VOL: 103, ISSUE: 21, PAGE NO: 32-33
Kathleen A. Docherty, BA, HV, RGN; Johanna C. Goll, MA;
Kathleen A. Docherty, BA, HV, RGN, is health visitor, pre-five family service,
Abstract Docherty, K.A., Goll, J.C. (2007) Effectiveness of a community-based early intervention service for families with children under five. www.nursingtimes.net
Abstract Docherty, K.A., Goll, J.C. (2007) Effectiveness of a community-based early intervention service for families with children under five. www.nursingtimes.netAimTo evaluate the effectiveness of the pre-five family service, an NHS primary care community-based multidisciplinary team that offers parenting support to families of children under five through group work. Method Parental mental health, child well-being and parent satisfaction were measured using a different questionnaire for each aspect: The GHQ-12 (General Health Questionnaire), Strengths and Difficulties Questionnaire, and a parent satisfaction questionnaire designed by the service, respectively. Results Families who attend the service experience improvements in child well-being and parental mental health, and rate the service to be highly satisfactory. Discussion The pre-five family service has developed an effective multidisciplinary team and strong links with social work, education, culture and leisure and voluntary agencies. These working practices have facilitated understanding, awareness and communication between professionals, increased cost-effectiveness and ultimately enhanced outcomes for families. Conclusion The pre-five family service may therefore act as a model of effective community healthcare delivery within the NHS.
IntroductionThe pre-five family service is a primary care community-based early intervention service operating in West Glasgow. The service aims to promote well-being in children under five and their carers, and particularly those in vulnerable and deprived families. The service is led by a health visitor and includes a team of health visitors, a staff nurse, a dietitian, a consultant clinical psychologist and an assistant psychologist. The pre-five family service runs short-term and long-term groups for parents and carers that aim to promote child well-being through positive parenting practices and parent-child bonding. These courses are regularly provided in local community centres. Most parents who engage with the service attend one of these groups. This family service also provides similar support on a one-to-one basis for parents and carers whose specific needs cannot be met within a group setting. For example, parents experiencing problems in addition to parenting difficulties such as alcohol or drug addiction, mental health problems, physical health problems or learning difficulties are offered one-to-one sessions by the service. Parents are visited in their homes or met in community centres, nurseries or other locations that are familiar to them. The service aims not only to promote child well-being through the provision of parenting guidance but also to tackle parental mental health problems that are known to impinge negatively on children’s well-being. This is guided by considerable evidence showing associations between parental mental health and child development. Goodman and Gotlib (1999) and Downey and Coyne (1990) provided reviews of evidence linking parental depression and child psychological problems. Mechanisms mediating these associations have been suggested; for example, depressed parents may be less responsive to their children, who become more distressed than controls (Cox et al, 1987). In addition, significant associations have been found between parental psychological health and child behaviour problems (Najman et al, 2000; Sonuga-Barke et al, 1996; Alpern and Lyons-Ruth, 1993; Ghodsian et al, 1984). For example, specific mental health problems such as parental stress have been associated with child behaviour problems (Crnic et al, 2005). In support of these associations, studies of parenting courses commonly give evidence for simultaneous improvements in parenting practices, child behaviour and parental mental health (Hutchings et al, 2002). Through the provision of groups, the service intends to encourage social interaction among parents and engagement with professionals, and thereby reduce problems of social exclusion, depression and postnatal depression. In this way the service aims to increase child well-being and to prevent child abuse or neglect (Naughton and Heath, 2001). Lastly, through the provision of successful engagement with practitioners, the service hopes to encourage future engagement by parents with health and education professionals as necessary, so that families obtain appropriate support for their children throughout development. Group coursesThe pre-five family service provides group-based interventions and is able to deliver healthcare to a large number of families; therefore the service is extremely cost-effective. Between the inception of the service in July 2001 and March 2006, more than 970 families attended a group. In reality, this figure is a considerable underestimate since it does not include families attending ‘baby bounce and rhyme time’ groups, which are run on a drop-in basis. However, it is estimated that around 50 families take up this service each week. The group courses provided by the pre-five family service are as follows: Infant massage courseClient group: