Antisocial Behaviour – Health Dissertations

Antisocial behaviour

Aggression and fighting are part of normal child development and can help children to assert and defend themselves. Persistent, poorly controlled antisocial behaviour, however, is socially handicapping and often leads to poor adjustment in adults (Scott 1998). It occurs in 5% of children (Meltzer et al 2000), and its prevalence is rising (Rutter et al 1998). The children live with high levels of criticism and hostility from their parents and are often rejected by their peers.3 Truancy is common, most leave school with no qualifications, and over a third become recurrent juvenile offenders (Farrington 1995). In adulthood, offending usually continues, relationships are limited and unsatisfactory, and the employment pattern is poor. Thelon term public cost from childhood for individuals with this behaviour is up to ten times higher than for controls and involves many agencies (Scott et al 2001b) Antisocial behaviour accounts for 30-40% of referrals to child mental health services (Audit Commission 1999). Most referrals meet general clinical diagnostic guidelines for conduct disorder from ICD-10(international classification of diseases, 10th revision), which require at least one type of antisocial behaviour to be marked and persistent. Rather fewer meet the diagnostic criteria for research, which for the oppositional defiant type of conduct disorder seen in younger children require at least four specific behaviours to be present (World Health Organisation 1993). The early onset pattern typically beginning at the age of 2 or 3 years is associated with comorbid psychopathology such as hyperactivity and emotional problems(Taylor et al 1996, language disorders, neuropsychological deficits such as poor attention and lower IQ, high heritability (Solberg et al1996), and lifelong antisocial behaviours (Moffitt 1993). As a result of its prevalence and significant consequences, the management of these childhood behavioural problems has received an increasing level of attention, research and theory over recent years. Two of the more prominent interventions for the behavioural management of children are health visitors and Group Parenting Programmes. Each of these approaches will now be outlined and will be the focus of the systematic literature review to be discussed.

1.1 Health Visitors and behaviour management

The health visitor's first task is to identify health care needs. Together with general practitioners, they provide the child health surveillance programme of immunisations, screening, and advice. They aim to identify those important conditions that parents might overlook and, for the rest, to help parents access professional expertise, voluntary agencies, and local facilities (NHS Executive 1996). Health visitors make key contributions regarding immunisation, breast-feeding, good nutrition and depression. This role can extend to help make appropriate interventions regarding the management of child behavioural problems through home visits. Health visitors can help to identify problem situations and refer the parent/child to the right agency. Furthermore, they can advise the parent and help to equip them with the skills needed to effectively manage and reduce the behavioural problems. If the health visitor can meet the parent when the child is under 10 days old, or even at the ante-natal stage, then a trusting and effective relationship can be formed (Beecham 1997) which can have positive effects. It has been suggested that this is of particular relevance to subgroups such as single parents. They have been shown tube less likely to attend health care environments for immunisations and their children appear to have more accidents around the home (Flemmingand Charlton 1998). These are clearly key issues within community service provision (Hall 1996). The health visitors can provide much needed support, particularly with the more vulnerable groups. This social support can have significant benefits during pregnancy/labour(Match and Sims 1992), after birth (Kumar et al 1993) and in reducing the probability that the mother will experience post-natal depression(Ray and Hornet 2000). The health visitor can therefore have a range of benefits for the parent and the child and the extent to which these benefits extend to the child’s behavioural problems merits consideration.

1.2 Group Parental Programmes

Harsh, inconsistent parenting is strongly associated with antisocial behaviour in children (Rutter et al 1998), but whether this is a cause or consequence or is due to a common genetic predisposition has been less clear (Farrington 1995). The pioneering work of Patterson and colleagues showed that parents had a causal role in maintaining antisocial behaviour by giving it attention and in extinguishing desirable behaviour by ignoring it (Patterson 1982). Such findings have facilitated the development of group parenting programmes which aim to reduce children’s anti-social behaviour by working with parents. These programmes include the Webster-Stratton programme (Webster-Stratton and Hancock 1998) and the Solihull approach. They generally involve group sessions with parents of children who have behavioural problems. Sessions take place over a few months and involve the discussion of topics such as play, praise, limit setting, rewards and the handling of misbehaviour. The children do not attend the sessions. Video tapes aroused to provide examples of good and bad parenting behaviour and encourage the parents to talk about their experiences. This approach provides an alternative way of managing child behavioural problems rather than the need for health visitors to attend the parents’ homes.

1.3 Evaluating Health Interventions

Before selecting any health-related intervention it is vital that theyare assessed on a number of grounds through empirical research which investigates their effectiveness and efficacy. Within the NHS, cost restraints pose a significant issue and hence any intervention needs to provide value for money relative to other potential options (Royal College of Paediatric and Child Health 1997). The Audit Commission(1997) reported that the annual maternity costs in England and Wales are £1.1 billion. Hence, any savings, or more cost-effective approaches, could have significant impacts on the financial performance of the NHS. Both group parenting programmes and health visiting have been evaluated within empirical research. Most of this research has taken place within America (Deal 1994). The following review will consider this research in order to evaluate the use of group parenting programmes and home visits by health visitors with regards to their effectiveness and efficacy for managing child behavioural problems. The methodology employed within this research will now be outlined before ten relevant research studies are discussed and critically analysed. These findings will then be related to the research discussed in this introduction to the review before overall conclusions are drawn regarding the research question.

1.4 Method and search history

A systematic review aims to integrate existing information from comprehensive range of sources, utilising a scientific replicable approach, which gives a balanced view, hence minimising bias (Clarke& Oman 2001). In other words, a scientific approach will help to ensure that research evidence is either included or excluded based upon well-defined and standardised criteria. This should ensure that the possible effects of researcher bias should be kept to a minimum. Berkley and Glenn (1999) also states that systematic reviews provide a means of integrating valid information from the research literature to provide a basis for rational decision making concerning the provision of healthcare. Literature reviews are important as they can help to consolidate the knowledge which is available on a given topic. The main themes and findings can be highlighted and this information can inform the design, implementation and evaluation of future research. In this instance, the research evidence can be used to make recommendations and decisions regarding the use of health visitors and Group Parenting Programmes for behaviour management in children.

1.5 Reviewing process

Whenever one reviews or compares research reports, it is important that clear set of criteria are established upon which the evaluations can be made. Table 1 below outlines the global process which was used to conduct the literature review. This process was based upon that employed by Berkley et al (1999) It is important that such a framework is identified and used to structure a literature review so that all of the relevant stages are addressed and that limitations which could be associated with the methodology employed can be reduced where ever possible. Table 1: Systematic Review (Summary of Framework)(Adapted from Berkley and Glenn 1999) Identify the need Rationale, background information, existing work Formulate problem and specify objectives Background, problem specification, objectives Develop review protocol Design, resources, refinement Literature search and study retrieval Sources, search strategy, documenting a search strategy Assessing studies for inclusion Defined criteria, minimising reviewer bias, tables of studies included and excluded Assessing and grading studies Appraising checklists, hierarchies of evidence Extracting Data Data collection forms, extraction methodology Synthesizing data Qualitative overview, quantitative synthesis Interpreting results Strength of evidence implications of results Disseminating and implementing results Methods of dissemination and implementation In terms of the process used to review the selected research, the guidelines used by McInnis et al (2004) were adopted. These are displayed in Table 2 below: Table 2: Core Principles Used in Reviewing Selected Research Articles (adapted from McInnis et al 2004) Systematic reviews Adequate search strategy Inclusion criteria appropriate Quality assessment of included studies undertaken Characteristics and results of included studies appropriately summarized Methods for pooling data Sources of heterogeneity explored Randomised controlled trials Study blinded, if possible Method used to generate randomisation schedule adequate Allocation to treatment groups concealed All randomised participants included in the analysis (intention to treat) Withdrawal/dropout reasons given for each group Cohort All eligible subjects (free of disease/outcome of interested) selected or random sample 80% agreed to participate Subjects free of outcomes on interest at study inception If groups used: comparable at baseline Potential confounders controlled for Measurement of outcomes unbiased (blinded to group) Follow-up sufficient duration Follow-up complete and exclusions accounted for ( 80% included in final analysis) Case control Eligible subjects diagnosed as cases over a defined period of time or defined catchment area or a random sample of such cases Case and control definitions adequate and validated Controls selected from same population as cases Controls representative (individually matched) 80% agreed to participate Exposure status ascertained objectively Potential confounders controlled for Measurement of exposure unbiased (blinded to group) Groups comparable with respect to potential confounders Outcome status ascertained objectively 80% selected subjects included in analysis Cross-sectional/survey Selected subjects are representative (all eligible or a random sample) 80% Subjects agreed to participate Exposure/outcome status ascertained standardized way Qualitative Author's position clearly stated Criteria for selecting sample clearly described Methods of data collection adequately described Analysis method used rigorous (i.e., conceptualised in terms of themes/typologies rather than loose collection of descriptive material) Respondent validation (feedback of data/researcher's interpretation to participants) Claims made for generalizability of data Interpretations supported by data The results of this analysis will be presented via the CAST tool. Thesis available in two formats. The first concerns the evaluation of qualitative research studies and the second provides a framework forth evaluation of studies which have used a randomised and controlled approach within their methodology. The use of such a framework can provide structure within the results section and ensure that the data is presented in a way which is easily read and understood by the reader.

