Early years briefing paper:
Early Years Pathfinder Project
Authors: Rosalind Reilly, Lynne Hockey, Shantini Paranjothy
Date: 14 September 2012
Version: v1 FINAL
Publication/ Distribution: Public (internet)
Review Date:
Purpose:
 Summarise evidence base on early years parenting and family interventions
 Summarise potential early years parenting and family interventions that can be
used in Wales to improve behavioural, social and cognitive outcomes
 Provide overview on current service delivery in Wales.
Summary of key findings:
Several methods of improving children’s outcomes have been suggested by Frank
Field and Michael Marmot: high quality and consistent support for parents during
pregnancy and in the early years, support for better parenting, support for a good
home learning environment, high quality childcare, provision of parental leave during
the first year and provision of early years education.
Marmot states a need for targeted services underpinned by universal services,
advocating for universal actions, but with a scale and intensity that is proportionate to
the level of disadvantage.
A set of key life chance indicators have been proposed by Frank Field to measure
how successful we are as a country in making more equal life’s outcomes for all
children. These are
Public Health Wales
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Early years evidence synthesis
Cognitive development at age 3
Behavioural, social and emotional development at age 3
Physical development at age 3
Home learning environment
Maternal metal health
Positive parenting
Mothers educational qualifications
Mother’s age at birth of first child
Quality of nursery care
Currently in Wales, there is no central collation of data on Early Years indicators, so it
is difficult to get a comprehensive picture of early years health and well-being across
Wales. We are seeking to address this by developing an early years surveillance
programme, with pilot work under-way in Aneurin Bevan (the Plentyn Gwent project).
Two recent comprehensive reviews in the UK of early years interventions, which have
identified numerous interventions. Two interventions have a strong evidence base: (i)
the Incredible Years parenting programme and (ii) Family Nurse Partnership.
The mapping exercise showed a wide range of activity across the different Health
Boards, and although there is variation in the types of parenting programmes and
interventions available, the Incredible Years programme is used in most Health
Boards.
Next steps
 The Family-Nurse Partnership has a clear evidence base and consideration
should be given to testing the feasibility of implementing this intervention in
Wales, in the context of existing programmes in place such as Flying Start. A
task and finish group was set up to explore this and will report in March 2013.
 Work is ongoing within the Plentyn Gwent project to look at the feasibility of
using data collected by local government, Health Boards and other agencies
to report on the early years indicators recommended in Frank Field’s report.
Work Plan reference: Early Years Pathfinder Programme
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Contents
EARLY YEARS BRIEFING PAPER: ................................................... 1
EARLY YEARS PATHFINDER PROJECT ............................................ 1
1
BACKGROUND ......................................................................... 4
2
METHODOLOGY ..................................................................... 10
3
OVERVIEW OF THE EVIDENCE ............................................... 11
3.1 Early years indicators ........................................................... 11
3.2 Parenting and family interventions ......................................... 18
4
MAPPING OF SERVICES ........................................................ 23
5
CONCLUSIONS ...................................................................... 25
6
NEXT STEPS .......................................................................... 25
7
REFERENCES ......................................................................... 27
8
APPENDICES ......................................................................... 29
8.1 Appendix 1 – Reproductive and early years indicators .............. 29
8.2 Appendix 2 – Interventions identified by each source ............... 30
8.3 Appendix 3 – Interventions ................................................... 31
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Early years evidence synthesis
Background
The experiences and environment during the early years of a child’s life
are important and have a lasting influence on their emotional and social
development and on adult health and wellbeing.1 Pregnancy and early
childhood are considered to be the most important developmental stage of
life and outcomes in the early years have a strong relationship with later
life outcomes.2 Emotional and social health in childhood underpins the
adoption of healthy lifestyles, interpersonal relationships, educational
achievements and employment prospects.
Parenting is the key
determinant of children’s social and emotional development.3 Negative
outcomes relating to adverse early experiences includes emotional and
behavioural problems, poor educational attainment, substance misuse,
conduct disorder and criminality.1 It is in the early years that the socioeconomic gaps in outcomes appear (figure 1). Already by age three there
are large and systematic differences between children from lower and
higher income families and these gaps persist throughout childhood, as
later attainment tends to be heavily influenced by early development.2
Figure 1 - Inequality in early cognitive development of children in the 1970 British
Cohort Study, at ages 22 months to 10 years.4
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Early years evidence synthesis
Figure 2 shows the relationship between child outcomes and income. It
shows that there is a negative relationship between average percentile
score of school readiness at 3 years and vocabulary at 5 years and
poverty i.e. the lower the income the lower the average scores. Conduct
problems at age 5 are positively related to poverty, i.e. there are more
conduct problems in the lower income groups.
Figure 2 – Mean child outcome scores by income (ages three and five).2
Child poverty is an important issue within Wales and the United Kingdom.
Although the previous government stated it would halve child poverty in
the UK by 2010/11 and would totally eradicate child poverty by 2020
within the UK, it is unlikely that these targets will be met.2
Field’s review states that the current approach to monitoring progress
towards tackling child poverty has incentivised a strategy that is heavily
focused on reducing child poverty rates in the short term through income
transfers. Field points out that the evidence shows that increased income
does not automatically protect poor children against the high risk that
they will end up in poverty themselves as adults. He states that it is
necessary to shift the focus of the child poverty strategy from financial
poverty to address the factors that affect life chances, with the ultimate
aim of achieving a programme of childhood interventions which can
overcome the influence of income and social class. Field’s report sets out
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Early years evidence synthesis
a broader approach to tackling child poverty which focuses on improving
the life chances of poor children.2
Field makes the case that while income has a direct effect on children’s
outcomes, this effect is small when other drivers are taken into account
and indeed much of the effect of income is transmitted (or mediated)
through other factors. These factors include:
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child factors, such as cognitive (including language and
communication) development
parent factors, such as positive parenting
environmental factors, such as quality of nursery care.2
Field described that the factors influencing children’s outcomes change
over the life course but the consistent factor throughout is the role of
parents and families. Figure 3 summarises these drivers.
Figure 3 - The key drivers of life chances.2
Several methods of improving children’s outcomes have been suggested
by Field and Marmot: high quality and consistent support for parents
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Early years evidence synthesis
during pregnancy and in the early years, support for better parenting,
support for a good home learning environment, high quality childcare,2
provision of parental leave during the first year and provision of early
years education.4 By intervening early, from conception to five years,
children can be made ready to meet all the challenges they face and use
the opportunities for development when they enter primary school.5
Currently, more money is spent on education at university level, than on
pre-school service provision, yet there is strong evidence to support
investing more money in pre-school education, as this provides greater
returns in the future.2,5,6,7 Figure 4 shows that the return on investment
in early learning is high in terms of human capital and figure 5
demonstrates the public spend throughout childhood.
Figure 4 - Rates of return to investment in human capital as function of age when the
investment was initiated.8
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Early years evidence synthesis
Figure 5 – Public spending and brain research.9
Children in low-income families can derive proportionately greater benefits
(compared to their more well-off peers) from participation in universal
high-quality, early-education programmes (3-4 years).10 Marmot states a
need for targeted services underpinned by universal services. He said
that ‘focusing solely on the most disadvantaged will not reduce health
inequalities sufficiently. To reduce the steepness of the social gradient in
health, actions must be universal, but with a scale and intensity that is
proportionate to the level of disadvantage. We call this proportionate
universalism’.4
Clearly there are multiple methods for improving children’s outcomes of
which parenting and family interventions are one. A Cochrane systematic
review and meta-analysis looked at whether group based parenting
programmes were effective in improving the emotional and behavioural
adjustment of children three years of age or less. It found that parentreport and independent observations of children’s behaviour produced
significant results favouring the intervention group post-intervention, and
