The Nurtured Heart Parenting Intervention for Children's Behavioural Problems: A Single Case Design
Phase: NA
Conditions: Parent-Child Relations, Child Behavior Problem
Sponsor: University of Lincoln

 
Page 1 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
 
Cover Page  
 
 
 
 
The Nurtured Heart Parenting Intervention for Children’s Behavioural 
Problems: A Single Case Design 
Protocol Version 1.2 
Date: 08.02.2022 
 
NCT06195579 
 
 
 
 
 

 
Page 2 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
 
 
 
 
 
 
 
 
 
 
 
 
PROTOCOL 
The Nurtured Heart Parenting Intervention for Children’s Behavioural 
Problems: A Single Case Design 
Nurtured Heart parenting intervention for child behavioural problems 
 
Protocol Version 1.2 
Date: 08.02.2022 
 
 
IRAS Project ID 
306642 
Registration ID 
- 
Sponsor  
University of Lincoln 
Sponsor ID 
22004 
Funder 
Own account – student research  

 
Page 3 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
SIGNATURE PAGE 
 
The undersigned confirm that the following protocol has been agreed and accepted and that the Chief 
Investigator agrees to conduct the study in compliance with the approved protocol and will adhere to the 
principles outlined in the Declaration of Helsinki, the Sponsor’s SOPs, and other regulatory requirement(s). 
I agree to ensure that the confidential information contained in this document will not be used for any other 
purpose other than the evaluation or conduct of the investigation without the prior written consent of the 
Sponsor 
I also confirm that I will make the findings of the study publicly available through publication or other 
dissemination tools without any unnecessary delay and that an honest accurate and transparent account of 
the study will be given; and that any discrepancies from the study as planned in this protocol will be explained. 
 
Chief Investigator: 
Signature: ............................................................................. 
Date: ..31..../..01.../..2022... 
Name: (please type) Nima Moghaddam 
 
 
 
 
 
 

 
Page 4 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
STUDY/TRIAL CONTACTS 
Chief Investigator 
 
Name: Dr Nima Moghaddam 
Address: Sarah Swift Building, 8 Brayford Wharf E, Lincoln, LN5 7AT 
UoL job title: Research Clinical Psychologist and Associate 
Professor 
Phone: 01522 882000 
Email: nmoghaddam@lincoln.ac.uk  
 
Primary research supervisor for the doctoral student 
Sponsor  
 
Contact details: 
 
University of Lincoln 
Stephanie Maloney | Head of Research and Enterprise 
University of Lincoln  
Brayford Pool, Lincoln, LN6 7TS 
Sponsor contact for queries: 
Sam Lewis 
Research Governance Manager sponsor@lincoln.ac.uk  
 
Collaborators/Co-
Investigators/Protocol Contributors 
Name: Dr Sarah Wilde 
Address: Sarah Swift Building, 8 Brayford Wharf E, Lincoln, LN5 7AT 
UoL job title: Senior Lecturer in Clinical Psychology 
Phone: 01522 882000 
Email: sarahwilde@lincoln.ac.uk 
 
Research supervisor for the doctoral student 
 
Name: Dr Mark Gresswell 
Address: Sarah Swift Building, 8 Brayford Wharf E, Lincoln, LN5 7AT 
UoL job title: Senior Clinical Academic, Co-Director of the Trent 
Doctoral Programme in Clinical Psychology  
Phone: 01522 882000 
Email: mgresswell@lincoln.ac.uk 
 
Research supervisor for the doctoral student 
 
Student  
 
Henrietta Hall, doctoral student on Trent Doctorate of Clinical 
Psychology (DClinPsy).  
Phone: 01522 882000.  
Email: 25511189@students.lincoln.ac.uk 
FUNDER DETAILS 
FUNDER(S) 
 
FINANCIAL AND NON FINANCIALSUPPORT GIVEN 
Higher Education England 
Student research – no specific project funding. This research project 
is being completed in partial fulfilment of the Doctorate in Clinical 
Psychology programme, funded by Health Education England  

 
Page 5 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
STUDY SUMMARY 
Study Title 
The Nurtured Heart Parenting Intervention for Children’s 
Behavioural Problems: A Single Case Design 
Study Design 
The study will use a non-concurrent across-participant multiple 
baseline A-B single case design.  
Study Participants 
Participants will be parents/carers of children who have been 
referred to National Health Service (NHS) specialist children’s 
services. Participants will be recruited from the waiting lists of 
children’s services at two NHS trusts in the East Midlands. 
Eligibility Criteria 
Inclusion criteria: the parent/carer identifies their child’s 
behaviour as problematic; the child’s behavioural problems are 
one of the primary presenting problems; and the referred child 
is aged between three and eleven years old. 
Exclusion criteria: the child has a diagnosis of developmental 
delay or learning disability; the family is receiving active multi-
agency involvement; and the participant is unable to 
read/speak English fluently. 
Planned Sample Size 
The planned number of participants is six. 
Study Duration 
The duration of the intervention for participants is 13 weeks: 3 
weeks baseline data collection, 6 weeks intervention, post-
intervention follow-up 4 weeks after intervention completion. 
Total participant duration from first contact with participants will 
be approximately 16 weeks. 
 
The total expected duration of the study is 13 months. Planned 
start date: February 2022 (dependant on approval by ethics 
committee). The research will be submitted in the form of a 
thesis in partial fulfilment of the requirements for the Trent 
Doctorate in Clinical Psychology. Planned submission date: 
February 2023.  
Objectives 
The primary research question is: When delivered in a guided 
self-help format, is the NHA effective in reducing parent-
reported children’s behavioural problems? 
The secondary research questions are: 
1. When delivered in a guided self-help format, is the NHA 
effective in: 
a. reducing negative parenting practices? 
b. increasing parental reflective functioning?  
2. To what extent is the NHA a feasible and acceptable 
intervention for parents of children with behavioural 
problems when delivered in a guided self-help format?  
Outcome Measures 
Measures: Brief Problem Monitor (BPM; Achenbach et al., 
2011), Psychological Outcomes Profiles (PSYCHLOPS; 
Ashworth et al., 2009), Multidimensional Assessment of 
Parenting Scale (MAPS; Parent & Forehand, 2017); Parental 

 
Page 6 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Reflective Functioning Questionnaire (PRFQ; Luyten et al., 
2017), 
Warwick-Edinburgh 
Mental 
Well-Being 
Scale 
(WEMWBS; Tennant et al., 2007) 
A semi-structured change interview (based on Rodgers and 
Elliott (2015) will be completed with participants 4 weeks post-
intervention.  
Data Analysis  
Visual analysis and calculations of reliable and clinically 
significant change will be used to analyse the quantitative data. 
Framework analysis as outlined by Gale et al. (2013) will be 
used to analyse the change interviews.  
 
KEY WORDS 
Nurtured Heart Approach; parenting; child behavioural problems; single case design.  
 

 
Page 7 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Table of Contents 
 
SIGNATURE PAGE ................................................................................................................. 
 
3 
STUDY/TRIAL CONTACTS ..................................................................................................... 
 
4 
FUNDER DETAILS .................................................................................................................. 
 
4 
STUDY SUMMARY ................................................................................................................. 
 
5 
KEY WORDS .......................................................................................................................... 
 
6 
LIST OF ABBREVIATIONS ..................................................................................................... 
 
9 
STUDY MANAGEMENT .......................................................................................................... 
 
10 
ROLE OF STUDY SPONSOR AND FUNDER ..................................................................................... 10 
STUDY BACKGROUND and RATIONALE .............................................................................. 
 
10 
Development of the problem ................................................................................................................... 10 
Interventions ........................................................................................................................................... 11 
STUDY OBJECTIVES AND PURPOSE .................................................................................. 
 