1.6 Sources of data

The methodology employed within the research will involve obtaining data from three key sources: Computerised searches, Manual searches, and the Internet. Each of these data sources will now be considered in more detail.

1.6.1 Computer-based searches

The methods used in this research will include a detailed computerised literature search. Multiple databases, both online and CD–Rom will be accessed to retrieve literature because they cite the majority of relevant texts. (Ford and Miller 1999) The computerised bibliographic databases are:- • MEDLINE • EMBASE • CINAHL • PSYCHINFO • British Nursing Info BNI • Cochrane • Science Direct (All Sciences Electronic Journals) • Asia • DETOC • HMIC • However because articles may not be correctly indexed within the computerised databases, other strategies will be applied in order to achieve comprehensive search (Sindh & Dickson 1997).

1.6.2 Manual searches

A manual search will be performed to ensure that all relevant literature is accessed. The manual searches will include:- • Books relevant to the topics from university libraries and web sites • Inverse searching- by locating index terms of relevant journal articles and texts • Systematically searching reference lists and bibliographies of relevant journal articles and texts

1.6.3 The Internet

The internet will provide a global perspective of the research topic and a searchable database of Internet files collected by a computer. Sites accessed will include:- • Department of Health • National Institute of Clinical Excellence • Google • The British Medical Journal website (www.bmj.com)

1.7 Identification of key words

Databases use a controlled vocabulary of key words, in each citation. To assist direct retrieval of citations techniques Boolean logic will be applied using subject indexing, field searching and truncation to narrow the topic focus (Hicks 1996, Goodman 1993). As part of this approach, key words will be based on the components of the review question. An imaginative and resourceful technique of searching electronic databases will be used including recognising the inherent faults in the indexing of articles. Misclassification and misspelling will be included in the searches with searches utilising keywords and the subheadings, (Hicks 1996). Based on these principles, the following search terms will be used in different combinations: • Behaviour Management • Children • Anti-Social Behaviour • Health Visitors • Group Parenting Programmes • Webster-Stratton • Solihull • Evaluation Further search terms may be used within the methodology if they are identified within some of the initial search items. Whenever one is searching literature ‘sensitivity’ and ‘’specificity’ are important issues when conducting searches of research on a database. The searches need to be as ‘sensitive’ as is possible to ensure that as many of the relevant articles are located. This may be a particularly salient issue with regards to the evaluation of behavioural management techniques for children as the number of appropriate entries may be limited. Thus an attempt to locate as many of these articles as possible becomes a more relevant and important objective. Furthermore, the search needs to be ‘specific’. In other words, it needs to be efficient where appropriates that a higher number of the articles identified through a database search can be included and hence the time allocated to reviewing articles which are ultimately of no relevance, can be kept at inacceptable level.

1.8 Inclusion/Exclusion criteria

In order that a manageable quantity of pertinent literature is included in this study, it is essential that inclusion and exclusion criteria are applied. In order that a diverse perspective of the topic is examined broad criteria will be used. (Benignant 1997). However, it is important to note that a balance needs to be achieved through which the scope of the inclusion criteria is sufficiently wide to include relevant articles whilst also being sufficiently specific such that the retrieval of an unmanageable set of articles is avoided.

1.8.1 Inclusion criteria:

The articles which are highlighted within the proposed searches will be assessed in terms of whether or not they meet the following criteria. Each article will need to be viewed as appropriate with regards to all of these constraints if they are to be included in the final analysis. • A literature review encompassing all methodologies will be applied ( Pettigrew 2003) • International studies will be included • Available in English • Relate to the evaluation of Health Visitors and/or Group Parenting Programmes • Focus on the behaviour of young children 1.8.2 Exclusion criteria The articles highlighted by the searches will also be assessed in terms of whether or not they fulfil the following exclusion criteria. If a potential relevant article meets one or more of these criteria then they will be immediately excluded from the data set and will not be included within the analysis stage of the methodology. • It is not the purpose of this review to discuss the development of behavioural management interventions so studies focusing on this will be excluded • Literature in a foreign language will be excluded because of the cost and difficulties in obtaining translation. • Research reported prior to 1990 will not be included within this review.

1.9 Consideration of ethical issues

Any research involving NHS patients/service users, carers, NHS data, organs or tissues, NHS staff, or premises requires the approval of ankhs research ethics committee (REC).(DH 2001) A literature review involves commenting on the work of others, work that is primarily published or in the public domain. This research methodology does not require access to confidential case records, staff, patients or clients so permission from an ethics committee is not required to carry out there view. However, it is essential to ensure that all direct quotes are correctly referenced. Permission must be sought from the correspondent before any personal communication may be used. All copyrights need tube acknowledged and referenced. The researcher will also act professionally when completing this report and ensure that research is identified, reviewed and reported accurately and on a scientific basis. The analyses of the ten selected articles will now be summarised.

