Organisation submitting example
Centre for Parent & Child Support
Local authority/local area:
Southwark, Camden, Ealing and Maidenhead
The context and rationale
The Helping Families Programme (HFP) is targeted specifically at the small but significant number of families with multiple problems, where chaotic parenting is likely to give rise to disruptive antisocial behaviour. The Helping Families Programme is an intervention which improves the outcomes of children who live in some of the most complex and disadvantaged families in the UK. Children and families with such difficulties offer significant challenges to service providers and are the least likely to benefit from existing parenting programmes. Multi-stressed, high need families are particularly difficult to engage, retain and treat.
Severe and persistent conduct problems during the middle and later stages of childhood are characterised by frequent and serious non-compliance, aggression, destructiveness and violation of social rules such as lying and bullying. Their severity and persistence is associated with the enduring presence of key child, family and social risk factors (Ferguson et al., 2005), which lead to highly problematic outcomes affecting emotional and social development, family functioning and peer relationships. They have a detrimental effect on academic achievement and increase the risk of school exclusion. As a result, children with severe and persistent conduct problems living in complex family circumstances are exposed to significantly elevated risk of future negative outcomes such as criminal activity, substance misuse and unemployment (Broidy et al., 2003) and are more likely to be responsible for the significant social and economic costs associated with conduct disorder (Scott et al., 2001).
Numerous efficacious interventions are available to both prevent and treat conduct problems as they manifest during childhood through to adolescence (for a review see National Institute for Health and Clinical Excellence, 2006). However, a small but significant group of children and their parents, particularly those with severe and persistent difficulties living in complex family circumstances, do not participate in, or respond as expected to these interventions (Nock & Ferriter, 2005). With the aim of improving outcomes for this group of families, a research collaboration led by the National Academy for Parenting Research (NAPR), UK, and involving the University of Queensland and Griffith University, Brisbane, Australia, has developed an innovative intervention for families with children aged five to 11 years old demonstrating severe and complex conduct problems that place them at risk of being excluded from school.
The development of the Helping Families Programme has been guided by the Medical Research Council (MRC) framework for the development and evaluation of complex interventions (Campbell et al., 2007). A systematic literature research review was undertaken.
We concluded that programmes aiming to work with potentially alienated and disaffected families need to incorporate explicit models for developing and maintaining effective relationships with marginalised families, such as the Family Partnership Model (Davis & Day 2010)and Parents Under Pressure (Harnett and Dawe 2008).
• Reduced frequency and severity of child conduct problems.
• Improvement in parents’ reports of their ability to monitor, regulate and control their emotions.
• Reduction in parents’ negative beliefs.
• Improvement in parenting behaviours and access to universal parenting resources e.g. parenting programmes.
• Improved school attendance.
The Helping Families Programme aims to help multi-stressed parents to address their children’s immediate behavioural and school attendance difficulties and in doing so help parents to bring up their children safely, lovingly and with confidence that they are doing the best by their children. Over the last two years the Helping Families Programme has been developed and evaluated, using principles of action research, with 24 families. It is currently being implemented in the London Borough of Ealing and in the Windsor and Maidenhead local authority area. Approximately 24 practitioners are working with approximately 160 families exclusively in the Helping Families Programme. The teams are receiving an intensive ‘Learn and Sustain’ programme to ensure integration of HFP into practice.
A snapshot of the Helping Families Programme in practice:
• An intensive 20 session programme delivered over a maximum of 6 months;
• Assertive and proactive outreach – Reaching Out;
• Individualised, working in partnership with the family;
• Addresses risk factors inhibiting effective parenting;
• Goal driven, strengths-based, future-focused;
• Supports change in the context of chaotic family environments;
• Empowers parents to help themselves and look after their families;
• Parent tool kit to help parents sustain changes.
The Helping Families Programme is organised into core practice modules and intervention modules.
The content and methods of the core practice and intervention modules is multimodal and uses a range of evidence-based strategies and techniques, derived from cognitive, behavioural, social learning, relational, attachment and systems theories to develop individualised implementation plans. These are structured but non-sequential, accommodating the complexity and individual variation in families’ needs and allowing for additional problems to be addressed as they emerge during the course of the intervention. The core practice module requires practitioners to continually demonstrate an explicit set of characteristics and procedures to engage and maintain goal-orientated partnerships with parents.
