Abstract
Controlled trials demonstrate that parenting programs work, but less is known about the processes of change, contextual factors or intervention characteristics that influence trial outcomes. This qualitative study assessed the experiences of Irish parents involved in a randomized controlled trial of the Incredible Years BASIC parenting program, with a view to understanding how and why the program works, or does not work, within disadvantaged settings. Data from 33 parents of young children (aged 3–7 years) with conduct problems were collected by semi-structured interviews and analysed using constructivist grounded theory. Emerging themes indicated that parents perceived the program to have produced positive changes through learning key parenting skills (e.g. positive attention, empathy and problem-solving skills) and through enhanced parental mood/confidence, derived primarily from gaining non-judgmental support from the group. Parents also experienced cultural, personal and environmental challenges in learning the new skills, including discomfort with praise and positive attention, conflict with their partner and parenting within an antisocial environment. Parents dropped out of the course for largely circumstantial reasons. These findings should help to inform the future implementation of this well-known parenting program both in Ireland and elsewhere.
Introduction
Conduct problems are estimated to affect approximately 5% to 10% of children aged 5 to 15 years in the United States, United Kingdom and Ireland, with the prevalence rate increasing to 20% in socially disadvantaged areas (Loeber & Farrington, 2001; Cleary, Nixon & Fitzgerald, 2004; Task Force, 2006). Children with the most severe disruptive behaviours may be diagnosed with Conduct Disorder or Oppositional Defiant Disorder, but less severe conduct problems, if left untreated, may also develop into Conduct Disorder (Burke, Loeber & Birmaher, 2002). Early onset conduct problems tend to develop in the context of punitive and inconsistent parenting (Patterson & Yoerger, 2002), and can lead to an increased risk of future antisocial and criminal behaviour, early school leaving and low occupational status, as well as greater utilization of health, education, social and legal services (Farrington & Welsh, 2007; Scott, Knapp, Henderson & Maughan, 2001).
Although the incidence of childhood conduct problems is a cause for public concern, there is increasing evidence that parent training interventions provide a cost-effective means of preventing and treating conduct problems, particularly when delivered in a group format (NICE, 2006; Webster-Stratton & Hancock, 1998). The Incredible Years BASIC Preschool/Early School Years Parent Training (IYP) program has been identified in several systematic reviews (e.g. Brestan & Eyberg, 1998; Mihalic, Fagan, Irwin, Ballard & Elliot, 2002; NICE, 2006) as one of the few “model” parenting interventions that has proven effectiveness in improving parent-child interactions and child behaviour outcomes (e.g. Hutchings et al., 2007; Larsson et al., 2008; Webster-Stratton et al., 1998).
Despite the number of randomized controlled trials (RCTs) demonstrating the effectiveness of the IYP, less is known about processes of change, contextual factors or intervention characteristics that may have influenced trial outcomes, particularly when delivered in real-world service settings (Weersing & Weisz, 2002). Thus, qualitative analysis may help to identify the critical ingredients that contribute to success under ‘real world’ conditions, thereby informing the future development and refinement of the program. The development of a briefer, low-cost version of the program may become increasingly necessary in a recessionary era where there are limited economic resources available to services and organizations to implement the full program with fidelity, and especially the version of the program which comprises 22–24 weekly sessions (Webster-Stratton, Reid & Hammond, 2004).
