United Kingdom

Last updated : 29.11.2024
Country of origin
USA
Last reviewed:
Age group
0-5 years
6-10 years
11-14 years
Target group
Parents of children's with behavioural problems
Programme setting(s)
Family
Level(s) of intervention
Indicated prevention

TripleP is a multi-level parenting and family support prevention strategy programme that aims to prevent severe children’s behavioural, emotional and developmental issues by enhancing parental knowledge, skills, and confidence. Triple P encompasses five levels with different types and intensity of interventions: from providing parents with access to information using print and electronic media (level 1) to highly targeted interventions for the most severe cases of family behaviour intervention (level 5). 

The five core principles of the intervention are creating a safe, engaging and positive learning environment, employing assertive discipline, having realistic expectations and prioritizing self-care as a parent. Most of the studies available in Europe assess level 4 of the intervention targeted to children with behavioural problems. However, in some studies, level 4 has been implemented at the universal level. Research conducted in Germany and Switzerland indicates positive outcomes for parental competence, primarily reported by mothers; however, no evidence is available to assess the programme's effectiveness on child-related outcomes as it’s only reported by parents. 

Links to this programme in other registries
Blue Prints - Triple P
Level 4 Standard Triple P - Early Intervention Foundation
Contact details

Jenna McWilliams
11 Market Street N, Indooroopilly, QLD, 4068, Australia
Contact: +6173236 1212
Email: PIES[at]triplep.net
 

 

Show link
0
Evidence rating
Possibly beneficial
Studies overview

Two RCTs in Germany have examined the effectiveness of Triple P at Level 4 (Heinrichs et al., 2014; Kim et al., 2021). The study by Heinrichs et al. (2014) targeted parents of 2.6 to 6-year-olds. The intervention group (n=186) participated in Triple P level 4 workshops and seminars, while the control group (n=93) underwent repeated assessments to monitor child development. According to mothers’ reports on children's behaviour, there was a significant effect after the intervention; however, this effect was not found in fathers. A significant reduction in dysfunctional parenting behaviour in mothers was maintained at the 4-year follow-up (d = 0.38), but effects on child behaviour problems were not sustained (d=0.19). Notably, all outcomes were parent-reported, with long-term benefits observed only in mothers. 

Kim et al. (2021) assessed the impact of Triple P on parenting behaviour and adolescent bullying. Families were randomized to either the intervention group (n=86) or the control group (n=94). After a 10-year follow-up, a notable reduction in bullying behaviours (0.259 standard deviations) was observed in adolescents whose parents had participated in the intervention. However, it is unclear how they achieved such a high retention rate over ten years. 

An RCT by Bodenmann et al. (2008) in Switzerland evaluated Triple P’s efficacy in improving parenting and child behaviour among 2-12-year-olds.  Fifty couples were randomly assigned to one of three conditions: Triple P programme, a distress prevention programme (CCET) or were left untreated. Mothers who attended the Triple P intervention at 1-year follow-up showed less parental dysfunctionality and a greater sense of parental competence compared to mothers from the other two groups. However, there were no significant effects of the intervention on fathers in any of the three groups. The child behaviour outcomes were only reported by parents, it is unclear what the control group received, and many outcomes were measured but statistical adjustments for these multiple comparisons were not applied. 

Little et al. (2012) conducted an RCT in Birmingham to evaluate the effectiveness of Triple P for children exhibiting problematic behaviour. The control group received services as normal (n=73) and the intervention group (n=73), the 8-week Triple Parent Program. There were no significant differences between the groups in any of the child-related outcomes. The authors noted that these results could be explained by low fidelity of implementation or low adherence to the programme.  

The report by Fives et al. (2013) was excluded from the assessment due to methodological issues, only a subsample of the original intervention group was analysed (n=59; 34% response rate). The analysis is within a group and not between groups, measures are not blind to intervention, there is no randomisation of participants, no assessment of participants for inclusion (targeted intervention), attrition has not been accounted for and the data included is only available for the post-test. 

 

References of studies

Studies Included in the Assessment:

Bodenmann, G., Cina, A., Ledermann, T., & Sanders, M. R. (2008). The efficacy of the Triple P-Positive Parenting Program in improving parenting and child behavior: A comparison with two other treatment conditions. Behaviour Research and Therapy, 46(4), 411–427. 

Heinrichs, N., Kliem, S., & Hahlweg, K. (2013). Four-Year Follow-Up of a randomized controlled trial of triple P group for parent and child outcomes. Prevention Science, 15(2), 233–245. https://doi.org/10.1007/s11121-012-0358-2

Kim, J. H., Hahlweg, K., & Schulz, W. (2021). Early childhood parenting and adolescent bullying behavior: Evidence from a randomized intervention at ten-year follow-up. Social Science & Medicine, 282, 114114. https://doi.org/10.1016/j.socscimed.2021.114114

Studies not Included in the Assessment:

Fives, A., Pursell, L., Heary, C., Gabhainn, S. N., & Canavan, J. (2014). Parenting Support for Every Parent: A population-level evaluation of Triple P in Longford Westmeath. Final report. https://aran.library.nuigalway.ie/bitstream/10379/14832/1/parenting_sup…

Steketee, M., Jonkman, H., Naber, P., & Distelbrink, M. (2021). Does Teen Triple P Affect Parenting and the Social and Emotional Behaviours of Teenagers? A Study of the Positive Parenting Programme in the Netherlands. Behaviour Change, 38(2), 95–108. doi:10.1017/bec.2021.2

Graaf, I. de, Bohlmeijer, E., Blokland, G., & Tavecchio, L. (2009a). Helping Families Change. The adoptation of the Triple P – Positive Parenting Program in the Netherlands. Chapter 5: What are the results of Group and Standard Triple P for parents and children in the Dutch mental health care and youth care? (PhD). Utrecht: University of Amsterdam. 

Schapping, R., De Graaf, I.M., Reijneveld, S.A., Effectiviteit van Triple P in Nederland: stand van zaken en controverse. Kind Adolescent, DOI 10.1007/s12453-017-0140-0 (https://www.researchgate.net/profile/SaReijneveld/publication/316455304… nd_van_zaken_en_controverse/links/5e159cad92851c8364ba8be7/Effectiviteitvan-Triple-P-in-Nederland-stand-van-zaken-en-controverse.pdf).
 

Countries where evaluated
Germany
Switzerland
United Kingdom
Protective factor(s) addressed
Family: attachment to and support from parents
Family: Parental monitoring (supervision)
Family: positive family management
Risk factor(s) addressed
Family: aggressive or violent parenting
Family: family management problems
Family: low parental education
Family: neglectful parenting
Family: other
Outcomes targeted
Emotion regulation, coping, resilience
Positive relationships
Social behaviour (including conduct problems)
Description of programme

Level 4 is an intensive, eight-session parenting program delivered in various formats (individual, group, or self-help) for parents of children with significant behavioural challenges. Parents receive five group sessions of parent training (each session lasting two and a half hours). Upon completion of the group sessions, parents participate in three individual telephone consultations (15–30 min duration each).  The intervention aims to teach positive parenting strategies to encourage children’s self-regulation, manage misbehaviour and enhance social competence. During the training, are encouraged to practice these strategies and reflect on their effectiveness.

Implementation Experiences
Feedback date
Last updated : 29.01.2024
Country of origin
United Kingdom
Last reviewed:
Age group
No defined Age group
Target group
General population
Programme setting(s)
Environmental setting
Community
Level(s) of intervention
Environmental prevention

Local strategies to intensify the licensing enforcement — aimed both at regulating the availability of alcohol and modifying the drinking environment — can reduce alcohol-related harms such as hospital admissions, violent crimes, sexual crimes and public order offences. This kind of regulatory intervention is replicable (in countries where municipalities or counties have regulatory power and decision latitude), with results that are likely to be transferable. In none of the studies was any intervention developer involved. The interventions and their dosage are clearly described and defined but can be deployed in different ways as interventions. There are also no promotion or direct costs or commercial interests.

Keywords
alcohol
communities
crime
environmental indicators
Links to this programme in other registries
No link
Contact details

Main author of studies (not intervention developer): 

F de Vocht, School of Social and Community Medicine, University of Bristol, 

frank.devocht[at]bristol.ac.uk
 

Evidence rating
Possibly beneficial
Studies overview

Licensing data were obtained at local level from the Home Office Alcohol and Late Night Refreshment Licensing data and local areas were coded as ‘passive’, low, medium or highly active based on whether they made use of cumulative impact areas and/or whether any licences for new premises were declined. These data were linked to 2009–2015 alcohol-related hospital admission and alcohol-related crime rates obtained from the Local Alcohol Profiles for England. Population size and deprivation data were obtained from the Office of National Statistics. Changes in directly age-standardised rates of people admitted to hospital with alcohol-related conditions were analysed using hierarchical growth modelling.

Stronger reductions in alcohol-related admission rates were observed in areas with more intense alcohol licensing policies, indicating an ‘exposure–response’ association, in the 2007–2015 period. Local areas with the most intensive licensing policies had an additional 5% reduction (p=0.006) in 2015 compared with what would have been expected had these local areas had no active licensing policy in place (De Vocht et al. 2016).

Local areas in England with more intense alcohol licensing policies had also a stronger decline in rates of violent crimes, sexual crimes and public order offences in the period up to 2013 of the order of 4–6% greater compared with areas where these policies were not in place, but not thereafter (De Vocht et al. 2017b).

An experimental design study used Home Office licensing data (2007– 2012) to identify (1) interventions: local areas where both a cumulative impact zone and increased licensing enforcement were introduced in 2011; and (2) controls: local areas with neither. Outcomes were 2009–2015 alcohol-related hospital admissions, violent and sexual crimes, and antisocial behaviour. Bayesian structural time series were used to create post-intervention synthetic time series (counterfactuals) based on weighted time series in control areas. Intervention effects were calculated from differences between measured and expected trends and showed moderate reductions in alcohol-related hospital admissions and violent and sexual crimes associated with introduction of local alcohol licensing policies (de Vocht et al. 2017a).

Using the same analytic methods (Bayesian structural time–series), a paper with three natural experiments in English local areas of 1000–15000 people each evaluated the impact of local licencing interventions at small spatial scale by using a causal inference framework. Interventions were (a) the closure of a nightclub following reviews; (b) closure of a restaurant/nightclub following reviews and (c) implementation of new local licensing guidance (LLG). Data from emergency department admissions, ambulance call-outs and alcohol-related crime at the lower or middle geographical aggregation level showed that a) closure of the nightclub led to temporary 4-month reductions in antisocial behaviour with no change in other outcomes, b) closure of the restaurant/nightclub did not lead to measurable changes in outcomes, while c) the new licensing guidance led to small reductions in drunk and disorderly behaviour (nine of a predicted 21 events averted), and the unplanned end of the LLG coincided with an increase in domestic violence of two incidents per month (De Vocht el al. 2020).

With an inverted design, a study in Brabant, NL (de Goeij et al. 2017) assessed how youth alcohol consumption trends were related to the development and implementation of integrated policies: six municipalities with stronger declines in youth alcohol consumption between 2007 and 2011 (cases) were compared to four municipalities with weaker declines (controls). Information on the policy process in the same period was obtained through semi-structured in-depth interviews with policy advisors and extracted from policy documents. Municipalities with stronger declines in alcohol consumption involved sectors other than public health and had started to implement interventions that use regulatory or enforcement strategies. Their involvement was facilitated by framing youth alcohol consumption as a safety rather than a health problem, whereby local media played a substantial role.

References of studies

England

De Vocht, F., Tilling, K., Pliakas, T., Angus, C., Egan, M., Brennan, A., … Hickman, M. (2017a). The intervention effect of local alcohol licensing policies on hospital admission and crime: a natural experiment using a novel Bayesian synthetictime-series method. Journal of Epidemiology and Community Health, 71(9), 912–918. https://doi.org/10.1136/jech-2017-208931

De Vocht, F., Heron, J., Angus, C., Brennan, A., Mooney, J., Lock, K., … Hickman, M. (2016). Measurable effects of local alcohol licensing policies on population health in England. Journal of Epidemiology & Community Health, 70(3), 231–237. https://doi.org/10.1136/jech-2015-206040

De Vocht, F., Heron, J., Campbell, R., Egan, M., Mooney, J. D., Angus, C., … Hickman, M. (2017b). Testing the impact of local alcohol licencing policies on reported crime rates in England. Journal of Epidemiology and Community Health, 71(2), 137–145. https://doi.org/10.1136/jech-2016-207753

De Vocht, F., McQuire, C., Brennan, A., Egan, M., Angus, C., Kaner, E., … Hickman, M. (2020). Evaluating the causal impact of individual alcohol licensing decisions on local health and crime using natural experiments with synthetic controls. Addiction, add.15002. https://doi.org/10.1111/add.15002

Case-control study: Netherlands

De Goeij, M. C. M., Harting, J., & Kunst, A. E. (2017). Stronger declines in youth alcohol consumption thanks to stronger integrated alcohol policies? A qualitative comparison of ten Dutch municipalities. Substance Abuse Treatment, Prevention, and Policy, 12(1), 13. https://doi.org/10.1186/s13011-017-0091-8

 

Countries where evaluated
Netherlands
United Kingdom
Protective factor(s) addressed
Environmental physical: Reducing outlet density
Environmental: Comprehensive and strict local alcohol policy and enforcement
Environmental: Enforcement strategy in on-site alcohol-selling premise
Environmental: RBS (Responsible Beverage Service) available
Environmental: Restriction of opening hours
Community: other
Risk factor(s) addressed
Community: laws and norms favourable to substance use and antisocial behaviour
Community: perceived availability of drugs/alcohol
Environmental physical: High density of alcohol-selling off-site premises
Environmental physical: High density of licensed alcohol-on-site premises
Environmental physical: Level of crowdedness in on-site alcohol-selling premise
Environmental physical: Low alcohol policy comprehensiveness and enforcement
Outcomes targeted
Emergency visits
Crime
Other behaviour outcomes
Sexual violence
Social behaviour (including conduct problems)
Violence
Description of programme

Local authorities in England (United Kingdom) and in other countries have regulatory powers to influence the local alcohol environment by modifying the licensing process and controlling the enforcement of existing licenses (but not, for example, to set levels of tax). Such interventions include, for example, defining cumulative impact zones (CIZs) where there is cumulative stress caused by excess alcohol supply. CIZs and restrictions on new licenses shall regulate the availability of alcohol and change the drinking environment. Applicants for a new alcohol license have to demonstrate how they will avoid causing harm, hence reversing the burden of proof.

Two studies showed a linear dose-response relationship between the intensity of such regulatory strategies and reduced alcohol-related harm. One study confirmed this in a quasi-experimental controlled design, and another one showed in three local experiments that the impact of local alcohol regulations, even at the level of individual premises, can be evaluated using a causal inference framework and that even single interventions such as closure or restriction of alcohol venues and alcohol licensing may have a positive impact on health and crime in the immediate surrounding area. One reversed case-control study (where intervention intensity is the dependent variable) confirms the findings in one Dutch context.

Last updated : 29.01.2024
Country of origin
USA
Last reviewed:
Age group
0-5 years
6-10 years
11-14 years
Target group
The programme has been used with a diverse population - girls with elevated depressive symptoms; pupils living in low-income areas; it has also been evaluated as a universal school-based prevention programme for adolescents.
Programme setting(s)
School
Level(s) of intervention
Indicated prevention
Selective prevention
Universal prevention

The Penn Resiliency Program (PRP) is a school-based group intervention that teaches cognitive behavioural and social problem-solving skills. PRP strives to teach students to think flexibly and accurately about the challenges and problems that they confront. Students learn about (a) the link between beliefs, feelings, and behaviours; (b) cognitive styles, including pessimistic explanatory styles; and (c) cognitive restructuring skills, including how to challenge negative thinking by evaluating the accuracy of beliefs and generating alternative interpretations. PRP sessions meet after school once each week in a 90-minute session over 12 weeks.

Op Volle Kracht (OVK; On Full Power) is a Dutch adaptation that incorporates cultural and content-related modifications. It comprises 16 weekly 50-minute group sessions. The first 8 lessons are devoted to explaining and practising the CBT derived principles. Lessons 9 to 16 are directed at social and coping skills, self-esteem, problem solving, and decision-making.

The programme has also been evaluated in the UK with some adaptations. It is called the UK Resiliency Programme (UKRP). It is delivered over 18 hours, with the length of each session and the gap between sessions being flexible for schools to base on their timetables. There are minor changes in examples and adaptations to programme vocabulary.

Links to this programme in other registries
No link
Contact details

Rutger Engels

Voorzitter - Raad van Bestuur

Hoogleraar Developmental Psychopathology, Radboud Universiteit Nijmegen

T +31 30 29 71 102 F + 31 30 29 71 111 M + 31 6 40 70 33 77

Email: rengels[a]trimbos.nl

Da Costakade 45 - 3521 VS Utrecht

Postbus 725 - 3500 AS Utrecht

 

Jane Gillham, Ph.D.

Co-Director, Penn Resiliency Project

University of Pennsylvania

Department of Psychology

Solomon Laboratories

3720 Walnut St.
Philadelphia, PA 19104-6241

Email: info[a]pennproject.org

Evidence rating
Additional studies recommended
Studies overview

The programme has been evaluated in four randomised controlled trials in the Netherlands and one quasi-experimental study in the UK.

In a cluster randomised controlled trial in the Netherlands, in which schools were randomised, 118 female adolescents, aged 11 to 15 years, with elevated depressive symptoms participated. Depressive symptoms (but not controlling for baseline values) were significantly different between conditions at posttest and 6-month follow-up, but not at 1-month follow-up.

A second cluster randomised controlled trial in the Netherlands, evaluated the programme on a universal prevention level. Secondary schools in which at least 30% of their pupils lived in low-income areas were eligible. 61 classes including 1440 adolescents aged 11-16 were randomly allocated. A latent growth curve approach found the increase or decrease in depressive symptoms across follow-ups did not differ between the intervention and control condition.

Another cluster randomised controlled trial in the Netherlands, evaluating the programme as universal prevention, randomised 9 schools. 1341 adolescents, with a mean age of 13.9 years participated. There was no significant intervention effect on level of depressive symptoms or the number of adolescents with elevated symptoms at posttest, one and two-year follow-ups. An iatrogenic effect was found at post-test, where adolescents in the intervention condition reported less optimism, less active coping, less social self-efficacy and lower school grades; these effects were not sustained at follow-ups.

A randomised controlled trial, randomising individuals, has also been conducted in the Netherlands 208 Dutch female adolescents (mean age 13 years) with elevated depressive symptoms. The study compared Op Volle Kracht against another intervention (SPARX), a combination of Op Volle Kracht and SPARX and a self-monitoring control group, where participants completed questionnaires weekly to monitor their depressive symptoms. There was a significant time effect across conditions, but there were no significant intervention effects. The control group was not a treatment-as-usual or no-treatment control group, and thus the study cannot be considered to provide definite evidence of intervention ineffectiveness.

The English study included 2910 children aged 11 or 12 years at baseline. There was a significant, positive effect of the intervention on depressive symptoms at posttest (but not at one- or two-year follow-up). No significant effects were found for anxiety or behaviour problems at any post-baseline assessment period.

References of studies

Brunwasser, S.M., Gillham, J.E., Kim, E.S. (2009). A meta-analytic review of the Penn Resiliency Program’s effect on depressive symptoms. Journal of Consulting and Clinical Psychology, 77(6), 1042-1054.

Cardemil, E.V., Reivich, K.J., Beevers, C.G., Seligman, M.E.P., James, J. (2007). The prevention of depressive symptoms in low-income minority children: Two-year follow-up. Behaviour Research and Therapy, 45(2), 313-327.

Cardemil, E.V., Reivich, K.J., Seligman, M.E.P. (2002). The prevention of depressive symptoms in low-income minority middle school students. Prevention and Treatment, 5, 1-31.

*Challen, A. R., Machin, S. J., and Gillham, J. E. (2014). The UK Resilience programme: A school-based universal nonrandomized pragmatic controlled trial. Journal of Consulting and Clinical Psychology, 82(1), 75-89.

Chaplin, T.M., Gillham, J.E., Reivich, K.J., Elkon, A.G.L., Samuels, B., Freres, D.R., Winder, B., and Seligman, M.E.P. (2006). Depression prevention for early adolescent girls: A pilot study of all girls versus co-ed groups. Journal of Adolescence, 16(1), 110-126.

Gillham, J.E., Reivich, K.J. (1999). Prevention of depressive symptoms in schoolchildren: A research update. Psychological Science, 10(5), 361-462.

Gillham, J.E., Reivich, K.J., Freres, D.R., Chaplin, T.M., Shatte, A.J., Samuels, B., Elkon, A.G.L., Litzinger, S., Lascher, M., Gallop, R., Seligman, M.E.P. (2007). School-based prevention of depressive symptoms: a randomized controlled study of the effectiveness and specificity of the Penn resiliency program. Journal of Consulting and Clinical Psychology, 75(1) 9-19.

Gillham, J.E., Reivich, K.J., Jaycox, L.H., Seligman, M.E.P. (1995). Prevention of depressive symptoms in schoolchildren: Two-year follow-up. Psychological Science, 6(6), 343-351.

