NIHR DC Discover

NIHR Signal Parental training improves a child’s disruptive behaviours regardless of socio-economic disadvantage or ethnicity

Published on 30 January 2018

doi: 10.3310/signal-000540

Children from low-income families, or with an unemployed or single parent, benefitted as much as did economically advantaged groups. The Incredible Years programme worked better for children with more severe behaviour problems or a parent with depression.

This NIHR-funded review pooled individual-level data for pre-school and primary aged children with persistent disruptive behaviours. The 14 European trials, including eight studies in the UK, took place in diverse settings including schools, children’s centres and mental health clinics.

The Incredible Years parent training is widely funded in the UK by the NHS, local authorities and voluntary organisations. Parents gain skills to support their children at risk of or with behavioural problems. These findings show that the programme has the potential to improve outcomes for both advantaged and disadvantaged families similarly.

NICE already recommends evidence-based parenting programmes for children with conduct problems. Commissioners may need to provide additional resources for outreach to the most socially disadvantaged or disengaged families. 

Share your views on the research.

Why was this study needed?

In 2004, 7% of boys and 3% of girls aged five to 10 had a diagnosable conduct problem. Prevalence rates were higher amongst children from socially deprived households. These persistent disruptive childhood behaviours can lead to substance abuse, poor education, and involvement in crime in adolescence and adulthood. Annual costs from age 10 to 28 have been estimated as £351 million for additional education, and £1,360 million for the criminal justice system.

Several UK trials have shown positive benefits from the Incredible Years intervention for children with behavioural problems. Training, supervision and implementation checks ensure fidelity to the developers’ manual in this licensed parenting programme.

The research to date has given conflicting findings on whether disadvantaged families, who might most, need help, and those with more severe problems derive greater or less benefit. This review aimed to use a sufficiently large dataset to test whether effectiveness differs according to family and child characteristics and whether there is potential for reducing inequalities in outcomes or at least not making them worse as some programmes might.

 

What did this study do?

This systematic review analysed data from 14 of the 15 European randomised controlled trials completed by 2015. Reviewers asked study authors to provide individual-level participant data for combining into one large dataset of 1,800 families.

Trials compared the Incredible Years Basic Programme (12 to 14 weekly sessions) to a waiting list control (ten trials), minimal intervention or usual care. Children were on average aged five years. Nine trials included only children with a clinical level of disruptive behaviours. About a third of practitioners were certified in Incredible Years.

Unavoidably, parents and practitioners were aware of their allocation to treatment groups; the reviewers assessed trials as having a low risk of bias. The reviewers had to make assumptions to combine data from trials using different measures.

Behaviours were rated on the 36-item Eyberg Child Behavior Inventory Intensity scale (ECBI-I), in which higher numbers indicate a higher level of disruptive behaviours.  

What did it find?

  • At two months following programme completion, the intervention had led to a moderate reduction in parent-rated disruptive behaviour, compared to a waiting list control, minimal intervention or usual care. Unadjusted pooled standardised mean difference 0.46, range 0.01 to 1.25 in individual trials. A difference of over 0.3 is often considered important on such a measure.
  • Having a low income did not change how much the programme reduced behavioural problems (effect modification index [EMI] 1.9 points on the ECBI-I, 95% CI -4.8 to 8.6 points; 13 trials, 1,614 families). Neither did whether they were unemployed nor a single parent.
  • There was no difference in effectiveness according to ethnicity, nor for the age of the child.
  • The programme’s effect was greater for children with worse baseline behaviours (EMI -4.3 points, 95% CI -7.9 to -0.7 points; 13 trials, 1,622 families). It was also more effective for children with a depressed parent (EMI -4.8 points, 95% CI -8.4 to -1.1 points; 11 trials, 1,395 families).
  • The programme cost £2,414 per person on average (range £1,733 to £2,586 as offered across five UK trials, 2014 prices, excluding set-up costs), with an average offer of 13 sessions. Potential savings across health, justice and education over 20 years ranged from £1,000 to £8,400 per child and probably offset the cost of the intervention.

