Parenting Interventions: Effectiveness Across Cultures

1. Parenting interventions: For whom do they work? How well do they transport across countries and cultures?Frances Gardner Professor of Child & Family PsychologyCentre for Evidence-Based Intervention Dept of Social Policy & InterventionUniversity of OxfordBangor April 2019

2. Acknowledgements Project teams: Frances Gardner Patty Leijten University of Amsterdam Wendy Knerr, Oxford University, Dept Social Policy & Intervention GJ Melendez Torres, Cardiff Stephen Scott, Child Psychiatry; Sabine Landau, Victoria Harris, Biostatistics, IOPPN, Kings London Judy Hutchings - Bangor Jennifer Beecham, Eva Bonin LSE Collaborators Bram Orobio de Castro, Utrecht Sinead McGilloway, NUI, Ireland Filomena Gaspar, Coimbra Portugal Ulf Axberg, Gothenburg, Sweden Willy-Tore Mørch, Tromso, Norway Vashti Berry, Plymouth, UK Thanks for funds & inspiration: Swedish Board of Health & Welfare NIHR Public Health Research-12-3070-04 The views expressed are those of the authors and not necessarily those of the NHS, NIHR or Department of Health.

3. Overview Parenting interventions for child problem behavior - a mature field, much data on effectiveness, with extensive influence on policy So- what do we need to know more about? - - questions about generalisability: • For whom do they work? - investigation of moderators: including questions about poverty & social equity, culture, age effects - limitations of usual studies – & how to overcome • How well do they transport across countries & cultures? - examining cultural & cross-country effects

4. Parenting vital to early child development - health, well-being, behavioural, educational outcomes Positive, consistent parenting predicts better child mental health, lower levels of problem behaviour & child abuse (Hoeve, 2009) Harsh, inconsistent parenting conversely predicts later poor outcomes: conduct problems, delinquency, drug use, family violence, school failure, poor health These outcomes of poor parenting are very costly to multiple systems (Knapp economic modelling studies) Parenting is modifiable, much evidence & practice knowledge on how to improve parenting skill - So a logical choice for early intervention

5. Parenting interventions: What are they?

6. Features of parenting interventions Most effective interventions are based on social learning theory, & attachment principles. Focus on: • Building positive parenting skills • Learning alternatives to harsh punishment • Use active learning & practice, not just knowledge/ information • Deliver to parents in groups, or to one family. • Universal or targeted; many service settings Well known evidence-based brands, tested in randomised trials (RCTs) from USA & Australia, work on similar principles: egIncredible Years, Triple P, PMTO-Parent Management Training Oregon; Parenting for Lifelong Health (PLH), our new WHO program

7. Example of high quality program: Incredible Years Parenting • 12-14 two hour sessions weekly (basic version, as used in most RCTs) • Curriculum begins on building positive relationships - pyramid • Collaborative (not didactic) leader style: • Starting point is the parents goals, needs & values, • Parents generate - and learn to apply - parenting principles flexibly to own family; shared problem solving in group • Focus on changing behaviour: discuss video clips, role-play; home practice with child • Manualised curriculum, but flexibility in working thru individualised problem solving • Developed & tested in USA; tested in randomized controlled trials (RCTs) in many European countries (Wales a pioneer!)

9. Brief summary of parenting intervention evidence base 100’s randomised trials (RCTs) & systematic reviews; quantitative & qualitative evidence: -Show effectiveness of early parenting interventions based on changing parenting behaviour & skills (eg IY, Triple P for • Parent: Reducing harsh & improving positive parenting & parent-child relationship; Parent confidence, stress; mental health in some studies • Child: Reducing child problem behavior; violence against children • Teenagers: Reducing delinquency, drug use Leijten, Gardner et al 2016, 2018; Barlow et al 2012 Photo credit: UNICEF

10. What else do we want to know about parenting interventions? Many big questions for the field: • How effective and cost-effective are they in the longer term? • How can we take them to scale and maintain effectiveness? (e-health) • Which mechanisms & ingredients are essential? Can we ‘slim down’ or optimise these programs? • Are there differential effects for different kinds of families? • How well do they transport to new countries?