Gillham, J. E., Reivich, K. J., Brunwasser, S. M., Freres, D. R., Chajon, N. D., Kash-Macdonald, V. M., Chaplin, T. M., Abenavoli, R. M., Matlin, S. L., Gallop, R. J., & Seligman, M. E. (2012). Evaluation of a group cognitive-behavioral depression prevention program for young adolescents: A randomized effectiveness trial. Journal of Clinical Child & Adolescent Psychology, 41(5), 621-639.

Jaycox, L.H., Reivich, K.J., Gillham, J.E., Seligman, M.E.P. (1994). Prevention of depressive symptoms in school children. Behaviour Research and Therapy, 32(8), 801-816.

*Kindt, K. C. M., Kleinjan, M., Janssens J. M. A. M., & Scholte, R. H. J. (2014). Evaluation of a School-Based Depression Prevention Program among Adolescents from Low-Income Areas: A Randomized Controlled Effectiveness Trial.International Journal of Environmental Research and Public Health, 11, 5273-5293.

Pattison, C., Lynd-Stevenson, R.M. (2001). The prevention of depressive symptoms in children: The immediate and long-term outcomes of a school-based program. Behaviour Change, 18(2), 92-102.

Quayle, D., Dziurawiec, S., Roberts, C., Kane, R., Ebsworthy, G. (2001). The effect of and optimism and lifeskills program on depressive symptoms in preadolescence. Behaviour Change, 18(4), 194-203.

Roberts, C., Kane, R., Thomson, H., Hart, B., Bishop, B. (2003). The prevention of depressive symptoms in rural school children: A randomized control trial. Journal of Consulting and Clinical Psychology, 71(3), 622-628.

Roberts, C., Kane, R., Bishop, B., Matthews, H., & Thomson, H. (2004). The prevention of depressive symptoms in rural school children: A follow-up study. International Journal of Mental Health Promotion, 6(3), 4-16.

*Wijnhoven, L. A., M., W., Creemers, D. H., M., Vermulst, A. A., Scholte, R. H. J., Engels, R. C. M. E. (2014). Randomized controlled trial testing the effectiveness of a depression prevention program ('Op Volle Kracht') among adolescent girls with elevated depressive symptoms. Journal of Abnormal Child Psychology, 42(2), 217-28.

Yu, D.L., Seligman, M.E.P. (2002). Preventing depressive symptoms in Chinese children. Prevention & Treatment, 5, Article 9, doi: 10.1037/1522-3736.5.1.59a.

Poppelaars, M., Tak, Y. R., Lichtwarck-Aschoff, A., Engels, R. C., Lobel, A., Merry, S. N., ... & Granic, I. (2016). A randomized controlled trial comparing two cognitive-behavioral programs for adolescent girls with subclinical depression: a school-based program (Op Volle Kracht) and a computerized program (SPARX). Behaviour research and therapy, 80, 33-42.

Tak, Y. R. (2017). Op Volle Kracht: Preventing depressive symptoms in adolescence: Examining cognitive risk factors and evaluating universal and indicated depression prevention(Doctoral dissertation)

Countries where evaluated
Netherlands
United Kingdom
Protective factor(s) addressed
Individual and peers: Problem solving skills
Risk factor(s) addressed
No defined risk factors
Outcomes targeted
Emotional well-being
Depression or anxiety
Other mental health outcomes
Other behaviour outcomes
Description of programme

The Penn Resiliency Program (PRP) is a group intervention that teaches cognitive behavioural and social problem-solving skills. PRP strives to teach students to think flexibly and accurately about the challenges and problems that they confront. Students learn about (a) the link between beliefs, feelings, and behaviours; (b) cognitive styles, including pessimistic explanatory styles; and (c) cognitive restructuring skills, including how to challenge negative thinking by evaluating the accuracy of beliefs and generating alternative interpretations. Students also learn a variety of techniques for coping and problem-solving, including assertiveness, negotiation, decision making, and relaxation. Students apply the cognitive and problem-solving techniques in their lives through group discussions and weekly homework assignments. PRP sessions meet after school once each week in a 90-minute session over 12 weeks.

Op Volle Kracht (OVK; On Full Power) is a Dutch adaptation that incorporates cultural and content-related modifications. It was developed to meet the need in the Netherlands for a school-based depression prevention programme for adolescents. It comprises 16 weekly 50-minute group sessions that have a cognitive-behavioural focus similar to the original program, and it targets, among other skills, cognitive biases, coping skills and social skills. The first 8 lessons are devoted to explaining and practising the CBT derived principles. Lessons 9 to 16 are directed at social and coping skills, self-esteem, problem solving, and decision-making. During every lesson, the theory behind the techniques is shortly explained followed by actively practicing the skills by students. Teaching occurs through discussions, role-plays and skits. Each lesson includes homework for the next lesson.

The programme has also been evaluated in the UK with some adaptations. It is called the UK Resiliency Programme (UKRP). It is delivered over 18 hours, with the length of each session and the gap between sessions being flexible for schools to base on their timetables. There are minor changes in examples and adaptations to programme vocabulary.

Last updated : 09.01.2024
Country of origin
USA
Last reviewed:
Age group
0-5 years
6-10 years
Target group
Children aged 4-8 years who have oppositional defiant disorder and/or ADHD
Programme setting(s)
Community
School
Level(s) of intervention
Indicated prevention
Selective prevention

The child training component is comprised of weekly two-hour sessions for 18-19 weeks during which two therapists work with 6-7 children and focus on social skills, conflict resolution, empathy-building, problem solving and cooperation. Teachers and parents receive weekly letters explaining the concepts covered and strategies to reinforce skills taught. Children are assigned homework to complete with their parents and receive weekly good behaviour-charts that parents and teachers complete. The child training prevention programme is also described in a separate write-up.

Links to this programme in other registries
USA - Blueprints Programs
The Netherlands - Databank Effectieve Jeugdinterventies
UK - CYAT - mentor-adepis
UK - Early Intervention Foundation Guidebook
Contact details

Dr. Carolyn Webster-Stratton, Ph.D
Incredible Years, University of Washington
1411 8th Avenue West
Seattle, WA 98119
USA
Phone: 1 (206) 285-7565 / 1(888) 506-3562
Email: cwebsterstratton[a]comcast.net
Website: www.incredibleyears.com

Evidence rating
Additional studies recommended
Studies overview

The programme has been evaluated in two small studies, one each in Wales, UK and Turkey, and two randomised controlled trials, one each in Ireland in Norway.

The Welsh study was a small pilot with 24 children aged 5 to 9 years. It is unclear how groups were allocated but the implementation was alongside the Incredible Years Teacher Classroom Management programme. There were no significant differences between groups on any of the measures (assessing behaviour).

Another small study was conducted in Turkey with 32 children aged 4 to 6 years. The study found effects on social problem-solving, but not on child behaviour and social competence.

The Irish study was conducted with 45 children aged 3-7 years with symptoms of ADHD. There were two intervention groups and one control group. Both intervention groups received the Incredible Years Parent Programme; one also received the child training. The difference between the combined group and control group were largely insignificant, with the exception of SDQ impact scale. Compared to the parent-only intervention group, there was a significant difference only on one outcome – hyperactivity – in favour of the parent-only group, suggesting no added benefit of the child training.

The Norwegian study used a similar design with 136 children aged 4-8 years displaying oppositional or conduct problems randomly allocated to three groups: parent-only, parent and child training combined and control group. At posttest, children in the combined parent and child training had significantly lower aggression scores (as reported by mothers, but not fathers) compared to the control. In terms of parent measures, there were significant intervention effects on all 4 mother reports (harsh discipline, inconsistent parenting, positive parentings and stress), and 2/4 father reports. There were no effects on attention problems, internalising problems or intensity. Compared to the parent-only group, the only significant difference (father reported problems) favoured the parent-only group.

References of studies

Bayrak, H. U., & Akman, B. (2018). Adaptation of the" Incredible Years Child Training Program" and Investigation of the Effectiveness of the Program. Educational Sciences: Theory & Practice, 18(2).

Beauchaine, T. P., Webster-Stratton, C., & Reid, M. J. (2005). Mediators, moderators, and predictors of one-year outcomes among children treated for early-onset conduct problems: A latent growth curve analysis. Journal of Consulting and Clinical Psychology, 73(3), 371-388.


*Drugli, M. B., & Larsson, B. (2006). Children aged 4-8 years treated with parent training and child therapy because of conduct problems: Generalizing effects to day-care and school settings. European Child and Adolescent Psychiatry, 15(7), 392-399.


*Drugli, M. B., Larsson, B., Fossum, S., & Morch, W. T. (2010). Five- to six-year outcome and its prediction for children with ODD/CD treated with parent training. The Journal of Child Psychology and Psychiatry, 51(5), 559-566.


*Hutchings, J., Bywater, T., Gridley, N., Whitaker, C., Martin-Forbes, P., & Gruffydd, S. (2012). The incredible years therapeutic social and emotional skills programme: A pilot study. School Psychology International, 33, 285-293.

*McGilloway, S., Ni Mhaille, G., Leckey, Y., Kelly, P., & Bracken, M. (n.d.)

*Larsson, B., Fossum, S., Clifford, G., Drugli, M., Handegard, B., & Morch, W. (2009). Treatment of oppositional defiant and conduct problems in young Norwegian children. European Child Adolescent Psychiatry, 18, 42-52.


Reid, M. J., Webster-Stratton, C., & Hammond, M. (2003). Follow-up of children who received the Incredible Years intervention for oppositional defiant disorder: Maintenance and prediction of 2-year outcome. Behavior Therapy, 34, 471-491.


Webster-Stratton, C., & Hammond, M. (1997). Treating children with early-onset conduct problems: A comparison of child and parent training interventions. Journal of Consulting and Clinical Psychology, 65, 93-109.


Webster-Stratton, C. H., Reid, M. J., & Beauchaine, T. (2011). Combining parent and child training for young children with ADHD. Journal of Clinical Child and Adolescent Psychology, 40(2), 191-203.


Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33(1), 105-124.


Webster-Stratton, C., Reid, M.J., & Stoolmiller, M. (2008). Preventing conduct problems and improving school readiness: An evaluation of the Incredible Years Teacher and Child Training Programme in high risk schools. Journal of Child Psychology and Psychiatry, 49(5), 471-488.

Countries where evaluated
Ireland
Norway
United Kingdom
Protective factor(s) addressed
Family: attachment to and support from parents
Family: parent involvement in learning/education
Family: parent social support
Individual and peers: Problem solving skills
Individual and peers: skills for social interaction
School and work: opportunities for prosocial involvement in education
Risk factor(s) addressed
Family: aggressive or violent parenting
Family: family management problems
Family: neglectful parenting
Individual and peers: anti-social behaviour
Individual and peers: hyperactivity
Individual and peers: other
School and work: low commitment/attachment to school/workplace
Outcomes targeted
Positive relationships
Relations with peers
Other behaviour outcomes
Description of programme

The Incredible Years Series is a comprehensive programme for parents, teachers, and children with the goal of preventing, reducing, and treating behavioural and emotional problems in children aged two to eight. There are versions for parents, teachers and children.

The last addition was the training series for children (Dina Dinosaur Curriculum), a "pull out" treatment programme for small groups of children exhibiting conduct problems. This curriculum emphasizes emotional literacy, empathy and perspective taking, friendship development, anger management, interpersonal problem-solving, following school rules, and school success.

Last updated : 09.01.2024
Country of origin
USA
Last reviewed:
Age group
0-5 years
6-10 years
11-14 years
Target group
Children aged 5-11 years
Programme setting(s)
School

The PATHS curriculum is a comprehensive programme for promoting emotional and social competencies and reducing aggression and behaviour problems in elementary school-aged children in grades K-6 (5 – 12 years of age) while simultaneously enhancing the educational process in the classroom.

The Grade Level PATHS Curriculum consists of separate volumes of lessons for each grade level from K – 6 (5-12 years of age), all of which include developmentally appropriate pictures, photographs, posters, and additional materials (www.channing-bete.com/prevention-programmes/paths/). Five conceptual domains, integrated in a hierarchical manner, are included in PATHS lessons at each grade level: self-control, emotional understanding, positive self-esteem, relationships, and interpersonal problem-solving skills. Throughout the lessons, a critical focus of PATHS involves facilitating the dynamic relationship between cognitive-affective understanding and real-life situations. PATHS is designed to be taught two to three times per week (or more often if desired, but not less than twice weekly), with daily activities to promote generalization and support on-going behaviour. PATHS lessons follow lesson objectives and provide scripts to facilitate instruction, but teachers have flexibility in adapting these for their particular classroom needs. Although each unit of PATHS focuses on one or more skill domains (e.g., emotional recognition, friendship, self-control, problem solving), aspects of all five major areas are integrated into each unit. Moreover, each unit builds hierarchically upon and synthesizes the learning which preceded it.


The PATHS curriculum is designed to be used by educators and counsellors in a multi-year, universal prevention model. To encourage parent involvement and support, parent letters, home activity assignments, and information are also provided.

Links to this programme in other registries
USA - Blueprints Programs
UK - Early Intervention Foundation Guidebook - PATHS
UK - Early Intervention Foundation Guidebook - Preschool PAHTS
Contact details

Prevention Research Centre
Penn State University, United States of America
Email: mxg47[a]psu.edu

Evidence rating
Additional studies recommended
Studies overview

The programme has been evaluated in several cluster randomised controlled trials, two in the UK - one in Northern Ireland (Ross et al., 2011) three in England (Hennessey et al., 2019, 2021; Panayiotou et al., 2020; Humphrey et al., 2015, 2016; Little et al., 2012) – one in Switzerland (Malti et al., 2011, 2012) and one in Sweden (Eninger et al., 2021). There have also been four quasi-experimental studies, one each in Turkey (Seyhan et al., 2017) and the Netherlands (Goossens et al., 2012) and two in the UK (Curtis & Norgate, 2007; Hughes & Cline, 2014).

One UK trial (Little et al., 2012) was conducted with 5397 children aged 4 to 6 years from 29 schools that were randomised to intervention and 27 schools that were randomised to control. Measures were gathered using five scales from the teacher-completed Strengths and Difficulties Questionnaire and nine scales from the PATHS Teacher Rating Survey. Results indicated that while there were some statistically significant improvements in the intervention group compared to the control group at mid-intervention, these improvements disappeared post-test and no statistically significant differences were observed between groups at immediate post-test.

In another UK trial (Humphrey et al., 2015, 2016), 4516 children aged 7 to 9 years from 45 schools, that were randomly allocated to intervention or control, participated. Of the 14 scales, there was a significant positive intervention effect on 1 measure and a significant negative intervention effect on 2 measures. There was a statistically significant increase in teachers' perceptions of change in children's social–emotional competence in the intervention group. A statistically significant effect favouring the control group was found on SDQ peer problems and SDQ emotional symptoms scales.

Hennessey et al. (2019, 2021) and Panayiotou et al. (2020) used the former sample of (45 schools with 5218 school-aged children). Academic performance was measured with a national curriculum assessment for English, Mathematics and Science. The intervention did not show more effectiveness in improving the academic attainment of children compared to the control group. The results concerning loneliness (KIDSCREEN27) revealed a significant positive effect compared to the control group. Psychological wellbeing, peer social support and school connectedness showed a small, but statistically significant improvement after the PATHS intervention at a 2-year follow-up. However, the intervention had no discernible impact on peer social support and school connectedness.

The study from Northern Ireland (Ross et al., 2011) included 1448 students, aged 4 to 10 years, from 12 primary schools that were evenly randomised to intervention or control. Students were from primary 1 and 2, and 5 and 6; some analysis was reported separately for these groups. For primary 1 and 2, there were no significant effects on teacher-reported behaviour. For primary 5 and 6, there were three significant differences between groups, two of which favoured the control group: reflectivity and perseverance. There was a positive intervention effect on negative affect. There were positive intervention effects that were significant on 4 of 11 observed teacher behaviour: positive behaviour management, supporting peer interaction, supporting mutual respect and understanding, and providing feedback on peer interactions 6 of 20 observed measures of child behaviour also indicated a significant programme effect: compliments others, mutual respect and understanding, involvement, taking turns in play, compliance with playground rules and including others (in play).

The Swiss trial (Malti et al., 2011, 2012) included 1675 first-grade students, with an average age of 7 years, from 56 schools. The trial compared PATHS to Triple P, a group parenting programme. Compared to the control group, children receiving PATHS displayed a significant reduction in aggressive behaviour (based on teacher and parent reports, but not child reports) and in ADHD symptoms (based on teacher reports only, not on parent or child reports). There were no effects on nonaggressive externalising behaviour or on social competence based on any measure. At the two-year follow-up, the effect on teacher-reported aggression and ADHD symptoms was statistically significant, but the effect on prosocial behaviour was not.

The Swedish trial (Eninger et al., 2021), comprised a sample of 285 children, aged 4-5 years from 26 schools. Children were randomly assigned to an intervention group (145 children) or a control group (140 children). The intervention resulted in significant improvements after 6 months in working memory, prosocial play and hyperactive behaviours in the intervention group compared to the control group.

One quasi-experimental study in the UK (Curtis & Norgate, 207) included 287 students, aged 5 to 7 years, from 5 intervention and 3 comparison schools. There were significant intervention effects on all 5 subscales of the SDQ. There was a significant improvement on emotional symptoms, conduct problems, hyperactivity, peer problems, and consideration, for intervention schools but not for the comparison schools. It is important to note that the levels of behavioural and emotional problems were already at a lower level in the comparison schools at pre-test.

The Dutch study (Goossens et al. 2012) included 1333 children aged 5 to 11 years from 18 kindergarten and elementary schools, half of which delivered the intervention and the other half served as control. There was a significant effect on only 1 of 27 outcome measures – emotional awareness - immediately after the intervention.

A quasi-experimental (Hughes & Cline, 2014) evaluated of the Preschool version was conducted in the UK with 57 children, aged 3 to 4 years, from 3 different preschools. One school delivered the full version, while one school delivered an adapted (shortened) version and the third school did not deliver PATHS. There was a significant interaction effect: the full PATHS group significantly improved their receptive emotion vocabulary from pre to post test, while the other groups did not. There was no effect on affective perspective taking skills, or parental measure of behaviour (SDQ). There were significant interaction effects on 6/7 scales of the teacher-reported SDQ: children in the full PATHS version improved significantly while the other two groups did not.

The Turkish study (Seyhan et al., 2017) also evaluated the Preschool version and included 565 children aged 4 to 6 years from 41 classrooms in 4 preschools. There were significant intervention effects on teacher-reported children’s social and emotional skills reflecting interpersonal relationships and emotion regulation, and observed quality of classroom environment. The effect on observed behaviours and management techniques of teachers was not significant. In terms of student-teacher relationship, as reported by teachers, there was no effect on conflict or closeness, but there was a significant effect on dependency. Teachers in intervention group reported significantly more dependency in their relationships with children. Children in the intervention group described their relationships as significantly more positively than did children in the comparison group.

References of studies

Curtis, C., & Norgate, R. (2007). An evaluation of the Promoting Alternative Thinking Strategies curriculum at key stage 1. Educational Psychology in Practice, 23, 33-44.

Goossens, F., Gooren, E., Orobio de Castro, B., Van Overveld, K., Buijs, G., Monshouwer, K., ... & Paulussen, T. (2012). Implementation of PATHS through Dutch municipal health services: A quasi-experiment. International Journal of Conflict and Violence, 6(2), 234-248.

Hughes, C. & Cline, T. (2015). An evaluation of the preschool PATHS curriculum on the development of preschool children. Educational Psychology in Practice
31(1), 73-85.

Humphrey, N., Barlow, A., Wigelsworth, M., Lendrum, A., Pert, K., Joyce, C., ... & Calam, R. (2016). A cluster randomized controlled trial of the Promoting Alternative Thinking Strategies (PATHS) curriculum. Journal of school psychology, 58, 73-89.

Little, M., Berry, V., Morpeth, L., Blower, S., Axford, N., Taylor, R., Bywater, T., Lehtonen, M., & Tobin, K. (2012). The impact of three evidence-based programmes delivered in public systems in Birmingham, UK. International Journal of Conflict and Violence, 6(2), 260–272.

Malti, T., Ribeaud, D., & Eisner, M. P. (2011). The effectiveness of two universal preventive interventions in reducing children’s externalizing behavior: A cluster randomized controlled trial. Journal of Clinical Child & Adolescent Psychology, 40(5), 677-692.


Ross, S. M., Sheard, M. K., Cheung, A., Elliott, L., & Slavin, R. (2011). Promoting primary pupils’ social-emotional learning and pro-social behaviour: longitudinal evaluation of the Together 4 All Programme in Northern Ireland. Effective Education, 3(2), 61-81.      

Seyhan, G. B., Karabay, S. O., Tuncdemir, T. B. A., Greenberg, M., & Domitrovich, C. (2017). The Effects of Promoting Alternative Thinking Strategies Preschool Program on Teacher-Children Relationships and Childern’s Social Competence in Turkey.”. International Journal of Psychology.

Hennessey, A., & Humphrey, N. (2019). Can social and emotional learning improve children’s academic progress? Findings from a randomised controlled trial of the Promoting Alternative Thinking Strategies (PATHS) curriculum. European Journal of Psychology of Education, 35(4), 751-774.

Eninger, L., Ferrer-Wreder, L., Eichas, K., Olsson, T. M., Hau, H. G., Allodi, M. W., ... & Herkner, B. (2021). A cluster randomized trial of Promoting Alternative Thinking Strategies (PATHS®) with Swedish preschool children. Frontiers in Psychology, 2866.

