WHAT WORKS?

A LITERATURE REVIEW OF THE EVIDENCE FOR THE

EFFECTIVENESS OF PARENTING STRATEGIES
Prepared for Child ad !o"#h Heal#h
$% Pa& Li'e i ("e )**+
Upda#ed O,#o$er )**-
1
CONTENTS
Introduction
Executive summary
Background
current context for parenting
risk and protective factors
cost of risk factors
Rationale for parenting programs
introduction
research
reports
Evaluated parenting programs
introduction
interventions that address risk and protective factors
elements of programs that work
cost effectiveness
Recommendations from the literature
Conclusion
References
Appendices
program examples
2
INTRODUCTION
his literature review has !een undertaken to provide a !asis for decision making a!out
Child and "outh #ealth services to parents$ Apart from a few exceptions% which have
!een noted in the text% it focuses on parenting interventions which have !een rigorously
evaluated and have shown !enefits in positive outcomes for children$ here are many
other parenting programs which may also !e effective% !ut have not met the standards of
evaluation so have !een omitted$ Because this study was undertaken for Child and "outh
#ealth purposes% it looks mainly at the health&socio'emotional aspects of parenting$ his
means that to a large extent early literacy programs per se are excluded% although it is
acknowledged that there is evidence that these can have a positive impact on children(s
development and this offers opportunities for Child and "outh #ealth to link with the
)epartment of Education% raining and Employment in partnerships to assist children*s
development$ +any of the programs for parents covered in the report do have a specific
literacy component and all programs could !e expected to have an impact on literacy
through focus on communication$
,ider areas where support for parents and parenting could !e important have not !een
considered in this paper !ecause of the scope of the literature review$ hese could
include% for example% areas such as family friendly work practices% family friendly
communities% housing% child and family impact considerations on government and
community policies and practices$
In spite of the clear evidence of the disadvantages of children in this group I was una!le
to find evaluations of successful programs for A!original children$
-
E.ECUTIVE SU//AR!
his report highlights the fact that there are cost effective programs which can !ring
a!out more positive outcomes for children who are at risk of social or emotional or
mental pro!lems which inhi!it their living skills% contri!ution to the community and
en.oyment of life !oth in childhood and ongoing into adulthood$
Risk factors have !een well documented !y considera!le international and cross
cultural research as have the factors which help to protect children against adverse
outcomes$ +ost protective factors for children can !e addressed through
parenting$
he cost to the community of not addressing risk factors% particularly in the early
years% is very large in relation to the cost of intervention% however expenditure is
in the present and savings are in the future$
/arenting programs tend to have more cost !enefits for the community when used
with parents who have more risk factors than for the general community$
Current research into the development of the !rain as well as current and past
research into social% educational and mental outcomes for children highlights the
importance of a positive and supportive early environment ' the environment
provided% usually% !y parents$
0umerous national and international government reports support the importance of
programs for parents% especially in the early years !ut also at transition or crisis
points$
/rograms that have !een shown !y rigorous evaluation to have potential to lead to
positive outcomes for children include1 home visiting !y professionals% parent
education groups% antenatal support and early childhood and parenting centres$
2ther programs such as community development&social capital !uilding have not
!een rigorously evaluated in the same way !ut may have contextual !enefits in
providing positive and supportive environments for families and children$
3ocial marketing can play a ma.or role in community education and the raising of
community literacy a!out parenting and outcomes for children$
Elements that contri!ute to programs that work include careful design and program
planning and staff with !oth appropriate 4ualifications and personal skills$
/rograms such as home visiting% alone% are not as likely to !e successful as
interventions which involve a raft of different options and resources for families%
eg selected services for particular needs within universal services$
A num!er of recommendations from this literature review have !een highlighted in
the recommendations section of the report and offer considera!le possi!ilities for
effective support for parents and children in 3outh Australia$
5
0ACKGROUND
Glad to have you aboard
For the next 18 years you will
be personally responsible for the
care and well-being of another
human being. Youre on your own
Good !uc"#
/opkin% 1678$
C"rre# ,o#e1# for pare#i2
,e live in an era and a culture where we know more a!out parenting and what works for
children than ever !efore% so there are huge windows of opportunity to make a real
difference$ ,hile it is clear that conditions for children have improved in many ways
over the past century there are still too many children who are not getting the start they
need to make the most of their lives$
here is pro!a!ly more pressure on parenting than ever !efore$ ,hile the evidence
presented daily in the media a!out the importance of parents to outcomes for children can
!e helpful% it also can !e seen !y parents as an added responsi!ility and pressure and
even% sometimes% !lame$ In spite of rhetoric a!out the importance of 9the village9 to raise
children% child rearing is largely seen in our community as a private responsi!ility of
parents unless it goes seriously wrong$
In all other parts of home management% technology has reduced the workload$ In
parenting the opposite effect has !een o!served especially where !oth parents work
outside the home% so the time for the complex roles of parenting has !een eroded$ At the
same time many of the traditional structures to support parenting are also !eing eroded '
structures like clear marriage expectations and parenting roles% and support networks such
as families% extended families% communities and villages$ ,hile many of these changes
offer new opportunities to parents ' employment all over the world% opportunities to leave
dysfunctional relationships and much more choice for women% ade4uate new supports for
the parenting function of adults have often not !een put into place$
In 3outh Australia in 1667 17: of children lived in a family with neither parent
employed% and more than 2;: in families where no male was employed$ he num!er of
sole parent families in 3outh Australia is growing% including sole parent families where
the head of the family is unemployed$ In the 1668 census 5;$8: of all children in
Adelaide were living in families receiving income support$ he 3outh Australian Child
#ealth Council <1666= noted that 9increasing num!ers of children in 3outh Australia face
socioeconomic and other forms of disadvantage% resulting in significant adverse effects
on their health and well'!eing>particularly in the case of many indigenous children$9
;
As a society we give lip service to the value of children% !ut services and resources have
not followed the rhetoric% especially for young children$ here is an assumption that flies
in the face of consistent evidence that young children are 9resilient9 so that what they
re4uire for optimum development can !e easily overlooked$ ?he concept of resilience is
discussed later@$
/rograms for parents are still largely focused on treatment$ In ,estern societies% where
parenting is considered a private rather than community responsi!ility% this can lead to
difficulties in parents asking for and accepting help$ his is exacer!ated !y increasing
knowledge a!out child development and higher expectations of parents% !oth personal
and from the community$
3ome of the current issues for parents and parenting as identified !y parents include1
poverty
family !reak'upA including residence and access issues after separation
isolation
living and working away from family supports
step family parenting
isolation of parents from their cultures of child rearing
community values and confusion a!out the importance of childrearing
4uality of out of home care for young children$<#ogg et al% 2BBB=
0ote1 in parts of this report the term early intervention is used$ In the context of the paper
this implies early intervention with parenting$ he term mental health as used in this
report indicates the literal meaning of mental and emotional well'!eing% not as is often
inferred% mental illness$
Ri3' ad pro#e,#i4e fa,#or3
Resilience
In discussing programs for parents and children it is important to view them in relation to
the risk factors they are intended to address% and the protective factors they are working
to develop$ 2ften these factors are seen in the context of the development of resilience in
children$ Resilience may !e defined as the a!ility to cope with the challenges of growing
up and living in the adult world without ma.or disruptions such as criminal convictions or
mental illness$ Resilience is always defined in relation to risk factors ' usually risk for
mental illness% criminality or drug dependence$ ?Resilience is never a!solute% and studies
of adults who have coped in the presence of risk factors have shown that there are still
some damaging effects from the risk factors% al!eit not ma.or life'disruptive ones
<,erner% 1662=@$ here is always an imperative to try to remove the risk factors where
possi!le as well as to develop protective factors$
Risk and protective factors have !een the su!.ect of much research over many years and
results are remarka!ly consistent over time and culture <Cinke% 1667=$ /rotective factors
can !e classified into three main areas% factors in the child eg temperament% factors in the
8
family eg positive attachment in the first year and factors in the environment eg a
supportive relationship with a school$
Exactly how the protective factors work is not clear from the research !ut accumulated
risks lessens the possi!ility of children developing resilience <or coping skills= while
accumulated protective factors enhance this$
Risk factors
3ome of the risk factors that are associated with .uvenile delin4uency and antisocial
!ehaviour in adolescence and adulthood include harsh or a!usive discipline% parent
offending% !eing a victim of child a!use% need for special education% a family death or