at follow-up parent reports remained significantly improved and
independent observations were non-significantly improved.11 A report by
the UCL Institute of Health Equity looked at where children’s centres
should be focussing their efforts to improve the early years for children
and reduce inequalities in outcomes and stated that parenting and
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Early years evidence synthesis
parenting circumstances should
influencing children directly.12
be
placed
on
equal
footing
with
This paper will focus on the evidence for specific parenting and family
interventions and will focus on children under 5 years old as it has been
shown that this period of life has an important influence on development.
Although targeting this age group is important, other age groups should
not be neglected as interventions in all stages of childhood are needed to
break the cycle of dysfunction.
Giving every child a healthy start in life is a priority for Welsh
Government. There are a number of programmes and setting in which
parenting and family interventions can be delivered across Wales,
including Flying Start, Families First, Communities First, Sure Start teams,
integrated children’s centres, and the integrated family support service.
Flying Start is targeted at 0-3 year olds in the most disadvantaged
communities in Wales.13
Currently in Wales, there is no central collation of data on Early Years
indicators, so it is difficult to get a comprehensive picture of early years
health and well-being across Wales.
This briefing paper, developed as part of the Public Health Wales Early
Years Pathfinder Programme, aims to:
(i)
(ii)
(iii)
(iv)
identify potential indicators appropriate for monitoring early
years wellbeing
identify evidence-based parenting and family interventions to
improve behavioural, social and cognitive outcomes and
reduce inequalities for children 0–5 years in Wales
identify current service delivery across Wales
make recommendations for the future development of
parenting and family interventions in Wales.
A number of UK reviews have been carried out to identify and describe the
evidence base for parenting and family interventions and also indicators
for monitoring early years wellbeing. In this paper we summarise findings
from these reviews and map the evidence base against current
programmes in Wales. Interventions related to other aspects of early
years, e.g. physical health, are described in separate papers
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Early years evidence synthesis
Methodology
The overview of the evidence presented in this paper is based on a
pragmatic high level search of key sources. This is not a systematic
review of parenting and family interventions.
Two reports have reviewed early intervention programmes.5,7 The
Department of Education’s commissioning toolkit (Parenting Programme
Evaluation Tool) lists parenting interventions that have been evaluated by
an independent team of researchers from the National Academy of
Parenting Research at King’s College London against standards for best
practice in the field of parenting work:
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The
The
The
The
specificity of the programme’s target population
programme’s theories and activities
programme’s training and implementation support systems
strength of the programme’s evaluation evidence
All programmes receive a rating from 0 to 4 within each category,
resulting in four ratings. A rating of 4 means that the programme meets
all of the criteria in the category (in other words, the programme is
strongly developed in this domain) and a rating of 0 if they do not meet
any of the criteria. 14
Marmot’s Fair Society, Healthy Lives4 referred to a review of parenting
programmes, the results of which were included in this evidence
synthesis.
Several reports have described outcomes suitable for monitoring early
years wellbeing; these will be discussed.
In this paper we have focussed on describing those indicators
recommended for monitoring early years health and wellbeing and
parenting programmes and family interventions which focus on
behavioural, social and cognitive outcomes for children aged 0-5 years.
Both group and one-to-one interventions, and home and community
settings were included.
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Early years evidence synthesis
Overview of the evidence
3.1
Early years indicators
Field identified a set of key factors in the early years which are predictive
of children’s future outcomes. These include child, parent and
environmental factors (figure 3 above). Field proposes a set of Life
Chances Indicators to measure these factors, ‘that measure how
successful we are as a country in making more equal life’s outcomes for all
children’.2 The recommended measures are shown in figure 6.
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Early years evidence synthesis
Figure 6 – Life chance indicators – recommended measures.2
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Each indicator can be presented separately, and together they will
provide a tool for monitoring the impact of policy on the key factors that
influence life chances. The report recommends the use of these
indicators to measure annual progress at a national level on a range of
factors that are predictive of children’s future outcomes. Improvements
in these indicators for each new cohort of children from low income
families are expected to correlate with better future outcomes in
adulthood. It is expected that short term progress on these indicators
will be aligned with long term progress on tackling the effects of child
poverty, and this will improve the incentives for policy makers to invest
in long term solutions. Therefore the aim of measuring these indicators
are to:
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incentivise policy-makers to focus policy and investment on
improving the future life chances of children, particularly those
from low income households
enable regular, national level monitoring of the gap in life chances
between children from low income households and the average of
all children
provide a clear message to service providers and parents about
the things that matter most for improving children’s school
readiness and future life chances.2
The review recognises that the existing national child poverty measures
are defined in legislation at a national level, but many of the levers
available for tackling child poverty are increasingly controlled locally and
not subject to central targets. Therefore the report recommends the
use of these nine indicators at a national level, thus providing local
authorities with a set of nine factors that need to be addressed in order
to improve the life chances of poor children. It is anticipated that these
indicators also provide an incentive for national government and policy
makers to reinforce this message and encourage local partners to act to
improve life chances, because without this kind of cooperation the
national measures will not improve.
Field’s report also considers the role of local information in collating
these data and potential concerns and solutions. There is already a lot
of local data collected for administrative or professional purposes and
which could be used to create these indicators.
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Early years evidence synthesis
Geddes et al7 listed the nine maternal and child health indicators collected
in Scotland (figure 7). The authors state that there are no measures of
cognitive-language or social/emotional development in children normally
used in Scotland but that the indicators are under review.
Figure 7 – Maternal and child health indicators currently collected at a
community health partnership level.7
The UCL Institute of Health Equity report on Improving Outcomes in
Children’s Centres suggested several outcomes that could be measured
related to areas of focus to improve children’s early years.12 These are
shown in figure 8.
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Early years evidence synthesis
Figure 8 – Areas for focus and proposed outcomes.12
The recent Report of the Children and Young People’s Health Outcomes
Forum recommended a number of new or amended indicators in the
Public Health Outcomes Framework (England).15 The indicators under
four domains are shown in figure 9.
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Early years evidence synthesis
Figure 9 – Outcomes for children and young people in the Public Health Outcomes
Framework.15
(1=no change to existing outcome framework indicator, 2=extension of existing indicator to
reflect the life course, 3= adaptation of indicator to make it more relevant to children, 4=new
indicator or area to be included in framework) (Blue=indicator is, or being developed for,
existing outcomes framework, Green=indicator readily available, Amber=data available,
definition needs development, Red=new data source required).
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Early years evidence synthesis
Public Health Wales are developing a Reproductive and Early Years
surveillance system. The indicators for pregnancy and birth have been
finalised and aligned with the Welsh Government strategy indicators
(see appendix 1). The proposed list of early years indicators include
those measures recommended by Field where data are available. Pilot
work is currently being carried out in Aneurin Bevan (the pilot Plentyn
Gwent project). Currently there is no data available to measure
cognitive development at age 3, behavioural, social or emotional
development. Physical development, BMI, is measured by the Child
Measurement Programme at age 4. There are also no universal data
collection systems in place to measure the home learning environment,
positive parenting, maternal metal health or quality of nursery care.
The next step will be to assess the feasibility of collecting data for the
full set of life chances indicators as proposed by Field; working in
partnership with local governments and other agencies within the
Plentyn Gwent project.
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Public Health Wales
3.2
Early years evidence synthesis
Parenting and family interventions
The two reviews of early years interventions identified numerous
interventions. In this paper we focus on interventions targeted at children
aged 0-5 years and parenting and family interventions only (not preschool
or school based) which were either targeted or universal.
The
interventions were identified from the following:

Allen’s list of 19 interventions which had level 1 evidence: high
quality evaluation and/or impacts5

In the Scottish review,7 those interventions recommended in the
summary of the evidence review as being effective

Marmot’s list of parenting programmes that were found by the
National Academy of Parenting Practitioners to have a good evidence
base4

The Department of Education’s Parenting Programme Evaluation
Tool (PPET) list of interventions that scored a rating of 4 in all the
categories and were applicable to children age 0-5 years14
In total, 14 interventions were identified. There was some overlap in the
list of effective interventions between the four sources. Four interventions
were included by two or more sources: Incredible Years, Family-Nurse
Partnership, Triple P and Families and Schools Together. These are
described below. Although cost-effectiveness information were not always
available, this has been added from other sources where possible.
Appendix 2 shows the interventions identified from each source. The
remaining ten interventions identified from the sources are described in
appendix 3.
Table 1 – Parenting and family interventions
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Programme
Population
Programme description
Outcomes
Cost benefit
Incredible Years
Families with
children at risk
of behavioural
problems.7
This is a series of programmes
focused on strengthening
parenting competences
(monitoring, positive
discipline, confidence) and
fostering parents’ involvement
in children’s school
experiences in order to
promote children’s academic,
social and emotional
competences and reduce
conduct problems. The parent
programmes are grouped
according to age: Babies &
Toddlers (0–3 years); BASIC
Early Childhood (3–6 years);
BASIC School-Age (6–12
years); and ADVANCED (6–12
years).7
Significant improvements in:
 child problem behaviour
 child independent play
 antisocial and hyperactive
behaviour