Mothers of new infants aged from six weeks Duration:Two hours weekly, for four weeks. Attendance: 680 families between July 2001 and March 2006. Mothers are taught skills for massaging their babies, which promotes healthy mother-infant bonding. The group also provides an excellent opportunity for mothers to engage in social interaction with other mothers, and thereby aims to tackle the problems of isolation and postnatal depression commonly experienced by this client group. Barlow et al (2004) suggested that infant massage classes can promote bonding and attachment, particularly in depressed mothers. Managing children’s behaviour courseClient group: Parents of under-fives experiencing problems in the management of their children’s behaviour. Duration: Two hours weekly, for eight weeks. Attendance: 100 families between July 2001 and March 2006. Parents are provided with information about normal child development and behaviour, and encouraged to develop skills that promote positive child behaviour. They are also helped to develop ways to interact positively with their children and to provide praise, appropriate activities and affection. The course is based on Handling Children’s Behaviour - A Manual (Finch, 1983). Many studies provide evidence to show that similar courses help reduce behaviour problems in pre-school children (Barlow and Stewart-Brown, 2000). First-time parent courseClient group: First-time parents. Duration: Two hours weekly, for five weeks. Attendance: 180 families between July 2001 and March 2006. This group is a five-week course covering topics relevant to first-time parents such as pregnancy, birth, immunisations, weaning, accident prevention and cot death prevention. Teenage mothers’ groupClient group: Teenage mothers and mothers in their early twenties. Duration: Two hours weekly, for eight weeks. Attendance: 13 mothers and their children between October 2004 and March 2006 (the room was small and could only accommodate a small number of mothers and babies). This group offers parent training of a similar nature to the training provided in the ‘managing children’s behaviour’ and ‘first-time parent’ training courses. However, the delivery of material is tailored to the specific needs of this client group: information is presented in an informal, conversational format and a broader range of topics is covered in response to suggestions and questions from mothers. This group particularly aims to tackle the problems of social exclusion experienced by young mothers and encourages social interaction among attendees and their children. Baby bounce and rhyme timeClient group: Babies and toddlers, with their parents. Duration: One hour weekly, ongoing. Attendance: It is estimated that around 50 families take up this service weekly although exact attendance figures are unattainable since the group is run on a drop-in basis by parents but was originally set up and facilitated by a nursery nurse. ‘Baby bounce and rhyme’ classes are held at local libraries. They aim to help parents understand the benefits of reading and singing with children. The classes involve action songs, rhymes and storytelling, intended to support children’s early language acquisition. Through attendance parents may also improve literacy skills or benefit from opportunities for social engagement. In turn, these benefits could potentially have a positive impact on their children’s development, particularly in the areas of language, literacy and social development. Attendance at the end of the session, by professionals, provides a link with health visitors and other services. EvaluationTo determine whether the service succeeds in improving child and parent/carer well-being, parents attending the service complete three different questionnaires. The total sample size was 406. General Health Questionnaire, 12 question version (GHQ-12) by Goldberg, 1978Completed by: 406 parents/carers. The GHQ-12 is a brief questionnaire that may be used to screen for general mental health problems in parents or carers. It defines a mental health problem as a recent loss in the ability to carry out normal ‘healthy’ functions and/or the experience of any new psychological phenomena of a distressing nature (Goldberg and Williams, 1988). It produces a score that tells professionals whether or not a parent is likely to be experiencing a mental health problem. It is quick and easy to complete and is designed for use in primary care services and community settings. The GHQ is completed by parents at the beginning and end of engagement with the pre-five family service, so that changes in score can be measured. Strengths and Difficulties Questionnaire (SDQ) by Goodman, 1999Completed by: 33 parents/carers attending ‘managing children’s behaviour’ courses. For examples of this questionnaire see www.sdqinfo.com.This questionnaire is completed by parents and assesses the general mental well-being of their children. It provides ‘difficulty’ scores in four separate areas: - Emotional symptoms; - Behaviour problems; - Hyperactivity/inattention; - Peer relationship problems. ‘total difficulties score’ is calculated as the sum of these four separate difficulty scores. The questionnaire also provides one ‘strength’ score (the fifth score): positive social behaviour. The SDQ is used at the beginning and end of engagement with the service, so that changes in child well-being can be measured. Given that it is designed