Papers not included in the rating process

Referring to the same trial (Hennessey et al., 2019, Humphrey et al., 2016 or Malti et al., 2011)

Hennessey, A., Qualter, P., & Humphrey, N. (2021). The Impact of Promoting Alternative Thinking Strategies (PATHS) on Loneliness in Primary School Children: Results From a Randomized Controlled Trial in England. In Frontiers in Education (p. 510). Frontiers.          

Panayiotou, M., Humphrey, N., & Hennessey, A. (2020). Implementation matters: Using complier average causal effect estimation to determine the impact of the Promoting Alternative Thinking Strategies (PATHS) curriculum on children’s quality of life. Journal of Educational Psychology, 112(2), 236.

Humphrey, N., Barlow, A., Wigelsworth, M., Lendrum, A., Pert, K., Joyce, C., ... & Calam, R. (2015). Promoting Alternative Thinking Strategies (PATHS): Evaluation Report and Executive Summary. Education Endowment Foundation.

Malti, T., Ribeaud, D., & Eisner, M. (2012). Effectiveness of a universal school-based social competence programme: The role of child characteristics and economic factors. International Journal of Conflict and Violence, 6, 249-259.

From non-EU studies

Conduct Problems Prevention Research Group. (2010). The effects of a multiyear universal social-emotional learning programme: The role of student and school characteristics. Journal of Consulting and Continuing Psychology, 78(2), 156-168.


Conduct Problems Prevention Group (Karen Bierman, John Coie, Kenneth Dodge, Mark Greenburg, John Lochman, Robert McMahon, and Ellen Pinderhughes). (1999). Initial Impact of the Fast Track prevention trial for conduct problems: I. The high-risk sample. Journal of Consulting and Clinical Psychology, 67, 631-647.


Crean, H.F., & Johnson, D.B. (2013). Promoting Alternative Thinking Strategies (PATHS) and elementary school aged children's aggression: results from a cluster randomized trial. American Journal of Community Psychology, 52, 56-72.

Greenberg, M. T., & Kusche, C. A. (1998). Preventive intervention for school-aged deaf children: The PATHS Curriculum. Journal of Deaf Studies and Deaf Education, 3, 49-63.


Greenberg, M. T., Kusche, C. A., Cook, E. T., & Quamma, J. P. (1995). Promoting emotional competence in school-aged children: The effects of the PATHS curriculum. Development and Psychopathology, 7, 117-136.

Kam, C., Greenberg, M. T., & Kusché, C. A. (2004). Sustained effects of the PATHS curriculum on the social and psychological adjustment of children in special education. Journal of Emotional and Behavioral Disorders, 12, 66-78. 


Kam, C., Greenberg, M. T., & Walls, C. T. (2003). Examining the role of implementation quality in school-based prevention using PATHS Curriculum. Prevention Science, 4, 55-63.

Schonfeld, D. J., Adams, R. E., Fredstrom, B. K., Weissberg, R. P., Gilman, R., Voyce, C., Tomlin, R., & Speese-Linehan, D. (2014). Cluster-randomized trial demonstrating impact on academic achievement of elementary social-emotional learning. School Psychology Quarterly, advance online publication. 


Seifer, R., Gouley, K., Miller, A.L., & Zabriski, A. (2004). Implementation of the PATHS curriculum in an urban elementary school.” Early Education & Development, 15(4), 471-486.

Riggs, N. R., Greenberg, M. T., Kusché, C. A., & Pentz, M. A. (2006). The meditational role of neurocognition in the behavioral outcomes of a social-emotional prevention programme in elementary school students: Effects of the PATHS curriculum. Prevention Science, 7, 91-102.

Countries where evaluated
Netherlands
Switzerland
United Kingdom
Protective factor(s) addressed
Individual and peers: clear morals and standards of behaviour
Individual and peers: individual/peers other
Individual and peers: interaction with prosocial peers
Individual and peers: opportunities and rewards for prosocial peers involvement
Individual and peers: Problem solving skills
Individual and peers: skills for social interaction
School and work: commitment and attachment to school
School and work: opportunities for prosocial involvement in education
School and work: rewards and disincentives in school
Risk factor(s) addressed
Family: parental attitudes favourable to anti-social behaviour
Individual and peers: anti-social behaviour
Individual and peers: favourable attitudes towards anti-social behaviour
Individual and peers: other
School and work: low commitment/attachment to school/workplace
School and work: other
Outcomes targeted
Emotional well-being
Depression or anxiety
Emotion regulation, coping, resilience
Other behaviour outcomes
Description of programme

The PATHS curriculum is a comprehensive programme for promoting emotional and social competencies and reducing aggression and behaviour problems in elementary school-aged children in grades K-6 (5-11 years of age) while simultaneously enhancing the educational process in the classroom.


PATHS is available by grade level in the following grades: Kindergarten (5 years of age), Grade 1 (6 years of age), Grade 2 (7 years of age), Grade 3 (8 years of age), Grade 4 (9 years of age), and Grade 5/6 (10-12 years of age). The original multi-year version is also available from the publisher. The grade level versions maintain all key elements of the original version and now organize them more discretely by grade levels.

PATHS targets five major conceptual domains: (1) self-control; (2) emotional understanding; (3) positive self-esteem; (4) relationships; and (5) interpersonal problem solving skills. In addition, a 30-lesson non-mandatory supplementary unit reviews and extends PATHS concepts that are covered in other units.


The PATHS curriculum is designed for use by regular classroom teachers who are trained by Educational Psychologists. Lessons are sequenced according to increasing developmental difficulty and designed for implementation in approximately 20-30 minutes 2 to 3 times per week. The curriculum provides detailed lesson plans, exact scripts, suggested guidelines, and general and specific objectives for each lesson. However, the curriculum has considerable flexibility so that it can also be integrated with an individual teacher's style. Lessons include such activities as dialoguing, role-playing, story-telling by teachers and peers, social and self-reinforcement, attribution training, and verbal mediation. Learning is promoted in a multi-method manner through the combined use of visual, verbal, and kinaesthetic modalities.

Implementation Experiences
Feedback date
Contact details

The certified trainers can be found on the following website: www.pathseducation.com

Two trainers from Croatia are also available:
Josipa Mihić, PhD,
josipa.mihic[a]erf.hr

and Miranda Novak, PhD,
miranda.novak[a]erf.hr

Main obstacles

With respect to individual professionals

The PATHS programme is delivered by teachers and the level of motivation of some teachers that were involved was rather weak. The reason for that was that the schools were randomly selected to participate in the study.

With respect to social context

The legislation was a big problem since it was hard for teachers to find time to deliver two PATHS lessons per week in their curriculum. Although we had formal support from the Ministry of Science, it was not possible to get special time for the programme’s delivery during the school day. Also, once the project was over, the policymakers did not ensure the sustainability of the programme.

With respect to organisational and economic context

We had no financial problems in delivering the programme, since it was financed through the project. However, once the project was over, the Ministry of Science did not provide financial support for the programme to continue. We see that as a huge obstacle for the delivery of this programme.

How they overcame the obstacles

With respect to individual professionals

During the programme implementation we organised regular meetings with all the teachers delivering the programme to try to motivate them and give them more support in delivering the programme.

With respect to social context

School principals suggested that teachers should deliver the programme within time that was scheduled for leisure and art activities.

With respect to organisational and economic context

In the region of Istra, the local authorities have decided to finance the continuation of the programme.

Lessons learnt

With respect to individual professionals

In the phase of testing the programme’s effectiveness, it might be better to start with motivated teachers. We have also learnt that in order to deliver a comprehensive social-emotional learning (SEL) curriculum, a lot of effort should be invested in preparing teachers and developing their socio-emotional skills. The training course for teachers should, therefore, be longer, and teachers should have regular meetings with programme supervisors.

With respect to social context

We would make a stronger request to the Ministry of Science to assign special time for the programme’s delivery during the school day.

With respect to organisational and economic context

From the ethical perspective, we believe that we should try to test and offer more affordable/free prevention programmes, since our policymakers and key people are not ready to invest any money into the prevention programme’s delivery on a national level. Also, we have learnt that we should offer the programme to local communities willing to invest some funds into prevention.

Strengths

A great collaboration with scientists from abroad and a motivated group of professionals in Croatia; formal support from the Ministry of Science; financial support from an EU fund.

Weaknesses

Not all teachers were motivated to participate (the school principals made that decision for them); the initiative for this programme came from the scientific community, and policymakers were not aware of the importance of prevention.

Opportunities

A great number of teachers were interested in participating, and smaller local communities were ready to finance the continuation of the programme.

Threats

Policymakers and key people were only slightly interested, and did not have sufficient knowledge of effective school prevention measures.

Recommendations

With respect to individual professionals

We would suggest offering this programme to motivated teachers and providing them with enough support during the programme delivery, and working with school principals and making them understand the importance of implementing effective prevention programmes.

With respect to social context

Invest in advocating for prevention and increasing key people’s knowledge of effective prevention programmes.

With respect to organisational and economic context

Assure the financial support needed for the delivery of the programme. Once the teachers are trained, you will need money for programme materials and programme licences (a significant cost).

Note from the authors

Implemented in Istria region, cities of Zagreb and Rijeka from 2009

Number of implementations
1
Country
Croatia
Last updated : 09.01.2024
Country of origin
USA
Last reviewed:
Age group
0-5 years
6-10 years
11-14 years
Target group
Teachers of children aged 3-8 years
Programme setting(s)
School
Level(s) of intervention
Selective prevention
Universal prevention

The Incredible Years Teacher Programme emphasizes effective classroom management skills such as: the effective use of teacher attention, praise and encouragement, use of incentives for difficult behaviour problems, proactive teaching strategies, how to manage inappropriate classroom behaviours, the importance of building positive relationships with students, and how to teach empathy, social skills and problem-solving in the classroom. Teachers receive 4-6 days of training spread out over several months.

Links to this programme in other registries
USA - Blueprints Programs
The Netherlands - Databank Effectieve Jeugdinterventies
UK - CYAT - mentor-adepis
UK - Early Intervention Foundation Guidebook
Contact details

Ms. Lisa St. George
Incredible Years
USA
Email: lisastgeorge[a]comcast.net
Website: www.incredibleyears.com

Evidence rating
Possibly beneficial
Studies overview

The programme has been evaluated in three cluster randomised controlled trials, one each in Ireland, England (UK) and Wales (UK), as well as three quasi-experimental studies, one in Wales (UK) and two in Norway.

In the Welsh trial, 107 students, aged approximately 5 years, from 11 primary schools that were randomised to intervention or control groups. From each class, 9 students were selected representing the three highest, lowest and middle scores on teacher-rated behaviour. At the classroom level, only one of eight measures of teacher and classroom behaviour observational measures showed a statistically significant positive intervention effect: classroom off-task behaviour. At the child level, 5 of 8 measures showed a significant intervention effect: child compliance to commands, child negatives to the teacher, teacher negatives, teacher commands and child off-task behaviour.

In the Irish study, twenty teachers from 11 schools were randomly assigned to intervention of control. 12 students from each classroom four highest scoring, four lowest scoring, and the four middle-scoring on teacher-rated behaviour problems were included, resulting in a sample of 234 children after parental consent and drop-out due to absent for baseline assessments. At post-test, there was a significant effect on 1/8 measures of child behaviour: Intervention group children showed significant improvements in emotional symptoms (self-regulation and cooperation skills), compared to control group children. At post-intervention, there was a significant intervention effect on teacher behaviours: observed incidence of teacher negatives, observed opportunity provided for child to comply and self-reported frequency of use of appropriate and inappropriate strategies. There was no effect on observed teacher positives, observed teacher praise, observed indirect and direct commands.

In the UK trial, 80 schools were randomised, resulting in 3113 students aged 4 to 9 years participating. The primary outcome was teacher-reported SDQ total difficulties score. The intervention group showed a significant improvement compared to the control at posttest based on partially-adjusted analysis, but this did not persist at 18 or 30 months. When total difficulties was analysed as a binary variable (struggling range), there was a significant intervention effect across the follow-up points. The difference between groups was not significant when fully-adjusted analysis was conducted. 2 of 7 other secondary measures showed the same pattern with effects significant at posttest but not sustained: peer relationships and pro-social subscales. 2 secondary measures showed effects across the follow-ups: overactivity subscale and pupil behaviour questionnaire.

one Norwegian study, the programme was implemented with 829 students aged 6 to 8 years in 21 schools and compared with 22 schools matched on geographical location and school size. There were significant positive intervention effects on 7 of 10 teacher-reported measures of student behaviour: problem behaviour, behaviour intensity, total problems, attention problems, cooperation, self-control and social skills total. There was no significant effect on aggression, assertion and academic performance.

In the second Norwegian study, 1049 students aged 3 to 6 years from 46 intervention and 46 control kindergartens participated. There were significant effects on all 6 child behaviour measures: behaviour problem, intensity, internalising behaviour, aggression, attention and total problem.

In another Welsh study, 10 teachers trained in the programme and 11 teachers not trained from 3 primary schools participated. Teacher and child behaviour was measured using the Teacher-Pupil Observation Tool. There were effects on 2 teacher and 2 child outcomes: teacher direct commands and teacher opportunity, and child non-complaint behaviour, positive behaviour. There were no effects on teacher negatives, positives, praise or indirect commands and child compliance or negative behaviour.

References of studies

Aasheim, M., Reedtz, C., Handegård, B. H., Martinussen, M., & Mørch, W. T. (2018). Evaluation of the Incredible Years Teacher Classroom Management Program in a Regular Norwegian School Setting. Scandinavian Journal of Educational Research, 1-14.

Baker-Henningham, H. Scott, S., Jones, K., & Walker, S. (2012). Reducing child conduct problems and promoting social skills in a middle-income country: cluster randomised controlled trial. The British Journal of Psychiatry, 1-8. doi: 10.1192/bjp.bp.111.096834.


Carlson, J. J., Tiret, H. B., Bender, S. L., & Benson, L. (2011). The influence of group training in the Incredible Years Teacher Classroom Management Programme on preschool teachers' classroom management strategies. Journal of Applied School Psychology, 27, 134-154.


*Davenport, J., & Tansey, A. (2009). Outcomes of Incredible Years classroom management training with multiple schools. Article submitted for publication.


Ford, T., Hayes, R., Byford, S., Edwards, V., Fletcher, M., Logan, S., ... & Ganguli, P. (2018). The effectiveness and cost-effectiveness of the Incredible Years® Teacher Classroom Management programme in primary school children: results of the STARS cluster randomised controlled trial. Psychological medicine, 1-15.

Fossum, S., Handegård, B. H., & Drugli, M. B. (2017). The Incredible Years teacher classroom management programme in kindergartens: Effects of a universal preventive effort. Journal of Child and Family Studies, 26(8), 2215-2223.

*Hutchings, J., Daley, D., Jones, K., Martin, P., Bywater, T., & Gwyn, R. (2007). Early results from developing and researching the Webster-Stratton Incredible Years Teacher Classroom Management Training Programme in North West Wales. Journal of Children's Services, 2, 15-26.


*Hutchings, J., Martin-Forbes, P., Daley, D., & Williams, M.E. (2013). A randomized controlled trial of the impact of a teacher classroom management programme on the classroom behavior of children with and without behavior problems. Journal of School Psychology, 51, 571-585.


Hsueh, J., Lowenstein, A. E., Morris, P., Mattera, S. K., & Bangser, M. (2014). Impacts of social-emotional curricula on three-year-olds: Exploratory findings from the Head Start CARES demonstration. Report from the Office of Planning, Research, and Evaluation, U.S. Department of Health and Human Services.
OPRE Report, 78.

Kirkhaug, B., Drugli, M. B., Handegård, B. H., Lydersen, S., Åsheim, M., & Fossum, S. (2016). Does the Incredible Years Teacher Classroom Management Training programme have positive effects for young children exhibiting severe externalizing problems in school?: a quasi-experimental pre-post study. BMC psychiatry, 16(1), 362.

Mattera, S., Lloyd, C. M., Fishman, M., & Bangser, M. (2013). A First Look at the Head Start CARES Demonstration: Large-Scale Implementation of Programmes to Improve Children’s Social-Emotional Competence. OPRE Report, 47. Washington, DC:

*McGilloway, S., Hyland, L., Ni Mhaille, G., Lodge, A., O’Neill, D., Kelly, P., & Donnelly, M. (2010). Positive classrooms, positive children: A randomised controlled trial to investigate the effectiveness of the incredible years teacher classroom management programme in an Irish context (short-term outcomes). Dublin: Archways.

Morris, P., Mattera, S. K., Castells, N., Bangser, M., Bierman, K., & Raver, C. (2014). Impact Findings from the Head Start CARES Demonstration: National Evaluation of Three Approaches to Improving Preschoolers' Social and Emotional Competence. Executive Summary. OPRE Report 2014-44. MDRC.

Raver, C. C., Jones, S. M., Li-Grining, C. P., Metzger, M., Smallwood, K., & Sardin, L. (2008). Improving preschool classroom processes: Preliminary findings from a randomized trial implemented in Head Start settings. Early Childhood Research Quarterly, 23, 10-26.


Reid, M .J., Webster-Stratton, C., & Hammond, M. (2003). Follow-up of children who received the Incredible Years intervention for oppositional defiant disorder: Maintenance and prediction of 2-year outcomes. Behavior Therapy, 34, 471-491.


Webster-Stratton, C., Reid, M. J., & Hammond, M. (2001). Preventing conduct problems, promoting social competence: A parent and teacher training partnership in Head Start. Journal of Clinical Child Psychology, 30(3), 283-302.


Webster-Stratton, C., Reid, M. J., & Hammond, M. (2004). Treating children with early-onset conduct problems: intervention outcomes for parent, child, and teacher training. Journal of Clinical Child and Adolescent Psychology, 33(1), 105-124.


Williford, A. P., and Shelton, T. L. (2008). Using mental health consultation to decrease disruptive behaviors in preschoolers: adapting an empirically-supported intervention. Journal of Child Psychology and Psychiatry, 49, 191-200.

Countries where evaluated
United Kingdom
Ireland
Protective factor(s) addressed
Family: parent involvement in learning/education
Individual and peers: Problem solving skills
Individual and peers: skills for social interaction
School and work: opportunities for prosocial involvement in education
School and work: rewards and disincentives in school
Risk factor(s) addressed
School and work: other
Outcomes targeted
Emotional well-being
Emotion regulation, coping, resilience
Positive relationships
Relations with parents
Relations with peers
Other behaviour outcomes
Description of programme

The Incredible Years Series is a comprehensive programme for parents, teachers, and children with the goal of preventing, reducing, and treating behavioural and emotional problems in children ages two to eight.

The Incredible Years Teacher Programme emphasizes effective classroom management skills such as: the effective use of teacher attention, praise and encouragement, use of incentives for difficult behaviour problems, proactive teaching strategies, how to manage inappropriate classroom behaviours, the importance of building positive relationships with students, and how to teach empathy, social skills and problem-solving in the classroom. Teachers receive 4-6 days of training spread out over several months.

Implementation Experiences
Feedback date
Main obstacles

With respect to individual professionals

The main obstacle was getting schools to release teachers and fund supply cover.

With respect to social context

Some teachers believe that they are unique individuals with their own style.

With respect to organisational and economic context

The main obstacle was getting funding for supply cover for teachers to attend training.

How they overcame the obstacles

With respect to individual professionals

We publicised the benefits and results from our research trials.

With respect to social context

We agreed that we have our own styles but that there are common principles of effective classroom management.

With respect to organisational and economic context

We were able to get some grant funding from the local authority towards supply costs and some individual teacher grants.

Lessons learnt

With respect to individual professionals

Sometimes people were initially reluctant but the programme sold itself.

With respect to social context

Use pilot schools to allow visits to discuss the programme.

With respect to organisational and economic context

Sufficient time is needed to plan the programme. Understanding the challenges facing schools on the funding front is important so that they can be discussed and explored.

Strengths

A clear teacher classroom management curriculum based on social learning theory; great supporting resources; substantial evidence from research trials; and excellent classroom activities.

Weaknesses

Mainly the cost and the logistics of setting up the training — five full days, one day per month.

Opportunities

It provides support for schools that have poor performance reports.

Threats

There are other programmes without similar levels of evidence.

Recommendations

With respect to individual professionals

Start by establishing your own goals.

With respect to social context

Work with the school head teacher.

With respect to organisational and economic context

Work with system bosses, regional collaborators and local and national government officials. Describe how the programme improves the chances of low-achieving disadvantaged children.

Number of implementations
1
Country
United Kingdom
Feedback date
Contact details

Service provider

Dr Sean McDonnell
Deputy CEO and Research and Training Manager
Archways
smcdonnell[a]archways.ie

Lead Research Collaborator/Principal Investigator, National Evaluation of Incredible Years in Ireland

Professor Sinéad McGilloway
Centre for Mental Health and Community Research
Department of Psychology
Maynooth University, Ireland
Sinead.McGilloway[a]mu.ie

Main obstacles

With respect to individual professionals

Initially, there was some suspicion regarding evidence-based manualised programmes, particularly those produced by international developers. Among many professional bodies, the Incredible Years (IY) programmes (including the teacher classroom management (TCM) programme) were seen as faddish, not culturally appropriate and unlikely to gain purchase in an Irish context. There was also a general feeling that these programmes were a money-making enterprise with overly rigid protocols regarding adherence and fidelity that consequently did not allow the professionals to bring their own learning, skills and experience in to play.