11. Are there differential effects for different kinds of families? Many risk factors for poor parenting, and for child problem behavior: -- these problems are highly patterned by social disadvantage, parent mental health, family violence, gender. • But do we know if these same risk factors which predict poor child outcomes, also make interventions less effective? • Evidence much less clear on whether intervention outcomes also patterned like this • These are questions about moderators of intervention outcome

12. Moderator effects - and equity effects Ask: for whom does it work: understanding intervention theory, practice, policy Moderator analyses examine interaction effects; Identify subgroups where intervention is suitable or does no good - improve targeting, alter or enhance intervention methods As interventions go to scale – can ask what effect they might have on populations, not just individuals - wider ‘equity’ questions about effects on social inequalities • If interventions have differential effects, could they serve to further increase social inequalities in child outcomes? – (if the most needy benefit the least?)

13. Inconsistent moderator findings in parenting intervention trials Do more disadvantaged and distressed families show less or more improvement? Two large systematic reviews of parenting intervention predictor effects (924; 700 citations; Lundahl, 2006; Reyno & McGrath, 2006) • Tested effects by poverty, lone parent, parental depression • Conclude: more disadvantaged & distressed families benefit less Recent large trials give a different picture “no moderator effects” or “more disadvantaged and distressed families can benefit more” (Gardner et al., 2009, 2010; Beauchaine et al., 2005). - Thus unclear what potential effects on social disparities

14. What problems with usual approaches to studying moderators? Individual trials • Well-powered to test main effects • Not powered to test moderation effects (Brown, 2012) • Criticised for ‘cherry picking’ outcomes & analyses, posthoc. • Need pre-registration, transparent reporting to overcome this problem (“Open Science”) Meta-analyses • Even more power and precision for maineffectsBUT... • Moderation only by trial level characteristics, eg by average level (per trial) of family characteristics • Means all variability within trials in participant characteristics lost • Power for moderator effects low - is linked to the number of trials • Trial level moderators often confounded (Lipsey, 2003)

15. To overcome these drawbacks, what is needed?

16. To share and pool data- Individual Participant Data meta-analysis, IPD Benefits • Uses all within-trial individual variability (eg in ethnicity, poverty) • Enhanced power to detect moderator effects (+rarer benefits & harms) • Greater generalisability across families, service contexts, regions • Consistent, transparent analytic strategies • Fits with current climate pushing for greater transparency, replicability, data sharing (BMJ ‘All trials’; Open science) • In psychosocial intervention - transparency less well-developed, but improving (eg new CONSORT ‘SPI’; Grant 2018; Cybulski 2016) Challenges • Ethical issues re consent, full anonymity • Accessing, then interpreting data • Harmonising varied data across trials - validity & resources Cochrane Methods IPD Meta-analysis

17. So that’s what we did - the Incredible Years Pooling Study • IntegrativeData Analysis • N = 1799 Who benefits from parenting interventions? Combining data (IPD meta-analysis) from near total sample of randomized trials of the Incredible Years parenting intervention in Europe Funder: NIHR Public Health Research The views expressed are those of the authors and not necessarily those of the NHS, NIHR or Department of Health.

18. Incredible Years: What and Why? Trials aimed at preventing or reducing disruptive behaviour problems in early-middle childhood - Mostly treatment or indicated prevention Govt policy in England, Wales, Norway: - Widely disseminated in health & family services, to varying degrees in different countries

19. Questions for pooling study To examine if IY parenting intervention is less or more effective for reducing disruptive child behaviour in the most disadvantaged and most distressed families. • by family poverty/ socioeconomic status? • by child & family mental health problems? • by child age - is earlier intervention better? • by ethnic minority status?- later Help inform ‘equity’ question: Are interventions, when taken to scale, likely to help widen or narrow social disparities? (Tugwell et al 2006).