self control in the children
 intervention mothers were
more positive, less critical,
and more consistent in
their parenting than the
control groups
 parenting skills and
confidence.7
The incremental cost
effectiveness ratio
point estimate was £73
per one point
improvement on the
intensity score of the
Eyberg child behaviour
inventory (95% CI £42
to £140). It would cost
£5486 to bring the
child with the highest
intensity score to below
the clinical cut-off point
and £1344 to bring the
average child in the
intervention group
within the non-clinical
limits on the intensity
score (<127). For a
ceiling ratio of £100
per point increase in
intensity score, there is
an 83.9% chance of
the intervention being
cost effective. The
mean cost per child
attending the parenting
group was £1934 for
eight children and
£1289 for 12
children.16
Public Health Wales
Nurse-family
partnership/
Family-Nurse
Partnership
Early years evidence synthesis
Designed to
serve lowincome, at-risk
pregnant
women bearing
their first
child.5
Nurse Family Partnership
provides intensive visitation by
nurses during a woman’s
pregnancy and the first two
years after birth. The goal is to
promote the child’s
development and provide
support and instructive
parenting skills to the
parents.5
Statistically significant:
 improvement in
cognitive/language
development and
behavioural adaptation in
children

48% fewer officiallyverified incidents of child
abuse and neglect

23% fewer health care
encounters and 78%
fewer days hospitalised,
for children’s injuries or
ingestions