Furthermore, many of the professionals felt that (a) the programmes were too universal in terms of their focus and, therefore, would not address the needs of children experiencing the most difficult conditions (specifically extreme externalising behaviours), and (b) to implement such programmes would present them with additional responsibilities and tasks when they were already operating within an environment characterised by long working hours and poor pay.

With respect to social context

As stated previously, we began our implementation carefully, as there was a cultural bias against the introduction of non-Irish programmes. Teacher training programmes were not considered to be popular or to be a social norm, and it was clearly the case that those who most required the intervention were the least likely to access and gain from the programme. However, attitudes slowly began to change as implementation continued and the research findings began to emerge.

Economically, we were initially delivering the IY TCM programme at a time of some prosperity, but this changed drastically in subsequent years, and we therefore had to change our implementation process to some extent. The programme was seen, in some cases, as a luxury that schools could not afford, and there was no governmental impetus for change.

With respect to organisational and economic context

Economically, we began our implementation at a time when the country was extremely strong, and so, initially, there were few economic challenges. However, as indicated earlier, this changed rapidly when the recession in Ireland took hold from around 2009 onwards. Budgets were cut across the country and community-based organisations were closed. Those that remained took a reductive approach, focusing only on the explicit terms and objectives of their funders. Both urban and rural poverty grew, although school budgets in deprived areas were retained to some degree because of their ‘disadvantaged’ status, so our access to schools was not as seriously affected as we had anticipated.

While the ‘politics’ involved in the economic crash were tumultuous and the government cutbacks drastic, the nature of the problems we were seeking to address did not fundamentally change: every child can experience difficulty, every teacher has one or more children in their class who may prove troublesome, and every parent can experience difficulties managing their child. This is not to say that economic factors are not important — the fewer risk factors there are and the more protective factors and inputs that are available, the easier a problem may be to address.

How they overcame the obstacles

With respect to individual professionals

We initially piloted and evaluated the programmes on a small scale in schools with which we already had established relationships. We provided free training and supervision to those introducing the IY TCM programme and in all cases made the link between the skill sets of the teachers and the benefits that these would bring to the programme itself. We also sought to develop advocates in each pilot site who would speak to others about the benefits of the programme for their colleagues and relevant professional bodies.

The programmes were promoted on the basis of the positive skills and abilities that they would bring to professional practice in order to produce positive outcomes for children and teachers. For example, we indicated the potential of the programme for improving academic performance in schools, making teaching easier and generating better home-school collaboration. We highlighted the universal application, but also the fact that more difficult behaviours could be addressed, making interactions and engagement more positive for the children and teachers, as well as for the parents, while also allowing the teachers to develop skills that would help to promote such positive changes — in line with social learning theory. The research findings from our initial research were promising, and this then provided a foundation to begin more extensive implementation and more rigorous evaluation. In schools, we took a holistic approach and so initially, for example, we provided teacher substitution costs. However, as the programme began to bed down and the (generally positive) findings emerged from the larger evaluation (McGilloway et al.), the need to meet these costs diminished.

With respect to social context

Our network of advocates and champions was hugely instrumental in helping us to overcome these obstacles. We also provided ongoing supervision to all teachers and schools that were implementing the TCM programme. In addition, the outcomes from the national evaluation, led by Professor Sinéad McGilloway, proved to be invaluable in convincing teachers and schools to begin or to continue their delivery of the programme.

Last, the growing emphasis on evidence-based practice meant that any programmes that were found to be both clinically effective and cost-effective, were strongly supported by the government and, therefore, were more likely to be funded and implemented.

With respect to organisational and economic context

Actually, the financial crisis both hindered and helped. Obviously, budget cuts to organisations meant that they had less flexibility in terms of introducing or championing new services. At the same time, however, the budgetary cuts meant that the Irish Government began to focus more attention and resources on evidence-informed and evidence-based practices and programmes, and we were deliberately targeting more needy, disadvantaged populations. Our philanthropic funder (the then Atlantic Philanthropies) also helped to drive this agenda.

Lessons learnt

With respect to individual professionals

  • The need to match the TCM programme to existing needs in relevant areas (e.g. in areas of high disadvantage).
  • The need to be aware of teacher sensitivities.
  • The importance of providing information that clearly outlined the benefits not only for the children, but also for the professionals/teachers that were introducing the programme.
  • The importance of evaluating the programme and keeping teachers, schools and relevant professional and organisational bodies informed of the mid-point and post-programme outcomes.
  • The need to provide support and ongoing coaching for those delivering the programme.
  • The importance of identifying advocates for the programme within community-based organisations and using these as a means of accessing schools and teachers (as well as other relevant organisations).
  • Most importantly, it is crucial to work collaboratively with teachers and schools, to be honest and to dispel the inevitable myths and fears around the implementation of any new programme in schools that already have their own cultures and ethos.

With respect to social context

  • The buy-in is crucial — the message must be positive, and, most importantly, it requires time to properly implement a programme.
  • Ongoing support and coaching, and being a visual presence on the ground were all crucial.
  • Identify and engage actively with advocates for the programme (e.g. teachers, school principals, representatives of community-based organisations that are seeking to address issues of social disadvantage).
  • Adopt a holistic approach to both the problem and those charged with changing and challenging the problem.
  • Ensure that the research is conducted sensitively, to take account of, for example, social issues such as disadvantage.

With respect to organisational and economic context

  • The need to adapt creatively to the economic and organisational context — to prepare for change and recognise the limitations.
  • The importance of challenging yourself and not making sweeping generalisations.
  • Deal with each school and individual teachers as they come.
  • Always focus on the universality of the problems to be tackled.
  • Recognise that sometimes an economic crisis creates opportunities and that problems continue to exist regardless of the fluidity and robustness of the economy.
  • Acknowledge that we, as organisations, must invest in the implementation process to a greater extent at some times than others, which is fine, as long as we do not create a precedent in the longer term or create learnt helplessness in communities and individuals.
  • Become self-sustaining as an organisation.
Strengths

Highly skilled and engaged staff; staff with relevant backgrounds and experience in teaching, psychology counselling and social care; good networks at both local and national levels; research and evaluation; funding and philanthropic support; strong organisational leadership; and strong community development experience.

Weaknesses

Over-reliance on the initial investment; time-specific philanthropic support; lack of preparation for reduced funding; challenges in dealing with programme developers; economic factors slowed us down.

Opportunities

Bedding down and scaling up; further development; tackling different populations; well-being in schools, which is now a major issue in the UK and Ireland; increasing government support.

Threats

Competing programmes; potential bombardment of teachers; reaching saturation in terms of programme distribution; financial sustainability as an organisation supporting programme implementation.

Recommendations

With respect to individual professionals

  • Work collaboratively with teachers, schools and community-based organisations.
  • Pilot the programme first.
  • Start with those schools with which you already have an established relationship.
  • Provide initial workshops so that teachers know what is required and can see the benefits.
  • Provide training and ongoing support.
  • Evaluate the programme and provide ongoing feedback and do not fear making mid-point corrections in terms of implementation.
  • Identify advocates for the programmes in specific areas and relevant teacher support organisations.
  • Be patient — successful implementation can take two years or more.

With respect to social context

  • Start delivering the programme based on emerging or present needs.
  • Be sure that the programme meets these needs — do not overstate its value.
  • Recognise and state clearly that no evidence-based programme is a silver bullet that will meet the needs of all children and especially those living in disadvantaged areas.
  • Problems that are ‘long in the making’ are ‘long in the shifting’ — successful implementation takes time, so expect this.
  • Accept that those who most require these programmes may not always benefit from them due to the many other social factors that come into play. Changing behaviour can be difficult and these programmes are often the beginning of a long (but hopefully productive) journey.

With respect to organisational and economic context

  • The proof of implementation success for an organisation working in this space is that they may not be needed in the longer term — accept this!
  • Always place your programmes into the organisations that are best placed to implement the programme on a sustainable mainstream basis. For example, the TCM programme is now delivered exclusively by the government-funded National Educational Psychology Services.
  • Economically, the best defence against financial crisis is to invest in those programmes that are proven to work, so it is crucially important to evaluate, evaluate, evaluate!
  • Remember to always build into your evaluation process an effective dissemination strategy that will make financial sense and reach the key funding bodies in your area (e.g. government, third sector or philanthropic sources).
  • Expect financial downturns and plan accordingly.
Note from the authors

The implementation experiences regarding The Incredible Years suite of parent, teacher and child programmes. We have introduced the programme in 10 of our 26 counties and regions since 2007 onwards.

Number of implementations
1
Country
Ireland
Last updated : 18.06.2024
Country of origin
Norway
Last reviewed:
Age group
6-10 years
11-14 years
Target group
Children aged 10-14
Programme setting(s)
School
Level(s) of intervention
Selective prevention

The Olweus Bullying Prevention programme is a school-wide programme designed to prevent bullying amongst children aged 10-14. It includes administering a bullying survey, establishing a Bullying Prevention Coordinating Committee and addressing bullying incidents through separate follow-up meetings for bullies and victims. The classroom level component involves establishing clear and consistently enforced rules against bullying, along with regular class discussions and activities designed to reinforce rules and anti-bullying values and norms. Discussions and activities also present the harm caused by bullying and strategies for preventing it. The programme encourages parental involvement through meetings and discussion of the problem and efforts to address it.

Links to this programme in other registries
USA - Blueprints Programs
Germany - Grüne Liste Prävention
Norway - Ungsinn
Contact details

Ms. Lydia Arneson
OBP Programme Coordinator
Clemson University
2038 Barre Hall
Clemson, SC 29634
USA
Phone: 1 (864) 656-6712
Email: lydia[a]clemson.edu / nobully[a]clemson.edu
Website: www.clemson.edu/olweus

Evidence rating
Likely to be beneficial
Studies overview

The programme has been evaluated in two quasi-experimental studies in Norway and one quasi-experimental study in England, UK.

The original Norwegian study used comparisons of adjacent age-cohorts, with 2500 students in Grades 4 to 7 from 42 schools. There were reductions in self-reported bullying, antisocial behaviours (theft, vandalism and truancy) and self-reported victimisation, improved school climate, as well as teacher and peer reports of bully-victim problems. The outcomes were found in the first follow-up (8 months after baseline) as well as the second follow-up (20 months after baseline).

The second Norwegian study was conducted in grades 7 to 9 in 6 schools. The study evaluated the effects on substance use behaviours and did not include bullying measures. There were significant effects on 3 of 9 measures. There were significant differences between groups in levels of cannabis use, smoking, and drunkenness between groups, with levels much higher among control group.

The English study was also conducted with adjacent age-cohorts. of 6,758 students, aged 8 to 16 years, from 24 schools participated. Although for most measures, changes were better in treatment schools than in comparison schools, the study only showed a significant intervention effect on frequency of bullying.

References of studies

*Amundsen, E. J., & Ravndal, E. (2010). Does successful school-based prevention of bullying influence substance use among 13- to 16-year-olds? Drugs: education, prevention and policy, 17(1), 42-54.

Bauer, N.S., Lozano, P., & Rivara, F.P. (2007). The effectiveness of the Olweus Bullying Prevention Programme in public middle schools: A controlled trial. Journal of Adolescent Health, 40, 266-274.

Bowllan, N. M. (2011). Implementation and evaluation of a comprehensive, school-wide bullying prevention programme in an urban/suburban middle school. Journal of School Health, 81(4), 167-173.

*Eslea, M. (1998). The long-term effectiveness of anti-bullying work in primary schools. Educational Research, 40, 203-218.


Limber, S. P., Olweus, D., Massiello, M., Molnar-Main, S., & Moore, D. (2012). Evaluation of the Olweus Bullying Prevention Programme in a large scale study in Pennsylvania. Unpublished.

Melton, G.B., Limber, S.P., Cunningham, P., Osgood, D.W., Chambers, J., Flerx, V., Henggeler, S., & Nation, M. (1998). Violence among rural youth. Final report to the Office of Juvenile Justice and Delinquency Prevention. Washington, DC: Office of Juvenile Justice and Delinquency Prevention.


*O'Moore, A.M., & Minton, S.J. (2005). Evaluation of the effectiveness of an anti-bullying programme in primary schools. Aggressive Behavior, 31, 609-622.

* Olweus, D. (2005). New positive results with the Olweus Bullying Prevention Programme in 37 Oslo schools. Report. Bergen, Norway: Research Centre for Health Promotion, University of Bergen.

*Olweus, D. (1993). Bullying at school: What we know and what we can do. Oxford, England: Blackwell.

*Olweus, D. (1992). Bullying among school children: Intervention and prevention. In R.D. Peters, R.J. McMahon, & V.L. Quinsey (eds.), Aggression and violence throughout the life span (pp.100-125). Newbury Park, CA: Sage Publications.

*Olweus, D., & Alsaker, F.D. (1991). Assessing change in a cohort-longitudinal study with hierarchical data. In D. Magnusson, L.R. Bergman, G. Rudinger, & B. Torestad (Eds.), Problems and methods in longitudinal research: Stability and change (pp. 107-132). New York, NY: Cambridge University Press.

*Olweus, D. (1987). Schoolyard bullying-grounds for intervention. School Safety, 4, 4-14.

Pepler, D.J., Craig, W.M., Ziegler, S., & Charach, A. (1994). An evaluation of an anti-bullying intervention in Toronto schools. Canadian Journal of Community, 13, 95-110.


Schroeder, B. A., Messina, A., Schroeder, D., Good, K., Barto, S., Saylor, J., Masiello, M. (2011). The implementation of a statewide bullying prevention programme: Preliminary findings from the field and the importance of coalitions. Health Promotion Practice, 13(4), 489-495.

*Smith, P.K. (1997). Bullying in schools: The UK experience and the Sheffield anti-bullying project. The Irish Journal of Psychology, 18, 191-201.

*Whitney, I., & Smith, P.K. (1993). A survey of the nature and extent of bullying in junior/middle and secondary schools. Education Research, 35, 3-25.


*Whitney, I., Rivers, I., Smith, P.K., & Sharp, S. (1994). The Sheffield Project: Methodology and findings. In P.K. Smith and S. Sharp (eds.), School bullying: Insights and perspectives (pp. 20-56). London, England: Routledge.


Countries where evaluated
Ireland
Norway
United Kingdom
Protective factor(s) addressed
Community: opportunities and rewards for prosocial involvement in the community (including religiosity)
Family: parent involvement in learning/education
Individual and peers: clear morals and standards of behaviour
Individual and peers: individual/peers other
Individual and peers: interaction with prosocial peers
Individual and peers: opportunities and rewards for prosocial peers involvement
Individual and peers: Problem solving skills
Individual and peers: refusal skills and decision making
Individual and peers: skills for social interaction
School and work: opportunities for prosocial involvement in education
Risk factor(s) addressed
No defined risk factors
Outcomes targeted
Education
Academic performance
Positive relationships
Relations with peers
Substance-related behaviours
Bullying
Crime
Other behaviour outcomes
Description of programme

The Olweus Bullying Prevention Programme targets the problem of bullying at three levels: the school, the classroom and the individual. Designed for elementary and middle schools, the programme addresses the problem of bullying with multiple strategies at each level. At the school level, students are given an anonymous questionnaire (25-45 minutes long) to assess the nature and prevalence of bullying at the school. The survey is administered in spring of the school year prior to programme implementation. Secondly, the school administration convenes a conference day, during which programme consultants and school staff discuss findings from the student questionnaire, familiarize themselves with the programme and its effects (through discussions with programme consultants, handbooks and videos), form a Bullying Prevention Coordinating Committee, and plan for programme implementation. The coordinating committee includes representatives from all constituencies involved with the school, i.e. administration, teachers, counsellors, health professionals, parents and students. The school level component also involves increased adult supervision of school areas that are frequently the setting for bullying, i.e., the playground, cafeteria and restrooms.

The classroom level component involves establishing clear and consistently enforced rules against bullying, along with regular class discussions and activities designed to reinforce rules and anti-bullying values and norms. Discussions and activities also present the harm caused by bullying and strategies for preventing it. The programme encourages parental involvement through meetings and discussion of the problem and efforts to address it.

Individual level components include interventions with bullies, victims and their parents. Interventions are designed to ensure the cessation of the bullying behaviour and to provide support to victims.

Last updated : 09.01.2024
Country of origin
USA
Last reviewed:
Age group
11-14 years
15-18/19 years
Target group
Young offenders aged 12-17 years
Programme setting(s)
Community
Family
Juvenile justice setting
Level(s) of intervention
Targeted intervention

Multisystemic Therapy® (MST®) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behaviour in juvenile offenders. The MST programme seeks to improve the real-world functioning of young people by changing their natural settings — home, school and neighbourhood — in ways that promote prosocial behaviour while decreasing antisocial behaviour. Therapists work with young people and their families to address the known causes of delinquency on an individualised yet comprehensive basis. By using the strengths in each system (family, peers, school and neighbourhood) to facilitate change, MST addresses the multiple factors known to be related to delinquency across the key systems within which young people are embedded. The extent of treatment varies by family according to clinical need. Therapists generally spend more time with families in the initial weeks (meeting daily if necessary) and gradually reduce the frequency of their meetings (to as infrequently as once a week) over the three- to five-month course of treatment.

Keywords
No data
Links to this programme in other registries
USA - Blueprints Programs
Norway - NUBU
Norway - Ungsinn
The Netherlands - Databank Effectieve Jeugdinterventies
UK - Early Intervention Foundation Guidebook
Contact details

Mr Marshall Swenson
MST Services
Email: marshall.swenson[a]mstservices.com
Website: www.mstservices.com or www.mstinstitute.org

Evidence rating
Possibly beneficial
Studies overview

The programme has been evaluated in four randomised controlled trials, one each in Norway, Sweden, the UK and the Netherlands.

In Sweden, 156 young people aged 12-17 with a clinical diagnosis of conduct disorder using the DSM-IV-TR were randomly allocated to either receive MST or to continue with treatment as usual. No significant differences between groups was found at post-test or month follow-up  – indicating no effects on child behaviour, social skills, delinquency, alcohol or drug use.

In Norway, 105 young people aged 12-17 years referred for problem behaviour such as law-breaking or other anti-social acts, serious academic difficulties, dysfunctional interpersonal relationships, verbal aggression and threats of hurting others were randomly allocated to MST or regular services. At posttest, there a marginally significant positive intervention effect on internalising and externalisaling behaviour, social competence and family cohesion, but not of family functioning.

In the Netherlands, 256 young people aged 12-18 years displaying severe and violent antisocial behaviour were randomly allocated to MST or usual service. At post-test and six-month post intervention, intervention group adolescents improved significantly more compared to the control group on parent and self-reported externalizing, parent-reported oppositional defiant and conduct disorder, and self-reported property offences. The There were no significant differences in groups in frequency or number of arrests two years after the program ended.   effect on self-reported violence was not significant.

In the UK, 108 young people aged 13-17 years on a court referral order for treatment, supervision, or following imprisonment were randomized into MST or Youth Offending Teams control group. The number of offenses between the two study groups did not differ at post-test, and 6-month follow-up but became significant (p<.001) at the 12-month follow-up assessment. There was a significant difference between groups, favouring MST, on the measure of six-month period of no offences, although the effects at different assessments points is not disentangled. Sub-group analyses showed this was significant for non-violent offences, and not for violent offences. Out of 21 tests for secondary outcome measures, 5 (24%) were significant, including aggression and delinquency.

I a quasi-experimental study in the Netherlands (Eeren et al., 2018), 697 adolescents with an average age of 15 years, were allocated to either the FFT intervention or the MST intervention according to the Risk-Need-Responsivity model. The FFT intervention is thereby seen as the control group. In this aspect, results of the comparison showed no significant differences between outcomes. Only the engagement in school or work after the treatment was higher in the group who completed MST.

References of studies

Outcome evaluations/results:

Asscher, J. J., Deković, M., Manders, W. A., van der Laan, P. H., Prins, P. J.M., van Arum, S., & Dutch MST Cost-Effectiveness Study Group. (2014). Sustainability of the effects of multisystemic therapy for juvenile delinquents in The Netherlands: effects on delinquency and recidivism. Journal of Experimental Criminology, 10(2), 227-243.

Asscher, J. J., Deković, M., Manders, W. A., Van der Laan, P. H., Prins, P. J. M., & Dutch MST Cost- Effectiveness Research Group (2012). A randomized clinical trial of Multisystemic Therapy in The Netherlands. Journal of Experimental Criminology. doi: 10.1007/s11292-012-9165-9.

Butler, S., Baruch, G., Hickey, N., & Fonagy, P. (2011). A randomized controlled trial of Multisystemic Therapy and a statutory therapeutic intervention for young offenders. Journal of the American Academy of Child and Adolescent Psychiatry, 50(12), 1220-1235.

Löfholm, C., Olsson, T., Sundell, K., & Hansson, K. (2009). Multisystemic therapy with conduct-disordered young people: stability of treatment outcomes two years after treatment. Evidence & Policy, 4, 373-397.

Ogden, T., Hagen, K. A., & Andersen, O. (2007). Sustainability of the effectiveness of a programme of multisystemic treatment (MST) across participant groups in the second year of operation. Journal of Children’s Services, 2, 4-14.

