Rationale

The following examples are included as support for model 1 as evidence is available to demonstrate impact on the long-term outcomes for parents, families and CYP:

a.Interventions for parents of infants and children in the early years

i.Supporting secure attachment

ii. Maternal mental health and wellbeing

iii. Home-visiting programmes and early years education

b.Interventions for parents of older children

i. Supporting parents and family functioning

ii. Multi-component initiatives

c.Interventions for parents of adolescents

a. Interventions for parents of infants and children in the early years

i.Supporting secure attachment.
Evidence shows[1]:

• there are links between a child’s attachment style and later social and emotional outcomes. However, this association is not deterministic.

• secure attachment is associated with positive outcomes including self-esteem, self-confidence, resilience and emotional regulation. Disorganised attachment is a strong predictor of later relationship and emotional difficulties.

• promotion of secure attachment and sensitive, responsive parenting has the potential to reduce health inequalities in Scotland.

ii. Maternal mental health and wellbeing [2]
There is evidence that maternal mental health and wellbeing is recognised as a key influence on a child’s development during the early years of their life, and interventions which enhance maternal mental health and wellbeing and those that promote positive parent infant relationships can have long-term benefits.

iii. Home-visiting programmes and early years education [3]
There is evidence that:

• action to provide home-visiting programmes and early years education can lead to longer-term improvements in outcomes for children and young people.

• home-visiting programmes are associated with improvement in some child cognitive outcomes, improvement in positive health behaviours and the prevention of injury.

There is evidence that early childhood interventions, including home visiting and early education, result in lasting improvements in the outcomes of at-risk or disadvantaged children. The greatest positive effects include:

• improved cognitive development

• educational success during adolescence

• reduced social deviance

• increased social participation.

Smaller improvements in family wellbeing and social-emotional development have also been reported.

(See model 2, ‘Home visiting’ and ‘Early childhood educations/children’s centre’ and model 3 ‘Ensuring implementation success’ for further detail)

Moderate review-level evidence [2] indicates:

• that overall home visits in the post-partum period may improve outcomes for a range of vulnerable parents, particularly if delivered by nurse practitioners. The evidence of effective interventions in response to the support needs of families at risk of significant dysfunction or child abuse remains inconclusive

• lasting improvements in cognitive development for at-risk or disadvantaged young children from studies of developmental prevention programmes, (including structured preschool programmes, centre-based developmental day care, home visitation, family support services and parental education). The largest effects were observed in relation to educational success during adolescence, reduced social deviance, increased social participation, and cognitive development.

Evidence relating to preschool education and interventions delivered in day care or educational settings has a differential impact on the most vulnerable children, with full-day programmes shown to be more effective for improving the cognitive development of children who are particularly disadvantaged (see model 2 ‘Early childhood educations/children’s centre’ for further detail).

b. Interventions for parents of older children

i. Supporting parents and family functioning [4]

• There is evidence that the relationship between family-centred help giving (characterised by practices that treat families with respect and dignity; information-sharing; family choice regarding involvement and provision of services and parent/professional collaboration and partnerships) and child outcomes is indirect and mediated through self-efficacy. This approach is also associated with more positive and less negative parent, family and child behaviour and functioning.

• There is review-level evidence of an association between community-based interventions with families, parents and carers of children and young people aged between 7 and 19 years and some improvements in attainment, behaviour and emotional outcomes. The findings suggest that community-based programmes have the potential to improve child behaviour, welfare, and reduce the amount of time spent in care and levels of juvenile crime.

• There is evidence that analysis of parents perceptions of taking part in a parenting programme (mainly Incredible Years) suggest that perceptions of control and confidence in ability to parent, guilt, social influences, knowledge and skills and mothers' needs are key themes.

ii. Multi-component initiatives [4]
There is evidence from multi-component initiatives (including both universal services and targeted services) of post-intervention improvements in children and young people’s outcomes:

1. Universally available and targeted services for higher-need families are associated with improvement in adolescent outcomes.

2. Parenting programmes are associated with reduction in youth crime, child abuse and improvements in child behaviour; no evidence on child healthy behaviours.

3. Support to parents linked to improved family relationships.

4. Training for treatment of children with a conduct disorder improved child behaviour.

5. Strategies to enhance positive parenting improved parent and child functioning in the short term. They were also associated with improved parent outcomes but no/inconclusive evidence regarding the long-term impact on child behaviour is provided.

6. Telephone helplines and innovation services: limited evidence of improvements in family relationships and child behaviour, but most parents felt that accessing web and social media sites did not have a direct impact on their children.

7. General parenting programmes to improve attendance and behaviour in school (often in combination with helplines) are associated with improved child behaviour.

See model 2 under ‘Multi-component initiatives’and model 3 for evidence relating to the effective delivery of service.

c. Interventions for parents of adolescents

Evidence suggests links between parenting and adolescent health behaviours, uptake of health services and susceptibility to illness in adulthood. [5,6,7,8,9,10] Based upon a literature review and expert consensus meetings, the World Health Organization (WHO) identified five dimensions of parenting contributing to adolescent health: connection, behavioural control, respect for individuality, modelling, and provision (see Apendix 2: Glossary for definitions). [11]

i. Parenting styles and adolescent health outcomes
In general, reviews of observational studies conclude that the authoritative parenting style[b](high warmth, high control) produces better adolescent health outcomes (see Box 1 ). [12] This is consistent with the WHO dimensions of parenting, which embody both the high warmth (connection) and high control (behavioural control) features of this parenting style.

Box 1: Adolescent outcomes associated with the authoritative parenting style [12]

• Lower levels of substance abuse and risky sexual behaviour.