What does current guidance say on this issue?

The NICE guideline (updated 2017) recommends group parent training for children aged three to 11 with or at high risk of developing an oppositional defiant disorder or conduct disorder or in contact with the criminal justice system due to antisocial behaviour.

Individual programmes can be delivered to families with severe and complex problems or when parents are unable to participate in a group.

NICE specified that parent training should follow a manual, be based on social learning, and enable parents to rehearse scenarios and receive feedback to improve parenting skills.

What are the implications?

This group parenting programme appears to be an effective method of early intervention which works equally across social groups. Commissioners may need to expand capacity with accredited programme facilitators to meet families’ needs in disadvantaged areas. The cost of programmes and the extent to which this intervention might produce benefits for local budgets in other sectors, such as justice or education, will need to be considered.

Engaging and retaining socially disengaged and minority ethnic families may require proactive outreach and support through schools, GPs and trusted local voluntary organisations

Incredible Years is the only parenting programme assessed by the Early Intervention Foundation to have evidence of positive impacts across populations and settings from multiple high-quality evaluations.

Citation and Funding

Gardner F, Leijten P, Mann J, et al. Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective. Public Health Res. 2017;5(10). 

This project was funded by the National Institute for Health Research Public Health Research Programme (project number 12/3070/04).

Bibliography

NHS Choices. New guidelines on child antisocial behaviour: Behind the headlines. London: Department of Health; 2013.

NICE. Antisocial behaviour and conduct disorders in children and young people:  recognition and management. CG 158. London: National Institute for Health and Care Excellence; 2013; updated 2017.

NICE. Antisocial behaviour and conduct disorders in children and young people. QS59. London: National Institute for Health and Care Excellence; 2014; updated 2017.

NICE. NICE support for commissioning for antisocial behaviour and conduct disorders in children and young people. London: National Institute for Health and Care Excellence; 2014.

JCPMH. Guidance for commissioning public mental health services. London: Joint Commissioning Panel for Mental Health; 2013; updated 2015.

Brown E, Khan L, Parsonage M. A chance to change: Delivering effective parenting programmes to change lives. London: Centre for Mental Health; 2012.

Why was this study needed?

In 2004, 7% of boys and 3% of girls aged five to 10 had a diagnosable conduct problem. Prevalence rates were higher amongst children from socially deprived households. These persistent disruptive childhood behaviours can lead to substance abuse, poor education, and involvement in crime in adolescence and adulthood. Annual costs from age 10 to 28 have been estimated as £351 million for additional education, and £1,360 million for the criminal justice system.

Several UK trials have shown positive benefits from the Incredible Years intervention for children with behavioural problems. Training, supervision and implementation checks ensure fidelity to the developers’ manual in this licensed parenting programme.

The research to date has given conflicting findings on whether disadvantaged families, who might most, need help, and those with more severe problems derive greater or less benefit. This review aimed to use a sufficiently large dataset to test whether effectiveness differs according to family and child characteristics and whether there is potential for reducing inequalities in outcomes or at least not making them worse as some programmes might.

 

What did this study do?

This systematic review analysed data from 14 of the 15 European randomised controlled trials completed by 2015. Reviewers asked study authors to provide individual-level participant data for combining into one large dataset of 1,800 families.

Trials compared the Incredible Years Basic Programme (12 to 14 weekly sessions) to a waiting list control (ten trials), minimal intervention or usual care. Children were on average aged five years. Nine trials included only children with a clinical level of disruptive behaviours. About a third of practitioners were certified in Incredible Years.

Unavoidably, parents and practitioners were aware of their allocation to treatment groups; the reviewers assessed trials as having a low risk of bias. The reviewers had to make assumptions to combine data from trials using different measures.

Behaviours were rated on the 36-item Eyberg Child Behavior Inventory Intensity scale (ECBI-I), in which higher numbers indicate a higher level of disruptive behaviours.  