Sundell, K., Hansson, K., Löfholm, C., Olsson, T., Gustle, L-H., & Kadesjö, C. (2008). The transportability of Multisystemic Therapy to Sweden: Short-Term Results From a Randomized Trial of Conduct-Disordered Youths. Journal of Family Psychology, 22, 550-560.

 

Concept papers/other:

*Asscher, J. J., Deković, M., Van der Laan, P. H., Prins, P. J. M. and van Arum, S. (2007), ‘Implementing randomized experiments in criminal justice settings: an evaluation of multi-systemic therapy in the Netherlands’, Journal of Experimental Criminology 3, pp. 113–129.

* Asscher, J. J., Dekovic, M., Manders, W. A., van der Laan, P. H. and Prins, P. J. M. (2013), ‘A randomized controlled trial of the effectiveness of multisystemic therapy in the Netherlands: post-treatment changes and moderator effects’, Journal of Experimental Criminology 9, pp. 169 187.

Borduin, C. M., Henggeler, S. W., Blaske, D. M. and Stain, R. J. (1990), ‘Multisystemic treatment of adolescent sexual offenders’, International Journal of Offender Therapy and Comparative Criminology 35, pp. 105-114.

Borduin, C. M., Mann, B. J., Cone, L. T., Henggeler, S. W., Fucci, B. R., Blaske, D. M. and Williams, R. A. (1995), ‘Multisystemic treatment of serious juvenile offenders: long-term prevention of criminality and violence’, Journal of Consulting and Clinical Psychology 63, pp. 569-578.


Borduin, C. M., Schaeffer, C. M. and Heiblum, N. (2009), ‘A randomized clinical trial of Multisystemic Therapy with juvenile sexual offenders: effects on youth social ecology and criminal activity’, Journal of Consulting and Clinical Psychology 77, pp. 26-37.


Brown, T. L., Henggeler, S. W., Schoenwald, S. K., Brondino, M. J. and Pickrel, S. G. (1999), ‘Multisystemic treatment of substance abusing and dependent juvenile delinquents: effects on school attendance at posttreatment and 6-month follow-up’, Children’s Services: Social Policy, Research, and Practice 2, pp. 81-93.


Camp, G. M. and Camp, C. G. (1993), The Corrections Yearbook, Criminal Justice Institute, South Salem, NY.


Dekovic, M., Asscher, J. J., Manders, W. A., Prins, P. J. M. and van der Laan, P. (2012), ‘Within-intervention change: mediators of intervention effects during Multisystemic Therapy’, Journal of Consulting and Clinical Psychology 80, pp. 574-587.

Eeren, H. V., Goossens, L., Scholte, R. H., Busschbach, J. J., & Van der Rijken, R. E. (2018). Multisystemic therapy and functional family therapy compared on their effectiveness using the propensity score method. Journal of Abnormal Child Psychology, 46(5), 1037-1050.

Fain, T., Greathouse, S. M., Turner, S. F. and Weinberg, H. D. (2014), ‘Effectiveness of Multisystemic Therapy for minority youth: outcomes over 8 years in Los Angeles County’, Journal of Juvenile Justice 3, pp. 24-37. 


Henggeler, S. W., Rodick, J. D., Borduin, C. M., Hanson, C. L., Watson, S. M. and Urey, J. R. (1986), ‘Multisystemic treatment of juvenile offenders: effects on adolescent behavior and family interaction’, Developmental Psychology 22, pp. 132-141.


Henggeler, S. W., Borduin, C. M., Melton, G. B., Mann, B. J., Smith, L. A., Hall, J. A., Cone, L., et al. (1991), ‘Effects of multisystemic therapy on drug use and abuse in serious juvenile offenders: a progress report from two outcome studies’, Family Dynamics of Addiction Quarterly 1, pp. 40-51. 


Henggeler, S. W., Melton, G. B. and Smith, L. A. (1992), ‘Family preservation using multisystemic therapy: an effective alternative to incarcerating serious juvenile offenders’, Journal of Consulting and Clinical Psychology 6, pp. 953-961.


Henggeler, S. W., Melton, G. B., Smith, L. A., Schoenwald, S. K. and Hanley, J. H. (1993), ‘Family preservation using multisystemic treatment: long-term followup to a clinical trial with serious juvenile offenders’, Journal of Child and Family Studies 2, pp. 283-293.

Henggeler, S. W., Melton, G. B., Brondino, M. J., Scherer, D. G. and Hanley, J. H. (1997), ‘Multisystemic Therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination’, Journal of Consulting and Clinical Psychology 65, pp. 821-833.


Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D. and Cunningham, P. B. (1998), Multisystemic treatment of antisocial behavior in children and adolescents, The Guilford Press, New York.


Henggeler, S. W., Pickrel, S. G. and Brondino, M. J. (1999), ‘Multisystemic treatment of substance-abusing and dependent delinquents: outcomes, treatment fidelity, and transportability’, Mental Health Services Research 1, pp. 171-184.


Henggeler, S. W., Clingempeel, W. G., Brondino, M. J. and Pickrel, S. G. (2002), ‘Four-year follow-up of Multisystemic Therapy with substance-abusing and substance-dependent juvenile offenders’, Journal of the American Academy of Child and Adolescent Psychiatry 41, pp. 868-874.


Henggeler, S. W., Letourneau, E. J., Chapman, J. E., Borduin, C. M., Schewe, P. A. and McCart, M. R. (2009), ‘Mediators of change for multisystemic therapy with juvenile sexual offenders’, Journal of Consulting and Clinical Psychology 77, pp. 451-462.


Henggeler, S. W., Schoenwald, S. K., Borduin, C. M., Rowland, M. D. and Cunningham, P. B. (2009), Multisystemic therapy for antisocial behavior in children and adolescents (2nd edn), The Guilford Press, New York.


Huey, S. J., Henggeler, S. W., Brondino, M. J. and Pickrel, S. G. (2000), ‘Mechanisms of change in multisystemic therapy: reducing delinquent behavior through therapist adherence and improved family and peer functioning’, Journal of Consulting and Clinical Psychology 68, pp. 451 467.

Leschied, A. and Cunningham, A. (2002), Seeking effective interventions for serious young offenders: interim results of a four-year randomized study of multisystemic therapy in Ontario, Canada, Centre for Children and Families in the Justice System, Canada.


Letourneau, E. J., Henggeler, S. W., Borduin, C. M., Schewe, P. A., McCart, M. R., Chapman, J. E. and Saldana, L. (2009), ‘Multisystemic Therapy for juvenile sexual offenders: 1-year results from a randomized effectiveness trial’, Journal of Family Psychology 23, pp. 89-102.


Ogden, T. and Halliday-Boykins, C. A. (2004), ‘Multisystemic treatment of antisocial adolescents in Norway: replication of clinical outcomes outside of the US’, Child and Adolelscent Mental Health 9, pp. 77-83.


Ogden, T. and Hagen, K. A. (2006), ‘Multisystemic Therapy of serious behaviour problems in youth: sustainability of therapy effectiveness two years after intake’, Journal of Child and Adolescent Mental Health 11, pp. 142-149.


Ogden, T. and Hagen, K. A. (2009), ‘What works for whom? Gender differences in intake characteristics and treatment outcomes following Multisystemic Therapy’, Journal of Adolescence 32, pp. 1425-1435.


Sawyer, A. M and Borduin, C. M. (2011), ‘Effects of Multisystemic Therapy through midlife: a 21.9-year follow-up to a randomized clinical trial with serious and violent juvenile offenders’, Journal of Consulting and Clinical Psychology 79, pp. 643–652.


Schaeffer, C. M. and Borduin, C. M. (2005), ‘Long-term follow-up to a randomized clinical trial of Multisystemic Therapy with serious and violent juvenile offenders’, Journal of Consulting and Clinical Psychology 73, pp. 445-453.


Schoenwald, S. K., Ward, D. M., Henggeler, S. W., Pickrel, S. G. and Patel, H. (1996), ‘Multisystemic Therapy treatment of substance abusing or dependent adolescent offenders: costs of reducing incarceration, inpatient, and residential placement’, Journal of Child and Family Studies 5, pp. 431-444.


Timmons-Mitchell, J., Bender, M., Kishna, M. A. and Mitchell, C. (2006), ‘An independent effectiveness trial of Multisystemic Therapy with juvenile justice youth’, Journal of Clinical Child and Adolescent Psychology 35, pp. 227-236.


Wagner, D. V., Borduin, C. M., Sawyer, A. M. and Dopp, A R. (2014), ‘Long-term prevention of criminality in siblings of serious and violent juvenile offenders: a 25-year follow-up to a randomized clinical trial of multisystemic therapy’, Journal of Consulting and Clinical Psychology 82, pp. 492-499.


Weiss, B., Han, S., Harris, V., Catron, T., Ngo, V. K., Caron, A., Gallop, R. et al. (2013), ‘An independent randomized clinical trial of Multisystemic Therapy with non-court-referred adolescents with serious conduct problems’, Journal of Consulting and Clinical Psychology 81, pp. 1027-1039.

Countries where evaluated
Netherlands
Norway
Sweden
United Kingdom
Protective factor(s) addressed
Community: opportunities and rewards for prosocial involvement in the community (including religiosity)
Family: attachment to and support from parents
Family: opportunities/rewards for prosocial involvement with parents
Family: parent involvement in learning/education
Family: parent social support
Individual and peers: clear morals and standards of behaviour
Individual and peers: interaction with prosocial peers
Individual and peers: opportunities and rewards for prosocial peers involvement
Individual and peers: Problem solving skills
Individual and peers: skills for social interaction
School and work: commitment and attachment to school
School and work: opportunities for prosocial involvement in education
School and work: rewards and disincentives in school
Risk factor(s) addressed
Community: community disorganisation (crime, drugs, graffiti, abandoned buildings etc)
Community: laws and norms favourable to substance use and antisocial behaviour
Community: low neighbourhood attachment
Family: aggressive or violent parenting
Family: family conflict
Family: family management problems
Family: neglectful parenting
Family: parental attitudes favourable to alcohol/drug use
Family: parental attitudes favourable to anti-social behaviour
Family: parental depression or mental health difficulties
Individual and peers: anti-social behaviour
Individual and peers: early initiation of drug/alcohol use
Individual and peers: interaction with antisocial peers
Individual and peers: peers alcohol/drug use
Individual and peers: rebelliousness and alienation
School and work: low commitment/attachment to school/workplace
Outcomes targeted
Depression or anxiety
Other mental health outcomes
Relations with parents
Relations with peers
Alcohol use
Use of illicit drugs
Crime
Other behaviour outcomes
Violence
Description of programme

Multisystemic Therapy® (MST®) is an intensive family- and community-based treatment that addresses the multiple causes of serious antisocial behaviour across key settings, or systems, within which young people are embedded (family, peers, school and neighbourhood). Because MST emphasises promoting behavioural change in the young person’s natural environment, the programme aims to empower parents with the skills and resources needed to independently address the inevitable difficulties that arise in raising teenagers, and to empower young people to cope with the problems they encounter in the family, peer, school, and neighbourhood domains.

In the context of support and skill building, the therapist places developmentally appropriate demands on adolescents and their families to reduce problem behaviour. Initial therapy sessions identify the strengths and weaknesses of the adolescent, the family and their transactions with extrafamilial systems (e.g. peers, friends, school, parental workplace). Problems identified both by family members and by the therapist are explicitly targeted for change by using the strengths in each system to facilitate such change. Treatment approaches are derived from well-validated strategies such as strategic family therapy, structural family therapy, behavioural parental training and cognitive behavioural therapy.

While MST focuses on addressing the known causes of delinquency on an individualised yet comprehensive basis, several types of interventions are typically identified for serious juvenile offenders and their families. At the family level, MST interventions aim to remove barriers to effective parenting (e.g. parental substance abuse, parental psychopathology, low social support, high stress and marital conflict), to enhance parenting competencies, and to promote affection and communication among family members. Interventions might include introducing systematic monitoring, reward and discipline systems; prompting parents to communicate effectively with each other about adolescent problems; problem solving for day-to-day conflicts; and developing social support networks. At the peer level, interventions are frequently designed to decrease affiliation with delinquent and drug-using peers and to increase affiliation with prosocial peers. Interventions in the school domain may focus on establishing positive lines of communication between parents and teachers, ensuring parental monitoring of the adolescent’s school performance and restructuring after-school hours to support academic efforts. Individual-level interventions generally involve using cognitive behavioural therapy to modify the individual’s social perspective-taking skills, belief system or motivational system, and encouraging the adolescent to deal assertively with negative peer pressure.

A master’s level therapist, with a caseload of four to six families, provides most mental health services and coordinates access to other important services (e.g. medical, educational and recreational). While the therapist is available to the family 24 hours a day, 7 days a week, the direct contact hours per family vary according to clinical need. Generally, the therapist spends more time with the family in the initial weeks of the programme (meeting daily if necessary) and gradually reduces the frequency of their meetings (to as infrequently as once a week) during a three- to five-month course of treatment.

Treatment fidelity is maintained by weekly group supervision meetings involving three to four therapists and a doctoral level or advanced master’s level clinical supervisor. The group reviews the goals of and progress in each case to ensure the multisystemic focus of the therapists’ intervention strategies, identify barriers to success and facilitate the attainment of treatment goals. In addition, an MST expert consultant reviews each case with the team weekly to promote treatment fidelity and favourable clinical outcomes.

The design and implementation of MST interventions are based on the following nine core principles of MST. An extensive description of these principles, with examples that illustrate the translation of these principles into specific intervention strategies, is provided in comprehensive clinical volumes (Henggeler et al., 1998; 2009).

  • The primary purpose of assessment is to understand the ‘fit’ between the identified problems and their broader systemic context.
  • Therapeutic contacts emphasise the positive and use systemic strengths as levers for change.
  • Interventions are designed to promote responsible behaviour and decrease irresponsible behaviour among family members.
  • Interventions are present-focused and action-oriented, targeting specific and well-defined problems.
  • Interventions target sequences of behaviour within and between multiple systems that maintain the identified problems.
  • Interventions are developmentally appropriate and fit the developmental needs of the young person.
  • Interventions are designed to require daily or weekly effort by family members.
  • Intervention effectiveness is evaluated continuously from multiple perspectives, with providers assuming accountability for overcoming barriers to successful outcomes.
  • Interventions are designed to promote treatment generalisation and long-term maintenance of therapeutic change by empowering caregivers to address family members’ needs across multiple systemic contexts.

Intervention variation

The study was a randomised controlled trial with participants randomly allocated either to receive multisystemic therapy (MST) or to continue with treatment as usual. Randomisation was computer-generated at a ratio of 50:50 and with sites used as a blocking variable. Over 12 months, from March 2004, young people aged 12-17 were referred to the study and screened for a clinical diagnosis of conduct disorder using the DSM-IV-TR.

A total of 256 juveniles who were referred for MST between 2006 and 2010 participated in the study. The study took place in three MST institutions in the Netherlands. Adolescents were referred by primary healthcare workers (GPs) or child social workers in 39 % of cases. Of the adolescents, 51 % were referred for treatment as a result of a court order and 11 % were self-referred. Immediately after referral, participants were randomised using a computerised randomisation programme. This programme was executed separately for each site. The randomisation ratio was adjusted in a 1:2 ratio in favour of MST for a 6-month period, due to a low number of referrals.

The programme allocated 147 young people to the intervention group and 109 to the control group. Participants in the control group received an alternative treatment that would have been offered had MST not been available. Mostly, these services included individual treatment (individual counselling or supervision by a probation officer or case manager, 21 %) and family-based interventions (family therapy, parent counselling, parent groups or home-based social services, 53 %). Of this group 7 % received a combination of care (e.g. individual treatment and family counselling) and 4 % were placed in a juvenile detention facility. For various reasons such as moving house or repeated failure to attend treatment sessions, 14 % received no treatment in the end.

Implementation Experiences
Feedback date
Contact details

Terje Ogden
terje.ogden[a]nubu.no
 

Main obstacles

With respect to individual professionals

Some practitioners opposed the manual-driven approach, stating that it was a threat to professional autonomy and to the principle of freedom of method choice. At the clinical level, the lack of specific, explicit therapeutic skills also turned out to be a challenge. Weekly group supervision and consultation in MST, and feedback from families on the therapists’ treatment adherence were collected on a regular basis. But, to our knowledge, no trainees dropped out of training because of these requirements, and the therapists gradually adapted to the skills-oriented approach and the increased transparency of the therapy process.

With respect to social context

The MST and MST/CM programmes were not immediately accepted by the Norwegian public and practitioners. Adolescents with behavioural and substance abuse problems were placed out of home on a regular basis. Moreover, a common objection was that ‘MST may have worked in the United States, but it won’t work here.’ No matter how many studies proved that evidence-based programmes worked in the United States, it was not assumed that the same results would be achieved in Norway. Norway previously had a strong tradition of incarcerating drug-abusing and criminal youth or transferring them to treatment institutions or homes. Home-based treatment of this target group was quite difficult to grasp for the public, politicians and professionals.

In RCTs, treatment-as-usual (TAU) groups in the United States are often exposed to risk factors that are both more severe and more numerous than those in Norway. The prevalence of stressors such as neighbourhoods with high rates of crime and substance abuse is more common in the United States. Moreover, the regular services to which MST was compared in Norway were likely to be more comprehensive and to have more elements of treatment than the regular services offered to comparison groups in previous MST trials in North America. In the United States, ‘regular services’ often consist of probation office visits and referral to social services when deemed necessary. In Norway, they involve a wide array of social services and mental health treatment, including placement in institutions and in-home services.

With respect to organisational and economic context

The new programme challenged the traditional strategy of placing children and youth out of home in institutions or foster homes for longer periods of time. When children and, to a greater extent, youth are treated within their family and local environment, the result can be increased pressure on their social networks, including families, schools and neighbourhoods.

Some local agency leaders were not prepared for the new demands that were put on them and their agencies to establish practical routines for recruiting and training, as well as to support the evidence-based practices of MST. There are still great variations in how much leaders of local agencies and regional services have adapted their leadership style to the needs and demands of MST. Some still claim that it would be better to incarcerate the young offenders. This is as much a policy discussion as a discussion about ‘what works’ for children who act out, and we expect this to be a part of the continuing discussion about ‘punishment or treatment’ in Norwegian society. Efforts to treat drug abuse in family-based treatment programmes such as MST and MST/CM were particularly challenging. There were several challenges and controversies in the process of implementing the evidence-based programmes, particularly in the initial phases. Critics claimed that the ‘relation’ was more important than the ‘evidence’ and that the practitioners had to be more important than the programmes.

How they overcame the obstacles

With respect to individual professionals

In addition, to ensure that they had pragmatic appeal, the interventions were robust enough to adapt to contextual and cultural variations. Norwegian MST therapists and supervisors reported few problems in engaging ethnic minorities in treatment, stating that the highly contextual nature of the model helped to make it possible to adapt the treatment to each family’s cultural needs.

The introduction of the new programme was considered by some to be an implicit critique of regular practice, and the implementation team had to engage in several information and negotiation activities. No systematic strategy was applied in this process, and several ad hoc countermeasures were used, such as information meetings, emails, phone calls and distribution of written information such as journal articles, newspaper articles, etc.

With respect to social context

The power of the RCT replication studies nonetheless influenced attitudes towards MST and MST/CM in Norway, and both are now part of regular practice in Norway.

With respect to organisational and economic context

The RCT replication studies made an important contribution to establishing the credibility of the programmes. MST and MST/CM developed in North America seemed to work equally well in Norway. The programmes were initially implemented with no major modification of the original model. Few adaptations were called for in order to make the programmes work in the Norwegian context, and the programmes’ ability to match the individual families’ needs and situations were indicated by the low number of dropouts from treatment, encouraging youth outcomes and positive user evaluations. ‘Core components’ were defined by both the developers and the Norwegian change agents as those with the strongest empirical underpinnings in controlled trials. They appeared to work equally well in Norway and the United States.

An large amount of MST training material has been translated, but it could not be translated back and forth in a rigorous way without totally altering the clinical meaning of the texts. Therefore, English sentences had to be rewritten to make sense in Norwegian. It was considered clinically important that the translation be done by the staff members at the Department for Adolescents, who were all bilingual and specialists in clinical psychology.

To a very small extent, the local services had to transfer funding from existing resources. Long-term financial support from the ministries through the Norwegian Centre for Child Behavioural Development (NCCBD) has been crucial for the sustainability of the fidelity of the programmes and to handle turnover of therapists.

Lessons learnt

With respect to individual professionals

The turning point for many of the therapists happened when the parents receiving PMTO (Parent Management Training — Oregon mode) and MST expressed their satisfaction with the positive changes in their families and in their children’s behaviour. Moreover, the objections and resistance did not reduce the number of practitioners volunteering to learn and practise the programmes.

With respect to social context

The experiences from Norway could serve as a model and inspiration for large-scale implementation of MST in other nations. It is possible to have clear standards for training and evaluation of competence that ensure implementation fidelity and support local efforts.

With respect to organisational and economic context

Federal funding of training and technical support, combined with allowing agency employees to volunteer to participate, is a promising strategy. Moreover, research should be an integrated part of the implementation of MST.

Among the factors that may have contributed to the long-term sustainability and effectiveness of MST in Norway, the following seem to be most important: (1) a genuine interest in and commitment to the national implementation of evidence-based practices at the political and administrative levels, (2) increased interest in evidence-based practices among practitioners, (3) establishing a self-sustaining national centre for implementation and research, (4) the ability of the programme developers to support the implementation and research efforts, and (5) positive evaluations from families and positive media feedback.