family !reak'up and anti'social !ehaviour at a young age <,alker et al% 1667=$ Dactors
that relate to the family and are therefore potentially amena!le to parenting interventions
include harsh discipline% weak parental supervision% lack of positive discipline% lack of
parent involvement with the child% poor pro!lem solving and negative family
communication </atterson et al$% 1662=$
A recent report from the Australian Institute of Criminology <Bor% 2BB1= highlights the
9predicta!le developmental tra.ectory of !ehaviour pro!lems !eginning in childhood9 for
antisocial !ehaviour in adolescence$ hey note that there is evidence of continuity
!etween aggressive% non'compliant !ehaviours measure !etween one and three years of
age and externalising !ehaviour pro!lems at five years of age and a significant proportion
of the children <up to ;B:= will experience similar pro!lems into adolescence$
,e!ster'3tratton <166E= notes that risk factors that lead to continuation of pro!lems into
adolescence include1 !eginning in the preschool years% pro!lems in different settings eg
home and school% fre4uency and intensity of antisocial !ehaviour% having many different
antisocial !ehaviours and the presence of A)#)$
Risk factors for mental health pro!lems and delin4uency <Commonwealth of Aust$ 2BBB=
and delin4uency include1
/renatal !rain damage
Cow !irthweight <8$7: of children in 3outh AustraliaF=
/erinatal stress
/hysical and Intellectual disa!ility <E$7: of children in 3outh AustraliaF=
Cow intelligence
)ifficult temperament
#aving a teenage mother
#aving a single parent <EB: of children in one parent families were in the lowest
5B: of income distri!ution in 1668&EF=
A!sence of the father in childhood
Carge family siGe
Cong parental unemployment
+ental illness in a parent
/arental alcoholism
E
/arental criminality
/oor 4uality care in the first year of life% if !oth parents are working outside the
home
+a.or separations in the early years
Damily !reak'up especially where there is parental conflict$ <21: of Australian
children with one natural parent living away from their homeF=
FChildren Australia1 a social report <1666=
Risk factors are not necessarily causal and may !e associations with other causal
pro!lems rather than causal in themselves$ It is important to note that risk is not destiny
and these factors are related to populations% not individuals$
Cost of risk factors
he cost to the community of the risk factors that parenting programs seek to address is
considera!le$
2ver H2 !illion is spent each year in Australia for mental health services <2(#anlon%
2BBB=$ A!out 2B: of people have some kind of mental health pro!lem$
he economic cost of child a!use to 3outh Australia in 166;&8 was estimated at
H-B-$-- million$<+cIurk% 1667=
he cost of the criminal .ustice system to the 3outh Australian community per annum
is approximately H-BB per person <H5;B million% pa$=
Appropriate early parenting interventions are associated with !etter outcomes for children
and less demand on services for all of the a!ove areas$
Drom JCrime in Australia K Caw enforcement resourcesL$
http1&&www$ncavac$gov$au&ncp&pu!lications&crime&lawMenforcementMresources$htm
7
/rotective factors
/rotective Dactors <Cinke% 1667= which mitigate against damaging outcomes from risk
include
secure attachment
positive discipline
parental supervision <knowing where children are=
family support eg grandparent
a sense of achievement
!eing needed <re4uired helpfulness=
external supports such as school
!elonging to a supportive community group such as a church group
internal locus of control < a sense of !eing a!le to impact on what happens to a
person=$
It should !e noted that most of the protective factors are related to parenting and
potentially can !e impacted on !y supporting parents$
6
RATIONALE FOR PARENTING PROGRA/S
$f we do not attend to the needs of children %we ris" paying a terrible price in our
childrens later behavior - drugs and anti social and violent acts..our grandchildren
will live together in a society with the offspring of neglected families. &o will yours.%
<BraGelton% 2BBB=
I#rod",#io
he evidence to support interventions for parents is overwhelming and comes from the
.uvenile .ustice% mental health% physical health and more recently !rain research spheres$
+uch of this research has already !een summarised in various government reports$
Re3ear,h
Criminal .ustice
,ilson and Coury <167E= in a ma.or investigation of .uvenile crime in 0orth America
found that 9defiance% disrespect% class distur!ance% aggression and diso!edience in
kindergarten and year one as rated !y teachers predicted a high rate of offending
!ehaviour in adolescence$ hey found that parent education programs produced the most
promising results when they targeted early !ehaviour pro!lems$ he ma.ority of fre4uent
offenders rated as !adly !ehaved in the first grade$ ,hile risk is not destiny this presents
an opportunity with high pro!a!ility of making a positive impact not only on the lives of
individual children !ut also on the community !oth in cost and comfortN
+ental #ealth
he research of Cynne +urray <166E= into the outcomes for infants of untreated maternal
postnatal depression during the early months of the infant(s life shows long term impact
on children(s social% emotional and psychological health$ he Commonwealth report
9/romotion% prevention and early intervention for mental health9 <2BBB= recommends
interventions with parents as ma.or strategies to promote mental health in Australia$
Brain Research
In ma.or international reports Oeating and #ertGman <1666=% +armot <1666=% 3hore
<2BBB=% +cCain and +ustard <1666= have stressed the importance of the now
incontroverti!le evidence that the 4uality of environment and nurture in the early years
has far'reaching and important effects on health% social development and education and in
the end the productivity of the nation$ +cCain P +ustard <1666= in summing up the
evidence from research into early development of the !rain conclude that 9nurturing !y
parents in the early years has a decisive and long'lasting impact on how people develop%
their capacity to learn% their !ehaviour and a!ility to regulate their emotions and their
risks for disease in later lifeA and <that= negative experiences in the early years% including
sever neglect of a!sence of appropriate stimulation% are likely to have decisive and
sustained effects>$$,hat is fascinating a!out the new understanding of !rain
development is what it tells us a!out how good nurturing creates the foundation of !rain
development and what this foundation means for later stages of life9$ hey identified
1B
parenting as a key factor in early child development for families at all socioeconomic
levels$
Repor#3
International
In response to the evidence of the importance of supporting parents governments in
developed countries are investing large amounts in programs for parents of infants and
young children$
In response to the Acheson report into ine4ualities in health% the British
Iovernment is investing more than Q;5B million into the 3ure 3tart program for
supporting families$
A 0ational Commission on the Damily Report in Ireland <Iovt of Ireland% 1667=
recommends a national information strategy for parents% ranging from media
campaigns% a telephone helpline% printed information and parent education and
skills programs$
A national report into school readiness in the R3 <Beth'/ierce= states that social and
emotional competence !eginning in the first year is critical to early school success
and accomplishments in the work place$
he 3cottish 2ffice Report% 9A safer 3cotland1 tackling crime and its causes9 has
identified the 4uality of family life as one of the most important factors in
explaining youth crime and has allocated Q52 million over the next three years to
support parents and children in the B'- age range including parenting classes and
easier access to child guidance$
he Drom 0eurons to 0eigh!orhoods report from the R3 Committee on 3cience
and Early Childhood )evelopment give the following take home messages1
Early experiences matter and early interventions can shift the odds% !ut the
focus on !irth to three !egins too late and ends too soon$
#ealthy early development depends on nurturing and dependa!le
relationships$
#ow young children feel is as important as how they think% particularly with
regard to school readiness$
3ociety is changing and the needs of young children are not !eing met$
And they assert that 9at a time when scientific advances could !e used to strengthen early
childhood policies and practices% knowledge is fre4uently dismissed or ignored and our
children are paying the price9$
Australian Iovernment Reports
+a.or government reports in Australia have concluded that prevention and early
intervention will save communities( and the 0ation(s resources !oth financial and
psychological$
he Australian 0ational Action /lan for /revention and Early Intervention for
+ental #ealth recommends1 workplace support for families% antenatal education to
promote mental health literacy for parents% identify the core effective mental health
components of home visiting and provide home visiting and parent support
11
programs>% develop and evaluate demonstration high 4uality child care programs%
implement and coordinate screening programs for infant health and parent mental
health pro!lems$
he Australian 0ational +ental #ealth 3trategy <Commonwealth of Aust% 2BBB=
presents a rationale for adopting a promotion% prevention and early intervention
approach to mental health% arguing that 9accumulating evidence shows the
widespread and long'term !enefits of this approach9 <p xi= and includes as process
indicators 9the presence of evidence !ased programs related to promotion%
prevention and early intervention for all priority groups < p28=$
/athways to prevention1 developmental and early intervention approaches to crime
in Australia$ his report states 9there are good reasons for intervening early in life$
Damilies with !a!ies and preschoolers that are- at risk of poverty% relationship
!reakdown and a!usive or inept parenting styles are more likely to produce
teenagers at risk of criminality and su!stance a!use>$successful intervention at an
early age is a cost effective preventive strategy$ his could !e seen as a generic
form of early intervention9$ <p1B=
Children and disadvantage1 the 3outh Australian picture1 directions for action$ his
report recommends 9an investment in early emotional and educational development
in the first years of life and throughout childhood>and strategies that are inclusive
of the child(s family% school and peer networks% neigh!ourhood% community and
culture% and target not only the child(s !ehaviour% !ut also social and pro!lem
solving skills% and social and environmental conditions9$
