Home and community based parenting support programmes and interventions: report of Workpackage 2 of the DataPrev project

The last decade has witnessed an increasing interest in the promotion of mental health and wellbeing because of its importance for health and social functioning at the individual level and for the social and economic wellbeing of societies. Recent research from a range of disciplines has highlighted the importance of the quality of the parent-child relationships and parenting on children‟s emotional and social development, and on adult mental health and wellbeing. Intervention studies involving children of all age groups have shown that if parenting can be influenced for the better outcomes can be changed. The DataPrev project was funded by the 6th Framework of the European Community Research Programme under Policy-Orientated Research with the aim of establishing a database of evidence-based programmes in Europe that promote mental health and wellbeing and prevent mental illness throughout the life course. This is the report of the Workpackage 2 describing the international evidence base on programmes to support parenting, including home and community based programmes

Evaluating the responsiveness of the Warwick Edinburgh Mental Well-Being Scale (WEMWBS) : group and individual level analysis

Background: Mental well-being now features prominently in UK and international health policy. However, progress has been hampered by lack of valid measures that are responsive to change. The objective of this study was to evaluate the responsiveness of the Warwick Edinburgh Mental Well-being Scale (WEMWBS) at both the individual and group level. Methods: Secondary analysis of twelve different interventional studies undertaken in different populations using WEMWBS as an outcome measure. Standardised response mean (SRM), probability of change statistic (P̂) and standard error of measurement (SEM) were used to evaluate whether WEMWBS detected statistically important changes at the group and individual level, respectively. Results: Mean change in WEMWBS score ranged from −0.6 to 10.6. SRM ranged from −0.10 (95% CI: -0.35, 0.15) to 1.35 (95% CI: 1.06, 1.64). In 9/12 studies the lower limit of the 95% CI for P̂ was greater than 0.5, denoting responsiveness. SEM ranged from 2.4 to 3.1 units, and at the threshold 2.77 SEM, WEMWBS detected important improvement in at least 12.8% to 45.7% of participants (lower limit of 95% CI>5.0%). Conclusions: WEMWBS is responsive to changes occurring in a wide range of mental health interventions undertaken in different populations. It offers a secure base for research and development in this rapidly evolving field. Further research using external criteria of change is warranted

A systematic review of reviews of interventions to promote mental health and prevent mental health problems in children and young people

Background: There is a growing policy imperative to promote positive mental health as well as preventing the development of mental health problems in children. This paper summarises the results of published systematic reviews evaluating interventions to promote mental health and prevent mental illness in children. Method: A search was undertaken of ten electronic databases using a combination of medical subject headings (MeSH) and free text searches. Systematic reviews covering mental health promotion or mental illness prevention interventions aimed at infants, children or young people up to age 19 were included. Reviews of drug and alcohol prevention programmes or programmes to prevent childhood abuse and neglect were excluded because these have been the subject of recent good quality reviews of reviews. Critical appraisal of all studies was undertaken using a standardised appraisal tool for systematic reviews. Where possible effect sizes and 95% confidence intervals are reported. A narrative summary has been provided. Results: A total of 27 systematic reviews were included and grouped pragmatically under the following headings: parenting interventions; programmes for the prevention of anxiety and depression, programmes to promote self esteem, violence and aggression prevention programmes, school-based programmes, and general reviews. Included studies targeted a range of risk and protective factors, and a range of populations (including both parents and children). While, many lacked methodological rigour, overall, the evidence is strongly suggestive of the effectiveness of a range of interventions in promoting positive mental well-being, and reducing key risk factors for mental illness in children. Conclusion: A variety of programmes have been shown to be effective in promoting children’s mental health, albeit with modest effect sizes. Based on this evidence, arguments are advanced for the preferential provision of early preventive programmes

Utility of accelerometers to measure physical activity in children attending an obesity treatment intervention

Objectives. To investigate the use of accelerometers to monitor change in physical activity in a childhood obesity treatment intervention. Methods. 28 children aged 7–13 taking part in “Families for Health” were asked to wear an accelerometer (Actigraph) for 7-days, and complete an accompanying activity diary, at baseline, 3-months and 9-months. Interviews with 12 parents asked about research measurements. Results. Over 90% of children provided 4 days of accelerometer data, and around half of children provided 7 days. Adequately completed diaries were collected from 60% of children. Children partake in a wide range of physical activity which uniaxial monitors may undermonitor (cycling, nonmotorised scootering) or overmonitor (trampolining). Two different cutoffs (4 METS or 3200 counts⋅min-1) for minutes spent in moderate and vigorous physical activity (MVPA) yielded very different results, although reached the same conclusion regarding a lack of change in MVPA after the intervention. Some children were unwilling to wear accelerometers at school and during sport because they felt they put them at risk of stigma and bullying. Conclusion. Accelerometers are acceptable to a majority of children, although their use at school is problematic for some, but they may underestimate children's physical activity

Can the 12-item General Health Questionnaire be used to measure positive mental health?

