LITERATUREREVIEW ON THESUPPORTNEEDSOFPARENTS of CHILDRENWITHBEHAVIOURALPROBLEMS

For BARNARDOS,CARLOW

SiobhanBradley NoirinHayes CentreforSocial&EducationalResearch DublinInstituteofTechnology

2007

Foreword

despitethefactthatpartnershavebeenhavingbabiesformillennia,contemporaryparents arejourneyingintouncharteredterrain,whichappearstoholdunexpectedriskstotheirown andtheirchildrensdevelopment. (Skolnick&Skolnick,2005,p.271)

Itiswidelyacceptedthatthetaskofchildrearingisexceedinglydifficultinacontextofrapid societal change which is reflected in the complexities of changing family structures, the challengeofworklifebalanceandthesocialandenvironmentalissueseffectingcommunities. Barnardos Family Support Project in Carlow is supported and informed by a multiagency advisorygrouprepresentingvoluntaryandstatutoryagenciesandthelocalcommunity. The collective experience of the member agencies of this group and that of the local communitycoupledwithincreasinganecdotalevidence,suggeststhatanincreasingnumberof parents in the general population are experiencing difficulty with regard to managing and respondingtotheirchildrensbehaviour. With consideration of the specific roles, responsibilities and limitations of existing service providers both statutory and voluntary itwas agreedthat further informationwasrequired in order to establish on one hand the extent to which families in Carlow are under pressure trying to respond to problematic behaviour i.e. maintain adequate boundaries with their childrenandontheothermodelsofgoodpracticeinparentsupport.Primaryresearchwillbe undertakeninrelationtotheneedsofparentswhohavenotyetaccessedexistingservicesand willbeinformedbythefindingsofthisreport. This literaturereviewwas commissionedto identify modelsofgoodpractice andsubsequent learning in order to inform current service provision and the development of new services whererelevant.Thisstudy,commissionedbyBarnardoswasfundedbyCarlowAreaNetwork Development Organisation (CANDO) and RAPID. Research was carried out by Siobhan BradleyoftheCentreforSocialandEducationalResearch(CSER)atDIT. MarianDowd ProjectManager Barnardos

TABLEOFCONTENTS

SectionOne:Introduction 1.0 Introduction....1 1.1 PaperOutline.....2

Section Two:SettingTheContext:OverviewOfBehaviouralProblems 2.0 DefiningBehaviouralProblems:...2 2.1 Prevalenceand OccurrenceofBehaviouralProblem....3 2.2 TrendsinChild/AdolescentBehaviourProblems.....4

SectionThree:RiskandProtectiveFactors 3.0 Introduction ...6 3.1 Parent/ChildBiologicalFactors.6 3.2 FamilyFactorsandProcesses7 3.3 TheCommunity.9 3.4 ProtectiveFactors..9

Section Four:AddressingBehaviouralProblems:AssessmentAndIntervention 4.0 Introduction..11 4.1 CurrentAssessmentandInterventionServicesforChildrenwithBehaviouralProblems..11 4.2 SupportingParentsasanInterventionMechanism.12

Section Five: Supporting Parents In Addressing And Responding To Child And Adolescent BehaviouralProblems 5.0 Introduction..13 5.1 StagesofInterventiontoSupportParentsandChildren..13 5.2 ProgrammeSamples16 5.3 EffectiveTargeting..22 5.4 StrategicIssuesforConsideration...24 5.5 FocusonChildAlso25

Section Six:SummaryofKeyFindings&Recommendations..26

References

SECTIONONE:

INTRODUCTION

1.0Introduction "Thetoughestthinganyonefacesintheirpersonallifeisbringingupachild. (Tony Blair,21November,2006,onannouncementoftheUKSupernanny Scheme) Alittlehelpataparticularlydifficulttimeforparentscanbehugelyeffective. (ClaireTickel,NationalChildrensCharity,UKonannouncementoftheSupernannyScheme) Itsverydifficulttheolderthechildrengettoactuallyreinthembackin. (SingleMother,Natalie).

TheexperiencesofIrelandschildrennowareconsiderablydifferenttothoseexperiencedbyIrelands children even fifteen years ago. An increasing number of children live in one parent households, in dual income families and in migrant and refugee households. The unprecedented economic growth whichIrelandhasexperiencedfromthemid1990sandthebenefitsofoureconomicaffluencehavenot beenequitably sharedandthe longstandingpromiseof successive Irishgovernmentsthatthe risingtide liftsallboatshasnotmaterialized(CallanandNolan,2002Reynolds,2005).Itisnowestimatedthatone 1 in every seven children in Ireland live in poverty . Disadvantage experienced by children is likely to impact on their behaviour, life style and opportunities. Recent years have witnessed and increased emphasisonparentingandthevitalandpivotalroleparentsplayinprovidingforandinsupportingtheir children.PolicydocumentssuchasTheReportoftheCommissionoftheFamily(1998),ChildrenFirst (1999)andTheNationalChildrensStrategy(2000)allemphasisetheStates commitment to supporting parentsintheirparentingrole. Therisk factorsofdisadvantage,andtheincreasingattentionto growingbehaviouralproblems (orat least, recording and reporting of such problems) has acceleratedd public debate around the support needsofparents,andwhatworksbest,intermsofserviceprovisionandsupportsforparentsinraising their children. Daily media reports and academic research highlight the growth in youth antisocial behaviour,crimeratesandindeedthegrowingintensityofyouthcrimes.However,whileresearchand reviewsofantisocialbehaviouramongstchildrenarelongdocumented,amoreextensivefocusonthe behavioural problems of children, to include emotional and mental health problems, such as ADHD, have only recently come under the research and policy microscope, largely fuelled through the Department of Healths Vision for Change and the Health Service Executives Child Mental & Emotional Health. Both reports brought attention to the growing behavioural and mental health problems experienced by Irelands youth and the scarcity of resources, and often, the difficulties experiencedbyparentsandchildreninaccessingappropriateprofessionalsupportandtreatment. In the UK, growing levels of antisocial behaviour led to the introduction of a number of policy measuressuchasParentingOrdersandtheSuperNannyscheme.Therearealsoagrowingnumberof informationservices,supportsandtrainingprogrammesavailabletoparentstoassisttheminmeeting their parenting responsibilities. In Ireland, such supports continue to remain limited. A Vision for ChangeandChildMentalandEmotionalHealthbothemphasisethekeyroleofparentsinsupporting childrenwithbehaviouralproblemsandthegenerallackofsupportsandservicesforbothparentsand childrenindealing with behaviouralproblems.Despitecompellingevidence,that early identification andresponsetoachildsbehaviouralproblemspromotesbetteroutcomesforchildrenandreducesthe
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http://www.barnardos.ie/news62.htm

burdenofsuffering forfamilies andthe community, services andsupportsforfamilies in Irelandare stillintheirinfancyandremaininsufficienttotrulytackletheprevalenceanddiversityofbehavioural problems.Recentmediareportshighlightedtheextensivewaitingperiodchildrenmustendureforan assessment. Howlongachildisforcedtowaitdependsonwhereheorshelives.InDublin,theymay waitforuptotwoyears,inCarlow/KilkennyitcantakenearlyfouryearsandinKerryachildwhogoes 2 onawaitinglistonhis fifth birthdaymaynot get adiagnosis untilhe is nineandahalf .Giventhe extensivewaitingperiodstoaccesssecondaryandtertiaryservicesinIreland,andindeedinternationally (e.g. Australia, US), the emphasis on the importance and pivotal role primary services within the communitycanplayhasincreasedinrecentyears. 1.1PaperOutline Thisbackgroundpaperaimstoprovideanoverviewofthetype,extentandprevalenceofbehavioural problems of children and young people in Ireland. The paper will review risk factors which may contribute to and/oraccelerate the development of such problems, andprotective factors and support programmes/services which may respond to behavioural problems or reduce their likelihood of occurrenceinthefirstinstance.Itpaysparticularattentiontothesupportneedsofparents,andthekey role supports can and do play in preventing the development of behavioural problems, and in resolving/respondingtosuchproblems whereexistent. Itconcludes withasummaryofkeyfindings from the literature review to guide Barnardos in the identification and design of possible supports/strategiestosupportparentsofchildrenwithbehaviouralproblemintheCarlowregion. ThepaperwascommissionedbyBarnados,Carlowandaimstoprovideanintroductorycontexttothe organisationofkeyconsiderationsandpotentialapproacheswhichmayinformdiscussionregardingthe organisationsresponsetosupportingparentswhosechildrenexperiencebehaviouralproblemslocally. Thepaperwillalsoassisttheorganisationindesigningtheirresearchinstrumentsforprimaryresearch toassessthescaleandextentofchildandyouthbehaviouralproblemsintheareaandthesupportneeds ofparentsincoping/respondingtothese.

http://www.rte.ie/news/2006/1205/health.html

SECTION TWO: SETTINGTHECONTEXT:OVERVIEWOFBEHAVIOURALPROBLEMS

2.0DefiningBehaviouralProblems: Hall&Elliman(2003)definepsychological,emotionalandbehaviouralproblemsas behaviours or distressedemotions, whichare commonor normal inchildrenat some stageofdevelopment,butbecomeabnormalbyvirtueof theirfrequencyor severity,or theirinappropriatenessforaparticularchildsagecomparedtothemajorityofordinary children. Themostprevalenttypesofdisordersdisclosedinchildrenare: emotionaldisorders,e.g.depression,anxietystates,phobiasandpsychosomaticdisorders oppositional defiant disorders and conduct disorders (ODD and CD), e.g. non compliance, defiance,stealing,truancy,aggressionandmorepersistentdelinquency. attentiondeficitdisorder,withorwithouthyperactivity(ADHDandADD) majorpsychiatricdisorderse.g.psychosis,whichincreasinglyoccurfrompubertyonwards developmentaldelayandautism eatingdisorders,e.g.anorexianervosa antisocialbehaviour e.g.drugandalcoholabuse (Cummins,McMaster2006) The spectrum of behaviours can therefore vary from very mild to clinically problematic, and their definitionandnatureoftenexpandsbeyondthetermbehaviouralproblemsitselftoincorporatemental and emotional health problems. Often the behavioural problem is a manifestation of a deeper emotional/mental health problem. This paper will focus on the most commonly experienced and reportedproblemsamongstchildrenandadolescents.Emotionaldisorders(suchasdepression,anxiety and obsessions), hyperactivity (involving inattention and overactivity) and conduct disorders (involving awkward, troublesome, aggressive and antisocial behaviour) are the three most common 3 groupsofchildhoodmentalhealthproblems . 2.1PrevalenceandOccurrenceofBehaviouralProblems TableOnepresentsestimatedprevalenceratesofbehaviouralproblemsamongstzerotoeighteenyear olds in Ireland. It is estimated that a fifth of the child and adolescent population may suffer from psychologicalproblemsatanygiventime(CumminsandMcMaster,2006),astatisticwhichisnotout 4 5 oflinewithotherinternationallydevelopedcountriessuchas theUS , andCanada .

3 4

http://www.counsellingdirectory.org.uk/childrenstats.html TheUSSurgeonGenerals2000 ReportonChildrensMentalHealthestimatesthatoneinfivechildrenand adolescentswillexperienceasignificantmentalhealthproblemduringtheirschoolyears. 5 ACanadianstudyestimatedthatapproximately26%ofschool agechildrenexperiencementalhealthproblems (Offord,Boyle,&Szatmari,1987).

