How to improve the Nation’s

Parenting to achieve more secure

attachments and more considerate attachments and more considerate

behaviour in children

Stephen Scott

Professor of Child Health and Behaviour

Director, National Academy for Parenting Research

Antisocial Behaviour (ODD,CD)

Age 7 Anti-social

Violent offending

Heavy drug use

Teen

Parent

No exams

On

benefits

Outcomes at age 25 by how antisocial aged 7(Fergusson et al 2005)

social

Top 5% 35 20 20 52 33

0- 50% 3 5 4 6 9

Total extra cost to age 28(Scott, Knapp et al 2001, BMJ)

70,000

50,000

60,000

70,000

Mea

n c

ost

£ 1

998

10,400

24,300

0

10,000

20,000

30,000

40,000

No problems Conduct

problems

Conduct

disorder

Mea

n c

ost

£ 1

998

Social Learning Theory & aggression

� Coercive cycle: child rewarded (by attention) for antisocial acts, ignored when sociable, so aggression actively trained

� Evidence strong – eg Patterson et al 1982, Gardner 1989

� Good account of developmental progression: outside home peers reinforce antisocial values - supervision crucial

� Interventions: behaviourally-based parenting skills often very effective eg Triple P , IY

� clarify rules; punish for misbehaviour (eg ignore, sanctions),

� contingent rewards for prosocial behaviour;

� CBT (“anger management”) with child

Individual intervention for antisocial behaviour

but SLT doesn’t address:

� why attention is rewarding (drive to relate)

� Why once trust in humans lost, attention isn’t rewarding (unresponsive abused foster child)

� In some programmes, beliefs of parents not formally handled; these may get in the way even where skills OK

� Good clinicians often address them

� Impact of emotion: anger management often not effective in real life when provoked; evoking emotion increases effectiveness of training (role play)

Attachment theory(John Bowlby, 1969-1982)

• Was mainly about and babies & young children

• Infant’s needs met by Sensitively Responding parent

- Infant then secure to explore the world

• Over time, infant builds up Internal Working Model

- This aids emotional regulation (help is at hand)

Attachment theory (2)

� Different parenting styles lead to certain patterns

Sensitive → secure

Dismissive → avoidant

Inconsistent → ambivalent, pre-occupiedInconsistent → ambivalent, pre-occupied

Abusive → disorganised

� Last two may lead to aggression through frustration at

not being comforted, lack of learning emotional

soothing/modulation, need to control parent to make

predictable, overwhelm coherent response

But AT doesn’t address:

� Setting of limits and boundaries and relation to non-compliance

� Impact of rewards, sanctions, and skills modelling on child social behaviour

� Other environmental influences on children, eg peers, educational difficulties

�

Some questions about attachment:

1. Does attachment matter past infancy?

(or do other influences take over?)

2. What about in adolescence: does it still matter?2. What about in adolescence: does it still matter?

3. If so, is it just a read-out of current parenting, or

are there traces of the past?

4. What kind of parenting helps teenage security?

Does attachment matter after infancy?

• Study with 113 4-6 year olds

• Manchester Child Attachment Story Task (MCAST)

• Security predicts a range of better functioning; • Security predicts a range of better functioning;

Disorganisation, especially, predicts

• conduct problems;

• poorer prosocial behaviour,;

• impairment as rated by Teacher as well as parent

SO YES IT DOES!

Futh, O’Connor, Matias, Green & Scott, JAACAP, 2008

And attachment in adolescence?

• Study of 248 teenagers of varying risk using CAI interview

• Did attachment security relate to functioning? Yes

• But did attachment predict anything after taking current

parenting quality into account? Yesparenting quality into account? Yes

• What kind parenting was associated with security? Sensitive

responding AND limit –setting and supervision

• Conclusion: Secure Attachment still matters in adolescence

SLT Parenting courses aid attachment promoting parentingScott, Matias, Joseph, Briskman & O’Connor , JCPP 2011

Can behaviourally-based

interventions affect attachment

past infancy?

1. Through direct Individual work?1. Through direct Individual work?

2. Through group-based parent-training?

3. What about adolescence?

Fostering Changes

12 session UK -

developed group

programme for programme for

Foster Carers based

on social learning

theory

Participants in the RCT

� 63 Registered Foster Carers looking after a total

of 89 foster children aged between 2 and 12

years (and 113 foster children of all ages). years (and 113 foster children of all ages).

� 34 Carers were randomly allocated to the

intervention group,29 Carers to the control

Quality Attachment Relationships

Questionnaire (QUARQ)

Ability to use carer as a secure base:

� Seeking help under stressful conditions� Seeking help under stressful conditions

� Seeking proximity to carer

� Talking about things that bother them

� Trust / allowing carer to look after them

� Expressing appreciation/accepting praise

� Ability to show/accept affection

The Heart of the matter: the

Quark

Impact of Programme on Attachment Impact of Programme on Attachment

RelationshipRelationship (p=.04, es 0.4)(p=.04, es 0.4)

52

53

54

Training

No Training

48

49

50

51

52

BeforeAfter

Ways of Increasing the Reach

of parenting programmes

1. Market penetration: Numerical reach

influenced by politics and beliefs of the duties of the State influenced by politics and beliefs of the duties of the State

