In England, as in the USA and other Westernised countries, there is considerable concern for the well-being of children. Data reviewed in the authoritative Good Childhood report Reference Layard and Dunn1 confirms that in many respects children have never lived so well – they have more possessions, better homes, are more educated and less often sick. However, the proportion of 15- to 16-year-olds in Britain suffering significant behavioural difficulties such as conduct problems and hyperactivity rose significantly between 1974 and 1999, with a similar rise in emotional difficulties. This rise does not appear to be artefactual since the same measures were used each time. Reference Collishaw, Maughan, Goodman and Pickles2 Since then, the level of diagnosable disorders with impairment has remained roughly constant at 10%. Reference Green, McGinnity, Meltzer, Ford and Goodman3
These time trends are likely to be connected with the changing world in which children are growing up, both inside and outside the family unit. Compared with 21 other high-income countries, the UK and the USA were bottom of the 2007 United Nations Children's Fund (UNICEF) report on the quality of childhood: more children are living in single-parent families, and the proportion of children living in relative poverty (defined as less than half the median income) is higher – 10% in most high-income countries, 16% in the UK and 22% in the USA. 4 To ameliorate this will require a range of social and political actions at local and national level. However, improving only the material environment will not necessarily enhance the quality of childhood. An increasing body of evidence suggests that ameliorating the quality of parenting children receive can contribute to reducing disorders and promoting success.
The contribution of parenting to child well-being
A good parent–child relationship can generate positive experiences within the family and provide the child with emotional security and social skills that enable them to cope with life in a resilient way. A wealth of observational literature confirms that the quality of the parent–child relationship has a strong association with child outcomes. Sensitive responding by the parent in infancy lays the foundation for secure attachments; in middle childhood and beyond, good role-modelling and active encouragement for sociable behaviour coupled with firm, calm limit-setting promotes good adjustment. Reference O'Connor and Scott5 In contrast, predominantly harsh, rejecting and inconsistent parenting promotes antisocial behaviour and delinquency. Reference O'Connor and Scott5 The quality of the parental relationship affects more than child behaviour; for example, in one careful study, it explained a third of the 13 percentile point gap in language development between 4-year-olds in low- and middle-income countries. Reference Berger, Paxson and Waldfogel6 Of course, the parent–child relationship is not a one-way affair: a child's temperament and genetic make-up contribute. However, this doesn't mean that parenting is irrelevant – indeed, recent studies that disentangle genetic and rearing effects confirm that parenting effects are especially powerful in the genetically vulnerable, and particular genotypes are now being identified that confer increased susceptibility to poor parenting. Reference Belsky, Bakermans-Kranenburg and van Ijzendoorn7
The case for expanding evidence-based parenting programmes
High long-term cost of child antisocial behaviour and social exclusion
Nearly half of children with early-onset conduct problems (typically starting at age 3 or 4 years) go on to have persistent, serious ‘life-course’ problems, including crime, violence, drug misuse and unemployment. Reference Fergusson, Horwood and Ridder8 They cost society dear. An empirical follow-up study showed that by age 27, children in England with oppositional and conduct disorders at age 10 had each cost the public around £200 000 – ten times more than controls. Reference Scott, Knapp, Henderson and Maughan9 Therefore interventions with a relatively modest impact could be cost-effective.
Effectiveness of evidence-based parenting programmes
Scores of randomised controlled trials (RCTs) attest to the effectiveness of good-quality parenting programmes for treating conduct problems, which are now recommended by the National Institute for Health and Clinical Excellence. For example, in one UK trial, local clinicians were carefully trained to deliver the basic 12-week Incredible Years programme to 3- to 8-year-olds referred to child and adolescent mental health services, and achieved a large reduction in conduct problems, with an effect size of 1.1 standard deviation and no loss of effectiveness at 1 year follow-up. Reference Scott, Spender, Doolan, Jacobs and Aspland10 Programmes are also effective for symptoms of attention-deficit hyperactivity disorder and other outcomes such as educational attainment. Reference Scott, Sylva, Doolan, Price, Jacobs and Crook11 They also reduce harsh parenting, so should be used more widely with parents who are at risk of abusing their children. The contents of a typical programme are shown in the Appendix. In general, effects are largest for children with more severe problems, so that treatment of individuals referred with marked difficulties is probably more cost-effective than primary prevention for whole communities, at least in the shorter term. Reference Dodge12
Caveat: some approaches are ineffective
Although the drive towards evidence-based practice is becoming increasingly accepted in the mental health context, albeit variably implemented, it is less well known and accepted among social workers and those who work with parents, including practitioners from the voluntary sector, in children's centres. Evaluations of generic counselling approaches show that they may be very popular with parents, but they do not necessarily improve child outcomes; Reference Scott, Rutter, Bishop, Pine, Scott, Stevenson and Taylor13 a number of widely used home-visiting schemes have no effect on child outcomes. Reference McAuley, Knapp, Beecham, McCurry and Sleed14 Less than 10% of over 150 approaches currently used in England have good evidence of effectiveness. To work, parenting programmes need to be evidence-based and delivered by skilled practitioners, since less-competent therapists often have no effect. 15 Because many practitioners do not have specific skills – for example, 90% of outreach workers in children's centres have no specific training at all in parenting work – there is a pressing need for training.