Table1:Prevalenceofchildemotionalandmentalhealthproblems(018) Disorder Percentage PsychologicalProblems 20% MentalIllnesswithsomeimpairment 10% MajorPsychiatricDisorder 5% MentalIllnessrequiringinpatientadmission .5% ADHD 3 5% Autismandrelatedconditions .5 1% Mentalhealthproblemsamongchildrenincare 60 70% Mental health problems among children in residential 90% homes Source: IrishCollegeofPsychiatrists(2006) inCummins,McMaster,2006 Ratio 1in5 1in10 1in20 1in200 1in20to30 1in100200 >1in2 <1in1

CurrentdatafromepidemiologicalstudiesofpsychologicaldisordersinchildreninIrelandarelimited. In 2004, a HSE commissioned epidemiological study of behavioural problems in children screened 3,274childreninClonmel(representing74%ofallpeopleundereighteeninthearea)formentalhealth 6 difficulties usingthe ChildBehaviourChecklistandrelatedinstruments . Thestudyfoundanestimatedprevalencerateof18.71%foratleastonepsychologicaldisorderinthe precedingyear. Thestudyfound17%oftwotofiveyearolds,10%ofsixtotwelveyearoldsand26% of1318yearoldsscreenedpositiveforamentalhealthproblem. Almosthalfofthese(43%)hadan anxietydisorder,aquarterhadODDandjustoverafifthhadADHD.Slightlymorethanatenthhada conductdisorderproblem,andoneintenhadamooddisorder,alcoholabuseorintellectualdisability (Martin&Carr,2005). 2.2 TrendsinChild/AdolescentBehaviourProblems Researchgenerallysuggeststwokeyentrypointsinthedevelopmentofbehaviouralproblemsearly childhoodandearlyadolescencewithpotentiallydifferentriskfactorsassociatedwitheach(Lahey,B, Waldman,I,McBurnett,K,1999)(riskfactorsarediscussedingreaterdetailinSection2). Themost significantagedifferenceisthatADHDismorecommonamongstchildren,whileconductdisorderis morecommonamongstadolescents(Martin&Carr,2005).Severalinternationallongitudinalstudies haveprovidedapictureofthechangingformsofbehavioural problemsfromearlychildhoodthroughto adolescence. Richman and colleagues found that 67% of children who displayed externalising behavioural problems (e.g. non compliance, oppositional behaviours and overt physical and verbal aggression)atage3werestillaggressiveatage8(Richman,Stevenson,&Graham,1982). Similarly,a UKstudyfoundthat60%ofthreeyearoldswithconductdisordersstillexhibitproblemsattheageof eight if left untreated and predict that many problems will persist into adolescence and adulthood (NationalInstituteforHealth andClinicalExcellence,2006). Anumberofstudies havedocumented thatboyswhoreachthecriteriaforADHDinchildhoodareatincreasedriskforconductdisorderand antisocialbehaviourinadolescenceandearlyadulthood (Hann,D.,Borek,N., 2001). The Australian Temperament Project (ATP), a large scale, longitudinal study, which followed approximately1600Victorianchildrenfrominfancythroughto18yearsofage,recentlyreleaseddata supporting two different pathways associated with the development of anti social behaviour in adolescents. Thestudyidentifiedthreegroupswereidentifiedonthebasisofselfreportedinvolvement inantisocialbehaviourduringadolescence. Groupsweredesignatedlow/nonantisocialandpersistent andexperimentalantisocial.Thoseinthepersistentgroupbegantoexhibitsignificantlyhigherratesof
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NotethattheBehaviourChecklistscreensforawiderangeofbehaviouralproblemsandisusedtoidentify problemssuchasaggression,hyperactivity,bullying,conductproblems,defianceandviolence. Thefirstsection ofthequestionnaireconsistsof20competenceitemsandthesecondsectionconsistsof120itemsonbehaviouror emotionalproblems.

antisocialbehaviourfromtheageof5/6,increasinguntilage11/12whentheybegantoplateau.Those in the experimental group did not begin to exhibit anti social behaviour at a significantly higher rate thanthelow/nonantisocialgroupuntil12/13,withthesedifferences increasinguntiltheageof15/6, whentherewasaslightdownwardtrend (Ralph&Sanders, 2003). KeyEntryPointstoDevelopmentofBehaviouralProblems 2.2.1EarlyChildhood Early behavioural problems has been cited as one of the strongest predictors of later problems, including psychological difficulties, involvement in crime and antisocial behaviour (Kolvin, Miller, Scott, Gatzanie, Fleeting, 1990). Children who exhibit particularly high levels of externalising behaviourproblemsearlyintheirlivesareathighriskforintensifyingtolying,bullyingandfightingin middlechildhood,andmoreserious behaviours such as crueltyto animals,vandalismandaggressive criminalbehavioursinadolescence(Hann,D.,Borek,N.,2001). Childrenwithconductdisordersata youngagearemorelikelytohavehigherratesofjuvenileoffending,substanceuseandmentalhealth problemsinlateradolescence(Fergusson&Lynskey,1998). Currentthinkingthereforeemphasisesa focusontheearlyprimaryschoolyearstopreventthedevelopmentofpersistentantisocialbehaviour. However,thinkingalsoconcludesthatinterventionstargetingexperimentalantisocialbehaviourshould focusontheearlysecondaryschoolyears (Ralph,Sanders,2003). 2.2.2EarlyAdolescence Adolescence is a key stage of life development when children require an understanding of the life challenges theyfaceandneedto developbasicskills to copewith difficult emotions. It is atimeof increasedriskofpoormentalhealthwithanxiety,depression,psychosis,eatingdisorders,andsubstance misuse becoming more prevalent, as well as an increasing risk of deliberate self harm and suicidal behaviour (DepartmentofHealth&Children,2006). Someyoungpeoplebegintoexhibitproblembehavioursduringearlyadolescence.Insuchcases,entry into conduct problems generally occurs through associations with peers. Externalising behaviour problemscanintensifyduringthisperiodwhenpeerinfluencescanleadtorulebreakingbehavioursuch asdelinquentandantisocialbehaviours,substanceuse,andinsomecases,ganginvolvementanddrug dealing(Hann& Borek, 2001). TheATPfoundthatthelateonsetgroupwhobegantoengageinantisocialbehaviourforthefirsttime in late adolescence did not appear to be associated with a more difficult transition to adult life, but changingbehaviourcoincidedwithnewfriendshipswithotherantisocialyoungpeople,psychosocial adjustment problems, substance use and difficulties in relationships with parents and friends(Smart, Richardson,Sanson,Dussuyer,Marshall,(2005).Initialdataontheselatestarterssuggeststhatmuch of their antisocial behaviour tended to be non aggressive and that they are more likely to desist in problem behaviours as they become older. However, other research suggests that some late starters mightbeinvolvedinhighlyaggressiveandproblematicbehaviours (Hann& Borek,2001). UKsurveys haveshownthat upto90%ofparentsbelieve youngpeoples drugusederives fromthe needto conform with theirpeergroup.However,placingtoo muchemphasis onpeerpressure,may leadparentstounderestimatetheirowninfluenceonchildren,which,thoughitvariesatdifferentages, hasbeenshowntoaffectyoungpeopleslongtermbehaviour(Oyguardetal.,1999).Targetedsupports which highlight the role and influence of parents as well as the risk factors of an adolescents associationwithpeergroupsarethereforeessential.

SECTIONTHREE:

RISKANDPROTECTIVEFACTORS

3.0Introduction Risk factorscanbedefinedas thosefactorsassociatedwith ahigherlikelihoodofnegativeoutcomes and have mainly been studied in relationship to the development of problem behaviour (Dekovi, 1999). Inordertoaccuratelyidentifysupportstrategiesforparentswhosechildrenexhibitbehavioural problems, it is essential to have an understanding of the factors that place children at risk of, or contributetothe developmentofsuch behaviour inthefirstplace. Research suggests, that, in isolation, risk factors may make relatively little contribution to the development of behavioural problems, whereas such factors in combination may be powerful determinantsofnegativeoutcomes(Klein&Forehand,2000Kolvinetal1990). Problemsresultfrom interactionsbetweencharacteristicsofthechildandsituationswithinthefamily,peergroup,schooland community. Therefore, it can be expected that families with multiple risk factors experience more problemsandthusalsoagreaterneedforsupport. CumminsandMcMastersstudy(2006)foundthat children who screened positive for mental health difficulties were more socially disadvantaged, had more behavioural difficulties and adaptivebehaviourproblems, more physical health problems, more familyproblems,morelifestressandpoorercopingskills. An understanding of the key risk factors associated with the onset and development of child and adolescent behavioural problems, and in turn, an identification of high risk groups of children is important in the effective identification and design of supports for parents and children. Key risk factorsarebrieflysummarisedinSection2.1. 3.1Parent/ChildBiologicalFactors Maternal Factors 3.1.1Age Althoughitisnotclearhowmaternalageisrelatedtochildbehaviourproblems,atleasttwokindsof variablescanbehypothesisedasmediators.Firsthavingachildearlierinlifeoftenrestrictsmaternal educational and occupational attainment and related life circumstances, such as neighbourhood of residence,that areassociatedwith youth conductproblems andcrime (Hann,Borek,2001). Bradley andHayess2006studyinadisadvantagedareaofDublinfoundhalfofallmothers intheareawho 7 resided in local authority housing had their first child before the age of 20 . Almost three quarters (73%)ofthesemothershadleftfulltimeeducationbytheageofsixteen. Aquarterreporteddifficulty incopingwiththeirchildsometimesandafurther14%reporteddifficultyincopingwiththeirchild allthetime. Researchalsosuggeststhatlessmaturewomenmaybemorelikelytoraisetheirchildreninwaysthat foster conduct problems, such as use of harsh and inconsistent discipline (Hann, Borek, 2001). The impactofparentaldisciplineonchildrensbehaviourisdiscussedinmoredetaillaterinthissection.

Totalpopulationofmothersinsurveysample=74.

MaternalSmoking/AlcoholConsumption Researchhasconsistentlyassociatedfactorssuchaslowbirthweightandmaternalsmokingoralcohol consumption during pregnancy with later health, education and behaviour problems (Sutton, Utting, Farrington,2004). 3.1.1ChildGender Fitzgerald and Jeffers (1994) categorised almost a fifth of the Irish children they studied as behaviourallydisorderedwithtwiceasmanyboysasgirlsclassifiedinthisway. Boysarevulnerablein terms of developing conduct and behavioural difficulties and for offending (Kolvin et al., 1990). Anxiety disorders are more common amongst girls and disruptive conduct behaviour amongst boys (Martin&Carr,2005). 3.2FamilyFactorsandProcesses A number of aspects of family interaction can increase the risk of developing behavioural problems fromearlychildhoodthroughtoadolescence.Specifically,lowerlevelsofengagement,greateruseof invalidation,andharshandinconsistentdisciplinehaveallbeenidentifiedascausalriskfactorsforthe development of behavioural problems (Hann, Borek, 2001). Links drawn between low educational achievement,unemployment,involvementincrime,poorhealth,teenagepregnancy,andfamilyfactors have further underlined the importance of promoting and supporting positive family experiences (Riordan,2001). 3.2.1ParentsRelationshipStatus Researchinrelationto theimpact ofparentsrelationshipstatus onchildwellbeingandbehaviouris mixed.McKeown,PratschkeandHaase(2003)found practicallynostatisticallysignificantvariationin 8 thewellbeingofchildreninfourfamilytypes ,indicatingparentsmaritalstatusandpresenceofoneor two parents in household do not, of themselves, affect the childs wellbeing. Existing evidence in relationtotheeffectsofdifferingfamilytypesonchildrensuggeststhatthenatureofthehouseholdis not themostsignificant factor,but ratherthequality oftherelationships andtheeconomic resources availabletothefamily(Hobcraft&Kiernan,2001).Otherstudieshaveshownthatahigherproportion ofchildreninloneparenthouseholdshavescholasticoremotionalproblems,comparedtothoseliving with both parents, but report this to be more likely due to economic circumstances than to parental maritalstatus(McMunn,Nazroo,Marmot,Boreham&Goodman,2001Flanagan,2001). 3.2.2ParentingApproach Ongoing parental conflict, particularly where it directly involves children increases the risk of poor outcomes for children. McKeown et al., (2003) found the first and most importantprocess to affect child wellbeing, as reported by the child, was that of unresolved problems between the child and its parents,includingconflictsrelatingtobehaviour(e.g.homework,schoolprogress,drinking/smoking), family issues(e.g.doingthings as afamily, communication)andpersonalautonomy (e.g.how much 9 pocketmoneyisspent,boyfriend/girlfriend) . Similarly,anAustralianstudyofparentsexperiencesof their teenagers behaviour revealed that issues around family conflict and management of emotions featuredstronglyandwereidentifiedasareaswhereparentswantedassistance(Ralph,Sanders,2003). Conflict withparentshasbeenfoundtobestronglyassociatedwithcontact withantisocialpeersand substanceuse.Highlevelsofpositivefamilyrelations,parentalmonitoring,rulesetting,andpositive reinforcement for appropriate behaviour are associated with less contact with disruptive peers, less engagement inantisocialbehaviourandlesssubstanceuse. Arangeofparentingskillsandattributes are important. A close parent child bond may discourage drug use directly, and choice of non drug using friends (Crundall, 1993), while low family cohesion may predispose children towards deviant behaviourswhichparentsthenlacktheinfluencetocontrol.
8

Fourfamilytypesincludedinstudyweretwoparentmarriedfamilies,twoparentcohabitingfamilies,one parentsinglefamiliesandoneparentseparatedfamilies. 9 Thisreferstobehavioursthataidinexploringagivenproblemandgeneratepotentialsolutions.Foryoung children,thisalsoincludesparentalexplorationofproblems,helpingtogivestructuretothesituationand encourageprosocialmeansofunderstandingthesituation.