Intervening early1 opportunities to support young 3outh Australian children and their
families$ his draft report of the Child #ealth Council&Child #ealth Advisory
Committee of the )epartment of #uman 3ervices highlights the importance of
intervening in the early years in response to research that has Jgenerated a deeper
appreciation of1
' the importance of early life experiences>
' the central role of early relationships>
' the capa!ilities% complex emotions and essential social skills that develop through '
the earliest years of lifeA
' and the opportunity to increase the odds of favoura!le developmental outcomes
through timely effective interventions and supportive community environments$
,hile the su!stance of this report is devoted to early intervention rather than parenting
per se% many of the examples of early intervention recommended are targeted to
parents eg home visiting programs% community !ased group education programs for
parents and early childhood development programs$ he report also recommends a
universal com!ined with targeted approach$
12
EVALUATED PARENTING PROGRA/S
I#rod",#io
his section looks at programs which have !een evaluated and show positive outcomes
for children$ Except incidentally it does not cover outcomes for parents% although in many
programs these have !een positive even where they are not the ma.or program goals$
9#igh risk intervention% <preventive or therapeutic= is a clinical rather than an
epidemiological task <Donagy% 1667=$ In looking at what works it is important to take into
account the way the programs are delivered$ 3imilarly designed programs can have very
different outcomes depending on implementation and the risk factors !eing addressed$
Evaluation of a home visiting program for CB, infants where home visits over two years
were accompanied !y parent group meetings and educational programs in specially
designed preschools showed no significant health or !ehaviour effects in the long term
<Bradley et al 1665=$ 2ther programs have shown sustained !eneficial effects
<Oowalenko% 2BBBA +urray and Cooper% 166E= !oth on prevention of pre'term deliveries%
less child a!use% cognitive and social outcomes for children$ his highlights the
importance of program design and staff training ' of how interventions are implemented
as well as what is done$
Criteria for effective prevention and early intervention parenting programs include1
An empirically !ased and tested model of the aetiology of the pro!lem which
identifies risk and protective factors
A relia!le and valid method of identifying children at risk
Effective methods for reducing risk and enhancing protective factors
he opportunity to apply these methods in practice <Oosky et al% 2BB% p11=
hese criteria have !een met !y research into many issues including anxiety% resilience%
delin4uency% and antisocial !ehaviour$
A num!er of well designed delin4uency prevention programs !ased on knowledge of risk
factors have !een shown to !e effective% the most important parent'related programs
!eing1
Intensive home visiting
/arenting skills education
/re'school intellectual enrichment programs <Darrington% 1668=
1-
I#er4e#io3 #ha# addre33 ri3' ad pro#e,#i4e fa,#or3
he following interventions have !een identified as successful in addressing some risk
general and some particular factors$
#ome Sisiting
/rograms that enhance attachment !etween parent and child in the first year of life have
!een shown to have sustained positive outcomes for social and cognitive development$
Early positive attachment is an important component of resilience$ Donagy <1667= notes
that mothers who have positive ante natal attachment scores have children who have
more secure attachments into childhood$ Evidence shows that early intervention for
parents of infants with difficult temperament can !e effective in modifying attachment
over time$
,ell designed and delivered early home visiting programs are one of the interventions
which have !een shown to !e cost effective over time$ he effective programs are
intensive in the early months% linked to other resources where appropriate% delivered !y
professionals% sustained over the first two years% have strategies clearly linked to risk
factors and expected outcomes% and have well trained and mentored staff$ <Behrman%
1666=$ 2ne such program in Australia <Armstrong% 2BBB= is showing promise in early
evaluations$
It is also important to note that many home visiting programs have important effects on
the parents as well as for the children% eg in spacing out further children% !etter entry to
education and the work force and less dependence on welfare payments <OitGman% 2BBB=$
#ome visiting programs !y volunteers have not !een shown to have the same sustained
positive outcomes !ut may !e a helpful part of a raft of interventions in providing social
support for parents and helping to !uild community$
/arent Education&training
In Australia% currently most programs for parents are run !y women <Allen% 1665= and
most are run for middle class groups although the latter is changing with more !eing run
across class and culture$ A significant num!er are !eing run for parents from 3outhern
Europe$
here is general acceptance that many parent education programs are effective in
improving parenting skills% parent child relations and children(s !ehaviour however there
are comparatively few rigorous evaluations$
3ome which have !een evaluated include the following$
Dollow up studies for programs for parents of children with A)#) show a
sustained improvement in oppositional !ehaviour !ut effects on A)#) symptoms
are e4uivocal <Oosky% 2BBB=
15
A recent review of group !ased parent education programs for children with
!ehaviour pro!lems <Barlow% 2BBB= found considera!le heterogeneity in the
programs studied$ +ost of the programs did not meet the evaluation criteria to !e
included% however of those that did the results showed that 9structured parent
education programs can !e effective in producing positive change in !oth parental
perceptions and o!.ective measures of children(s !ehaviour and that these changes
are maintained over time$9
Antenatal
Antenatal classes focused on psychological issues regarding child!irth% support and
parenting have shown positive effects on emotional ad.ustment% mood and parenting
satisfaction$ <Oowalenko% 2BBB=$ #ome visits during pregnancy have !een shown to lead
to teenage mothers having heavier !a!ies% less smoking in mothers% and fewer pre'term
deliveriesA thus directly impacting on risk factors$ <Darrington% 1665=
/ostnatal parenting groups
/ost natal parenting groups using a mental health model have shown positive effects on
parental responsiveness to the infants and parenting skills$ <Oowalenko% 2BBB=
/reschool&early years
/arent education programs for parents whose children are difficult to manage or
aggressive have !een shown to produce ongoing positive outcomes$ ,hile% for many
children these !ehaviours decrease with age% there is a significant proportion who go on
to adolescent antisocial !ehaviour making this an important area for intervention$
<Darrington% 1665A ,ilson and Coury% 167E=$
3chool age
Barlow P 3tewart'Brown <1667= in a review of school age programs for children with
!ehaviour pro!lems <not A)#)= including temper tantrums% aggression and non
compliance found the 9structured parent education programs can !e effective in
producing positive change in !oth parental perceptions and o!.ective measures of
children(s !ehaviour and these changes are maintained over time$9
3ocial capital !uilding
he evidence for volunteer programs that provide parents with support and&or home help
shows that such programs are valued !y parents !ut do not have an impact on outcomes
for children or reduce the risks of a!use <Carr% 2BBB=$ #owever they may have an
ad.unctive role eg in providing supportive environments for families% and more
systematic evaluation is needed to support this$ he Australian 0ational +ental #ealth
3trategy sees the !uilding of supportive environments as a goal of early intervention$
/arents of adolescents
+ore research is needed into whether there are effective treatments for adolescents$
Iroup programs for adolescents with conduct pro!lems outside the family system can
make them worse <Carr% 2BBB= !ecause of the peer group learning effect$ Ienerally
1;
programs for parents of adolescents with conduct pro!lems do not seem to !e effective in
terms of !ehaviour change for the adolescents and the evidence for 9early determinants of
adolescent !ehaviour9 is strong <oum!ourou% 166E=$
#owever part of the reason for the lack of evidence for programs for parents of
adolescents may !e due to the lack of proper evaluation$ here are some well evaluated
programs for parents of adolescents which have !een shown to have positive effects <eg
Citrownik et al% 2BBB% #enricson et al$% 2BBB=$ he program for parents </f/= pro.ect is an
Australian 0ational /ro.ect funded !y the )epartment of #ealth and Aged care and has
!een piloted across Australian with culturally diverse communities including 0E3B and
A!original families% and independently evaluated$ /arents and young people surveyed
after the program reported positive effects on parent well !eing and confidence% parent'
adolescent conflict and adolescent depression% antisocial !ehaviour and self harming
!ehaviours$
here are a num!er of reasons why there is potential for piloting and exploring models
for effective intervention with parents of young people$
Adolescence is a time of transition where parents and young people are coping with
changed expectations and demands$
Resiliency literature support the relevance of ongoing family support within the
context of appropriate differentiation for positive outcomes for young people$
/arents have a strong psychological influence on through the adolescent years$
,ith changing community structures and later moves to independent living there
are !oth pressures on and opportunities for parents of young people to have a
positive influence$
Adolescent risk taking !ehaviours eg drug use% !ring a!out family crises and hence
openness to change$
he num!er of programs offered to parents of older children and adolescents is minimal
compared with those offered for the early years% and yet there are many families with
ma.or parenting and relationship difficulties in these years$
/rograms for parents which keep help to family networks intact over the transition to
adolescence have the potential to !e effective as research shows that continued family
attachment is a protective factor in resilience <,erner% 1665=however there is little
research into programs that are addressed to parents of children in early adolescence$
Early Childhood and /arenting Centres