Previous qualitative research of parents’ experiences of the IYP has suggested that several factors may act as the essential ingredients or mechanisms of change, including new-found parental confidence obtained through group support (Morch et al., 2004), the acquisition of new parenting skills (Patterson, Mockford & Stewart-Brown, 2005; Spitzer, Webster-Stratton & Hollinsworth, 1991) and the use of the group process to reflect on the experience of being parented in order to develop empathy for the child (Levac, McCay & Merka, & Reddon-D’Arcy, 2008). Correspondingly, previous mediator/moderator analyses in the field have investigated similar variables as putative mechanisms of change (e.g. parenting skills and parental mood/confidence), with varying results. For example, some studies have found that more depressed mothers tend to show greater improvement in conduct problems, suggesting that enhanced parental well-being may act as a mechanism of change (Bayder, Reid & Webster-Stratton, 2003; Beauchaine, Webster-Stratton & Reid, 2005; Gardner, Hutchings, Bywater & Whitaker, 2010), whereas other research indicates that this does not play a mediating role (Gardner, Burton & Klimes, 2006). Studies also vary in the extent to which a reduction in critical parenting (Bayder et al., 2003), or an increase in observed positive parenting strategies (Gardner et al., 2006), mediates outcomes. Only one study (Gardner et al., 2010) compared the relative mediating effects of critical and positive parenting skills and found that an increase in positive parenting skills was more important than a reduction in negative parenting practices in explaining trial outcomes. However, no specific skills were identified as being more instrumental than others. Thus, the essential ingredients of the IYP program are not yet wholly understood. Further qualitative research may provide a more detailed and comprehensive analysis as to which aspects of the program are considered by parents to be most influential in producing trial outcomes.
Transporting the IYP into ‘real world’ service settings, within socially disadvantaged communities and to countries with differing child-rearing traditions, poses an important challenge for the program (Gardner et al., 2010; Webster-Stratton, 2009). Two recent meta-analyses (Lundahl, Risser, & Lovejoy, 2006; Reyno & McGrath, 2006) concluded that children of disadvantaged parents, including those with depression, low income, and single parents, show poorer intervention outcomes when compared to those facing lower levels of adversity. The IYP has reported some success in engaging disadvantaged parents, largely due to its accessibility and strong focus on collaborative engagement with parents (Gardner et al., 2010; Hartman, Stage & Webster-Stratton, 2003). For example, Gardner et al. (2010) found that the IYP was at least as successful at helping the most disadvantaged families (teen or single parenthood, depressed mothers, very low income, high initial levels of problem behaviour) when compared to the more advantaged. However, other research indicates that parents of lower socioeconomic status tend to have an increased risk of non-engagement with parenting programs as they are typically more difficult to recruit and retain and more likely to relapse following completion of the program (Weissberg, Kumpfer & Seligman, 2003). Thus, qualitative research may reveal whether Irish parents from disadvantaged areas experience any additional challenges when participating in the IYP, while also enhancing our understanding of the reasons why parents may drop out of the program.
In addition, it is important to understand to what extent a program based on principles of child-directed play and praise will be accepted by Irish parents. Irish parenting culture has traditionally valued obedience, compliance and modesty, punishment of misdemeanours, coupled with a lack of positive reinforcement for desirable behaviours (Greene, 1994; Littleton, 2009). Other research has found substantial resistance to using praise for child compliance to parental instructions, in a variety of cultural groups, including African American families (Forehand & Kotchick, 2002) and South-Asian families (Paiva, 2008). However, it is important to note that no culture produces a homogenous set of values and there is also evidence which indicates that Irish parents are suspended between the uncertainties of conventional and newer parenting approaches, such that parents practise elements of both traditional, authoritarian parenting as well as more democratic or permissive parenting styles (Wieczorek-Deering et al., 1991; Williams et al., 2009).
This study was nested within a randomized controlled trial (RCT) of the Incredible Years BASIC Preschool/Early School Years Parent Training Program (IYP) in Ireland for children aged approximately 3–7 years (32–88 months) with persistent conduct problems (McGilloway et al., in press). The results of this trial showed statistically significant improvements on outcomes of childhood conduct problems, parental mental health and parenting practices in the intervention group when compared to the control group at six-month follow-up (McGilloway et al., 2009; McGilloway et al., in press). The current qualitative study, which was conducted to complement the quantitative analysis, aimed to assess Irish parents’ experiences of the IYP within high risk, socially disadvantaged settings. More specifically, the study objectives were to explore: (1) which aspects of the program were most valued by parents and perceived as producing positive changes; (2) what challenges they encountered in learning the new skills; and (3) the experiences of the small number of parents who dropped out of the program.