20. Methods – for Individual Participant Data (IPD) Meta-Analysis • Sought data from trial investigators for complete sample of RCTs of IY parenting in Europe- searches found 15 eligible trials • Data from 14 trials available, all PIs agreed to share data • Item and Individual-level data (IPD)received, cleaned and, harmonised; • Research questions limited by what available; and by whether variables operate at trial vs individual level Useful resources if you want to do IPD MA: - Cochrane IPD; PRISMA-IPD Statement (Preferred Reporting Items for Systematic Review & Meta-Analyses of IPD) - Hendricks Brown- Chicago- NIMH collaborative group on adolescent depression

22. Pooled IPD sample (N=1799; k=14)

23. Key elements of Individual Participant Data (IPD) meta-analysis • Huge job harmonising data across trials, many assumptions. • 13 trials had data on primary outcome: Child disruptive behaviour at post-test. N= c 1700 for moderator analyses. • Intention-to-treat: all families included, whether took up intervention or not • Multilevel modelling to analyse effects of moderators on children, nested in parenting groups, nested in trials • Multiple imputation of missing data (MICE) • Controlled for key baseline variables (child behaviour, age, gender, selective prevention vs indicated/ treatment trial)

24. What did we find?Children in a low income family - Will they benefit more or less than those in higher income families?What would you predict?(‘Benefit’ expressed in terms of change in the primary outcome, parent reported child disruptive behaviour (ECBI)Moderator variable is binary)

25. Low income didn’t make a difference to child outcomes No evidence that intervention effect varies by low vs higher income (p=0.87). .

26. Child in lone parent family- Will they benefit more or less?

27. Lone parent status didn’t make a difference to child outcomes - No evidence that intervention effect varies by lone parent status (p=0.99). -

28. Child whose parent has a higher level of depression (continuous score) Will they benefit more or less?- high burden of depression in families experiencing child behavioural problems(depression symptoms as continuous variable)

29. Parental depression did.. Evidence of moderator effect (p=0.01) - Children of parents with higher depression benefit more. No evidence of a non-linear effect (p=0.22) O

30. Children with higher or clinical levels of disruptivebehaviour problems at the start Will they benefit more or less?(behaviour as continuous variable)Implications for targeting:Can a 12- session weekly programs can help families with quite severe problems?

31. Child disruptivebehaviour problems did… • Evidence of moderator effect (p=0.015). • Children with higher scores at baseline benefit more - No evidence of a non-linear effect (p=0.79)

32. Younger vs. older children, range 2-10Will they benefit more or less?(age as continuous variable)- important question for psychology, neuroscience, policy

33. Is early intervention better? • Evidence for sensitive periods in the very early years, implying greater malleability (Wachs et al, 2014) But how strong is the direct evidence for superior effects of early intervention? • Rare to experimentally compare early & later interventions • Other evidence non-randomised; or comes from extreme environments (eg orphanages) • Yet global policies recommend early intervention- in first 2-5 years (or 0-5) for enhancing child cognitive & behavioural outcomes

34. What data? Heckman 2006: Compared effects of different interventions, from early childhood through adolescence, concluded there was greatly diminished effectiveness & cost-effectiveness with increasing age.

35. Heckman won the Nobel prize in Economics - data hugely influential, but has limitations : • Compares good quality early interventions with ineffective later ones – e.g. preschool enrichment with teen bootcamps & job training; • Timing effects may depend not only on developmental stage, but also on intervention goals, mechanisms and outcomes – Heckman mixes all together! • Maybe better to examine one type of intervention – so keep the mechanisms & outcomes constant, whilst comparing across ages..? This is what we found…….

36. Child age didn’t make a difference to outcomes - No evidence that intervention effect varies by child age (2-10 years) (p=0.95).

37. Cost effectiveness - increases with age Cost-effectiveness went up with age – cautious conclusion, as based on subset of 5 trials in Wales & England (Bonin et al. 2019) So- Heckman’s curve doesn’t seem to work for one very common intervention - parenting for behaviour problems .. -

38. But…. • We found no age effects, but maybe its just this particular IY parenting intervention • Does the effect generalize? • To check, we tested using bigger, regular meta-analytic approach – at trial aggregate level - including all parenting interventions (age 2-10).