2.0 Results and CAST tool

Based on the inclusion and exclusion criteria for this literature review, a set of ten research studies were selected. They will now be analysed using the CAST Tool. Article 1: Morrell and Walters (2000) TITLE Costs and effectiveness of community post-natal support workers: Randomised controlled trial AUTHORS Morrell CJ and Walters PS SOURCE British Medical Journal, 2000: 321, 593-598 QUESTION 1: FOCUS This research was sufficiently focussed on assessing the cost effectiveness of a series of home visits by a health visitor. It aimed to determine the cost of this intervention compared to that which would be normally incurred through the maternity process. It also aimed to investigate the health benefits of these individual home visits for the mothers and children involved. QUESTION 2: APPROPRIATENESS A randomised controlled trial was employed within the methodology of this research as it provided a group with which the results of the women in the intervention group could be compared. Therefore the progress of women who had recently given birth could be monitored and analysed to see if there were any significant differences as a result of the attendance of a Community post-natal support worker. QUESTION 3: ALLOCATION A total of 623 women who had recently given birth were recruited for the study at a university teaching hospital. They were randomly allocated to either the intervention group (N = 311)or the control group (N = 312). The only requirement for inclusion in the study was that the participants were giving birth. Participants were not matched for factors such as their age, marital status or whether or not it was their first child. It was presumed that such individual differences would be controlled for by the random allocation of the participants within the relatively large sample. Subsequent analysis of the characteristics of those in the sample revealed that there was no significant differences in terms of age between the intervention and the control group. Neither did they differ on a set of88 socio-economic details. QUESTION 4: BLINDED The intervention participants were not blind to the fact that they were receiving help from a support worker. No detailed information is given of the control group and of what their perception and knowledge of the research was. Inevitably the support workers themselves knew that they were in the intervention group. The potential, however, for observational bias was relatively small as the dependent variables were provided by the participant. As they had nuclear interest in demonstrating that the intervention had made appositive effect when it actually had not, this should have helped to ensure that the data given were accurate accounts of what had actually happened. . QUESTION 5: ACCOUNTED FOR Of the 623 participants who were recruited for the original study, a total of 551 participants completed the whole study through to the follow up stage. The cases of drop out were due tithe participants not wanting to complete the course of home visits or because they did not return the questionnaires at the follow up stage. QUESTION 6: FOLLOW-UP A range of questionnaires were completed by the participants at the six week and six month follow up stages. It would have been interesting to combine this approach with a more qualitative method, such as a focus group, such that a more in-depth data set could be gained to supplement the quantitative data. QUESTION 7: CHANCE The study employed a relatively large sample of 551 participants. QUESTION 8: FINDINGS Therefore were no significant health benefits associated with the intervention at the six week or six month follow up periods. The cost of the intervention to the NHS was £815 for the intervention group and £639 for the control group. There were no differences between the groups in terms of their use of the social services and in personal costs. QUESTION 9: PRECISE The study provides p values which indicates that there are no significant benefits associated with this intervention despite it being significantly more expensive. QUESTION 10: OUTCOMES As a result of the relatively large sample it would appear that these results could be generalised to other simple hospital situations in the UK. Based on the statistics provided, one would not recommend this intervention in terms of the health benefits. Having said this, it was a popular intervention with the women who received it and this may have value in itself. Article 2: Scott et al (2001a) TITLE Multi-centre controlled trial of parenting groups for childhood anti-social behaviour in clinical practice. AUTHORS Scott S, Spender Q, Dolan M, Jacobs B and Ashland H SOURCE British Medical Journal, 2001, 323, 194 QUESTION 1: FOCUS This research was sufficiently focused on the evaluation of a specific programme for a specific age group and set of behaviours. QUESTION 2: APPROPRIATENESS A sample of 141 3-8 year olds were allocated to either receive the intervention or to go on a waiting list(control group). Allocation was based on the date of referral This was an appropriate approach for this research study as it enabled the effects of the intervention programme to be evaluated. QUESTION 3: ALLOCATION The controlled trial approach was used as the allocation procedure should help to ensure that the children in the intervention and control groups exhibited equivalent anti-social behaviour and hence individual differences could be controlled for. QUESTION 4: BLINDED The participants were blind to the allocation stage of the methodology. The participants were aware that they were taking part in an evaluation study. The people who rated video tapes on the parent participants and their children was blind to whether the participant had been in the intervention group or in the control group. Therefore the ratters were blind to treatment and condition. QUESTION 5: ACCOUNTED FOR A total of 31 participants dropped out of the study as they did not attend a sufficient number of the intervention sessions. QUESTION 6: FOLLOW-UP Participants were followed up five to seven months after the base line stage. Six measures of child behaviour were taken as well as one measure of parenting behaviour. This is inacceptable follow up period for this form of study. A long term follow-up, however, would have helped to establish the permanence of any significant changes which result from the intervention. QUESTION 7: CHANCE A power calculation was reported in this study and the sample size exceeds that which is recommended. Thus it could be argued that sufficient steps have been taken to minimise the possible influence of chance. QUESTION 8: FINDINGS The referred children who took part in the study were highly anti-social. A significant reduction was observed in taint-social behaviour of those within the intervention group. The behaviour of those within the control group was found to remain constant. The praise given by parents was found to increase three fold by those in the intervention group and to decrease by a third for those in the control group. QUESTION 9: PRECISE Confidence levels are provided within the statistical section of the study. Based on these it could be concluded that the parental group behavioural programme does have a significant impact on serious anti-social behaviour among children. QUESTION 10: OUTCOMES The large sample and sound methodology employed within this research would lead one to conclude that these results could be generalised to children of similar ages and with similar levels of anti-social behaviour. Article 3: Harrington et al (2000) TITLE Randomised comparison of the effectiveness and costs of community and hospital based mental health services for children with behavioural disorders. AUTHORS Harrington R, Peters S, Green J, Byford S, Woods J and McGowan R. SOURCE British Medical Journal, 2000, 321, 1047-1050 QUESTION 1: FOCUS The research focused on the evaluation of a community based versus a hospital based delivery of mental health services for children with behavioural disorders. The question set was relatively broad including both the costs and effectiveness of the approaches but it was sufficiently focused on specific programmes. QUESTION 2: APPROPRIATENESS The parent/child participant pairing were randomly allocated to receive the behavioural programme either at community location or at the hospital. This allocation was performed bay researcher who was independent of the study. The allocation was performed using stratified sampling between the two different health authorities involved in the research. QUESTION 3: ALLOCATION This randomisation was performed such that no bias within the allocation procedure could have an influence on the results. The potential of parental expectations as a confounding variable was also acknowledged and assessed. No significant difference was found between the two groups on this variable. QUESTION 4: BLINDED At the observational stage of the research theatre was blind to the treatment group of the participants. This was demonstrated when they tried to identify the location which different participants had received the intervention. Their performance on this task was no better than chance. QUESTION 5: ACCOUNTED FOR A full set of data was available for 115 out of the 141 participants who took part in the research. The drop outs occurred through non-attendance to the programme sessions or no data being provided at the follow up stage. QUESTION 6: FOLLOW-UP The participants were followed up one year after the base line stage. QUESTION 7: CHANCE The sample size was selected based on the size of the effect which was required by the purchaser and the provider’s agreements regarding whether the programme would be accepted for wider implementation. QUESTION 8: FINDINGS It was reported that there were no significant differences between the intervention groups in terms of the parents’/teachers reports of the child’s behaviours, the parents ‘criticisms of the child and the impact of the child’s behaviour on the family. Parental depression was identified as a significant problem and variable which predicted the outcome of the child’s behaviour assessments. QUESTION 9: PRECISE The ultimate finding of this research was fairly specific in suggesting that the location in which a parental behavioural management programme was delivered did not have significant impact on the child’s behaviour. It appears more important that a range of services are made available, including those which address parental depression. QUESTION 10: OUTCOMES The large sample and the use of two different health care authorities would lead one to conclude that these findings could be generalised to other areas of the UK. Article 4: Buts et al (2001) TITLE Effectiveness of home intervention for perceived child behavioural problems and parental stress in children with utero drug exposure AUTHORS Buts AM, Pulpier M, Marino N, Belcher M, Leers M and Royall R. SOURCE Archives of Paediatric and Adolescent Medicine, 2001, 155, 1029-1037 QUESTION 1: FOCUS This research project was specifically focused on evaluating a home intervention programme which aimed to educate and provide support for parents of children with perceived behavioural problems. QUESTION 2: APPROPRIATENESS Participants were mothers who had recently given birth at one of two urban based hospitals in Baltimore, USA. They were randomly allocated to either receive the home visits or to be given the standard care package which would usually be given. QUESTION 3: ALLOCATION Random allocation was used to overcome any potential bias which could have been present if the researchers had allocated the participants. This enabled an assessment of the relative benefits of the home intervention to be determined over and above that which would be associated with standard care. QUESTION 4: BLINDED The data obtained within the study was via questionnaires completed by the parental participants. They were blind at the allocation stage of the study but clearly they knew that they had been either exposed or not exposed to the home visit intervention. The child behaviour ratings were given by an independent observer. QUESTION 5: ACCOUNTED FOR A total of 100 participants took part in the study. A sample of 51 participants comprised the standard care control group with 49 being in the intervention group. The details of the dropout rates were not clear. QUESTION 6: FOLLOW-UP A series of 16 home visits were given to those in the intervention group between the birth of the baby and when they were18 months old. The parents and child were then monitored when the child was between two and three. As a result of the long period of time involved, it is difficult to conclude with confidence whether any differences between groups were as a result of the 16 home visits. QUESTION 7: CHANCE The results were statistically significant with as ample of 100 participants. They meet the confidence levels of 95%. QUESTION 8: FINDINGS Significantly fewer children in the intervention group were identified as having behavioural problems during the follow-up period (14%) relative to those who had received standard care (31%).It was also reported that the parents in the intervention group were significantly less anxious and distressed (10%) than those in the control condition (31%) QUESTION 9: PRECISE This research indicates that the home intervention helped to significantly reduce the child’s behaviour problems and to reduce the probability that the parents would go on to experience significant levels of parental distress. QUESTION 10: OUTCOMES As this study was conducted in the USA, the extent to which the findings can be generalised to the UK is questionable The methodology would need to be replicated in