What did it find?

  • At two months following programme completion, the intervention had led to a moderate reduction in parent-rated disruptive behaviour, compared to a waiting list control, minimal intervention or usual care. Unadjusted pooled standardised mean difference 0.46, range 0.01 to 1.25 in individual trials. A difference of over 0.3 is often considered important on such a measure.
  • Having a low income did not change how much the programme reduced behavioural problems (effect modification index [EMI] 1.9 points on the ECBI-I, 95% CI -4.8 to 8.6 points; 13 trials, 1,614 families). Neither did whether they were unemployed nor a single parent.
  • There was no difference in effectiveness according to ethnicity, nor for the age of the child.
  • The programme’s effect was greater for children with worse baseline behaviours (EMI -4.3 points, 95% CI -7.9 to -0.7 points; 13 trials, 1,622 families). It was also more effective for children with a depressed parent (EMI -4.8 points, 95% CI -8.4 to -1.1 points; 11 trials, 1,395 families).
  • The programme cost £2,414 per person on average (range £1,733 to £2,586 as offered across five UK trials, 2014 prices, excluding set-up costs), with an average offer of 13 sessions. Potential savings across health, justice and education over 20 years ranged from £1,000 to £8,400 per child and probably offset the cost of the intervention.

What does current guidance say on this issue?

The NICE guideline (updated 2017) recommends group parent training for children aged three to 11 with or at high risk of developing an oppositional defiant disorder or conduct disorder or in contact with the criminal justice system due to antisocial behaviour.

Individual programmes can be delivered to families with severe and complex problems or when parents are unable to participate in a group.

NICE specified that parent training should follow a manual, be based on social learning, and enable parents to rehearse scenarios and receive feedback to improve parenting skills.

What are the implications?

This group parenting programme appears to be an effective method of early intervention which works equally across social groups. Commissioners may need to expand capacity with accredited programme facilitators to meet families’ needs in disadvantaged areas. The cost of programmes and the extent to which this intervention might produce benefits for local budgets in other sectors, such as justice or education, will need to be considered.

Engaging and retaining socially disengaged and minority ethnic families may require proactive outreach and support through schools, GPs and trusted local voluntary organisations

Incredible Years is the only parenting programme assessed by the Early Intervention Foundation to have evidence of positive impacts across populations and settings from multiple high-quality evaluations.

Citation and Funding

Gardner F, Leijten P, Mann J, et al. Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective. Public Health Res. 2017;5(10). 

This project was funded by the National Institute for Health Research Public Health Research Programme (project number 12/3070/04).

Bibliography

NHS Choices. New guidelines on child antisocial behaviour: Behind the headlines. London: Department of Health; 2013.

NICE. Antisocial behaviour and conduct disorders in children and young people:  recognition and management. CG 158. London: National Institute for Health and Care Excellence; 2013; updated 2017.

NICE. Antisocial behaviour and conduct disorders in children and young people. QS59. London: National Institute for Health and Care Excellence; 2014; updated 2017.

NICE. NICE support for commissioning for antisocial behaviour and conduct disorders in children and young people. London: National Institute for Health and Care Excellence; 2014.

JCPMH. Guidance for commissioning public mental health services. London: Joint Commissioning Panel for Mental Health; 2013; updated 2015.

Brown E, Khan L, Parsonage M. A chance to change: Delivering effective parenting programmes to change lives. London: Centre for Mental Health; 2012.

Could scale-up of parenting programmes improve child disruptive behaviour and reduce social inequalities? Using individual participant data meta-analysis to establish for whom programmes are effective and cost-effective

Published on 7 December 2017

Gardner F, Leijten P, Mann J, Landau S, Harris V, Beecham J, Bonin E, Hutchings J & Scott S.