Strengths

Home-based treatment, a national centre for training, quality assurance and research, long-term funding, support at the policy level and from the public.

Weaknesses

Expensive, not in accordance with the theoretical orientation of most practitioners in the field (who are eclectic or psychodynamically oriented), competition from non-evidence-based interventions, including treatment institutions and group homes.

Opportunities

Increased capacity and competence in the treatment of serious behavioural problems, including crime and drug abuse; early interventions for adolescents at risk of entering a drug abuse trajectory; and empowering parents, families and networks.

Recommendations

With respect to organisational and economic context

Implement several evidence-based programmes, for instance MST, functional family therapy and Treatment Foster Care Oregon, so that there are opportunities to choose from among them.

Note from the authors

Multisystemic Therapy (MST) & MST/ Contingency Management (CM)   

Number of implementations
1
Country
Norway
Last updated : 02.12.2024
Country of origin
USA
Last reviewed:
Age group
11-14 years
Target group
Young people aged 12-14 years and their families
Programme setting(s)
Community
Family
Level(s) of intervention
Selective prevention
Universal prevention

Strengthening Families 10-14 is a seven-session programme for families with young adolescents that aims to strengthen family protection and resilience-building processes and reduce family risk related to adolescent substance abuse and other problem behaviours. The weekly two-hour sessions include separate parent and child skills-building followed by a family session where parents and children practise the skills they have learned independently, work on conflict resolution and communication, and engage in activities to increase family cohesiveness and positive involvement of the child in the family.

Parents are taught how to clarify expectations based on child development norms relating to adolescent substance use, how to use appropriate disciplinary practices, how to manage strong emotions regarding their children and how to communicate effectively. Children are taught refusal skills to help them deal with peer pressure and other skills for personal and social interaction. These sessions are led by three-person teams and include an average of eight families per session.

Keywords
No data
Links to this programme in other registries
USA - Blueprints Programs
UK - CAYT - mentor-adepis
UK - Early Intervention Foundation Guidebook
Germany - Green List Prevention
Poland - Programy Rekomendowane
Spain - Prevención basada en la Evidencia
Contact details

Dr Cathy Hockaday, PhD
Iowa State University
1087 Lebaron Hall
Ames, IA 50011-4380
United States of America
Phone: 1 (515) 294-7601
E-mail: hockaday[a]iastate.edu
Website: www.extension.iastate.edu/sfp

Show link
0
Evidence rating
Unlikely to be beneficial
Studies overview

The Strengthening Families Programme was developed by Karol Kumpfer for children ages 6-11 in the 1990s and is known as the Utah version. Since that time the Utah Strengthening Families Program has been modified for younger children (ages 3-5) and young teens (ages 13-17). Researchers at Iowa State University collaborated to adapt and study SFP for families with early adolescence (SFP for Parents and Youth 10-14), which is known as the Iowa version or SFP 10-14.

The SFP 10-14 version has been evaluated in several randomised controlled trials (RCTs) in Europe in, respectively, Germany (Baldus et al., 2016; Bröning et al., 2017), Poland (Foxcroft et al., 2017), the UK (Moore, 2009; Segrott et al., 2022) and Sweden (Skärstrand et al., 2014; Jalling et al., 2016). Quasi-experimental evaluations were conducted in the UK (Coombes et al., 2012) and Spain (Ballester et al., 2020; Orte et al., 2015). Moreover, the program is cited by one of the developers (Kumpfer et al., 2018) to be implemented in Italy, the Netherlands, Norway, Slovenia, Austria and France.

In the German RCT (Baldus et al., 2016; Bröning et al., 2017), families with a young person aged 12-13 years were eligible to participate. The programme had a booster session 4-6 months later, and assessments were conducted at post-test, six months (i.e. after the booster) and 18 months after the post-test. The primary outcomes were self-reported lifetime tobacco, alcohol and cannabis use at 18 months. Parents and young people also reported behavioural problems. Only the outcome of lower lifetime tobacco use among the SFP 10-14 group compared to the control group was significant. A secondary analysis in this very small sample and relatively young sample indicates that high-risk groups in the SFP-D condition achieved the best results compared with all other groups, especially in mental health and quality of life.

In the Polish RCT (Foxcroft et al., 2017), communities were randomised and families with children aged 10-14 could participate. The primary outcomes were self-reported alcohol, cigarette and other drug use, alcohol use without parent permission, drunkenness and binge drinking in the past 30 days at 12 months and 24 months after baseline. There were no effects on primary outcomes, parenting skills, parent-child relations or child problem behaviour. Foxcroft et al. (2017) state that their null findings may be due to the 24-month follow-up being insufficient to detect positive effects, selection bias resulting from four communities not being randomised to study conditions, a high level of attrition and the fact that one-third of subjects were aged 13-14.

The Swedish cluster RCT study (Skärstrand et al., 2014) involved children aged approximately 12 years and the programme included additional material on alcohol and drugs. It conducted three yearly assessments i.e. mid-programme, post-test and a one-year follow-up. There was no statistically significant effect at any time point on any measure of self-reported smoking, alcohol or drug use. The evaluators contend that the failure to replicate the positive effects found in USA based studies could be due to failure to implement the program with sufficient fidelity, cultural differences or significant alterations to the content of the SFP 10-14.

In the other Swedish RCT (Jalling et al., 2016), at-risk young people aged 12-18 years (indicated by one delinquent behaviour, bullying, repeated conflicts regarding family rules, use of alcohol, tobacco or drugs, or excessive computer use) were randomised to ParentSteps (described as the Swedish shortened version of the Strengthening Families Program 10–14 although it only involves parent sessions), Comet (a programme aiming to help parents develop parenting skills) or a control group. No effects were found for parent-reported problem child behaviour or adolescent-reported anti-social behaviour, delinquency, alcohol or drug use or psychosocial functioning.

The English study (Moore, 2009) involved children aged 10-14 years. Segrott and colleagues (2022) evaluated this adapted UK version (SFP10-14UK, with seven weekly sessions) which brought together families who identified as likely or not likely to experience or present with challenges within a group setting. This pragmatic cluster-randomised controlled effectiveness trial, with families as the unit of randomization (n=715) measured occasions young people reported drinking alcohol in the last 30 days; drunkenness during the same period, and alcohol/tobacco/substance behaviours (age of initiation, frequency, related problems). No statistically significant differences between the two study conditions were observed at the 24-month follow-up on either of the two primary outcomes (previous 30-day alcohol use and having been drunk in the previous 30 days) (Segrott et al., 2022). The authors highlight the importance of evaluating interventions when they are adapted for new settings.

The programme has been rated as Promising by Blueprints for Healthy Youth Development based on a review of studies conducted world-wide.

References of studies

Studies Included in the Assessment Process:

Jalling, C., Bodin, M., Romelsjö, A., Källmén, H., Durbeej, N., & Tengström, A. (2016). Parent programs for reducing adolescent’s antisocial behavior and substance use: a randomized controlled trial. Journal of child and family studies, 25(3), 811-826.

Foxcroft, D. R., Callen, H., Davies, E. L., & Okulicz-Kozaryn, K. (2017). Effectiveness of the Strengthening Families Programme 10-14 in Poland: Cluster randomized controlled trial. European Journal of Public Health, 27, 494–500.        

Foxcroft, D. R., Callen, H., Davies, E. L., & Okulicz-Kozaryn, K. (2017). Effectiveness of the Strengthening Families Programme 10-14 in Poland: Cluster randomized controlled trial. European Journal of Public Health, 27, 494–500.    

 Skärstrand, E., Sundell, K., & Andréasson, S. (2013). Evaluation of a Swedish version of the Strengthening Families Programme. The European Journal of Public Health, 24(4), 578-584.Baldus, C., Thomsen, M., Sack, P. M., Bröning, M., Arnaud, N., Daubmann, A., & Thomasius, R. (2016). Evaluation of a German version of the Strengthening Families Programme 10-14: A randomized controlled trial. European Journal of Public Health, 26, 953–959.    

Segrott, J., Gillespie, D., Lau, M., Holliday, J., Murphy, S., Foxcroft, D., Hood, K., Scourfield, J., Phillips, C., Roberts, Z., Rothwell, H., Hurlow, C., & Moore, L. (2022). Effectiveness of the Strengthening Families Programme in the UK at preventing substance misuse in 10–14 year-olds: a pragmatic randomised controlled trial. BMJ Open, 12(2), e049647. https://doi.org/10.1136/bmjopen-2021-049647

Studies not Included in the Assessment Process:

Ballester, L., Amer, J., Vives, M., March, M. X., & Pozo, R. (2020). Preventing internalizing and externalizing symptoms in adolescents through a short prevention programme: An analysis of the effectiveness of the universal Strengthening Families Program 11-14. Child and Adolescent Social Work Journal, 37, 1–13.
Reason for exclusion: QED, not RCT. 6-month follow-up, positive outcomes on externalising and internalizing behaviour, no substance use outcome

Bröning, S., Baldus, C., Thomsen  M., Sack, P., Arnaud, A., Thomasius, R. (2017). Children with Elevated Psychosocial Risk Load Benefit Most from a Family-Based Preventive Intervention: Exploratory Differential Analyses from the German “Strengthening Families Program 10–14” Adaptation Trial. In Prevention Science (Vol. 18,  932–942)
Reason for exclusion: secondary analysis

Coombes, L. Allen, D. and Foxcroft, D. (2012), ‘An exploratory pilot study of the Strengthening Families programme 10-14 (UK)’, Drugs: Education, Prevention and Policy 19, 387-396.
Reason for exclusion: “Participant recruitment to the study was slow and many families were reluctant to be randomly allocated, instead indicating a preference for the SFP10–14 (UK) group. Rather than abandoning the trial, a decision was made to proceed as a quasi-experimental study, that is, without randomization” (study protocol)    

Kumpfer, K. L., & Magalhães, C. (2018). Strengthening families program: An evidence-based family intervention for parents of high-risk children and adolescents. Journal of Child & Adolescent Substance Abuse, 27(3), 174-179.        
Reason for exclusion: Review paper on contents and research of SFP. Not an effectiveness study. 

Kumpfer, K. L., Xie, J., & O’Driscoll, R. (2012, April). Effectiveness of a culturally adapted strengthening families program 12–16 years for high-risk Irish families. In Child & Youth Care Forum (Vol. 41, No. 2, pp. 173-195). Springer US.
Reason for exclusion: No follow-up (retrospective pre-test), No substance use related outcomes, No analysis of interaction of selection & maturation, Differential baseline differences not controlled for. 

Moore, L. (2009). Project SFP Cymru: Evaluating the impact of the Strengthening Families 10-14 UK Programme on substance misuse. Trial register: https://www.isrctn.com/ISRCTN63550893&nbsp;

Non-EU studies

Guyll, M., Spoth, R. L., Chao, W., Wicrama, K. A. S. and Russel, D. (2004), ‘Family-focused preventive interventions: evaluating parental risk moderation of substance use trajectories’, Journal of Family Psychology, 18, pp. 293-301.    

Harrison, R. S., Boyle, S. W. and Farley, O. W. (1999), ‘Evaluating the outcomes of family-based intervention for troubled children: a pretest-posttest study’, Research on Social Work Practice 6, pp. 640-655.     

Redmond, C., Spoth, R., Shin, C. and Lepper H. (1999), ‘Modeling long-term parent outcomes of two universal family-focused preventive interventions: one-year follow-up results’, Journal of Consulting and Clinical Psychology 67, pp. 975-984.      

Spoth, R., Redmond, C. and Shin, C. (1998), ‘Direct and indirect latent-variable parenting outcomes of two universal family-focused preventive interventions: extending a public health-oriented research base’, Journal of Consulting and Clinical Psychology 66, pp. 385-399.     

Spoth, R., Redmond, C. and Lepper, H. (1999), ‘Alcohol initiation outcomes of universal family-focused preventive interventions: one- and two-year follow-ups of a controlled study’, Journal of Studies on Alcohol 13, pp. 103-111.

Spoth, R., Reyes, M. L., Redmond, C. and Shin, C. (1999), ‘Assessing a public health approach to delay onset and progression of adolescent substance use: latent transition and loglinear analyses of longitudinal family preventive intervention outcomes,’ Journal of Consulting and Clinical Psychology 67, pp. 619-630.

Spoth, R. L., Redmond, C. and Shin, C. (2000), ‘Reducing adolescents’ aggressive and hostile behaviors’, Archives of Pediatric and Adolescent Medicine 154, pp. 1248-1257.

Spoth, R. L., Redmond, C. and Shin, C. (2001), ‘Randomized trial of brief family interventions for general populations: adolescent substance use outcomes 4 years following baseline’, Journal of Consulting and Clinical Psychology 69, pp. 627-642.

Spoth, R. L., Guyll, M. and Day, S. X. (2002), ‘Universal family-focused interventions in alcohol-use disorder prevention: cost-effectiveness and cost-benefit analyses of two interventions’, Journal of Studies on Alcohol 63, pp. 219-228.

Spoth, R., Guyll, M., Trudeau, L. and Goldberg-Lilehoj, C. (2002), ‘Two studies of proximal outcomes and implementation quality of universal preventive interventions in a community-university collaboration context,’ Journal of Community Psychology 30, pp. 499-518.

Spoth, R. L., Redmond, C., Trudeau, L. and Shin, C. (2002), ‘Longitudinal substance initiation outcomes for a universal preventive intervention combining family and school programmes’, Psychology of Addictive Behaviors 2, pp. 129-134.

Spoth, R., Redmond, C., Shin, C. and Azevedo, K. (2004), ‘Brief family intervention effects on adolescent substance initiation: school-level growth curve analysis 6 years following baseline’, Journal of Consulting and Clinical Psychology 72, pp. 535-542.

Spoth, R. L., Clair, S., Shin, C. and Redmond, C. (2006), ‘Long-term effects of universal preventive interventions on methamphetamine use among adolescents’, Archives of Pediatric Adolescent Medicine 160, pp. 876-882.

Trudeau, L., Spoth, R., Randall, G. K. and Azevedo, K. (2007), ‘Longitudinal effects of a universal family-focused intervention on growth patterns of adolescent internalizing symptoms and polysubstance use: gender comparisons,’ Journal of Youth and Adolescence 36, pp. 725-740.

Spoth, R. L., Trudeau, L., Guyll, M., Shin, C. and Redmond, C. (2009), ‘Universal intervention effects on substance use among young adults mediated by delayed adolescent substance initiation’, Journal of Consulting and Clinical Psychology 77, pp. 620-632.

Spoth, R., Clair, S. and Trudeau, L. (2014), ‘Universal family-focused intervention with young adolescents: effects on health-risking sexual behaviors and STDs among young adults’, Prevention Science 15, pp. 47-58.

Countries where evaluated
Germany
Poland
Sweden
United Kingdom
Protective factor(s) addressed
Family: attachment to and support from parents
Family: opportunities/rewards for prosocial involvement with parents
Family: parent social support
Individual and peers: refusal skills and decision making
Individual and peers: skills for social interaction
Risk factor(s) addressed
Family: family conflict
Family: family management problems
Family: neglectful parenting
Family: parental attitudes favourable to alcohol/drug use
Individual and peers: early initiation of drug/alcohol use
Individual and peers: favourable attitude towards alcohol/drug use
Individual and peers: favourable attitudes towards anti-social behaviour
Individual and peers: interaction with antisocial peers
Outcomes targeted
Academic performance
Depression or anxiety
Other mental health outcomes
Relations with parents
Alcohol use
Use of illicit drugs
Smoking (tobacco)
Other behaviour outcomes
Description of programme

The seven-session programme for families with young adolescents is based on the biopsychosocial model and aims to strengthen family protection and resilience-building processes and reduce family risk. Sessions are conducted once weekly for seven weeks. The first six sessions last two hours, consisting of one hour of separate parent and child skills-building followed by a one-hour family session where parents and children practise the skills they have learned independently, work on conflict resolution and communication, and engage in activities to increase family cohesiveness and positive involvement of the child in the family. The final session is a one-hour family interaction session without the concurrent parent and child training sessions.

Parents are taught means of clarifying expectations based on child development norms relating to adolescent substance use, how to use appropriate disciplinary practices, how to manage strong emotions regarding their children and how to communicate effectively. Essential programme content for the parent skills training sessions is contained on videotapes that include family interactions illustrating key concepts. Children are taught refusal skills to help them deal with peer pressure and other skills for personal and social interaction. During the family sessions, family members practise conflict resolution and communication skills and engage in activities designed to increase family cohesiveness and the positive involvement of the child in the family. These sessions are led by three-person teams and include an average of eight families per session. The length of the intervention may depend on where it is delivered, that is, in a school, in a group or at home. The programme is delivered by certified group leaders, site coordinators or supervisors.

The Strengthening Families Programme was developed by Karol Kumpfer for children ages 6-11 in the 90ies and is known as the Utah version. Since that time the Utah Strengthening Families Program has been modified for younger children (ages 3-5) and young teens (ages 13-17).

Researchers at Iowa State University collaborated to adapt and study SFP for families with early adolescents (SFP for Parents and Youth 10-14), which is known at the Iowa version or SFP 10-14.

Intervention variation

In Sweden, a version of the Strengthening Families 10-14 programme adapted to Swedish conditions, including through some modifications to the programme format agreed with the programme’s developer, is implemented. The Swedish version consists of two parts. Part one comprises seven sessions, delivered over seven consecutive weeks in grade 6 (12 years of age); there are six separate sessions for children and their parents, with one joint family session. Part two comprises five sessions, delivered over five consecutive weeks in grade 7 (13 years of age); there are four separate sessions for children and their parents, with one joint family session. This differs from the original programme, where each weekly session includes a separate hour for parent and child, and then one hour with parents and children together.

The programme content is similar to the original Strengthening Families 10-14 programme to a large extent, although some family session topics are omitted due to the change in format/delivery. Whereas the original programme is held in community centres with parent and child sessions run at the same time, for practical reasons, the child sessions in the Swedish version are run during school hours and parent sessions are run separately in the evening, so ‘some family components were lost’. Youth sessions are conducted by class teachers, with the assistance of a group leader. Group leaders conduct parent sessions. All group leaders are trained by certified Strengthening Families 10-14 trainers. The Swedish version also includes some new material in part two, designed to enhance the alcohol and drug content.

Implementation Experiences
Feedback date
Contact details

Cátia Magalhães
catiacmagalhaes[a]gmail.com
 

Main obstacles

With respect to individual professionals

- Recruitment of families when an agency or school start up is always difficult until there is positive word of mouth and agency staff buy-in to get referrals.
- Select and implement and evidence-based programme instead of other programmes that are on offer.

With respect to social context

Once in a while, the resistance to adopting EBPs from other countries arises because of the perceived difficulties in adapting them to new cultures or new situations.
- Initially the weeks of the programme and the number of sessions.

With respect to organisational and economic context

- Financial issues (raise the funds from local foundations and agencies).
- Selecting and implementing EBPs instead of other programmes that are on offer (and can be shorter and less expensive, although with less positive results).

How they overcame the obstacles

With respect to individual professionals

- Called and talked with families and targeted schools.
- Talked with people from the representative agencies of the targeted populations.
- Spread and disseminated EBPs and practices through professionals.

With respect to social context

- Adapt the programme to the unique needs and situational/social context while preserving the programme´s core content.
- Overcome barriers to programme implementation and implement strategies to increase recruitment and retention.

With respect to organisational and economic context

- Spread and disseminate evidence-based programmes and practices through local agencies and local government.
- Cost-effectiveness of EBPs compared with non-EBPs and practices.
- Explain risk and protective factors of the context.

Lessons learnt

With respect to individual professionals

- It is important to select, train and supervise staff (group leader or facilitator) to assure quality implementation.
- Supervision from programme implementer or national/local coordinator.
- Cultural adaptations are needed to maintain fidelity to the original programme.

With respect to social context

- Parents and families want universal family values. So it’s important to become familiar with the targeted population’s cultural values, priorities and characteristics.
- We can adopt EBPs from other countries and have similar positive and significant results.

Strengths

- The programme is durable and has large positive outcomes in its first implementation in Portugal, like in other several countries.
-The material and format are easy to use.
- Sensitivity towards language barriers and cultural factors.
- Topics and session contents.
- Three groups/moments: parents, children and family (parents and children together).

Weaknesses

- Group version is staff-intensive and costly.

Opportunities

- Having existing paid staff or volunteers from the community to implement the programme can help to reduce the staff costs.
- Working with local agencies and government services (e.g. social services, children protection commissions).

Threats

- Financial issues (taking into account economic, national and local context).

Recommendations

With respect to individual professionals

- Good staff selection and training/supervision.
- Training staff in EBPs and core components of the programme.
- Ethnically and linguistically matched to the target population.

With respect to social context

- Disseminate the results and effectiveness of the programme.
- Carefully identify the most pressing problems/risks and protective conditions (helps to guarantee better outcomes).
- Include cultural adaptation of the programme.

With respect to organisational and economic context

- Disseminate the results and effectiveness of the programme.
- Cost-effectiveness studies.
- Develop practical collaborations between practitioners, clients, policymakers, researchers, etc. to improve programme implementation and dissemination.