here are not many evidence !ased evaluations of these !ut the model has !een supported
!y !oth clinical and political leaders in 0orth America% Europe and Australia$ +any of
these centres are currently !eing trialed and offer the opportunity to provide welcoming
local !ases for parents to get a raft of services including home visiting% child care%
continuing education for parents% early literacy and parenting skills learning$ hey also
offer a structure for interagency colla!oration and for piloting and reviewing new
programs and training professionals$ he Chicago Child /arent Centres <Reynolds% 2BB1=
a large scale program developed on this model are showing promising results$ he model
18
provides educational and family support services to children aged - to 6 years$ hey are
located in the poorest neigh!ourhoods in Chicago$ It includes special learning activities
for children% and parenting and personal resources for parents including home visits%
resource mo!ilisation% educational workshops% health and nutrition services% health
screening% speech therapy% nursing and meal services$ At age 2B years there were less
school dropouts than the control group% and significantly lower .uvenile arrests$
Rniversal /rograms
Rniversal programs are few and usually limited to the provision of information% parent
helplines and child health checks and preparatory development information$ Reviews of
the efficacy of these are limited$ hey are generally are part of a raft of programs that
parents seek$
3ocial marketing&health promotion$
,hile it is harder to find evidence !ased assessment of the impact of social marketing on
developmental outcomes for children there is evidence of successful pu!lic education
campaigns regarding health% eg immunisation media campaigns$ he media influences
social attitudes and can play a ma.or role in community education <+ental #ealth
3trategy=$BraGelton and Ireenspan <2BBB=highlight the importance of pu!lic education in
developmental literacy$
he R3 3urgeon Ieneral(s conference Report on Children(s +ental #ealth <2lin% ed%
2BB1= recommends community awareness strategies regarding the needs of children$
Rniversal Information /rovision
Evidence that many parents turn to the Internet for information a!out parenting and
children(s health is growing% however evaluations of the efficacy of this as a method of
support for parents is not availa!le at this time$ In general information provision through
the world wide we! as part of a universal approach to supporting parents and families
should have !enefits in !eing availa!le at all times and empowering parents in their
parenting role and interaction with professionals$
3pecific issue ' conduct disorder
Early parenting interventions for conduct disorder with the most supporting evidence
<)avis% 2BBB% ,ilson P Coury% 167E% 3anders% 2BBB= are those which assist
parents&carers in providing 9effective% non coercive discipline% support for children(s
prosocial !ehaviour and achievements and effective family communication and pro!lem
solving styles9$ )avis notes <pE2= that there is less evidence of success with teenagers
with conduct disorders and relatively little success 9without the use of family
interventions9$ 3anders <2BBB= cites evidence 9for the efficacy of parent training9 with
early adolescents with 9oppositional !ehaviour pro!lems9$
3pecific issue ' A!original communities
Reduced parenting skills are amongst the effects of removing A!original and orres
3trait Islander children from their families% often depriving children of the experience of
exposure to family life and parenting$ here are no clearly evaluated parenting programs
1E
for A!original and orres 3trait Islander parents% however the Resourceful Adolescent
/rogram for /arents <RA/'/= which is !eing developed in 0orth Tueensland will !e
evaluated$<Clarke% 1667=$ Indigenous children represent 5: of all children in Australia
and the num!er is increasing <rewin% 1666=$
Ele&e#3 of pro2ra&3 #ha# 5or'
Effective early intervention programs should !e designed to divert pathways and produce
long'term effects </athways p1;E= and should !e 9guided !y an understanding of the risk
and protective factors of particular groups9$ he /athways to /revention report also
stresses that they should !e 9rigorously evaluated9 and demonstrate that prevention does
work$ he following are common elements of effective programs$
Ieneral factors
Clear goals and strategies are essential to effective programs% with selection of
appropriate models related to the target group$
/rograms that start early in a child(s life have the highest chance of success$
A relationship !ased approach is an essential component of successful prevention$
/rograms which enhance parent'child communication% strengthen parent sensitivity
to the child(s cues and improve parent'child relationships have shown significant
improvement on long term follow'up in children(s and young people(s conduct$
3uccessful programs are community !ased$
/rograms should attend to !oth parents( needs and parenting$
3ome local investment in planning and resources and selection of evaluation
criteria is important$
here needs to !e provision of materials for parents who cannot afford them$
/ersonal 4ualities of the leader&clinician are consistently shown as important '
responsiveness% participation% a!ility to relate to the knowledge !ase of parents ie
the process of care is important to maintain familiesA and personal 4ualities are
important as well as 4ualifications$
3trategies which allow for working !oth with parents and children eg some
program components addressed directly to the children appear to have a !etter
chance of !ringing a!out positive outcomes for children$<Behrman% 1666=
#ome visiting
0o single service strategy serves the needs of all families and a range of services is
needed eg including family support% parent education and enriched environments
<provided either !y in'home programs or individualised child care= for infants$
/rograms that go for at least two years have the most chance of success$
Docus should !e on the meaning of the infants( !ehaviour for the caregiver% and on
the listening to and responding to infants( communication cues$
/arent education
Docus on age appropriate social skills training$
17
rained leaders for parenting groups$
/rograms which provide training to !oth children and parents% !ut not !oth together
have !een shown to !e effective$$ <,e!ster' 3tratton% 166E=
Co3# effe,#i4ee33 da#a
9In Iod we trust% from every!ody else we demand outcome data9 <Donagy% 1667=$
Sery few programs have !een evaluated for cost effectiveness over the long term and
there is a need for more evaluations such as the following$
he /erry preschool program and the Elmira program have !oth !een shown to
have significant cost savings over the years% <Oaroly et al% 1667=$ here is an added
!enefit to the community of more of the children !ecoming wage earners and
contri!uting to the economy$
Reprinted with the permission of he )avid and Cucile /ackard Doundation$
he evaluation of he /erry preschool program showed that for every dollar
invested there had !een a long term saving in real terms of HE in welfare !enefits%
crime and remedial education$ ?If H12 million were spent on a program in 2%BB1'2%
providing a similar service for a!out 2%EBB children% there would !e a savings
across government of H75 million dollars$ If the program was continued each year
H75 million would !e saved in the future for each annual cohort of children <over ;
cohorts of children U H52B million= K a result of very su!stantial savings <net H-5B
million per ; year cohort= in criminal .ustice% mental health% welfare !enefits and
most important the health and well !eing of the children involved$@
wo and a half years of pre and postnatal home visiting !y child health nurses of
poor single mothers showed savings that were five times higher than program costs
?for mothers without risk factors% !enefits were less than program costs@$ <Oaroly et
al% 1667=$
16
6,hile the health system might argua!ly !e the !est (home( for nurse home visiting
the savings are across government1 welfare% criminal .ustice% tax increase from
future earned income% thus a whole of government perspective is needed to .ustify
costs9 <I!id=$
,hile it is important to !e aware that no programs are effective for all children% it is clear
that for some programs there is significant overall cost saving to the community as well
as !enefits to the families involved$
No#e7 2nly portions of such programs can !e evaluated for cost effectiveness$ 2ther
!enefits such as personal !enefits to the families% higher IT% !etter parent'child relations
and potential for !etter parenting in the next generation could also !e considered$
2B
All amounts are in 1668 R3
dollars and are the net present
value of amounts over time where
future values are discounted to
the !irth of the participating
child% using a 5 percent annual
real discount rate$
3ource1 Cynn a$ Oaroly et al$% Investing in
our children1 what
we know and don(t know a!out the costs
and !enefits of early
childhood interventions% Rand&+r'767%
3anta +onica% CA1 Rand%
1667$ Copyright RA0) 1998.
Reprinted !y permission
RECO//ENDATIONS FRO/ THE LITERATURE
1$ +ost programs are aimed at treatment and more attention should !e given to
prevention% although accessi!le early treatment options are important$
2$ he )avid and Cucile /ackard Doundation(s review of home visiting programs
<Behrman% 1666= recommends that 9existing home visiting programs should focus on
efforts to enhance implementation and the 4uality of their services and that home
visiting should not !e relied on as the sole service strategy for families with young
children9$ #ome visiting is not enough on its own !ut should !e used with a raft of
programs tailored to need eg groups% counselling% early literacy etc$ he most
effective interventions generally seem to !e those which offer com!inations of
methods across different contexts$
-$ /rograms such as professional home visiting in the first two years which are effective
for 9at risk9 families are not cost effective for the general population$ In order to make
most effective use of resources a targeted approach to intensive home visiting should
!e taken$
5$ hat a range of programs !e developed ' responsive within a universal framework$
argeted within universal could !e one way of reducing stigmatisation ?there are few
universal parenting programs% most are targeted ' universal programs are usually early
health checks and developmental information@$ Consideration must !e given to the
!alance and rationale for universal compared with targeted$<Oosky% 2BBB%p6=% taking
account of the potential impact of la!eling <,ilson% 167E=$
;$ Even with programs which have !een shown to !e effective there is some attrition