39. Can we replicate no age effect in wider range of interventions? -- 50 different parenting interventions, 20 countries Found: • No moderation of child conduct problem outcomes by (average) age of children in trial • No moderation by age range - targeting a developmentally more specific stage was not more effective • 154 trials, 15,000 families, trial-level meta-analysis • Mean child age - range 2-10 (mean 5 years) • Paper just out – Gardner, Scott et al (2019): The earlier the better? Child Development

40. read all about it…

41. Conclusions on moderators Pooled IPD analyses found few moderators: Child disruptive behaviour just as likely to reduce if in low income or lone parent family • But - if family has high distress at the start (worse child disruptive behaviour or parent depression) child is more likely to benefit. • No age effects - interesting, first well powered study on this; does not fit with thrust of neuroscience /early intervention work

42. Parenting across cultures and countries • Our pooled data suggest IY parenting intervention is generalizable across sub groups – defined by social disadvantage, child age, level of child or parent clinical symptoms • Do parenting interventions generalise across ethnic groups in Europe? • Prior data mixed from USA; hard to have large enough studies, when analysing only single trials

43. Back to IY pooling study: Child in ethnic minority family- Will they benefit more or less?Relatively few well-powered studies of moderators by ethnicity; trials often too small.Our pooled IY sample: - n= 500 minority families (30% of 1650)- Diverse sample, hugely varied immigrant histories & ethnicities (UK- London, Birmingham, Netherlands- cities & prisons); - Parents in mixed groups in communities, not separated by ethnicity, not adapted

44. Ethnic Minority status didn’t make a difference to child outcomes No evidence that intervention effect varies by ethnic minority status (p=0.48). UK, Netherlands; naturally occurring groups, mixed ethnicity urban children’s services

45. Parenting across cultures and countries What about generalizability of parenting interventions at country level, where cultural, economic and other factors vary hugely?

46. Governments, policy makers, service providers who want to introduce an evidence-based program need to choose... • Transported? • Save time and money. • Effectiveness abroad indicates effectiveness here? • Need adapting? • Homegrown? • Fit program to needs of local families, • More culturally acceptable? • Any evidence?

47. Study 1:How well do parenting interventions transport across countries?What factors predict successful transportation? • Systematic search for trials of interventions tested in country of origin, then transported & tested in ‘new’ countries • Meta-analysis assessed effects on child behaviour: - effects in new countries • country-level factors that might predict successful transportation - sought data on cultural values, policy regimes Gardner et al. (2016) Journal of Clinical Child & Adolescent Psychology With thanks to Knut Sundell, Socialstyrelsen, Stockholm

48. Transportability of parenting interventions across countries: systematic review. Gardner et al 2016 17 trials 10 countries, eg Norway, Holland, Iran, Iceland, H.Kong, Iran, UK Incredible Years Sweden Iceland Canada Norway NL IrelandUK PMTO Triple P Puerto Rico Iran Hong Kong PCIT

49. Study 1- Findings Found 17 trials of interventions transported to 10 ‘new’ countries Yes – mean effect size on child disruptive behaviour d=.5 (similar to effects found in ‘origin’ countries). Most had been little adapted No – most effects not related to how similar/ dissimilar countries were in cultural values, wealth, or family policy regimes. But - effects were stronger in ‘non-western’ countries, & those with more traditional values (cultures lower on ‘self expression’) Yes- Small, focused only on transported trials, info on adaptation limited Do they transport? Meta-analysis asking: does it depend on country context? Limitations

50. Heterogeneity: I² = 79% Test for subgroup differences: (P = 0.01) 95% CI [-0.72 to -0.27] 95% CI [-2.25 to 0.75] Do effects differ by country/culture? All interventions developed in ‘western’ countries (USA, Australia)