Research shows that preschool children who develop attention/hyperactive difficulties experience coercivefamilyinteractionsandtheirparentsoftenreportdisciplinaryconcerns(Bor,Sanders,Markie Dadds,2002). Research also suggests that parents of children with conduct disorder frequently lack severalimportantparentingskills. Predictivelongitudinalstudies indicatethat harshandinconsistent parentingpredictslateryouthconductproblems(Patterson, Chamberlain,Reid,1982).
10 FirmDisciplineVHardDiscipline Parents who provide firm discipline and monitoring of their adolescents tend to have children who becomeinvolvedwithpeersofsimilarparentingdisciplinestyles.Beinginvolvedinnetworksofthis type protect against delinquency because parental monitoring protects against association with disruptive peers (Hann,Borek,2001).

Parental discipline and conflict management have been primary targets for many intervention programmes and trials have consistently documented that improvements in these areas leads to improvementsinchild/adolescentbehaviour.Beginningintoddlerhoodthroughmiddlechildhoodand adolescence, interventions that include improvement in parental discipline, in addition to monitoring andvalidation,showreductionsinyouthconductandantisocialbehaviour(Pattersonetal,1982). 3.2.3FamilyIncome Economic disadvantage is linked with relatively high rates of martial unhappiness, general dissatisfaction,vulnerabilitytodepressionandrestrictedaccesstoemploymentopportunities,childcare andsocialparticipation(Riordan,2002). Comparedtotheireconomicallyadvantaged peers,childrenin economicallydisadvantagedhouseholdsareexposedtomorefamilyturmoil,violence,separationfrom theirfamiliesandinstability (Evans,2004). Studiesalsoshowthatlowincomechildrenarereadtorelativelyinfrequently,watchmoreTVandhave lessaccesstobooksandcomputers.Theirhomesaremorecrowded, noisierandoflowerquality (Ibid., 11 2004). For example, while 55% of parents of four year old children in Hayes and Bradleys aforementionedstudyplayedletter/numbergameswiththeirchildrenonadailybasis,theremaining 45%didsolessoften. Furthermore,almosthalfofallparents(49%)statedtheirchildrenwatchedat leastthreehoursofTV/DVDperday (Bradley,Hayes,2006). Thereis evidenceofaclose responserelationshipbetweenchildbehaviourandpoverty: the longera childisinpoverty,themoreatrisktheyareofbehaviouralproblemswhencomparedtochildrenfrom familiesinshorttermpovertyoraffluence(Duncan,BrooksGunn,Klebanov,2004).Theprevalence ofsignificantemotionalandbehaviouralproblemswerefoundtobe6%higherforchildrenfromlower socioeconomicgroupsthantheaverage10%forchildrenatprimaryschoollevelinarecentstudyin theSouth East ofIreland.Forchildren insecondary school,theprevalence ratewas 10%higherfor thosefromlowersocioeconomicclassesthantheaverage26%(Martin&Carr,2005). Parentalstructuringofthelearningenvironment Research to date conducted with school aged children and adolescents suggests that families that encourageinvolvementwithschoolandmaintaincontactwiththeschoolhavechildrenwhoshowfewer problematicbehavioursthandofamilieswhoarelessinvolved (Hann,Borek,2001).

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Firmdisciplinereferstoparentalstrategiesformanagingandcontrollingchildbehaviourthatconsistentlyuse rules,setlimits,providereasonsfortherules,andoffernonpunitiveconsequencesforbreakingtherules.Hard disciplinereferstononabusivestrategies,controllingchildbehaviourthatmayinvolveinappropriateor inconsistentuseofrules,littlereasoning,andpunitiveorexcessively negativereactionstorulebreaking(Hann, Borek,2001). 11 Totalsurveypopulation:95

Familyhistoryofproblembehaviour Asizeablebodyofliteraturehasexaminedwhetherthepresenceofantisocialbehaviour,delinquency orcriminalbehaviourinotherfamilymembersplaceschildrenatincreasedrisksforsimilarbehaviours. Much of this work has found increased risk when mothers, fathers, or siblings were rated as more antisocialorhadahistoryofdelinquencyorcriminalbehaviour(Farrington,Hawkins,1991). OneUK studyfoundthat63%ofboyswithconvictedfathersweresubsequentlyconvictedthemselves. Having a convicted parent at age 10 was the best single predictor of an antisocial personality at age 32 (Farrington, Coid, 2003). 3.3 TheCommunity 3.3.1TheNeighbourhood Socialfactorsplayanimportantroleinparentingandmayplacecertainfamiliesatriskofsuboptimal parenting, leading to an increased risk of emotional and behavioural problems in children. The neighbourhoodonelivesincanprovideprotection,orincreaserisk.InKolvinetal's(1990)study,the surroundingenvironmentwasalmostasimportantinpredictingdelinquencyaswasfamilydeprivation. In Bradley and Hayess Ballymun study,60% of surveyed eleven year olds reported aproblem with crimeintheir neighbourhoodand 68%wishedtheylivedinadifferentneighbourhood. Other neighbourhood factors cited in research which influence child behaviour include community disorganisation and neglect, availability of drugs, general disadvantage in the neighbourhood, high turnoverandlackofneighbourhoodattachment. 3.3.2PeerInfluences Particularlyaschildrenmatureintoadolescents,peersplayalargeroleinshapingbothappropriateand inappropriatebehaviours. 3.3.3School Thewaythatyoungpeopleengagewithordisengagefromformaleducationandtrainingiscrucialto theirlaterexperiences andbehaviours. Ensuringthatchildrenandadolescentsremainengagedinthe educational system is a crucial first step that can be taken to break the cycle of social exclusion. Schoolmayact as animportant risk orprotective featureinthechild's life(Hayes & Kernan,2001). School offers the possibility of academic and social success and factors that will influence outcome include socioeconomic and family background, IQ, the ability to learn and the school environment (Brazelton, T., 1992). 2.4ProtectiveFactors For every risk factor, an increased exposure to risk is found to relate significantly to an increased likelihood of reported involvement in problem behaviour. Conversely, the more young people are exposed to protective factors, the less likely they are to report taking part in antisocial activities (Beinart,Anderson,Lee,Utting,2002). Whiletherehasbeenanabundanceofresearchonriskfactors,therehasbeenmuchlessresearchonthe protectivefactorsthatenableachildtobouncebackorshowresilienceinthefaceofchallengesand threats (Cummins,McMaster,2006).Protectivefactorscanoperate inavarietyofways.Theycan: Directlyreducearisk Bufferanindividualagainsttheeffectsofarisk Disruptthemediatingfactorsassociatedwiththerisk Preventtheinitialoccurrenceoftheriskfactor Place,Reynolds,CousinsandONeil (2002)havedescribedprotectivefactorsunderthreemain headings:

 Individualfactors:goodproblemsolving,goodsocialskills,selfreliance,positiveoutlookon life,highcognitiveability,emotionalresilience Familyfactors:qualityofattachment,socioeconomicstatus Communityfactors:parentalsatisfactionwithsocialsupport. Protective factors are linked to positive outcomes even when children are growing up in adverse circumstancesandheavilyexposedtorisk. Theymayalsoincludepositiveeventsorturningpointsin people'slivessuchaseducationalsuccess(Garmezy1987). Inadditiontotheabove,protectivefactors encouragehealthstandardssetbyparents/teachers/communityopportunitiesforinvolvementinfamily schoolandcommunitysocialandlearningskillsthatenableparticipationandrecognitionandpraisefor positive behaviour (Beinart et al., 2002). Overall, then, any strategy or support which fosters and enhancesexposuretoprotectivefactorsforparentsandtheirchildrenarelikelytoimpactpositivelyon childrensbehaviour. Resilience is also an important feature when considering/promoting protective factors to address behavioural problems. Resilence refers to the strengths and protective factors which cushion a vulnerablechild/youngpersonfromtheworsteffectsofadversityinwhateverformittakesandhelpa child/young person to cope, survive and even thrive in the face of hurt and disadvantage (Gilligan, 1997).Rutter(1979)estimatedthatevenwiththemostseverestressesandadversities,itisunusualfor morethanhalfofallaffectedchildrento succumbto amaladaptiveoutcome.Gilligan(2000)notes, that although child qualities are important in understanding resilience, the experiences the child encountersandhowshe/heprocessesthesearealsoimportant,sinceitisthispartofresiliencewhichis susceptibletoinfluence. Hearguesthatreducing,evenbyonethenumberofproblemareainachilds life may have a disproportionate and decisive impact as adversity seems most debilitating when it comes inmultipleforms.Swedish researchers also reportthatreducingtheaccumulationofproblem areasseemstoreducetheriskoflaterproblems(StattonandMagnusson,1996). Thestrengthandprotectivefactorsassociatedwith(thedevelopmentof)resiliencehavebeenexplored (Masten&Garmezy,1985WernerandSmith,1992)underthreesetsofcharacteristics: Attributes of children/young people themselves (e.g. selfesteem, positive values and social competencies) Characteristics of their families (e.g. quality of parent child relationship, family environment wherethereareclearexpectationsandopportunitiesforchild/youngpersonsparticipation) Characteristics of their wider social environment (includes nature of friendships, education, community). A resilience led approach focuses on developing strengths and protective factors that help children adapt to difficulties and do better than might be expected. They attempt to shift the balance from vulnerability to resilience by increasing the number of availableprotective factors in childrens lives (Werner,1990).Thismeansidentifying,andincreasingstrengths(protectivefactors)inchildrenslives whereverpossible.

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SECTIONFOUR: ADDRESSINGBEHAVIOURALPROBLEMS:ASSESSMENTANDINTERVENTION 4.0Introduction InIreland,childhoodemotional,developmentaldisorders,behaviouralproblemsandmentalillnessare underrecognised, oftenremainuntreatedandaresubjecttodelaysindiagnosisandreceiptoftreatment. This canadverselyaffect thechilds behaviour,emotionalwellbeingandeducationalattainments,as well as affecting family, friends and society at large (Cummins, McMaster, 2006). Research on changinglifestylesandparentingstyles,aswellasthosefocusedonriskandprotectivefactorssuggest theneedtoplanearlyinterventionorpreventionprogrammesandarebasedontheassumptionthatif childrenarereachedearlyenough,theirlifecoursecanbesignificantlychangedforthebetter(Barlow & Parsons, 2003). A Vision for Change (2005) recommended programmes addressing risk and protectivefactorsearlyinlifebetargetedatchildpopulationsatriskandcitedtheCommunityMothers 12 13 Programme and Lifestart asexamplesofbest practiceinthis regard.