Number of implementations
1
Country
Portugal
Feedback date
Contact details

Joan Amer
joan.amer[a]uib.es
 

Main obstacles

With respect to individual professionals

Lack of training and need of understanding of the theory of change of the programme. Temporary jobs, which mean lack of stability: changes in professionals from one application to other.

With respect to social context

Need of network and social support within neighbourhoods. Need of cooperation between social services and educational services.
Seasonal job market. Lack of bond with communities, due to unstable housing.

With respect to organisational and economic context

  1. Eventually, in some applications, specific support had to be implemented for some children who disrupted the functioning of the sessions.
  2. In other cases, the protocol had to be implemented in order to exclude some participants that fullfilled the requirements of exclusion criteria. This is the case of some children with active antisocial behaviour. This rarely happened and it was because these children were not detected at the selection process prior to the programme.
How they overcame the obstacles

With respect to individual professionals

Improvement of the system of selection of professionals, better connections with those NGOs with competent and experimented professionals.
Increase and improvement of training: further hours of training, more dedication to emotional techniques and roleplaying.

With respect to social context

Better networking with professionals in the communities: preparatory sessions, linking and bonding with relevant educational professionals.
Utilisation of social networks (web etc.) for improving communication.

With respect to organisational and economic context

  1. Once the specific educational needs were identified, the implementation team (educators, coordinator and members of our research group) would decide the type of adapations of the programme.
  2. Principally, specific support to the child would be implemented (sometimes with the participation of some collaborator from the university).
  3. Different strategies were also prepared for the child to make sure that she or he acquires the essential contents and participates as much as possible in the dynamics of the group.
Lessons learnt

With respect to individual professionals

The importance of experienced professionals, but also of availability for learning and adherence to the programme.

With respect to social context

The counterpart: social service, school and/or NGO that you are working with is critical for the quality of the implementation.

With respect to organisational and economic context

The opportunity to implement a standardised academic programme with elements of community and family intervention.

Strengths
  1. Taking into account the results and the evaluation of the Spanish programme, we are able to state that SFP can be successfully adopted without compromising effectiveness. Our results suggest that the validated programme for the Spanish population (PCF) accomplishes its objectives and is valid for positively modifying protection and risk factors. Furthermore, effectiveness of the culturally adapted programme is tested in parents, children and families. Training for parents increases their parenting skills; training for children enhances their social capacities and personal development; and family training improves both positive relations at home and parental implication.
  2. This programme addresses issues that an "insider" or "autochthonous" (using the terms of the questionnaire) may not have considered. Different aspects are incorporated. External perspective offers new ideas and proposals.
  3. The allochthonous component of the programme makes the results more valuable. It is feasible to implement succesfully a programme of these characteristics: results of the applications in the Spanish adaptation are consistent with those obtained by SFP in reference applications (Kumpfer, 2003; Kumpfer et al., 2008), demonstrating its effectiveness.
  4. Spanish adaptation of the programme (PCF) has demonstrated that the programme is valid to work with populations that are socially and culturally different. Results of this adaptation demonstrate that the programme is able to be effective both in Spain and internationally.
  5. Overall evaluation is positive. We are satisfied with the results. Last, we specially appreciate and highlight the innovative component of the programme within family intervention
  6. The protocol has been implemented without major or significant difficulties. In the case of families with uncovered basic needs, we had the support of professionals from social services. These professonials also monitored the demands of those families.
Weaknesses

Previous to the implementation of the programme, aspects such as physical punishment were not included in the Spanish adaptation.

Opportunities
  1. It is important to share the specific experiences, implementations and outcomes in different countries and settings in order to exchange experience and improve/polish the programme. In this sense, initiatives such as this questionnaire are very useful.
  2. Adaptations were made taking into account both the curriculum and the objectives of the programme. Adaptations implied modifications of formal aspects such as language and the presentation of resources. New activities and proposals were introduced to facilitate the performance of the sessions. Also incentives for children were revised.
  3. Context adaptation consisted mostly of modifications in language aspects, teaching proposals, games, illustrations, songs.
  4. Recent restrictive legislation on tobacco has had an important impact on levels of consumption.
  5. Advertising of alcohol (allowed) — even though legislation is becoming more restrictive.
Threats
  1. The Balearic Islands are an important mass tourism destination in Western Europe. Different implementations of the programme have been executed in coastal populations with high risk levels of social exclusion. Social exclusion in tourist resorts is principally due to the characteristics of the labour force in the tourism sector in the Balearic Islands: it is an unskilled, seasonal, intensive and low-wage workforce.
  2. In the case of our applications in the Balearics, seasonality of the tourist economy impacts in the scheduling of the programme. Parents can have serious difficulties attending the sessions during peak tourist season.
  3. The Balearic Islands have the highest rate of school drop out in Spain, greater than the average of the European Union.
  4. Age restrictions for going out — there is a permissive culture. The phenomenon of "Botellón": outdoor alcohol drinking.
  5. Negative attitudes towards illicit drug users — stereotypes or social prejudice can arise. It is frequently associated with crime.
Recommendations

With respect to individual professionals

Proper selection of trainers, and proper training. Training with both a theoretical background but also a practical focus (emotional techniques, leading group skills, roleplaying, etc.).

With respect to social context

It is important, first, to be aware of the level of cultural adaptation needed in each country or context and, second, to make use of the evaluation as a tool for permanent improvement of the programme.

With respect to organisational and economic context

  1. Organisational culture of the institution where the implementation takes place is important.
  2. Regarding economic context, characteristics of jobs of parents influence the level of participation. In our case, seasonal and unskilled jobs are predominant. Also the environment for adolescents is relevant. In the case of the Balearic Islands (Spain), there is easy acces to the job market (abandoning school) and a high presence in the resorts of leisure lifestyles with drug abuse due to the type of tourism.
Note from the authors

Family Competence Program (Spanish SFP)
PCF7-12 (Spanish adaptation of SFP6-11);  2015 on the PCF12-16 (adaptation)  

Number of implementations
1
Country
Spain
Feedback date
Contact details

Robert O'Driscoll
robert.odriscoll[a]hse.ie

Main obstacles

With respect to individual professionals

Staffing.

With respect to social context

The need to make sure that a needs assessment was conducted in the communities where the programme was intended to be implemented.

With respect to organisational and economic context

A lack of consistent organisational support.

How they overcame the obstacles

With respect to individual professionals

We developed an interagency implementation model. The key stakeholders included the Health Service Executive, local and regional drugs and alcohol task forces, the Child and Family Agency (TUSLA), the Gardaí (Community Policing) and Young Person’s Probation.

With respect to social context

Consulted with local service providers, who in turn consulted with service users around the need for and their willingness to participate in the SFP.

With respect to organisational and economic context

Sometimes sheer determination was required to overcome the lack of support from senior management and administrators.

Lessons learnt

With respect to individual professionals

The important lessons learnt were multi-level. Funding and management support were necessary at all levels; well-trained staff and facilities committed to the programme implementation and sustainment were needed. Including the families as much as possible in the planning, implementation and evaluation of programmes was necessary. It is important to create a space within the implementation infrastructure and architecture for the implementers to come together and work through the tensions and dilemmas that are likely to arise throughout the implementation process, so that the problems do not become embedded or become obstacles to the implementation process. Having well-qualified coordinators to guide the implementation process and to ensure programme fidelity and support the programme team was important.

With respect to social context

  • Implementing an evidence-based programme requires a well thought out implementation plan with commitment from all major stakeholders. It was interesting to see the competition among stakeholders for recognition of individual and agency-level commitments and the political climate that a successful implementation can create. It is worth noting that each agency wants to be recognised and associated with a successful programme, sometimes above and beyond the level of commitment they may have given to the implementation process, and very few want to work on or be associated with working through the problems that arise during the implementation.
  • An implementation team needs to be created around the SFP so that experience can accumulate over time.

With respect to organisational and economic context

A successful and sustained implementation of SFP requires a local “Champion” to promote the programme within and outside the organisational context. Programmes must be evaluated and the findings shared within the wider network of service providers, regionally at least and nationally if possible. The evidence will support the future sustainability of the programme in terms of funding and political support and contribute to an accumulating evidence base for the programme. An alliance with the programme developer can help to overcome organisational obstacles to the successful implementation of SFP.

Strengths

The evidence base for the programme is the strength of SFP.

Weaknesses

The resource-intensive nature of the programme.

Opportunities

The interagency model of service delivery can be used for other types of programme implementation but also contributes to the development of a strong network of distributed expertise that can be harnessed on behalf of vulnerable service users.

Threats

The political environment that can accrue around an evidence-based programme like SFP. Administrators and funders trying to implement a programme without the necessary knowledge and skills around the nuances of practice.

Recommendations

With respect to individual professionals

Make every effort to train staff well in the programme and to ensure that they have the requisite skills to work with families individually and in a group setting. To make evidence-based programmes like SFP part of the undergraduate curriculum.

With respect to social context

Undertake a needs analysis of the communities where SFP is intended to be implemented to make sure it is the correct fit for the local context.

With respect to organisational and economic context

Ensure adequate funding by evaluating programmes and publishing the results. Keeping administrative and funding support out of the practice environment while balancing the need for ongoing management support to sustain the programme with fidelity over time.

Number of implementations
1
Country
Ireland
Feedback date
Main obstacles

With respect to individual professionals

We implemented the RCT in 19 schools in Stockholm. The main obstacle was recruiting leaders to the programme to deliver both the children’s sessions, the parents’ sessions and the family sessions. We were planning to train teachers to deliver the children’s sessions, but they were not allowed to work extra hours during the evenings for the parents’ and family sessions.

With respect to social context

Recruiting schools, as this was an RCT and schools were randomly allocated to the programme and control groups.

With respect to organisational and economic context

Since this was a study, we had a limited budget.

How they overcame the obstacles

With respect to individual professionals

We resolved that obstacle by training retired schoolteachers to be in charge of the parents’ sessions in the evenings (on the same day that their children had their sessions). The retired schoolteachers also took part in the children’s sessions during the day, so they could make links between the children’s and parents’ sessions. We also changed the original programme format, in that we only had two family sessions in order to make it possible for children and parents to be together in the evening.

With respect to social context

We offered the control schools the chance to implement the programme after the study was over.

With respect to organisational and economic context

We had to make some alterations to the programme format and limit the family sessions.

Lessons learnt

With respect to individual professionals

It is hard to balance cultural adaptation and programme fidelity.

With respect to social context

Go out in person to the schools and talk about the study and the importance of taking part.

Strengths

The Swedish version does not differ significantly from the SFP 10-14 in terms of content. All the core components, like communication skills, family bonding, peer resistance skills, stress management, handling emotions, and communicating rules and consequences in relation to household chores, as well as expectations concerning substance use, are intact. Even though some of the family session components were omitted, we tried to make up for this by introducing links between the children’s and parents’sessions, and by adding extra weight to the content of the two existing family sessions.

Weaknesses

We were not able to hold all the family sessions.

Threats

It is not an easy task to adapt intervention programmes from one context or country to another. You must be able to culturally adapt the programme without losing the core components.

Note from the authors

Steg-för-Steg - a Swedish version of the Strengthening Families Program 10-14 (SFP 10-14)

Number of implementations
1
Country
Sweden
Feedback date
Main obstacles

With respect to individual professionals

  • Dominant practices to help parents are group discussions under the supervision of psychologists. Evidence-based educational and manualised programmes are not used.
  • Multiplicity of actors and actions
  • Heterogeneity and low level of training for family support professionals
  • Inexperience and reluctance to implement educational programmes for parents
  • No culture of scientific evaluation
  • Reluctance in relation to the project itself, in particular the commitment of families over time (14 weeks)

With respect to social context

  • Multiplicity of actors to inform and convince
  • Astonishment to see support for parenthood in the field of health
  • Frequent opposition in principle by the professionals involved in traditional forms of support to parenthood (standardised programme, Anglo-Saxon programme, caricature of behaviouralism)
  • Difficulties in choosing families: risk of touching "those who do not need it"

With respect to organisational and economic context

  • Municipal doubts during the first implementation of the programme:
    • Fear f not having qualified staff to play the role of facilitator
    • Financial cst (average announced = 15,000 euros for year 1)
      • appointment of a municipal coordinator of the programme plus four facilitators
      • funding of their working hours, training and facilitation of the 14 sessions
      • logistics: organisation of information meetings, provision of rooms adapted for the training and animation of the sessions
  • Low external "visibility" of the project for elected representatives (few families, unlike the "conference" mode)
How they overcame the obstacles

With respect to individual professionals

  • Slow progress of implementation on each site
  • On each site of implementation:
    • Several meetings setting up detailed infrmation about the programme: origin, concepts, principles, philosophy and ethics, results
    • Systematic invitatin of professionals involved in supporting families at our meetings
    • Distributing infrmation to the largest possible number of professionals from various fields (social, education, sport, culture) in contact with families
  • Positioning of the programme in the educational field, in complementarity with other parenting support actions
  • Presentation of the work done for SFP's cultural adaptation
  • Reinforcement of the training of those responsible for the programme’s implementation (at the theoretical level and at the level of action) highlighting the programme’s philosophy and its ethics

With respect to social context

  • Enthusiasm and perseverance
  • Clear and explicit, intense and diversified communications with elected representatives, funders, professionals and parents
  • Involvement and appreciation of local partners in reflection and implementation
  • Identification of cities as privileged partners in the implementation, valuing the benefits to them, in terms of training their teams
  • Targeting living areas of low income families

With respect to organisational and economic context

  • For the first implementations of PSFP in France:
  • Natinal funding
  • Supprt of decentralised departmental services: prefecture, social cohesion, city policy
  • Inclusion or support of PSFP to a device already in place: city health workshop, local education plan
  • Enthusiasm of professionals during the discovery of the programme
  • Interest, enthusiasm and satisfaction of parents
  • Interest of the elected officials
Lessons learnt

With respect to individual professionals

  • Interest in and necessity of a long phase of presentation and explanations to the greatest possible number of professionals on each site of implementation
  • Interest in and need to broaden the base of the professionals concerned; mobilisation of professionals in contact with families, not just those already involved in parenting support
  • Interest in and need for strengthening training, both in its content and in the number of people benefiting from it
  • Added value of the implementation and training process:
    • Individual: strengthening the prfessional skills in parenting support
    • Collective: better mutual knowledge and articulation between the professionals on each side

With respect to social context

  • Relevance of the association with the cities, recognized as a strong local partner, identified in the diversified support for families (social, educational, prevention, culture, sports, leisure) and already working in a network
  • Give incentives to cities (elected policy makers and local professionals) for the implementation and management of the programme
  • Need to obtain a commitment from elected representatives through a partnership agreement

With respect to organisational and economic context

  • Adaptation to the context and searching for local support are essential
  • Support from the cities in their search for funding
Strengths
  • The programme itself:
    • Its cncrete and experiential aspect for parents
    • The assciation of 3 time periods: parents / children / families
    • Quick enthusiasm frm trained professionals and parents
    • The ethics f facilitation
    • Orientation to parenting skills, mental health promotion
Weaknesses
  • Heaviness of initial investment, especially financial
Opportunities
  • Expansion of programme’s positioning
    • In the fight against the misuse f screen time
    • In the fight against social inequalities in health
Threats
  • Enough rigour to keep the programme in its original form, in 14 sessions and 3 time-periods (parents / children / families) and avoid losing fidelity
  • Enough perseverance in the training of professionals who develop and facilitate
Recommendations

With respect to individual professionals

  • Involve local professionals in setting up the programme
  • Analyse the training needs of developers and professionals
  • To be attentive to ethics of the facilitation of a programme that values parents
  • Strengthen training

With respect to social context

  • Analyse the appropriateness of the programme to local standards of support for parenting
  • Carefully choose target audiences
  • Broaden the objectives of the programme in the fight against the abuse of screens

With respect to organisational and economic context

  • Rely on existing partners or networks
  • Provide funding
Note from the authors

Programme de Soutien aux Familles et à la Parentalité 6-11 ans - French adaptation of the Strengthening Families Program

Number of implementations
1
Country
France
Feedback date
Contact details

Dina Kyritsi (Psychologist, MA, MBPsS)

dina_kyritsi[a]yahoo.gr

Main obstacles

With respect to individual professionals

Competition between the facilitators, especially in the youth sessions (which are delivered by two professionals  ), was an issue that we tried to overcome. Not all our facilitators had attended the same training course and most of them had never worked together as a team. The Strengthening Families Programme SFP10-14 presupposes good chemistry between the three facilitators who are responsible for a given group of families. In addition, it was important for the programme’s facilitators to always come very well prepared for the sessions. Their initial training was not enough, without investing personal time in preparing and practising for the sessions.  Cultural accommodation of the SFP10-14 for Greece provided strong grounds to warrant a pre-implementation stage in future planning, wherein all the facilitators meet and go through every activity of the sessions together to ensure a uniform understanding of its function and purpose within the session.  It is hard to evaluate how well the SFP10-14 was implemented in every group or the variation in the implementation between different groups. The post-implementation interview data could possibly point to weaknesses in the programme itself or how well the programme was executed. At the moment, there is no standardised tool to measure how well the sessions were delivered (external observers or a self-evaluation by the facilitators themselves could perhaps have served this purpose).  

With respect to social context

It was hard for our participants to follow the English-language DVDs with Greek subtitles that we utilised during the first implementation of the programme (we ended up reshooting the DVDs with Greek actors). In several vignettes (e.g., the shoplifting vignette), the responses of parents in the video were much milder than what would be ‘natural’ for a Greek parent, which made the DVD families ‘too good to be true’ in our participants’ eyes. It was hard to find something equivalent to replace such scenes, as this would have required rewriting the script, without having the option to consult or obtain permission from the programme’s US authors. Using ‘chores’ as a behaviour management tool was another core concept of the US programme that we found hard to intregrate into Greek family practice, as assisting with the household chores is usually not a highly valued behaviour in Greece for an adolescent pupil (frequently not even by his or her parents, who would prefer that he or she studies instead).
As regards the general social context, the parents were reluctant at some points to consider the methods proposed by the programme; they felt that they were somehow ‘American’ and they would be realistically hard to implement with their youth. In addition, several parameters related to background work for the implementation were very different from the US. For example, fortunately volunteerism is still common in the US, whereas in Greece - especially after our deep economic recession - there is no place for volunteerism, as everybody is striving to make ends meet. We had to consider not only the SFP10-14 families, but also our facilitators, who often had to leave their own, young children unsupervised, in order to undertake unpaid work for the programme.

With respect to organisational and economic context

It was hard to obtain license from the Greek Ministry of Education to access public schools, in order to inform parents and young people about the programme and recruit participants. Our country is not very open to innovative healthcare initiatives that are not centrally organised by the state.
Furthermore, as already argued, much of the facilitators’ work went beyond the SFP10-14 sessions. A flexible financial planning was able to account for the extra work that typically arises at the stage of adaptation (e.g., private, one-to-one time with the families who faced special challenges, identified when special needs came up during the sessions, or feedback from the facilitators, such as the observation diaries that they were asked to complete following each session). The financial demands are quite different between countries in which the SFP10-14 has been implemented for years and is running smoothly and countries in which the programme is being first introduced, such as Greece.

How they overcame the obstacles

With respect to individual professionals

An effort was made to build positive relations, empathy and team spirit within the Greek SFP10-14 team and to ensure the best match between the facilitators and our groups of families. In addition, we prepared plans and small maps for the facilitators’ use, as ‘personal assistants’, and we organised the various materials that the facilitators would need to use during each session. The Greek SFP10-14 manual has also included helpful tips proposed by the facilitators who had already delivered the programme in Greece.

With respect to social context

We reshot the DVDs using much simpler language. We replaced specific activities and chores that were considered ‘too American’ (e.g., billiards, bowling, gardening, cleaning the basement etc.) with more plausible alternatives. We replaced a few scenes that seemed ‘unnatural’ (e.g., the parents’ response to shoplifting). We also made sure that our DVDs did not include families of ethnicities that rarely immigrate to Greece (e.g., no coloured families were included, as in the UK DVD set; the Greek video portays an immigrant family of Filipino descent instead).
In addition, the adaptation of the DVDs has had to account to an extent for the difference in parenting values. It also required skilful handling on the part of the facilitators, who often anticipated the families’ concerns or opposition, before they were explicitly expressed in the group by the families.

With respect to organisational and economic context

We made every effort to highlight the affiliation of the US SFP10-14 with the Agia Sophia Hospital for Children, which is a University Clinic and the largest paediatric hospital in Greece and has formed for years the official basis of the Greek programme. This affiliation added weight to our endeavour in the eyes of officials in the Ministry of Education and the School Division of the Municipality of Athens as well as in the eyes of the participant families.
As to the financial demands, volunteer work was additionally required, in order to overcome financial shortage.
 

Lessons learnt

With respect to individual professionals

Our practice pointed to the need for supervision and evaluation of the programme’s facilitators, not only of the programme. Given that the pool of certified facilitators in Greece is necessarily limited (as very few training sessions have been offered), there were not many alternatives in case that something did not work out as planned. As with every project, tasks and deliverables need to be extremely clear right from the start (which is not easy when adapting an allochthonous programme, where several things may come up that were not prescribed, creating tension when several deliverables are not predicted from the outset).  

With respect to social context

It is important not to get carried away with the original material and to make sure that you test every  adaptation of the original material on several samples from the target population in advance, so as to ensure that all parts of the programme are meaningful in terms of language and cultural norms. When implementing an allochthonous programme  , you need to be faithful yet creative.

