Organisation submitting example
Nottinghamshire County Council
Local authority/local area:
Nottingham and Nottinghamshire
The context and rationale
The Parent Child Game is a treatment method which was developed in the United States in response to research by Forehand and McMahon (1981), and which was adapted in Britain by Sue Jenner and colleagues at the Maudsley Hospital London. Forehand and McMahon found that parents of ‘problem children’ typically issued more frequent and vaguer commands and that commands were more punitive; attended more to unacceptable than acceptable behaviour; were involved in more extended, coercive hostile interchanges; and were less likely to interpret oppositional behaviour as such. These more coercive styles of parenting were found to be associated with child maltreatment.
The aim of the Parent Child Game (PCG) is to train the parent to use positive child-centred strategies to influence their child’s behaviour. The programme is used for families where the difficulties are severe and / or longstanding. It offers intensive support to parents and combines live parent skills training work, which is undertaken during 10-minute play sessions, with interventions using a range of therapeutic methods, such as behaviour management advice, supportive counselling and home- based outreach support alongside the play sessions.
The play sessions take place in a controlled learning environment, in a video suite with a one-way screen. The therapist remains behind the screen and communicates directly with the parent with the use of a microphone, transmitter and earpiece, whilst the parent and child play together. The therapist then supports the parent and prompts them (by the use of the earpiece) whilst they play and interact with their child.
In the first session, there is an assessment interview with the parents after which an initial baseline of parental behaviours is recorded by the therapist over a 10-minute period. This is discussed with the parents and they are taught how to increase their child-centred behaviours over a series of intervention sessions. After several sessions, a second baseline is recorded.
The Parent Child Game can be used to help parents experience and understand their own progress in a manner which can be understood. It can measure the type and frequency of parental behaviours and helps clarify what specific changes in parental behaviour have been achieved. PCG appears to be particularly helpful in facilitating warmer, more nurturing relationships between parents and children. Its focus is to enable parents to recognise and reflect upon their parenting behaviour and to make links between their own experiences of being parented and their parenting style in a manner which is designed to encourage greater sensitivity of the parent to the child’s emotional responses.
The programme targets families with children between the ages of 18 months and approximately eight years (or similar developmental level) where there may be severe behaviour problems or entrenched relationship difficulties, and where parents may have struggled to access or respond to other approaches, such as a parent skills training group.
The Parent Child Game benefits appear to be that it is an activity-based approach, which has a rapid impact with significant change being achieved within four to seven sessions. It has an effect on the child’s behaviour, on the parent’s psychological state in terms of confidence and upon parenting behaviours, which appears to improve parent/child relationships. Specifically, it trains parents to reinforce their child-centred behaviours such as praise, positive touch and descriptive comments (attends) and decreases the frequency of child directive behaviours, such as saying ‘no’, criticising and issuing commands. Research in the USA has identified the PCG as a useful approach which has “contributed to the alleviation of parenting skills difficulties and child conduct problems” (McMahon and Forehand, 2003). (Further details of research conducted into the PCG is available by contacting the C4EO team at the NFER.)
Development of the service
The idea for the service originated from a QED television programme in 1993 which presented the Parent Child Game (PCG) as used by Consultant Clinical Psychologist Sue Jenner of the Maudsley Hopital, London. Initial training and accreditation was provided by Sue Jenner, with subsequent training and accreditation provided by Helen Carlton Smith of Bolton Community Trust Child and Adolescent Mental Health Services (CAMHS).
A pilot project was initiated in Newark, Nottinghamshire between 1997 and 1999 and a research grant was provided by Boots Charitable Trust via Nottingham University, with additional funding from the local authority and resources from Central Nottinghamshire Child and Family Therapy Service. A qualitative analysis of parents’ attributions was undertaken by a clinical psychology trainee.
Between 2000 and 2001 ‘quality protects’ monies facilitated the establishment of clinics in five Family Centres in North Nottinghamshire, and South Trent Training Confederation (Health) provided £5,000 to support training of Family Centre Workers. In June 2001, the first five-day programme of introductory training was undertaken with 10 Family Centre staff. Introductory training covered baseline levels of knowledge, including attachment and behaviour management, and initial skills training regarding reliable baseline recording, feedback, initial assessment interviews and microphone skills. Following successful completion of the five-day course, delegates were accredited as being able to work under supervision. Phase 2 of the training involved working for between 20 and 40 sessions (one to two years) in supervised training clinics. Trainees completed a log book, containing details of their experience, for example, cases, goal setting, time on the microphone, feedback, interview practice etc. The log allowed for reflective comments and this collaborative learning approach was supplemented by DVD recordings of trainees’ performance. These were evaluated by the Consultant Clinical Psychologist and trainees could then be accredited to work under consultation. Once accredited, clinicians may be in a position to lead a clinic and to provide supervision to other trainees.