4.1CurrentAssessmentandInterventionServicesforChildrenwithBehaviouralProblems 4.1.1SecondaryandTertiaryServices 14 Currently,secondaryandtertiary servicesforchildrenareinequitablydistributedacrossthecountry, not all teams are fully resourced and many have unfulfilled posts. Some geographical areas lack provisionaltogetherandwaitinglistsareoftenlong (Cummins,McMaster,2006: Itseemsunlikelythatchildandadolescentmentalhealthserviceswill everbeextensive enoughinanycountrytotreatallchildrenwithmentalhealthproblems. Itistherefore necessarytoidentifydisordersataprimarycarelevelandtointerveneearlytoprevent progressiontodisordersofmarkedseverityorchronicity. Resource shortages and promotion of intervention at primary level are emphasised in several other developedcountries.Forexample,MentalHealthofYoungPeopleinAustralia(2000)highlightsthe disparitybetweenthenumberofyoungpeoplewithmentalhealthproblemsandthelimitednumberof clinicians available to help them which makes it unlikely that specialised programmes based in secondaryandtertiarysettingswilleverbeabletoprovidedirectcareforallthosewithproblemsin Australia(Sawyer,M.,Arney,F.,Baghurst,P.,Clark,J.,Graetz,B.,2000). Thereisthereforeaneedto focusonsupportstorespondtobehaviouralproblemsandtoprovideassistanceandsupportasearlyas possible.

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TheCommunityMothersProgrammeisaParentSupportProgrammeinwhichfriendlylocalwomenknownas CommunityMotherscarryoutmonthlyvisitstofirstandsecondtimeparentsintheirownhomes.Thesevisitsare made by appointment and they focus on health care, nutrition and the baby's overall development. The CommunityMothersarevolunteersandareguidedandsupportedbyFamilyDevelopmentNurses.Objectivesof theProgrammearedetailedinAppendixA.
13

Lifestart isahomebased,educationalandfamilysupportprogrammeforparentsofchildrenagedbirthtofive years.Theaimof theprogramme istoempowerparentstoenabletheirchildrentoreachtheirfullpotential. Monthly,ageappropriate,childdevelopmentalmaterialisdeliveredinthehomebytrainedfamilyvisitorsto parentsthroughoutthefirstfiveyearsofthechildslife.Thematerialusedistakenfromthe GrowingChildand coversthephysical,intellectual,emotionalandsocialdimensionsofchildreninthisagegroup.

14

Includeschildandadolescentmentalhealthservicesanddepartmentsofpsychiatryinhospital.Servicesare usuallydeliveredby multidisciplinaryandearlyinterventionteamsfromavarietyofdisciplines,including communitybasedclinicalpsychologists,socialworkers,PHNs,speechandlanguagetherapists,physiotherapists andoccupationaltherapists,aswellaspaediatriciansandchildandfamilysupportworkers

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4.1.2PrimaryCareServices Itisrecommendedthatyoungpeopleandtheirfamilies,identifiedthroughscreening,shouldbeoffered promptintervention,withinthecontextofasteppedcaremodel. Thereareawiderangeofcommunity care services that deliver mental health care at primary care level in the community, particularly for children. Lessintensiveinterventionsshouldbeofferedwithinaprimarycarecontextinitiallyandonly ifchildrendonotrespondtothese,shouldmoreintensiveinterventionsbeoffered,orreferralmadeto secondaryortertiaryservices(Martin,Carr,2005). ThechildrenscentreprogrammeintheUKisbasedontheconceptthatprovidingintegratededucation, care,familysupportandhealthservicesarekeyfactorsindetermininggoodoutcomesforchildrenand theirparents.IthasbeenproposedthatChildandFamilyCentresinIrelandaredevelopedinasimilar fashion and facilitated by cooperation of the HSE, Community Development Programmes, Family ResourceCentresandotherstoprovide: earlyeducationand daycare,includingearlyidentificationofanprovisionforchildrenwith specialeducationalneedsanddisabilities, familyandparent outreachsupport,includingsupportforparentsofchildrenwith special needs, healthservices, servicehubwithinthecommunityforparentsandprovidersofchildcareservices, effective links with local employment services, local training providers and further and highereducationinstitutions, effectivelinkswithchildrensinformationservices,outofschoolandafter schoolclubs, managementandworkforcetraining. (Cummins,McMaster,2006). 4.2SupportingParentsasanInterventionMechanism Aparticularlyeffectivemeansofsupportingfamiliesistofocusonparentingbehaviour. Mentalhealth problemscanhaveasignificantandadverseimpactonchildren,adolescents,parentsandfamilies.Itis thereforeimportantthatinterventionsprovidebroadlybasedhelpfortheparentsandfamiliesofyoung peoplewithproblemsaswellastheyoungpeoplethemselves(Sawyeretal.,2000). Interventionsthat haveaddressedparentalengagement(aswellasdisciplineandproblemsolving)havebeensuccessfulin decreasing later childhood behaviour problems (Hann, Borek, 2001). The development of effective parenting skills has been considered as theprimary mechanism for change in child conduct disorder, 15 throughthereductionintheseverity,durationandmanifestationofthedisorder . Sincebehavioural problems have not been found to be attributable to a single source or situation, interventions for changingthesebehavioursneedtofocusonmultipleriskfactorsacrossmultiplesettings.Similarly,the relative contribution of individual risk factors may change with development suggesting different targetsforinterventionsatdifferentages(SeeSection4.1forfurtherdiscussion).Behaviourstargeted for intervention, as well as the immediate expected outcome from such interventions will therefore differ depending on the age of the child (Hann, Borek, 2001). Sample interventions and support programmesforparentsofchildrenwithbehaviouralproblemsarediscussedindetailinSection4.

15

http://www.adhd.com.au/conduct.html

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SECTIONFIVE: SUPPORTINGPARENTSINADDRESSINGANDRESPONDINGTOCHILDAND ADOLESCENTBEHAVIOURALPROBLEMS 5.0Introduction Parentingisalifelongprocessandparentsneedforsupportvariesdependingonfamilycircumstances, the stage of development of the child, the number of children, the childs behaviour etc. A child's family system plays an important role in the prevention and treatment of behavioural problems.The childrearingpracticesofparentsareanimportantpartofthisdynamic. Ithasbeenwellestablishedthat childrens early experiences are important and that intervention and support for parents in the early years can stimulate childrens intellectual, social and physical development (Riordan, 2001). Parent behaviourcansetthestageforchildrentodevelopandusecopingskillsthatmakethemmoreresilient, orconverselyplacethematriskforproblems. Preventativeworkwithfamilieshasbeenidentifiedby numeroussourcesasthemosteffectivemeansofavoidingseverelongtermproblems(Pugh,DeAth, Smith,1994Kamerman&Kahn,1993). Indesigningsupportservicesforparents,itispivotaltorememberthatparentsarenotahomogenous group. Their backgrounds and experiences vary, their needs are dynamic and change with circumstancesandsupportsmustreflectandrespondtothediverselifestyles,experiencesandneedsof parentsandtheirchildren.Forexample,increasingnumbersofdualincomehouseholds,ethnicfamilies andyoungparentswho(duetoreasonssuchashousepricesandemploymentoptions)arelivingfurther distancesfromthefamilyhomeallhighlighttheneedfornewandvariedsupportstoassistparentsin raisingtheirchildren.Incertaininstances,especiallyforthoseaffectedbydisadvantage,awidesupport from a myriad agencies may be required to help parents in their role, again highlighting the multi dimensionalriskfactorsand associatedbehaviouralproblemschildrenmayexperience. 5.1StagesofInterventiontoSupportParents&Children Theageofthechildwillveryoftenaffectthetypeofsupportrequired,howeveritisnevertooearlyto make support available nor is it ever too late. Assertive strategies should be used to engage young people with behavioural problems and their families in treatment. With young children, engagement shouldtargetparents.Withadolescents,servicesmaydirectlytargetteenagers,aswellastheirparents (Martin,Carr,2005). Familydisorganisationandlackofknowledgeormotivationmaypreventyoung people and their families from proactively engaging with health and/or other support services. Communitybased,attractive,accessible,evidencebasedtrainingprogrammesmaybeusedasavehicle for identifying children at risk, and engaging with families of children with problems. A variety of professionals,includingfamilydoctors,PHNs,preschoolandschoolstaffmayallplayaroleinhelping parents engage with such programmes (Ibid., 2005). The key intervention stages to prevent, reduce, controlorrespondtobehaviouralproblemsarebrieflydiscussedinthissection.Theremainderofthe sectionpaysparticularemphasistothesupportneedsofparentsandreviewspotentialstrategiesinthis regard. 5.1.1PreventionDuringPregnancy Good anti natal preparation is a way of giving parents and children a good start in life and is often delivered through Home Visiting Programmes (HVPs). Programmes focus on the importance of the earlyyearsandthepivotalroleparentsplayinshapingchildrenslives,andoperateonthepremisethat oneofthebestwaystoreachfamilieswithyoungchildrenisbybringingservicestothem,ratherthan expecting them to seek assistance in their communities. Programmes in the US now number in the thousands andaresupportedthrougha varietyofpublicandprivatefunds. Manyprogrammes begin duringpregnancytosupportparentsandfocusandbetteroutcomesforparentandchildfromtheonset.

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17 Examples include the Nurse Family Partnership Programme (NFPP) 16, Hawaiis Healthy Start , 18 19 ParentsasTeachers(PAT) andtheComprehensiveChildDevelopmentProgramme(CCDP) . Irish examplesincludetheaforementionedLifestartandCommunityMothersProgramme.

Giventhestronglink,betweenmothersstressandanxietyduringpregnancyandchildrensbehavioural problems(O'Connor,Heron,Glover,2002),thisisoneareawhereawelldesignedandprofessionally delivered home visiting programme, such as the NurseFamily Partnership, appears especially promising. This programme was found to have longterm effects on childrens behaviour, including fewerarrestsandconvictionsbytheageof15(Olds,Henderson,Cole,Eckenrode,Kitzman,&Luckey, 1998). 5.1.2BirthtoTwoYears Research literature in child and adolescent behavioural and emotional problems strongly supports refocusing a significant proportion of resources towards an early intervention/prevention model that providesparentswithappropriatesupportandassistanceduringchildrensearlyyears(Sanders,1999). Assciencebecomesmoresystematicandskilledatdiagnosingmaladaptivebehaviourinchildrenunder 3and in identifying some of the early warning signs in infants as young as six months, intervention supports forparents of young children are gaining increasing recognition (Sutton, Utting, Farrington, 2006). Parents may be more willing to hold the door open to friendly, nonstigmatising support and advice whentheyhaveyoungchildrenthanatanyothertimeastheSureStartprogrammehasdemonstrated (Suttonetal.,2004). SupportsforchildreninthisagerangealsousuallytakeplacethroughHVPsand evaluations of such programmes demonstrate long as well as shortterm benefits (Also discussed Section 4.2.1). Programmes send individuals into the home and seek to improve the lives of the childrenbyencouragingchangesinattitude,knowledge,and/orbehaviouroftheparents.Thevaluable role that trained nurses/health visitors can play is reinforced by evidence that they can successfully deliverprogrammesasvariedasscreeningandsupportformotherswithpostnataldepression(Cooper etal,2003)andparentingcoursesfortheparentsofchildrenwithattentiondeficit (ADHD)disorders (Suttonetal.,2004). 5.1.3ThreetoEightYears In objective terms, severe conduct problems are relatively stable and easier to identify by age three. Thereisalsoarichseamofresearchconcerningeffectivepreventiveinterventionsforthisagegroup.

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The NurseFamily Partnership consists of intensive and comprehensive home visitation by nurses during a womans pregnancy and the first two years after birth of the womans first child to improve parent and child outcomes. Home visiting also promotes the cognitive and socialemotional development of the children, and providesgeneralsupportandparentingskillstotheparent Theprogramisdesignedtoservelowincome,atrisk pregnant women bearing their first child. Nurse home visitors work with families in their homes during pregnancyandthefirsttwoyearsofthechildslife..Typically,anursevisitorisassignedtoafamilyandworks with that family through the duration of the program. A fifteen year follow up study of programme outcomes included79%fewerverifiedreportsofchildabuseorneglect,44%fewermaternalbehaviouralproblemsdueto alcoholanddrugabuse,56%fewerarrestsonthepartofthe15yearoldchildrenand56%fewerdaysofalcohol consumptiononthepartofthe15yearoldchildren .
17

HawaiisHealthy Start,ahomevisitingprogrammethatservesfamiliesidentifiedthroughscreeingatbirthas highlystressedand/oratriskofchildabuse.

