Hilton Davis

Role of home visiting in improving parenting and health in families at risk of abuse and neglect: results of a multicentre randomised controlled trial and economic evaluation

Objectives: To evaluate the effectiveness and cost effectiveness of an intensive home visiting programme in improving outcomes for vulnerable families. Design: Multicentre randomised controlled trial in which eligible women were allocated to receive home visiting (n = 67) or standard services (n = 64). Incremental cost analysis. Setting: 40 general practitioner practices across 2 counties in the UK. Participants: 131 vulnerable pregnant women. Intervention: Selected health visitors were trained in the Family Partnership Model to provide a weekly home visiting service from 6 months antenatally to 12 months postnatally. Main outcome measures: Mother–child interaction, maternal psychological health attitudes and behaviour, infant functioning and development, and risk of neglect or abuse. Results: At 12 months, differences favouring the home-visited group were observed on an independent assessment of maternal sensitivity (p<0.04) and infant cooperativeness (p<0.02). No differences were identified on any other measures. A non-significant increase in the likelihood of intervention group infants being the subject of child protection proceedings, or being removed from the home, and one death in the control group were found. The mean incremental cost per infant of the home visiting intervention was £3246 (bootstrapped 95% CI for the difference £1645–4803). Conclusion: This intervention may have the potential to improve parenting and increase the identification of infants at risk of abuse and neglect in vulnerable families. Further investigation is needed, along with long-term follow-up to assess possible sleeper effects.

Parent Counselling: An Evaluation of a Community Child Mental Health Service

Health visitors and Clinical Medical Officers (CMOs) were trained in parent counselling and worked at home in a highly deprived area with parents of pre-school children with multiple psychosocial problems. Their basic aims were to establish a mutually respectful partnership and to support parents in managing their diverse problems. Detailed evaluation indicated that the Service was highly valued by both parents and referrers, and suggested significant changes, including: improvements in the severity of problems; increased parental self-esteem; decreased levels of parental stress and emotional difficulties; more positive constructions of their children; improvements in the home environment; and decreased child behavioural problems.

A comparison of the effectiveness of three parenting programmes in improving parenting skills, parent mental-well being and children's behaviour when implemented on a large scale in community settings in 18 English local authorities: the parenting early intervention pathfinder (PEIP)

BackgroundThere is growing evidence that parenting programmes can improve parenting skills and thereby the behaviour of children exhibiting or at risk of developing antisocial behaviour. Given the high prevalence of childhood behaviour problems the task is to develop large scale application of effective programmes. The aim of this study was to evaluate the UK government funded implementation of the Parenting Early Intervention Pathfinder (PEIP). This involved the large scale rolling out of three programmes to parents of children 8-13 years in 18 local authorities (LAs) over a 2 year period.MethodsThe UK governments Department for Education allocated each programme (Incredible Years, Triple P and Strengthening Families Strengthening Communities) to six LAs which then developed systems to intervene using parenting groups. Implementation fidelity was supported by the training of group facilitators by staff of the appropriate parenting programme supplemented by supervision. Parents completed measures of parenting style, efficacy, satisfaction, and mental well-being, and also child behaviour.ResultsA total of 1121 parents completed pre- and post-course measures. There were significant improvements on all measures for each programme; effect sizes (Cohens d) ranged across the programmes from 0.57 to 0.93 for parenting style; 0.33 to 0.77 for parenting satisfaction and self-efficacy; and from 0.49 to 0.88 for parental mental well-being. Effectiveness varied between programmes: Strengthening Families Strengthening Communities was significantly less effective than both the other two programmes in improving parental efficacy, satisfaction and mental well-being. Improvements in child behaviour were found for all programmes: effect sizes for reduction in conduct problems ranged from -0.44 to -0.71 across programmes, with Strengthening Families Strengthening Communities again having significantly lower reductions than Incredible Years.ConclusionsEvidence-based parenting programmes can be implemented successfully on a large scale in community settings despite the lack of concentrated and sustained support available during a controlled trial.