and more research should !e done into which families do not stay with programs and
why$ In some of the most successful programs <2lds et al% 1678=% a!out 2B: of
parents refused to take part and many of these were those in greatest need$ It is
o!viously important to present programs in a way that is as inclusive as possi!le and
to evaluate and document where this is successful$
8$ Implementation is fundamental especially training and support for staff <2(#anlon%
2BBB =$ here is 9increasing recognition that the success of interventions of this nature
<home visiting' depends on the capacity of the person providing the service to develop
a trusting and respectful relationship with the mother (parent'.% <3tewart'Brown% 2BBB
=$ 3ome of the skills identified as needed for all home visitors !y Iross et al <2BBB=
<p-1= include1
o!serving1 attention to cues% especially non ver!al and environmental
listening1 attending to and correctly interpreting messages
4uestioning1 to o!tain information% verify facts and feelings% facilitate
expression of pro!lems and help focus
pro!ing1 seeking additional information a!out a pro!lem% !ehavior or
feelings
prompting1 facilitating particular responses !y encouragement
supporting1 encouraging% giving feed!ack and praise$
21
E$ Being a!le to standardise 4uality of programs across service delivery centres is
important to success$
7$ /rograms should !e sustaina!le and not end a!ruptly !ut with planned transitions to
appropriate community resources$
6$ Although 4ualifications are important the personal 4ualities and life experience of
service providers should also !e considered$ <2lds% 1677=
1B$ Vero to hree% the R3 early development specialist organisation% recommends
training of multidisciplinary teams of development specialists including nurses%
teachers and social workers to work with parents of infants and young children$
<Oaplan'3anoff% 2BBB=$ hey also support the concept of infant mental health
specialists % multidisciplinary teams with special training in early development and
relationships <,eatherston% 2BBB=
11$ +ore research is needed to support which are the !est program designs% which can !e
effectively generalised% how to !est target programs and whether the pilot&selected
programs will !e effective on a large scale <Oaroly% 1667=$
12$ )avis <2BBB% p5E= highlights the fact that programs should !e !uilt on well articulated
and evidence !ased theory of risk% resilience and outcomeA the need for program
procedures and methods to !e stated as explicitly as possi!le so the programs can !e
repeated !y othersA and the need for programs to !e monitored and evaluated$ 3he also
recommends
9standardised !ut not restrictive service activities% delivery and principles
the modification and expansion of the role of staff and service providers from
traditional roles
the existence of planned immediacy !etween training% research% evaluation and
service
a direct service focus within a conceptual understanding of a continuum of care>9
1-$ BraGelton P Ireenspan <2BBB= recommend the consideration of partnerships with !ig
!usiness to set up child parent centres offering preventive health care% child care and
parent support on site which employ large num!ers of people$
15$ 3anders <2BBB= notes an 9increasing emphasis on a pu!lic health perspective to child
mental health pro!lems% which stresses the importance of developing cost effective
prevention initiatives targeting entire populations>9A the importance of the concept
of levels of intervention according to need and a 9developmental perspective which
seeks to identify key transition points in the family life cycle which may constitute
periods of greater receptivity to intervention9$
1;$ Because the 9at risk9 approach% while effective% also includes some children who
would cope without intervention the assessment of families for targeted services is an
important component of intervention$
18$ Because of the evidence that conduct disorder and delin4uency is a significant cost to
the community% can often !e predicted at a young age and is resistant to treatment in
adolescence and older <Donagy% 1667=% and that early intervention can !e successful
programs to assist parents in managing children(s early aggression and !ehaviour
pro!lems should !e a priority preventive intervention$
22
1E$ ,hile there are enough properly run evaluations of parenting interventions to support
the efficacy and value of the some programs% many programs which could !e valua!le
have not !een ade4uately evaluated$ he need to evaluate in order to find out what
works and for whom cannot !e overstressed and should !e part of any new parenting
programs$
Research and evaluation of programs is fundamental especially aspects on which
there is not yet enough information such as the optimal intensity and duration of
programs% which families !enefit and which aspects of which models are most
effective$ In the !est programs% some parents drop out% some families do not seem
to !enefit and research is needed into these areas$
/rograms need to !e evaluated against clear goals$ he Australian 0ational
+ental #ealth 3trategy <2BBB= outlines outcome and process indicators for
interventions for mental health and the /athways to /revention report <1667=
indicates process goals for interventions for crime prevention together with
evaluation strategies$
0ote1 Iuidelines for evaluating parenting programs for context% content% process and
product are outlined in a recent article in Damily Relations <+atthews% 2BB1=
2-
CONCLUSION
It is clear from all the evidence that intervening in the early years where there are risks of
child a!use% antisocial !ehaviour and mental illness is the most cost effective and
successful way to prevent ma.or costs to !oth the individual and the community$ Risk
factors are readily identifia!le <,erner% 1665% Cinke% 1667= as are protective factors$
?0ote1 intervening in the early years almost always involves parenting so that in many
ways early intervention and support&education for parents are synonymous$@
/arent education programs in the early and primary school years% multifaceted programs
and professional home visiting programs have all clearly !een shown to provide positive
and cost effective outcomes$ 2ther measures such as social capital !uilding through
volunteer programs and programs for parents of adolescents have not such clear evidence
of efficacy however this may !e !ecause of lack of relia!le evaluations and research into
these initiatives$
he varying success of programs and interventions highlights the importance of careful
planning% goal setting and program design$
,hile it is clear from the evidence that children with risk factors such as poverty can !e
effectively assisted% the studies involved have usually !een pilot programs or programs
run in a particular area$ I was a!le to find no studies where a comprehensive statewide
planned approach to parenting% !ased on the evidence has !een carried out and evaluated$
2!viously if this could !e done it would !e a ma.or step forward in improving children(s
health and development and in providing for safe and healthy futures for communities$
iming is important in terms of intervention eg1
Infancy for protective interventions
/reschool and early childhood for preventive programs for anti social !ehaviour
ransition points such as divorce% stepfamily formation% toddlerhood% adolescence%
immigration% children with a parent in prison$ <Rutter% 167;=
,hile there are many model pro.ects !eing run in different parts of Australia and for
different periods of time <)avis% 1667=% lack of proper evaluation and lack of
predicta!ility of funding <I!id= is a ma.or concern$ he large ma.ority of programs are
selective% very few universal$ In choosing interventions consideration needs to !e given to
the prevalence and seriousness of the pro!lem% the efficacy of interventions and
sustaina!ility$
he research presented in this review supports the importance of programs for parents
which address protective factors for children in terms of outcomes for children% parents
and the community$ hese should !e delivered within the context of the o!ligation of
government to provide appropriate information and support for all parents$ Community
25
efforts to eliminate risk factors should not !e forgotten$ Eliminating the risk% where
possi!le% should !e the first step$
RESEARCH UPDATE )**-
he following section comprises an update from selected research papers not
availa!le when the original ,hat ,orks was written <2BB1=$ In general they confirm
the content of the original report !ut there is some added value from the new papers$
,hile the following interventions have !een evaluated to show effectiveness there are
!roader pu!lic health initiatives which have also !een shown to !e effective which are
not considered here$ hese include improved nutrition% improved housing% improved
access to education% strengthening community networks and community wide
education to reduce su!stance a!use <,#2% 2BB5=$
Child Pare# Ce#re3
Durther evidence has !een presented on the effectiveness of the Chicago Child /arent
Centres <Reynolds% 2BB5=$ Reynolds notes that the long term effects of the early
childhood interventions were tracea!le to school support% cognitive&educational
experiences and family support experiences$ 3chool commitment also contri!uted to
lower delin4uency$ Each C/C has a staffed resource room coordinating activities% an
outreach program and parent involvement in early education activities <from age -=$
Pare#i2 Gro"p Pro2ra&38
Iroup programs for parents can !e effective and very suita!le for enhancing
parenting skills and sustaina!le child outcomes even with high risk families$
</uckering% 2BB5=$
Ho&e 4i3i#i2 9 E4ide,e
Again the importance of rigorous evidence is highlighted !efore initiating costly
programs which may not !e effective% Chaffin :2BB5=$ Chaffin notes that while the
prevention literature is full of studies supporting program effectiveness very few meet
criteria for evidence'!ased interventions$ J0on'randomiGed designs are particularly
vulnera!le to overestimating the siGe of intervention effectsL$ +any studies show only
immediate rather than sustaina!le effects$ he nota!le exception to these criticisms is
the Elmira nurse home visiting model <2lds et al%$ 1667=$ he Elmira study has !een
taken as evidence that home visiting in general is a proven prevention method
<Chaffin% 2BB5= !ut 2lds* further research <2lds et al$% 2BB2% 2BB-= shows that
paraprofessional home visiting programs do not provide the same positive outcomes
for children$
Chaffin further recommends that where evaluated programs are replicated or
generalised they are rigorously evaluated on an ongoing !asis$