18

PAT,aprogramthatbeganinMissouriandnowoperatesatmorethan2,000sitesacrosstheUStopromotethe developmentofchildrenfrombirthtoagethree.
19

CCDP,afiveyearfederaldemonstrationprogramthatworkedwithpoorfamiliestopromotechildrens development,parentsabilitytoparent,andfamilyselfsufficiently.

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The Incredible Years Programme in the US is amongst the best known of all groupbasedparenting programmes and amongst the more extensively and rigorously evaluated (Sutton et at., 2004). Improvementsinparentalstyle,relationshipsandparentchildbehaviourhavebeenrecordedfromtrials in clinical and community settings (WebsterStratton, 2001), positive findings which have been replicatedinbothtypesofsettingintheUK,CanadaandNorway(Morph,Clifford,Larsson,Rypdal, Tjeflatt,Lurie,2004).ThePositiveParentingProgramme(TripleP)devisedandpositivelyevaluated inAustralia(Sandersetal.,2002)has also gainedafootholdintheUK. Highqualitypreschoolprogrammesforyoungchildrenbeen alsobeenshowntocontributetocognitive, emotional and social development in childhood and later school success, economic performance and reduced levels of crime in adulthood. The short and long term benefits of preschool, are now, universallyrecognisedandacceptedasevidencedthroughtheincreasingtrendforbetweenoneandtwo yearsfreepreschooleducationinseveralEuropeancountries(Schweinhart,2000,NWCI,2006,OECD 2004). Foranolderagegroup,thePromotingAlternativeThinkingStrategies(PATHS)programme(Kushce, Greenberg,1998)isanexampleofastronglyevaluatedcurriculumbeingusedinUKprimaryschools topromotesocialcompetence,selfcontrolandproblemsolving. 5.1.4NinetoThirteenYears As children reach the cusp between the end of primary school and their first years of secondary education, the influences on their behaviour grow increasingly complex. Their relationships with parentsarestillhugelyimportant,but soincreasingly arefriendships andtheexampleset byteachers andothersignificantadultsintheirlives.Theyaremoreawareoftheneighbourhoodswheretheylive andofmessagesdeliveredthroughtelevisionandothermedia(Suttonetal.,2004). Thisisalsoanage groupwheresomechildrenwillbecomeinvolvedinearlyonsetoffendingandinunderagesmoking, drinkingandothersubstancemisuse.Interms ofprevention,thereis acontinuingneedforuniversal services this is,forexample,theagegroupmostlikelyto benefit fromdrugandalcoholeducation, includingstrategiesforresistingnegativepeerpressure(Ibid.,2004).Wholeclassandwholeschool approaches havealsoprovedeffective inreducingtherisks associated with antisocial behaviour,for examplethe BullyingPreventionProject(Smith&Sharp,1994). SomeinterventionsforthisagegrouporiginallyevaluatedintheUS,havebeenintroducedintotheUK inrecentyears.Somehaveworkedthroughschoolsoryouthorganisationstoreduceconductproblems, and delay the onset of substance use and/or offending. For example, mentoring programmes have soughtwithvaryingdegreesofsuccesstotackleantisocialbehaviourthroughregularcontactwithan adult/olderpeerwhobefriendsayoungpersonandoffersthemapositiverolemodel.TheBigBrothers & Sistersprogramme, workingwith childrenandyoungpeoplefromoneparent families,has yielded someofthemostpositiveevaluationresultstodate,intermsofpreventingantisocial behaviour(Sutton et al., 2004). Other interventions make families the main focus for intervention, albeit in a more intensiveandagespecificformat.SomeYouthOffendingTeamsinEnglandhave,forexample,made useoftheFunctionalFamilyTherapymodel(Barton,Alexander,Waldron,Turner,Warburton,1985) when designing programmes for use with the Parenting Order introduced by theCrime and Disorder Act,1998. Various evaluations of Multisystemic Therapy (MST) (Henggeler, 1999) are an even stronger indicationoftherangeanddepthofservicedeliverythatmaybeneededtoachievepositiveresultswith children from the most dysfunctional and disadvantaged families. Practitioners in London and Cambridgehavebegunusingthisapproach,which,intheUS,ispresentedasacosteffectivealternative toyouthcustody(Uttingetal.,2004).However,preventionatthislevelrequirestheintensiveservices of a multidisciplinary team, oncall for much of the day, providing a combination of behavioural therapywithtailoredsupportservicesforthewholefamily(Henggeleretal,1998).

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5.2 SampleProgrammes Parentsofchildrenwithbehaviouraldifficultiesbearaheavyburdenandstressanddepressionaswell asfamilialandmaritaldiscordoftendevelop.Greatemphasishasbeenplacedonprogrammeswhich address parents situations and needs and treatments must take account of the fact that parents and family members suffer considerable stresses even while when the child is of preschool or primary schoolage.Acentralissuerelatingtotreatmentishowitaffectsthefamilyasaunit,andwhatkindsof benefitareobtained (Morchetal.,2004). A number of parent training programs focus on increasing parents' skills in managing their child's behaviour and facilitating social skills development. Research indicates such programs have been positive, resulting in significant changes in parents' and children's behaviour. For example, research suggeststhatparentswhohaveparticipatedinparenttrainingprogramsaresuccessfulinreducingtheir 20 child's level of aggression by20 60% .The skills focused on, include parents learning to assist in administrationofappropriatereinforcementanddisciplinarytechniques,effectivecommunicationwith thechildandproblemsolvingandnegotiationstrategies.Afurthercomponentoftrainingincorporates behaviouralmanagementandinvolvesprovidingfamilieswithsimpleandeffectivestrategiesincluding behavioural contracting, contingency management, and the ability to facilitate generalisation and 21 maintenanceoftheirnewskills,thusencouragingparents'positiveinteractionwiththeirchild . There are other types of programmes which help parents understand their and their childs emotions and behaviourandimprovecommunications. Research has found that parent training programmes result in significant decreases in overall internalisingandexternalisingbehaviourproblems.Theyalsodecreasesfamilyconflictandstress,the numberoneidentifiedcauseof reducedchildwellbeing inMcKeownetal.s 2003study. Parentingprogrammesusually lastonetotwohoursaweekforbetween8and22weeksandareusually heldingroupsofbetweensixandtenparticipants. Thismayvarysomewhatdependingonthenatureof theproblemandtheextent/severityofparentalneed. Trainingissometimesdeliveredonaonetoone basis whereaparentsneedsaretoo complexforgroupwork. IntheUK,parentingprogrammes are increasinglyattachedtoschoolsand/orchildrenscentres. Thisusuallyfacilitatesgreaterengagement anduptakeamongstparents. Socialorchildrensservicesalsoprovideandalsocontractvoluntaryor privateorganisationstodelivercoursesforthem.Youthoffendingteamsalsoprovideparentingcourses ormakethemavailablethroughvoluntaryorganisations,particularlywherechildrenareinvolvedorat 22 riskofinvolvementincrimeand/orantisocialbehaviour .

A list of sample programmes with the strongest evidence of improving the quality of parenting are summarisedinTable 2andanoutlinedescriptionofprogrammesareprovidedthereafter.

20 21 22

http://www.adhd.com.au/conduct.html http://www.adhd.com.au/conduct.html

http://www.respect.gov.uk/uploadedFiles/Members_site/Articles/Resources/Respect_academies/Supporting_paren ts.pdf

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Table2: SampleProgrammestoSupportParentsofChildrenwithBehaviouralProblems ProgrammeName TargetGroup Webster Stratton 212Years IncredibleYears Detail Evidence Treats aggression and conduct USresearchfoundthatthebenefitsofevery$1spentis$4.25from problems, helps parents support reductionsinthecostofcrimealone their childs education, and deal UKcontroltrialfoundthatchildrenshowedalargereductioninanti withbadbehaviour. social behaviour while those in the waiting list (control group) did not. ProvidesGuidanceforParentson 66%ofchildrendiagnosedwithODD/ConductDisorderwhose ParentingSkillstoPromoteGood parentsreceivedtheparentingprogrammewereinthenormalrange Behavioural and Emotional ofbehaviours(atboth1and3yearfollowups). Adjustment.Usesatieredsystem of increasing intervention accordingtoparentalneed Focusonmotherchild Successfulinengaginghardtoreachfamilies,oftenwithsevere, relationship multigenerationalparentingproblems.Changehasbeen demonstratedinmaternalwellbeing,childbehaviour,child developmentandmotherchildinteraction. PilotstudyinUSfoundreductioninriskofabuse.

Positive Parenting MiddleChildhood(A Programme(TripleP). Teen Triple P has also been developed specifically for adolescent problems SectionN) MellowParenting Family must include child <5, aimed at parents whose relationships with children are under severestress. StrengtheningFamilies Programme 317Years

14sessionfamilyskills programmedesignedtoreduce riskfactorsforsubstanceabuse, aggression,depressionand delinquency Clinicallysignificantantisocial behaviour Intensiveparentingintervention involvingtherapists,(availableto families24hoursaday)whohelp parentstosetrulesaimedto improvedifferentaspectsof childsbehaviour.

Improvingparentingbehaviourandchildoutcomes:substanceuse, problemconduct,schoolrelatedproblembehaviours,affiliationwith antisocialpeersandpeerresistence.

MultiSystematic Therapy

Decreasingbehaviourproblems,improvingfamilyrelations, reducingrecidivism Reducingrearrestrates,reducingtime spentbyjuvenileoffenders ininstitutions

Source:Gomby,Culross,Behrman,1999

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5.2.1WebsterStrattonIncredibleYears The Incredible Years is a programme designed for children aged 4 to 8 with behavioural problems andis widelyregardedas oneofthebestdocumentedandsuccessful intervention approaches(Suttonetal.,2004).Inadditiontotreatmentbasedonparentgroups,knownas theBasicProgramme,thereisanAdvancedProgrammewithanumberofsessionsforparents and a focus on parents relationship and functioning. Two versions of the treatment programmehavebeendesignedforgroupsofchildren,oneclinicbasedandtheotheradapted foruseinpreschool. Aclassroommanagementprogrammehasalsobeendevelopedtoassist teachersandpreschoolstaff.Notleastbecauseofthestringentdesigns,WebsterStrattons methods have been regarded as fulfilling the strictest criteria of evidencebased treatments. The basic programme has produced impressive and consistent results evaluations have shownparentsrespondverywelltotheprogrammeandnearly70%ofchildrenwhoseparents participate in theprogramme show a significant improvement by leaving the clinical group (Morchet al.,1999). An18monthpost treatment followupstudywith parents,foundthat mostparentshadbeensatisfiedwiththeprogrammeand reported: improved selfesteemandselfconfidence reducedfeelingsofguiltandisolation. learningofnewparentingskills whichenabledthemtorelatetothechildinamore positiveway. (Ibid.,1999) A Norwegian evaluation found that while some parents reported quite dramatic changes in childrens behaviour, others reported little or no improvement, despite having gained self esteem and new skills. Parents generally felt that the group aspect of the programme was most valuable for most meeting parents in a similar situation was very important for their morale and self esteem and it helped reduce feelings of stigmatisation, guilt and isolation. Parents also found it encouraging to meet other parents who understood the problems they facedwiththeirchild.Itwasagreatbenefittobeabletotalkhonestlyandopenlyaboutthe difficultiestheyhadtodealwith,inasupportivegroupenvironment.Parentsweregenerally very satisfiedwithgroupleadersandwere mostimpressedwith what theyperceivedas the leaderspositivepersonalqualitiesincludingwarmth,optimism,enthusiasm,supportiveness, attentiveness andhumour,however,theyspokemore positivelyabout their interaction with otherparentsthatwithgroupleaders (Ibid.,1999). Intermsofprogrammecontent,roleplaywasenjoyedbymostmotherswhofounditagood way to break the ice and reduce tension. Others (mainly fathers) found it intimidating, artificialandlargelyawasteoftime. Likewise,somefoundthevideoclipswereausefulway ofpresentinggroupsessionobjectives,whileothersfoundthemoldfashioned,unrealisticand 23 too American . Home assignments were seen by some as useful while others found it difficulttodevotetimeandenergytothemwithotherworkandfamilycommitments(Morch etal.,1999). Parentsviewsoftheirsituationeighteenmonthspostprogrammecompletionvaried.Many felttheprogrammewastooshortandwantedfollowuporboostersessions,andcontinuing contact with other group members, and with child psychiatry. Parents who had seen improvementsfelttheyhadacquiredtoolstheycouldusetomeetfutureproblemsandwere confidentof theirabilitytocopewithdifficultiesthatmightarise(Ibid.,1999).

