Title: How far could widespread dissemination of parenting programmes improve child antisocial behaviour and reduce social inequalities? Combining datasets from trials in different communities to establish for whom programmes are effective
Funder: Department of Health (England)

Abstract: There are compelling public health reasons for investing in parenting interventions. Poor parenting skills are predictive of a wide range of poor health outcomes in the next generation especially youth antisocial behaviour (Ermisch 2008; Hoeve et al 2010). Persistent antisocial behaviour is a major public health issue because it is the commonest child mental health problem (ONS 2004) and carries high health burdens into adulthood including a 5-10 fold risk of alcoholism drug abuse criminality domestic violence unemployment and early death (Odgers et al. 2007; Piquero et al 2011). The extra public costs are 10 times that of controls (Scott et al 2001). As with poor parenting there is a strong association with social disadvantage with a 4-5 times the rate of antisocial behaviour in the most disadvantaged groups (ONS 2004). Parenting interventions potentially form an important public health strategy for preventing antisocial behaviour and other poor outcomes in children for a number of reasons. Firstly because of the high public health and financial burden of antisocial behaviour it provides an excellent opportunity for early preventive intervention. Secondly systematic reviews of RCTs (Dretzke et al 2007; Furlong et al 2012) show clear beneficial effects; NICE found a mean effect-size of 0.6 SD on child problem behaviour with good long-term effects an extremely worthwhile effect in public health terms Furthermore our modelling study shows good financial returns from investment in parenting programmes. Although high quality parenting interventions are effective for most families and carry the potential to improve public health substantially most trials have been of modest size and little is known about their ability to bring about change in more disadvantaged groups. The proposed study will address this question bringing to bear 4 important design features. Firstly it will analyse randomised trials thus reducing risk of bias that may arise from observational studies. Secondly rather than combining data at the trial level as is usual in meta-analysis it will combine data at an individual participant level from 13 trials thus greatly enhancing the opportunity to detect moderating effects of social disadvantage as well as wider benefits and potential harms of the interventions. This represents a unique opportunity to overcome the problems of low power and reporting bias that beset subgroup analyses in many individual trials and meta-analyses and hence to enhance our understanding of how parenting interventions may reduce or widen health and social inequalities (Petticrew et al 2011; Thompson & Higgins 2005). Thirdly it will draw upon qualitative research and public involvement soliciting parents views on factors affecting intervention success to inform hypotheses for testing. Fourthly it will apply cost and cost effectiveness approaches to examine potential benefits to public health. The intervention is the Incredible Years (IY) group parenting programme identified as effective in many systematic reviews (Furlong et al 2012) for preventing antisocial and conduct problems in children and improving parental mental health. Although developed in the US it has proven effective in many trials in Europe. It has received Government funding for training in England Wales and Scotland and as a result of its widespread dissemination there have been 7 randomised trials in the UK in a range of community settings (Sure Start nurseries schools NGOs). However although each trial was powered to detect main effects they were not powered to conduct secondary analyses testing differential effects on families with different levels of social disadvantage and from different ethnic groups. Our pooled set of 13 trials would be the largest of its type in the world comprising all the non-NHS RCTs of IY in Europe (total N 1729 families) including 7 UK trials and 6 in other European systems It will considerably advance our understanding of differential intervention effects and cost-effectiveness of parenting interventions for families with differing levels of social disadvantage and child risk factors thus helping to determine whether such programmes are likely to reduce or widen social inequalities. Most importantly if there are groups for whom programmes work less well it will stimulate change in working practices to improve availability and effects of these programmes to such groups. The proposed study would address the following three questions: (1) To what extent do parenting interventions benefit the most socially disadvantaged families? Moderator analyses will examine whether the intervention is less or more effective and cost-effective i) for the most disadvantaged families sub-grouping families by SES poverty lone parent status ii) by ethnicity and iii) by child factors including age gender and initial severity of behaviour problems We will examine effects of trial-level contextual factors and whether any subgroup effects may be better accounted for by family level variables. (2) What are the wider public health benefits and potential harms of parenting interventions? We will examine effects on harsh and positive parenting parent depression child co-morbid problems (e.g. ADHD). Consumer satisfaction data will be pooled and analysed by subgroup. We will model potential long-term cost-benefit generated by the intervention. (3) What are the key ingredients (mediators) of the effect of the intervention on child outcome? Study population (see Chart for summary of trials). Our pooled sample of 1729 families each with a target child aged 1-9 identified by screening or referral as being at risk of antisocial behaviour; most are low income families but with a wide range of levels of social disadvantage. In 4 UK trials and 2 trials from the Netherlands a high percent are from ethnic minorities. Primary outcome measures: Child antisocial behaviour/conduct problems: measured by standardised well validated instruments including parent self-report; semi-structured parent interview and directly observed child behaviour. Secondary outcomes measuring wider benefits: 1. Parenting behaviour: by standardised parent questionnaire; direct observation. 2. Parent mental health: by standardised parent questionnaire 3. Child ADHD emotional symptoms 4. Other outcomes: sibling behaviour problems; social support; partner relations parenting confidence.


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