Helping Families Programme Core Practice Modules:
• Building a Purposeful Partnership Relationship and Making First Contact;
• Exploring and Assessing;
• Developing a Clear Understanding with Parents;
• Developing Parent Led Goals;
• Planning Strategies and Implementation;
• Reviewing the Goals and the Relationship;
• Preparing for the Ending of the Work and Relationship.
Helping Families Programme Implementation Modules:
The strategy modules that follow form the basis by which the goals and outcomes of the Helping Families Programme are achieved. The strategy modules improve outcomes across five key risk domain areas, not all of which will be relevant to each family. Parents’ behaviour, cognition and emotional regulation are the direct targets of the intervention. The Programme’s intervention modules focus on specific risk and resilience factors that will increase parents’ capacity to:
1. Increase positive relationships and conflict management skills;
2. Increase skills to maintain a tolerant, stable and regulated mood;
3. Increase positive and supportive family and social networks;
4. Reduce harmful substance use;
5. Increase adaptive instrumental and emotional coping.
The five risk factors outlined above are addressed through the structured yet non-sequential use of both Parenting Groundwork and Parenting Strategies. The implementation modules offered within the Helping Families Programme are summarised below.
The strategies are organised into Parenting Groundwork and Parenting Strategies. A menu is developed with the parents to address their goals to reduce their risk factors and increase family resilience:
A) Parenting Groundwork (Cognitive, emotional & behavioural strategies to address parent risk factors).
1. Constructs of self as a parent & child (The parent I want to be);
2. Mindfulness (Being in the Moment);
3. Relaxation (Chilling Out);
4. Activity Scheduling (Finding Space/ Making Time);
5. Challenging Unhelpful thinking (A Brighter view…);
6. Assertiveness (Being heard, being valued);
7. Family Orientated Social Support (Who’s around me and my family);
8. Substance Misuse (Keeping a Clear Head);
9. Instrumental & Emotional Coping (Fire Fighting –managing daily crises and hassles).
B) Parenting Strategies (Evidence based strategies, grounded in social learning theory).
1. Strengthening Positive Behaviour (Enjoying being a parent with my child)
(e.g. child centred play, connecting with your child, modelling, praise.)
2. Reducing Disruptive Behaviour (Keeping going when the going gets tough)
(e.g. punishment vs. discipline, giving clear instructions, setting limits.)
Practitioners and parents agree on goals for treatment and then formulate a strategy plan based on the equation: OUTCOME = Goal x (A1+(A2-9)) + (B1+B2) which is then implemented over the course of the programme.
• National Academy of Parenting Research
• Clinical pilot sites: Southwark Youth Offending Service and Camden Family Intervention Project
• Workforce development sites: LB Ealing and Windsor & Maidenhead Intensive Family Support Service
Referral processes: Referrals to the Helping Families Programme are made by clinicians and managers within the services detailed above. Referrals to these services can arise from a number of sources within a family’s professional network (e.g. school, GP, health visitor). Once received the HFP practitioner helps the parents to identify the risk and resilience factors present using the processes described above, works through the stages of the HFP and tailors a programme with the parents. Working systematically with the HFP Process, together parents and practitioner establish goals and measure baseline, plan strategies and, implement and review progress regularly using the modules of HFP while continuing to case manage the families and work across agencies.
Evidence and evaluation - making a difference to children, young people and families
Evidence and evaluation of the Helping Families Programme in Camden and Southwark over two years is provided below. The findings for Year 1 and Year 2 are presented separately, as learning from Year 1 informed the development of practice for Year 2.
Evidence and evaluation - Year 1:
• 15 children and their families were recruited. Children in the families were aged 5 -11 with severe conduct problems, at risk of or currently excluded from school. Families were chaotic with at least one severe risk factor (substance misuse, frequent family crises, inability to maintain a stable and regulated mood, interpersonal conflict with the child, close family or school).
