• By Kevin Mount
  • Posted on Thursday 22nd May, 2008

An "odd couple" traveling a long road

em>Implementation and evaluation of The Incredible Years in Ireland by the new Archways NGO represent an important step forward for prevention in the country. Here the program’s Canadian developer Carolyn Webster-Stratton and her highly influential disciple in Wales, Judy Hutchings, look back across 30 years of hard-won progress and contemplate the challenges ahead in Ireland and elsewhere.Carolyn Webster-Stratton It’s been exciting and heart warming to see what’s happening in Ireland. Archways are rolling our the Incredible Years programs with great attention to quality delivery and support for practitioners. I expect there’ll be a few stumbling blocks along the way as we’ve had in other countries. But the kinds of issues we’re facing today with implementing evidence-based programs is far different from those we had 30 years ago when no-one knew what an evidence-based program was! There was very little evidence to support prevention or children's mental health programs and very little interest in prevention then. Government was afraid to tinker in family life and support families by providing parenting programs. Look at what’s been achieved. Look at what you as a champion for children's mental health services have managed to do in Wales, Judy. That’s a fantastic story in its own right. It’s the story of what change is possible with the right evidence and the right determination - even on the part of a single individual.Judy Hutchings It probably reflects my childhood origins in the Labour Party and the Peace Movement! If there’s one person you can change it's yourself and by changing yourself you can change others. But moving forward I’m a little more optimistic for Europe than I am for the US. For all its faults we still have universal health care. We have resources in Europe. For a long time we didn't need to bother about effectiveness. Now we do, and that creates a great opportunity for prevention.CW-S You may be right about the European context. But in all places the challenge is to get the programs embedded in ongoing services. Too many people think that 12 or 20 sessions of The Incredible Years is an inoculation for families for life. I think that’s short-sighted. I'd like to see prevention programs being offered across the lifespan. Why not offer parenting training or consultation at each of the sensitive periods of children's development – at key points of transition such as during infancy, the preschool period, then early school age, then adolescence. At each developmental transition parents would get support and understanding of the issues involved in the next developmental phase and ideas about how to manage these. It would be like having a "tune up" every 1000 miles as your child matures. Parenting changes over time. What you learn about responding to baby's cries is different from managing a teenager's homework issues.JH Yes, even where we’ve got The Incredible Years in Wales into basic prevention services like Children's Centres it’s not truly universal. There’s a long way to go before we stop thinking of prevention as an inoculation for children from economically disadvantaged families. In the UK context I’d like to see all Health Visitors trained in these methods. They understand child development and they can spot the parents who are likely to have later problems and they’re very receptive to the collaborative, attachment-based, philosophy of Incredible Years programs.CW-S Unfortunately we don't provide universal Health Visitor or home visiting nursing provision in the US, but school psychologists, counselors and public health nurses may represent a similar opportunity. Getting a better connection between schools and mental health services, and utilizing schools as the home of service delivery for children is something that should happen on both sides of the Atlantic. It’s a less stigmatizing way of offering these services to large numbers of families and also for strengthening communities around schools.JH Too often existing provision is a hindrance to effective prevention and intervention. Some provision hasn’t kept pace with changing needs and knowledge. I worry for example about the training of mental health workers, about how to ensure that they get a broad education covering behavioral, collaborative and counseling skills.CW-S And everywhere there’s a tendency to spend a long time doing assessments and then not providing any services. Or a long assessment followed by referral to a mental health clinic which isn’t then taken up by the family. Your doctoral study Judy I think showed nearly a third of children referred aren’t seen. We find the same thing in Head Start. The teacher may refer a child for mental health services but rarely do the families take up this help. And it’s practical things that get in the way. A family that can’t afford a bus fare. A parent who can’t get time off work for a daytime appointment. Or they simply may be unable to work out how to get to this clinic.JH It’s true. I found 40% referred to child and adolescent mental health services never attended their first appointment and the only predictive factor was low socio-economic status. That’s an issue. Another is how to take prevention programs like Incredible Years to scale while preserving the effective components. The Welsh Government are making the Incredible Years programs widely available and are incorporating the essential supervision and consultation. For a sustainable service that means getting 22 mentors, one for every county in Wales. After ten years of hard work and the most rigorous evidence of effectiveness in the country, so far we have just two mentors. Although it should be said that Government in Wales has given a five year commitment to the program and the roll-out in Wales is only just starting its third year.CW-S Here in Seattle we’ve tried to provide a lot of support to help schools, agencies and countries around the world to move forward with delivering Incredible Years programs. We’ve sent our people all over to train group leaders, therapists and teachers. But in the long term our goal is to help agencies or districts to become more self-sufficient and to be able to set up an infrastructure so they can do their own training and provide their own consultation and quality control. But typically we see that most agencies or schools have a short-term vision. They want their current staff trained and have a grant for a limited time. They don't have plans for a five or ten year period. They seldom have a plan for sustainability of services offered. Even the six Pathfinder sites supported recently by the UK Government were given just 18 months to establish a base, and it was three months into that time frame before their budgets were confirmed. A year and a half is not sufficient to accredit a group leader let alone an accredited mentor to deliver training and supervision to other group leaders. Also when a grant runs out or when the current trained group leader changes jobs, the programs may be dropped. And the agency’s investment in delivering the program is lost because of a lack of longer range planning.JH Good mentors and accredited group leaders are so important if we’re taking the programs to scale. And we need clinicians who are also researchers to monitor outcomes and lead the work forward. We have good clinicians. We have good researchers. But we don't have people who can do both.CW-S We’re bit of an odd couple you and I, Judy. We’re clinicians who want to do research. Why are there so few of us? I think it makes a big difference in the advancement of effective prevention programs to both run groups and research them. I ran two 20-week groups myself this year. I think you do more than me. How important this skill is, Judy. Why is there such a disconnect between researchers and clinicians? How can we train clinicians to think more like researchers and researchers to think more like clinicians.JH I think its structural. Universities are wonderful places for researchers. And they rightly have expectations to bring in grants and publish. But they don't adapt for the clinician, as I myself have found. Children's services can support good clinicians, but they don't create opportunities for research, innovation and there’s no reward for bringing in grants or publishing. I have a wonderful researcher to take forward the work in Wales. And I've a wonderful clinician to take forward the training. But I haven't found the person who has the opportunity to do both.CW-S Well clearly we still have much to do! But when we started this journey there were so many obstacles and slowly, one by one, they’ve been overcome. Now we’ve reached this stage on the road there are more barriers to overcome, but we can use our experience to tackle them. And there are more of us now than in the past. I’m optimistic that significant differences in parenting can be achieved in the future, with children's health and development being the major beneficiary.

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