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ryantunnardbrown
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development : children and families
Family support interventions - Research evidence about effectiveness
INTRODUCTION
For this paper on research evidence I�ve clustered information into themes. The themes used are some of the common �need groups� that arise in our multi-agency work of auditing needs, identifying realistic outcomes for children and families, and developing services in response.
The focus of the session is on studies that tell us something about outcomes, and so enable us to say with some confidence �this works�. This is because the studies drawn on have comparison groups or because several studies about the same issue all point in the same direction. The references are clustered under these theme headings in the hope that they can be used easily in your future work. I�ve drawn on four main sources � these are the first four references listed. The session is brief, so inevitably I haven�t covered all the need groups that emerge in multi-agency audits, nor have I included all relevant research studies.
The following topics are included:
� DEFINITIONS � of family support and effectiveness
� THEME - MATERNAL MENTAL HEALTH
� THEME - IMPROVING FAMILY RELATIONSHIPS
� STYLE OF WORKING � family centres, social work support, day care
� WHY DO SOME SERVICES WORK AND OTHERS DON�T?
� CONCLUDING COMMENTS
� REFERENCES
DEFINITIONS
The term became current in the consultation exercise before the Children Act. It was used to mean services with the broad aim of helping children be brought up by their families. It was distinguished from the narrower aim of preventing children from becoming looked after.
The final version of the Act gave us section17, promoting:
� a wide definition of 'in need�
� a wide definition of �family�
� the notion of a continuum of services so that family support can include accommodation
� and the specific duty to prevent abuse and neglect.
So, family support services could be seen as the range of services available for children and their families to help prevent long-term family breakdown.
In the USA they make a distinction between "family support" and "family preservation":
Family support services � are for families coping with the normal stresses of parenting, to provide reassurance or prevent child maltreatment.
Family preservation services - are for families at serious risk or in crisis, typically those known to child protection services, juvenile justice, or the mental health system.
This US definition doesn't reflect the intention of the legislation here in the UK, but I know that many practitioners and others do make a similar distinction, between �family support� work and �child protection� work.
It's important to be alert to that unhelpful distinction.
Research and commentary on the implementation of the Children Act has consistently stressed that child protection needs to be located within the wider framework of family support, not seen as something separate. Focus on the wider welfare needs of children and families is more likely to achieve good outcomes.
Put simply, this is about finding out whether an intervention or service does what it intends to do.
There are difficulties about doing this:
�
Most
services are not evaluated
- so it's difficult to know whether or not they are making a difference.
As the Seebohm Report said over 30 years ago:
"The personal social services are large scale experiments in ways of helping those in need. It is both wasteful and irresponsible to set experiments in motion and omit to record and analyse what happens."
That�s why he argued for the new SSDs to have a research department.
� Few evaluated interventions have been evaluated rigorously - this makes it difficult to know whether it is the service that is making the difference, or some other factor.
� Evaluations tend to be short term - so a service might be deemed to fail in the short term but, if evaluated much later, might be shown to have had other wider effects that have made a positive difference. This was the case in the large US projects of early pre-school intervention in socially deprived neighbourhoods.
� Some outcomes are difficult to measure - There's a growing use of scales to measure outcomes. But not everything lends itself to being measured easily (e.g. a child's self esteem).
� Information about processes is important - Measurable outcomes may not tell us much about the way outcomes are achieved, and yet this process information is helpful when considering how to provide effective services. So is the perspective of different people involved, including families.
� Evaluation is costly - of time, energy and expertise.
So there are problems. But all is not doom and gloom. There are messages from research about family support services. Some are from the UK. Rather more are from the USA, where they have a stronger tradition of evaluating outcomes.
THEME - MATERNAL MENTAL HEALTH
We know about the advantages of early support before and after birth.
� Local experienced mothers acting as volunteer buddies can help first-time mothers feel less tired and miserable and get out more. The advantage of the volunteers is that they reduce the distance between mothers and professionals, and they offer social support as well as advice on health and child development. The gains were about injections being up to date, and parents reading to babies and playing cognitive games.
� Home visits by trained health visitors can make a difference. Their counselling can help reduce post-natal depression. Visits to the home, rather than work in clinics, is key here, to avoid the barriers of access and mental health difficulties.
There are gains for fathers too:
� Trained midwives for low birth weight babies and anxious mothers are effective in listening and giving advice. The gains were about mothers being less depressed and in better health, babies being healthier, and partners being more helpful with the children. At age 7, the children had fewer behavioural problems and mothers were less anxious than those in the control group.