• Data collection began in June 2009. Standard pre and post measures for conduct disorders and parenting were used: Parent Report Versions of the Strengths and Difficulties Questionnaire, Alabama Parenting Questionnaire, and school attendance records. Data was collected at the start, mid-point and end of the intervention (i.e. 0, 10 and 20 weeks). All parents consented to participate in a semi-structured evaluative interview post-intervention.
• Data was collected throughout the intervention on parent goal achievement (Goal Attainment Scale), parent wellbeing (Outcome Rating Scale) and the parent-practitioner relationship (Session Rating Scale).
Of the 15 families recruited, within the first 2-4 weeks, one family had the target child removed by social services, one family with two target children moved out of London, it became evident post-recruitment that one family with two children did not meet the criteria, and two families dropped out within the first four weeks of starting the Programme. Of the remaining families, all remained engaged in the Helping Families Programme and five children and their parents showed clinically significant changes i.e. 62% of the completing families. This is almost double what would be expected when working with multi-stressed families. The international ratio of positive outcomes with multi-stressed families is 1/3 improvement, 1/3 no change and 1/3 deterioration.
Key findings from Year 1:
• Multi-stressed families are notoriously difficult to engage and sustain in a programme requiring step-by-step disciplined change. Their attendance and participation in interventions is typically very poor, hence successful outcomes are limited. This attendance pattern is in stark contrast to our findings from Year 1: the maximum number of cancellations for one family was four and there was only one family who did not attend (DNA), on one occasion.
• Engagement was authentic and sustained as after the initial four weeks all families remained engaged. To achieve this the Helping Families practitioner had to consistently and continuously demonstrate a specific set of characteristics, in at times incredibly stressful and chaotic circumstances in the community, where parents, children and other family members were highly aroused or in crisis. Effective practitioner characteristics included genuine respect, humility about what HFP could achieve, strength and integrity, intellectual and emotional attunement, resolute and quiet enthusiasm, technical expertise and high-level communication skills.
• All parents consistently rated the relationship with their Helping Families practitioner very highly.
• The manualised approach was found to be accessible and acceptable to both the families and the practitioners.
• As parents’ intervention goals were achieved, parents reported improvements in their overall sense of wellbeing.
• There were significant improvements for all families in relation to goal achievement.
Evidence and evaluation - Year 2:
• 14 families were recruited and we continued to work with the sites (Camden and Southwark) where we had well established referral pathways and good relationships and apply the rigorous frame and measurements that had been developed from the piloting with a single case series.
• Using our learning from Year 1 a number of research procedures, processes and pathways were refined.
• Quantitative and qualitative results for 10 families who completed the Helping Families Programme, and for whom we have pre- and post-intervention data, are presented below.
• We do not have post intervention data for four families who did not complete. They all engaged with practitioners but were unable to make time and space (both practically and psychologically) to actively engage with the work required of them during the Helping Families Programme. In all cases, ending the work early was negotiated between and agreed by practitioners and parents.
Key findings from Year 2:
Below is a summary of the quantitative and qualitative data for the 10 completing families.
A range of standardised measures were administered to participating parents and the identified child’s teacher:
• Strengths & Difficulties Questionnaire (SDQ)
• Behaviour for Learning Questionnaire (BfL)
• Adapted Goal Attainment Scale (GAS)
• Overall Rating Scale (ORS)
• Session Rating Scale (SRS)
Key findings are as follows:
• 80% of parents and 70% of teachers reported improvements in their child’s conduct problems.
• 100% of parents and 80% of teachers reported improvements in their child’s skills and behaviour at school.
• 100% of participating parents reported that their overall wellbeing and their goal achievement improved over the course of the intervention.
• 90% of parents reported a consistently high or improved partnership relationship with their practitioner.
• Levels of engagement were high, given the multi-stressed contexts families were operating in. None of the parents failed to attend a session without prior arrangement.
Clinical activity and service use data
Clinical activity data:
• The total number of pre-arranged cancellations over the course of a parent’s engagement with the Helping Families Programme ranged from 1 to 16.
• None of the participating parents failed to attend a session without prior arrangement.