a Upsetting for one to accurately assess the applicability of this home intervention to the UK population. Article 5: Webster-Stratton et al (1998) TITLE The long-term effectiveness and clinical significance of three cost-effective training programs for families with conduct-problem children. AUTHORS Webster-Stratton C, Hollingsworth T, Kolpacoff M SOURCE J Consult Clin Psyche 1989; 57: 550-553 QUESTION 1: FOCUS This research focused on evaluating three different cost-effective parent training programmes for people who have conduct-problem children. Both their clinical effectiveness and long-term effects were assessed. QUESTION 2: APPROPRIATENESS Parents of conduct-problematic children were randomly allocated to receive one of three different formats of apparent training programme. QUESTION 3: ALLOCATION They were randomly allocated to avoid any research bias. It allowed comparisons to be made on the results gained from the three treatment groups. QUESTION 4: BLINDED The ratters of behaviour who attended the participants’ homes were blind to the treatment condition of the participant. Again this avoided the potential influence of researcher bias. QUESTION 5: ACCOUNTED FOR A total of 93.1% of those who attended the courses were available for the follow up stage of the research. did drop out.. QUESTION 6: FOLLOW-UP Participants were followed up one year after attending the course. Teacher and parent perceptions were recorded as were home observations of behaviour by a researcher QUESTION 7: CHANCE The statistics were significant at the 95% confidence level. QUESTION 8: FINDINGS The research found that the significant improvements in terms of child behaviour were made after the course and that these were maintained at the follow up stage. It was also reported that 2/3 of the children involved had made further significant improvements. Parent perceptions revealed that the course which involved both video tapes and group discussions led to the most satisfaction. QUESTION 9: PRECISE Based on this research all three forms of this parent training programme were effective both after the intervention and at the follow up stage. It was also claimed that all three approaches were cost-effective but information is not provided to support this claim. QUESTION 10: OUTCOMES The results of this research support the use of the parent training programme for child behavioural problems both for short and longer term benefits. However, one must include the caveat here that the research was conducted by the designers of the courses and hence it was not an independent evaluation. Also it was conducted in America and the results may not transfer to the UK. Article 6: Conduct Problems Prevention Research Group (1999) TITLE Initial impact of the fast track prevention trial for conduct problems: 1, The high risk sample. AUTHORS Conduct Problems Prevention Research Group SOURCE J Consult Clin Psyche 1999; 67: 631-647 QUESTION 1: FOCUS A multi-faceted approach for the management of child behavioural problems was the focus of this study. QUESTION 2: APPROPRIATENESS Children were randomly allocated to the Fast Track programme or to a control condition.. QUESTION 3: ALLOCATION This design ensured that there would be comparative group with which the results of the intervention group could be compared. This would an appropriate approach for the evaluation of the programme QUESTION 4: BLINDED Ratters of the children’s behaviour at the follow upstage were blind to the condition which was participant had be allocated. QUESTION 5: ACCOUNTED FOR Information was not given regarding the dropout rate. Presumably as this research involved an intervention which was incorporated into the education programme, the dropout rate would have been relatively low if attendance to the kindergarten/school was compulsory. QUESTION 6: FOLLOW-UP The participants were followed up when they reached Grade 1 level of the education process. QUESTION 7: CHANCE The results section provided p values to demonstrate statistical significance on the key findings of the research. QUESTION 8: FINDINGS It was reported that there were moderate improvements in terms of social, emotional and academic skills, peer interactions and conduct problems. The parents reported a reduced need for physical discipline and an improvement in their satisfaction levels regarding being a parent. The parents were observed to use more appropriate and consistent discipline, show more warmth and involvement and to be more involved with the school. QUESTION 9: PRECISE This research indicates that a comprehensivemulti-faceted approach using home visits and a parental training programme can have a significant impact on behavioural problems. QUESTION 10: OUTCOMES It is difficult to conclude which aspects of thecourse caused the significant improvements and hence to recommend specific interventions based on this evidence. It is also difficult to comment on whether this research would be generalizable to countries outside of America. Article 7: Webster-Stratton (1989) TITLE Preventing conduct problems in Head Start children: strengthening parenting competencies. AUTHORS Western-Stratton C SOURCE J Consult Clin Psyche 1998; 66: 715-730 QUESTION 1: FOCUS This study evaluated a group parenting programme for mothers involved in the Head Start programme.. QUESTION 2: APPROPRIATENESS A sample of 394 mothers within 9 Head Start centres were involved in the study. These Head Start centres were randomly allocated to either an experiment condition (in which parents, teachers and family service workers were involved in the intervention)or the control which received the standard Head Start programme QUESTION 3: ALLOCATION This random allocation was an appropriate approach to assess the benefits of the intervention QUESTION 4: BLINDED Observations of the parents and children during the study were made by ratters who were blind to treatment condition. QUESTION 5: ACCOUNTED FOR No information was given regarding dropout rates. QUESTION 6: FOLLOW-UP Participants were followed up one year after the intervention. QUESTION 7: CHANCE The standard 95% confidence level was used to statistically test the significance of the improvements made. QUESTION 8: FINDINGS Parents in the intervention group were found to use less critical remarks and commands, less harsh discipline and to be more positive and confident in their parenting relative to the control group. Teachers reported that the intervention mothers were more involved in their child’s education and that the children were more socially competent. Intervention children were observed to exhibit lesson-compliance and conduct problems. QUESTION 9: PRECISE The main finding of this project is that a group parental programme has a number of advantages over and above the standard Head Start programme. These benefits were found to still be present at the one year follow up stage. QUESTION 10: OUTCOMES These findings are encouraging but again the project was conducted by those who developed the intervention. Having said this, the use of blind ratters should have removed observational bias but other implementers of the strategy may not be as motivated to ensure its success. Article 8: Sleep (2003) TITLE A randomised controlled trial for comparing alternative strategies for preventing infant crying and sleeping problems in the first three months of life. AUTHORS Sleep J SOURCE Mother and Child Health, Doha guidance/research and development 2003 QUESTION 1: FOCUS This research aimed to evaluate a behavioural intervention, a low-cost education approach and the standard NH procedures to prevent child with problematic sleeping behaviour. QUESTION 2: APPROPRIATENESS Mothers were randomly allocated to one of three treatment conditions, the behavioural intervention, the low-cost education approach and the standard control condition. QUESTION 3: ALLOCATION The random allocation was appropriate as it allowed the effectiveness and efficacy of the three interventions to be evaluated. QUESTION 4: BLINDED There was no need for blinding to be used within this methodology as the data source was predominantly based on them others’ perceptions of the situation and their children’s behaviour. QUESTION 5: ACCOUNTED FOR A total of 610 mothers took part in the study. No information was given regarding any participants dropping out. QUESTION 6: FOLLOW-UP The mothers and their children were monitored at the six week and twelve week stages and were then followed up when the child was nine months old. QUESTION 7: CHANCE Statistical analyses were tested for significance at the 5% level. This was appropriate for this research. QUESTION 8: FINDINGS The number of interrupted nights were recorded byte mothers (defined as when they had less than five hours of uninterrupted sleep). All three groups had made similarly significant improvements at the six week stage. Those in the behavioural group then went on to make significantly more improvements by the twelve week stage relative to the other groups. At the nine month follow up, the behavioural group felt that the intervention was more convenient. Significantly fewer of the behavioural group required the services of health visitors and 10% more of them reported that their child had acceptable sleeping behaviour. QUESTION 9: PRECISE The behavioural approach of this study proved to have significant benefits over and above the low-cost educational approach and the standard NHS approach. The contact between the motherland the health visitor appeared to promote faster improvements in sleeping behaviour. QUESTION 10: OUTCOMES This is a good study with a large sample. It would have been interesting to continue the follow up to monitor behaviours other than those relevant to sleeping. Article 9: Worth and Hogg (2000) TITLE A qualitative evaluation of the effectiveness of health visiting practice. AUTHORS Worth A and Hogg R SOURCE British Journal of Community Nursing, 2000, 5 (5), 224-228 QUESTION 1: AIMS The objective of research was to evaluate parents ‘perceptions of the effectiveness of health visiting practices. QUESTION 2: APPROPRIATENESS The qualitative approach allowed rich data to be obtained regarding the topic. It ensured that all aspects of peoples’ perceptions could be gained, some of which may have been missed by a quantitative method. QUESTION 3: ADDRESS The qualitative approach did afford a verbal evaluation of health visiting practices and hence addressed the research aims of the project. QUESTION 4: RECRUITMENT Participants were through letters and contact with the health visitors. This was an appropriate approach. QUESTION 5: Data were collected via interviews with parents. They were semi-structured to ensure that specific topics were covered but that it was flexible enough to cover topics outside of those identified by the researcher before the interviews. QUESTION 6: FOLLOW-UP Interviews were conducted by a set of researchers who had received the same instructions and training. The potential was there, however, for the researcher/participant relationship to influence responses but efforts were made to ensure that the participants were relaxed and aware that their opinions were both confidential and voluntary. QUESTION 7: ETHICS The participants’ responses were confidential and they were reminded of their right to withdraw at any time. QUESTION 8: ANALYSIS The interviews were transcribed and analysed to identify the salient themes. This was appropriate for this nature of study. QUESTION 9: FINDINGS The study found that the health visitor/parent relationship was an important one in providing much needed support and advice regarding the parenting role. QUESTION 10: VALUE The study is very important in demonstrating that health visitors have benefits which lie outside of the realm of quantitative targets. Their relationship with the health visitor provides a key source of support for the parent. Article 10: Weeks and Laver-Bradbury (1997) TITLE Behaviour modification in hyperactive children. AUTHORS Weeks A and Laver-Bradbury C. SOURCE Nursing Times, 1997, 93 (47), 56-58 QUESTION 1: FOCUS This study was focused on evaluating the effect of eight home visits by health visitors on child behaviour. QUESTION 2: APPROPRIATENESS Children were randomly allocated to either the intervention group (who were visited) or the control group (who provided data at the base-line and follow up without receiving an intervention). QUESTION 3: ALLOCATION This approach was appropriate as it afforded direct comparison of child who had and who had not received the intervention. This should, in theory, have allowed the benefits of the intervention to be highlighted. QUESTION 4: BLINDED The ratters of the children’s behaviour at the baseline and follow up stage were blind to the treatment condition of the child. QUESTION 5: ACCOUNTED FOR No reported drop out information was provided. QUESTION 6: FOLLOW-UP Children were followed up after the eight visits of the health visitor were completed. No longer term follow up was reported. QUESTION 7: CHANCE Statistical tests of significance were conducted at the 95% confidence level. QUESTION 8: FINDINGS The children in the intervention group were found to show significantly less disobedience, fewer temper tantrums and improved concentration. QUESTION 9: PRECISE Therefore the intervention of eight home visits by health visitors did appear to have a number of beneficial effects on child behaviour. QUESTION 10: OUTCOMES The cost of the intervention is not reported and the extent to which the significant improvements were maintained over longer follow up period could have been tested. However, it would be expected that such benefits could transfer to other UK locations and these merit further empirical research.