� Weekly visits from trained Parent Advisers put emphasis on the needs of the family as a whole, with a focus on partnership work and putting parents in control. The gains are in self-esteem, reduced anxiety and depression, less stress about the parenting role, and an improvement in the child's environment and behaviour.
THEME - REDUCING SOCIAL ISOLATION
Home-Start
� The regular visits from Home-Start volunteers can help reduce parenting difficulties
� Can improve the emotional well being of mothers
� And give parents peer support, to build self-confidence, and use local services and networks to regain control over their life
But it takes time, up to 12 months.
And it's not for everyone. Some parents don't engage, some don't benefit - in one study only two thirds of mothers said they felt better.
And there's a need to find ways of engaging with different communities, such as through bilingual co-ordinator.
Newpin
� The emphasis on sharing and mutual support provides intensive therapeutic services without creating dependency
� Mothers report that it helps with child rearing problems (33% of sample), avoiding hitting children (17%), and helping children remain at home (7%)
Again, it's not for everyone, and it takes time to have an impact. In one study half the mothers referred didn't take up the service and only a third using it found it helpful. The research suggests that the service tends to suffer from traditional health centre problems of access difficulties or not meeting the perceived needs of families referred.
General points are about:
� There's no research about young carers using comparison groups or controls. But two studies, with some evidence of effectiveness, tell us what young carers want:
- Someone to talk to
- Recognition for their role
- Opportunities for normal activities
- To achieve their full potential
- Support at school if needed
- Domestic and practical help
- Information about the prognosis for their parent
- A contact person for crises.
� Two other issues are raised in studies:
- do schemes get to young people who fear family separation and so are reluctant to come forward?
- do parents get the direct help they need for their illness, disability, substance misuse and other mental health needs? If not, why not? In part, the answer here is that Community Care legislation and guidance does not put enough emphasis on responding to parents� needs for help with the normal parenting tasks. Attention needs to shift to how they can get that help, rather than focusing on how to help children do the job of adults.
�
For
families with long-standing and complex problems, a more intensive programme has
been found to be effective. It's called Mellow Parenting.
It provides personal and group therapy plus parenting support, led by qualified
psychiatrists and psychologists, for one day a week over 4 months. More children
stay at home or are removed from the CPR than similar children in the locality.
There are improvements in mothers' mental state, mother/child interactions and
the child's behaviour. If fathers are involved there are better outcomes over
time.
The general message about these parenting programmes is that:
� group-based work is better, and preferred by parents, and cheaper
� valuing parents' ideas and experience makes a positive difference
� the benefits sustain over time
� But work is needed to engage reluctant parents
� Many continue to have difficulties
� And courses have better outcomes where the need for information and skills training has been accurately assessed by parents and others.
� Direct work
is needed with the child or young person as well as parents
A combination of parent training, plus PSST (Problem Solving Skills Training)
for children is more effective than either programme alone. PSST has 4 elements
- self-monitoring, setting goals that are pro-social, work on peer
relationships, and problem solving and communication skills. For 7-13 year olds,
it brings anti-social behaviour within the normal range.
� There are tested techniques for
dealing with moderate depression and anger
� Short-term gains at least can be made if parents are helped to improve the quality of their relationship with children. This was the finding of a course that stresses listening to children, remembering what childhood is like, and giving children clear and firm messages.
� With more entrenched problems, there are promising results in the US from Multi-Systemic Therapy. It's for young people with serious and complex problems. The family is the core focus of the intervention. It's intensive, includes home-based work, and lasts several months.
� In family breakdown the worst outcomes for children occur where the break-up is accompanied by conflict. Conflict is reduced where discussions are about all causes of conflict in the divorce rather than just custody and contact issues. In relation to domestic violence, evaluated schemes support the development of outreach and advocacy work.
� Again,
school has a role. It can provide a safe and supportive group environment
where children can share experiences, clarify misconceptions and develop skills
to cope with family change. Two studies are of note:
In the US a large, school-based preventive mental health programme has
been validated on different populations and in different areas. Children show
significant improvement in behaviour and competence. Parents report better home
adjustment, communication and reduction in divorce-related concerns. The gains
persist, with children more positive about their future.
A UK school-based programme offers the opportunity for similar safe
exploration for children referred for emotional/behavioural problems or
social worries, including family separation. Outcomes from the first 6
schemes are good for three-quarters of the children.
STYLE OF WORKING
A Northern Ireland study of family support concluded that family support is better viewed as "a policy direction and style of working", rather than as a collection of particular services.
What do we know about style?
Family Centres
� There are many descriptive studies � about who uses family centres, the types of support offered, and the views of families. And on the effectiveness of individual services, like parenting. But there's very little rigorous research on the impact of family centres as a whole - the range of services offered, and the difficulty in defining the target population, make this difficult.