The Client Service Receipt Inventory (CSRI; Beecham & Knapp, 2001) was used to evaluate family service use pre and post the Helping Families Programme. Findings are tentative but suggest that:
• The mean cost of service use was similar at baseline and follow-up.
• There is an indication of change in the types of services used at follow-up.
• There is tentative yet initial support for a shift to potentially more effective and preventative services e.g. findings show a higher use of school-based support and lower use of social workers’ time.
All participating parents volunteered to take part in a semi-structured evaluative interview at the end of the Helping Families Programme; below is a selection of comments from the interviews.
“Hope started after I saw little changes start to happen … is this the same child?!”
“You feel as though the practitioners are still there for you even though they’re not physically there.”
“The most important thing is being listened to. If you listen to the parent about their child then the strategies will work.”
Feeding back to partners
Consistent with principles of the Helping Families Programme, processes were developed to ensure all families, the professionals involved in their care, the service sites and the schools were provided with feedback that was collated in partnership with the families about progress through the intervention and outcomes achieved. Documents developed to facilitate feedback include case summaries, school feedback and clinical site summaries of the participating families.
Summary of Year 2 findings
The data presented above provides initial positive support for the effectiveness of the innovative, systematic intervention provided by the Helping Families Programme. In standard interventions with complex families, 33% improve with 66% staying the same or deteriorating. Preliminary findings indicate that in the Helping Families Programme 70-100% of parents and teachers show improvements in children's behaviour, emotional wellbeing, parents’ goals and overall sense of wellbeing. We also demonstrated very high levels of genuine engagement and retention with no parents failing to attend arranged appointments over a six month period.
We have prepared a further research proposal to conduct a cohort study to build the evidence base for this programme and continue to make a fundamental difference to child and family outcomes.
The final report: “High Need Families Project: Developing and piloting a new parenting intervention (The Helping Families Programme) for children with severe and persistent conduct problems”, published in February 2012, is available on theDfE website.
Sustaining and replicating your practice
• Adherence to the programme – a manual has been published, a compendium of fidelity tools developed, and a Learn and Change training and supervision programme.
• Developing organisational systems necessary to sustain practice - current workforce development projects, which include a 12 month development and integration package aimed at ensuring future sustainability with the organisations.
Costs and benefits:
• Funding from DoE/NAPR for Research and Development
• Ealing and Maidenhead Workforce Development Pilots
Costs - Approximately £35,000 for staff training and support for 12 practitioners working with approximately 70 Tier 4 families (stable and protected caseload with families who have at least 2-3 risk factors and 1-2 children that are subject to child protection) delivering HFP in 20 sessions over six months. Working exclusively in HFP and continuing to case manage and work as part of the team, undertaking duty and crisis cover etc, backfill costs the LA approximately £80, 000. Total cost is approximately £1,642 per family to receive the HFP with improved outcomes across family life. It is estimated that improvements (as measured in the HFP) will occur in 50% of families, there is an expected increase in early clear systematic decision-making using the goal and review processes with families who are not able to undertake the HFP and therefore accurate and timely processes will be employed to ensure children are able to develop in safe and adequate environments.
During the Research and Development phases, we collaborated with the London School of Economics to adapt economic measures and systematically measure service use and cost effectiveness of HFP. The size of the sample prevented any statistical analysis being done. However there was a general trend towards a move from tertiary, specialist and high cost services to more universal, community and early intervention services.
Learning from the experience:
• Families who meet the criteria to receive the Helping Families Programme have been involved with multiple services over long periods of time, with little or no effect.
• The Helping Families Programme practitioner actively collaborated and worked alongside all agencies in the professional network, which was attributed to reductions in child protection concerns as reported by social care.
• The planned 2-3 contacts per week to facilitate engagement and change was neither always necessary, nor acceptable for families at the early stages of engagement. One or less face to face contact per week plus active multi-agency working, text and email contact was more helpful to facilitate engagement and change.
• It is difficult to maintain focus and a methodical approach with chaotic, multi problem, crises driven families. The process of ‘Fire-fighting’ was developed and became central to building stability and facilitating the tasks of the helping families process and increase instrumental and emotional coping with families.