Method
Participants and settings
The RCT was delivered across five family resource centres based in four urban areas in Dublin which are designated as “disadvantaged” (Haase & Pratschke, 2008). Family resource centres aim to combat social disadvantage and improve family adjustment, and are typical of voluntary-sector, community-based services in Ireland. Families were recruited to the study using existing service systems including public health service waiting lists, local schools, community-based agencies and self-referral. A total of 149 families took part in the RCT. All index children met the eligibility criteria for inclusion in the study in terms of scoring above the clinical cut-off point on either subscale of the parent report Eyberg Child Behaviour Inventory (ECBI; Eyberg & Ross, 1978). Participants were randomly allocated, on a 2:1 ratio, to the IYP intervention (n = 103) or to a waiting list control group (n = 46). The intervention arm comprised nine groups, with each group containing 8–12 parents. Assessments were carried out at baseline and at six and 12 month follow-up periods. At six-month follow-up, 137 parents were retained in the trial.
For the qualitative study, one-to-one semi-structured interviews were undertaken at the six-month follow-up period with 33 parents (31 mothers and two fathers) who had participated in the IYP. Parents were recruited using a purposive sampling method in which prospective participants were approached for interview on the basis of key demographic variables (e.g. their marital status and age, age and gender of their child, level of socio-economic disadvantage) and their membership across the nine intervention groups. The parents had a mean age of 34 years; 21 were from two-parent families while 12 were lone parents. The sample of children included 21 boys and 12 girls who had a mean age of 57 months. Within the sample, 22 parents (67%) were socially disadvantaged when compared to average Irish norms (Central Statistics Office, 2009); 60% (90/149) of parents were socially disadvantaged in the overall RCT. There were no differences between those parents who were, and were not, interviewed in terms of any demographic variables. Twenty-five of the 33 interviewed participants attended 10 or more of all 14 sessions. Eight of the 33 interviewed parents (24%) dropped out of the intervention after completing less than five sessions and were interviewed to provide a “negative case” analysis. (Within the overall RCT, 32 parents (31%) dropped out after completing fewer than five sessions). All interviews took place in the parents’ homes.
Procedure/analysis
An interview schedule was devised in order to guide, and provide a framework for the interview. All interviews were recorded using a digital recorder and transcribed verbatim by the research interviewer (MF). The data from the semi-structured interviews were analyzed using constructivist grounded theory (Charmaz, 2006) in order to identify and organize emergent themes. Constructivist ground theory is similar to other methods of grounded theory (e.g. Glaser & Strauss, 1967) in terms of the overall approach to data analysis; that is, data are analyzed using line-by-line and focussed coding, constant comparison of data units to find similarities and variations within categories and hierarchical linking of categories to generate super-ordinate (or overarching) themes. For instance, within the current study, ‘initial codes on beneficial aspects of the programme developed into more focussed codes on ‘Importance of confidence’ and ‘Key skills taught in program’; both of these themes provided the basis for exploring an overarching theme of ‘Key mechanisms of change’.
However, the epistemological stance of constructivist grounded theory, unlike other grounded theory approaches, acknowledges the interpretive or constructivist nature of generating themes. For example, the Irish cultural background of the researchers meant that they were sensitive to the possibility that traditional Irish parenting practices might conflict with the positive ethos of the IYP. All of the data were coded and analysed by one author (MF) and an independent reviewer assessed the reliability of coding on eight of the 33 (25%) interviews. All parents gave written informed consent for their data to be published anonymously.