With respect to organisational and economic context

The programme’s protocol should explicitly allow time for the work required outside the sessions, instead of focusing on session delivery only. Especially in Greece where the SFP10-14 has not received any backing from the national health system or well-established agencies (which have supported the program in the US and the UK), project planning should allow time, space and a budget for the introduction, familiarisation, promotion and dissemination of the programme, rather than implementation only.

Strengths

1)    The SFP10-14 can be adapted successfully to other contexts (wider community/society, multiple settings) without compromising effectiveness.
2)    An allochtonous programme draws on the scientific advances of a different country. Most programmes produced in the same cultural context draw on a similar pool of resources and are based on the same mentality, the same ‘air’, the same dead ends. An allocthonous programme can bring a very refreshing innovation with a different perspective, which therefore prevents it from encountering the same, old dead ends. In addition, the Greeks generally trust scientifically based and tested allocthonous interventions (at least healthcare initiatives from North America and the UK).
3)    Therefore, it is feasible to successfully implement an allochthonous programme without compromising effectiveness.
4)    All parts of the US protocol were effective and continued to play their part; surprisingly, even the slogans (i.e, the SFP10-14 creeds or mottos), which are not common in Greece (except in advertisements) and thus would not normally be expected to work well in the context of a healthcare programme.
The US SFP10-14 addresses a very diverse socioeconomic and structural context. As long as you maintain this feauture, the programme will remain effective. For example, the home of a poor family in Greece may be different from the home of a poor family in the US, but the DVDs for both countries explicitly include both affluent and less affluent households, so that a Greek family of low socioeconomic status would also feel included.

Weaknesses

1)    Assessment of the effects of the SFP10-14 should not focus on prevention only. The budget for any cultural accommodation of the SFP10-14 in Europe was offered by the alcohol industry, perhaps with the effect that assessment focused heavily on alcohol prevention. Our implementation suggested that the true potential of the programme is highlighted only, when measures of family well-being are introduced. It is the Strengthening Families Program, after all! Our results (obtained from a battery of valid tests coupled with participant interviews) suggest that the programme did make a significant difference to the families’ lives (in terms of communication, conflict resolution, quality time together etc.), although we obtained non-significant results for most alcohol-related measures. A question of course would be how long after implementation do we measure the programme’s effectiveness as prevention (only longitudinal research could achieve this with validity) and also how can one measure effects in prevention, when the majority of the adolescent participants have zero contact with alcohol or drugs as a starting point during the sessions (floor effects are to be expected…). When an allochthonous programme is introduced, it is only natural that you have to adapt not only the programme, but also the allochthonous assessment, which usually depends on the funding resources of a foreign country and thus may obscure the true potential of the specific programme in your own country.
2)    10-14 does not necessarily correspond to the same age range across cultures. In several cases, our Greek participant parents reacted negatively, when the sessions made reference to drug use (e.g., the mention of ‘cannabis’), as they felt that their adolescents were too young to know about drugs. The SFP10-14 probably encompasses two quite different age groups already, with quite different challenges and needs.

Opportunities

1)    There is a fine line between being faithful to the original programme and coming up with materials that are too ideal for the country’s reality and are therefore perceived as artificial. It is important that the participants feel as if the programme were written exclusively for them, rather than as if they are being pushed towards believing that the programme is relevant to their own lives. In practice, things that seem awkward need to be replaced (even if 3 in a sample of 10 say that they are OK), rather than having the facilitators try to persuade the participants that they are OK, because the original programme includes them. The SFP is effective, only if the participants feel that it is.
2)    All references to non-relevant cultural context were omitted and replaced with their nearest, culturally appropriate equivalent. As an example, nobody gets a driving licence in Greece before the age of 18. Therefore, the mother’s anxiety in the video that her teenage son might drive drunk was replaced by anxiety that the boy might get into the car of an older friend who drinks and drives, or anxiety that he might get into a stranger’s car, when invited to do so, because of alcohol that is impeding his judgement. All such alterations were based on common sense, testing, feedback from the SFP10-14 pilot participants, survey feedback from an independent advisory group (our ‘panel of experts’) and data gathered from all our facilitators, who recorded their own subjective experience in delivering each session.
3)    We adjusted the time allocated to each activity during the SFP10-14 sessions, depending on the participants’ ability to follow as well as the relative weight of each activity. All our facilitators found it impossible to follow the rigid US time plan.
4)    As an exception, we allowed younger siblings (below 10 years) to attend, if a family really wanted to attend, but had nowhere to leave their younger child (We could not afford day care for the younger siblings’ during our sessions, as the US programme did).
5)    Finally, we provided extra services to several participant families for free, which was not included in the programme’s protocol. All the participant parents asked for some private counselling time, some feedback about special issues that the facilitators might have identified in relation to their child or their family during the sessions as well as feedback about their test results. Our team of psychologists did give them this extra time, but focused on remaining facilitators rather than family therapists. We also referred families to external services (e.g., the Municipality, public hospitals etc.), where they could continue receiving support after the programme, depending on the nature of their needs. We made use of our professional status, in order to intervene and ensure that they booked an appointment quickly, when it was hard for them to do so on their own. We helped a few families become eligible for discounts in specific supermarkets in the city. All the above were not included in the SFP protocol, but professional responsibility and human concern did not allow leaving individual families without any support, after they completed the programme.
 

Threats

By nature, the SFP10-14 targets a variety of heterogeneous domains and has a variety of objectives. A real threat to the programme would be to split it into parts, with each part being used independently. In this way, apart from unity, the programme would lose its validity and effectiveness. We witnessed such an attempt, when official agencies of status that work with addiction in Greece expressed their interest in showing the videos for sessions 5 and 6 only (i.e., the DVDs that focus on addiction) to the families of young people with addictions. Other professionals expressed a wish to use only the SFP10-14 tools and materials that specifically address stress and coping, etc. The possibility that the programme could be split into pieces in this way is still a big threat, as there is no centralised supervision at the moment and the holder of the original copyright is so far away from Greece (in kilometres).

Recommendations

With respect to individual professionals

It is crucial that the facilitators are higly motivated and very well prepared for each session that they deliver. The sessions entail much more than executing the instructions of the SFP10-14 manual (which nevertheless need to be very simple and explicit, so that the sessions are implemented in a uniform manner).

With respect to social context

1)    Implementation requires envisaging the actual practice of the sessions, deciding which activities you could save time from (i.e., time management — more than the ‘optional activities’ of the manual) and anticipating possible resistance from parents to the parts that feel too foreign to them. How will you defend the cultural appropriateness of your SFP?
2)    A group with a lot of children in the younger age range (10-12 years) will probably be more challenging, making it harder to fulfil the session targets. Youth sessions need to carefully invite a relatively uniform, in terms of age, group of pupils.

With respect to organisational and economic context

1)    The SFP10-14 utilises a pool of very impressive materials and posters, which, however, need to be covered very quickly in the sessions, due to time constraints. In practice, this might prove impossible, when the participants are not fluent readers (as in the case of our participant immigrant parents). You may need to sacrifice aesthetic quality, in order to maximise comprehension (colours, typeface, language) and to minimize the related costs of course.

2)    Finally, there has to be a uniform policy about how to handle very personal or ‘touchy’ issues that might be disclosed during the sessions, as the participants gradually open up. For example, at family session 6 (when all our parents were certain that their children were too young to know about drugs and a few even asked the facilitators to refrain from talking about drugs, because ‘the kids are still innocent’), a 10-year-old boy disclosed in front of the group that he had smoked hashish  at school. The boy was really innocent: he did not realise the significance of what he was saying. How do you handle this? Implementation needs to include a uniform policy about such issues, to be followed by all faciliators for the benefit of the programme.

Note from the authors

Strengthening Families Program, SFP10-14

Implemented in Athens between 2009-2013

Number of implementations
1
Country
Greece
Last updated : 07.05.2019
Country of origin
Netherlands
Last reviewed:
Age group
11-14 years
15-18/19 years
Target group
All adolescents
Programme setting(s)
Community
Family
School

The European Smoking Prevention Framework Approach (ESFA) addresses four target groups/situations: young people, parents, schools and the out-of-school situation. Programme components consist of (i) smoking prevention through health education within the curriculum (a range of smoking prevention lessons that use the essential elements of a social skills approach); (ii) stimulating a smoke-free school environment (e.g. smoking regulation policies, smoking cessation training for teachers and parents); and (iii) out of-school regional smoking prevention activities (e.g. ongoing regional publicity and out-of-school smoke-free activities for adolescents). The programme is teacher-led and lasts about two school terms.

The programme has been implemented in six countries. To meet local and cultural needs, each country developed and used its own materials, taking into account the core goals and objectives.

Keywords
No data
Links to this programme in other registries
Spain - Prevención basada en la Evidencia
Contact details

Professor Hein de Vries PhD
Department of Health Education and Promotion
Maastricht University
PO Box 616, 6200 MD
Maastricht, the Netherlands
Phone: + 31-43-388 2410
E-mail: devries[a]gvo.unimaas

Evidence rating
Possibly beneficial
Studies overview

The programme has been evaluated in one quasi-experimental study across Finland, Denmark, Netherlands, UK, Portugal and Spain. The average age of young people was 13.3 years. Self-reported measures were completed, and all results reported here were post-test.

In Spain, fewer young people in the intervention condition began to smoke (statistically significant) and more participants in the control group began to smoke weekly (only marginally statistically significant p=0.08). There was no effect on intention to take up smoking in the next year.

In Finland, fewer intervention group participants began smoking but this was not a statistically significant effect. Fewer intervention group participants began to smoke weekly (statistically significant at 24 months after baseline, and marginally significant (p=0.06) at 30 months i.e. post-test). There was no effect on intention to take up smoking in the next year.

In Portugal, there were fewer participants from the intervention group who began to smoke, and who began to smoke weekly, compared to the control group. Fewer intervention participants reported intentions to smoke in the next year. (All of these differences were statistically significant.)

In the UK, there was no effect on smoking. However, there was a statistically significant favouring the intervention on intention to take up smoking in the next year.

Counter-productive effects were found in the Netherlands and Denmark, where more participants in the intervention group became smokers and more participants began to smoke weekly compared to the control group. Although the negative effect on weekly smoking was statistically significant in Denmark in the initial years of the programme, the only (negative) effect that was statistically significant at the end of programme was weekly smokers in the Netherlands. The effect on intention to take up smoking in the next year was not statistically significant in either country.

Overall analysis showed that there was a statistically significant effect on weekly smoking, but not on the number of smokers. The study also measured attitudes and self-efficacy using five measures, the effects on which were largely not statistically significant at the end of the programme (30 months from baseline) across the different countries. Overall, fewer intervention participants believed in the advantages of smoking and more intervention participants had social self-efficacy (refraining from smoking in social situations).

References of studies

*Ariza, C., Nebot, M., Tomás, Z., Giménez, E., Valmayor, S., Tarilonte, V. and De Vries, H. (2008), ‘Longitudinal effects of the European smoking prevention framework approach (ESFA) project in Spanish adolescents’, The European Journal of Public Health 18, pp. 491-497.

*De Vries, H., et al. (2003), ‘The European smoking prevention framework approach (ESFA): short-term effects’, Health Education Research 18, pp. 649-663.

*De Vries, H., Dijk, F., Wetzels, J., Mudde, A., Kremers, S., Ariza, C., ... and Candel, M. (2006), ‘The European Smoking prevention Framework Approach (ESFA): effects after 24 and 30 months’, Health Education Research 21, pp. 116-132.

*Vartiainen, E., Pennanen, M., Haukkala, A., Dijk, F., Lehtovuori, R. and De Vries, H. (2007), ‘The effects of a three-year smoking prevention programme in secondary schools in Helsinki’, The European Journal of Public Health 17, pp. 249-256.

Countries where evaluated
Denmark
Finland
Netherlands
Portugal
Spain
United Kingdom
Protective factor(s) addressed
Individual and peers: refusal skills and decision making
Risk factor(s) addressed
Family: parental attitudes favourable to alcohol/drug use
Individual and peers: favourable attitude towards alcohol/drug use
Outcomes targeted
Smoking (tobacco)
Description of programme

The European Smoking Prevention Framework Approach (ESFA) addresses four target groups/situations: young people, parents, schools and the out-of-school situation. Programme components consist of (i) smoking prevention through health education within the curriculum (a range of smoking prevention lessons that use the essential elements of a social skills approach); (ii) stimulating a smoke-free school environment (e.g. smoking regulation policies, smoking cessation training for teachers and parents); and (iii) out-of-school regional smoking prevention activities (e.g. ongoing regional publicity and out-of-school smoke-free activities for adolescents). The programme is teacher-led and lasts about two school terms.

The programme has been implemented in six countries. In each of the participating countries, a special national project manager was appointed, who was responsible for the development and implementation of the project. The project manager worked in conjunction with a national steering group made up of representatives of relevant national organisations in the field of smoking prevention. The content of the ESFA programme was finalised when consensus was reached on goals and core objectives during meetings between the contractors and national project managers. Despite reaching consensus on the core objectives, all countries wanted the freedom to aim for other objectives, so each country used and/or developed its own materials, taking into account the core goals and objectives. The programmes were all implemented in the autumn and winter of 1998, and were all teacher-led.

Finland: this programme has been implemented in 13 experimental schools. The programme includes five one-hour lessons that provide information on smoking prevention in general; how to say no; the consequences of smoking and reasons for smoking; the development of refusal skills; and opinions on and reasons for not smoking. A video demonstrates social influences and a drama group demonstrates social influence resistance skills. The participants do not receive a student manual. The lessons are teacher-led; the teachers receive 20 hours of training, manuals and credits for following training. At school level, the ESFA School Policy Guide is used. Parents receive a ‘Quit & Win’ brochure on smoking cessation and are invited to participate in the ‘Quit & Win’ competition. For the out-of-school component, three posters are developed to be displayed in places in schools where children spend much of their free time. Finally, the participants are sent two tabloid-style newsletters, which include peer models explaining their decision to be non-smokers and offering advice on how to avoid smoking.

Denmark: this programme has been implemented in 30 schools. The programme includes six one-hour lessons that discuss smoking prevention in general; personal responsibility and alternatives to smoking; social pressure; refusal skills; making one’s own choices; skills training; the impact of advertising; and smoking policies. Pupils receive a student manual. Teachers receive a tutorial, background information, transparencies, and worksheets for the children. At school level, the ESFA School Policy Guide is disseminated. Parents receive a letter about the ESFA project, how to discuss tobacco use with their child and how to order smoking cessation materials. For the out-of-school component, two posters are developed for schools, classroom walls, canteens and public places such as libraries, swimming halls and sports centres. The participants are sent three postcards featuring the same images as the posters. Finally, a brochure is disseminated to community youth leaders describing how to discuss non-smoking with adolescents.

The Netherlands: this programme includes five one-hour lessons. The first three lessons consist of the national programme, providing information on general smoking prevention, personal decision making, and intentions. The lessons use teacher and student manuals. Two video lessons using soap operas demonstrate social influences and social influence resistance skills using verbal and non-verbal communication. At school level, the ESFA School Smoke-Free Policy Guide is used. Regional health coordinators receive a package describing how to inform parents and school personnel about smoking prevention and the ESFA project, along with examples of presentations and letters introducing the ESFA project, promotional materials (posters, postcards and stickers) and cessation materials. Posters and flyers are disseminated out of school in cases where schools are interested in this.

The United Kingdom: this programme includes five lessons, lasting 30 minutes each. The lessons address smoking prevention in general; economic and environmental consequences of smoking; reasons for smoking; advertising; and decision making. The schoolchildren use worksheets and computer games. Teachers attend a one-day training course and receive manuals. Quit, a national non-smoking organisation, implements drama sessions where children interact with actors, discussing their opinions about smoking and how to stick to their opinions. The Seven Steps to Success policy manual produced by the Health Education Authority is disseminated in schools. There are no parental or community activities.

Portugal: this programme includes six lessons, partly based on the adapted PASE project implemented in Barcelona, that address the effects of tobacco; reasons for not smoking; and social influences, skills and decision making. The schoolchildren use worksheets. Teachers attend a 48-hour training course and receive a manual, and they are given credits for following the training course and giving lessons. Schools receive the ESFA non-smoking policy manual and a non-smoking poster for the national no-smoking day. On that day, teachers receive a letter asking them to discuss issues relating to smoking again with their pupils, and many schools also organise other activities (mainly involving sports). At the community level, the Portuguese health minister and the mayor of the local community publicise the ESFA project on the national no-smoking day.

Spain: in this programme, at the individual level, the PASE project has been adapted to the standards of ESFA, and includes sessions on increasing self-efficacy and training in refusal skills. The materials include teacher manuals, two videos, and worksheets for the children. Pupils receive six lessons on the effects of tobacco; peer pressure; advertising; the prevalence of smoking behaviour; the difficulty of quitting; refusal skills training; and planning future behaviour. Teachers receive four training sessions of two hours. Schools receive the ESFA schools policy manual, along with a letter for parents and non-smoking stickers. One poster is disseminated out of school.

Implementation Experiences
Feedback date
Contact details

Carles Ariza, MD,PhD,MPH
Agència de Salut Pública de Barcelona (Public Health Agency, Barcelona)
cariza[a]aspb.cat

Main obstacles

With respect to individual professionals

The programme is implemented by teachers, with the support of health professionals from the Agència de Salut Pública de Barcelona (the Public Health Agency of Barcelona (ASPB)) for resources and training.
The main obstacle is the lack of training in and awareness of teaching professionals with regard to the importance of smoking and alcohol consumption prevention among young people.

With respect to social context

The main obstacle until now has been that the implementation of health promotion programmes in school is not mandatory for schools.
Second, being the oldest programme offered by the ASPB, we have observed a certain difficulty in maintaining the interest of schools that have previously been regular participants.
Third, as it is a programme that, above all, addresses smoking prevention, and smoking has decreased over recent years among young Spaniards, schools believe that the programme is no longer necessary.

With respect to organisational and economic context

The main obstacle is that the programme has to compete with other preventive programmes, and also other proposals from other companies and bodies, which in most cases have not been evaluated.
In addition, many of these offers are made with the proposal that the intervention be carried out by a health professional, supplanting the teacher.

How they overcame the obstacles

With respect to individual professionals

Despite the obstacles, the programme covers about 35-40 % of schools in the city.
Each year, the ASPB calls on schools to participate in the programme and a training and counselling workshop is held for new implementer professionals at its premises.

With respect to social context

We have attempted to renew and update the programme, with major and minor changes, but not as often as we would have liked. The most recent version, the fourth, was first used during the 2016-17 school year.
We have also lobbied at the political level, so far without success, for health education to be made a mandatory part of the school curriculum.

With respect to organisational and economic context

The agency has improved the presentation and characteristics of its resources to make them more competitive and has intensified the message to school managers about the importance of preventive interventions being effective. It has also highlighted the lack of sustainability when these interventions are carried out by non-school professionals.

Lessons learnt

With respect to individual professionals

Most importantly, the good response of teaching professionals and schoolchildren to work on social skills and decision-making to enable children to make informed decisions when offered drugs such as tobacco or alcohol.

With respect to social context

A number of schools, which could nonetheless be larger, have decided that the prevention of smoking and other drug addictions should be retained as part of the school curriculum.

With respect to organisational and economic context

In an earlier version of the programme, the cost per student was EUR 12.45. A study showed that the cost-benefit ratio is 22:74 and that, if the programme had a 1 % effectiveness rating (a very conservative assumption), it would prevent 67 children becoming smokers. In the evaluation of the second version (Ariza et al, 2008), the programme PASE.bcn was found to have an effectiveness of 4.6 %. The cost saved was EUR 1 022.78 for each person prevented from smoking (Hormigo, 2009).

Strengths
  • Easy application of the programme.
  • Good coverage, given the context.
  • Good programme effectiveness.
  • Sustainability of the programme over time.
Weaknesses
  • The programme can be tiring for the professionals involved in delivering it.
  • Need for periodic renewal.
  • Competitiveness of the other interventions available.
  • Changes in young smokers’ behaviour.
Opportunities
  • To maintain smoking prevention in an important part of the target population.
  • To keep the teachers involved motivated on the subject.
  • To follow the evolution of the problem and adapt the preventive messages of the programme.
  • To continuously improve the intervention.
Threats
  • Teachers less worried by adolescent smoking behaviour.
  • Lack of regulation and a curricular framework for health education.
  • Difficulty of keeping programme resources up to date.
  • Shortage of curricular time and competition with other training activities.
Recommendations

With respect to individual professionals

Ensure that teachers are sufficiently trained in and committed to the prevention of smoking and use of other addictive substances.
Provide feedback to teachers with data on changes in smoking behaviour and offer them updated preventive resources.

With respect to social context

Emphasise to teachers that the prevention of drug addiction involves teaching a personal skill: learning how to say no when you do not want to participate.
Support public policies on smoke-free places, and also those aimed at limiting the consumption of other addictive substances.

With respect to organisational and economic context

Increase the price of tobacco and alcohol.
Advertising campaigns supporting non-smokers and promoting the enjoyment of free time without drugs can be effective.
It is helpful to provide regular high-quality information to families and school staff on the progress of the implementation of the programme.

Note from the authors

Implemented in the region of Catalunya.
It is also offered, in a complementary way in Spanish, in Navarra.

Number of implementations
1
Country
Spain
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