3.0 Narrative

This literature review has focused on research studies which have investigated the efficacy and effectiveness of interventions for child behavioural management. It has particularly focused on research which has evaluated the effect of health visitors and the effectiveness of Group Parenting Programmes. Ten relevant research articles were selected to be included within the detailed literature review. Each of these were subject to the CAST analysis check list. Depending on whether they were quantitative or qualitative in nature, the methodology and results of the research were assessed against a set of criteria. These are provided within the results section of the report. Each of these studies will now be discussed and critically analysed to determine what they can offer as evidence upon which to answer the research question. Firstly the research regarding the effectiveness of health visitors will be considered. Then the research which has addressed the effectiveness of Group Parental Programmes will be outlined and its advantages identified. The two approaches will then be compared in order that conclusions can be drawn regarding whether Group Parenting Programmes are more effective than individual home visits by health visitors in terms of behavioural management.

3.1 Health Visitor focused research

Five of the ten articles reviewed in this research were focused on the evaluation of health visitors in terms of promoting positive behavioural changes. These studies will now be considered with references to the role of a health visitor at the earliest stage of child’s life through to when they are of school age. A relatively recent study in this area was conducted by Sleep (2003).It focused on addressing the effectiveness of a health visitor in managing a baby’s sleeping behaviour. A total of 610 baby/parents were randomly allocated to one of three treatment conditions. The FirstGroup received a behavioural intervention which was provided by a health visitor attending the house. The parent was encouraged to extenuate the difference between day and night time such that the baby could learn to sleep based on environmental cues. The parent was encouraged not to try and rock, hold or feed their babies to sleep, to place the baby in a darkened environment when it was time to sleep and to minimise the amount of interaction between themselves and the baby during a time when the baby should be sleeping. The second group received an educational intervention. They were given information regarding best practice in terms of promoting sleeping behaviour. This information was designed in collaboration with health visitors. The parents were also made aware of a help line which they could use that was run by a voluntary organisation. The third and final condition waste control group. They received the standard community based care which would normally be given to any parent and baby in the UK. It was found that at the six week stage, the babies had all made significant improvements in terms of the number of uninterrupted night’s sleep which they had had. However, more significant improvements had been made by those in the behavioural group at the twelve week stage. At the nine month follow up, 10% more of the behavioural group reported that their child slept regularly and to a satisfactory level. They also felt that the intervention benefited from being convenient and that they now needed to use less of the health services, such as health visitors, which were available to them. This demonstrates that the health visitor can provide an effective intervention regarding behavioural management at the earliest stages of the baby’s development. The fact that the parents reported that convenience was a key benefit is important. With the health visitor visiting them at home it removes the need for the parent to leave the house, possibly find a baby sitter and do so at time which may not prove to suit them. Another study which evaluated the effectiveness of the health visitor at the earliest stages of the child’s life was conducted by Morrell and Walters (2000). Health visitors made ten three hour visits in the first month of the baby’s life. Although no specific health benefits of the intervention were identified, the support given by the health visitor and the benefit of this relationship for the parent was viewed as being very important. Thus, health visitors as an intervention were seen as providing much needed support for the parents involved in the study. Research has also evaluated health visitors with slightly older children in America. Buts et al (2001) assessed the impact of 16 home visits when the child was aged between 0 and 18 months. At the follow-up stage, when the child was between 2 and 3 years old, significantly lower behavioural problems were associated with the intervention group relative to the control group. The children involved in this research were identified as being at a high risk of developing behavioural problems and hence this is an interesting finding. It was also reported that parents in the intervention group experienced significantly lower levels of distress relative to parents in the control condition. Therefore health visitors were again shown to have benefits for the parent and to have benefits regarding the child’s behaviour. The work of the health visitor has also been shown to be effective withholder children. Weeks and Laver-Bradbury (1997) evaluated the effects of eight home visits by health visitors to parents with a child between the ages of 4 and 8 years old. By comparing the observations of the children’s behaviour after the intervention, with those of a control group of children, a number of significant effects were identified. Significant improvements were made as a result of the home visits in terms of a reduction in the level of disobedience, a reduction in the number of temper tantrums that were observed and an increase in the level of concentration shown by the children. This research demonstrates that the health visitors do have specific behavioural benefits associated with their application to children between 4 and 8years of age. As well as these behavioural benefits, one cannot underestimate the role which is played by the health visitor in terms of the supportive relationship which they have with the parent. They can provide a useful source of advice, information and guidance regarding referral to other health services that may be required. The benefits of these intangible factors which are not generally focused on by targets were illustrated by further relevant research. Worth and Hogg (2000) conducted qualitative interviews with the parents who had been visited by health visitors. They reported that the key benefits of the health visitors help was in supporting the parent, the teaching of important skills and guidance regarding the parental role and what is required of them byte child to ensure that behavioural problems do not present themselves. Therefore the research reviewed within this literature review regarding health visitors has shown that their effectiveness can be discussed in terms of three key aspects. Firstly, they can have benefits in terms of behaviour management right from when the baby is first born through to when they become infants and children. The second broad area of advantage, which should not be ignored, concerns the benefits for the parent which stem from their relationship with the health visitor. Finally, the fact that the intervention is convenient for the parent is another important benefit. This discussion will now move on to consider the benefits which are associated with Group Parenting Programmes in terms of behavioural management.