/arents who do not receive at least a minimum num!er of visits are less likely to have
significant improvement through home visiting programs$ Retention is more likely if
home visitor is a!le to !uild a strong and respectful relationship with the client$
<)aro% 2BB-=
2;
In an evaluation of #awaii*s Early 3tart /rogram% )uggan <2BB5= found that program
impact was compromised not only deficiencies in implementation !ut also drift in the
model itself in taking the model to scale% while turnover in administrators and
program directors led to a gradual shift in program perspective K moving from a risk
reduction focus to a strengths !ased model$ his compromised staff a!ility to work
with families to identify and address risks$ )uggan*s study suggests that am!iguity in
the program model and challenges to implementation reduce the pro!a!ility of
positive outcomes$
In the Early 3tart program <)aro% 2BB-= programs which used a com!ination of
professionals and paraprofessionals and provided them with regular supervision had
the greatest success$ 3he also found that the initial relationship made with the home
visitor is crucial to enrolling in and maintaining the home visiting program$
A review of the impact of fathers involvement in #awaii*s #ealth 3tart /rogram
<)uggan% 2BB5= found no impact on fathers and varying impact on families$ In
families with non violent fathers the greater involvement of fathers seemed !eneficial
!ecause it was accompanied !y greater maternal satisfaction$ /romoting of more
involvement of violent fathers in couples who had previously not seen each other
often was not positive !ecause the greater involvement was not accompanied !y a
decrease in violence$ +ore research is needed in this area$ he study noted that home
visitors also felt less competent to work with fathers$
#ome visiting programs for teenage mothers were investigated !y Wulie Tuinliven
<2BB-=$ 3he highlights the difference !etween 17'16 year old mothers and under 17
year old mothers who have the greatest risks of child a!use% neglect and su!se4uent
pregnancies$ A trial program for teenage mothers% not including under 17s and !y
paraprofessionals showed now significant outcomes for the intervention group$
<+orell et al 4uoted in Tuinliven% 2BB-=$ Tuinliven*s own study shows that a nurse
home visiting program for under 17 year old teenage mothers can result in reduction
of adverse neonatal outcomes at least in the short term$ Repeat teenage pregnancy
within a year was reduced from 1-: to -:$ his is supported !y RO studies 4uoted
in her paper$
I&pli,a#io3 for ho&e 4i3i#i2 pro2ra& de3i2 ad i&ple&e#a#io8
3everal papers made the point that home visiting per se is not the intervention
!ut the context for a specific intervention$ he context does not specify the
intervention nor the outcome$ <+c0aughton% 2BB5=$ he home visit provides a
facilitating context for the intervention !ut it is the intervention and the
relationship with the home visitor which leads to the outcome$
Risk factors such as family violence% su!stance a!use and parental depression
present ma.or challenges to home visiting programs$ 2ften these are the areas
that home visitors feel least e4uipped to address$ his finding is consistent
with home visitors* self assessment$ Durthermore home visitors are less likely
to recognise the risk factors that they are less e4uipped to manage$ <Chaffin%
2BB5% )uggan% 2BB5=$ Chaffin also notes that domestic violence may !e a
pro!lem that home visitors% even trained nurses% find difficult to manage$
28
Adding a cognitive therapy component showed dramatic effect in the #ealthy
3tart home visiting program% suggesting that this is a worthwhile component
of program content$ <Bugental et al in Chaffin% 2BB5=$
Risk relevant intervention targets are important$ Interventions should address
protective factors ,hile empowerment philosophy !rings valua!le elements
to programs such as development of colla!orative partnerships and positive
motivation% prevention interventions should !e guided !y known risk and
protective factors$ <Chaffin% 2BB5% )uggan% 2BB5=$
Effective home visiting programs have a well'defined and documented
program protocol and curriculum that allows flexi!ility to individualiGe
activities to respond to particular client needs$
/rograms need to have a strong theoretical foundation% as well as !e perceived
as relevant !y the community they serve$ <hompson et al% 2BB1% )uggan%
2BB5=$ )evelopmental&pedagogical interventions are likely to have more
impact on children*s social competence and adaptation while interactional
methods have more effect on maternal responsiveness$ Empowerment
strategies are more effective in engaging Jat'riskL families$ Interventions that
work with !oth parent and child have the !est outcomes$ <Barnes% 2BB-=$
Although it is important to have only one primary home visitor% esta!lishing
multi'disciplinary teas can !ring the full resources of a program to families
through case consultation and supervision$ hompson maintains that training
and supervision are critical for 4uality in home visiting services$ <hompson
et al% 2BB1=
#ome visiting programs cannot operate in isolation and need to !e integrated
with other health and community programs$ hese should include some centre
!ased programs where children spend time in direct activities related to
developmental outcomes$ <hompson et al% 2BB1=
)aro <2BB-= found that for the programs evaluated !etter outcomes were
o!tained !y moderate levels of supervision <reflective consultation= for direct
service staff than higher <more than once a fortnight= or lower <less than once
a month= levels$
)uggan <2BB5= notes that where more than one home visitor works with a
family eg male with fathers or cultural consultant there needs to !e a clear
overall plan and policies and procedures for sharing information% monitoring
progress% and changing the plan as families reach individual or family goals$
he ,orld #ealth 2rganisation <2BB5= summarises the main features of effective
programs as follows1
here is evidence that the program is effective
Consumers&funders&decision makers were involved in its development
he host organisation provides real or in'kind support from the outset
he potential to generate additional funds is high
he host organisation is mature <sta!le% resourceful=
he program and host organisation have compati!le missions
2E
he program is not a separate unit !ut rather its policies% procedures and
responsi!ilities are integrated into the organisation
3omeone in authority% other than the program director% is a champion of the
program at high levels$
he program has few Jrival providersL who would !enefit from the program
discontinuing
he host organisation has a history of innovation
he value and mission of the program fit in well with the !roader community
he program has community champions who would decry its discontinuing$
2ther organisations are copying the innovations of the program$
JIn our formal evaluation of ,ashington*s effort at implementing research'proven
programs for .uvenile offenders% one important lesson was learned$ he programs work
and they produce more !enefits than costs K !ut only when implemented rigorously with
close attention to 4uality control and adherence to the original design of the program$
,ithout 4uality control% the programs do not workL$ <,ashington 3tate Institute for
/u!lic /olicy% 2BB5=$
27
REFERENCES
1$ Acheson% ) et al <1667= Independent in4uiry into ine4ualities in health report
http1&&www$official'documents$co$uk&document&doh&ih&synopsis$htm
2$ Armstrong% OC et al <2BBB= 9/romoting secure attachment% maternal mood and health
in a vulnera!le population1 a randomiGed controlled trial9 in W$ /aediatrics P child
#ealth% -8% ;;;'82
-$ Bar!our% W <2BBB= A #ealthy start to life1 a review of Australian and international
literature a!out early intervention% 3outh Australia% Child #ealth Council%
unpu!lished paper$
5$ Barnes% Wac4ueline <2BB-= JInterventions Addressing Infant +ental #ealth /ro!lemsL
in Children P 3ociety <1E= -78'-6;
;$ Barlow% Wane P 3tewart'Brown% 3arah <2BBB= 9Behavior pro!lems and group'!ased
parent education programs9 in )ev$ P Behav$ /ediatrics% 21 <;=% 2ct$
8$ Barnett% 3teven <166-= Xconomic evaluation of home visiting programs9 in he
Duture of children1 #ome visiting - <-= ,inter
E$ Behrman% R <ed= <1666= 9#ome visiting1 recent program evaluations9 in he Duture
of children 6 <1=% 3pring&3ummer
7$ Beth'/ierce% Ro!in A Iood !eginning1 sending America(s children to school with the
social and emotional competence they need to succeed% 0orth Carolina1 he Child
+ental #ealth Doundation and Agencies 0etwork$
6$ Bor% ,illiam et al <2BB1= Aggression and the development of delin4uent !ehaviour in
children% Australian Institute of criminology1 rends And Issues In Crime And
Criminal Wustice 3eries Dact 3heet$ http1&&www$aic$gov$au
1B$ Bradley% R$# et al <1665=% 9Impact of the infant health and development program
<I#)/= on the home environments of infants !orn prematurely with low !irthweight9
in Wournal of Educational /sychology% 78% pp;-1';51$
11$ BraGelton% Berry P Ireenspan% 3tanley <2BBB= he irreduci!le needs of children1
what every child must have to grow% learn and flourish 0"1 /erseus
12$ Carr% Alan <ed= <2BBB=% ,hat works with children and adolescents1 a critical review
of psychological interventions with children% adolescents and their families ; Condon1
Routledge$
1-$ Centre for the 3tudy and /revention of Siolence% DA3 track program
15$ Chaffin% +ark <2BB5= JIs it time to rethingk #ealthy 3tart&#ealthy DamiliesYL in
Child A!use and 0eglect% 27% ;76';6;
1;$ Child #ealth Council of 3outh Australia <1666= Children and disadvantage1 the 3outh
Australian picture1 directions for action% 3outh Australia1 Child #ealth Council
18$ Child #ealth Council of 3outh Australia <2BB1= Intervening early1 opportunities to
support young 3outh Australian children and their families <draft=% 3A1Child #ealth
Council of 3outh Australia
1E$ Clarke% Colleen <1667= /romoting family and community resilience in indigenous
communities% Indigenous therapies% Daculty of Arts% #ealth and 3ciences% Central
Tueensland Rniversity$ /aper presented to the 8
th
Australian Institute of Damily
3tudies Conference% +el!ourne$
26
17$ Commission on the Damily <1667= 3trengthening families for life1 final report of the
Commission on the Damily to the +inister for 3cial% Community and Damily Affairs%
)u!lin1 Iovernement of Ireland$
16$ Commonwealth )epartment of #ealth and Aged Care <2BBB= 0ational action plan for
promotion% prevention and early intervention for mental health% +ental #ealth and
3pecial /rograms Branch% Commonwealth )epartment of #ealth and Aged Care%
Can!erra$
2B$ Commonwealth )epartment of #ealth and Aged Care <2BBB= /romotion% prevention