2. Psyche penetration: (numerical activity is not enough)

- Bigger effect sizes

- Wider effects outside the home

Proportion & numbers of children in a

typical Local Authority of 250,000 people

5% 2,500

2% 1000

.5% multiple complex needs FIPS/MST?

moderate or severe disorder individual PT?

mental health diagnosis Group PT +

.5

© Stephen Scott

50% 25,000

10% 5,000

10-50% 20,000

Only 1 or 2 needs 4+ session Parenting Classes

behaviour problems at school & home group PT

No additional needs Online Parenting Classes

Use evidence-based parenting programmes

Effect sizes av 0.6 with EB progs (Barlow et al 2002) Effects 0-0.2 otherwise

0.4

0.5

0.6

0.2 otherwise

Eg Fort Bragg, Homestart,

Oxford Home Visiting (Weisz et al 1998) 0

0.1

0.2

0.3

0.4

not EB Ev-Based

0.6

0.8

1

1.2

child

agg

ress

ion

impr

ovem

ent

Child outcome and professional skill

Develop Quality(Scott, Carby and Rendu 2007)

-0.2

0

0.2

0.4

0.6

child

agg

ress

ion

impr

ovem

ent

lowest lower third middle third upper third

Skill of professional in delivering programme

National Academy for Parenting

Practitioners and Research

• For Selective and Indicated prevention

• Behaviour problems only

• Basic (3 or 4 day) training in programmes with good

evidence base

• Some selection of practitioners• Some selection of practitioners

• 4,000 practitioners trained 2008-2010

• No guaranteed ongoing supervision or support

• No assessment effectiveness

• Also Commissioning Toolkit

• Research trials separate from training: Trials on FFT,

IY/SPOKES, High-Need Families, Fostering Changes,

Children with Callous-Unemotional Traits

Increasing Access to Psychological

Therapy (CY-IAPT)

• CAMHS referrals = Clinically indicated cases

• Behavioural problems equal weight as Emotional

• Parent training for Beh Probs, CBT for Emotional

• High-end Evidence-based approaches

• Individual delivery as well as group programmes

• Thorough training of practitioners (1 yr course, 60 pa PT )

• Close monitoring of patient progress (each session)

• Aims to “modernise” CAMHS; 18% cover in 3 yrs

CAN (Classes and Advice Network)

Parenting Classes Trial

• Universal 0-5 years

• Any concern of parents

• “overcome stigma” “Stimulate the market”

• Should be commercially sustainable • Should be commercially sustainable

• Wide range of programmes/ interventions – should be E-B

• £100 voucher all parents 0-5s

• Include internet/online and phone lines

• Test areas Camden (20,000 parents), High Peak

(14,000),Middlesborough (11,000)

• Aim to reach 40% of parents (not 1 parent of 40% of children)

• Independent evaluation

• And now....BRISTOL! But no pay vouchers – some marketing

Clinical trial (Scott, Spender et al 2001, BMJ)

� 141 children age 3-7 referred to CAMHS

� severe, persistent antisocial behaviour

(worst 1%)

‘Incredible Years’ parenting programme:� ‘Incredible Years’ parenting programme:

� videotapes shown in group, 3 wks each of

� Play

� praise & rewards

� setting limits

� handling misbehaviour

1.82 1.87

1.9

1.5

2

PACS Interview Score

Child Antisocial Behaviour

0.75 0.75

Pre Post 1 Year

0

0.5

1

1.5

Waiting List Parent Group

Long-term follow up

� Follow up 2005-07 7-10 years later of 94 children

now aged 10-17 (mean 13)

� Intention to treat, 74 allocated to IY, 20 controls

Parenting effects

� Improved Expressed Emotion

� Better supervision on CAPA interview� Better supervision on CAPA interview

� No effect on Alabama qu’re, Parent or Child

� No effect on directly observed parent-youth

interaction (Oregon “hot topics”)

ODD diagnosis(p< 0.007)

0.53

0.4

0.5

0.6

0.22

0

0.1

0.2

0.3

0.4

IYControls

Parent SDQ total(p<0.003)

18

20

22

10

12

14

16

18

IYControls

Youth report home

beh(p<0.038)

3

3.5

4

0

0.5

1

1.5

2

2.5IYControls

Youth report school

beh(ns)

6

7

8

0

1

2

3

4

5IYControls

Teacher SDQ total(ns)

10

12

14

0

2

4

6

8

10

IYControls

School

School

Good PT programmes “translated” for teachers to

use, eg Incredible Years

No widespread adoption in UK and no trials yetNo widespread adoption in UK and no trials yet

Trial of universal IY in 24 shools but measuring worst 3

kids in class aged 3-6 in Jamaica es .42 on ODD, .74

on friendship skills (Baker-Henningham, Taylor, Scott & Walker,

2012)

Summary

Attachment is important beyond infancy and predicts adjustment

SLT based parent training can be used for attachment problems;

SLT based parent training promotes limit setting, which increases

attachment security in adolescenceattachment security in adolescence

Parenting Interventions are being made more available. However,

the message on the need for training in evidence-based

approaches and supervision needs to go wider

Due to uncertain generalization to school and over longer term,

Need teachers to be trained; boosters for parents