� What can be said is this:
- Family centres help reduce re-abuse. The family centre is better than a social work team alone in reducing registration and the need for accommodation.
- local people, open access and other community development principles may be a better way of reaching a greater range of people than relying solely on professionals and referrals.
- Fathers need to be attracted to family centres - it's about selling the work, and having men to lead the work.
� Some centres appear to work successfully with black families. The factors include having:
- an equal opportunity policy for services (as opposed to employment)
- ethnic recording and monitoring for service use (as well as employment)
- specific ways of targeting black communities, including via outreach work, faith groups, and black voluntary organisations
- black staff members, including in management
- specific services for black parents
- attention to the high emphasis black parents place on their children's health, education and social needs and on the stresses induced by finance, housing, loneliness and isolation
- an appreciation of the anxiety that has stemmed from the reduction of existing services, in particular day care, which is valued for enabling parents to work or support their family.
There's very little empirical data on this major activity. What can be said is this:
� It�s helpful to have a clearly identified target problem, with a style of work that is contractual, and an approach that is task-centred or behaviourist, where the work is intensive and there's good co-ordination with other agencies.
� The worker's personality and skills make a difference to outcomes.
� The venue can make a difference - support offered from a community building can make other support easier to access.
� Structured help to tackle problems can get children back home.
� Social workers can help parents by providing a listening ear and helping them access the services they need. Does that happen less since the introduction of the Assessment Framework and the speedy moving on from Referral and Assessment teams?
� Plans won't be translated into good outcomes without supportive and therapeutic services in place. Social workers play a key role in holding the arrangements together when children are in planned foster care. What is very important is that there needs to be a service other than just the placement. Research confirms the anecdotal knowledge that this is often lacking.
Day care
�
US
evidence, from a systematic review of 900 programmes, concludes that
disadvantaged children benefit (in terms of their educational attainment and
emotional development) from day care and early intervention, provided it is
good-quality day care and has educational components.
The effects are strongest where there is also support for parents, such
as home visits.
A key UK finding is similar - quality is more important than the type of
provision. Continuity is an important aspect of quality.
� Sponsored day care
can help
Parents who got day care had significantly better outcomes in terms of financial
problems and parent/child problems than those getting some (small) practical
material help from social services. Neither service had a significant impact on
parental distress levels. But at follow up, day care was likely to have had an
impact on their problem levels. This study used scales at referral and 4 months
later, and parent self report.
Sponsored day care may not be enough on its own. It may leave unmet need at the end of the service (findings from a study on childminding).
WHY DO SOME SERVICES WORK AND OTHERS DON�T ?
Success tends to be linked to:
� Involving local people in planning and implementation
� Targeting local areas
� Bringing services closer to families
� Providing services by people who are similar to users
� Professionals being able and willing to acknowledge the barriers that exist between themselves and families
� Making multi-agency work local and focused, with designated budgets and an officer to act as co-ordinator
� The ability of charismatic people to get people on board and funding in place.
What's effective at getting to the needs of individual children and families?
� Match input to individual needs - a sensitive process of assessment should lead to an intervention being selected because it has the best chance of meeting particular needs. This pre-supposes the availability of a number of possible options.
� Provide more than a single intervention - a response to the separate needs of children and parents is likely to be better than focusing on just one. Where more than one is provided, each has the chance of creating a momentum for positive change.
� Provide variety in the level of intensity and the timing of services - to reduce the risk of stigma, to provide a preventive element, and to reduce possible resentment from targeting resources solely at those most in need.
� Reduce inequalities rather than pathologise - geographically targeted interventions are best presented in a positive light as a mechanism for reducing inequality rather than in a "problem-centred" way.
� Combine low-level interventions with targeted services - protect against stigma, and support the more intangible factor of confidence and self-esteem at the community level, by providing low-level interventions that will benefit everyone, e.g. safe and stimulating play spaces. Taking a corporate approach to responding to children in need is called for here.
What specific categories of intervention work?
� Quality pre-school education that increases a child's receptivity for learning.
� Involving parents in home or centre-based activities that focus on children's cognitive development.
� Using a child's instinct for play, fun and physical activity.
� Boosting self-esteem and inner resilience by encouraging problem solving and social supports.
� Promoting good relationships at all levels - child/parent, parent/professional, professional/child.
� Improving maternal mental health, via increased support in or out of the family, because reduced stress indirectly benefits the child.
(Summary of points in Oliver, C and Smith, M (2000) The Effectiveness of Early Interventions. Institute of Education)
What are the key pointers to making sense of all this evidence?