and early intervention for mental health ' a monograph% Can!erra1 Commonwealth
)epartment of #ealth and Aged Care
21$ Council of Ireat City 3chools ,hat works in ur!an education
www$cgcs$org&services&whatworks&parent
22$ )aro% )e!orah et al$ <2BB-= Cuyahoga County Early Childhood Initiative Evaluation
Report1 ,elcome #ome and Early 3tart% Chapin #all Center for Children at the
Rniversity of Chicago$
2-$ )avis% Cathy <1667= 0ational stocktake of early intervention programs1 AusEikit 0o
1% Bedford /ark1 AusEinet
25$ )avis% Cathy <1667= 0ational stocktake of early intervention programs1 AusEikit 0o
2% Bedford /ark1 AusEinet
2;$ )avis% Cathy <2BBB= Early intervention in the mental health of young people1 a
literature review% Commonwealth of Australia% 2BBB$
28$ )uggan% Anne et al <1666= 9Evaluation of #awaii(s #ealthy 3tart /rogram9 in Mhe
Duture of Children 6<1=% 3pring&summer
2E$ )uggan% Anne et al$ <2BB5= JEvaluating a state'wide home visiting program to
prevent child a!use in at'risk families of new!orns1 fathers* participation and
outcomesL in Child +altreatment <6= 1% -'1E
27$ )uggan% Anne et al$ <2BB5= JRandomiGed trial of a statwide home visiting program to
prevent child a!use1 impact in reducing parental risk factorsL in Child A!use P
0eglect <27= 82-'85-
26$ Darrington )/ <1665= 9Early developmental prevention of .uvenile delin4uency9 in
Criminal !ehaviour and mental health% 5 <-= 2B6'2E
-B$ Darrington )/ <1668= Rnderstanding and preventing youth crime% "ork1 Woseph
Rowntree Doundation$
-1$ Donagy% /eter% <1667=% 9/revention1 the appropriate target of infant psychotherapy9 in
Infant +ental #ealth Wournal% Sol$ 16<2=% pp125'1;B$
-2$ Drank /orter Iraham Child )evelopment Center% he Carolina Adecedarian /ro.ectA
Rniversity of 0orth Carolina$ www$fpg$unc$edu&overview&a!c&a!cfind$htm
--$ Iovernment of Ireland <1667= 3trengthening families for life1 final report of the
Commission on the Damily to the +inister for 3ocial% Community and Damily affairs%
)u!lin1 Iovernment of Ireland$
-5$ Iross% Ruth et al eds$ <166E= #elping low !irth weight% premature !a!ies1 the infant
health and development program% 3tanford1 3tanford Rniversity /ress
-;$ #enricson% Clem and Roker% )e!i <2BBB= J3upport for parents of adolescents1 a
reviewL in Wournal of adolescence% 2-% E8-'E7-
-8$ Oaplan'3anoff et al <2BBB= 90ew roles for developmental specialists in primary
health care9% in Vero to hree 2cto!er&0ovem!er
-B
-E$ Oaroly% Cynn et al <1667= Investing in our children1 what we know and don(t know
a!out the costs and !enefits of early childhood intervention R31 Rand Corporation
-7$ Oeating )/ P #ertGman C <1666= )evelopmental health and the wealth of nations
0"1 Iuilford /ress
-6$ OitGman% #arriet et al <2BBB= 9Enduring effects of nurse home visitation on maternal
life course1 a -'year follow'up of a randomiGed trial9 in WA+A 27- <1;=
5B$ Oosky% Ro!ert et al <2BBB= Clinical approaches to early intervention in child and
adolescent mental health1 Sol$ 1 Attention deficit hyperactivity disorder in preschool
aged children% Can!erra1 Commonwealth of Australia$
51$ Oosky% Ro!ert et al <2BBB= Clinical approaches to early intervention in child and
adolescent mental health1 Sol$ 21 Early intervention for anxiety disorders in children
and adolescents% Can!erra1 Commonwealth of Australia$
52$ Oowalenko% 0ick <2BBB= 9Early intervention as early as possi!le1 what(s practicalY9 in
AusEinetter 1B <1&2BBB=
5-$ Oowalenko% 0ick <2BBB= he perinatal period1 early interventions for mental health
Sol$ 5% Adelaide1 Australian Early Intervention 0etwork for +ental #ealth in "oung
/eople
55$ Cally% Ronald et al<1667= 9+ore pride% less delin4uency1 findings from the ten'year
follow'up study of the 3yracuse Rniversity family )evelopment Research /rogram9
in Vero to hree April% 1-'17
5;$ Cinke% /am<2BB1= 9Resilience9 /aper presented at the )epartment of Education%
raining and Employment Conference$ Child and "outh #ealth$
58$ Citrownik% A$ et al <2BBB= 9Evaluation of a to!acco and alcohol used prevention
program for #ispanic migrant adolescents1 promoting the protective factors and
parent'child communication9 in /reventive +edicine -1 125'1--
5E$ +acmillan% #$C% et al <1665a=% 9/rimary prevention of child a!use and neglect1 a
critical review$ /art I9 in Wournal of Child /sychology and /sychiatry% -;% 7-;'7;8$
57$ +acmillan% #$C% et al <1665!=% 9/rimary prevention of child a!use and neglect1 a
critical review$ /art II9 in Wournal of Child /sychology and /sychiatry% -;% 7;E'7E8$
56$ +armot +I <1666= 9he solid facts1 the social determinants of health9 in #ealth
/romotion Wournal of Australia vol 6 <2= pp1--'1-6
;B$ +atthews% W P #udson% A <2BB1= 9Iuidelines for evaluating parent training
programs9 in Damily Relations% ;B% EE'78
;1$ +cCain% +argaret P +ustard% Draser <1666= he Early "ears 3tudy% 2ntario1
Children(s 3ecretariat
;2$ +cIurk% # <1667= he Economic cost of child a!use and neglect in 3outh Australia1
a report .ointly prepared !y the 2ffice for Damilies and Children and the Australian
Institute of Damily 3tudies 3A1 2ffice for Damilies and Children
;-$ +cCoughlin% W and 0agorcka% <2BBB= W 3ooner not later1 an international literature and
program review of early childhood initiatives for disadvantaged families % DitGroy1
Brotherhood of 3t Caurence$
;5$ +c0aughton% )iane J0urse #ome Sisits to maternal'child clients1 a review of
intervention researchL in /u!lic #ealth 0ursing <21= -% 2BE'216
;;$ +urray% C P Cooper% B <166E= 9/ost partum depression and child development9% RO1
Iuilford /ress
-1
;8$ 0ational Crime /revention <1666= /athways to prevention1 developmental and early
intervention approaches to crime in Australia% Can!erra1 0ational Crime /revention
;E$ 0ational +ental #ealth 3trategy% <2BBB= 0ational action plan for promotion
prevention and early intervention for mental health 2BBB% Can!erra1 Commonwealth
of Australia$
;7$ 2(#anlon% Anne et al$ <2BBB= +odel pro.ects for early intervention in the mental
health of young people1 reorientation of services% Can!erra1 Commonwealth of
Australia$
;6$ 2lds )$C$ et al$ <2BB2= J#ome visiting !y paraprofessional and !y nurses1 a
randomiGed controlled trialL in /ediatrics% 11B% 578'568$
8B$ 2lds )$C$ et al$ <2BB-= JReply to IuttermanL in /ediatrics% 111% 578'568
81$ 2lds )$C$ <1677= 9he prenatal&early infancy pro.ect9 in R# /rice et al <eds= 15
ounces of prevention1 a case !ook for practitioners$ American /sychological
Association$ ,ashington$
82$ 2lds% ) P OitGman% #arriet <166-= 9Review of research on home visiting for
pregnant women and parents of young children9 in he Duture of children1 #ome
visiting - <-=% ,inter
8-$ 2lds% ) et al <1667= 9Cong term effects of nurse home visitation on children(s
criminal and antisocial !ehavior9 in WA+A 12-7'55
85$ 2lds% )$C$ et al$<1678= 9Improving the delivery of prenatal care and outcomes of
pregnancy1 a randomiGed trial of nurse home visitation9 in /ediatrics% EE% 18'27
8;$ 2lin% 3 <ed= <2BB1=Report of the 3urgeon Ieneral(s Conference on Children(s +ental
#ealth 3tatus1 a 0ational Agenda% R31 )epartment of #ealth and #uman 3ervices$
88$ 2lweus% )an <1661= 9Bully&victim pro!lems among schoolchildren1 !asic facts and
effects of a school !ased intervention program9 in /epler )W P Ru!in O# eds he
development and treatment of childhood aggression% 0W1 Cawrence Erl!aum
8E$ /atterson I et al$ <1662= Antisocial !oys Eugene 2R1 Castalia /ress
87$ /uckering% Christine <2BB5= J+ellow parenting1 an intensive intervention to change
relationshipsL in he 3ignal <12= 1$
86$ /ugh% I et al <1665= Confident parents% confident children1 policy and practice in
parent education and support% Condon1 0ational Children(s Bureau
EB$ Tuinliven% Wulie <2BB-= J/ostnatal home visits in teenage mothers1 a ranomised
controlled trialL in he Cancet <-81= 6-81% p76-
E1$ Reynolds% Arthur W$ et al <2BB1= JCong'term effects of an early childhood intervention
on educational achievement and .uvenile arrestL in WA+A% 27;<17=% +ay 6$
E2$ Reynolds% Arthur W et al <2BB5= J/aths of effects of early childhood intervention on
educational attainments and delin4uency1 a confirmatory analysis of the Chicago
Child'/arent CentresL in Child )evelopment% E;<;=% 1266'1-27
E-$ 3anders% +att et al <2BBB=% Early intervention in conduct pro!lems in children%
Adelaide1 he Australian Early Intervention 0etwork for +ental #ealth in "oung
/eople$
E5$ 3eitG% Sictoria et al <167;= 9Effects of family support intervention1 a ten year follow'
up9 in Child )evelopment% ;8% -E8'-61
E;$ 3eitG% Sictoria et al <1665= 9/arent'focused intervention1 diffusion effects on si!lings1
in Child )evelopment% 8;% 8EE'87-
-2
E8$ he 3cottish 2ffice A 3afer 3cotland1 tackling crime and its causes
www$scotland$gov$uk&li!rary&documents'w8&cp'B5$htm
EE$ 3hore% R$ <1668= Rethinking the Brain1 0ew Insights into Early )evelopment 0"1
Damilies and ,ork Institute$
E7$ 3honkoff W and /hillips <eds= <2BBB=% )e!orah% Drom 0eurons to 0eigh!orhoods1 he
3cience of Early Childhood )evelopment % R31 Committee on Integrating 3cience
and Early Childhood )evelopment$
E6$ 3tagner% + P )uran + <166E= 9Comprehensive community intitiatives1 principles%
practices and lessons learned9 in he future of children E <2=% 1-2'15B
7B$ hompson C et al <2BB1= J#ome Sisiting1 a 3ervice 3trategy to )eliver /roposition
1B ResultsL in 0 #alfon et al <eds= Building Community 3ystems for "oung
Children% RCCA Center for #ealthier Children% Damilies and Communities$
71$ oum!ourou% Wohn , et al <166E= Behaviour exchange systems training1 the 9BE39
approachfor parents stressed !y adolescent drug pro!lems9% in A$0$V$W$ Dam her$%
17<2=% pp62'67
72$ ,ashington 3tate Institute for /u!lic /olicy <2BB5= Benefits and costs of prevention
and early intervention programs for youth% ,ashington 3tate Institute for /u!lic
/olicy1 2lympia
7-$ ,eatherson% ) <2BBB= 9he infant mental health specialist9 in Vero to hree%
2cto!er&0ovem!er 2BBB$
75$ ,alker #$ et al <1667= 9Dirst step to success1 intervening at the point of school entry
to prevent antisocial !ehaviour patterns9 in /sychology in the 3chools -; <-= 2;6'286
7;$ ,e!ster'3tratton% C and #ammond + <166E= 9reating children with early 'onset
conduct pro!lems1 a comparison of child and parent training interventions9 in Wournal
of consulting and clinical psychology 8; <1= 6-'1B6
78$ ,erner% Emmy E$ Sulnera!le !ut invinci!le1 high risk children from !irth to
adulthood% R31 Cornell Rniversity% 1662
7E$ ,orld #ealth 2rganiGation <2BB5= /romoting +ental #ealth1 3ummary Report%
,orld #ealth 2rganiGation% Ieneva$
77$ ,ilson% W P Coury I eds$ <167E= Drom children to citiGens1 Sol$ III1 Damilies% schools
and delin4uency prevention% 0"1 3pringer'Serlag$
76$ Vigler% E P 3tyfco% 3$ <2BB1= 9Extended childhood intervention prepares children for
school and !eyond9 in WA+A 27; <17=$
--
APPENDI.