Child and Adolescent Mental Health Needs Assessment and Service Implications in an Inner City Area

A random sample of 253 parents and young people were interviewed to elicit: (i) the number, type and severity of psychosocial problems in children/young people; and (ii) the number and type of risk factors for mental health in a very deprived inner city locality. The results suggest high levels of need for mental health services, with, for example, 37% of children having three or more problems, and over 51% having three or more risk factors. From subjective case-by-case analysis, preliminary criteria were derived for judging the level of required service response and the numbers likely to present appropriate to the various tiers of service. Of the 25% of the sample expressing a need for help, 6% were judged to be manageable by community staff (e.g. health visitors) with support from child mental health specialists, 4% by specially trained community staff (e.g. parent advisers), 8% by solo child and adolescent mental health specialists and 7% by generic or specialist child mental health teams.

Child and Family Outcomes of the European Early Promotion Project

This chapter concerns the outcomes for the families involved in the European Early Promotion Project and presents data collected when the children were between six and eight weeks old and when they were 24 months old. A total of 824 families were recruited from the five countries involved. At baseline, differences were found between country samples in the extent and type of need (Finnish families having the lowest risk factor rates and Serbia the highest, for example), but recruitment was generally successful in including families from the whole range of need, excluding those with the most severe physical and psychiatric problems. Although not randomised, Intervention families (receiving the EEPP service) were reasonably matched with Comparison families (receiving usual services) on most variables initially, except in Greece, where Intervention families were somewhat more at risk. At 24 months, in spite of low intensity of service provision and methodological difficulties likely to reduce effects, there was evidence, particularly in Greece, of differences in outcome favouring the Intervention group, who also showed significantly higher levels of satisfaction with the intervention they had received. It was concluded that the service merits further exploration to assist in understanding promotional and preventative processes.

Promoting Children's Mental Health: The European Early Promotion Project (EEPP)

The prevalence of psychosocial disorders in children is high internationally (Bird, 1996), with rates in the UK in the region of 10-15% (Fonagy et al, 2002; Meltzer et al, 2000). Levels rise dramatically (for example to 40%), particularly in disadvantaged areas (Attride-Stirling et al, 2001; Davis et al, 2000) if one takes an approach based on problems and not on disorders. Given the serious consequences of such difficulties (including distress, impaired development and adult functioning, and costs of later services), it is worrying to find major service problems. They include lack of universal, accessible, high-quality specialist services (Kurtz et al, 1994; NHS Health Advisory Service, 1995; Audit Commission, 1999), poor co-ordination with accessible community professionals (for example health visitors and teachers), who may also lack the skills (Mitcheson & Cowley, 2003) and confidence (Fundudis, 1990; Kurtz et al, 1994) to deal with psychosocial issues. Services offer little in the way of effective parenting preparation (Henricson et al, 2001) or high-quality child care and preschool education to compensate (Boocock, 1995; Shonkoff & Phillips, 2000) for the problems parents have in meeting their children’s needs. The aim of this special issue of the Journal is to describe a major project set up to address these problems by developing a promotional and preventative service in a European context, and to evaluate its effects. This introductory chapter will set the scene for the papers to follow, by considering service developments in this area and previous research that has been done on the effectiveness of prevention strategies. Focusing largely on home visiting as the main vehicle for service delivery, we will consider the outcomes of these methods, before exploring neglected questions about the effective ingredients of these strategies and the processes involved. The chapter finishes with a brief description of the origins of the European Early Promotion Project (EEPP), a design specification for the service and the theory upon which it was based.

