of only a very few studies undertaken in a community setting and targeting parents, teachers and children

• Will attempt to build upon and develop existing research -> transferability and effectiveness

• Considerable potential to inform service delivery and

to provide best possible evidence to influence policy and practice within an Irish context

Contact details and funding sources

sinead.mcgilloway@nuim.ie

This research is supported by Archways with funding from the Atlantic Philanthropies and Dormant Accounts Fund