23

Dataon18monthfollowupwithparentsbasedondatacollectedfromparticipantsintheIncredible YearsProgrammeinNorway.

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5.2.2PositiveParentingProgramme(TripleP) 24 TripleP,isanAustraliandevelopedsystem whichaimstoprovideguidanceforparentson parentingskillsinordertopromotegoodbehaviouralandemotional adjustment. Itisamulti 25 level parenting and family support strategy that aims to prevent severe behavioural, emotionalanddevelopmentalproblemsinchildrenfrombirthtoage12byenhancingparents knowledge,skillsandconfidence.Theenhancedinterventiontargetsparentingskillstogether with other family adversity factors such as marital discord, depression and high levels of parenting stress. The aim is to provide highly accessible resources for parents, including newsletters, leaflets, loans of videotapes, and 'seminars' for parents to provide consistent, highqualityadviceonparenting (Ralph,Sanders,2003). The project also provides training and accreditation to enable staff who come into regular contactwithparentstoprovideclearadviceandhelpto thosewhohave difficultywithaspects of their child's behaviour. Referral routes have been specified to ensure that families with greaterdifficultiesareseenbyappropriatelytrainedprofessionals.TriplePpromotespositive, caring relationships between parents and their children and helps parents develop effective management strategies for dealing with a variety of childhood behavioural/developmental 26 problems .Programmeprinciplesincludeensuringasafe,interestingenvironmentcreatinga positive learning environment using appropriate discipline strategies having realistic expectations,andtakingcareofoneselfasaparent.Thesystem is empiricallyproventobe helpfultofamiliesandiscurrentlyemployedbyhealthprofessionalsinternationally(Burley, Hayes,Martin,2005).Implementationtakestheformofprovisionofinformationandadvice atanumberoflevels.

Schools will distribute newsletters with parenting tips and information on help availabletoallparents Leafletswillbeavailableinschools,andcommunitycentres(eglibraries) Videotapeswillbeavailableforparentstoborrowfromschools Short Triple P 'seminars' on parenting will be presented in schools by trained professionals,toprovideadviceoncommon behaviourproblems Individual consultations will be available throughTriple P trainedprofessionals for 27 parentsrequiringspecificadviceonaspecificproblem

5.2.2.1TeenTripleP TeenTriple Paims to specificallyprepareparents fortheir childs transition to the teenage years by focusing on the common difficulties for children (and parents) of making a successful transition to secondary school. Schools provide a potentially convenient and appropriate community based contact point where parenting issues can be legitimately discussed (Ralph,Sanders,2003).

24

TheprogrammewasdevelopedbyProfessorMattSandersandcolleaguesfromtheParentingand FamilySupportCentreoftheSchoolofPsychologyattheUniversityofQueensland,Australia. 25 Level1,UniversalTriplePtargetsanentirepopulationwiththeaimofpreventingthedevelopment ofadverseoutcomes.Level2,SelectedTriplePtargetsspecificsubgroupsofthegeneralpopulation whoarebelievedtobeatgreaterriskthanothersfordevelopingaproblemthroughprimarycareor communityservices.Level3,PrimaryCareTripleP,isamoreintensive,selection,preventative strategytargetingparentswhohavemildandrelativelydiscreetconcernsabouttheirchildsbehaviour ordevelopment.Level4,Standard/Group/SelfDirectedTriplePtargetshighriskindividualswhoare identifiedashavingproblems,butwhodonotyetmeetthediagnosticcriteriaforabehavioural disorder.Level5,EnhancedTriplePisdesignedforfamilieswhoareexperiencingongoingchild behaviourdifficultiesaftercompletingalessintensiveTriplePlevel,orwhomayhaveaddditional familyadversityfactorssuchasparentaladjustmentdifficultiesandpartnersupportdifficulties. 26 http://www.psychsci.manchester.ac.uk/research/projects/ppp 27 http://www.psychsci.manchester.ac.uk/research/projects/teenppp

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TeenTriplePcanbedelivereduniversallyasanindicatedpreventionprogramforteenagers andalsoasanearlyinterventionprogramforthosewhomeetdiagnosticcriteriawiththeaim ofpreventingprogressionofproblembehaviour.Thislevelofinterventioncantargetparents ofindividualteenagersthoughttobeatriskoranentirepopulationas apreventativeapproach toriskreduction (Ibid.,2003). Group Teen Triple P is an 8 session program, optimally conducted in groups of 10 12 parents.Itemploysanactiveskillstrainingprocesstohelpparentsacquirenewknowledge and skills. The Programme consists of four two hour group sessions that provide opportunities for parents to learn through observation, discussion, practice and feedback. Parents receive constructive feedbackabout their use of skills in an emotionally supportive context. Following the group sessions, four 15 30 minute follow up telephone sessions provide additional follow up support to parents. The benefits of the group rather than individual sessions include support, friendship, constructive feedback from other parents as wellasopportunitiesforparentsto discussandlearn throughpeerinteractions (Ibid,2003).
28 Anevaluativepostcoursecompletionfollowupstudy found : Parent teenager conflict as reported by parents was reduced significantly post treatment. Parentallaxnessandoverreactivityimprovedsignificantlyposttreatment. Parentsreportedsignificantimprovementsfollowinggrouptreatmentonmeasuresof selfefficacy,selfsufficiency,andselfmanagement,butnotonpersonalagency. Parents reported a significant reduction on disagreements over their parenting strategies post treatment. (Ibid.,2003)

The evaluation also found group facilitators reporting anecdotal evidence that most parents enjoyed participating in the group program and parents also reported good consumer satisfactionindicatingthattheprogramwasappropriateforthemhelpedthemtoachievetheir goals. 5.2.3MellowParenting 29 Mellow Parenting is a 14 week one day a week group designed to support families with relationshipproblemswiththeirinfantsandyoungchildren.Itcombinespersonalsupportfor parents with video and direct work with parents and children on their own parenting strategies,andhasprovedeffectiveinrecruitingandengaginghardtoreachfamilies with a 30 variety of problems . The programme aims to empower parents, to find better ways of relatingtotheirchildrenandfocusesonfamilieswithchildrenunder5whoareexperiencing 31 relationshipproblemswiththeirchildren . The programme combines personal group therapy with parenting support using behaviour modification principles. By agreement, videotapes record parent/child interactions in the home,whicharethenusedasanaidtogroupdiscussions.Theprogrammehasshownlasting
28

Findingsarebasedon25parentwhohadparticipatedintheTriplePprogramme. Parentswere contactedthroughtheirchildshigh schoolinQLD(locatedinasocioeconomicallydisadvantaged region)andhadparticipatedintheparentprogramme.

29

TheMellowParentingorganisationdoesnotdirectlyrungroupsitselfbuttrainsprofessionalstorun thegroupaccordingtothemodel. Itwasdevelopedbyagroupofprofessionalswithpsychologyand social work expertise: Christine Puckering, Maggie Mills, Tony Cox and John Rogers. It is administeredthroughtheAssociationforChildPsychologyandPsychiatry.
30 31

http://www.mellowparenting.org/ http://www.northamptonshire.gov.uk/child/family/ParProg.htm

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gains in maternal well being, parentchild interaction, child behaviour, development and mothers effectiveness and confidence in parenting. Changes were sustained over an 18 month period. In the UK, the programme improved parenting on several dimensions. Negative interaction as evaluated on videotapes dropped threefoldand 80% of the parents involvedwereabletocomeoffthelocal ChildProtection Register(Scott,1998).
32 5.2.4StrengtheningFamiliesProgramme(SFP) The Strengthening Families Programme targets parents and children aged 10 14. It is a universal, familybased intervention programme which enhances parents general child managementskills,parentchildaffectiverelationships,andfamilycommunication.Basedon a developmental model, it assumes that increasing the familys protective processes while decreasingitspotentialriskfactorscanalterachildsfuture,sothatproblembehaviourscan bereducedoravoided.Theprogramalsoseekstodelaytheonsetofadolescentalcoholand substanceusebyimprovingfamilypractices.

In the sevenweek intervention programme,parents and children learn individual skills and are thenarebroughttogethertoimprovefamilycommunicationandpractices. Duringtheparenttrainingsessions,heldingroupswithanaverageofeightfamilies, parentsaretaughttoclarifyexpectationsofchildrensbehaviour,especiallysubstance useutilizeappropriateandconsistentdisciplinetechniquesmanagestrongemotions concerningtheirchildrenanduseeffectivecommunication. In the child sessions, adolescents learn similar skills, as well as peer resistance and refusal techniques personal and social interaction skills and stress and emotion management. Inthecombinedparentandchildrenclasses,familiespracticeconflictresolutionand communication skills, and engage in activities designed to increase family 33 cohesiveness .

Bothposttestevaluationsoffamilyprocessesandfollowupstudiesofindividualsubstance use have demonstrated positive effects for amilies and adolescents, compared to control groups. Inaddition,posttestparticipantsshowed: Improvedchildmanagementpractices,includingmonitoring,disciplineandsettingof standards Increasedparentchildcommunication Increased childinvolvementinfamilyactivitiesanddecisionsand Strengthenedfamilyaffectivequality.

One andtwoyearfollowupstudies revealedthatparticipatingadolescentshad:

Lowerratesofalcoholinitiationatboth followupsand 3060% relative reductions in alcohol use, using without parents permission, and 34 beingdrunk .

In 1993, Project Family in the US conducted an experimental test of the IFSP with 442 familiesinareaswithahighpercentageofeconomicallydisadvantagedfamilies.Allfamilies werevideotapedduringstructuredfamilyinteractionsintheirhomeandcompletedextensive survey forms before and after the programme. Data revealed significant gains in targeted behaviour.Forexample,youthwhosefamiliestookpartintheprogrammeweremorelikely
32 33

Fomerly,theIowaStrengtheningFamiliesProgram(ISFP) http://www.colorado.edu/cspv/blueprints/promising/programs/BPP18.html 34 http://www.colorado.edu/cspv/blueprints/promising/programs/BPP18.html