Public Health Research Volume 5 Issue 10 , 2017

Background Child disruptive behavioural problems are a large and costly public health problem. The Incredible Years® (IY) parenting programme has been disseminated across the UK to prevent this problem and shown to be effective in several trials. It is vital for policy to know for which families IY is most effective, to be sure that it helps reduce, rather than widen, socioeconomic inequalities. Individual trials lack power and generalisability to examine differential effects; conventional meta-analysis lacks information about within-trial variability in effects. Objectives To overcome these limitations by pooling individual-level data from the IY parenting trials in Europe to examine to what extent it benefits socially disadvantaged families. Secondary objectives examine (1) additional moderators of effects on child behaviour, (2) wider health benefits and potential harms and (3) costs, cost-effectiveness and potential long-term savings. Design Individual participant data meta-analysis of 14 randomised trials of the IY parenting intervention. Settings UK (eight trials), the Netherlands, Ireland, Norway, Sweden and Portugal. Participants Data were from 1799 families, with children aged 2–10 years (mean 5.1 years; 63% boys). Interventions IY Basic parenting programme. Main outcome measures Primary outcome was disruptive child behaviour, determined by the Eyberg Child Behavior Inventory Intensity scale (ECBI-I). Secondary outcomes included self-reported parenting practices, parenting stress, mental health, children’s attention deficit hyperactivity disorder (ADHD) and emotional symptoms. Results There were no differential effects of IY on disruptive behaviour in families with different levels of social/socioeconomic disadvantage or differential effects for ethnic minority families, families with different parenting styles, or for children with comorbid ADHD or emotional problems or of different ages. Some moderators were found: intervention effects were strongest in children with more severe baseline disruptive behaviour, in boys, and in children with parents who were more depressed. Wider health benefits included reduced child ADHD symptoms, greater parental use of praise, and reduced harsh and inconsistent discipline. The intervention did not improve parental depression, stress, self-efficacy or children’s emotional problems. Economic data were available for five UK and Ireland trials (maximum n = 608). The average cost per person of the IY intervention was £2414. The probability that the IY intervention is considered cost-effective is 99% at a willingness to pay of £145 per 1-point improvement on the ECBI-I. Estimated longer-term savings over 20 years range from £1000 to £8400 per child, probably offsetting the cost of the intervention. Limitations Limitations include a focus on one parenting programme; the need to make assumptions in harmonising data; and the fact that data addressed equalities in the effectiveness of, not access to, the intervention. Conclusions There is no evidence that the benefits of the IY parenting intervention are reduced in disadvantaged or minority families; benefits are greater in the most distressed families, including parents who are depressed. Thus, the intervention is unlikely to widen socioeconomic inequalities in disruptive behaviour and may have effects in narrowing inequalities due to parent depression. It was as likely to be effective for older as for younger children. It has wider benefits for ADHD and parenting and is likely to be considered to be cost-effective. Researchers/funders should encourage data sharing to test equity and other moderator questions for other interventions; further research is needed on enhancing equality of access to interventions. Funding The National Institute for Health Research Public Health Research programme.

Challenging behaviours are normal from time to time in children’s development. Conduct problems are non-age-appropriate persistent disruptive behaviours. Oppositional defiant disorder (mainly under age 11) and conduct disorder (older children) are diagnosable conditions. It has been estimated that a further 10% of primary aged children have moderate behavioural problems, which may come to the attention of GPs or teachers.

The Incredible Years parenting programme is based on a collaborative social learning model involving videos, role play and peer support. Parents are set goals for home practice and receive weekly telephone calls.

Expert commentary

Effective interventions can improve outcomes for everyone or improve them for a few, and they can either widen or narrow social inequalities. The Incredible Years parenting programme improves child behaviour outcomes across socio-economic groups, and this makes it more attractive to commissioners.

Although Incredible Years does not widen social inequalities, it isn’t for everyone. Focussing the programme on families with children with the most disruptive behaviour, boys, and on those with parental depression, will probably yield the best value for money.

Engaging the families most likely to benefit from the programme in the first place remains the biggest challenge for services.

Phil Wilson, Professor of Primary Care and Rural Health, University of Aberdeen