Background. Well-being is an important determinant of health and social outcomes. Measures of positive mental health states are needed for population-based research. The 12-item General Health Questionnaire (GHQ-12) has been widely used in many settings and languages, and includes positively and negatively worded items. Our aim was to test the hypothesis that the GHQ-12 assesses both positive and negative mental health and that these domains are independent of one another. Method. Exploratory (EFA) and confirmatory (CFA) factor analyses were conducted using data from the British Household Panel Survey (BHPS) and the Health Survey for England (HSE). Regression models were used to assess whether associations with individual and household characteristics varied across positive and negative mental health dimensions. We also explored higher-level variance in these measures, between electoral wards. Results. We found a consistent, replicable factor structure in both datasets. EFA results indicated a two-factor solution, and CFA demonstrated that this was superior to a one-factor model. These factors correspond to ‘symptoms of mental disorder’ and ‘positive mental health’. Further analyses demonstrated independence of these factors in associations with age, gender, employment status, poor housing and household composition. Statistically significant ward-level variance was found for symptoms of mental disorder but not positive mental health. Conclusions. The GHQ-12 measures both positive and negative aspects of mental health, and although correlated, these dimensions have some independence. The GHQ-12 could be used to measure positive mental health in population-based research

Impact of a general practice based group parenting programme on the mental health of children and parents 12 months post intervention : quantitative and qualitative results from a controlled trial

Objective To test the effectiveness at one year of the Webster Stratton Parents and Children Series group parenting programme in a population sample of parents Design multicentre block randomised controlled trial Setting 3 urban General Practices in Oxford. Participants Parents of children aged 2-8 years in 116 families who scored in the upper 50% on a behaviour inventory. Intervention Webster-Stratton’s 10-week parenting programme led by health visitors. Outcome measures. Eyberg Child Behaviour Inventory, Goodman Strengths and Difficulties Questionnaire, General Health Questionnaire, Parenting Stress Index, Rosenberg Self Esteem Scale. Qualitative interviews with volunteer parents from both intervention and control groups immediately post intervention. Results The intervention significantly reduced child behaviour problems and improved mental health at immediate and 6-month follow-ups. One-year differences between control and intervention groups were not significant. Possible methodological reasons for this are: Hawthorne effects and contamination of control group. At interview parents spoke of a need for further sessions and a desire for attendance by both parents. They also described how, as a result of the programme, they had gained in confidence, felt less stressed, shouted less and achieved more cooperation from their children. Conclusions Parenting programmes have the potential to promote mental health and reduce social inequalities, but further work is needed to improve long-term effectiveness

Role of home visiting in improving parenting and health in families at risk of abuse and neglect : results of a multicentre randomised controlled trial and economic evaluation

Objectives – To evaluate the effectiveness and cost-effectiveness of an intensive home visiting programme in improving outcomes for vulnerable families. Design – Multicentre randomised controlled trial in which eligible women were allocated to receive home visiting (n=67) or standard services (n=64). Incremental cost analysis. Setting – 40 GP practices across two counties in the UK Participants – 131 vulnerable pregnant women. Intervention: Selected health visitors were trained in the Family Partnership Model to provide a weekly home visiting service from 6-months antenatally to 12 months postnatally. Main outcome measures – mother-child interaction, maternal psychological health attitudes and behaviour, infant functioning and development, and risk of neglect or abuse. Results – At 12-months differences favouring the home visited group were observed on an independent assessment of maternal sensitivity (p<0.04) and infant cooperativeness (p<0.02). No differences were identified on any other measures. There was a non-significant increase in the likelihood of intervention group infants being the subject of child protection proceedings, or being removed from the home, and one death in the control group. The mean incremental cost per infant of the home visiting intervention was £3,246 (bootstrapped 95% confidence interval for the difference: £1,645 - £4,803). Conclusion – This intervention may have the potential to improve parenting and increase the identification of infants at risk of abuse and neglect in vulnerable families. Further investigation is needed together with long term follow up to assess possible sleeper effects

Systematic review of interventions for the secondary prevention and treatment of emotional abuse of children by primary carers