This cascade model of training allowed for the extension of the service to incorporate 12 clinics, and the Parent Child Game has now become part of the core business of Family Centres. To date, 32 trainees from a range of disciplines, including social services and health, have completed the introductory training and 18 trainees have been accredited to work under consultation.
In order to preserve the quality and integrity of the service, all clinicians have access to monthly half-day consultation and supervision meetings which rotate around Family Centre and clinic venues to allow for equal access. There are also quarterly meetings for all staff to discuss organisational issues, service development, concerns and problem solving. Working groups have provided standardised parent information sheets, handouts, trainee log books, feedback forms etc. Service managers attend the meetings as necessary.
In 2005, the service was launched via a multi-agency promotional day in Nottinghamshire. Service users and clinical staff made presentations and gave feedback to referrers. At this session, referral pathways were also identified and referral criteria qualified.
Initially, referrals were received on a clinic basis. More recently they have been processed via a single entry point for Specialist Family Support Services before being directed to locality clinics.
The referral criteria are as follows:
1. children with severe and complex behavioural difficulties aged between three and eight; children over the age of eight are considered depending on their developmental abilities
2. children where there are compromised attachments and difficulties with the parent-child relationship
3. children within Child Protection or where there may be concerns regarding child protection issues
4. parents and children where there is a reunification plan.
Nottinghamshire’s ‘Pathway to Provision’ document provides a comprehensive toolkit for all practitioners working with children, young people and families. It supports practitioners in identifying the child, young person and/or families’ level of need and enables the most appropriate referrals to access provision. The Common Assessment Framework (CAF) is also used in the assessment processes for children and families where there are significant attachment issues and severe behavioural difficulties. Levels 3 and 4a of the Pathway to Provision are referred for Parent Child Game intervention. The Pathways to Provision document, along with various items of information and training packs that are distributed to parents and professionals to accompany the intervention and training courses, are available by contacting the C4EO team at NFER.
The Parent Child Game intervention offers intensive support to parents and combines live parent skills training work, which is undertaken during 10-minute play sessions, with interventions using a range of therapeutic methods, such as behaviour management advice, supportive counselling and home-based outreach support alongside the play sessions. The play sessions take place in a controlled learning environment, in a video suite with a one-way screen. The therapist remains behind the screen and communicates directly with the parent with the use of a microphone, transmitter and earpiece whilst the parent and child play together. The therapist then supports the parent and prompts them (by the use of the earpiece) whilst they play and interact with their child. In the first session, there is an assessment interview with the parents after which an initial baseline of parental behaviours is recorded by the therapist over a 10-minute period. This is discussed with the parents and they are taught how to increase their child-centred behaviours over a series of intervention sessions. After several sessions, a second baseline is recorded.
During the parent interview, which is undertaken during the remaining 50 minutes of the session after the 10-minute guided play activity, the following interventions are used:
• praise for success
• feedback and discussion on the 10 minutes (may involve showing DVD recordings and discussing what worked well and what could have been done differently)
• discussion of homework (sessions which the parents undertake at home to assist with generalising their child-centred skills to the home environment)
• problem solving related to behavioural or emotional issues
• advice on applying the skills in real life settings
• review of progress
• discussion of parents’ emotional relationship with the child
• discussion of parents’ experiences as a child and a parent
• provision of handouts and information relating to the different categories of behaviour
• role play and modelling appropriate strategies
• setting homework tasks.
Intended measurable outcomes
• to provide a Parent Child Game service across Nottinghamshire and Nottingham Family Centres on an equitable basis
• to enable early intervention to prevent the development of entrenched conduct and/or mental health difficulties
• to improve parent-child interaction in order to prevent later relationship problems and psychopathology
• to intervene at an early stage with coercive patterns of parenting to improve safe-guarding and prevent registration of children as children in need or children in care
• to improve behavioural presentation in order to optimise children’s capacity to access education and enable children to achieve their full potential
• the reduction of parental stress and enhancement of parental confidence and skills to enable parents to prioritise and meet their children’s emotional needs.
