• By Dartington SRU
  • Posted on Friday 27th January, 2012

A rare view into the designers’ workshop

Finding the right program or intervention to meet a family's needs is like shopping for a new outfit. You might get lucky and find the perfect fit in the first shop you enter. Or you might need to try on a few before finding one that really suits, or go to several shops before being able to buy. Sometimes you go home empty handed because there is nothing that meets your needs.The same is true for interventions. Not everything works for everybody, and sometimes a family will need to try several different interventions or visit several agencies before finding something that works for them. But what happens when nothing “fits,” when what is on offer and what is required do not match? Is it time to go back to the drawing board and design something new?We don't tend to talk about the design process in children's services. The pages of this website are full of stories about programs that have been put through their paces to find out their impact on children's lives – but we, and the researchers who assess them, usually see them as finished products. Rarely do we get to open the door to the designers’ workshop, and see the thinking and design work that takes an idea from the drawing board into the real world.A recent article by an international group of psychiatrists describes their work to develop a new intervention for children with severe and persistent conduct problems. The collaboration, led by Crispin Day of the UK’s National Academy for Parenting Research at King’s College London with two Australian universities, used a framework from the UK’s Medical Research Council that sets out a series of phases for developing and evaluating complex interventions to guide their design work.Phase 1: The Case for the InnovationIn Phase 1, the concern was with theory – that is, establishing a logical case for the innovation and its underlying principles. Day and colleagues started with a literature search and consultations with experts. They needed to determine what current research says about the pathways that lead to persistent and severe conduct disorder, the necessary features of interventions that might work, and the best ways of optimizing family participation.Unsurprisingly, they found that there is no single causal pathway that neatly determines problematic behavior. Rather, there is an unpredictable interplay of a familiar set of child, family, and social factors – including a child’s early impulse control difficulties, harsh and uninvolved parenting, and poverty. As a result, they needed to design an intervention that could both address the common key risk factors and be adjusted to the child and their family's circumstances.While they reviewed a number of promising interventions, none specifically targeted children who were at risk of primary school exclusion. The team concluded that there was indeed a case for designing something new.Finally, the team’s trawl through the literature highlighted the practical problems that families often have in making use of services, such as being able to get to the venue and feeling respected rather than judged by practitioners. These barriers, too, were factored into the design process.Phase 2: The Program ComponentsPhase 2 turned to setting out the program components. The first step was to determine who the program would serve – and who it wouldn’t. The Helping Families Programme was designed to treat children aged 5-11 years who have severe conduct disorder and are at risk for school exclusion. Families were also expected to have at least one additional risk factor, such as substance misuse, lack of supportive social networks, or frequent family crises. However, families were ineligible if children had severe mental or developmental disabilities, if parents had acute mental illness or low levels of spoken English, or if sexual abuse was a concern.The next step was to determine the underlying principles of the program. In this case, the collaborators decided to take a “strengths-based and future-oriented” approach targeting parents' behavior, cognition, and emotional regulation. This means that practitioners would focus less on why the family is in their current situation, and more on what will help them change it.The strategies and techniques of the program were documented in a practitioner's handbook and manual with the expectation that it would take a minimum of 20 weeks of contact, with multiple contacts per week, to effect change. Families were to be engaged by “proactive and assertive outreach” and offered the program in a location of their choosing, including in the home.Phase 3: Pilot and AdjustmentNow, the Helping Families Programme is in Phase 3 – the pilot phase. While no data are yet available about its potential impact, useful information is already emerging that has challenged the designers’ assumptions. Families, it turns out, do not want contact more than once per week. Many are already in contact with multiple agencies. One family had contact with 28 workers from 14 different agencies! Families appear to appreciate the emphasis on partnership between parents and practitioners. And if voting with your feet is a measure of satisfaction, an attendance of 94% of sessions is a good endorsement.The results of this study will be reported as a single case study analysis. If successful, further design and refinement will take place in preparation for a larger comparative evaluation.A model processDay and colleagues have followed a design process that has appropriate and proportionate monitoring and evaluation built into each phase. They are clear about the standard of evidence they will need to generate at each stage to provide a compelling rationale for further refinement, testing as they move closer to making their program replicable and suitable for use at scale.This view into the designers’ workshop offers a model for the design and introduction of evidence-based children’s interventions – and a strong rebuke to children’s services policy that introduces interventions without consideration of a theory of change, the existing evidence base, or how impact will be reliably measured. References: Day, C., Kowalenko, S., Ellis, M., Dawe, S., Harnett, P., & Scott, S. (2011). The Helping Families Programme: a new parenting intervention for children with severe and persistent conduct problems. Child and Adolescent Mental Health, 16 (3), 167-171.Campbell, M., Fitzpatrick R., Haines, A., Kinmonth, A.L., Sandercock, P., Spiegelhalter, D., & Tyrer, P. (2000). Framework for design and evaluation of complex interventions to improve health. British Medical Journal, 321, 694-696.

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