E1a&ple3 of 3o&e pro2ra& o"#,o&e3
Na&e Ti&e Co#rol T%pe of Pro2ra& Re3"l#3 Co&&e#
Bristol child
development
/rogram
+onthly for 1
st
yr% ongoing
where needed
"es #ome visits for 1
st
!a!y$
Including handouts$
E-: found home visits v$
useful
5B: found written material v$
useful
+ostly used in
deprived areas% if
not universal parents
can feel singled out$
Adelaide
Children(s
#ospital
2ngoing "es S health promotion
programs for parents in
waiting room
Experimental group had
sustained increase in
knowledge <lessened over
time=
Y2ptions for other
waiting rooms eg
health clinics$ Y
impact of
knowledge on
practice and skill
/arenting
adolescents
<Reisch=
8 weeks%
weekly
"es Communication skills training )ecrease in antisocial
!ehaviour with fathers and
young people% not mothers$
#igher satisfaction with family
system
3ample not extreme
eg not in therapy or
violent conflict
Children and
young teens% post
divorce <Carr=
8'25 sessions
over 8'18
weeks
"es Iroup prog$ Including info$%
social skills% stress
management
/ost tests after 1 yr ' decrease
in !ehaviour pro!s% school
pro!s% increased self esteem%
!etter relationships
/rog for non
custodial fathers
could add value
/arents as
teachers
Ante natal or
!irth ' - yrs
Z1B home
visits
"es /arent ed$ child dev$
/reparation for school$
3mall effect$ 1month dev$ Dor
1B visits$ Better with case
management services as well
#I//" <#ome
instruction for
preschool
youngsters
2 yr program
for 5'; yr olds
"es #ome visits and groups for
parents with limited education
Inconclusive
-5
Na&e Ti&e Co#rol T%pe of pro2ra& Re3"l#3 Co&&e#3
#ealthy Damilies
America
/rograms vary Improved parent child
interaction$ +ixed success
with a!use% health status$
Recommend 3tate
or 0ationwide
context in which
support for all new
parents is the norm$
Tueensland
#ome visiting
program
,eekly for
8wks% monthly
to - months%
up to 8 months
post partum
"es Child health nurse home
visiting program for English
speaking families with a new
!a!y$ Relationship !uilding%
anticipatory guidance%
supported !y 3, and
/aediatrician
Cess a!use% less smoking%
more parental confidence%
!etter attachment
Elmira /rogram
<0#S/=
Drom 26 wks
pregnancy to
2
nd
!irthday
E home visits
pre !irth% 28
home visits
2
nd
!irthday
"es Dirst parents with 2
sociodemographic risk factors%
Z12 yrs education eg
unmarried% unemployed
Child health nurse home visits
with detailed guidelines% goal
setting for the woman as well
as parenting intervention
Benefits the neediest families%
little !enefti for !roader popn$
reduced child a!use% fewer
arrests and convictions at 1;%
smoked and drank less% fewer
sex partners% less child a!use$
0urses the key$
Rse for neediest
families$ Important
to stick to the model
for research$
#ealthy 3tart 2 years ' 3tatewide home visiting
program
Improved parenting% less
a!use% more positive discipline
0eeds comparison
groups$
Implementation
should !e
monitored$
Infant #ealth
)evelopment
/rog
Z - years "es #ome visits 1
st
year
Child dev centre years 1'- [
parenting groups
/ositive effects on !ehaviour
and IT at age -$ )ecrease over
time$ <lack of effect on SCB,
1;BBgm and ITZEB=
#ead 3tart -'; yrs "es 1&2 day academic program for
one preschool year for
children in poverty$ #ealth
and nutrition services$ Adult
ed$ for parents and family
support services$
/ositive effects on school
readiness% weak evidence for
long term effectiveness$
-;
Na&e Ti&e Co#rol T%pe of Pro2ra& Re3"l#3 Co&&e#3
A!ecedarian
/ro.ect
B'; yrs
"ear round all
day
educational
childcare&presc
hool prgram
"es /rogram emphasises the
development of cognitive%
language and adaptive
!ehaviour skills$ [ nutritional
supplements and social
services as needed
#igher academic achievement$
Reduced need for special ed%
less dropout% less .uvenile and
adult crime$
Conger involvement
associated with
!etter outcomes$
/erry /reschool
/ro.ect
2 yr
intervention x
2 \ hrs per
day ; days a
week% E
months of yr
"es Includes weekly home visits
!y teachers% small classes%
specially trained teachers%
support and supervision for
staff
By age 2E !etter .o!s% fewer
arrests% lower likely hood of
receiving pu!lic assistance
Chicago Child
/arent Centres
Docuses on child(s total
environment and for some
groups continues for 8 years$
0eigh!ourhood centres
providing health% education%
parent involvement$
Iains in school achievement
depending on num!er of years
in program
Because there are no
overall specific
standards !etween
centres% some show
su!stantial
achievements% some
show none$
"ale Child
,elfare /ro.ect
/regnancy '
2 \ yrs
yes #ome visits focused on
current concerns% assistance in
achieving long term goals and
liaison to support services$
/aediatric care and
anticipatory guidance$ #igh
4uality day care$
+others achieved higher
education% smaller families%
almost all !ecame
economically independent%
male children !etter ad.usted
<teacher rating=% pro.ect
children !etter achievement%
less a!senteeism% !etter
!ehaviour$
/rogam also had a
positive effect on
si!lings$
0ote1 this was a
very small sample
so generalisation
would !e difficult$
3chool !ullying
program%
0orway
/rimary school
' 2 yr program
0o All children in schools grades
1'6% child training% parent info%
staff training
After 2 yrs% ;B: less !ullying%
also less antisocial !ehaviour%
!etter attitude to school
3yracuse Damily
)evelopment
Research
/rogram
; yrs%
pregnancy on
yes #ome visits from pregnancy
on% weekly$ Assist with parent
child interactions and referral$
#igh 4uality individualised
child care for ; year$$
7B: reduction in crime
Cess serious crime
!etter school grades
#igher self esteem and !etter
parent'child relationships
-8
Na&e Ti&e Co#rol T%pe of pro2ra& Re3"l#3 Co&&e#3
DA3 track Irades 1'8%
most intensive
at transitions
eg 3tarting
3chool]
"es Cearning programs including
tutoring and anger control and
social skills training at school$
Bi'weekly home visits% parent
training$
Early evaluations show
improved !ehaviour% parenting
skills% less aggression$
3eattle 3ocial
development
program
Irades 1'E
primary school
"es /arent ed groups% proactive
classroom management% social
skills training% home visits$
+ultilevel intervention
Cess alcohol and delin4uency%
!etter family attachment and
communication% more
commitment to school
+ontreal
/revention
/ro.ect
2 yrs% early
primary age
"es /arent ed$ Child training$
Docused on disruptive !oys in
early primary school$
Cower delin4uency and anti
social !ehaviour at age 12
-E