Children’s behavioural difficulties are known to impair adjustment and performance in school. An intervention which improves children’s behaviour where there are clinically significant levels of behavioural disturbance, therefore, is likely to correlate with an improved ability for them to access education and achieve their full potential. Where behavioural problems in school/nursery were disclosed by the parent, then Rutter Teacher Measures were sought (see below), in order to monitor progress. Currently, insufficient data is available to quantify outcomes, however, where appropriate, this is one of the goals for specific children.
Measures and case study example
Outcomes are measured from a pre-intervention baseline.
At the home-based initial interview, for example, the Rutter School Aged or Pre-school Behaviour Rating for Parents and Teachers is used to provide a measure of total behavioural difficulties; hyperactivity and inattentiveness; conduct difficulties; emotional difficulties; and pro-social behaviours. The Parental Stress Index is also used to provide a measure of validity; parental distress; parent-child interaction; difficult child; and total stress. This data is collected for all referrals and the indices are reapplied at the conclusion of therapy.
In addition, at the initial consultation, the frequency and ratio of child-centred compared with child directive behaviours is assessed during a 10-minute observation period. Repeat baselines are normally undertaken after six sessions and, depending on degree of progress, the goals of the intervention and the needs of the individual family, this process may be repeated a number of times.
A basic data set is completed for all closed cases which includes:
• demographic information
• reason for referral
• pre- and post-intervention measures for child-centred and child directive behaviours
• parental Stress and Rutter Parent and Teacher Scales.
In addition, data is currently being gathered from all completed data sets with a view to subjecting these to detailed statistical analysis as a means of providing a more comprehensive measure of outcomes with regard to the service.
Case study example:
• Child S, gender male, referred aged 10 years.
• S lives with both his parents and has two siblings, both of whom are on the autistic spectrum.
• Work was undertaken with the father who was presenting with a low mood and may also be on the autistic spectrum.
• S has been diagnosed with pathological demand avoidance (PDA). There are no child protection concerns. The parents have no drug or alcohol issues and there have been no recent losses or bereavement.
• There were some birth-related difficulties; S was born by emergency caesarean section and the family were living in homeless accommodation at the time of his birth. The reasons for the referral were both relationship difficulties, in particular focusing on the interaction between the father and S, and behavioural difficulties at home and at school.
Having presented with complex needs, S and his family undertook the Parent Child Game to help S’s father to use more child-centred behaviours and to help with parental sensitivity, to improve the relationship between parent and child, and to improve S’s behaviour at home and at school.
Repeat baseline measures showed:
• an increase in child-centred actions from eight at initial baseline to 38 at repeat
• a decrease in child directive actions from 16 at initial baseline to eight at repeat
• a decrease in parental child interaction difficulty from 51 at initial baseline to 39 at repeat
• a decrease in total stress factors from 158 at initial baseline to 130 at repeat.
The intervention appears to have resulted in both quantitative and qualitative change with regard to observed parental behaviours. In particular, S’s father was using more positive and child-centred parenting strategies, including praise and imitation, and there was also an increase in the amount of interaction which took place during the 10-minute sessions.
Further detail on this case study example, along with additional case study examples, is available from the C4EO team at the NFER.
Evidence and evaluation - making a difference to children, young people and families
The cascade model of training and the collaborative working necessary for the Parent Child Game has provided an accessible locality-based service with a strong theoretical foundation in attachment theory, social learning theory and behaviourism. The process of accreditation has sought to ensure the quality and integrity of the service. The service provides an objective quantifiable measure of parenting behaviours and empowers parents, providing them with an opportunity to interact directly with their children whilst they are under instruction as a means of promoting the child’s improved behaviour, parental sensitivity and improved parent-child interaction.
The cascade model has enabled the service to be delivered in a wide range of localities across the whole of North Nottinghamshire and parts of Nottingham. Clinicians are flexible and mobile and, therefore, changes in the pattern of referrals and / or staffing difficulties have been accommodated, as clinicians have supported each other.
All clinics have extended their provision and referrals are normally managed with just a small waiting list, such that vulnerable families in crisis can usually access the service within a short timescale.