12 
PURPOSE AND PRIMARY OBJECTIVES .............................................................................................. 12 
SECONDARY OBJECTIVE(S) ................................................................................................................ 12 
OUTCOME MEASURES/ENDPOINTS .................................................................................... 
 
12 
PRIMARY OUTCOME MEASURE/ENDPOINT ....................................................................................... 12 
SECONDARY ENDPOINTS/OUTCOMES .............................................................................................. 13 
STUDY DESIGN...................................................................................................................... 
 
13 
DATA ANALYSIS .................................................................................................................................... 14 
STUDY SETTING ................................................................................................................................... 14 
SELECTION OF PARTICIPANTS ........................................................................................... 
 
14 
ELIGIBILITY CRITERIA .......................................................................................................................... 14 
Inclusion Criteria .................................................................................................................................. 14 
Exclusion Criteria................................................................................................................................. 15 
Sampling ............................................................................................................................................. 15 
Size of sample ..................................................................................................................................... 15 
Sampling technique ............................................................................................................................. 15 
RECRUITMENT ...................................................................................................................................... 16 
Participant Payment ............................................................................................................................ 16 
CONSENT .............................................................................................................................................. 16 
STUDY PROCEDURES/REGIMEN ......................................................................................... 
 
17 
STUDY FLOWCHART ............................................................................................................................ 17 
Flowchart for Participants .................................................................................................................... 18 
STUDY REGIMEN .................................................................................................................................. 20 
SCHEDULE OF PROCEDURES ............................................................................................................ 22 
WITHDRAWAL ....................................................................................................................................... 22 
ETHICAL AND REGULATORY CONSIDERATIONS ............................................................... 
 
22 

 
Page 8 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
ASSESSMENT AND MANAGEMENT OF RISK ...................................................................................... 22 
ADVERSE EVENTS................................................................................................................................ 22 
ETHICS REVIEW AND COMPLIANCE ................................................................................................... 23 
PEER REVIEW ....................................................................................................................................... 23 
PUBLIC & PATIENT INVOLVEMENT .................................................................................................. 23 
PROTOCOL COMPLIANCE ................................................................................................................... 23 
DATA PROTECTION AND PATIENT CONFIDENTIALITY ...................................................... 
 
23 
INDEMNITY ............................................................................................................................. 
 
24 
ACCESS TO THE FINAL DATASET ....................................................................................................... 24 
DISSEMINATION POLICY ...................................................................................................... 
 
24 
Authorship eligibility guidelines and any intended use of professional writers ...................................... 25 
REFERENCES ........................................................................................................................ 
 
25 
 
 
 
 

 
Page 9 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
LIST OF ABBREVIATIONS 
 
AE 
Adverse Event 
CAMHS 
Child and Adolescent Mental Health Service 
CF 
Consent Form 
CI 
Chief Investigator 
CRF 
Case Report Form 
DClinPsy 
Doctorate of Clinical Psychology 
EudraCT 
European Clinical Trials Database 
GCP 
Good Clinical Practice 
GP 
General Practitioner 
HCPC 
Health and Care Professions Council 
HRA 
Health Research Authority 
ICF 
Informed Consent Form 
IRAS 
Integrated Research Application System 
ISF 
Investigator Site File (This forms part of the TMF) 
ISRCTN 
International Standard Randomised Controlled Trials Number 
LIH 
Lincoln Institute for Health 
NHA 
Nurtured Heart Approach 
NHS 
National Health Service 
NHS R&D 
National Health Service Research & Development   
NICE  
National Institute for Health and Care Excellence 
PI 
Principal Investigator 
PIS 
Participant Information Sheet 
PRF 
Parental Reflective Functioning 
RCT 
Randomised Control Trial 
REC 
Research Ethics Committee 
SAE 
Serious Adverse Event 
SOP 
Standard Operating Procedure  
SUCAP 
Service User and Carer Advisory Panel 
TMF 
Trial Master File 
UoL 
University of Lincoln 

 
Page 10 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
STUDY MANAGEMENT  
ROLE OF STUDY SPONSOR AND FUNDER 
The sponsor of the study is the University of Lincoln. 
The Chief Investigator has overall responsibility for the study and shall oversee all study management. 
STUDY BACKGROUND and RATIONALE 
Behavioural problems are common in childhood; estimates suggest that between 5% and 14% of children 
exhibit behavioural difficulties (Green et al., 2005; Merikangas et al., 2009). In the UK, 30% of general 
practitioner (GP) child consultations and the majority of referrals to children’s mental health services are for 
behavioural problems (National Institute for Health and Care Excellence (NICE), 2017). It is clear, therefore, 
the scale of the problem is significant. 
The term “behavioural problems” is widely used but its precise meaning is often not clear. However, defining 
what is meant by behavioural problems is difficult for several reasons. Problematic behaviour is age and 
context dependent; tantrums are developmentally appropriate at the age of two but not past the age of four 
(Gardner & Shaw, 2008). There is also a subjective judgement as to what behaviour presents a problem, and 
for whom.  
Achenbach (1966) identified two broad dimensions of behaviour in children: externalising and internalising 
behaviours. Externalising behaviours are generally defined as aggression, cruelty and rule-breaking 
behaviours (Achenbach, 1978; Achenbach & Edelbrock, 1979; Frick et al., 1993). Unlike internalising 
behaviours such as anxiety, which are most problematic for the child themselves, externalising behaviours 
mainly present problems for others (Carr, 2016). The focus of this study will be on externalising behaviour in 
childhood.  
Behavioural problems in childhood have numerous negative correlates in adolescence and adulthood. 
Children demonstrating higher levels of externalising behaviour have increased risks of poor school 
attendance, poor educational attainment, anxiety and mood disorders, substance misuse, unemployment, 
and criminal offending (Colman et al., 2009; Kratzer & Hodgins, 1997). Consequently, childhood behavioural 
problems have a pervasive impact on both individual and societal levels. 
Development of the problem 
The aetiology of childhood behavioural problems is complex due to the bidirectional relationship between a 
child and their environment, incorporating genetic, family and socioeconomic factors (Jaffee & Price, 2007; 
NICE, 2017). The role of parenting has been the focus of much research. Critical, punitive and inconsistent 
parenting has been grouped together into a parenting dimension labelled negative parenting practices 
(Parent & Forehand, 2017). These negative parenting practices consistently predict increased externalising 
behaviour in children (Gryczkowski et al., 2010; Reitz et al., 2006; Scaramella et al., 2008). 
Patterson’s (1982) coercion theory proposed a mechanism through which parents’ behaviour contributes to 
the development and maintenance of behavioural problems. Reinforcement, a central component of coercion 
theory, is any consequence that increases the likelihood of a behaviour occurring again; positive 
reinforcement is the introduction of a rewarding stimulus while negative reinforcement is the removal of an 
aversive stimulus (Ramnero & Törneke, 2011).  
Coercion theory states a parent initially positively reinforces a child’s undesirable behaviours by rewarding 
these with attention, in the absence of desirable behaviours receiving attention. The child’s continued 
aversive behaviour is then negatively reinforced by eventual withdrawal of the parent (for example, due to 
frustration). Over time, parent and child develop mutually reinforcing patterns of increasingly aversive 
behaviour (Eddy et al., 2001; Smith et al., 2014). 