for parents of children aged three and above, only attendees of the ‘managing children’s behaviour’ course are able to complete SDQs. Parent satisfaction questionnaire, designed by the pre-five family serviceCompleted by: 33 parents/carers. This questionnaire aims to collect data about individual experiences of engagement with the pre-five family service and about satisfaction with guidance provided. It is completed at the end of courses. The questionnaire asks parents how beneficial and enjoyable they found a course, and how approachable they found staff. It also asks about the range and amount of improvement experienced by their children and themselves. In addition, the questionnaire gives parents several opportunities to comment freely on their experiences of any aspect of a course. ResultsThrough the use of these three questionnaires, the pre-five family service has found evidence of positive outcomes. Specifically, the service has found evidence for the following outcomes:
- Parental mental health improves during the period of attendance at a pre-five family service group (as measured by the GHQ);
- Child well-being improves during the period of a parent’s attendance at a family service group (as measured by the SDQ);
- Parent satisfaction: parents report that groups are enjoyable and highly beneficial (as measured by the parent satisfaction questionnaire).
This evidence will now be presented in more detail. All data used was collected from parents attending ‘managing children’s behaviour’, ‘infant massage’ or ‘first-time parenting’ groups between the inception of the pre-five family service in July 2001 and March 2006. Parental mental healthThe pre-five family service has been able to evaluate changes in 406 parents attending one of three groups (‘managing children’s behaviour’, ‘first-time parenting’ and ‘infant massage’). For each type of group, Table 1 shows the average GHQ scores at the first and last sessions of courses, and the average GHQ score improvement. Lower GHQ scores indicate lower parental mental health problems. Table 1 shows that there was an average improvement in GHQ score associated with each type of group. The largest improvement was associated with the ‘managing children’s behaviour’ group; GHQ scores improved from 4.0 to 2.1, a total average improvement of 1.9. ‘First-time parenting’ GHQ scores improved from 2.6 to 1.4, an average improvement of 1.2. ‘Infant massage’ GHQ scores improved from 1.8 to 1.0, an average improvement of 0.8. In the GHQ-12, the version of the GHQ used by the pre-five family service, a score of 4 or above may be used as a general indicator of likely mental health problems. Findings therefore show that ‘managing children’s behaviour’ groups may have helped to improve parents’ mental health from the cut-off point of 4 to below 4, that is, they may have ceased experiencing mental health problems while attending a group course. Although ‘first-time parenting’ and ‘infant massage’ GHQ scores improved by less than ‘managing children’s behaviour’ scores, this may be because scores started below the cut-off point and therefore had less room for improvement. Child well-beingThe service has been able to measure SDQ score changes for the children of 33 parents who attended ‘managing children’s behaviour’ courses. This number is much less than the number of families that have attended these groups. This is primarily because parents must attend the first and last sessions of a course for the measurement of SDQ score changes, and attendance tends to decrease towards the end of a course. If parents miss the last session, perhaps because they feel that they have already acquired enough skills to manage their child’s behaviour successfully, the change in SDQ score for their child cannot be obtained. The amount of SDQ data available is also reduced because some parents decline to complete the questionnaires and some cannot complete questionnaires easily due to language barriers or literacy problems. Table 2 presents a summary of SDQ score changes for the 33 children for whom data is available. ‘Total difficulties’ score changed from an average of 14.3 to an average of 11.6 during attendance. The SDQ defines this as an improvement from a ‘borderline’ score to a score within the ‘normal’ range. When compared with norms from a large UK sample (Meltzer et al, 2000) this improvement represents a change from a ‘total difficulties’ score at the 85th percentile to the 78th percentile. On average, this means that children initially showed difficulties greater than 85% of other UK children but improved by the end of a course to difficulties greater than only 78% of other UK children. Given that these norms were based on all groups of UK children (whereas the pre-five family service engages with vulnerable and deprived children) this improvement may be quite substantial. The SDQ also incorporates a ‘pro-social’score to measure positive social behaviour in children. The SDQ again defines this as an improvement from a ‘borderline’ score to a score within the normal’ range. When compared with norms from a large UK sample (Meltzer et al, 2000) this improvement is equivalent to a change from a ‘pro-social’score at the 5th percentile to the 10th percentile. On average, this means that children initially showed ‘pro-social’ behaviour better than only 5% of other UK children but improved by the end of a course to behaviour better