Background Emotional abuse (or psychological maltreatment, as it is more commonly called in the US) is an inadequately researched and poorly understood concept, despite increasing awareness about the harm it can cause to children‟s lives. Although it unifies and underpins all types of maltreatment it also occurs alone and when it does, tends to elude detection and intervention. There have to date been no systematic reviews of the literature on the secondary prevention and treatment involving the parents or primary carers of emotionally abused children. Objective The objective of the review was to identify studies that evaluate the effectiveness of interventions in the secondary prevention and treatment of child emotional abuse involving the parents or primary carers of children aged 0 – 19 years. Methods Studies were included if they involved any intervention which was directed at emotionally abusive parenting and that measured change in (i) emotional unavailability (ii) negative attributions (i.e. that involve the parent attributing negative intentions, beliefs or attitudes toward the child); (iii) developmentally inappropriate interactions; (iv) lack of recognition of children‟s boundaries; (v) inconsistency of parenting role; (vi) missocialisation or consistent failure to promote the child‟s social adaptation. The primary outcomes evaluated involved proxy measures of a range of parent, family and child outcomes including parental psychopathology, parenting attitudes and practices, family functioning and/or child behaviour and the child‟s development and adaptation. . A broad search strategy was developed in order to identify as many relevant studies as possible. An electronic search of a wide range of databases was carried about. No study type was excluded. The search was augmented by direct contact with academics and practitioners known in this field. The search included studies written in English, Spanish, French and German. Studies were included if the intervention was described, and the impact on at least one indicator of emotional abuse was assessed. Included studies were critically appraised by two reviewers using standard criteria. Data were extracted using a standard proforma, and a qualitative synthesis of results was carried out. Results The initial search yielded 4248 publications of potential interest. Of these, 175 were obtained for possible inclusion or as background material. A total of 21 studies of 18 interventions, met all the inclusion criteria. A further 43 studies were relevant, but did not meet all of the inclusion criteria. Studies were organised according to the type of emotional abuse targeted: emotionally abusive parenting; parents of infants with faltering growth; missocialisation: parenting interventions with substance-abusing mothers. Twelve included studies had quantitative designs. Of these, 6 comprised randomised controlled trials; 1 comprised a follow-up of a randomised controlled trial; 2 were controlled studies; and 3 had one-group pre- and post-designs. The remaining 9 were case studies. Included studies involved a wide range of interventions. The 8 studies for parents which address emotionally abusive parenting (rejection, misattribution, parent-child role reversal and anger management) involved evaluations of cognitive-behavioural training (CBT), behavioural training and parent-infant psychotherapy. Two further case studies involved cognitive-behavioural training, mentalisation and family-based therapy. The 9 interventions with parents of infants with faltering growth evaluated CBT, behavioural training, parent infant psychotherapy and interaction guidance; lay home visitors, and a range of therapeutic options based on the diagnostic condition of the parents. The 3 studies of interventions for substance abusing mothers evaluated a relational psychotherapy group for mothers, and a residential treatment for substance abuse with a parenting component. The sample sizes for quantitative studies were small and ranged from 17 to 98 participants. Ten interventions involved mothers alone, while a further 11 included fathers, either at the outset or at a later stage, and in 3 cases extended family members. Interventions for emotionally abusing parents The findings from the 8 included studies evaluating CBT, psychotherapy, and behavioural approaches suggest that group-based CBT may be an effective means of intervening with this group of parents, although it cannot currently be recommended with parents experiencing symptoms of severe psychopathology. While one comparative study showed a psychotherapeutic intervention to be more effective than a CBT focused intervention, the outcomes measured in this study (i.e. parent and child representations) favoured the former. Behavioural case work involving the use of problem-solving techniques may also have a role to play with some parents, although further research is still needed. Interventions to enhance parental sensitivity The findings from a systematic review of 81 interventions that aimed at enhancing parental sensitivity and / or infant attachment found strong evidence that short term (less than 16 sessions) interventions, with a behavioural focus and aimed exclusively at enhancing maternal sensitivity were also most effective in enhancing infant attachment security. This supports the notion of a causal role of sensitivity in shaping attachment. Interventions that included fathers as well as mothers showed higher effect sizes but results are tentative since they are based on a small number of small scale trials. Parental behaviours associated with faltering growth Nine studies evaluated a range of interventions with parents of babies with faltering growth including interaction guidance, home visiting; parent-child psychotherapy, behavioural casework and multi-component interventions. The findings show that interaction guidance and parent-infant psychotherapy may be potentially effective means of working with this group of clients along with behavioural casework, but that further research is needed before these can be recommended. Missocialisation: Parenting interventions for substance-abusing parents 5 studies (one of which was a 6-month follow-up) evaluated interventions for substance abusing mothers, including a relational psychotherapy group and a residential treatment for substance abusing adults with a parenting component. The findings show that initial gains made in the former were not sustained at 6-months and few benefits from residential intervention. Conclusions Emotional abuse is a complex issue resulting in part from learned behaviours, psychopathology and/or unmet emotional needs in the parents, and often compounded by factors in the families‟ immediate and wider social environment. As such, a „one-approach-fits-all‟ is unlikely to lead to sustained change. The evidence base is weak, but suggests that some caregivers respond well to cognitive behavioural therapy. However, the characteristics that define these parents are not clear. There is currently no evidence to support the use of this intervention alone in the treatment of severely emotionally abusive parents. Some of the evidence suggests that a certain form of emotional abuse (for example, highly negative parent affect, which may be expressed as frightened and frightening behaviours in the parent) stemming from unresolved trauma and loss, is less amenable to CBT. There is some evidence that interaction guidance and psychotherapeutic approaches can generate change in parents with more severe psychopathology. Further research is urgently needed to evaluate the benefits of both psychotherapeutic and cognitive behavioural interventions, including those which take the form of family therapy, with parents at the more severe end of the spectrum, with fathers, and with older children. There is also a need to gain further understanding about which forms of emotional abuse respond best to different treatments