 
Page 11 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Recently, however, research has also identified parents’ ability to understand their own mental states, and 
that of their children, as fundamental to parenting behaviour (Camoirano, 2017). Parental reflective 
functioning (PRF) is a relatively new construct that captures parents’ mentalising ability specifically in relation 
to their children (Luyten et al., 2017). 
Research into the relationship between PRF and children’s behaviour is in its infancy. However, there is 
already evidence to suggest that lower levels of parental reflective functioning are correlated with: more 
negative parenting practices (Riva Crugnola et al., 2018); increased aggression in infancy (Smaling et al., 
2017); increased externalising behaviours in childhood (Ensink et al., 2016);  and poorer emotional regulation 
skills (Nijssens et al., 2020).  
Moreover, because all behaviour is perceived subjectively, the way a parent makes sense of their child’s 
behaviour becomes important. Staines et al. (2019) found that following a parenting programme which 
increased PRF, adoptive parents attributed children’s problematic behaviour less to behavioural problems 
and more to emotional and peer-related difficulties. When considering childhood behavioural problems, a 
parent’s perception of their child’s behaviour consequently appears to be an important factor. 
Interventions 
Parenting interventions are a NICE recommended and well-evidenced approach for reducing childhood 
behavioural problems for children aged three to eleven years old  (NICE, 2017). Parent training programmes 
differ in their focus, with the majority placing emphasis on behavioural and psychoeducational strategies that 
aim to reduce ineffectual and detrimental parenting practices (Tully & Hunt, 2016).  
Suchman et al. (2006), however, emphasised the importance of including relational aspects in parent training 
programmes. Improving parents’ behaviour management skills without also developing emotional and 
relational skills limits the potential impact of parenting interventions (Suchman et al., 2004). Emotionally 
attuned parenting is fundamental to children’s wellbeing and where this is lacking, children tend to have 
significantly poorer outcomes (Carr, 2016), including exhibiting externalising behaviours. Consequently, 
interventions are increasingly targeting emotional and relational aspects of parenting (Camoirano, 2017). 
The Nurtured Heart Approach (NHA; Glasser & Easley, 2016) is a parenting training programme that targets 
parents of children with behavioural problems. It is widely used in the USA and increasingly in the UK, 
currently in National Health Service (NHS) children’s mental health services in Lincolnshire. The NHA can be 
delivered as a one to one, group, or self-help intervention (Glasser, 2016), and is a short-term intervention 
usually delivered in four to six sessions.  
The NHA incorporates three stands (Glasser & Easley, 2016): refusing to energize negativity; energising 
success; and implementing limits and consequences. Glasser and Easley (2016) do not provide any 
theoretical grounding or empirical evidence, but state the NHA was developed based on clinical experience. 
Although not explicitly acknowledged, however, the NHA clearly draws on several psychological theories. 
The three stands are based upon well-established and well-evidenced behavioural principles, consistent with 
coercion theory (Hektner et al., 2013).  
The NHA also targets parents’ insight and understanding of their child (Glasser & Easley, 2016). Emphasis 
is placed the child’s perspective and strengths through illustrative examples and practice tasks. Parents are 
also required to reflect on their own mental states, learning to “self-reset” when experiencing heightened 
emotion (Glasser, 2016, p. 39). In this way, the NHA is introducing and reinforcing parents’ ability to 
understand their own and their child’s mental states, as captured by the construct of parental reflective 
functioning. 
Despite the increasing use in clinical practice, the NHA currently has an extremely limited evidence base. 
The only published research study found that the NHA reduced negative parenting practices, as well as 
increasing parents’ perception of their children’s strengths (Brennan et al., 2016). However, the study used 
a quasi-experimental design which Brennan et al. (2016) acknowledged was a fundamental weakness which 
prevented firm conclusions being drawn.  

 
Page 12 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Nuño et al. (2019) proposed a randomised control trial (RCT) protocol for assessing the effectiveness of the 
NHA but to date no RCT nor any other experimental design has been used to research the NHA. Moreover, 
while Hektner et al. (2013) and Kausik and Hussain (2020) have proposed conceptual frameworks, neither 
study hypothesised mechanisms of change. Consequently, there is a clear need for further research into the 
NHA.  
A meta-analysis exploring the impact of self-directed parenting interventions compared to therapist led 
parenting interventions for child externalising behaviour found both approaches to be effective in reducing 
children’s behavioural problems with no significant difference between modes of delivery (Tarver et al., 2014). 
In the context of public services requiring the most cost effective service delivery due to financial constraints 
(Robertson et al., 2017), self-help interventions can offer a valuable alternative to more resource intensive 
modes of delivery. Therefore, the focus of this research will be on the self-help delivery of the NHA.  
Greater understanding of the effectiveness and mechanisms of the NHA delivered in a self-help format will 
add to the evidence base around parenting interventions for externalising behavioural problems in children. 
In turn, this can allow current services to make informed about the most appropriate interventions which is 
particularly important given the NHA is currently being used in NHS services.  
STUDY OBJECTIVES AND PURPOSE 
PURPOSE AND PRIMARY OBJECTIVES  
The purpose of the study is to increase the evidence base for the NHA parent training programme.  
The primary objective of this study is to explore the effectiveness of the Nurtured Heart Approach parent 
training programme when delivered in a guided self-help format. Therefore, the primary research question is:  
When delivered in a guided self-help format, is the NHA effective in reducing parent-reported children’s 
behavioural problems? 
SECONDARY OBJECTIVE(S) 
The secondary research questions are: 
1. When delivered in a guided self-help format, is the NHA effective in: 
a. reducing negative parenting practices? 
b. increasing parental reflective functioning?  
2. To what extent is the NHA a feasible and acceptable intervention for parents of children with 
behavioural problems when delivered in a guided self-help format?   
OUTCOME MEASURES/ENDPOINTS 
PRIMARY OUTCOME MEASURE/ENDPOINT 
The primary outcome measure is parent-reported child behavioural problems and will be measured at 
baseline, throughout the intervention and post-intervention four weeks after the intervention has been 
concluded.  
Primary outcome measure 
The Brief Problem Monitor (BPM), a short version of the Child Behaviour Checklist (CBCL; Achenbach & 
Rescorla, 2001), will be used to measure parent-reported child behavioural problems. While both versions 
have been used extensively in research, the 113 item CBCL is too long to repeat regularly. The BPM is more 
suitable than the alternative Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997) because of the 
difference in factor structures; the externalising scale of the BPM is more consistently supported in factor 
analyses than the five-factor structure of the SDQ which has externalising behaviour represented across 
three different subscales (McCrory & Layte, 2012).  

 
Page 13 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
SECONDARY ENDPOINTS/OUTCOMES 
The secondary measures include a parenting practice measure, parental reflective functioning measure, a 
general wellbeing measure and an ideographic measure to capture parents’ perception of the problems and 
assess any change. A change interview will also be completed with participants. 
Parenting practice measure 
The Multidimensional Assessment of Parenting Scale (MAPS) uses a two-factor structure that assesses 
positive (e.g. nurturing, attuned) and negative (e.g. hostile, punitive, critical) parenting practices (Parent & 
Forehand, 2017). The MAPS takes approximately ten minutes to complete every session, which is a time 
burden for participants. There are very few alternatives, however, that are shorter and retain adequate 
psychometric properties. Relying on a self-report measure without observations of parenting is a limitation, 
although there is evidence to suggest that self-report measures of parenting do correlate with independent 
observations (Hawes & Dadds, 2006). An observational element is not included because this would impact 
the feasibility of the study in the given timescale, particularly in the context of the global pandemic. The MAPS 
will be shortened for repeated measurement purposes. This will be done by taking the top 3 items from the 
MAPS positive scale and the top 3 from the negative and using that as a proxy process measure. What 
constitutes ‘top’ can be established by either face-validity, relative factor loadings of each item derived from 
the original scale development, or a combination of both. 
Parental reflective functioning measure 
The Parental Reflective Functioning Questionnaire (PRFQ) will be used to assess parental reflective 
functioning. The PRFQ has not been validated by developers for parents of children aged six to eleven 
(Luyten et al., 2017). However, there is preliminary evidence that the measure is valid in children up to the 
age of ten (Pazzagli et al., 2018). Consequently, the PRFQ will be used for participants of this study as, 
despite the limited validation in age range of the PRFQ, it is the only measure in existence that captures 
parental reflectivity. 
Ideographic measure 
An ideographic measure is included to capture parents’ perception of the problems and assess any change. 
The Psychological Outcomes Profiles (PSYCHLOPS; Ashworth et al., 2009) items will be generated with 
each participant at the beginning of the baseline phase. The PSYCHLOPS is more proportionate than the 
Personal Questionnaire (Elliott et al., 2016) as it focuses on two problem areas rather than ten; this will reduce 
the time burden on participants during the generation of items and completion of the measure.  
General wellbeing measure 
Understanding general wellbeing is important as it is likely to impact parenting behaviour. The Short Warwick-
Edinburgh Mental Well-Being Scale (SWEMWBS; Tennant et al., 2007) will be used instead of the General 
Health Questionnaire (GHQ-12; McCabe et al., 1996) because the GHQ-12 primarily screens for 
psychopathology whereas the SWEMWBS also captures positive aspects of wellbeing. 
Change interview 
One month post intervention the participants will also be asked to take part in a semi-structured change 
interview (Rodgers & Elliott, 2015). The purpose of the interview is to capture parents’ views of any changes 
resulting from their participation in the NHA intervention. The addition of this qualitative data will allow for a 
more comprehensive evaluation of the intervention. 
STUDY DESIGN  
The study proposes using a non-concurrent across-participant multiple baseline A-B single case design. The 
baseline period (A) precedes the intervention period (B), where the NHA is delivered in a guided self-help 
format over six weeks. Data will be collected using psychometric measures and post-intervention data 

