Summary of the impact

Frances Gardner and her team in Oxford have been studying antisocial behaviour in children for two decades. This programme of research has been instrumental in demonstrating that parenting programmes are effective in significantly reducing antisocial behaviour, thus encouraging uptake of these programmes by bodies that play a major role in forming UK central government policy relating to parenting and child behaviour, such as NICE and the (then) Department of Children, Schools and Families (DCSF). Given that lifetime costs of antisocial behaviour are so high, these interventions are likely to produce high return on investment, with cost-benefit analyses (e.g. NICE; DCSF) suggesting that over £200,000 per child could be saved. The impact of Gardner's studies has subsequently expanded beyond the UK, contributing to family intervention development in US trials, and to policy change by organisations such as WHO and the UN Office on Drugs and Crime (UNODC), and by policymakers in New Zealand, Malta, Slovenia, Estonia and South Africa.

Underpinning research

The Oxford team is led by Professor Frances Gardner (since 1994 University Lecturer at Oxford, since 2007 Professor of Child and Family Psychology) Other team members include: Jennifer Burton (Research Officer, 1999-2007), Wendy Knerr (MSc Student, 2010-11; later consultant on the projects, 2011 to date), Dr Lucie Cluver (University Lecturer involved in parenting projects, 2010 to date), Jamie Lachman (DPhil Student, 2011 to date), and Professor Paul Montgomery (co-I on Swedish government funded systematic review [Section 5: C1])

Using randomised trial methodology, the research programme, led by Gardner, on parenting interventions investigates: i) can parenting interventions for troubled children and families (developed in the USA) successfully be transferred to regular UK service settings?; ii) how and for whom do these interventions work, and are they more or less effective for the most troubled parents and children?; and iii) how transportable are they across diverse cultures and countries?

The results of a randomised trial (1999-2005) funded by the Esmee Fairbairn Foundation (the first in the UK voluntary sector), showed that parenting interventions developed in the US are effective in reducing significant behavioural problems in children, and in improving parenting and parent mental health, in low-income families in Oxfordshire [Section 3: R1]. Importantly these effects on parent and child behaviour were found using multiple methods. Mediation analyses tested the theory of change underlying the programme — namely that change in positive parenting skill, rather than in parent confidence or well-being, is a key driver of change in child behaviour.

A second randomised trial, conducted collaboratively with Professor Judy Hutchings (PI) (Bangor University), (2002-07) funded by the Health Foundation, replicated these outcomes and mechanisms of change, in a larger, multi-agency study within North Wales `Sure Start' services [R2, R3]. Work within this study, led by Gardner, found that, contrary to expectations based on previous research and practice, there was no evidence for greater effects on more advantaged families [R3]. Moreover, Gardner found better outcomes for mothers who were more depressed or who had higher levels of parenting stress [R3]. These are vital messages for policymakers and practitioners, often sceptical about whether these programmes can reach the most troubled families (Section 4). This research is significant in being one of the first to use an experimental design to test further the mediating role [R2, R3, R6] of parenting influences identified in Gardner's earlier Oxford longitudinal studies (Gardner et al., 1999, 2003, Wellcome Trust funded, 1996-99).

Drawing on those early longitudinal studies to design new intervention strategies, the Oxford team replicated these findings on mechanisms of change and subgroup effects [R4-6] in a family intervention tested in two randomised trials in a nationwide child welfare service in the US. This work was funded by NIH (2000-13), and conducted in collaboration with Tom Dishion (University of Oregon), Daniel Shaw (University of Pittsburgh), and Melvin Wilson (University of Virginia). They carried out the US fieldwork, which was analysed [R4, R6] by the Oxford team.

Finally, in 2010, the Oxford team were commissioned by the Sexual Violence Research Initiative (SVRI) and MRC South Africa to conduct the first ever systematic review of parenting programmes in low and middle income countries (LMIC), for reducing harsh and abusive parenting (2010-12) [R7]. Extensive searching found 12 randomised trials of parenting interventions in LMICs. Despite the fact that many of these interventions had been transferred from other countries, it was striking how few made use of the extensive evidence-base on effective programmes. The team made a number of recommendations for further research and practice based on these findings. Despite its recency, this review has had considerable impact (see section 4), and has led to further funding for Gardner's team from the Swedish government's National Board of Health and Welfare [C1], for a systematic review of factors affecting the transferability of parenting interventions across countries and cultures.

References to the research

Peer-reviewed grants awarded to Gardner for parenting intervention research: Esmee Fairbairn Foundation, £149,000, 1999-2003; Health Foundation, £321,000 to Bangor (Gardner co-I), 2002- 06; US NIH / National Institute on Mental Health, total $786,827, with £93,406 awarded to Oxford, 2000-03; NIH / National Institute on Drug Abuse, total >$15m, with £244,624 awarded to Oxford, 2002-07 and 2008-13; SVRI, MRC South Africa, £9,091, 2010-11; Swedish National Board of Health and Welfare, 2011-13, £62,000; NIHR-Public Health Research, £335,401, 2013-15.