Five important messages emerge from the work that RTB Associates have been involved in across a range of local authority and PCT areas.
And finally:
� Avoid extending the social experiment that Seebohm referred to.
� Think small � chose just one service to evaluate and work from there.
� Learn from success as well as mistakes.
� Remember that we all have a part to play in plugging the gaps in research evidence.
REFERENCES
(linked to each of the above sections, and listed in order in which referred to)
GENERAL
Statham, J. (2000) Outcomes and Effectiveness of Family Support Services - a research review. Institute of Education.
Sure Start (1999) A guide to evidence-based practice (2d edition). DfEE.
Buchanan, A. (1999) What Works for Troubled Children? Family support for children with emotional and behavioural problems. Barnardo's.
Oliver, C and Smith, M. (2000) The Effectiveness of Early Interventions. Institute of Education.
DEFINITIONS
McCroskey, J. and Meezan, W. (1998) Family-centred services: approaches and effectiveness. Protecting Children from Abuse and Neglect, 8, 1, 54-71.
Audit Commission (1994) Seen but not heard. TSO.
Department of Health (1995) Child protection: messages from research. TSO.
Department of Health, Department for Education and Employment, Home Office (2000) Framework for the Assessment of Children in Need and their Families. TSO.
Report of the Committee on Local Authority and Allied Personal Social Services (1968) Cmnd 3703. TSO.
MATERNAL MENTAL HEALTH
Volunteer buddies
Johnson, Z., Howell, F. and Molloy, B. (1993) Community mother's programme: randomised controlled trial of a non-professional intervention in parenting. British Medical Journal 306, 1449-52.
Trained health visitors
Holden, J., Sagovsky, R. and Cox, J. (1989) Counselling in a general practice setting: controlled study of health visitor intervention in treatment of postnatal depression. British Medical Journal 298, 223-6.
Trained midwives
Oakley, A., Rajan, L. and Grant, A. (1990) Social support and pregnancy outcome. British Journal of Obstetrics and Gynaecology 97, 155-162.
Parent advisers
Davis, H. and Rushton, R. (1991) Counselling and supporting parents of children with developmental delay: a research evaluation. Journal of Mental Deficiency Research 35, 89-112.
REDUCING SOCIAL ISOLATION
Home-Start
Newpin
Pound, A. (1994) NEWPIN: a befriending and therapeutic network for carers of young children. TSO/National Newpin.
Oakley, A., Mauthner, M., Rajan, L. and Turner, H. (1995) Supporting vulnerable families: an evaluation of Newpin. Health Visitor, 68, 5, 188-191.
Parents of children who care for them (young carers)
Dearden, S., Aldridge, J. and Dearden, S. (1998) Young Carers and their Families. Blackwell Science.
CHILD'S DIFFICULT BEHAVIOUR
Webster-Stratton
Scott, S., Spender, Q., Doolan, M., Jacobs, B. and Aspland, H. (2001) Multi centre controlled trial of parenting groups for childhood antisocial behaviour in clinical practice. British Medical Journal 323, 194-198.
McGaw, S. (2000) What Works for Parents with Learning Disabilities? Barnardo's.
Mellow Parenting
Puckering, C., Rogers, J., Mills, M., Cox, A.D. and Mattson-Graff, M. (1994) Mellow Mothering: Process and Evaluation of Group Intervention for Distressed Families. Child Abuse Review 3, 299.
Problem Solving Skills Training
Kazdin, A.E, Siegel, T.C. and Bass, D. (1992) Cognitive Problem-Solving Skills Training and Parent Management Training in the Treatment of Antisocial Behaviour in Children. Journal of Consulting and Clinical Psychology 60, 5, 733-747.
Depression and anger
Harrington, R., Wood, S. and Verdyn, C. (1998) Clinically depressed adolescents. In Graham, P. (ed.) Cognitive Behaviour Therapy for Children and Families. University of Cambridge Press.
Novaco, R.W. (1975) Anger Control: The development and evaluation of an experimental treatment. D.C.Heath.
IMPROVING FAMILY RELATIONSHIPS
Davis, H. and Hestor, P. (1996) An Independent Evaluation of Parent-Link: A Parenting Education Programme. Parent Network. This was a study of 95 parents, with a comparison group, who did a 12 week course.
Multi-Systemic Therapy
Henggelar, S.W and Borduin, C.M. (1990) Family Therapy and Beyond: A Multi-Systemic Approach to Treating the Behaviour Problems of Children and Adolescents. Brooks/Cole.