3.2 Group Parenting Programmes focused research

Four of the studies considered in this literature review specifically focused on evaluating Group Parental Programmes as a behavioural management intervention. A major evaluation was conducted by Webster-Stratton (1998). A group of nine Head Start centres were randomly allocated to either the experimental condition or the control condition. A sample of 394 participants took part in the research. After the intervention the parents in the intervention group were observed to use significantly less critical remarks and commands, less harsh discipline and they were also more positive and confident in their role as a parent relative to the results of those in the control condition. The teachers of the children in the intervention group reported that the parents were more involved in their child’s education and that the children were more socially competent. They also perceived that the child performed a lower level of non-compliance andante-social behaviour relative to the teachers of the children who were allocated to the control condition. Therefore this Group Parenting Programme appears to have significant benefits in terms of the child’s behaviour and on the parents parenting style. One drawback of this project was that it was conducted by the team who developed the Group Parenting Programme. This may have ensured that the researchers and course providers were more motivated to work towards significant changes being demonstrated. Blind observers were used to help remove the possibility of researcher bias in the ratings of children and parent behaviours but the lack of an independent team of reviewers does place a question mark over the research. It may well be beneficial in this case but in order to have a positive effect in other situations, the course may need to be delivered by experienced researchers and developers in the field. Wider application of the course with less experienced course providers may not provide as significant results. However, such an assertion would need to be tested through empirical research before it can be confidently accepted or rejected. At this stage, however, it does remain a significant limitation of this research. Another study by this team of researchers was conducted in order to evaluate different forms of Group Parenting Programmes. Webster-Stratton et al (1989) compared the effects of interventions which involved group discussions, video tapes of examples or both approaches combined. All three groups were found to significantly reduce the anti-social behaviour of the children of the parents who took part in the research. These benefits were still found to be present at a one year follow up stage. It was noted that the intervention which incorporated both group discussions and video tapes of example behaviour were the most effective approach. They were said to provide the participants with an opportunity to share advice and experiences and to learn that they were not the only parents experiencing difficulties regarding their child’s behaviour. As discussed with the previous Webster-Stratton study, a significant limitation of this evaluation is that it was performed by the developers of the study and hence they had a vested interest in demonstrating that it had a significant effect. Furthermore, it was conducted in America. The extent to which American children and those living within the UK are comparable is difficult to assess. It may bethe case that a Group Parenting Programme may be effective in the US Abut not in the UK. A cross cultural study would need to be conducted inorder to accurately assess this. This study does, however, support the notion that the Group Parenting Programme has a significant and positive impact on children’s behaviour. An evaluation of a Group Parenting Programme has been conducted in teak by Scott et al (2001a). Children who were referred to the health services as a result of their anti-social behaviour were randomly allocated to either receive the intervention or to be assigned to the waiting list. It was this second group of participants which represented the control condition for this study. This was a useful study as it was conducted in a real life clinical environment within the UK. Therefore the extent to which the results should be generalizable to other UK clinical environments should be relatively high. A total of 110 parents took part in the research. At the end of the intervention, the behaviour of the children whose parents were in the intervention group and in the control group were observed. It was reported that the praise used by those within the intervention group increased three fold whilst that used by the parents in the control group fell by a third. The behaviour of the children associated with the intervention group was found to significantly improve with them performing less anti-social behaviour after the intervention. The behaviour of the children who were on the waiting list and hence in the control condition, was not found to change significantly from before toaster the intervention. This research demonstrates that a Group Parenting Programme can be effective in positively changing children’s behaviour in the UK. It was also conducted by therapists who were trained in the technique rather than people who had been involved in the development of the course. All of these factors ensure that this Isa good research investigation and that its results should effectively transfer to the UK population. Another UK based study compared whether the location at which the Group Parenting Programme was delivered had a significant impact on the effectiveness of the course. Harrington et al (2000) studied the effectiveness of a Group Parenting Programme which was delivered in community based location compared to a hospital location. A total of115 parents were randomly allocated to one of the two intervention conditions. When the child who belonged to each participant was observed after the Group Parenting Programme had been completed, significant improvements had been made by both groups. It can be concluded as a result that the location in which the Group Parenting Programme was delivered does not have a significant impact on the effectiveness of the course. Another interesting finding of this study was reported. Parental depression was found to be a significant issue and to be strongly associated with the behaviour of their child. The level of parental depression was not effected by attending either of the interventions. Therefore, it may be the case that other measures need to be put in place which work alongside the Group Parenting Programme which target other relevant factors, such as parental depression. Therefore the research within this systematic review which has evaluated Group Parenting Programmes for managing children’s behaviour has highlighted a number of significant advantages. Firstly, there are benefits regarding the parents. Their parenting skills appear to improve along with the extent to which they are involved in their child’s education. There are also significant improvements in terms of their children’s behaviour for parents who have attended a programme. They were observed to perform significantly less anti-social behaviour and temper tantrums. The location at which the Group Parenting Programme was delivered did not appear to have a significant impact on the effectiveness of the course. The follow up stages of the research reviewed demonstrated that the benefits of the Group Parenting Programme still remain significant in the medium term. One limitation of this set of research is that much of it is conducted in America(Deal 1994) and by the researchers who had developed the Group Parenting Programme. More independent research needs to be conducted in the UK in order that its effectiveness for behavioural management in this country can be determined. Thus far, the results are encouraging for the use of Group Parenting Programmes in the management of children’s behaviour.

3.3 Comparing the two approaches

These different approaches have been shown to have different benefits for different stages of the child’s development. For the first few weeks of life, the health visitor appears to have the major benefits. It can help to make significant improvements in terms of the child’s sleeping behaviour. Perhaps more importantly, they provide vital support for the parent in giving them advice and help in the difficult early weeks of parenthood. The Group Parenting Programme approach has not been evaluated for these early weeks and months of the child’s life. It does not have the advantage of convenience which is associated with the health visitor. For a range of reasons, a parent may not want to attend Group Parenting Programmes. Firstly, it may be inconvenient to them in term soft finding the time to attend the classes. Another possible disadvantage is that parents may perceive that they are viewed as being ‘bad parents’ They may not want to attend such a course until they perceive there to be a significant problem in their child’s development or behaviour. As such problems are generally identified when the child is over a year of age, it is perhaps unlikely that the parent will believe that their child has a behavioural problem in the early weeks and months of life. More research would be required here inorder to determine how health visitors and Group Parenting Programmes are viewed by parents of children who are different ages. For slightly older children, the benefits of the Group Parenting Programme may become more salient. They have been shown to have significant benefits in terms of reducing children’s anti-social behaviour. They were also seen as having the added advantage of providing an opportunity for the parent to discuss these issues with other parents. They may be able to learn from each other as well as from the providers of the course. By sharing different experiences and techniques, the parents can learn that they are not on their own in having a child with anti-social behaviour. Another benefit of the Group Parenting Programme is that the parents choose to attend the course. It therefore ensures that they are motivated to learn and to take serious role in their child development. Research would be required to clarify this ;but one could argue that this motivation would increase the probability that the parents’ experience of the course were positive and that this in turn has a positive effect on their child’s behaviour. Finally, the Group Parenting Programme was shown to significantly improve the parents’ parenting skills. They were seen to use more praise, fewer critical remarks/commands and to improve the parents’ level of confidence in their parenting skills. Parenting skills were not highlighted as a benefit of health visitors and hence this may be another way in which the Group Parenting Programme is more effective than the health visiting approach to behavioural management.

3.4 Multi-faceted approaches to behavioural management

It may be the case that the benefits of both health visiting and a Group Parenting Programme could be realised through the implementation of a multi-faceted approach. The positive elements of both interventions could be incorporated into a global solution which provides a more comprehensive and ultimately effective programme of behavioural management. One such approach was evaluated by the Conduct Problems Prevention Research Group (1999). They tested out the Fast-track programme. Fast Track is a multi-site, multi-component preventive intervention for young children at high risk for long-term antisocial behaviour. Based on a comprehensive developmental model, intervention included a universal-level classroom program plus social skills training, academic tutoring, parent training, and home visiting to improve competencies and reduce problems in a high-risk group of children selected in kindergarten. At the end of Grade 1, there were moderate positive effects on children's social, emotional, and academic skills; peer interactions and social status; and conduct problems and special-education use. Parents reported less physical discipline and greater parenting satisfaction/ease of parenting and engaged in more appropriate/consistent discipline, warmth/positive involvement, and involvement with the school. Evidence of differential intervention effects across child gender, race, site, and cohort was minimal. By combining the two approaches which have been evaluated in this review, the benefits of both approaches can be realised and the providers of both interventions can share and benefit from each other’s experience in the area. As health visitors have a more significant impact during pregnancy, birth and then after birth, they can be used as an initial behavioural management approach. The Group Parenting Programmes could then prove to be more effective when the child reaches the age of two or three when behavioural problems become more noticeable and problematic. The costs associated with such an approach would need to be evaluated by empirical research to determine whether the use of both approaches is economically viable.