• Higher levels of academic achievement, healthy eating and physical activity.

• Parenting behaviours that are consistent with the authoritative parenting style have been shown to be associated with better adolescent outcomes; for example, parental modelling of healthy behaviours, nurturance, open communication, acceptance, autonomy-granting, and open communication and behaviours that promote connectedness have been shown to be associated with a range of positive health and wellbeing outcomes. In contrast, studies have shown associations between the authoritarian, permissive and neglectful parenting styles and poorer adolescent health outcomes, such as greater levels of substance use and lower levels of healthy eating and physical activity.

McAteer et al [12] conclude that there is good-quality review level evidence relating to the impact of interventions aimed at reducing sexual risk behaviour, substance, tobacco and alcohol use in adolescents (see also model 2 ‘Interventions for adolescents and parents of adolescents’ for further discussion of the interventions). The evidence suggests that such interventions can influence adolescent health outcomes. However, the evidence is predominantly US-based and it is unclear to what extent findings might translate into the Scottish context.

McAteer et al [12] also conducted an analysis of the characteristics of interventions reported in those reviews focusing upon substance, tobacco and alcohol use in adolescents. A total of 21 interventions were included, nine of which reported an effect upon behaviour, and 11 reporting no effect (see the full review for further detail). Effective interventions tended to be delivered in a community or home setting, provided by a trained deliverer, consist of at least eight weeks’ contact time, and informed by theory. A greater proportion of interventions reporting an effect used techniques targeting the WHO dimensions of ‘connection’ and ‘behaviour control’, consistent with findings related to the authoritative parenting style. Although this review found that descriptions of specific intervention techniques were sparse; some observations were made based upon the available evidence (see Box 2).

Box 2: Intervention techniques used in effective and ineffective interventions involving parents to influence adolescent alcohol, substance and tobacco use [12]

Intervention reporting an effect:

• A higher proportion of the effective interventions focused upon providing encouragement in relation to communication between the child and parent and parent/bonding. Additionally, half of these interventions incorporated provision of encouragement around parental rule-setting, etc. Almost half of the effective interventions provided the opportunity for parents and children to rehearse skills learned as part of the intervention.

Interventions reporting no effect:

• Behavioural contracts or commitments with parents were a characteristic of almost half of the ineffective interventions.

Taken as a whole, the evidence suggests that support for parents – including information, and other support materials, and formal interventions – with adolescent children should focus upon promoting ‘connection’ and ‘behaviour control’ through fostering open, and responsive communication, relationship support to foster bonding, and sensitive appropriate responses to behaviour. [12]

Those delivering content through parenting interventions should be mindful that such interventions appear to be most effective when they are delivered in a community or home setting, provided by a trained deliverer, consist of at least eight weeks’ contact time, and informed by theory.[12]

There is promising evidence of the effectiveness of existing interventions (see also model 2 ‘Interventions for adolescents and parents of adolescents’ for further discussion of the interventions). However, these are predominantly US-based and it is unclear how they might translate into the Scottish context. UK based evaluations are needed.

References :

1. Scott E. Briefing on Attachment. NHS Health Scotland, 2012. Available from: www.healthscotland.com/documents/5755.aspx

2. Scott E, Woodman K. Evidence summary: Interventions to support parents, their infants and children in the early years (pregnancy to 5 years) NHS Health Scotland, 2012. Available from: www.healthscotland.com/documents/6089.aspx

3. Scott E, Woodman K. Guidance about Effective Interventions to Support Parents, Their Infants and Children in the Early Years. A paper to the Scottish Government Early Years Taskforce; 2012. Available from: www.scotland.gov.uk/Resource/0041/00413580.pdf

4. Scott E, Woodman K. Evidence summary: Public health interventions to support parents of older children and adolescents. NHS Health Scotland, 2014. Available from: http://www.healthscotland.com/documents/5755.aspx

5. Collins WA, Maccoby EE, Steinberg L, Hetherington EM, Bornstein MH. Contemporary research on parenting. The case for nature and nurture. American Psychologist. 2000; 55: 218–232.

6. Beveridge RM, Berg CA. Parent-adolescent collaboration: An interpersonal model for understanding optimal interactions. Clinical Child and Family Psychology Review.2007; 10(1): 25–52.

7. Fergusson DM, Horwood LJ, Ridder, EM. Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal of Child Psychology and Psychiatry. 2005; 46(8): 837–49.

8. Stewart-Brown SL, Fletcher L, Wadsworth MEJ. Parent-child relationships and health problems in adulthood in three UK national birth cohort studies. European Journal of Public Health. 2005; 15(6): 640–646.

9. Stewart-Brown S. (2012). Peer led parenting support programmes. British Medical Journal. 2012; 344: e1160.

10. Temcheff CE, Serbin LA, Martin-Storey A, Stack DM, Ledingham J, Schwartzman AE. Predicting adult physical health outcomes from childhood aggression, social withdrawal and likeability: a 30 year prospective, longitudinal study. International Journal of Behavioural Medicine. 2011; 18(1): 5–12.

11. World Health Organization. Helping parents in developing countries improve adolescent health. 2007. Available from: www.who.int/maternal_child_adolescent/documents/9789241595841/en/

12. McAteer J, Jepson R, Wight D, Jackson C. Characteristics of effective and ineffective adolescent health interventions with a parental component. Scottish Collaboration for Public Health Research and Policy, University of Edinburgh and MRC Social and Public Health Sciences Unit, University of Glasgow. Available from: http://www.scphrp.ac.uk/characteristics-of-effective-ineffective-adolescent-health-interventions-with-a-parental-component/