59% fewer self-reported
arrests
Adolescents of higher risk
subgroup (poor unmarried
mothers) displayed:
 54% fewer arrests
 69% fewer convictions
 59% fewer sexual
partners
 28% fewer smokers
 51% fewer days drinking.7
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For every dollar spent,
$5.06 return on
investment.7
NFP for low income
women:
 Benefits-$26,298
 Costs-$9,118
 Benefits/dollar$2.88
 Benefitscosts=$17,180
NFP for higher risk:
 Benefits-$41,419
 Costs-$7,271
 Benefits/dollar$5.70
 Benefitscosts=$34,148
NFP for low income
women:
 Benefits-$9,151
 Costs-$7,271
 Benefits/dollar$1.26
 Benefitscosts=$1,880.17
Public Health Wales
Triple P Positive
Parenting
Programme
Early years evidence synthesis
Universal but
intensity
tailored to
need. Children
aged 0-12yrs.7
Behavioural Family
Intervention programme based
on social learning principles. It
can be delivered by health
visitors and incorporates a
combination of parenting
seminars, skills-training
sessions, telephone
consultations and in some
cases home visits (although
this is not primarily a homevisiting programme).
It is delivered to parents and
consists of five delivery levels
each of increasing intensity
ranging from universal
population level with
promotion of parenting style
through media and parent tip
sheets, to individually tailored
intensive input for families
with persistent childhood
behavioural problems and
other sources of family stress.7
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Measured outcomes from
Triple P include: –
significantly lower levels of
conduct problems; and –
noted clinical changes on
behaviour scale (33% vs
13% of children with
problems).5
Significant reduction in
substantiated child
maltreatment cases, out-ofhome placements and child
maltreatment injuries in the
hospital and emergency
rooms.7
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Identified by NICE as
cost-effective in
reducing conduct
disorder. The large
lifetime costs
associated with conduct
disorder, estimated to
average £75,000 in
milder cases to
£225,000 in extreme
ones, suggest that
even a low success rate
would constitute good
value for money.5
The Triple P
programme has been
estimated to save
£19.5 million,
compared to its £4.6
million costs.17
Public Health Wales
Families and
schools together
Early years evidence synthesis
Families and
Schools
Together
(FAST) is for
any parent or
carer of a child
between the
ages of three
and 11 who is
interested in
supporting their
child’s
development.14
Parents and children attend
eight weekly sessions where
they learn how to manage
their stress and reduce their
isolation, become more
involved in their children’s
school, develop a warm and
supportive relationship with
their child and encourage their
child’s pro-social behaviour.
After parents ‘graduate’ from
the eight-week programme,
they continue to meet together
through parents’ sessions that
occur on a monthly basis.14
Children significantly:
- less aggressive
immediately after
attending the programme
and at the one-year
follow-up
less withdrawn at the
post intervention
assessment. And at oneyear follow-up
- greater improvements in
academic skills.
- improvements in their
family functioning,
perceived selfefficacy,
social connectedness and
knowledge of substance
misuse issues
Parents reported:
- greater involvement in
their child’s school and
significant decreases in
their child’s emotional
problems.
Teachers reported:
- significant improvements
in children’s pro-social
behaviour.14
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Not available
4
Mapping of services
A mapping exercise was completed in 2011, and updated in August 2012,
as part of the PHW Early Years pathfinder project. This involved asking all
Health Boards in Wales about the early years interventions currently in
place (see table 2 below). The mapping document is used to describe
current practice in Wales and progress with implementation of the
evidence base. There were several limitations to this exercise. It was
extremely difficult to compile a list of early interventions across Wales as
there is no system or resource that captures this information. Collecting
the information took a huge amount of chasing and the accuracy very
much depended on interviewing the right individual in each Health Board
about each intervention. Consequently there were some gaps, and it isn’t
possible to know if this is because interventions are not in place or that
the right individual was not interviewed. Also the information provided by
Health Boards was a snap shot, and developments in the individual areas
are happening all the time. Regular surveys would be needed to capture
progress on key programmes.
Table 2 - Mapping of Early Years interventions across Health Boards in Wales
Health Board
Betsi
Cadwaladr
Progress with parenting and family interventions
- Three counties (out of 6) have parenting co-ordinators,
seen as essential for delivery, consistency, quality and
value of parenting programmes
- Mapping/overview has been carried out in 4 out of 6
counties
- Some counties have parenting action plans and/or
strategies
- Holistic parent assessments signpost parents to most
appropriate programme and wider sources of support:
parenting programmes are not always the best or only
solution.
- Incredible Years is the most common programme run in
all counties, for parents of children of all ages across
North Wales, with some variation according to need /
organisation
- Other programmes used in some areas include Mellow
Bumps (antenatal stage); Solihull Approach; Nurturing
programme
- Barnardos deliver work at all ages including a preparation
course for attending Incredible Years
- All areas have numbers of front line staff from all
settings trained to deliver one-to-one family / parenting
Public Health Wales
-
-
-
Cardiff and
Vale
-
-
ABMU
-
Early years evidence synthesis
support. Majority trained through programme developed
from Incredible Years. Glyndwr University currently
delivering both accredited and non-accredited versions.
Therapeutic / dedicated parenting teams linked to LAs
deliver support for more complex cases
Families First expected to have influence on future
development of approaches to parenting programmes
and areas of delivery.
Bangor University looking at standardising evaluation
measures for Incredible Years. Recognition that all
programmes should use the same measures relevant to
the particular programme
All areas use pre and post measures, as well as
qualitative evaluations from each session. GHQ version
30 and Eyberg Child Behaviour Inventory (ECBI) main
measures in use for Incredible Years programmes
A North Wales Parenting Learning Set meets quarterly to
share new developments and promote learning in topics
of relevance to co-ordinators and parenting teams.
Research programmes under way in some areas
including links with Bangor and York Universities
Parenting support workers have been employed in one
area based in primary schools working one-to-one and in
parent-led groups
The Cardiff parenting framework and Vale of Glamorgan
Family support strategy and action plan outlines
a structure for the development of parenting
programmes A range of evidence based parenting
programmes to suit different needs is provided through
Flying Start centres, the generic health visiting service,
Child and Family Mental Health Service, local authority
Children’s Services, Alcohol and Drug Team Barnardos,
Action for Children and Women’s Aid.
The parenting programmes promoted and used with
families by age range:o Brazelton Neonatal Behavioural Assessment Scale –
NBAS Age range - 0-2 months
o Solihull Approach Age Range - 0-5yrs
o Parenting Positively Age range - 8 months to 8 year
o Incredible Years Programme Age range - 0-12
months, 1-3yrs, 3-6yrs, 6-12yrs
o Family Links Parent Nurturing Programme Age Range
– 3-12yrs
 (Additional material available to adapt
for use with 0-2 yrs)
o Strengthening Families Programme SFP 10-14 (UK)
Age range – 10-14years
o Triple P Teen Parenting Programme Age range – 1216years
Integrated Children’s Centres provide parenting classes
Date: 14/09/2012
Version: v1 final
Page: 24 of 39
Public Health Wales
Aneurin
Bevan
-
Cwm Taf
-
Hywel Dda
-
Powys
-
5
Early years evidence synthesis
All localities have a parenting co-ordinator with a focus
on Flying Start areas. Parenting interventions are run
throughout the ABHB area – including Webster Stratton
Incredible Years and Family Links Nurturing Programme
Merthyr Tydfil Integrated Children’s Centre supports a
wide range of family support/parenting programmes
Webster-Stratten parenting programme (Incredible
Years) delivered by Flying Start and generic health
visitors
Surestart provides parenting skills groups
Conclusions
The interventions included in this paper have been identified by at least
two other reviews as having a good evidence base. Much of the evidence
is US based and may not be directly generalisable to the Welsh context.
Other interventions which are described in the appendix have been classed
as having a good evidence base by one source but not the other sources.
This may have depended on the evaluation studies available at the time.
Cost effectiveness information was rarely available, and again where it
was available may depend on the evaluation studies available at the time.
Many of the interventions have shown positive outcomes at evaluation but
in the reviews often effect sizes were not available. If an intervention is
not included in this paper it does not necessarily mean it is not effective,
but has not been classed as an effective intervention by the sources used
here.
The interventions that stood out as having a strong evidence base for
effectiveness when considering all four sources and reviewing the evidence
were the Family-Nurse Partnership (or Nurse-Family Partnership) and
Incredible Years. The Family Nurse Partnership also had evidence of being
highly cost-effective, especially for higher risk parents. However these
data were from the USA although there is currently an ongoing
randomised controlled trial in England. The Incredible Years programme
has been shown to be cost-effective in the UK.
6
Next steps
The following are the key recommendations arising from this paper:

The Family-Nurse Partnership has a clear evidence base and
consideration should be given to testing the feasibility of
Date: 14/09/2012
Version: v1 final
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Public Health Wales