Intervention
This version of the Incredible Years BASIC Preschool/Early School Years Parent Training (IYP) program consists of 14 weekly, two-hour, parent-group training sessions guided by behavioural and social learning principles and delivered by trained IYP facilitators who received regular supervision. The program utilizes a collaborative approach and presents a structured sequence of topics. Topics include learning to play with the child, increasing positive behaviour through praise and incentives, and managing non-compliance and aggression through limit setting, ignoring, and other strategies. Sessions use videos, role-play, modelling, group discussions and homework to help parents rehearse and adopt positive parenting strategies (e.g. Webster-Stratton et al., 1998). Free transportation, crèche facilities or financial reimbursement for childcare and refreshments were provided for the participants to encourage attendance.
Implementation fidelity was demonstrated in the trial through the assessment of: (1) the percentage of all prescribed material covered by the group facilitators; and (2) parents’ satisfaction with the program. The findings showed high levels of implementation fidelity, in that group facilitators covered 90.32% (SD 5.77%) of all prescribed material and 97% of program attendees were either satisfied, or highly satisfied with the program (McGilloway et al., in press).
Results
Three main themes emerged from the analysis including: ‘perceived mechanisms of change’; ‘trials of parenting’; and ‘failure to launch’. Further sub-themes within each of these were also identified. See Table 1.
Themes and Subthemes of the Analysis (and proportion of respondents who spoke about these).
Percentages within the themes of ‘Mechanisms of change’ and ‘Trials of parenting’ represent proportions of parents (N = 25) who attended 10 or more sessions.
Proportions within the theme of ‘Failure to launch’ represent proportions of parents (N = 8) who dropped out from the course after less than five sessions.
Perceived mechanisms of change
All parent attendees (n = 25) reported that the IYP produced positive changes in the child’s behaviour and parent-child relationship, and that they derived personal mental health benefits for themselves and for their wider family and community networks. Parents attributed the key mechanisms of change more to the acquisition of positive parenting practices than to limit-setting skills and also to an increase in personal confidence.
Key skills and principles: “When I praised the good … the rest fell into place”
While parents found most of the program content to be relevant, they indicated that certain positive parenting skills (positive attention through play and praise, reacting calmly and problem-solving and developing empathy through labelling emotions) were most useful in helping them to manage their child’s behaviour. A large proportion of participant attendees (88%, 22/25) indicated that the most fundamental insight for them was to learn to focus on their child’s positive behaviour (achieved through play and praise) rather than constantly seeking to eliminate their child’s negative behaviour. Approximately half (13/25) of the parents reported that learning to become emotionally articulate helped them to attune to their child’s emotional state so as to understand the feelings of anxiety or frustration that may underlie misbehaviour. Almost two-thirds (16/25) identified one of the essential skills as learning to react more calmly and problem-solve when their child misbehaved. Although parents valued the effectiveness of play, more than half felt that they would have learned the skill in fewer sessions and that more time could perhaps be dedicated to teaching problem-solving skills.
I found that when I praised the good she was doing, the rest just fell into place.
I understand his temperament more now. I recognise when he’s nervous … He can get all hyper and destructive if he’s nervous because he’s acting out the feeling he has. I say, “Do you have stress-belly?” … And he’ll cuddle into me and say, “Yeah”, and he’ll calm down and he’s happier.
I grasped what they were saying around child-led play very quickly so they could have cut some of those sessions. But then again they kind of rushed through the problem-solving part and I would have liked more time around that.
Ten parents (40%) also indicated that limit-setting skills (e.g. consequences and follow-though, clear commands and ignore) were occasionally useful and were glad to learn that they could be authoritative with their children without being authoritarian. Time out was generally disliked by parents (n = 18) and perceived as difficult to implement. Interestingly, although most parents (20/25) reported that they entered the IYP to seek advice around “time out” or other disciplinary strategies to deal with their child’s conduct problems, all but two of this group (n = 18) related, at six month follow-up, that the use of skills such as positive attention were so effective that they obviated the need to regularly employ limit-setting skills:
“I don’t use the time out. I’m not sure whether I’m doing it wrong but it doesn’t work for me … I prefer to use other techniques really”.
“It’s great to have the back-up of warnings and consequences but I find that I rarely need to use them as he’s just great now with the play and praise”.