Government initiatives to promote children's well-being
The Labour government introduced several initiatives to give all children a better chance to achieve their potential. Delinquent behaviour by youths was a particular concern (e.g. Respect Agenda, 2006: www.homeoffice.gov.uk/documents/respect-action-plan); new legal powers included parenting orders to force parents to take steps to control their children. Poor attainment in disadvantaged families has also been a focus (e.g. Every Child Matters, 2005: www.dcsf.gov.uk/everychildmatters) and led to the ambitious preventive programme whereby Sure Start centres were set up in the most deprived areas to help mothers of under-3-year-olds access a range of services. Reference Melhuish, Belsky, Leyland and Barnes16
On the parenting front, the Department for Children, Schools and Families has introduced several initiatives to increase the number of people working with parents, for example Parenting Early Intervention Pathfinder projects in disadvantaged areas, a parent support advisor for every school, parenting experts in each local authority, and family intervention projects for those families experiencing the most difficulties. These developments have meant that a large number of practitioners are now employed in England to work with parents on their relationships with their children.
The need for an academy to increase practitioners' skills
The case for parenting initiatives to be evidence-based was presented to many government departments, including the Treasury and the Prime Minister's Strategy Unit; many other interested parties were also influential. This led to a competitive bid to set up the National Academy for Parenting Practitioners in England, which was launched in November 2007. With a budget of £30 million for the first 3 years, its mission is ‘to transform the quality and size of the parenting workforce across England so parents can get the help they need to raise their children well’ (www.parentingacademy.org). There are two strands of work: training and research.
Training and workforce development
Free training is being offered in evidence-based programmes for 3400 practitioners, followed by ongoing supervision to refine their skills; there is training in basic skills for less-qualified practitioners. At a managerial level, local authority staff who commission parenting services are being helped to purchase better programmes through an online quality rating described below. In the first instance, training is being targeted at practitioners offering treatment rather than a primary preventive service, as this is where the immediate demand lies.
The two main themes are the improvement of commissioning of training, and the development and testing of promising interventions.
Currently, the many parenting programmes used in England vary greatly in theoretical orientation, quality of written materials, sophistication of training available for practitioners, and evidence of effectiveness. Over the past year, each local authority in England has appointed a parenting commissioner whose job it is to draw up a parenting strategy. Commissioners need to know which programmes are ‘fit for purpose’, so they can know which to purchase (and which to drop). The Academy has developed four detailed criteria to rate programmes (www.commissioningtoolkit.org): the quality of specification of the intervention and for whom it is intended; whether the content is based on empirically tested theory and is clearly written down in a manual so that it can be replicated; the quality of the procedures for training and supervision of practitioners; and trial evidence of effectiveness on parenting and child outcomes.
Most intervention evaluation schemes include only the last dimension. The first three were added because it was desirable on the one hand to indicate interventions that were not very replicable (because of poor training procedures) even if they were effective, and on the other, not to overly penalise programmes that had the right ingredients and good training procedures, but had not had the resources to mount an RCT. A team from the London School of Economics is assessing programme costs and benefits.
Developing and testing of parenting interventions is under way for several groups of children in need. Questions addressed by all the trials include whether the intervention works and if so, for how long, for whom it works (moderators), how it works (mediators), the impact of therapist skill, and its acceptability and cost-effectiveness. There are two RCTs of well-developed interventions: one of functional family therapy for teenage antisocial behaviour, and one of an intervention called Supporting Parents on Kids Education in Schools for literacy and behavioural improvement in primary-school children. Reference Fergusson, Horwood and Ridder8 Additionally, there are three trials that are using case series to refine new interventions, for high-need families, for foster parents, and also for parents of ‘callous–unemotional’ children. Across the trials, the relative usefulness of questionnaires, interviews and direct observation for assessing parenting will be compared, as there is currently no accepted standard way of assessing parenting.
The setting up of a parenting academy is an example of how expertise held by mental health professionals can be disseminated far more widely to raise the competence of workers from many agencies and backgrounds. The overall goal of improving public mental health in childhood and beyond through parenting is an ambitious one. Whether it is effective will require careful evaluation, and the Academy has a sizeable research facility to contribute to this.
Appendix: Characteristics of effective parenting programmes
• Structured sequence of topics, introduced in set order over 8–12 weeks
• Subjects include play, praise, incentives, setting limits, and discipline
• Emphasis on promoting sociable, self-reliant child behaviour and calm parenting
• Constant reference to parent's own experience and predicament
• Theoretical basis informed by extensive empirical research and made explicit
• Detailed manual available to enable replicability
• Collaborative approach acknowledging parents' feelings and beliefs
• Difficulties normalised, humour and fun encouraged
• Parents supported to practise new approaches during session and through homework
• Parent and child seen together in individual family work; just parents in some group programmes
• Crèche, good-quality refreshments and transport provided if necessary
• Therapists supervised regularly to ensure adherence and to develop skills
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