Early years evidence synthesis
implementing this intervention in Wales, in the context of existing
programmes in place such as Flying Start.
Current parenting and family interventions in Wales should have a
good evidence base for effectiveness and if cost-effectiveness data
are not available, should be sought
Work is ongoing within the Plentyn Gwent project to look at the
feasibility of using data collected by local government, Health Boards
and other agencies to report on the early years indicators
recommended in Frank Field’s report.
Date: 14/09/2012
Version: v1 final
Page: 26 of 39
Public Health Wales
7
Early years evidence synthesis
References
1.
Killoran, A. Weighing the evidence – what actually works. Public
Health Today. London: FPH, 2011.
2.
Field, F. The Foundation Years: preventing poor children becoming
poor adults. London: HM Government, 2010.
3.
Stewart-Brown, S. Meet the parents. Public Health Today. London:
FPH, 2011.
4.
Marmot, M. Fair Society, Healthy Lives: Strategic Review of Health
Inequalities in England post 2010. London: The Marmot Review,
2010.
5.
Allen, G. Early Intervention: The Next Steps. London: HM
Government, 2011.
6.
Bird, W et al. Thinking Ahead: Why we need to improve children’s
mental health and wellbeing. London: FPH, 2011.
7.
Geddes R, Haw S and Frank J. Interventions for promoting early
child development for health: an environmental scan with special
reference to Scotland. Edinburgh: SCPHRP, 2010.
8.
Knudsen, EI et al. Economic, neurobiological, and behavioral
perspectives on building America’s future workforce. PNAS 2006;
103 (27): 10155-10162.
9.
Early Childhood Development Coalition. 2008. Public Policy.
[Online]. Available at:
http://earlychildhoodswi.org/PublicPolicy.html [Accessed 19th
August].
10.
Shonkoff, JP and Phillips, DA in Killoran, A. Weighing the evidence
– what actually works. Public Health Today. London: FPH, 2011.
11.
Barlow, J et al. Group-based parent-training programmes for
improving emotional and behavioural adjustment in children from
birth to three years old. Cochrane Database of Systematic Reviews
2010, Issue 3. Art. No.: CD003680. DOI:
10.1002/14651858.CD003680.pub2.
Date: 14/09/2012
Version: v1 final
Page: 27 of 39
Public Health Wales
Early years evidence synthesis
12.
Bowers, AP and Strelitz J. An Equal Start: Improving outcomes in
Children’s Centres, an evidence review. London: UCL Institute of
Health Equity, 2012.
13.
Welsh Government. 2012. Help for families. [Online]. Available at:
http://wales.gov.uk/topics/childrenyoungpeople/parenting/help/?la
ng=en [Accessed 19th August 2012].
14.
Department of Education. 2012. Parenting Programme Evaluation
Tool (PPET) [Online]. Available at:
http://www.education.gov.uk/commissioningtoolkit/Programme/CommissionersSearch [Accessed 19th August].
15.
Lewis I and Lenehan C. Report of the Children and Young People’s
Health Outcomes Forum. London: DH, 2012.
16.
Edwards, RT et al. Parenting programme for parents of children at
risk of developing conduct disorder: cost effectiveness analysis.
BMJ 2007 doi:10.1136/bmj.39126.699421.55.
17.
London Economics. Cost-benefit analysis of interventions with
parents. London: DCSF, 2007.
Date: 14/09/2012
Version: v1 final
Page: 28 of 39
Public Health Wales
8
Early years evidence synthesis
Appendices
8.1
Appendix 1 – Reproductive and early years
indicators
1. SMOKING
 Percentage of women who smoked during pregnancy (measure at
initial assessment)
 Percentage of women who stopped smoking during pregnancy
(measured at birth).
2. SUBSTANCE MIS-USE
 Percentage of women misusing substances during pregnancy
(measured at initial assessment)
 Percentage of women who stopped misusing substances during
pregnancy (measured at 36-38 weeks).
3. WEIGHT IN PREGANCY
 Percentage of women who are overweight or obese at the beginning
of pregnancy (measured at initial assessment)
 Percentage of women who gain more than the recommended weight
during pregnancy (measured at 36-38 weeks).
4. ALCOHOL
 Percentage of women who drink more than 1-2 units of alcohol once
or twice a week at the beginning of pregnancy (measured at initial
assessment)
 Percentage of women who reduced alcohol intake to 1-2 units of
alcohol once or twice a week or less during pregnancy (measured at
36-38 weeks).
5. LOW BIRTH WEIGHT BABIES
 Percentage of babies born with weight below 2.5kgs (at birth).
6. BREASTFEEDING
 Percentage of women exclusively breastfeeding at birth
 Percentage of women exclusively breastfeeding at 10 days following
birth
 Percentage of women breastfeeding at 8 weeks following birth.
Date: 14/09/2012
Version: v1 final
Page: 29 of 39
Public Health Wales
8.2
Early years evidence synthesis
Appendix 2 – Interventions identified by each
source
Allen5 – level
1 evidence
(high quality
evaluation
and/or
impacts)
Geddes et al7 –
interventions
described as
being effective
Department of
Education
Parenting
Programme
Evaluation
Tool14 – rated
4 in all
categories
Marmot4 –
parenting
programmes
found to have a
good evidence
base by
National
Academy of
Parenting
Practitioners
Incredible Years