Increased confidence: “I know now that I’m a good enough parent”
All of the attendees (n = 25) reported that participation in the program had increased their confidence and well-being and helped them to believe that they could cope with any current or future behavioural difficulties. Typically, parents (22/25) explained that their new-found confidence was based on various aspects of the group experience; they valued the non-judgemental support received from the group facilitators and other parents, which helped to dispel/normalize parental feelings of guilt and isolation and also affirmed them as being “good enough” parents. In addition, 12 parents identified the experiential and collaborative learning format as a very encouraging aspect of the program as it established an egalitarian relationship between the parent and the group facilitator and allowed parents to set their own goals. Other important sources of confidence included the sense of competence and control which parents (25/25) experienced in being able to effect positive behavioural changes in their children. Even if some conduct problems had not improved, six parents indicated that they felt more confident because they perceived the problems more benignly. Seven parents also reported that their wellbeing and social life had improved due to receiving more support from their wider family who were now more willing to babysit as a result of the child’s improved behaviour:
Because you do tend to feel isolated that you’re the only one, that your child is the only one acting up like that. …We all really supported each other…I know now that I’m a good parent, even if I make mistakes.
I just feel more confident and competent as a parent. I have a system in place and I know I can help him with any obstacles that may happen in the future.
It was holistic … it wasn’t just about your child’s difficulties but about you as a whole person and I found that very welcome, being affirmed as a person. It’s about taking time for yourself and not always being focussed on the kids.
Trials of parenting
Whilst all attending parents derived some benefit from the program, they also experienced cultural, social and personal challenges in learning the skills. Potential barriers to program participation and success included: discomfort with the principle of positive attention and praise; living in a community with high levels of antisocial behaviour; increased conflict at home with their partner in implementing the new skills; and fears that without the group support, parents would slip into their old parenting patterns.
Difficulties with positive attention and “positivity”: “It’s a very ‘Irish’ thing…”
Approximately half of the parents (13/25) reported that during the initial sessions, they were puzzled why the program focussed on paying positive attention to their child and did not provide them with guidance on how to deal with negative behaviour. The emphasis on positive attention appeared to be inconsistent with their “informal” theories of successful parenting (e.g. negative behaviour should be punished immediately and not ignored) and, as a result, they found the program to be overly positive and unrealistic and believed it would not offer advice around eliminating behavioural problems. Twenty parents also found the vignettes to be too “American” in tone and overly positive:
I think, at the start, that it comes across as a bit fluffy … I wasn’t sure at the beginning that they would be dealing with more of the nitty-gritty … the time-out and the discipline. The positive thing doesn’t make much sense at first … it seems too “happy clappy”.
They [the vignettes] were somewhat contrived … A woman on my estate dropped out because she thought, “This is just silly nonsense, all happy smiling” … It was like watching the Cosby Show and I think it’s distracting and you have to get past it. I think Irish people would find it hard to relate to them.
Thirteen parents recounted their discomfort that praise and rewards might cause their children to become overbearing and arrogant:
It’s a very “Irish” thing not to give or accept praise … You know there is this thing: are you making them “bigheaded”, are you making them cocky, are you giving them too much confidence? … I know it works now … but at first when you praise them, it was really odd, awkward.’
Two parents experienced resistance towards praise, play and the generally positive relationship they were now building with their children because they felt envious, upset and angry that they had been treated harshly and had not received similar positive attention from their own parents. These two parents chose to attend counselling as they felt that they could not participate fully in the program if they did not deal with their unresolved childhood issues. Although eight other parents spontaneously reported that the course had caused them to reflect on their own experience of being parented, they did not report that their own personal history impeded their ability to implement the skills with their own children; rather they were grateful that the intergenerational cycle had been broken:
I think I would have given up the course if I hadn’t had the counsellor because it was too much at one point … I was jealous of the kids … And I think a lot of parents there haven’t had the perfect upbringing and I think there’s certain things that could come up out of the course that could upset a lot of people.