Details of the impact

Gardner's team's research on parenting interventions has had significant impact on central policy relating to parenting and child behaviour both within the UK and beyond.

Impact 1- UK policy

Persistent antisocial behaviour in children is a major social issue. The public costs, incurred by multiple systems, are estimated at £250,000 per child by age 27 (Sainsbury Centre for Mental Health, 2009). Thus the case for needing to implement interventions that can reduce these problems is very compelling. A decade ago, very little UK policy on parenting interventions was based on rigorous empirical evidence. Policy shifted in the late 2000s, with spending targeted increasingly on parenting interventions that had been found by Gardner's team (among others) to be effective for improving child outcomes in randomised trials [R1, R3]. Gardner made substantial contributions (authoring three chapters) to an influential government report `Support from the Start' (2004), which cites early findings from her Oxford trial [R1], and which was highly significant to this debate, and to driving subsequent policy shifts [C2, C3].

Drawing on these UK trials, Gardner was then invited in 2006 to be a member of the expert advisory panel for heath-led parenting interventions for the Prime Minister's Strategy Unit. This panel helped to devise the strategy, piloting, implementation, and testing of a national rollout of an evidence-based home-visiting programme for vulnerable families, which began in 2009 [C2]. Gardner's team's UK research was also a key contributor to bringing about the introduction of the National Academy of Parenting Practitioners (NAPP) in November 2007. NAPP aimed to `transform the quality and size of the parenting workforce', in order to improve parenting and children's well-being, by training large cohorts of staff in evidence-based parenting interventions, particularly those tested in Gardner's UK trials [C2, C3]. As explained by the then Deputy Director of the Social Exclusion Task Force at the Cabinet Office [C2], who played a major part in driving New Labour policies on early parenting interventions in the late 2000's: "Support from the Start" and Gardner's UK trials [R1-3] were highly influential in creating momentum towards these major policy developments, including the very substantial roll out led by the National Academy of Parenting Practitioners (NAPP) from 2008.

The founder and research director of NAPP [C3] adds to this: Gardner's research was pivotal in helping persuade the Cabinet Office to set up NAPP. Her trial [R1] was the first in the world to show that parenting programmes could be effective in reducing severe antisocial behaviour, outside the narrow confines of child mental health services, showing that the voluntary sector could do just as good a job with difficult cases. Influenced by these findings, the government awarded £35 million to NAPP to disseminate evidence-based parenting programmes across the voluntary sector; this is estimated to have benefited over 150,000 children; Gardner was an important member of its steering group to ensure this research was implemented.

Prominent commentators on family policy also attribute this policy shift to Gardner's trials: Jane Lewis (2011), in a recent article sees these trials as the key research driver of this policy shift: "Second, a small number of evaluations of ... EBPPs (evidence-based parenting programmes) have been undertaken in England using RCTs, ... obtaining positive results for disadvantaged as well as more advantaged families...[Scott 2001, Gardner et al. 2006, 2010, Hutchings et al. 2007] [R1-3]. These have played a part in influencing central government policy to ...provide financial incentives for LAs to adopt this type of programme rather than untested home-grown variants".

Gardner's team's research is frequently cited in influential systematic reviews, guidelines, and policy documents [see C4-7 for Cochrane, Campbell and other reviews]. For example, four of the trials [R1-6] have been cited in the NICE Guidelines (National Institute of Health and Clinical Excellence); the Chair confirms their policy influence [C3]: As Chair of the NICE Guideline on antisocial behaviour and conduct disorders, I oversaw the marshalling of the evidence which has to be relevant to British practice, and Gardner's work was important in shaping the recommendations, since it showed that the interventions work in Britain — not all psychosocial interventions developed in the USA do this. Their work also added to the plausibility of the recommendations since it demonstrated that the mediating mechanism was an increase in positive parenting.

In this way, Gardner's research [R1-7] has contributed to substantial policy change and investment in parenting interventions, across multiple sectors, including health, social care and the voluntary sector, in the UK and across the world.

Impact 2: International Policy

As stated by the Head of Research and Development, Swedish National Board of Health & Welfare [C1]: Gardner's research influenced parenting interventions in Europe; they showed that US parenting interventions could be transferable to European health and social systems, and contributed to a shift in practice and policy in multiple countries. Her recent innovative research on cross-country transportability has stimulated a good deal of policy debate and further government research on cross-country adaptation in Sweden. Since then, many countries have implemented and tested these programmes, and cite the Oxford research in numerous reports on parenting trials (e.g. from Sweden, Norway, Ireland, Holland, Portugal [C1]). In many of these countries, evaluators have closely followed the questions and methods Gardner used to test mechanisms of change and subgroup effects in her trials. Gardner has also been invited to participate in policy deliberations regarding the introduction of parenting programmes internationally. For example:

• New Zealand (2011): Gardner presented the research to 300 practitioners and policymakers at the Werry Centre, responsible for nationwide rollout, and in 2012 as Rotary Scholar, presented to the NZ Royal College of Psychiatrists. The head of national workforce development [C9] states that: Gardner's UK trials [R1-3] have been influential in determining national policy, as they demonstrated that US interventions could be effective in social care systems that are more similar to New Zealand's, and that they could work in non- specialised community services in the NGO sector. Over 1500 practitioners have now been trained in the programme Gardner tested.
• Slovenia (2013): Gardner presented findings to the national professional body for Child Psychiatrists and Psychologists, appearing on Radio Slovenia, which led to further policy discussions with the Ministry of Health, and initiation of several projects to implement evidence- based parenting programmes in schools and clinics.
• Estonia (2011): Gardner presented findings to the Head of the Government Department of Children and Families, and other policymakers and practitioners. Research presented on her UK trials [R1-3] at this visit contributed to a debate and a shift in Estonian policy toward adopting the parenting programme Gardner had tested, rather than others.
• Malta (2012): Gardner was invited to Parliament to discuss evidence-based parenting programmes with the (then Shadow) Minister for Social Policy and Spokesperson for the Family. Following this, the new Minister for the Family has initiated policy guidance on Positive Parenting.

Gardner's research has also had direct influence on international organisations such as UNODC [C6], and WHO [C7, C10]. As the WHO Violence Prevention Initiative, Technical Officer, explains: Gardner's research has had a very significant impact on policy and practice in high, middle and low income countries. Indeed her research has been central to a shift that has occurred within WHO's Violence Prevention Unit, whereby parenting interventions have been selected as the first of four priority violence prevention strategy we plan to scale up in coming years. Her research team are working directly with the WHO to develop, test, and scale up parenting programmes for developing world settings in South Africa, with future randomised trials planned in countries such as Brazil, the Philippines, and Ghana [C10].

In the USA, Gardner's parenting intervention research has led directly to her appointment to the Board of `Blueprints for Healthy Youth Development' [C8], a longstanding US violence prevention organisation, until recently funded by the US government Office of Juvenile Justice and Delinquency Prevention. Its role is to review and make decisions about which programmes qualify for the influential Blueprints `best practice' list, widely used by US policymakers and practitioners. Her Oxford trial is cited and used by many other influential US policy-making and policy-informing bodies (2006-12): Substance Abuse and Mental Health Services Administration's (SAMHSA) National Registry of Evidence-Based Programs & Practices; RAND's Promising Program Network; Partnership for America's Economic Success; Washington State Institute for Public Policy; and the Coalition for Evidence-Based Policy. Gardner's research therefore has clearly had significant impact on parenting and child behaviour policy in the UK and beyond.

Sources to corroborate the impact

[C1] Head of Research and Development, Swedish National Board of Health and Welfare (held on file) confirms influence of Gardner's research on parenting interventions in Europe; work on cross-country transportability has stimulated policy debate and new government research in Sweden.

[C2] Deputy Director of Social Exclusion Task Force at Cabinet Office (now NSPCC Head of Strategy & Development for Under-Ones) (held on file) confirms the influence of Gardner's research and its contribution to an influential government report, `Support from the Start', in paving the way to major implementations of evidence based parenting interventions.

[C3] Research Director, Founder, of DfES National Academy of Parenting Practitioners (NAPP) confirms role of Gardner's research in influencing UK national policy in voluntary and social care sector. This person is also Chair of the NICE Guidelines on Child Conduct Disorders, confirms role of Gardner's research in influencing NICE health policy (both held on file).

[C4 and C5] Cochrane & Campbell Collaboration Systematic Reviews - examples of two influential systematic reviews (of many) citing Gardner's trials: Piquero et al. (2008), Effects of early family/parent training programs on antisocial behavior and delinquency. Campbell Library of Systematic Reviews. http://campbellcollaboration.org/lib/project/43/ Furlong et al (2012), Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database of Systematic Reviews http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD008225/frame.html

[C6] UNODC: Gardner appointed to Expert Panel on Family Skills Training, Vienna. Contributed to report, [R1] trial cited; see: https://www.unodc.org/documents/prevention/family-guidelines-E.pdf

[C7] WHO report: `Preventing Violence: Evaluating outcomes of parenting interventions' (2013) cites Gardner's trial [R2, R3], systematic review [R7], chapter in UK report [C2], UNODC report [C6].

[C8] Blueprints for Healthy Youth Development: http://www.blueprintsprograms.com/about.php

[C9] Director of Workforce Development, Werry Centre for Child Mental Health, Auckland, New Zealand (held on file) confirms quote on role of Gardner's research in nationwide roll out.

[C10] Technical Officer, WHO Violence Prevention Initiative (held on file) confirms significant impact of Gardner's research on policy and practice, and its centrality to policy shift within WHO Violence Prevention Unit.