than 10% of other UK children. Parent satisfactionThe following findings are taken from parent satisfaction questionnaires completed by 32 parents who attended a ‘managing children’s behaviour’ course between 2003 and 2006. Space does not permit an analysis of parent satisfaction questionnaires from all groups, but the pre-five family service feels that the comments of these parents are representative of those regularly gathered from parents attending any of the groups offered. General satisfactionAll parents who completed questionnaires described the course as ‘very helpful’ or ‘helpful’. All 33 also rated the level of information and advice given within the course to be ‘about right’. Furthermore, all described the course as enjoyable, informative and sociable. Some 26 parents described the pre-five family service staff facilitating the course as ‘very approachable’, and another five described them as ‘approachable’. Of the 33 parents, 31 said that the course had been a good way to meet other parents and to get extra support and advice from healthcare professionals. A total of 16 parents said that they learnt about other useful local services for parents and children. When asked specifically what was most enjoyable about the course, comments frequently centred upon the ‘relaxed, ‘non-judgemental’ and ‘friendly’ atmosphere of the groups. This atmosphere meant parents felt ‘able to ask questions’. They reported that the pre-five family service staff members were ‘friendly’, ‘welcoming’, ‘brilliant and approachable’, and that ‘their being mothers and their being relaxed helped relax us’. Benefits of social interaction with other parentsParents said they received a valuable source of support from the other parents attending the course. They were able to discover that ‘most parents go through the same behaviour with their children’, and they were ‘not the only one’. One mother commented that through ‘realising that everyone has the same problems, I didn’t feel so alone’. Parents said they benefited from ‘meeting mums in similar situations and sharing experiences’. Comments also suggested that parents valued the opportunity to socialise with other adults. Parents said they enjoyed ‘adult conversation’; ‘meeting other mothers and comparing notes, not necessarily about our children’; and ‘having a nice friendly chat with other people I didn’t know’. Improvements in child behaviourOut of the 33 parents, 27 thought there had been improvements in their child’s behaviour since attending the course. Parents reported the following specific improvements: less tantrums, less hitting, less biting, improved toileting, improved eating, improved sleeping and more pleasant social behaviour. Improvements in parents’ ability to manage children’s behaviourOf the 33 respondents, 30 said they now felt more confident about managing their child’s behaviour, and 29 said that they have started using new strategies learnt from the course. All 33 said they had gained a better understanding of their child’s behaviour. In a comments section, parents reported that they are now more consistent, clear and calm when managing their children’s behaviour. One parent reported that she is ‘better at not shouting and getting angry’. Another said that she has stopped smacking and is ‘using time-out instead’. One mother commented that her increased understanding of child behaviour meant that she ‘no longer expect[s] too much [and is therefore] not so impatient and not so frustrated’. Improvements in parent-child relationshipsParents reported that they had begun praising their children for good behaviour more frequently. One parent said ‘I tell [my child] she is good every night and morning’. In addition, parents noted they now spend more time in positive interaction with their children and that these interactions are easier because they feel less stressed. Parents suggested that increased confidence in managing their children’s behaviour, together with a new awareness that problematic child behaviour is common, had allowed relationships with their children to become more relaxed. A number of parents reported that they now see things from their child’s point of view and treat them ‘with more respect’. Parents frequently said they are now ‘more close’ with their children and ‘do a lot of activities together’. A number of parents also commented that there was increased affection in their parent-child relationships: ‘She comes to us for lots of cuddles now [but] two months ago she avoided me’; ‘She gives me extra hugs and kisses and tells me she loves me more often’; ‘When I was reading him a story he gave me a cuddle and said he missed me’. Summary of evidenceThe pre-five family service has found improvements in parental mental health and child well-being for group attendees. In support of these findings, parents report that they find courses to be enjoyable and highly beneficial. Although we have reported improvements in child well-being and parental mental health separately, associations between these two areas are commonly found (Cox et al, 1987) and it is possible that improvement in either of these areas leads to improvement in the other. For example, a less stressed parent may manage a child’s behaviour more effectively, making the child feel more secure. Improvements in child well-being may also lead to improvements in parental mental health. For example, a secure child may demonstrate less