 
Page 14 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
collection will also include a qualitative semi-structured change interview. Full details are given below in 
“Study Procedure”.  
DATA ANALYSIS  
Visual analysis is the suggested method of analysing single case design data (Barlow et al., 2009) and 
consequently will be used to analyse the data resulting from this research. The data will be visually 
represented on graphs and examined for trends in the data indicating if and when change has occurred 
across the process measures for the three variables of interest. The data will also be analysed to establish if 
any changes are reliable and clinically significant. Assessment of reliable change identifies if change is 
genuine or resulting from measurement error; this will be calculated using the Reliable Change Index 
(Jacobson & Truax, 1991). If changes prove reliable, they will be analysed for clinical significance (Jacobson 
& Truax, 1991). The change interviews will be transcribed verbatim by the doctoral student and analysed 
using framework analysis as outlined by Gale et al. (2013). NVivo will be used to conduct the framework 
analysis.  
Data analysis will be completed by the doctoral student with support from the research supervisors (CI and 
collaborator). No interim analysis are planned.  
STUDY SETTING  
The study will be run across two mental health trusts in the East Midlands. The specialist children’s services 
(Child and Adolescent Mental Health Service; CAMHS) within [redacted NHS Trust] will be the primary study 
site. The CAMHS service consists of four locality teams across the county, all of which work together to form 
one service. The population being recruited from will be parents/carers of children on the waiting lists for 
these services. Recruitment will be supported by staff within these services who are aware of the research 
project and its aims. 
The secondary study site will be CAMHS services within [redacted NHS Trust]. Recruitment will only occur 
in the secondary study site if it has not been possible to recruit sufficient participants from the primary study 
site. Again, recruitment will be focused on parents/carers of children on the waiting lists for CAMHS services 
and will be supported by clinical psychologists within CAMHS who are aware of the research project and its 
aims.  
Across both sites the referred children of participants will remain on the waiting list, with an allocated lead 
professional, for the duration of the intervention. Consequently, the services will retain clinical responsibility 
throughout the intervention. When potential participants are identified by staff from the services, in the first 
instance the allocated lead professional will establish if parents/carers consent to being contacted for 
research purposes. If consenting to the contact, the doctoral student will then contact potential participants – 
see Study Procedure below for full details. Staff from the service will have no further role in the research 
study. However, notes from the intervention sessions will be uploaded to the record of the referred child for 
each service meaning staff can access session notes if they have a legitimate reason to do so. This will be 
made clear to participants at the outset of the study. 
SELECTION OF PARTICIPANTS 
ELIGIBILITY CRITERIA 
Participants will be parents/carers of children who have been referred to NHS children’s services for 
behavioural problems. Participants will be recruited from waiting lists of NHS children’s services as outlined 
above.  
Inclusion Criteria  
• 
The referred child is aged between three and eleven years old. 
• 
The referred child is on a waiting list for an NHS children’s service in the primary or secondary study 
site. 

 
Page 15 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
• 
The referred child’s behavioural problems are one of the primary reasons for referral to the NHS 
service. 
• 
The parent/carer identifies the referred child’s behaviour as problematic. 
NICE guidelines only recommend parent-focused interventions for behavioural problems with children aged 
between 3 and 11 years old (NICE, 2017). Child behavioural problems are an important focus of this research, 
hence the requirement for the referred child’s behaviour to be one of the primary reasons for referral. The 
requirement for children to be on a waiting list for an NHS children’s service means that the child and parent 
will be able to access treatment as usual regardless of this research and will retain an allocated lead 
professional from the service though the intervention. Finally, the parent/carer needs to identify the behaviour 
as problematic; otherwise, a guided self-help intervention would not be appropriate.  
Exclusion Criteria 
• 
The referred child has a diagnosis of developmental delay or learning disability. 
• 
The family is current receiving active multi-agency involvement (e.g. social care, police or youth 
offending in addition to NHS services). 
• 
The parent/carer is aged under 18. 
• 
The parent/carer is unable to read or speak English fluently.  
Crnic et al. (2004) state the function of behavioural problems is often different for children with a 
developmental delay or learning disability, making the NHA potentially unsuitable. Similarly, multi-agency 
involvement and parents aged under 18 years old (legally children themselves) indicate a level of need 
beyond what would be appropriate for a self-help intervention. The language requirement is necessary for 
the participants to be able to read the self-help chapters and partake in the guided self-help conversations.  
Sampling 
The study aims to recruit six participants and convenience sampling will be used to identify the participants.  
Size of sample 
Single case designs typically have between three and six participants; consensus indicates three cases is 
the minimum to demonstrate an experimental effect (Kratochwill et al., 2010), while more than six participants 
is unlikely to be feasible given the amount of data that is required from each participant in single case design 
research (Barlow et al., 2009) 
This study aims to recruit six participants. If successful, this maximises the power of the design without 
compromising feasibility. If recruitment proves challenging, there is capacity to reduce numbers to three 
participants without invalidating the findings. Participants will be replaced if drop-out occurs during the 
baseline phase. 
Sampling technique 
Convenience sampling will be used to select the participants. Staff working in the specific services will be 
aware of the eligibility criteria for the study and will identify potential participants. If there are more than six 
parents/carers willing to participate, participants will be contacted in the chronological order by which they 
were identified by staff.  
This will not result in a representative sample. However, this is not a problem in single case research designs 
(Barlow et al., 2009), as the small number of participants renders the sample unrepresentative regardless of 
the sampling technique. The strength of the design comes instead from the systematic and repeated 
measurement of specific variables (Barlow et al., 2009).  