Major health-related behaviours and mental well-being in the general population : the health survey for England

Background: Major behavioural risk factors are known to adversely affect health outcomes and be strongly associated with mental illness. However, little is known about the association of these risk factors with mental well-being in the general population. We sought to examine behavioural correlates of high and low mental well-being in the Health Survey for England. Methods: Participants were 13 983 adults, aged 16 years and older (56% females), with valid responses for the combined 2010 and 2011 surveys. Mental well-being was assessed using the Warwick-Edinburgh Mental Well-being Scale (WEMWBS). ORs of low and high mental well-being, compared to the middle-range category, were estimated for body mass index (BMI), smoking, drinking habits, and fruit and vegetable intake. Results: ORs for low mental well-being were increased in obese individuals (up to 1.72, 95% CI 1.26 to 2.36 in BMI 40+ kg/m2). They increased in a linear fashion with increasing smoking (up to 1.98, 95% CI 1.55 to 2.53, >20 cigarettes/day) and with decreasing fruit and vegetable intake (up to 1.53, 95% CI 1.24 to 1.90, <1 portion/day); whereas ORs were reduced for sensible alcohol intake (0.78, 95% CI 0.66 to 0.91, ≤4 units/day in men, ≤3 units/day in women). ORs for high mental well-being were not correlated with categories of BMI or alcohol intake. ORs were reduced among ex-smokers (0.81, 95% CI 0.71 to 0.92), as well as with lower fruit and vegetable intake (up to 0.79, 95% CI 0.68 to 0.92, 1 to <3 portions/day). Conclusions; Along with smoking, fruit and vegetable consumption was the health-related behaviour most consistently associated with mental well-being in both sexes. Alcohol intake and obesity were associated with low, but not high mental well-being

Pilot of ‘Families for Health’ : community-based family intervention for obesity

Objective - To develop and evaluate ‘Families for Health’ - a new community based family intervention for childhood obesity. Design – Programme development, pilot study and evaluation using intention-to-treat analysis. Setting – Coventry, England Participants – 27 overweight or obese children aged 7-13 years (18 girls, 9 boys) and their parents, from 21 families. Intervention – ‘Families for Health’ is a 12 week programme with parallel groups for parents and children, addressing parenting, lifestyle change and social & emotional development. Main Outcome Measures – Primary: change in baseline BMI z-score at end of programme (3 months) and 9 month follow-up. Attendance, drop-out, parents’ perception of programme, child’s quality of life and self esteem, parental mental health, parent-child relationships and lifestyle changes were also measured. Results: Attendance rate was 62%, with 18 of the 27 (67%) children completing the programme. For the 22 children with follow-up data (including 4 drop-outs), BMI z-score was reduced by -0.18 (95%CI -0.30 to -0.05) at end of programme and by -0.21 (-0.35 to -0.07) at 9 months. Statistically significant improvements were observed in children’s quality of life and lifestyle (reduced sedentary behaviour, increased steps and reduced exposure to unhealthy foods), child-parent relationships and parents’ mental health. Fruit and vegetable consumption, participation in moderate/vigorous exercise and children’s self-esteem did not change significantly. Topics on parenting skills, activity and food were rated as helpful and were used with confidence by the majority of parents. Conclusions Families for Health is a promising new childhood obesity intervention. Definitive evaluation of its clinical effectiveness by randomised controlled trial is now required