4.0 Discussion, conclusions and implications for practice

This literature review has critically analysed research which has assessed the effectiveness of health visitors and Group Parenting Programmes in terms of their use in behaviour management. A systematic search of the literature was conducted and ten relevant articles were selected for in-depth analysis. These articles were presented via these of the CAST tool. With regards to the effectiveness of health visitors, three key advantages were identified. Firstly, health visitors provide supportive relationship for the parent which can have many associated benefits. As argued by Beecham (1997) a positive trusting relationship can be developed, particularly when the health visitor is introduced tithe parent shortly before the baby is born or during the first few days of their life. This finding supports the argument that a health visitor can help during the pregnancy and labour stage which is proposed by Match and Sims (1992). It also supports other research which has demonstrated the benefits of health visitors in terms of the time shortly after birth (Kumar et al 1993) and in reducing the probability that the mother will suffer with post-natal depression (Ray and Hodnett2000). The second advantage of health visitors for behavioural management relates to convenience. As they visit the parents’ homes, it ensures that the parent does not have the worry which may be associated with attending the meeting at another location. They do not need to find a babysitter and the health visitor can attend at a time which best suits them. The issue of convenience is particularly important as it has been associated with parents not attending health interventions such as immunisation (Fleming and Charlton 1998). This is said to be key issue (Hall 1996) and hence any strategy which reduces the demands which are placed on the parent may reduce the probability that the parent takes advantage of the health related help which is available to them. The third and final highlighted advantage of health visitors is that they do have a significantly positive effect on behaviour patterns, such as the child’s sleeping behaviour and the number of nights of interrupted sleep which are suffered by the parent. Therefore by the health visitor attending the parents’ homes they can provide strategies and advice which can help to improve the children’s behaviours at the very early stages of their development. The three advantages of health visitors in terms of behavioural management are, therefore, that they provide a supporting relationship to the parent, a convenient intervention and have a positive effect on the child’s behaviour during the early stages of their development. The second possible behavioural management intervention to be evaluated by this literature review was Group Parenting Programmes. Poor parenting has been associated with anti-social behaviour in children(Rutter et al 1998). It is not clear whether such poor parenting causes or contributes to this anti-social behaviour. Previous research has indicated that there is a link between these variables (Farrington1995). Group Parenting Programmes were developed in order to address this situation by equipping the parents with the skills required to manage different situations involving their child and their behaviour(Patterson 1982). Research discussed in this review has highlighted three advantages of Group Parenting Programmes in terms of behaviour management. The first advantage relates to parenting skills. The courses were shown to encourage parents to use more praise and a lower level of critical remarks whilst being more confident in their parenting abilities. These parental skills were also seen at the follow-up stages of the research and hence it would appear that they are skills which remain after the programme has been completed. The second key advantage of Group Parenting Programmes is the significant impact which they have on children’s behaviour. They were seen to have less temper tantrums and to show a reduction in their anti-social behaviour both after the course and at the follow up stage. Therefore there was some evidence that these benefits were short as well as longer term. The third and final benefit of Group Parenting Programme is that it provided the parents with an opportunity to share experiences, strategies and advice regarding the management of their child’s behaviour. This advantage is not associated with health visitors and hence this is one area where Group Parenting Programmes are beneficial. Therefore, the Group Parenting Programmes were shown to be advantageous in terms of the parents’ skills, the child’s anti-social behaviour and in providing a supportive group environment for the parents. As both approaches have their own benefits, the possibility of using amulet-faceted approach was discussed. The Fast Track approach was outlined and research which had demonstrated its moderate effects of child anti-social behaviour was considered. By implementing amulet-faceted approach, it could be possible to realise all of these advantages and ensure that a more comprehensive solution is enabled. Due to the fact that the benefits of health visitors in terms of child behaviour were found to focus on the early stages in a child’s development, and that the benefits of Group Parenting Programme centre around children of a slightly older age, a form of vertical integration could be possible. Through this approach, health visitors could visit the homes of parents during pregnancy and then for the first year of the child’s life. A Group Parenting Programme would then be used when the child was a little older. This solution would ensure that the parent could benefit from the early support benefits of a health visitor before having the opportunity to share experiences and learn from other parents through a Group Parenting Programme. Clearly research is required to evaluate the efficacy and effectiveness of this solution. Resource constraints may ensure that only one approach is economically viable. Therefore in conclusion, both health visitors and Group Parenting Programmes have been shown to have a significant role to play in child behavioural management. More research is required to directly compare these too approaches. In terms of the research question, Group Parenting Programmes appear to be more effective than health visitors in terms of enabling interaction between parents and in developing these parents’ skills. However, Group Parenting Programmes are less effective at the early stages of the child’s life due to it being less convenient and because attendance to the course maybe seen as being assign of ‘bad parenting’ rather than of a parent wanting to improve their parenting skills and their child’s behaviour. Such findings have significant impacts for health visitors. The role of the health visitor needs to be clarified such that the potential benefits which come from their relationship with parents can be maximised. It highlights the need for health visitors to form at rusting and supportive relationship with the parents during pregnancy and then in the early stages of the child’s development. More researches required to help prolong the benefits of health visitors. In terms of Group Parenting Programmes, this research has significant implications regarding the way in which such programmes are perceived. The stigma associated with them only being for ‘bad parents’ need to be researched and manipulated such that more people who could benefit from these courses are willing to attend. Further research would also be merited regarding the awareness of Group Parenting Programmes and whether or not this is at a sufficient level. Finally, the ages at which the Group Parenting Programmes are effective requires further investigation such that their role in the education of parents can be identified. Both of these interventions need in-depth financial analysis. Costs are always a key issue and constraint within the health care industry and the field of behaviour management is no exception. Any proposed health intervention needs to be shown to be cost effective (Royal College of Paediatric and Child Mental Health 1997). With the costs of maternity within the UK being estimated at £1.1 billion each year, any approaches which are cost effective relative to the existing strategy will be welcomed. The significance of these interventions is highlighted by the fact that approximately 5% of children have been observed to perforate-social behaviour (Meltzer et al 2000). With this figure increasing, the demand for effective behavioural management interventions for children is likely to continue into the future(Rutter et al 1998). Any cost analysis will need to consider not only the development, implementation and evaluation of an intervention programme but also the cost savings which can be realised as a result of the intervention. It has been estimated that anti-social behaviour can cost up to 10 times that incurred by the country for people who are not regularly anti-social (Scott et al 2001b). With children who are performing anti-social behaviour having a significant chance of going on to be truant at school (Farrington 1995), and more likely to become young offenders (Scott 1998), the importance of this research topic cannot bounder stated Therefore any reduction in anti-social behaviour which can be achieved at a young age has the potential to have significant medium to long term benefits. By realising the benefits of health visitors and Group Parenting Programmes, it should be possible to make a significant reduction in the level of anti-social behaviour among children within the UK. A comprehensive approach would enable the various causes and contributing factors to the anti-social behaviours can be addressed and effective interventions can be put in place. This approach would then facilitate the effective management of parental skills and of children’s behaviour. It is likely that the health visitors and the Group Parenting Programme will not be the optimum solution on their own. Recent years have witnessed a growing acknowledgement of the importance of the role which is played by a child’s diet in determining their behaviour. Although the health visitor can provide advice on nutrition, a nutritional expert will be able to provide advice regarding diets which could promote more positive behaviour. In other circumstances, there may be need for medication to be given to the child if there anti-social behaviour increases to an extreme and unacceptable level. Behaviour of this nature may be less easy to manage via health visitors and Group Parenting Programmes. Therefore, health visitors and Group Parenting Programmes have a role to play alongside other experts in the field in helping to reduce anti-social behaviour and to shape a child’s behaviour in a positive and effective way.

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The essentials of effective community health services for children and young people: report of a working party. London: RCPCH, 1997. Rutter M, Hagel A, Gilled H. Antisocial behaviour by young people. Cambridge: Cambridge University Press, 1998. Scott S, Spender Q, Dolan M, Jacobs B and Ashland H Multi-centre controlled trial of parenting groups for childhood anti-social behaviour in clinical practice. British Medical Journal, 2001a, 323,194 Scott S, Knapp M, Henderson J, Maugham B. Financial cost of social exclusion: follow up study of antisocial children into adulthood. BMJ2001b; 323: 191-194 Scott S. Aggressive behaviour in childhood. BMJ 1998; 316: 202-206 Sindh, R and Dickson, R. The complexity of searching the literature. Nursing Standard, 1997, 11 (41), pp. 40-42. Solberg J, Meyer J, Pickles A, Simon off E, Eaves L, Hewitt J, et al.Heterogeneity among juvenile antisocial behaviours: findings from the Virginia twin study of adolescent behaviour. In: Bock G, ed. 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Presentation Material