The focus on guided play using a prescriptive approach ensures that some of the most vulnerable parents, including those with a learning disability or with a history of being in care, can improve their parenting skills, whilst interacting directly with their child in a manner which is safe and supported and which provides the children with a positive experience. Assessment can be undertaken alongside intervention in an open and honest, but non-critical environment, including situations where there are child protection concerns. Parents are supported to perform as best they can and the stress to children is minimised. The quality of the interaction is the focus, whether for the purposes of therapy or reunification or simply supporting a better quality of contact between parent and child.
The engagement of families is promoted via initial home visits and the generalisation of skill development is encouraged via outreach support. The approach offers an objective measure of change with calculable data which is fed back to the client, providing a transparent record of parental behaviour. DVD recordings are made of every session with the parents’ agreement, and can be used to provide immediate feedback and further evidence behaviours and change.
The Parent Child Game is now core business for Specialist Family Support (formerly Family Centres), providing a resource and intervention for some of the most complex and entrenched family problems. Intervention may be part of a package of support or may follow input from a range of tier three services. The extension of the service has enabled it to become more accessible to fulfil an early intervention role for families who will benefit from a more intensive hands-on approach, and/or for whom a didactic parent skills training group would not be the best approach.
The extension of the training programme to include ‘advanced training’, a focus on families who are difficult to engage and further training in attachment, has enhanced the skill base of Family Centre workers and other professionals contributing towards a team.
Children’s Centres are engaging cooperatively with Specialist Family Support and Early Intervention staff and will, in future, become integrated into the team, such that the Parent Child Game will be one of the parenting programmes promoted across Nottingham and Nottinghamshire.
In the UK, and specifically in Nottinghamshire, the Parent Child Game approach has been utilised to target “hard to reach” families where there are severe behavioural difficulties and/or relationship problems. Initial audit data and evaluation (see below) suggest that, when families engage, outcomes in terms of positive change to parenting behaviours are highly likely to occur, with data indicating a 95 per cent positive change rate.
Sustaining and replicating your practice
Evaluation audits have been undertaken as the service has developed and these have provided valuable information regarding access to the service, dropout rates and engagement. The service has been modified as a result, for example, by undertaking home visits to introduce service users to the ideas and principles of PCG and gather initial data on children’s behaviour and parental stress.
All cases are videotaped/recorded on DVD and all utilise a single case design model and therefore have ‘before and after’ measures which are quantifiable.
In addition, all training programmes have been evaluated and feedback has again been used to modify these.
An audit of referrals for Newark Family Centre and the Albion Family Centre covered a two-year year period when clinics were provided for one half-day on a fortnightly basis (between 2000 and 2003).
The Albion Family Centre received 14 referrals and Newark Family Centre 15 referrals. In both instances, seven of the referrals completed treatment and the remainder either dropped out or failed to attend, or were assessed as unsuitable for the intervention. In both instances, referrals were found to predominate from social services and CAMHS, (approximately 50 per cent from each service), with a small number of referrals received from Health Visitors and other referrers.
The average number of intervention sessions before case closure was nine, with a range of from five to 13.
The primary presenting problems for referral were parent-child relationship difficulties, behavioural difficulties, or both. Single parent families and married or cohabiting couples were equally represented in referrals, but the focus of the therapy in two-thirds of cases was the mother only.
Complete pre- and post-baseline data was available for the Newark Clinic only and of the seven cases successfully concluding treatment, five sets of complete data were available. In all instances, initial baselines verified more child directive than child-centred behaviour, with a range of from two to 10 times as many child directive as child-centred behaviours. Post-baseline data identified more child-centred than child directive behaviours in all five cases; the ratio ranged between 1.5 and 11 child-centred to each child directive behaviour.
In addition, an evaluation of attendance at, and outcomes from, the Parent Child Game clinics was undertaken in 2007. The study used pre-existing data and analysed the most recent 47 cases referred to the PCG clinics across North Nottinghamshire. The age range of children referred was from two to 12, the average age being seven years. There were equal numbers of single and two-parent families; 0.3 per cent were single fathers. The two-parent families included adoptive parents or step-parents. The most common referrals were for behavioural difficulties (40.6%), relationship or attachment difficulties (17.9%) or both (8.9%). Nearly three-quarters of referrals came from the Child and Family Therapy Service and Social Services including Family Centres; 4.2 per cent of referrals had been directed via the Courts. Of the 47 children referred, 42.6 per cent completed intervention and agreed an ending with the therapist, 34 per cent dropped out and 11 per cent did not attend any appointments. Of the 20 families who negotiated an ending to the Parent Child Game, only one family did not find the intervention useful and terminated treatment on this basis. Of the remaining cases, the ratio of child-centred to child directive behaviours increased by the end of the Parent Child Game intervention.