 
Page 16 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
RECRUITMENT 
Participants will be recruited from the treatment waiting lists of the CAMHS services. Staff working in these 
services will be aware of the research study and its aims; recruitment will use staff’s knowledge of the families 
awaiting support to identify potential participants. The initial approach will be from a member of the referred 
child’s usual care team, e.g. the allocated lead professional, who will screen potential participants who meet 
the study eligibility criteria (see Inclusion and Exclusion criteria above). During this initial approach, the 
member of the usual care team will explain the project and give the potential participant the Participant 
Information Sheet (PIS). 
Translator services will not be used because the eligibility criteria requires participants to be fluent in written 
and spoken English.  
The investigator or their nominee, e.g. a member of the participant’s usual care team, will inform the 
participant or their nominated representative (other individual or other body with appropriate jurisdiction), of 
all aspects pertaining to participation in the study. The initial approach will be via telephone or during a 
scheduled appointment. If the initial approach takes place in person, such as during a scheduled 
appointment, appropriate Personal Protective Equipment (PPE) will be worn in accordance with the Covid-
19 guidance issued by the relevant NHS Trusts. The PIS will be sent electronically (via email) or handed over 
in person dependant on whether the initial contact takes place in person or virtually.  
Potential participants will be given a minimum of 24 hours to consider their participation before they are 
contacted by a member of their usual care team to give their verbal consent. If they subsequently decide to 
take part, the doctoral student will contact them (contact details will be passed on by the clinician who made 
the initial contact with the participants permission) and will be asked to sign an Informed Consent Form (ICF). 
The member of the usual care team who made the initial approach will also be asked to record in the referred 
child’s clinical notes that verbal consent has been obtained for their parent/carer’s contact details to be 
passed on to the research team. Participants will be able to sign the ICF electronically or can sign, scan and 
send back the form electronically. It will be explained to the potential participants that participation in the 
research study will not impact the treatment as usual that they receive from the service for which the referred 
child is on a waiting list. 
It will be explained to the potential participant that entry into the trial is entirely voluntary and that their 
treatment and care will not be affected by their decision. It will also be explained that they can withdraw at 
any time, but attempts will be made to avoid this occurrence. In the event of their withdrawal, it will be 
explained that their data collected so far may not be erased in accordance with the University’s Research 
Privacy Notice and information given in the Participant Information Sheet and we will seek consent to use the 
data in the final analyses where appropriate. 
Participant Payment  
Participants will not be paid to participate in the trial. There is evidence to suggest that providing a financial 
incentive may reduce overall intrinsic motivation to participate in research (Zutlevics, 2016). Intrinsic 
motivation will be important for participants’ desire to learn and attempt new parenting strategies and 
consequently, anything that may threaten this could impact the validity of the study. Therefore, no payment 
will be made to participants. Participants will not incur any additional costs as a result of participating in the 
research. 
Through participating in the intervention, participants will receive the book “Transforming the Intense Child 
Workbook” (Glasser, 2016) in six parts and will keep their workbook on completion of the intervention.  
CONSENT 
All participants shall provide written informed consent. The ICF will be signed and dated by the participant 
before they enter the study.  
Potential participants will have been given the PIS by the member of the referred child’s usual care team. 
Potential participants will be given a minimum of 24 hours to consider their participation before they are 

 
Page 17 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
contacted by a member of their usual care team to give their verbal consent for their contact details to be 
passed onto the research team.  
The recruiting investigator (the doctoral student) will explain the details of the study and ensure participants 
have a PIS (and any other study related literature), making sure that the participant has sufficient time to 
consider participating or not. Opportunity will be given to the participant to ask any questions they may have 
has concerning study participation. Participants will be asked to consent to the research team accessing their 
child’s medical record for the researcher to create a note on the child’s record following each guided self-help 
session. It is usual practice for any clinical contact to be logged by the person making the contact, in this 
case the researcher, as soon after the contact as possible. By having access to the medical record, the 
researcher can upload the note directly after the session which is good practice and particularly important if 
any safeguarding issues are identified.   
The process for obtaining participant informed consent will be in accordance with the REC guidance, and 
Good Clinical Practice (GCP) and any other regulatory requirements that might be introduced. The 
investigator or their nominee and the participant shall both sign and date the ICF before the person can 
participate in the study. Participants will be able to sign the ICF electronically or can sign, scan and send 
back the form electronically. One copy of the ICF will be kept by the participant, one will be kept by the 
research team, and a third will be retained in the referred child’s medical records. It will be explained to the 
potential participants that participation in the research study will not impact the treatment as usual that they 
receive from the service for which the referred child is on a waiting list. Participants will be given the contact 
details of the research team should they have any further questions. Should there be any subsequent 
amendment to the final protocol, which might affect a participant’s participation in the trial, continuing consent 
will be obtained using an amended consent form which will be signed by the participant. Capacity will be 
assumed for all participants as they will be adults (over the age of 18). 
STUDY PROCEDURES/REGIMEN 
STUDY FLOWCHART  
Below are the study flowcharts written for the participant. The first explains the process of recruitment, the 
second explains participation in the intervention. 
 
 

 
Page 18 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Flowchart 
Recruitment. 
 
 
 
 
 
The participant receives the 
consent form and any other 
relevant information. 
The participant signs and returns the consent 
form. The researcher also signs the consent form. 
The participant is now part of the study. 
A child is referred to the participating NHS 
services for behavioural problems and 
placed on a waiting list. 
The child’s parent/carer is informed of the study by the 
family’s allocated professional and asked for consent 
to be contacted for research purposes. The 
parent/carer is given an information sheet. 
A researcher contacts the potential 
participant to describe the research and 
what being part of the study would involve. 
The potential participant is 
interested in taking part. 
The potential participant does not want to 
take part.  
The participant is interested 
in taking part. 
The participant no longer 
wants to take part.  
Start study. 

 
Page 19 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Procedure.  
 
 
Baseline Phase 
Intervention Phase 
Follow-up Phase 
The participant will be sent one 
chapter of the workbook to read 
each week. The researcher contacts 
the participant once a week to collect 
information using questionnaires and 
discuss the chapter. This phase lasts 
six weeks.  
The participant decides they do not want to continue 
taking part in the study, informs the researcher and is 
withdrawn from the study.  
The participant no longer meets the eligibility criteria 
for the study. The researcher informs them and the 
participant is withdrawn from the study.  
The participant completes the intervention phase and 
continues to the follow-up phase. 
The researcher contacts the 
participant twice per week to 
collect information using 
questionnaires (also called 
measures). This phase is likely to 
last three weeks but may be 
slightly longer. 
The participant decides they do not want to continue 
taking part in the study, informs the researcher and is 
withdrawn from the study.  
The participant no longer meets the eligibility criteria 
for the study. The researcher informs them and the 
participant is withdrawn from the study.  
The participant completes the baseline phase and 
continues to the intervention phase. 
The researcher will contact the 
participants to complete the 
questionnaires for the last time and 
arrange a follow-up interview with an 
independent researcher. The follow-
up interview is the participant’s 
chance to give feedback on the 
intervention and how you found it. 
The participant decides they do not want to continue 
taking part in the studyand informs the researcher.  
After taking part in the interview, the participant has 
completed the study and will be sent an overview of 
the research unless they have opted out.  

 
Page 20 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
STUDY REGIMEN 
The screening procedure is outlined above in the eligibility, recruitment and consent sections.  
Baseline phase 
Following informed consent, participants will begin the baseline phase. During the baseline phase, 
participants will be contacted twice a week by phone by the doctoral student to collect the data. The table 
below shows the frequency of administration for each measure throughout the study. The exact timing of 
phone calls will be organised with each participant around their availability and the availability of the doctoral 
student.  
The necessity to complete multiple measures will be made clear to participants both in the initial conversation 
and PIS. If participants do not consistently complete the measures, the researcher will speak to the participant 
to identify why and explain the impact on the research. If measures continue not to be completed during the 
baseline phase, participants may be withdrawn from the study. 
If stability is not achieved on any variable, participant data will be considered on a case-by-case basis. Lack 
of stability likely to undermine the validity of subsequent results may result in participants being withdrawn 
from the study. However, because each participant acts as their own control, a limited amount of variability 
may not have a significant impact on the study (Kratochwill et al., 2010).  
Intervention phase 
The intervention phase will exclusively use the official NHA self-help workbook (Glasser, 2016); a workbook 
will be purchased for each participant by the research team using the research budget. The doctoral student 
will also undertake the six-hour NHA online training course produced by the creators of the NHA (Glasser & 
Easley, 2016). This is to ensure that the guided aspect of the intervention is completed with as much fidelity 
to the approach as possible.  
A chapter from the book will be sent to the participants each week through the post. Each participant will be 
requested to read the chapter prior to the arranged guided self-help session. The doctoral student will then 
contact the participant by phone to complete the guided self-help session which involves discussing the 
prompt questions provided in the workbook. The exact timing of phone calls will be organised with each 
participant based around their availability, the availability of the doctoral student and when they received the 
workbook in the post. Process measures will be collected at the beginning of this phone call. These sessions 
will be audio-recorded. 
If participants do not read the chapter in advance of the phone call, the option will be given to the participant 
to read through the chapter jointly during the call, including prompt questions, or to postpone the phone call 
by a day. Flexibility will be prioritised as the time-intensive nature of the intervention is recognised. However, 
if participants do not attend the six intervention sessions, they will be withdrawn from the study as they will 
not be receiving the intervention in a standardised way.  
One month post intervention, the participants will be contacted again to complete all five measures and 
arrange the change interview. The measures will be completed by the doctoral student. The change interview 
will be completed by a second doctoral student who will not previously have been involved in the study; this 
interview will also take place via phone and will be audio-recorded. 