Parent-child Home
Program





Programme
Family-Nurse
Partnership

Triple P - Positive
Parenting
Programme
Stepping Stones
Triple P


Parents as teachers

Early Head Start

Chicago ChildParent Centers

Carolina
Abecedarian Project

Mellow parenting

Parenting positively

Family links

Families and
schools together

Parent Management
Training Oregon
Model

Date: 14/09/2012
Version: v1 final

Page: 30 of 39
8.3
Appendix 3 – Interventions
Programme
Population
Programme description
Outcomes
Cost benefit
Parent-child
Home Program
At-risk
children. Atrisk status was
defined as
having 5 of 8
listed factors:
child IQ score
under 100,
single parent
family,
unemployment
of mother,
unemployment
of father,
family receiving
AFDC
payments,
parent who did
not finish high
school, poverty
status of
family, and
older sibling in
a Chapter 1
remedial
programme.17
Twice-weekly home visits are
designed to stimulate the
parent–child verbal interaction,
reading and educational play
critical to early childhood brain
development. Each week the
home visitors bring a new
book or educational toy that
remains with the families
permanently. Using the book
or toy, home visitors model for
parents and children reading,
conversation and play
activities that stimulate quality
verbal interaction and ageappropriate developmental
expectations. It promotes
parent–child interaction and
positive parenting to enhance
children’s cognitive and socialemotional development. It
prepares children for academic
success and strengthens
families through intensive
home visiting.17
Statistically significantly
improved IQ scores, better
achievement test scores,
fewer placements in special
education and fewer grade
retentions. Little or no effect
on children who had normal
cognitive ability and welleducated parents.7
-$3,89017
Public Health Wales
Stepping Stones
Triple P
Early years evidence synthesis
Parents with
children with a
physical or
learning
disability, such
as autism
spectrum
disorder,
Down’s
syndrome,
Prader-Willi
syndrome, etc.
Children
between the
ages of two and
eight.14
Date: 14/09/2012
Can be delivered individually
to families or to groups
involving 10 to 12 parents:
• The individual version of the
programme is delivered by one
practitioner over 10
weeks involving 1-2 hour
sessions
• The group version is also
delivered by one practitioner,
but takes place over nine
weeks, lasting between 1 and
2 hours each. Training for the
group version includes clear
guidance about how to tailor
the content for families
confronting
similar issues, such as autism
spectrum disorder, Down’s
syndrome, Prader-Willi
syndrome, etc.
Sessions can take place in the
family’s home, a clinic, a
school or other community
setting. Both the individual
and group versions of the
programme provide parents
with skills for managing their
child’s behaviour and
encouraging their
independence.14
Version: v1 final
Significant:
- improvements in
children’s behaviour
- improvements in
parenting skills
- reductions in couple
conflict
- increase in perceived selfefficacy
- improvements in mothers’
stress levels
Positive outcomes
immediately after
programme completion
and at the six-month follow
up.14
Page: 32 of 39
Not available
Public Health Wales
Parents as
teachers
Early years evidence synthesis
Universal –
antenatal,
infancy and
toddlers.7
Date: 14/09/2012
This is a universal voluntary
early childhood parent
education and family support
programme that begins at or
before the birth of the child
and continues until school
entry. Parent education occurs
during home visits and group
sessions at a centre. The goal
of the programme is to
increase parent knowledge of
early child development,
improve parenting practices,
prevent child abuse and
neglect, increase children’s
school readiness, and detect
developmental delays and
health problems. Services also
include child development
screenings, a drop in and play
session, and referral to
resources.7
Version: v1 final
Cognitive/achievement:
Benefits - $4,300
Statistically significantly
higher cognitive skills,
language and school
achievement scores at age 3,
but small effect sizes.
Costs - $3,500
Social-emotional: No
difference on psychometric
tests at age three. Rated
better on ability to distinguish
self-identity, positive adult
relationships, coping abilities
and engagement in social
play. No difference was found
in expression of feelings and
peer relations. Effect sizes
were small.
Child maltreatment/ injuries.
Significantly fewer cases of
child abuse and injury were
found when compared with
US state average.7
Page: 33 of 39
Benefits/dollar - $1.23
Benefits-costs=$800.17
Public Health Wales
Early Head Start
Early years evidence synthesis
Low SES,
prenatal-3.7
Date: 14/09/2012
Provision of centre-based
services supplemented by
home visits by teachers and
other staff. As
with many large-scale targeted
programmes, there is not a
defined programme model but
core elements have to be
present. In Early Head Start
these are: child development;
family development (tailored
family development plans);
community building (resources
in the community assessed
and upgraded to provide a
network of support services);
and staff development
(training, supervision and
mentoring). A community
resources and needs
assessment is conducted after
which a programme model is
chosen –
home-based, centre-based or
a mixed approach. Child
services can have any of these
approaches with certified
childcare providers.7
Version: v1 final
Cognitive development:
Positive effect on cognitive
development at age two and
on language development
from age two to three. More
sustained attention in
intervention groups than in
controls.
Social/emotional: Better
social-emotional
development, higher
emotional engagement with
the parent in play and higher
sustained attention with play
objects. Lower aggressive
behaviour than control
groups.
Child health: No difference in
intervention and controls
Parenting and home
environment: Parents were
more emotionally supportive,
provided more language and
learning stimulation, read to
their children more, and
spanked less.7
Page: 34 of 39
Not available
Public Health Wales
Chicago ChildParent Centers
Early years evidence synthesis
Low SES, 34yrs.7
This programme provides
centre-based preschool
education. It is based in public
elementary schools and
operates through the public
school system. It is offered to
children aged three to four
years of age and emphasises a
child-centred, individualised
approach to social and
cognitive development. The
curriculum focused on school
readiness (developing reading
and language skills).
Parenting activities are
provided in parent resource