Fears of maintaining skills with lack of social support
Living in a disadvantaged community meant that many parents felt unsupported in implementing the skills. Approximately half (11/25) of the attendees reported that, while they could create a positive environment within their home, their children were routinely exposed to high levels of antisocial behaviour within their neighbourhood, which impacted negatively on the child’s behaviour:
This place is overrun with drugs and gangs … It is a horrible place to raise your children. I don’t personally allow my children out to play unless I’m there to supervise because there’s children and they’re as young as four and five and they are bullies. It is hard.
A similar proportion of parents (11/25) also reported a lack of support and increased conflict with partners or ex-partners due to the introduction of new behavioural management techniques in the home. Most parents (n = 20) would have preferred their partner to have attended the program, but most partners could not do so due to work or childcare obligations, although some partners were also resistant to the idea of a parenting program in the first place. The majority of the conflicts were resolved once partners witnessed the benefits of the program for themselves. However, four parents reported that, although their partner was less antagonistic than before, they still unwittingly caused confusion for the children as they did not implement the new techniques:
We had several rows about it … It’s hard to teach your partner the techniques you’ve learned in the class without sounding like you’re the “know-it-all” … But now he sees the difference hugely with the kids and I find now that he’s copying everything I’m doing and it’s all happier all round. I got him onside … eventually (laughs).
He often bulldozes through my system of rewards and consequences. He doesn’t mean to but it’s annoying.
Approximately half of the parents (11/25) reported that, without the group support, the daily implementation of the skills would be “hard work” and required much more conscious effort, time and organization on their part. As a result, they feared returning to some of their previous parenting patterns. These parents indicated that they would benefit from a refresher course in order to re-motivate themselves:
I have to make a big effort to keep it in my head, to keep the awareness of the techniques, or not I would let it go … I definitely miss the group … it kept me focussed … It’s quite a short, sharp burst as well. It’s 14 weeks after a lifetime of the other way of parenting.
“Failure to Launch”
The primary reasons (5/8) stated for leaving the course after less than five sessions, were predominantly practical or circumstantial in nature (i.e. starting a new job, illness, or having to care for a sick family member). One parent stated that she was seeking an alternative pharmacological intervention for her son’s conduct problems. Three parents also briefly mentioned potential intrusion of privacy as a concern since many parents within the group lived within the same area:
I didn’t like that talking about personal stuff … It was too confidential … Everyone knows everyone here.
I enjoyed the course but then I couldn’t go … my Mam got a stroke and there was no-one else to look after her so I had to.
Two parents indicated that they would not return to the IYP for a number of reasons: (1) they disliked the ethos of positive attention and the standardized format; (2) they would have preferred more individual, tailored advice for their problems; (3) they had previous experience of play (though psychology clinics) and had found it to be ineffective in reducing problem behaviour; and (4) they felt isolated from the other parents in the group, whom they perceived to have fewer problems with their children. One of the parents also seemed to struggle to attend the program in the morning:
All I wanted to know was how to nip a temper tantrum in the bud before it turned into a full-scale war … I’ve no problems in any other areas. I play with him all the time. I don’t need help with any of that. I just need help with his temper tantrums.
I felt really cranky after those sessions. It took a lot of effort to get to the place, to get the kids up … People were sitting around moaning and crying, talking all around the place and I was getting no tips or advice about how to deal with my child … They were looking down on you, like they were looking at you if you said that you’d slap him sometimes because he was so bold.
Discussion
Parenting programs are of considerable interest to researchers and practitioners and especially when informing the practical implementation of programs in routine settings. A key strength of this study lies in its focus on highlighting country-specific issues of parenting and punishment (and traditional Irish parenting values) and on identifying and exploring ‘mechanisms of change’. While many positive outcomes were achieved from participation in the IYP, this analysis underlines, firstly, the need for service providers to be alert to the cultural, personal and environmental challenges that exist for parents within disadvantaged settings when implementing an evidence-based parenting program. Initially, Irish parents were unconvinced that building a positive relationship with the child through play and praise would be an effective method of dealing with behavioural problems. They also expressed some discomfort that the praise and rewards, which are such an intrinsic part of the IYP, might cause their children to become overbearing and arrogant. This theme of discomfort and disbelief around the idea of positive attention has not been reported in other qualitative studies of parenting programs.
