Title: The effectiveness and cost effectiveness of the Incredible Years Teacher Classroom Management programme in primary school children: a cluster randomised controlled trial, with parallel economic and process evaluations
Funder: Department of Health and Social Care

Abstract: Design: A cluster randomised controlled trial with recruitment staggered over three years. The unit of randomisation is the school, and randomisation will be stratified to ensure balance on the following school characteristics: level of deprivation; rural/urban location; involvement in other emotional enrichment programmes. One teacher per school will participate. Setting: 80 primary schools in Devon, Torbay and Plymouth. Target population: Primary school age children from Reception and Years 1-4 in the class of the one teacher per school recruited to the trial. Teachers with mixed year groups, fewer than 15 children in their class, or in the classroom fewer than four days per week will be excluded. Intervention being evaluated: The IY TCM course; a manualised six-day course delivered to groups of up to 10 teachers. Control teachers will receive the intervention in the following academic year, which is a prerequisite for schools agreeing to participate. Schools will be randomised to intervention (TCM training) or control (teaching as usual). Measurement of outcome and duration of follow up: The primary outcome will be the children’s socio-emotional well-being assessed using the Strengths and Difficulties Questionnaire (SDQ; 22) completed by teachers and parents. The SDQ is a well-validated and widely used measure of behaviour, emotions, pro-social behaviour, peer relationships, and hyperactivity. The secondary outcome will be children’s academic attainment using teachers’ routine assessment of national curriculum levels (23), checked against the Wechsler Individual Achievement Test in a sub-sample (24). For economic evaluation, parent-completed Child and Adolescent Service Use Schedule (25, 26, 27) will report the use of health, education and social services, plus criminal justice sector resources. Responses will be supplemented by interview with a sub-sample of parents and reports from school about education-based services. Structured direct observation of teacher-child interaction using the Teacher Pupil Outcome Tool among a sub-sample of children will assess if TCM changes teachers behaviour (28). Teachers will also complete the Sense of Efficacy Scale (29), Maslach Burnout Inventory (30) and Everyday Feeling Questionnaire (31) to assess the impact on their well-being and efficacy. Our Feasibility Studies include the completed validation of a child-completed measure to assess how happy they feel about their school (32) and the planned validation of the EQ-5D-Y (33; a youth version of the EuroQol measure recommended for 7-19 year olds) among 4-7 year olds, as well as delivering four TCM courses. As illustrated in Appendix 2, we plan to recruit 15 schools in the pilot phase and 65 schools over the two subsequent years. The pilot phase will use the same methodology as the main phase, but will test acceptability of the study for parents, teachers and children, recruitment and data collection procedures, and provide qualitative information to improve recruitment and retention in the main phase. Progression from pilot phase to main phase will depend on being able to recruit at least 14 schools, achieving a 66% response rate among parents and retaining 80% of teachers and parents at first follow up (T1). Data collection for both groups will occur at the beginning (October, T0) and end (June, T1) of the academic year of recruitment, and TCM training will be delivered to the intervention group between these data collection points (See Appendix 3). Further follow up will occur annually in the spring term in the following two academic years (T2 and T3). The teachers and children will separate at the end of the first academic year (between T1 and T2), allowing the control teachers to access TCM without breaking the trial design in relation to the child well-being measures. A parallel process evaluation will use qualitative methods to build on work from the Feasibility Studies. In the pilot phase the process evaluation will seek to refine the research processes, and in the main phase it will investigate factors that influence the uptake of TCM strategies. We will use semi-structured interviews and focus groups with teachers, SENCos and head teachers to elucidate the experiences and perceptions of the TCM course. This will provide a multi-dimensional assessment of how TCM was implemented and received, identifying barriers and facilitators to TCM across participating schools. We will also examine access to other sources of support for teachers, and whether other teachers working in study schools but not selected to attend the TCM course, take up TCM strategies in the classroom. Sample size: 40 schools will be randomised to each of the intervention and control arms; the number of children per arm at final follow-up is expected to be 760 per arm (i.e. 19 per school) assuming that: each class contains 30 pupils; a recruitment rate of 71% was achieved among parents in a current trial using the SDQ (34) and a 10% loss to follow-up by T3. The sample size allows for clustering assuming an intra-cluster correlation coefficient for the SDQ total score to be 0.15, estimated using data from Sayal et al 2009 (35). This provides 85% power at the 5% level of significance to detect a difference in the mean SDQ score between trial arms equivalent to an effect size of 0.3 of a standard deviation or to a difference of 2 points on the SDQ scale. A two-point reduction would reduce the percentage of children classified in the borderline/abnormal range from 20% to 14% where borderline /abnormal is defined as those scoring 12 and above out of 40 on the SDQ scale (36). Planned analyses: Random effects linear regression models will be fitted to compare means for continuous outcomes between the trial arms according to the “intention to treat” principle, allowing for the correlation between outcomes of children from the same school using school as a random effect. A cost-utility analysis will be use the EQ-5D-Y should the measure prove valid and reliable; if not, we will assess cost-effectiveness using the SDQ. We will take a broad perspective including the health, social, education and criminal justice sectors; although results will be broken down to allow assessment of alternative perspectives. Timetable: As illustrated in Appendix 4, the study will last a total of five years with a two month setting up period, one-year pilot phase, two further years to recruit to the main phase, and two years of follow up for each school. This leaves the final six months for analysis, writing up and dissemination. Recruitment rate is dictated by the school year and will be 15, 30 and 35 schools in Years 1, 2 and 3 respectively.