The salient points of this literature review have been summarised into form which can be presented. It is structured in the same way in which the literature review was written. The client can put this information into a power point presentation should they decide that this is their favoured approach. In order to meet the requirement of submitting this document in rich text format, this information could not be inserted into power point but this is a relatively minor task should the client need to copy and paste this information. The information which should be included on each presentation slide will now be outlined. Slide 1: Title Page - Are Group Parenting Programmes more effective in comparison to individual home visits by health visitors? - A systematic review of the literature - Dissertation presentation - By (insert the name of the client) Slide 2: Anti-Social behaviour in Children - To a degree, aggression is a normal part of the development process - If this is not managed it can lead to anti-social behaviour - A total of 5% of children are anti-social - This figure is on the rise Slide 3: Consequences of Anti-Social Behaviour - Parental distress - Truancy when the child is of a school age - Increased chances of becoming a young offender - Increased chance that the individual will become an adult who performs anti-social behaviour - Requirement for multi-disciplinary and costly interventions in the medium and long term Slide 4: Diagnosis of Behavioural Problems - Anti-social behaviour involved in 30-40% of referrals to child mental health care services - Co-morbid symptoms including hyperactivity, emotional difficulties, language problems, poor attention and low IQ Slide 5: Behavioural Management Interventions - Aim to educate parents - Develop parental skills - Significantly reduce the level of anti-social behaviour in children - Two interventions to be focused upon within this systematic review - Health Visitors - Group Parenting Programmes Slide 6: Health Visitors - Identify health care needs - Health related advice - Help parents to access the health services which are available to them. - Advise parent in terms of nutrition, dealing with conflict and developing their parental skills in general Slide 7: Benefits of Health Visitors in General - Trusting and supportive relationship for the parents - Convenient source of health related information - Can help during pregnancy, labour and after birth - Reduce probability of the mother suffering with post-natal depression Slide 8: Group Parenting Programmes - Anti-social behaviour linked with poor parenting - Facilitate anti-social behaviour through giving it attention - Extinguish positive behaviour through ignoring it - Programmes include Webster-Stratton and the Solihull approach Slide 9: Group Parenting Programmes Emphasise - Play, praise, limit setting, rewards and managing inappropriate behaviour - Discuss video tape examples of good and bad parenting approaches - It only involves the parents and not the children - Parents share experiences and advice Slide 10: Methodology - Ten articles will be reviewed - The CAST tool will provide the framework for the analysis - This provides guidelines for the analysis of qualitative research and for randomly controlled trials Slide 11: Sources of Data - Computerised databases were searched - A manual search was also conducted - The internet for a global perspective of the field - Steps were taken to overcome the problems of misclassification and spelling errors Slide 12: Search Terms - Behavioural Management - Children - Anti-Social Behaviour - Health Visitors - Group Parenting Programmes - Webster-Stratton - Solihull - Evaluation Slide 13: Inclusion Criteria - A range of methodologies will be included - International studies will be included - Be available in English - Focus on the evaluation of Health Visiting and/or Group Parenting Programmes - Focus on behaviour management in children Slide 14: Exclusion Criteria - Research which focuses on the development of behavioural management interventions for children will not be included - Articles only available in a foreign language will not be included - Research reported prior to 1990 will be excluded Slide 15: Morrell and Walters (2000) - 623 mothers randomly allocated to intervention or control group - The intervention group received home visits from a health visitor in the early post-natal weeks - The control received the standard care - No health benefits but the support provided by the health visitor was viewed as very important Slide 16: Scott et al (2001) - 141 3-8 year olds referred to child mental health services - Randomly allocated to intervention or waiting list (control condition) - Intervention significantly reduced anti-social behaviour with control staying the same - Parental praise increased in the intervention group Slide 17: Harrington et al (2000) - Evaluated the effectiveness of community and hospital based behavioural programmes - 115 Parents were randomly allocated through stratified sampling between two health districts - No significant differences in parental perceptions of child’s behaviour - No significant differences in teacher’s perception of the child’s behaviour - No significant differences in the parents’ perceptions of the impact of the child’s behaviour on the family - Parental depression linked with child behaviour and outcome Slide 18: Buts et al (2001) - Urban based study in America - 100 randomly allocated mothers to either receive standard care (control) or a home visit intervention (experimental group) - 16 visits made when the child was between 0 and 18 months - Significantly fewer children in the intervention group were seen as performing anti-social behaviour at the 2 year follow up - Parental distress was also 10% lower in the intervention group Slide 19: Webster-Stratton et al 1989 - Three different Group Parenting Programmes were evaluated - Parents were randomly allocated to one of the three groups - Teacher/parent perceptions were recorded along with home observations - Courses which involve videotaped examples and group discussions are most effective Slide 20: Conduct Problems Prevention Research Group (1999) - Evaluated Fast Track programme - Multi-faceted approach involving both a Group Parenting Programme and home visits - Moderate improvements in social/emotional/academic skills - Improved peer interactions - Parents show more warmth, praise and involvement in their child’s education - Difficult to identify which elements of the course caused/contributed to the improvements made Slide 21: Webster-Stratton (1998) - Evaluated Group Parenting Programmes in 9 Head Start centres in USA - 394 randomly allocated to attend programme or receive standard programme - Parents in the intervention group used less criticism, less harsh discipline and more involvement in their child’s education - Child associated within the intervention showed significantly less anti-social behaviour - Benefits remained at one year follow up Slide 22: Sleep (2003) - Evaluation of an health visitors approach, an educational approach and the standard approach - They aimed to reduce the number of uninterrupted nights of sleep by improving the babies’ sleeping behaviour - All three groups made similar improvements at six week stage - More significant improvements made by health visitor group by 12 week stage - At nine month follow up the health visitor group reported that the approach was more convenient, they used less of the health services available to them and 10% more of them said that their child now slept satisfactorily Slide 23: Worth and Hogg (2000) - Qualitative evaluation of health visiting practices - Parents were interviewed using semi-structured interviews - Participants reported that the health visitor/parent relationship was very important as a source of advice, support and guidance regarding the parenting role Slide 24: Weeks and Laver-Bradbury (1997) - Evaluated the effects of eight home visits by a health visitor - Randomly allocated to receive the intervention or to receive the standard approach - The children in the intervention group showed significant improvements in terms of reduced disobedience, temper tantrums and their level of concentration relative to the control group Slide 25: Effectiveness of Health Visitors - They provide much needed support for the parent before, during and after the birth of their child - Health visitors are a convenient behavioural management intervention for the parents - They can have significant behavioural benefits in the early stages of life, such as with sleeping behaviour Slide 26: Effectiveness of Group Parenting Programmes - Significantly improves parental skills in terms of praise, criticism and in managing anti-social behaviour - Parents confidence in their own skills was seen to significantly increase - Parents became more involved in their child’s education - Children performed less anti-social behaviour - Children also perform less temper tantrums - Slide 27: Multi-Faceted Approach - ?Realise benefits of both health visiting and Group Parenting Programme - Fast-track: Universal classroom approach, Social Skills Training, Academic skills training, Parent Training and Home visits by health visitors Slide 28: Effectiveness of a Multi-Faceted Approach - Improvements in the children’s social, emotional and academic skills - Improved peer interactions - Significant reductions in the child’s conduct problems - Improved satisfaction among the parents - A reduction in the need for harsh discipline Slide 29: Comparison of the Interventions - Health Visitors are more appropriate during the first year of the child’s life - This is because of the support that they provide and because of its convenience - Group Parenting Programmes are more appropriate for slightly older children - They target parental skills and provide a good opportunity for parents to interact - Parents can benefit from sharing experiences and strategies Slide 30: Issues for Future Research - The importance of parental depression in influencing child behaviour - The effect of diet on behaviour in children - How these interventions are perceived by the parents who do and who choose not to use them - Do different approaches work in different cultures - Can these interventions work together in a global, more comprehensive, solution

Bibliographical Matrix

Author(s) Your No Title Source Year Volume Edition Page No’s Publisher Place of Publication Cohen S, Sims SL . Social support and health 1985 Harcourt Brace Jovanovich Rolando, Florida Melbourne Oakley A, and Chalmers I. Social and psychological support during pregnancy Effective care in pregnancy and childbirth. 1989 : Chalmers, Elkin M, Kiers MJNC, eds. 231-236 Oxford University Press Oxford Hart C Doing a Literature Review 1998 Sage Publications London Muldrow CD Systematic Reviewing: Rationale for Systematic Reviews 1994 Holder and Stoughton London Oman AD and Goat GH The Science of Reviewing Research 1993 Holder and Stoughton London Loy J New on the Net MIDIRS 2000 Midwifery Digest London Bell J Doing your research project 1999 Open University Press Milton Keynes Cormack D The Research Process in Nursing 2000 Blackwell Science Oxford Lo-Bind-Wood G and Haber J Nursing Research: Methods, Critical Appraisal and Utilisation 1994 Mosby London Enrol, Hussmann LR and Zell A The role of parental variables in the learning of aggression The Development and Treatment of Childhood Aggression 1991 Pepper DJ and Rubin KH 169-188 Erlbaum Hillsdale, New Jersey Patterson GR, De Garn DS and Knutson N Hyperactive and anti-social behaviours: Co-morbid or two points in the same process? Developmental and Psychopathology 2000 12 91-106

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