Conflict in divorce
McCarthy, P. and Walker, J. (1996) Evaluating the longer term impact of family mediation. Relate Centre for Family Studies.
Domestic violence
Kelly, L and Humphreys, C (2000) Reducing Domestic Violence � What Works? Outreach and Advocacy Approaches. Briefing Note. Crime Reduction Research Series. Policing and Reducing Crime Unit, Home Office.
School programmes
Pedro-Caroll, J.L. and Cowen, E.L. (1985) The children of divorce intervention programme. An investigation of the efficacy of a school-based prevention program. Journal of Consulting and Clinical Psychology 14, 277-290.
The Place2Be � www.theplace2be.org.uk
PARENTAL SUBSTANCE MISUSE
Residential treatment
Aktan, G.B., Kumpfer, K.L. and Turner, C.W. (1996) Effectiveness of a Family Skills Training Program for Substance Use Prevention with Inner City African-American Families. Substance Use & Misuse 31(2), 157-175.
Community methadone clinics
Catalano, R.F, Gainey, R.R., Fleming, C.B., Haggerty, K.P. and Johnson, N.O. (1999) An experimental intervention with families of substance abusers: one-year follow-up of the focus on families project. Addiction 94(2), 241-254.
Shulman, L.H., Shapira, S.R. and Hirshfield, S. (2000) Outreach Developmental Services to Children of Patients in Treatment for Substance Abuse. American Journal of Public Health 90, 12, 1930-1933.
Tunnard, J (2002) Parental problem drinking and its impact on children. Research in Practice.
Parental drug misuse
Tunnard, J (2002) Parental drug misuse � a review of impact and intervention studies. Research in Practice.
STYLE OF WORKING
Higgins, K., Pinkerton, J. and Devine, P. (1997) Family support in Northern Ireland: perspectives from practice. Centre for Child Care Research.
Family centres
Smith, T. (1999) Neighbourhood and preventive strategies with children an families: what works? Children and Society 13, 265-277.
Davey, D., Holland, S. and Pithouse, A. (1999) Newport Family Centre: a case study evaluation 1996-1999. University of Wales. A study of 41 referred families followed for 2 years.
Pithouse, A. and Lindsell, S. (1996) Child protection services: comparison of a referred family centre and a field social work service in South Wales. Research on Social Work Practice 6, 4, 473-491. A study of 10 families with a control group of 10.
Pithouse, A. and Holland, S. (1999) Open access family centres and their users: positive results, some doubts and new departures. Children and Society 13, 167-178.
Ghate, D., Shaw, C. and Hazel, N. (2000) Fathers and family centres: engaging fathers in preventive services. Joseph Rowntree Foundation.
Butt, J. and Box, L. (1998) Family Centred. A study of the use of family centres by black families. REU.
Qureshi, T., Berridge, D. and Wenman, H. (2000) Where to Turn? Family Support for South Asian communities - A case study. National Children's Bureau and Joseph Rowntree Foundation.
Social work activity
Sheldon, B. (1986) Social work effectiveness experiments: review and implications. British Journal of Social Work 16, 223-242.
Alexander et al. (1976) and Paterson et al. (1982) - See p36. What Works in the Early Years? Barnardo's.
Stein, T. and Gambrill, E. (1977) Facilitating decision making in foster care. Social Services Review 51, 502-521. This was the Alameda Project, a large RCT in which 50% of children returned home versus 11% in the control group.
Aldgate, J. and Bradley, M. (1999) Supporting families through short-term fostering. Reported in Aldgate, J. and Statham, J. (2001) The Children Act Now - Messages from Research. TSO.
Tunstill, J. and Aldgate, J. (2000) Services for Children in Need. Reported in The Children Act Now, see above.
Day care
Zoritz, B. and Roberts, I. (1997) The health and welfare effects of day care for pre-school children: a systematic review of randomised controlled trials. In Cochrane Database of Systematic Reviews, (September 1997). This is a review of 900 US programmes, including 8 RCTs.
Statham, J., Dillon, J., and Moss, P. (2000) Sponsored day care in a changing world. Children and Society 14, 23-36.
Melhuish, E. and Moss, P. (1991) Research in Day Care in Britain. In Moss, P. et al (eds) Current Issues in Day Care for Young Children. TSO.
Sylva, K., Siraj-Blatchford, I. et al (1999) Characteristics of pre-school environments: a longitudinal study funded by the DfEE 1997-2003. Institute of Education.
Gibbons, J. (ed.) (1992) The Children Act 1989 and family support: principles into practice. TSO.
Jo Tunnard, May 2002
Paper presented at the ADSS South-West Conference in May 2002 and the Borough of Poole Conference in September 2002