 
Page 21 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others persons without prior written authorisation from 
the University of Lincoln 
Frequency of measure collection 
Measure 
Baseline (A) 
Intervention (B) 
Follow-up 
Week 1 
Week 2 
Week 3 
Week 4 
Week 5 
Week 6 
Week 7 
Week 8 
Week 9 
Week 13 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 
1 
Day 
4 
Day 1 
Short 
Warwick-
Edinburgh  
Mental Wellbeing Scale 
(SWEMWBS) 
✓ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
✓ 
✓ 
Psychological Outcomes 
Profiles (PSYCHLOPS)  
 
✓ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
✓ 
✓ 
Multidimensional  
Assessment of Parenting 
Scale (MAPS) 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
✓ 
Parental 
Reflective 
Functioning 
Questionnaire (PRFQ) 
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
✓ 
Brief Problem Monitor 
(BPM)  
✓ 
✓ 
✓ 
✓ 
✓ 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
 
✓ 
✓ 
 

 
Page 22 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
SCHEDULE OF PROCEDURES 
Procedures 
Sessions 
Screening 
Baseline 
(weeks 1-3) 
Intervention 
(weeks 4-9) 
Follow 
up 
(week 13) 
Informed consent 
x 
 
 
 
Demographics 
 
x 
 
 
Measure collection 
 
x 
x 
x 
Intervention 
 
 
x 
 
Change interview  
 
 
 
x 
 
WITHDRAWAL  
Participants may be withdrawn from the trial either at their own request or at the discretion of the investigator 
(with input from the whole research team). The participants will be made aware that this will not affect their 
future care. Participants will be made aware (via the information sheet and consent form) that should they 
withdraw the data collected to date may not be erased in accordance with the University’s Research Privacy 
Notice and information given in the Participant Information Sheet and may still be used in the final analysis. 
Participants who withdraw prior to starting the intervention will be replaced. After starting the intervention 
phase, replacement of participants will be considered on a case-by-case basis depending on individual 
circumstances. If a participant withdraws before the start of the intervention phase, they will not receive the 
self-help workbook, but will be made aware that they can purchase the book themselves. 
ETHICAL AND REGULATORY CONSIDERATIONS 
ASSESSMENT AND MANAGEMENT OF RISK 
If information is disclosed during the study that could pose a risk of harm to the participant or others, the 
researcher will discuss this with the CI and where appropriate report accordingly. 
Risks will be managed in accordance with each trust’s safeguarding policy. The Health and Care Professions 
Council (HCPC) practitioner psychologist guidance will also be adhered to. During participation in the study, 
the doctoral student may become aware of harm being caused to the referred child or other children. If a 
disclosure or concerns about a child are raised, the trust policies will be followed and the referred child’s 
usual care team and the chief investigator will be informed at the earliest possible opportunity.  
It is also possible that the participant will disclose that they are at risk of harm to themselves or others, or are 
risk of harm from others, in which case trust policies will be followed and the child’s usual care team and the 
chief investigator will be informed at the earliest possible opportunity.  
Individual participant medical information obtained as a result of this study are considered confidential and 
disclosure to third parties is prohibited with the exceptions noted. Medical information may be given to the 
participant’s medical team and all appropriate medical personnel responsible for the participant’s welfare.  
ADVERSE EVENTS 
Due to the nature of this study no adverse events are anticipated, and no adverse event data will be collected.  

 
Page 23 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
ETHICS REVIEW AND COMPLIANCE  
The study shall not commence until the study protocol, information sheets and consent forms have been 
reviewed and approved from a Research Ethics Committee and relevant NHS/Social Care permission is 
obtained  
The sponsor will be responsible for deciding whether amendments are substantial and non-substantial in 
collaboration with the Chief Investigator.  
Where an amendment is required to study documentation that required REC approval, changes will not be 
implemented until REC approval and HRA categorisation is received. Where an amendment requires local 
approval this shall be sought prior to the amendment be implemented at each site in accordance with the 
categorisation given on the HRA approval letter.  
Should an amendment be required to eliminate an apparent immediate hazard to participants this may be 
implemented immediately and the REC/HRA and R&D will be notified as soon as possible.  
Minor amendments for logistical or administrative purposes may be implemented immediately 
Amendments will be logged on the Sponsor’s Study Amendment Log and stored in the Trial Master/Site 
File(s).  
Annual Progress Reports shall be submitted to the REC within 30 days of the anniversary date on which the 
favourable opinion was given – until the end of the study.  
A final report shall (where possible) be submitted to the REC within one year after the end of the study.  
If the study is terminated prematurely the CI will notify the REC, including the reasons for premature 
termination.  
PEER REVIEW 
The study was reviewed as part of the academic requirements for the DClinPsy course that the doctoral 
student is undertaken. The feedback from the peer review by university academic staff is detailed in the 
scientific critique document.  
PUBLIC & PATIENT INVOLVEMENT 
Input will be sought by the service user and carer advisory panel (SUCAP) attached to the Trent DClinPsy 
programme. Initial input from SUCAP members shaped the formation of the research idea in the early stage 
of development (January 2021). Additionally, parents/carers have been consulted to check the readability 
and suitability of the participant information sheet, consent form and interview schedules.  
PROTOCOL COMPLIANCE 
Accidental protocol deviations may occur at any time. Accidental protocol deviations will be adequately 
documented on the relevant forms and reported to the Chief Investigator and Sponsor immediately.  
Deviations from the protocol which are found to frequently recur are not acceptable, these will require 
immediate action and could potentially be classified as a serious breach. 
DATA PROTECTION AND PATIENT CONFIDENTIALITY  
All study staff and investigators will comply with the principles of the General Data Protection Regulation 
(GDPR) 2016/079 in protecting the rights of study participants with regards to the collection, storage, 
processing and disclosure of personal information and will uphold the Act’s/Regulations core principles.  
Each participant will be assigned a participant identification code, for use on study records, other study related 
documents and the electronic database. Personal data, as defined under the Data Protection Act, will include 
participant demographics, contact details, signed consent forms, recordings of intervention sessions and 