• The development of a process to establish ‘Quick wins’ was essential to assess the families readiness to engage in the Helping Families Programme and instil hope for change.
• It was helpful to use an example Parent Toolkit to assist parents to engage in the programme.
• Materials and tools used with parents were more accessible when these incorporated visual aids and activities.
• Outcomes were best where high fidelity to the manual was sustained. This was particularly the case when practitioners were implementing the Programme for the first time. With time, experience and an appreciation of the complexity and nuances of the intervention, they were able to develop increased flexibility with their use of the manual whilst adhering to its core principles (termed ‘The Bedrock’).
• Fidelity tools were effective in facilitating practice reflection and structuring supervision conversations with practitioners. This was essential in enabling practitioners to work with families in persistently chaotic and stressful environments, while maintaining fidelity to the programme and retaining hope and integrity for the work being undertaken.
• We learnt that in order to be effective, training and supervision needed to be directly and actively applied to practice, hence the development of Learn and Change programme.
• Over the two years we became much clearer about the characteristics and skills needed in practitioners to enable them to effectively implement and sustain working in the Helping Families Programme, these are included in the process sections of the manual as well as core practice. A Reflective Practice compendium was developed to support the development and reflexive practitioner when working in the Helping Families Programme.
• Using our learning from Year 1, a number of research procedures, processes and pathways were refined. These included recruitment for the Research Clinicians and the site practitioners. A number of educational and promotional materials were developed to assist with both the research and the understanding and dissemination of the Helping Families Programme. These included an updated practitioner information pack, guidance on explaining the intervention to other professionals and agencies and a promotional leaflet.
• Clinical Researchers provided feedback that they required more guidance in relation to recruitment and the use of evaluation measures. Therefore the research process was refined and a researcher resource pack was developed.
Challenges regarding the case control study
• Preliminary conversations and correspondence regarding conducting a case control study did occur did not result in any sites willing to participate. There were two main reasons for this. Firstly, services approached said that there were no established referral pathways for primary school aged children. Secondly, for those children that did meet the criteria, services were reluctant to provide referrals when the families would not receive the intervention due to the high needs of the sample population.
• Promoting resilience
• Together with children, parents and families
• Unite to succeed
Broidy, L.M., Nagin, D.S., Tremblay, R.E., Bates, J.E., Brame, B., Dodge, K.A., Fergusson, D., Horwood, J.L., Loeber, R., Laird, R., Lynam, D.R., Moffitt, T.E., Pettit, G.S. and Vitaro, F. (2003) ‘Developmental trajectories of childhood disruptive behaviors and adolescent delinquency: a six-site, cross-national study’, Developmental psychology, vol 39, no 2, pp 222–45.
Campbell, N., Murray, E., Darbyshire, J., Emery, J., Farmer, A., Griffiths, F., Guthrie, B., Lester, H., Wilson, P. and Kinmonth, A.L. (2007) ‘Designing and evaluating complex interventions to improve health care’, British medical journal, vol 334, pp 445–459
Davis, H. and Day, C. (2010) Working in partnership: the Family Partnership Model, Oxford: Pearson.
Fergusson, D.M., Horwood, L.J. and Ridder, E.M. (2005) ‘Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood’, Journal of child psychology and psychiatry and allied disciplines’, vol 46, no 8, pp 837–49.
Harnett, P.H. and Dawe, S. (2008) ‘Reducing child abuse potential in families identified by social services: implications for assessment and treatment’, Brief treatment and crisis intervention, vol 8, pp 226–235.
National Institute for Health and Clinical Excellence (2006) Parent-training/education programmes in the management of children with conduct disorders, London: NICE (available at http://www.nice.org.uk/TA102, accessed 18 July 2012).
Nock, M.K. and Ferriter, C. (2005) ‘Parent management of attendance and adherence in child and adolescent therapy: a conceptual and empirical review’, Clinical child and family psychology review, vol 8, no 2, pp 149–166.
Scott, S., Knapp, M., Henderson, J. and Maughan, B. (2001) ‘Financial cost of social exclusion: follow up study of antisocial children into adulthood’, British medical journal, vol 323, pp 191–194.
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