Lay abstract: The Incredible Years (IY) Teacher Classroom Management (TCM) course may enhance teachers’ skills in promoting socio-emotional well-being among their pupils. Disruptive behaviour is a common source of stress among teachers, and a common reason for many leaving the profession. Poor socio-emotional adjustment in childhood may compromise mental health and academic attainment and can adversely impact on life chances of all the children in a classroom, particularly children living in deprived circumstances. We will study whether delivering TCM to primary school teachers leads to improvement in children’s socio-emotional skills and academic achievement. If effective, TCM could transform the classroom from an environment where many children currently struggle to cope, particularly boys from low socio-economic backgrounds, into one where many more children can thrive. Enhancing teachers’ skills potentially benefits all children that come into contact with that teacher over subsequent years, so TCM may be a particularly cost-effective way to assist the most vulnerable children in our society. The research will take place in 80 primary schools in Devon, Plymouth and Torbay over five years; we will recruit schools over three years and each school will participate for three academic years to allow two years of follow up. One teacher from each school will be randomly allocated to attend the TCM course or to be a control. Control teachers will wait until the following academic year when they have a new class before attending the TCM course. TCM involves six one-day group sessions spread over six months with ten teachers in each group. The sessions will be led by educational psychologists and behavioural support teachers trained to deliver TCM and closely supervised to ensure that teachers experience the course as designed, rather than an approximation to it. We will measure socio-emotional well-being using a well-known and highly tested questionnaire - the Strengths and Difficulties Questionnaire (SDQ). The SDQ will be completed by teachers and the parents of all their pupils before and after the TCM course, and at one and two years after that. We will focus on teacher reports as we expect to collect more complete data from teachers, but demonstrating improved socio-emotional well-being reported by parents is a tougher test of TCM and we will study this also. Academic attainment will be measured using the National Curriculum standard levels used routinely in all state schools and we will check these scores against detailed standardised assessments in some children. We will also measure teachers’ self-efficacy, burn-out and well-being to see if the course leaves teachers feeling more confident, motivated and less stressed. We will also use a mixture of focus groups and interviews to find out from teachers, head teachers and special educational needs coordinators (SENCos) how useful they think TCM is, whether they use it in their practice and/or schools, and how it fits with other sources of support for emotional and behavioural difficulties. We will speak to them shortly after they attended the course and a year later. Using questionnaires completed by parents and SENCos backed up by detailed interviews with some parents, we will find out about additional help accessed by families in relation to their child’s socio-emotional adjustment to look for cost-savings that TCM might generate by reducing demands on educational support and mental health services. We are alert to the ethical issues that may be raised by head teachers nominating staff to attend TCM; teachers may feel unable to refuse or that their competence is being challenged. These issues will be explored in the interviews and focus groups with teachers, SENCos and head teachers. We have a detailed procedure for gaining consent from head teachers, teachers, parents and children that is described in our accompanying project description. Our team combines expertise in the fields of child mental health, education, trials, economics, statistics, qualitative research and the delivery of IY programmes. The study will be supported by UK Peninsula Clinical Trials Unit and our Steering Committee, which comprises teachers, behavioural support practitioners and parents as well as researchers. The costs cover research workers, trial management and vouchers for parents in recognition of their time, as well as the use of questionnaire measures and data management.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: MENTAL HEALTH