In sum, in the 2007 evaluation, the Parent Child Game had been successful in facilitating change with an increase in child-centred behaviours in over 40 per cent of the cases referred, and in 95 per cent of those cases where the intervention was completed. Excluding those who did not attend any sessions, the Parent Child Game was successful in 53 per cent of cases.
Single case studies are available for all cases as a means of evaluating progress on a case-by-case basis. There is limited collective evidence around the outcomes for children, as the design of the model is centred around this single case principle. Current evidence relating to the families and children that have received support includes:
• improved perceptions by parents/carers of their child/ren
• older children providing positive individual feedback, highlighting an improvement in their relationships and understanding
• positive evidence regarding improved relationships and behaviour
• improved behaviour in school, leading to improved attainment
• prevention of family breakdown.
An additional qualitative study exploring parents’ experiences of the Parent Child Game (PCG) was undertaken by George Johnson and submitted for his Doctoral Thesis to the University of Sheffield, D.Clin Psych, in 1999. Clinical Supervision for the thesis was provided by Julie Leather, Consultant Clinical Psychologist.
Dr Johnson’s study explored aspects of parents’ experience of the Parent Child Game intervention via interview and transcript analysis using interpretive phenomenological analysis (IPA). Eight parents who had completed PCG therapy via the Nottinghamshire PCG service were interviewed. All the referred children had oppositional/conduct problems. The results identified three main themes for parents which appear to support the notion that the PCG generates therapeutic change via a substantive shift in parental outlook. The three themes were parental confidence; a developed sense of objectivity; and strengthened parent-child relationships.
Introductory training (up to 14 trainees): £5,000
Advanced training: £1,000 - £2,000
Equipment and room hire: £20 per hour
Staff time and resources, £49.50 per hour (based on three staff )
Consultation sessions 12 x half days, £6,000
DVDs, earpieces, batteries, antiseptic wipes, £2 per hourly session
The current costs are based on three staff per hour; this is the maximum number of staff required to ensure good practice by offering an element of training, childcare support and consistency for the children and families attending. Staff time costs include on-costs for the venue, maintenance of equipment and resources. There are no planned additional costs to set up clinics with a camera link etc., as these have all been set up from previous Family Centre funds.
During a six-month period in 2011, an average of 600 sessions were delivered by 32 workers. Currently there are 19 workers at the accredited level and 13 trainees.
The plan is to build up this team of workers across the early intervention/family support service within the county and get all staff trained to be accredited to deliver the model of Parent Child Game within more clinic sessions. The aim is also to get support with crèches and childcare arrangements by linking with existing early years childcare resources, thus minimising the demand on staff who are undertaking the Parent Child Game role.
The maximum cost for a session is £50 per hour. The average number of sessions per family is eight, which amounts to a cost of £400 per family.
When considering the positive impact and outcomes of providing this intervention to individual children and families – at an early stage - this average cost of £400 is minimal, compared with the cost of the family having to receive more intensive support from a clinical psychologist, CAMHS practitioner or similar. The Legal Service Commission have, for example, recently evaluated Child Psychologists’ time at £126/hour for expert assessments in Child Protection legal proceedings.
The level and input of consultancy support will be reviewed annually to reflect ongoing developments and the increased expertise of internal staff.
Some key features of the PCG intervention – which are crucial to its successful implementation - have been identified during audit and evaluation of the service to date. These are:
1. Accessibility - the provision of a local, accessible resource.
2. Engagement of parents who are hard to reach.
3. It is possible to quantify parental behaviour and change in a manner which does not compromise children experience. This is an honest approach which recognises difficulties whilst promoting positive change
1. The standardisation of handouts and recording forms for reflective practice is very useful to ensure quality of service maintenance, and that the accreditation process is clear and transparent.
2. The support of managers to ensure that the ‘team’ approach is respected is an essential component.
3. Be prepared to demonstrate your work and to seek feedback from service users, which is invaluable. The approach “speaks for itself” via the DVD evidence.
4. It is useful to have a ‘technically minded’ person on the team and/or good technical support, as equipment can be temperamental.
Links to C4EO’s ‘golden threads’ are:
• You can do it
• Know your communities
• Unite to succeed
• Prove it
t. 020 7833 6825
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