The fact that so many parents within the current study struggled with positive attention is an interesting and unique finding. This might be best understood against a historical and cultural backdrop of common punitive parenting practices in Ireland (Greene, 1994; Littleton, 2009) and particularly within socio-economically disadvantaged settings where children are placed at an increased risk of intergenerational transmission of conduct problems (Fleming et al., 2002). However, resistance to positive attention is not exclusively a localized issue as there is evidence that other cultures demonstrate similar opposition to praise (e.g. Paiva, 2008). There is growing awareness that providers of parenting programs should attempt to become more culturally sensitive so that parents are encouraged in early sessions to share their family and cultural traditions and experiences of being parented as children (Webster-Stratton, 2009). This approach shows respect for different cultures and parenting styles, and encourages parents to talk about any resistances to the new parenting skills which might, in turn, enhance retention rates. In addition, such cultural sensitivity would raise awareness that some parents may have suffered difficult childhood experiences and may require additional support from group providers in implementing the skills.
Another key contribution of this study lies in its exploration of aspects related to living in disadvantaged communities, which clearly leads to extra challenges for parents participating in a parenting program. Recent research (e.g. Gardner et al., 2010; Reyno et al., 2006) has investigated how particular indicators of social deprivation (low income, lone parenthood, and maternal depression) may, or may not moderate outcomes. However, the parents who completed the program in the current study reported that the negative influence of antisocial peers within their neighbourhoods presented a barrier to maintaining outcomes. Participants often feel unsupported in their parenting efforts and consequently may require additional post-course supports, such as the IY ADVANCE program (Webster-Stratton & Reid, 2010), or a multi-environment approach (Reid & Patterson, 2002), such as the Incredible Years child and teacher training programs, to achieve optimal results and to prevent future relapse. However, this study is consistent with other research (e.g. Lundahl et al., 2006) which shows that high levels of social deprivation may affect retention rates. Six of the eight ‘drop out’ parents came from severely disadvantaged backgrounds (including maternal depression, low education and a history of substance abuse or criminality). These parents generally provided a practical reason for non-attendance, but the researcher had a sense, supported by information from the group facilitators, that a circumstantial reason was perhaps given when actually the parent suffered from depression, substance abuse or a lack of support, and consequently found it difficult to get up in the morning and attend the program. The IYP has already enhanced the accessibility of the program for parents through the provision of transport and childcare (Hutchings, Gardner & Lane, 2004). However, extremely vulnerable parents may require additional supports, such as a family support worker, to get themselves and their children out in the mornings.
Another challenge reported by parents concerns the increased conflict with partners with regard to the introduction of new techniques. This theme has been reported in three other studies (Kelleher & McGilloway, 2006; Mockford & Barlow, 2004; Spitzer et al., 1991). Such parental tension is an undesirable side effect that may occur when only one parent participates in the IYP and is a source of concern, given the effect of marital conflict on the emotional and behavioural well-being of children (Golombok, 2000). Some evidence suggests that targeting marital satisfaction, with sessions addressing interparental communication, support and problem-solving, directly enhances the effects of parent training (Ireland, Sanders & Markie-Dadds, 2003). However, most of the interviewed parents would have preferred their partner to attend the parenting program at the same time and research indicates that the involvement of both parents enhances the long-term maintenance of results (Webster-Stratton, 1985). Promoting the attendance of fathers at parenting programs may include the training of more male group facilitators and increased provision of evening courses. On a wider policy level, increased paternal leave may be necessary to enable fathers to have more time for family life. This is an area in need of further research.