 
Page 24 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
recordings and transcripts of change interviews. Completed measures will not be personally identifiable as 
an anonymised participant identification code will be used. 
Personal data, research data and the linking code will be stored in separate locations. When stored 
electronically, this will include using encrypted digital files within password protected folders and storage 
media. Personal information shall be stored separately to research data and will be kept secure, and 
maintained.  
All electronic data will be uploaded on a dedicated secure University of Lincoln web server which uses two 
factor authentication; access will be restricted by user identifiers and passwords. Paper-based data will be 
kept in a locked filing cabinet at the University of Lincoln; this will include all data except audio recordings. 
These recordings will be kept on a password-protected encrypted USB memory stick that will be kept in a 
locked draw when not being used. When uploaded to the University of Lincoln server, the original audio files 
will be deleted from the USB. Administrative staff on the Trent DClinPsy will have access to the filing cabinets, 
but hard copy data will be kept in sealed envelopes. Access to the information will be limited to the study 
investigators and relevant regulatory authorities. Data analysis will use anonymised data and all data files 
will be password protected and saved on University of Lincoln servers, which require two-factor 
authentication. Participants will be given pseudonyms in the write up of the research and any identifiable 
details will be changed. 
Personal data will be stored for 6 months following the end of the study, so that the Chief Investigator may 
provide participants with a summary of the research (should they wish to receive a copy). 
All study data will be stored for 5 years following the end of the study, so that the Chief Investigator may 
provide participants with a summary of the research (should they wish to receive a copy). 
Data generated as a result of this study will be available for inspection on request by the participating 
physicians, the University of Lincoln representatives, the REC, local R&D Departments and the regulatory 
authorities. 
INDEMNITY 
Insurance and indemnity for trial participants and trial staff is covered within the NHS Indemnity Arrangements 
for clinical negligence claims in the NHS, issued under cover of HSG (96)48. There are no special 
compensation arrangements, but trial participants may have recourse through the NHS complaints 
procedures. 
The University of Lincoln as research Sponsor indemnifies its staff, research participants and research 
protocols with both public liability insurance and clinical trials insurance. 
ACCESS TO THE FINAL DATASET 
The full study documentation and data will be restricted to staff on the research team. The anonymised 
quantitative dataset may be uploaded and stored on the open access University of Lincoln Repository 
(ePrints). All documents shall made be available at all times for review by the Chief Investigator, Sponsor’s 
designee and inspection by relevant regulatory authorities.  
DISSEMINATION POLICY 
The data custodian will be the Chief Investigator on behalf of the University of Lincoln.  
This research will be submitted in partial fulfilment of the requirements of the Trent Doctorate in Clinical 
Psychology. It is the intention to submit the research to a peer-review journal to allow for wider readership. 
The findings may be disseminated through relevant conferences. Participants will receive a summary of the 
findings, unless they have opted out on the consent form. All data disseminated will be anonymised.  

 
Page 25 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
The total expected duration of the study is 13 months. Planned start date: February 2022 (dependant on 
approval by ethics committee). Planned thesis submission date: February 2023. 
Authorship eligibility guidelines and any intended use of professional writers 
The doctoral student will be the primary author on all publications related to this project. The chief investigator 
and all co-investigators will be co-authors and authorship will be decided based on contribution at the time of 
publication.  
REFERENCES 
Achenbach, T. M. (1966). The classification of children’s psychiatric symptoms: a factor-analytic study. Psychological Monographs, 
80(7), 1–37. https://doi.org/10.1037/h0093906 
Achenbach, T. M. (1978). The child behavior profile: I. Boys aged 6–11. Journal of Consulting and Clinical Psychology, 46(1), 478–
488. 
Achenbach, T. M., & Edelbrock, C. S. (1979). The Child Behavior Profile: II. Boys aged 12-16 and girls aged 6-11 and 12-16. Journal 
of Consulting and Clinical Psychology, 47(2), 223–233. https://doi.org/10.1037//0022-006x.47.2.223 
Ashworth, M., Evans, C., & Clement, S. (2009). Measuring psychological outcomes after cognitive behaviour therapy in primary care: 
a comparison between a new patient-generated measure “PSYCHLOPS” (Psychological Outcome Profiles) and “HADS” 
(Hospital 
Anxiety 
and 
Depression 
Scale). 
Journal 
of 
Mental 
Health, 
18(2), 
169–177. 
https://doi.org/10.1080/09638230701879144 
Barlow, D., Nock, M., & Hersen, M. (2009). Single case experimental designs: strategies for studying behavior change (Third edit). 
Allyn and Bacon. 
Brennan, A. L., Hektner, J. M., Brotherson, S. E., & Hansen, T. M. (2016). A Nonrandomized Evaluation of a Brief Nurtured Heart 
Approach Parent Training Program. Child & Youth Care Forum, 45(5), 709–727. https://doi.org/10.1007/s10566-016-9351-4 
Camoirano, A. (2017). Mentalizing makes parenting work: A review about parental reflective functioning and clinical interventions to 
improve it. Frontiers in Psychology, 8, 1–12. https://doi.org/10.3389/fpsyg.2017.00014 
Carr, A. (2016). The Handbook of Child and Adolescent Clinical Psychology: A Contextual Approach (Third edit). Routledge. 
Colman, I., Murray, J., Abbott, R. A., Maughan, B., Kuh, D., Croudace, T. J., & Jones, P. B. (2009). Outcomes of conduct problems 
in adolescence: 40 Year follow-up of national cohort. BMJ, 338(7688), 208–211. https://doi.org/10.1136/bmj.a2981 
Crnic, K., Hoffman, C., Gaze, C., & Edelbrock, C. (2004). Understanding the emergence of behavior problems in young children with 
developmental delays. Infants and Young Children, 17(3), 223–235. https://doi.org/10.1097/00001163-200407000-00004 
Eddy, J. M., Leve, L. D., & Fagot, B. I. (2001). Coercive family processes: A replication and extension of Patterson’s coercion model. 
Aggressive Behavior, 27(1), 14–25. https://doi.org/10.1002/1098-2337(20010101/31)27:1<14::AID-AB2>3.0.CO;2-2 
Ensink, K., Bégin, M., Normandin, L., & Fonagy, P. (2016). Maternal and child reflective functioning in the context of child sexual 
abuse: Pathways to depression and externalising difficulties. European Journal of Psychotraumatology, 7(1), 1–10. 
https://doi.org/10.3402/ejpt.v7.30611 
Frick, P., Horn, Y. Van, Lahey, B. B., Christ, M. A. G., Loeber, R., Hart, E. A., Hanson, K., & Tannenbaum, L. (1993). Oppositional 
defiant disorder and conduct disorder: A meta-analytic review of factor analyses and cross-validation in a clinic sample. Clinical 
Psychology Review, 13, 319–340. https://doi.org/10.1016/0272-7358(93)90016-F 
Gale, N. K., Heath, G., Cameron, E., Rashid, S., & Redwood, S. (2013). Using the framework method for the analysis of qualitative 
data in multi-disciplinary health research. BMC Medical Research Methodology, 13(117), 1–8. 
Gardner, F., & Shaw, D. S. (2008). Behavioral Problems of Infancy and Preschool Children (0-5). In M. Rutter, D. Bishop, D. Pine, S. 
Scott, J. Stevenson, E. Taylor, & A. Thapar (Eds.), Rutter’s Child and Adolescent Psychiatry (Fifth edit, pp. 882–893). Blackwell 
Publishing Ltd. 
Glasser, H. (2016). Transforming the Intense Child: An Experiential Guide for Learning and Implementing the Nurtured Heart 
Approach (M. L. Lowenstein (ed.)). Prolong Press Limited. 
Glasser, H., & Easley, J. (2016). Transforming the Difficult Child (Fifth edit). Prolong Press Limited. 
Green, H., McGinnity, A., Meltzer, H., Ford, T., & Goodman, R. (2005). Mental health of children and young people in Great Britain, 
2004: summary report. 
Gryczkowski, M. R., Jordan, S. S., & Mercer, S. H. (2010). Differential Relations between Mothers’ and Fathers’ Parenting Practices 
and Child Externalizing Behavior. Journal of Child and Family Studies, 19(5), 539–546. https://doi.org/10.1007/s10826-009-
9326-2 