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toassociatewithappropriatepeersthanthosefromnonparticipatingfamilies. Positivegains weresustainedduringoneandtwoyearfollowups. 5.2.5MultiSystematicTherapy(MST) MSTis anintensivesupportprogrammefor youngpeopleaged10to17andtheirfamilies targetingthemultipleriskfactorsfordelinquencyandbehaviouralproblems.Evaluationand replication in clinical and community settings in the US suggest that it is a particularly effective intervention for adolescents with behavioural problems, including antisocial 35 behaviour,violentandchronicyoungoffendersandisnowbeingintroducedintheUK . MSTtargetsmultiplefactorsand promotesapproaches suchas:encouragingyoungpeoplenot tospendtimewithpeerswhoareabadinfluencebuildingstrongerbondswithfamily, school andotherconventionalgroupsenhancingparentingskillssuchasmonitoringanddiscipline anddevelopinggreatersocialandacademiccompetenceintheyoungperson.Theapproach views individuals as part of a complex network of interconnected systems that encompass individual,familyandextrafamilialfactors(school,peersandneighbourhood).Intervention 36 maybenecessaryinanyoneoracombinationoftheseareas . Individualised treatment plans are designed in collaboration with family members, and include addressing identified barriers to effective parenting such as parental mental health problemsordrugabuse.MSTalsohelpsfamilymembersbuildsocialsupportnetworksand uses the strengths of these to bring about changes in behaviour.The programme is usually provided in the home, school and other community locations over a period of about four 37 months . EvaluationsofMSThavedemonstratedthefollowingresultsforseriousjuvenileoffenders: reductionsof25 75%inlongtermratesofrearrest reductionsof47 64%inoutofhomeplacement extensiveimprovementsinfamilyfunctioning 38 decreasedmentalhealthproblemsforseriousjuvenileoffenders CommunityPrograms Communitybasedinterventionshavealsoaddressedbothtreatmentandprevention.Anumber ofprogramshavebeendeveloped,andfocusoninvolvingtheyouthsinactivityprogramsand providing training for those activities. The children are rewarded for attendance and participationintheprograms. Examplesinclude 5.3 EffectiveTargeting Parentsmaybeanxiousforhelpbutunawareofhowtofinditandthosewhomostneedhelp are very often those who are unlikely to seek help voluntarily, however, this does not, nor shouldit,ruleout intervention. Forexample,oneof themajorproblems parentingsupport programs face is that they do not reach all the families that need support (Barton, Roman, Fitzgerald, & McKinney, 2002). This is a common phenomenon in early intervention programs: especially as parents with children at greater risk are less likely to participate in such programs (Prinz, 1994). So far, most support has been given to those families who happen to know about the available services or to families that belong to particular target groupswithspecialneeds(e.g.,Llewellyn,McConnell,&Bye,1998). Althoughseveralof theaforementionedprojectsdidoperateinsociallydeprivedareas,thereisanawarenessthat in many instances projects/programmes are unable to engage the least educated and more marginalisedparents,whotraditionallydidnotattendschoolevents(Ralph, Sanders,2003).
35 36

http://www.literacytrust.org.uk/socialinclusion/children/support.html http://www.promoteprevent.org/documents/EBI/Multisystemic%20Therapy.pdf 37 http://www.literacytrust.org.uk/socialinclusion/children/support.html 38 http://www.promoteprevent.org/documents/EBI/Multisystemic%20Therapy.pdf

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Theveryfirststepinsupportingparentswhosechildrenexperiencebehaviouralproblems is throughtheprovisionofadviceandinformationwhichwillhelpthemcopewiththeproblem, access the supports they need and respond to the problem. Gaps in information provision impactuponparentsabilitytouseexistingresourcesandservicesandtobuildsocialsupport networks (Riordan, 2001). Studies have shown that the principal sources of advice and informationforparentsarefamilyandfriends,followedbyhealthprofessionals,teachers,and social services (Grimshaw & McGuire, 1998). Health and behavioural problems were the most frequently cited reasons by parents for seeking information from sources outside the circleoffamilyandfriendsandinmostcasesparentsturnedtoprofessionals,notablyGPs,for adviceinrelationto medicalandnonmedicalconcerns. Inher evaluationoftheTripleP Programme,Sanders(2003)foundschoolsandcommunity networkskeyinrecruitingparents. Key contact points, in terms of the provision of advice regarding community supports for children who experience behavioural problems include local GPs, preschool, primary and postprimaryschoolsandothercontactpointswith whichparentshaveregularcontact. The Triple P project in Zurich included several strategies to maximize participation including subsidisationofchildcarecosts,thepromotionoftheprogrammetoparentsthatmaynothave been successfully approached by other means of communication, personal contact with parents from minority groups to discuss the programme and implementation of the programme during the first year of primary school when parent interest in promoting and 39 supportingtheirchildrenwasexpectedtobeparticularlyhigh . Asimilarstrategycouldbe appliedwhereimplementationofparentsupportsparallelswiththeonsetofsecondaryschool commencement. Thereisaclearchallengetobemoresuccessfulwithregardtorecruitmentandengagementof parents. Inresponsetolowrecruitmentrates,anassertiveapproachhasbeendevelopedinthe US, including home visits, meetings at the familys convenience, written contacts, and concreteproblemsolvingaswellasincentivessuchasfreetransport,crchefacilities,meals andprizedraws (Kosterman,Hawkins,Spoth,Haggarty,Zhu,1995). Itisessential, when designing supports, to bear in mind how diverse a group parents are, and the subsequent mechanisms for recruitment and engagement must vary according to need, location, programmetypeetc. Researchhasfoundparentsinvolvementinprojectsis assistedby: activenetworkswithschools,localagencies,andcommunitygroups projectworkersskills,personality,persistenceandempathy theuseoffamiliarenvironmentsforsessions invitationsaddressedtothewholefamily courseswithawiderthantheproblemarea(e.g.notspecificallydrugs,antisocial behaviour) continuedworkerparentcontact flexibilitytofitwithparentscommitments and thejudicioususeofnewsmedia. (Vellerman,Mistral,Sanderling,2000). Forexample, theuseoflocalnewspapers,radioandtelevisionwerebelievedtohavebeentoo briefpriortoTriplePplacementoffersforparentsinoneregionandit wasfeltthatamore coordinatedandsustainedmediapromotionprogramwouldprobablyhavehelpedtoseedthe groundmoreeffectivelyintermsofgeneratinggreaterparentalawarenessandinterestwhich 40 could perhaps be translatedintogreaterparticipation (Ralph,Sanders,2003) .
39 40

http://www.zproso.unizh.ch/Projekt/project.en.html Theauthoralsohighlightstheurgentneedforresearchtotestthishypothesisasimprovedstrategies fortheengagementofparentsclearlyneedtobepartofanycommunitybasedinterventioninthe future.

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Parentsinvolvementinprojects hasbeen hinderedby: socialdifficulties (includingtheextrafinancialandorganisationaldifficulties of singleparents) thelocationoftheeventandpersonalsafety lackofengagementwiththeschoolorcommunity lackofselfconfidence fearofbeingstigmatisedasaparentofadruguser/violentchildetc lackofperceivedneed and lackofprojectresources. (Vellemanetal.,2000). 5.4 StrategicIssuesforConsiderationin DesigningSupportServicesforParents A key consideration in designing support services for parents of children with behavioural problemscentresaroundtailoringservicestoreflecttheneedsofparentsandchildreninthat area. Itisrecommendedthat supportsforparentsinclude: assistance to communicate adequately with their children about what is happening andwhy(goodcommunicationbetweenparentsandchildren) provisionofhelpfortheirowndistress(supportiveandappropriateparenting) supportforandinformationaboutparenting(reduction/minimisingparentaldistress) information about and opportunities for developing skills for containing and managing conflict (minimal conflict and no involvement of children in parental disputes) encouragement to fosterregularcontact forchildrenwith extendedfamilies onboth sides, and with childrens friends (optimal living and visiting arrangements for children) help to make arrangement for the future, including encouragement to foster involvement of parents in their childrens lives (successful fostering of childrens relationshipwithotherparentandwiderkin). (Hawthorn,Jessop,Pryor,Richards,2003). Itshouldalsobenotedthatthegroupaspectofprogrammes,whichprovidedparentswithan opportunitytoliaisewithparentsexperiencingsimilardifficultieswasconsistentlypraisedby programmeparticipantsandoftenlistedasoneofthekeyandmostbeneficialaspectsofthe programmes. Whattobearinmindwhenconsideringapproachestosupportingparents. Byaskingfundamentalquestionsatthebeginningofaservice,andinvolvingthosewhoare likelytobenefit,adifferentandmoreeffectiveapproachtodeliveringservicesmayemerge. Fundamentalquestionsinclude: Whoareweaimingto reach? Howdoparents/childrengainaccesstotheprogramme? Questions of privacy and confidentiality also arise as there may be some stigma attachedtochildrensattendanceatprogramme. Whataretheaimsoftheprogrammeandaretheyspecifiedtousers? Doesthechoiceofprogrammematchwhatwearetryingtoachieve?

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 Doesthe programmecontentreflectitsaims? Aretheaimsoftheprogrammebasedinresearch? Aretrainedpersonnelinvolved? Istheprogrammeageappropriate? Istheprogrammeculturallyandreligiouslyappropriate? 5.5 FocusonChildAlso Services which directly address the needs of the child are also pivotal, if child behavioural problemsaretobeeffectivelyaddressed,treated,andresolved. Forexample,a20002001 UKstudyonservicesandinterventionsforchildrenofparentswhohave/areseparatingfound that in line with the predominant caretaker view of childhood, many of the traditional support systems operated via parentsand other adults on the assumption that their benefits will flow through children. The impact on children of programmes designed for parents is thereforeindirectandmediatedbyparents. Whileresearchsuggeststhatchildrenmaybenefit frominterventionsthathelptoimproveadultrelations,childrenstillhaveseparateneedsfor support (Hawthorn et al., 2003). Gomby and colleagues (1999) reported that most home visitingprogrammestrytobenefitchildrenindirectlythroughchangesinparentsbehaviour, ratherthandirectlythroughinterventionswiththechildrenandarguethatitisnotsurprising, then, that the outcomes of home visiting programmes for childrens general health and development are not as positive as the outcomes for parents (Gomby et al., 1999). Internationalresearchonmodelsofbestpracticeinreducingandeffectivelyrespondingtothe behavioural problems of children within families incorporated, at least, a two pronged response of support for parents and the children (some cases also included wider reaching communitysupports).
41 TonyBates,CEOofHeadstrong recentlyoutlineda5stepplanforIrishsocietytoadoptin improving youth mental health. The plan proposed (1) involving young people, (2) 42 supportingfamilies,(3)workingtogether,(4)actingearlyand(5)investinginchange .

For adolescents, community based, attractive, accessible drop in centres may be used as a vehicle for engaging with adolescents at risk or in the early stages of developing mental health difficulties. Adolescents want accessible, user friendly services, specific to their needs. Young people say they are least likely to approach adults/professionals when they haveproblems andaremore likelyto dependonpeers. Familydoctors,schoolstaff,JLOs mayallplayaroleinhelpingadolescentsengagewithprogrammes,especiallywheretheyuse evidence basedapproaches for working with families to engage young people in treatment, suchasthosewhichhavebeenshowntoworkincasesofadolescentsubstanceabuse(Dept. ofHealth&Children,2006). Itisthereforeessentialtorecognisethatinaddressingthesupportneedsofparentsofchildren with behavioural problems, a simultaneous/parallel response to the needs of children who exhibit behavioural problems is essential. Such a strategy has resonances of a childrens rights approach to service planning, a primary commitment from the National Childrens Strategy.

41

HeadstrongisanewinitiativetoensurethatyoungpeopleinIrelandagedtwelvetotwentyfiveare bettersupportedtoachievementalhealthandwellbeing.Headstrongworkswithotherstoimprove servicesforyoungpeopleandto reducethestigmaaboutmentalhealthissues.Headstrongsgoalis thatthenormalexperienceofayoungpersonencounteringproblemswiththeirmentalhealthisthat theywillbeabletospeakopenlyabouthwtheyfeelandtogetthesupporttheyneedwhentheyneedit. 42 www.headstrong.ie

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SECTION SIX: SUMMARYOFKEYFINDINGS&RECOMMENDATIONS

Overview: The spectrum of child behavioural problems varies from very mild to clinically problematic, and their definition and nature expand beyond the term behavioural problemstoincorporatemental/psychologicalandemotionalhealthproblems.Often the behavioural problem is a manifestation of a deeper emotional/mental health problem. ThemostprevalenttypesofdisordersdisclosedinchildreninIrelandare, emotional disorders, oppositional, defiant and conduct disorders, attention deficit disorder, with or without hyperactivity, major psychiatric disorders, developmental delay and autism, eating disorders and antisocial behaviour e.g. drug and alcohol abuse. It is estimated that a fifth of the child and adolescent population may suffer from psychologicalproblemsatanygiventime.A2004Irishstudyfound17%oftwoto fiveyearolds,10%ofsixtotwelveyearoldsand26%of1318yearoldsscreened positive for a mental health problem (Cummins, McMaster, 2006). Almost half of these(43%)hadananxietydisorder,aquarterhadoppositionaldefiantdisorderand justoverafifthhadADHD. Researchsuggeststwokeyentrypointsinthedevelopmentofbehaviouralproblems early childhood and early adolescence with potentially different risk factors associated with each (Bartussch, Lynam, Moffitt and Silva, 1997). The most significant age difference is that ADHD is more common amongst children, while conductdisorderismorecommonamongstadolescents(Martin&Carr,2006). Earlybehaviouraldisturbancehasbeencitedasoneofthestrongestpredictorsoflater problems, including psychological difficulties, involvement in crime and antisocial behaviour(Rutter,1989Kolvinetal.1990). Childrenwhoexhibitparticularlyhigh levels of externalising behaviour problems early in their lives are at high risk for intensifying to lying, bullying and fighting in middle childhood, and more serious behaviourssuchascrueltytoanimals,vandalismandaggressivecriminalbehaviours inadolescence(Hann,D.,Borek,N.,2001). Adolescence is a key stage of life development when children require an understanding of life challenges they face and need to develop basic skills to cope with difficult emotions. It is a time of increased risk of poor mental health with anxiety, depression, psychosis, eating disorders, and substance misuse becoming more prevalent, as well as an increasing risk of deliberate self harm and suicidal behaviour (DepartmentofHealth&Children,2006). Someyoungpeoplebegintoexhibitproblembehavioursduringearlyadolescence.In such cases, entry into conduct problems generally occurs through associations with peers. However,placing too much emphasis onpeer pressure, may lead parents to underestimate their own influence on children, which, though it varies at different ages,hasbeenshowntoaffectyoungpeoples longtermbehaviour(Oyguardetal., 1999).