difficult behaviour, and parents may feel less stressed as a result. It is therefore interesting that attendees of ‘managing children’s behaviour’ groups show simultaneous improvements in parental mental health and child well-being. This result supports other studies that have shown simultaneous improvements in parental mental health and child well-being during attendance at parent training courses (Hutchings et al, 2002). Lessons learnt from setting up the early intervention serviceThe pre-five family service seeks not only to deliver health benefits for families but also to develop effective ways of working in primary healthcare. As the service was set up from scratch in 2001, the team was able to develop working practices and strategies in ways that it felt would prove most effective in work with families. Given that the service is intended as a local community resource, the team sought to develop strong links with other local services and agencies. As the service is intended to meet the needs of vulnerable and deprived families, who often face various problems covering health, education and welfare, the service sought to develop an effective multidisciplinary team and strong links with other agencies. The pre-five family service believes that the relations it has built with local services have greatly enhanced its effectiveness. These working relationships have facilitated understanding, awareness and communication between local professionals and helped the development of methods of practice and service delivery that work. Benefits of building links with other agenciesThe team has built alliances with Glasgow City Council Culture and Leisure Services, due to a shared interest in early literacy. Culture and Leisure Services allows the pre-five family service to use local library premises free of charge to run ‘baby bounce and rhyme time’ groups, making the provision of this group extremely cost-effective. This example of joint working also encourages parents to join the library, borrow books and take advantage of other services including internet access, IT and adult literacy classes. The pre-five family service works in partnership with ‘buddies club’, a local service that supports children with special needs and their families. Buddies club provides the use of their premises and creche facilities, again increasing the cost-effectiveness of the service. This partnership has also led the pre-five service and buddies club to run joint ventures including confidence and self-esteem classes for parents. The service has forged links with Sleep Scotland, which trains counsellors to support parents of children with special needs and poor sleep hygiene. Previously there were no trained sleep counsellors for the pre-five family service area and families were dependent on referrals to counsellors elsewhere, with waiting lists of up to two years. The pre-five family service applied for and received funding to enable training for four health visitors by Sleep Scotland. As a direct result, there is no longer a waiting list for sleep counselling among the service’s client group. Benefits of a multidisciplinary teamThe pre-five family service team includes a consultant clinical psychologist who also works within the psychology early intervention service (for children aged 0-12). Their service is part of children and young people’s specialist services of Greater Glasgow and Clyde NHS. The pre-five family service team is able to conduct joint consultations with the consultant clinical psychologist present when working with families experiencing complex mental health problems. In addition, the consultant clinical psychologist offers consultation for all health visitors working within the area served by the pre-five service. In response to common queries received through work with the family service, the psychology early intervention service has recently developed a pack of information leaflets about common problems experienced by families with children under five, which health visitors can use to reinforce information and advice. This resource pack is currently being reviewed for publication and distribution to a wider audience of professionals working with children under five. The pre-five family service has therefore benefited in a variety of ways from the support of a clinical psychologist. The team includes an assistant psychologist who conducts audits under the supervision of the consultant clinical psychologist to assess the effectiveness of the pre-five family service. In this way the service is able to provide an evidence base of outcomes achieved and to publicise the work of the team to other professionals. This practice also ensures that the service continues to meet the needs of local families, and provides insight for developing the service further. The pre-five service also includes a dietitian who offers a consultancy service to other health professionals in the team. It can therefore provide support and specialist advice for families with children experiencing weaning and feeding problems. Conclusion In summary, the range of professional relationships that the pre-five family service has developed with a broad range of healthcare professionals and other agencies directly improves interventions offered. It also enhances access for families to other health, education, culture and leisure, social work and voluntary sector services in the local area.