 
Page 26 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Hektner, J. M., Brennan, A. L., & Brotherson, S. E. (2013). A review of the Nurtured Heart Approach to parenting: Evaluation of its 
theoretical and empirical foundations. Family Process, 52(3), 425–439. https://doi.org/10.1111/famp.12030 
Jacobson, N., & Truax, P. (1991). Clinical significance: A statistical approach to defining meaningful change in psychotherapy 
research. Journal of Consulting and Clinical Psychology, 59(1), 12–19. 
Jaffee, S. R., & Price, T. S. (2007). Gene–environment correlations: a review of the evidence and implications for prevention of mental 
illness. Molecular Psychiatry, 12(5), 432–442. https://doi.org/10.1038/sj.mp.4001950 
Kausik, N. H., & Hussain, D. (2020). Integrating Nurtured Heart Approach with Self- Determination Theory : A Proposed Intervention 
Model 
for 
Managing 
Disruptive 
Behaviors 
of 
Children. 
Child 
Care 
in 
Practice, 
26(1), 
50–61. 
https://doi.org/10.1080/13575279.2018.1516627 
Kratochwill, T. R., Hitchcock, J., Horner, R. H., Levin, J. R., Odom, S. L., & Rindskopf, D. M Shadish, W. R. (2010). Single-case 
designs technical documentation. 
Kratzer, L., & Hodgins, S. (1997). Adult outcomes of child conduct problems: A cohort study. Journal of Abnormal Child Psychology, 
25(1), 65–81. https://doi.org/10.1023/A:1025711525255 
Luyten, P., Mayes, L. C., Nijssens, L., & Fonagy, P. (2017). The Parental Reflective Functioning Questionnaire - Adolescent version. 
Luyten, Patrick, Nijssens, L., Fonagy, P., & Mayes, L. C. (2017). Parental Reflective Functioning: Theory, Research, and Clinical 
Applications. Psychoanalytic Study of the Child, 70(1), 174–199. https://doi.org/10.1080/00797308.2016.1277901 
Merikangas, K. R., Nakamura, E. F., & Kessler, R. C. (2009). Epidemiology of mental disorders in children and adolescents. Dialogues 
in Clinical Neuroscience, 11(1), 7–20. https://doi.org/10.31887/DCNS.2009.11.1/krmerikangas 
National Institute for Health and Care Excellence (NICE). (2017). Antisocial behaviour and conduct disorders in children and young 
people. The NICE Guideline on recognition, intervention and management. National Clinical Guideline Number 158. The British 
Psychological Society; The Royal College of Psychiatrists. http://www.nice.org.uk/guidance/cg158 
Nijssens, L., Vliegen, N., & Luyten, P. (2020). The Mediating Role of Parental Reflective Functioning in Child Social–emotional 
Development. Journal of Child and Family Studies, 29(8), 2342–2354. https://doi.org/10.1007/s10826-020-01767-5 
Nuño, V. L., Wertheim, B. C., Murphy, B. S., Wahl, R. A., & Roe, D. J. (2019). Testing the efficacy of the Nurtured Heart Approach® 
to reduce ADHD symptoms in children by training parents: Protocol for a randomized controlled trial. Contemporary Clinical 
Trials Communications, 13, 1–6. https://doi.org/10.1016/j.conctc.2018.100312 
Parent, J., & Forehand, R. (2017). The Multidimensional Assessment of Parenting Scale (MAPS): Development and Psychometric 
Properties. Journal of Child and Family Studies, 26(8), 2136–2151. https://doi.org/10.1007/s10826-017-0741-5.The 
Patterson, G. R. (1982). Coercive family process. Castalia. 
Ramnero, J., & Törneke, N. (2011). The ABCs of Human Behavior: Behavioral Principles for the Practicing Clinician. New Harbinger 
Publications. 
Reitz, E., Deković, M., & Meijer, A. M. (2006). Relations between parenting and externalizing and internalizing problem behaviour in 
early adolescence: Child behaviour as moderator and predictor. Journal of Adolescence, 29(3), 419–436. 
https://doi.org/10.1016/j.adolescence.2005.08.003 
Riva Crugnola, C., Ierardi, E., & Canevini, M. P. (2018). Reflective functioning, maternal attachment, mind-mindedness, and emotional 
availability in adolescent and adult mothers at infant 3 months. Attachment and Human Development, 20(1), 84–106. 
https://doi.org/10.1080/14616734.2017.1379546 
Robertson, R., Wenzel, L., Thompson, J., & Charles, A. (2017). Understanding NHS financial pressures: How are they affecting 
patient 
care? 
In 
The 
King’s 
Fund 
(Issue 
March). 
https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Understanding NHS financial pressures - full 
report.pdf%0Ahttps://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Understanding NHS financial pressures - 
full r 
Rodgers, B., & Elliott, R. (2015). Qualitative Methods in Psychotherapy Outcome Research. In O. Gelo, A. Pritz, & B. Rieken (Eds.), 
Psychotherapy Research (pp. 559–578). Springer. 
Scaramella, L. V., Neppl, T. K., Ontai, L. L., & Conger, R. D. (2008). Consequences of Socioeconomic Disadvantage Across Three 
Generations: Parenting Behavior and Child Externalizing Problems. Journal of Family Psychology, 22(5), 725–733. 
https://doi.org/10.1037/a0013190 
Smaling, H. J. A., Huijbregts, S. C. J., van der Heijden, K. B., Hay, D. F., van Goozen, S. H. M., & Swaab, H. (2017). Prenatal 
Reflective Functioning and Development of Aggression in Infancy: the Roles of Maternal Intrusiveness and Sensitivity. Journal 
of Abnormal Child Psychology, 45(2), 237–248. https://doi.org/10.1007/s10802-016-0177-1 
Smith, J. D., Dishion, T. J., Shaw, D. S., Wilson, M. N., Winter, C. C., & Patterson, G. R. (2014). Coercive family process and early-
onset conduct problems from age 2 to school entry. Development and Psychopathology, 26(4), 917–932. 
https://doi.org/10.1017/S0954579414000169 

 
Page 27 of 27 
 
Nurtured Heart parenting intervention for child behavioural problems - Protocol Version 1 date 25.10.21 
 
This protocol is confidential and the property of the University of Lincoln. No part of it may be transmitted, reproduced, published, or used by others 
persons without prior written authorisation from the University of Lincoln 
Staines, J., Golding, K., & Selwyn, J. (2019). Nurturing attachments parenting program: The relationship between adopters’ parental 
reflective functioning and perception of their children’s difficulties. Developmental Child Welfare, 1(2), 143–158. 
https://doi.org/10.1177/2516103219829861 
Suchman, N. E., Mayes, L., Conti, J., Slade, A., & Rounsaville, B. (2004). Rethinking parenting interventions for drug-dependent 
mothers: From behavior management to fostering emotional bonds. Journal of Substance Abuse Treatment, 27(3), 179–185. 
https://doi.org/10.1016/j.jsat.2004.06.008 
Suchman, N. E., Pajulo, M., DeCoste, C., & Mayes, L. (2006). Parenting interventions for drug-dependent mothers and their young 
children: The case for an attachment-based approach. Family Relations, 55, 211–226. https://doi.org/10.1097/00005721-
200611000-00015 
Tarver, J., Daley, D., Lockwood, J., & Sayal, K. (2014). Are self-directed parenting interventions sufficient for externalising behaviour 
problems in childhood? A systematic review and meta-analysis. European Child & Adolescent Psychiatry, 23, 1123–1137. 
Tennant, R., Hiller, L., Fishwick, R., Platt, S., Joseph, S., Weich, S., Parkinson, J., Secker, J., & Stewart-brown, S. (2007). The 
Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation. Health and Quality of Life 
Outcomes, 5(63), 1–13. https://doi.org/10.1186/1477-7525-5-63 
Tully, L. A., & Hunt, C. (2016). Brief Parenting Interventions for Children at Risk of Externalizing Behavior Problems: A Systematic 
Review. Journal of Child and Family Studies, 25(3), 705–719. https://doi.org/10.1007/s10826-015-0284-6 
Zutlevics, T. L. (2016). Could providing financial incentives to research participants be ultimately. Research Ethics, 12(3), 137–148. 
https://doi.org/10.1177/1747016115626756