Risk factors for behavioural problems include maternal factors (age of mother, smoking/alcoholconsumptionduringpregnancy,maternalstress),familyfactorsand processes (parents relationship status, parenting approach, family income, family

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history of problem behaviour) and the community (neighbourhood, peer influences andschool). Foreveryriskfactor,anincreasedexposuretoriskisfoundtorelatesignificantlyto an increased likelihood of reported involvement in problem behaviour. Conversely, the more young people are exposed to protective factors, the less likely they are to report takingpart in antisocial activities (Beinart, S., Anderson, B., Lee, S., Utting, D.,2002).Protectivefactorsdirectly reducearisk,bufferanindividualagainstthe effectsofarisk,disruptthemediatingfactorsassociatedwiththeriskandpreventthe initialoccurrenceoftheriskfactor(Cummins,McMaster,2006). AssessmentandIntervention Early identification of behavioural difficulties and early implementation of family support programmes promote better mental health outcomes for children at risk of behavioural,emotionalandmentalhealthproblems.InIreland,childhoodemotional, developmental disorders, behavioural problems and mental illness are under recognisedandoftenremainuntreated.Thisunderrecognitionmayadverselyaffect the childs behaviour, emotional well being and educational attainments, as well as affectingfamily,friendsandsocietyatlarge(Cummins,McMaster,2006). Currently, secondary and tertiary services are inequitably distributed across the country,notallteamsarefullyresourcedandsomegeographicalareaslackprovision altogether. Waiting lists are often long, a situation which is not unique, even in developed countries. There is consequentially a need to develop alternative approachestoreducetheprevalenceofchildandadolescentmentalhealthproblems andtoprovideassistanceandsupportasearlyaspossiblewhereproblemsarise. The earliersupportisaccessedthebetter. Thereareawiderangeofcommunitycareservicesthatdelivercareatprimarylevel inthecommunity.Less intensiveinterventionsareusuallyofferedwithinaprimary care context initially and only if youngsters do not respond to these, should more intensiveinterventions beoffered,orreferralmadetosecondaryortertiaryservices (Martin,Carr,2005). A particularly successful means of supporting families is to focus on parenting behaviour. Mental health problems can have a significant and adverse impact on children,adolescents,parentsandfamilies.Itisthereforeimportantthatinterventions provide broadly based help for the parents and families of young people with problemsaswellastheyoungpeoplethemselves(Sawyer etal.,2000). Parentbehaviourcansetthestageforchildrentodevelopandusecopingskillsthat make them more resilient, or conversely can place children at risk for problems (Blout, 1989). Preventative work with families has been identified by numerous sourcesasthemosteffectivemeansofavoidingseverelongtermproblems(Pughet al.,1994Kamerman&Kahn,1993). Thedevelopmentofeffectiveparentingskills hasbeenconsideredastheprimarymechanismforchangeinchildconductdisorder, 43 throughthereductionintheseverity,durationandmanifestationofthedisorder . RecommendationsforSupportingParents Parentsofchildren with behaviouraldifficulties beara heavyburdenandstressand depressionaswellasfamilialandmaritaldiscordoftendevelop. Greatemphasishas
43

http://www.adhd.com.au/conduct.html

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beenplacedonprogrammeswhichaddressparentssituationandneeds.Treatments must take accord of the fact that parents and family members suffer considerable burdensandstressesevenwhilethebehaviourallydisturbedchildisofpreschoolor primaryschoolage.Acentralissuerelatingtotreatmentishowitaffectsthefamily asaunit,andwhatkindsofbenefitareobtained (Morchet al.,2004). Family disorganisation and lack of knowledge or motivation may prevent young people with psychological problems and their families from proactively engaging with health and/or other support services. Community based,attractive, accessible, evidencebased training programmes may be used as a vehicle for identifying childrenatrisk,andengagingwithfamiliesofchildrenwithmentalhealthproblems. With youngchildren,engagementshouldtarget parents.With adolescents,services may directly target teenagers, as well as their parents. A variety of professionals, including family doctors, PHNs, pre school and school staff may all play a role in helpingparentsengagewithsuchprogrammes. Theageofthechildwillveryoftenaffectthetypeofsupportrequiredbyparentsof childrenwithbehaviouralproblems. Research indicates that parenting programs have been positive, with significant changes in parents' and children's behaviour and parental perception of child adjustment. Research suggests that parents who haveparticipated in parent training 44 programsaresuccessfulinreducingtheirchild'slevelofaggressionby20 60% . ModelprogrammeswithprovenresultsincludetheWebsterStrattonIncredibleYears Programme, Positive Parenting Programme, Mellow Parenting, Strengthening FamiliesProgrammeandMultiSystematicTherapy. Evaluations of these and other programmes have highlighted several factors which parents reported as beneficial in supporting them in coping with their child(ren)s behaviour.Theseinclude: o The group dynamic of several parenting programmes: parents found it very encouragingtomeetotherparentswhounderstoodtheproblemstheyfacedwith theirchild.Itwasagreatbenefittobeabletotalkhonestlyandopenlyaboutthe difficultiestheyhadtodealwith,inasupportivegroupenvironment. o Thequalities ofgroupleaders:parentsweregenerallyverysatisfiedwithgroup leaders and were most impressed with what they perceived as the leaders positive personal qualities including warmth, optimism, enthusiasm, supportiveness,attentivenessandhumour. o Programme content: assistance to communicate adequately with their children about what is happening and why, provision of help for their own distress, support for and information about parenting, opportunities for developing skills forcontainingandmanagingconflict,encouragementtofosterregularcontactfor children with extended families on both sides, and with childrens friends and help to make arrangement for the future, including encouragement to foster involvementofparentsintheirchildrenslives (Morchetal.,1999). Follow up studies also highlighted the following factors which parents believed wouldbeofbenefitinfutureprogrammes:

44

http://www.adhd.com.au/conduct.html

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o Maintenanceofsmallgroupsizes:indesigningprogrammes,smallcoursesofno more than ten parents were thought to be most effective. This is because they encouragedmoreopencommunicationandinvolvement. o Follow upbooster sessions: where these excitedparents specifically noted their benefit and where they did not, many expressed a desire for follow up or boostersessions (Morchetal.,1999). Oneofthemajorproblems thatparentingsupportprograms faceis that theydonot reach all the families that need support. There is a clear challenge to be more successful with regard to recruitment and engagement of parents. A key point of contact,therefore,intermsoftheprovisionofadviceregardingcommunitysupports forchildrenwhoexperiencebehaviouralproblems is throughlocalGPs,preschool, primaryandpostprimaryschools andothercontact pointswith whichparentshave regularcontact.Inresponsetolowrecruitmentrates,anassertiveapproachhasbeen developed in the US, including home visits, meetings at the familys convenience, written contracts, and concrete problem solving as well as incentives such as free transport, crche facilities, meals and prize draws (Kosterman, Hawkins, Spoth, Haggarty,Zhu,1995). Itisrecommendedthatsupportsforparentsinclude: o assistance to communicate adequately with their children about what is happeningandwhy(goodcommunicationbetweenparentsandchildren) o provisionofhelpfortheirowndistress(supportiveandappropriateparenting) o support for and information about parenting (reduction/minimising parental distress) o information about and opportunities for developing skills for containing and managing conflict (minimal conflict and no involvement of children in parental disputes) o encouragement to foster regular contact for children with extended families on bothsides,andwithchildrensfriends(optimallivingandvisitingarrangements forchildren) o help to make arrangement for the future, including encouragement to foster involvementofparentsintheirchildrenslives(successfulfosteringofchildrens relationshipwithotherparentandwiderkin). (Hawthorn,Jessop,Pryor,Richards,2003) Services which directly address the needs of the child are also pivotal, if child behavioural problems are to be effectively addressed. The impact on children of programmesdesignedforparentsisnecessarilyindirectandmediatedbyparents.It is therefore essentialto recognisethat inaddressingthesupport needs ofparentsof childrenwithbehaviouralproblems,asimultaneous/parallelresponsetotheneedsof childrenwhoexhibitbehaviouralproblemsisessential.

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References Aos,S.,&Phillips,P.,&Barnoski,R.,&Lieb,R.(2001), TheComparativeCosts andBenefitsofProgramstoReduceCrime, Doc.No.01 05 1201, Washington. Barton,L.R.,Roman,L.A.,Fitzgerald,H.E.,&McKinney,M.H.(2002), Informalsocialsupportcharacteristicsandutilizationofparentingsupport servicesamonglowincomeAfricanAmericanmothersofprematureinfants, InfantMentalHealthJournal,23(3),278292. Barton, C., Alexander, J., Waldron, H., Turner, C., Warburton, J., (1985), Generalising Treatment Effects of Functional Family Therapy: Three Replications, AmericanJournalofFamilyTherapy13,12 26. Bor,W.,Sanders,M.R.,&MarkieDadds,C.(2002), TheEffectsofTripleP PositiveParentingProgramonPreschoolChildrenwithCooOccurring DisruptiveBehaviourandAttentional/HyperactiveDifficulties, Journalof AbnormalChildPsychiatry,Vol.30,No.6,pp.571 587 Cummins,McMaster(2006) ChildPsychologicalandEmotionalHealth,Health ServicesExecutive,Sligo. Barlow,J.,&Parsons,J.,(2003), GroupBasedParentTrainingProgrammesfor ImprovingEmotionalBehaviourandAdjustmentinZerotoThreeYearOld Children, TheCochraneDatabaseofSystematicReviews,Issue2. Beinart, S., Anderson,B.,Lee,S.,Utting,D.,(2002), Youthatrisk?Anational surveyofriskfactors,protectivefactorsandproblembehaviouramongyoung peopleinEngland,ScotlandandWales, CommunitiesThatCare,London. Bradley,SandHayes,N(2006), BallymunNeedsAnalysisStudy, CSER, Unpublished. Brazelton,T.(1992), HeartStart:TheEmotionalFoundationsofSchool Readiness,NationalCentreforClinicalInfantProgrammes,Arlington,VA Burley, S., Hayes, F., Martin, C., (2005), Evaluation of the Positive Parenting Programme within the Starting Well Demonstration Project,Scottish Centre for Social Research, & Centre for Research on Families and Relationships, Edinburgh. Davis,H.&Spurr,P.,(1997),ParentCounselling:AnEvaluationofCommunity ChildMentalHealthService, ChildJournalofPyschologyandPsychiatry,Vol. 38,pp.365 376. Dekovic,M.(1999), Riskandprotectivefactorsinthedevelopmentofproblem behaviorduringadolescence,JournalofYouthandAdolescence, 28(6),667685

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