Understanding the critical ingredients of the IYP is necessary for the development of briefer, low-cost versions of the intervention. This qualitative analysis of parents’ experiences suggests that the key ingredients involve both the enhancement of parental confidence and teaching of positive skills, with a focus on positive attention and relationship-building though play and praise, developing emotional literacy and empathy and coaching in problem-solving. Other qualitative and quantitative research has also found that an increase in positive parenting skills, rather than a reduction in critical parenting, is an important mechanism of change in breaking the cycle of poor parenting (e.g. Gardner et al., 2010; Patterson et al., 2005; Spitzer et al., 1991). This study replicates and extends the results of other qualitative and quantitative research by identifying particular skills that parents found most valuable in effecting change. The current findings also suggest that limit-setting strategies could be covered in fewer sessions (as parents did not regularly need to employ them), and that more time could be dedicated to problem-solving, which would improve parental mental health and conflict-resolution with partners. Although parents valued the relationship-building properties of play, they believed that the skill could be taught in fewer sessions. More refined versions of the program, focusing on positive parenting skills, would require testing by means of RCTs in order to ascertain the extent to which beneficial outcomes are maintained. Future mediator analyses should also identify which particular positive parenting skills are most instrumental in explaining outcomes.
Similar to other qualitative research (e.g. Patterson et al., 2005), parents also emphasized increased personal confidence as being important in removing guilt and isolation and instilling self-efficacy beliefs—factors that are likely to be important in maintaining positive outcomes over time (Hutchings, Lane & Kelly, 2004; Hutchings, Bywater, Williams & Whitaker, in submission). Although RCTs typically demonstrate that the IYP improves parental mental health, only one study (Gardner et al., 2006) has investigated the mediating impact of parental mood. This found that parental mood/confidence did not mediate child outcomes but, unlike other RCTs, there was no improvement in parental depression. Although enhanced parental confidence did not appear to be necessary in that trial, future mediator analyses are necessary to assess the relative mediating effects of parental confidence and specific parenting skills.
As evidenced in the current study, reflecting on childhood experiences of being parented may be important for some parents in overcoming cultural and personal barriers to implementing play and praise skills. Levac et al., (2008) reported that such reflection was the principal mechanism of change within their study as parents came to understand the origins of negative parenting practices, which allowed for the development of new insights and a shift to more positive approaches. While ten parents in this study talked about their childhood experiences, such reflection did not seem to operate as a primary mechanism of change for enhanced child outcomes, but rather appeared as a by-product of participating in the program. The IYP does not include a module that specifically directs parents to reflect on the origins of negative parenting, but it is perhaps possible that group facilitators within the Levac et al., (2008) study, led parents to reflect on the history of their particular parenting styles. Future qualitative research should explore the relative importance of reflection on childhood experiences as a mechanism of change across different cultural backgrounds.
One important caveat to the analysis of intervention mechanisms is that parents cannot fully account for other essential ingredients at the organizational level, such as the supervision and training of group facilitators (Hutchings, Bywater & Daley, 2007). Nevertheless, parents’ experiences offer valuable information on their perceptions of how the program worked for them. Another limitation of the current study is the focus on only short-term outcomes while fathers were also under-represented in this sample. All of these issues were addressed during subsequent follow-up stages of data collection, which will be reported in due course. The findings are generalizable to the extent that they are consistent with themes reported in the small number of other qualitative studies that have been conducted in this area, although they also highlight the country-specific issues and social challenges in implementing an evidenced-based program within disadvantaged communities.
Footnotes
Acknowledgements
We would like to thank all the parents who participated in this research for speaking so openly about their experiences of the Incredible Years parenting program.
This research is funded by a national voluntary organization called Archways, with support from the Atlantic Philanthropies. The Incredible Years Ireland Study involves an independent evaluation of the Incredible Years series in Ireland. Archways were not involved in conducting the evaluation, although they worked with the research team during the recruitment process of the RCT (to ensure that sufficient numbers of parents were available within the time frame). Some of their staff was also involved in delivering the parent training program.