centres and parents are
required to participate for half
a day each week. Activities
involve parenting classes,
providing clerical assistance,
developing resources for other
parents, coordinating school
projects, work training and
literacy programmes. There
are also health and nutrition
services, screening and
diagnostic services, meal
services and referral by
programme nurses. Although
not routine, home visits are
offered.7
Date: 14/09/2012
When compared with control
For every dollar spent,
groups, intervention groups
$6.89 return on
displayed significantly:
investment.7
• better school readiness
• fewer dropped out of school
(46.7% vs 55%) and higher
% completed high school
(49.7% vs 38.5%) and
attended college (24% vs
18%)
• fewer placed in special
education (13.5% vs 20.7%)
and less time was spent there
(0.51 vs 0.87 years)
• fewer experienced grade
retention (21.9% vs 32.3%)
• lower proportion of overall
(16.9 vs 25.1%) and violent
arrests (9% vs 15.3%)
• higher rates of full-time
employment (42.7% vs
36.4%)
• 52% fewer cases of child
maltreatment or abuse
• more likely to be covered
by health insurance (61.5%
vs 70.2%; p=0.005)
 fewer depressive
symptoms
(12.8% vs 17.4%; =0.06).7
Version:
v1 final
Page: 35 of 39
(Geddes
et al, 2010, p.98)
Public Health Wales
Carolina
Abecedarian
Project
Early years evidence synthesis
Low SES, high
risk, entry 6
weeks-3
months, exit 58yrs.7
Date: 14/09/2012
Provision of intensive
preschool services to children
from low-income families
beginning in infancy to five
years of age, with a subgroup
continuing to age eight.
Predominantly a centre-based
programme for children but
includes home visits, and at
school age there is a parent
programme. Medical and
nutritional services were also
provided to the children at the
centres.7
Version: v1 final
Intervention groups displayed
significantly:
• higher IQ scores than
controls up to age 15 years
and higher academic
achievement
• fewer placements in special
education (24% vs 48%) and
retentions in grade (39% vs
59%)
• higher percentage of high
school graduation (70% vs
67%) and college completion
(36% vs 13%)
• fewer regular smokers
(39% vs 55%) and less
marijuana use (18% vs
39%).
Programme teenage mothers
were more likely to:
• have completed high school
and participated in postsecondary training
• be self-supportive, be
employed (70% vs 58%) and
have jobs that were skilled or
semiskilled, and less likely to
have subsequent children.7
Page: 36 of 39
For every dollar spent,
$3.72 return on
investment.7
Public Health Wales
Mellow
parenting
Parenting
positively
Early years evidence synthesis
Mothers with a
child under five
where there
are high levels
of social and
health needs,
as well as child
protection
concerns.14
14 week, one day a week
group. Personal support for
the parents is combined with
direct work with parents and
children on their own
parenting problems.7
Improvements in:
 parent-child interaction
 parental child centredness
 mother’s mental health
 child behaviour problems
Parents with
concerns about
their child’s
behaviour
and/or
emotions.14
Parents attend 10 to 12
weekly group or individual
sessions where they learn how
to communicate effectively
with their child and manage
unwanted behaviour.14
Preliminary evidence of
improving child and parent
outcomes from several
studies. Significant
improvements in children’s
behaviour and parents’
personal stress immediately
after completing the
programme, These positive
outcomes were maintained
at the 18-month follow-up
assessment, although the
parents’ stress levels were
not as low as they were
immediately after completing
the course. Parenting
Positively is undergoing
further evaluation in Bexley,
Kent.14
Date: 14/09/2012
Version: v1 final
Not available
NB: unpublished research,
lack of control group and lack
of long term follow up.7
Page: 37 of 39
Not available
Public Health Wales
Family links
Early years evidence synthesis
Any parent
interested in
improving their
relationship
with their child.
Most
appropriate for
parents with
children
between the
ages of four
and 11, who
want to know
how best to
support their
child’s
development
and learn
effective
parenting
strategies.14
Date: 14/09/2012
Family Links has two primary
aims:
• To help parents and carers
understand their own
emotional needs
• To help parents learn
positive parenting practices.
Parents attend 10 weekly
group sessions where they
learn how to respond to their
child more empathetically and
effectively manage unwanted
child behaviour.14
Version: v1 final
Family Links has preliminary
evidence of improving child
and parent outcomes.
Use of standardised
measures of parent and child
behaviour completed before
and after parents attend the
course - Parents reported
significant improvements in
their wellbeing and their
children’s behaviour.
RCT - No significant
differences between the
intervention and the control
group on any of the
measures.14
Page: 38 of 39
Not available
Public Health Wales
Parent
Management
Training Oregon
Model
Early years evidence synthesis
Parents with
concerns about
their child’s
behaviour
and/or
emotions (age
4-11). PMTO is
appropriate for
children with
serious conduct
problems,
including
stealing and
fire-setting,
neglected and
maltreated
children, and
children with a
diagnosed
mental health
problem.14
Date: 14/09/2012
PMTO is typically delivered
within a child and adolescent
mental health service. Parents
learn five key skills linked to
improved child outcomes:
• Skill encouragement: Parents
learn how to scaffold their
child’s learning by
breaking down long-term goals
into achievable steps and
rewarding progress towards
the goals
• Setting limits: Parents learn
how to select sanctions (e.g.
time out, withholding
of privileges, etc.) to
discourage unwanted child
behaviour
• Monitoring: Parents learn
strategies for tracking their
child’s activities,
whereabouts and their
relationships with friends
• Problem solving: Helps
parents learn how to identify
family goals and strategies
for achieving them
• Positive involvement: Covers
the many ways parents can
show their child love and
interest.14
Version: v1 final
 Significant improvements
in parents’ use of discipline
and children’s behaviour
 Significant improvements
in parenting practices
and parents’ satisfaction with
their couple relationship
 No significant
improvements in PMTO
children’s behaviour, but
there a significant decline in
the behaviour of the children
assigned to the control
group,
resulting in a significant
difference favouring the
PMTO children
 PMTO mothers
demonstrated significant
improvements in their
parenting practices and
depression.14
Page: 39 of 39
Not available