ReferencesAlpern, L., Lyons-Ruth, K. (1993) Pre-school children at social risk: chronicity and timing of maternal depressive symptoms and child behaviour problems at school and at home. Development & Psychopathology; 5: 371-387. Barlow, J., Stewart-Brown, S. (2000) Behaviour problems and group-based parent education programmes. Journal of Development and Behavioural Paediatrics; 21: 5, 356-370. Barlow, J. et al (2004) Pre-school behaviour problems: innovative approaches. Community Practitioner; 77: 2, 52-55. Cox, A. et al. (1987) The impact of maternal depression on young children. Journal of Child Psychology and Psychiatry; 28: 917-928. Crnic, K. et al (2005) Cumulative parenting stress across the preschool period: Relations to maternal parenting and child behaviour at age 5. Infant and child development; 14: 2, 117-132. Downey, G., Coyne, J. (1990) Children of depressed parents: an integrated review. Psychological Bulletin; 108: 50-76. Finch, G. (1983) Handling Childrens’ Behaviour - A Manual.London:NCH Action for Children. Ghodsian, M. et al (1984) A longitudinal study of maternal depression and child behaviour problems. Journal of Child Psychology and Psychiatry; 25: 1, 91-109. Goldberg, D. (1978) Manual of the General Health Questionnaire. Windsor: NFER-NELSON. Goldberg, D.P., Williams, P. (1988) The Users’ Guide to the ‘General Health Questionnaire’. Berkshire: NFER-NELSON. Goodman, R. (1999) The Extended Version of the Strengths and Difficulties Questionnaire as a Guide to Child Psychiatric Caseness and Consequent Burden. Journal of Child Psychology and Psychiatry and Allied Disciplines; 40: 791-799. www.sdqinfo.comGoodman, S.H., Gotlib, I.H. (1999) Risk for psychopathology in the children of depressed mothers: a developmental model for understanding mechanisms of transmission. Psychological Review; 106: 458-490. Hutchings, J. et al (2002) Evaluation of two treatments for children with severe behaviour problems: child behaviour and maternal mental health outcomes. Behavioural and Cognitive Psychotherapy; 30: 279-295. Najman, J. et al (2000) Preschoool children and behaviour problems: A prospective study. Childhood: A Global Journal of Child Research; 7: 4, 439-466. Naughton, A. Heath, A. (2001) Developing an Early Intervention Programme to Prevent Child Maltreatment. Child Abuse Review, 10, 85-96. Meltzer, H. et al (2000) Mental health of children and adolescents in Great Britain. London: The Stationery Office. Sonuga-Barke, E. et al(1996) Mental health of preschool children and their mothers in a mixed urban/rural population. II. Family and maternal factors and child behaviour. British Journal of Psychiatry; 168: 1, 21-25.