The Effects of the European Early Promotion Project Training on Primary Health Care Professionals

This chapter explores the effects of the European Early Promotion project training on primary health care professionals, with regard to their knowledge, self-efficacy and ability to identify need in families, and to their satisfaction with the training received. A quasi-experimental group comparison design was developed, in which an Intervention and a Comparison group were assessed twice: the Intervention group before and after the special EEPP training and the Comparison at the same time interval but without the training. Overall results show a tendency for the Intervention group to improve in knowledge and perceived self-efficacy, and a significant improvement in their accuracy of need identification in families, compared with the Comparison group. These results were more prominent in Greece, Serbia and the UK than in Finland and Cyprus, whereas training satisfaction was high in all sites. The results are discussed in terms of their implications for early intervention as well as for training PHCPs to conduct preventative and promotional work with families.

The European Early Promotion Project: Description of the Service and Evaluation Study

This chapter describes an innovative cross-cultural method of working with families to promote the psychosocial well-being of children and to prevent the development of psychological and social problems. It also presents a study designed to evaluate the effects of the service. Primary health care workers in five countries from Northern, Central and Southern Europe were trained to conduct promotional interviews with all prospective mothers in their area one month before and one month after birth. They were also taught to work with mothers identified as in need of support as a parent, by using a specific counselling model to try to prevent the onset of child mental health difficulties. Effects of the intervention on childrens psychological development and family adaptation were evaluated at two years of age in comparison with matched groups not receiving the intervention, using a set of questionnaires, interviews and observation methods. The total sample of the study at the initial assessment was 824 families, of which 705 (85.6%) were retained for the outcome assessment.

Preventing obesity at weaning: parental views about the EMPOWER programme

BACKGROUND Infant growth and lifestyle are now recognized as being critical determinants of later obesity. EMPOWER (Empowering Parents to Prevent Obesity at Weaning: Exploratory Research) was developed as an intervention for parents whose babies are at high risk. Delivered by specially trained health visitors, it is underpinned by the Family Partnership Model and uses a strengths-based, solution-focused way of working with families. METHODS Mothers of babies participating in the pilot of EMPOWER in Leeds were recruited to take part in a study to examine perceptions about the programmes acceptability and usefulness. Interviews were taped and transcribed, and thematic analysis undertaken. RESULTS Families talked positively about the approach of the EMPOWER health visitor with her emphasis on listening, partnership working and shared problem-solving. Parents particularly valued the use of a non-judgemental approach, which they felt had helped them to discuss openly, sensitive issues such as weight and diet. They identified a number of important benefits ranging from increased knowledge about the most appropriate types and amount of food to feed their toddler, to more far-reaching changes within the family as a whole, including modifications to their own diet and lifestyle. Programmes of this nature were perceived as more valuable than the standard help that is currently available. CONCLUSION The EMPOWER programme appears to be both acceptable and valued by targeted parents and a potentially effective means of supporting high-risk families to prevent their children from developing obesity. An exploratory randomized controlled trial is now underway to ascertain the feasibility of conducting a definitive phase 3 trial.

The effectiveness and quality of routine child and adolescent mental health care outreach clinics

OBJECTIVES Little evidence has been available about the functioning and outcomes of child mental health services operating at the primary care interface. This study investigated the effectiveness and quality of one particular model of outreach clinic. DESIGN The study used a quasi-experimental design comparing outcomes of children attending the outreach clinics with a waiting list comparison. The intervention group (n=88) was assessed at referral, four months and twelve months later. The comparison group (n=99) completed measures at referral and four months. METHOD The main carers of participant children completed self-report measures of problem severity, impact, burden, parental stress and parent satisfaction. Clinicians provided clinical activity information. RESULTS There were significant reductions in childrens problem severity, distress and impairment, particularly for behavioural difficulties. In contrast, the results showed no effect upon the outcomes of childrens emotional problems or parental stress. High ratings of satisfaction were obtained for many aspects of care. CONCLUSIONS The children receiving care through this system of decentralised, outreach clinics derived clinical benefits that were maintained over time. The outreach clinics received strong consumer support suggesting the service offered a high level of acceptability to parents.