A growing body of international evidence demonstrates that prevention and early intervention programmes can significantly enhance child outcomes and contribute to better adult functioning and wellbeing (Allen, 2011). Children who show early signs of maladjustment are at greater risk of poorer adult outcomes including antisocial behaviour, criminality, low occupational status, welfare dependence, teenage parenthood and problematic relationships in adult life (Rutter et al., 2006; Odgers et al., 2008). Patterns of psychological problems and social dependency have also been found to echo across successive generations of the same family, perpetuating the cycle of disadvantage (Serbin and Kemp, 2004; Belsky et al., 2009). These difficulties have profound social and economic implications and costs, not only for affected individuals and families, but also for wider society (Scott, 2005).
Research has found that improvements in childhood outcomes are pivotal to preventing or alleviating harmful life trajectories and interrupting what is often an ntergenerational cycle of disadvantage (Engel et al., 2011). Children from birth to three years may be the most receptive to intervention, and early intervention and prevention programmes have also been found to more cost-effective than later interventions (Zero to Three, 2012). In addition, public investment in prevention and early intervention services must represent good value for money and policy makers, practitioners and researchers must work towards optimising the return on any such investment.
Development of early years services/interventions in Ireland
There has been a growing commitment in Ireland to investing in high-quality child and family services (DCYA, 2014). Recent years have seen the expansion of community-based initiatives based around prevention and early intervention programmes which focus on providing parenting supports and target childhood inequality (DCYA, 2013). There has also been increasing investment in research (DCYA, 2011) and considerable strides have been made towards identifying evidence-based parenting supports which can improve child outcomes in an Irish context. For example, the Incredible Years Ireland research programme demonstrated that group-based parenting programmes can result in sustained clinically significant improvements in child adjustment and in parental mental health and wellbeing whilst they are also cost-effective with potential long-run economic returns (McGilloway et al., 2012; McGilloway et al., 2014; O’Neill et al., 2013). Despite such developments, research also indicates that parenting programmes may not always reach, or meet the complex needs of, the most disadvantaged and vulnerable children and families (McGilloway et al. 2014; Reyno and McGrath, 2006). Notwithstanding the burgeoning research in this area, gaps remain in our understanding of what constitutes effective and cost-effective parenting intervention in the earliest years of life. Research is also needed to further our understanding of effective implementation and how evidence-based programmes can be embedded within routine or usual care services both in Ireland and elsewhere.
In this paper, we describe an innovative early years service model and research programme. The ‘Up to 2’ or ‘Parent and Infant’ programme is a complex, multicomponent intervention for parents and infants aged 0-2years. This new programme is being evaluated as part of the ENRICH (EvaluatioN of wRaparound in Ireland for CHildren and Families) research programme – a five-year programme of research funded by the Health Research Board and being undertaken by a research team in Maynooth University’s Department of Psychology, in collaboration with a multidisciplinary consortium of senior academics from other national and international institutions.
The local service model
The Up to 2/Parent and Infant (PIN) programme was developed by Archways (an NGO that specialises in the promotion of evidence-based programmes for children and young people), in collaboration with Public Health Nurses (PHNs) and other community-based organisations. The new programme is rooted in the principles of wraparound intervention and involves collaboration between key multi-disciplinary stakeholders to tailor service delivery to child/family/community needs, address multiple risk factors, tackle gaps in treatment and address barriers to engagement for ‘harder to reach’ families (Bruns and Walker, 2011).
The programme combines a range of developmentally-appropriate parent and family supports delivered in a single intervention process (Figure 1). The programme is designed to be flexible in the sense that content and delivery can be tailored to family/community needs, but also has standardised core elements including two newly developed Incredible Years parenting programmes. Parents who have recently given birth are offered a 16-week mother and infant programme straddling the first 6 months of development. During this period, the Incredible Years Parent and Baby Programme (IY-PBP) will be delivered in conjunction with information and awareness-raising workshops and courses for new mothers (e.g. baby massage classes, weaning workshops, paediatric first aid course; toddler healthy eating classes). Around the 12 month developmental period, further support is provided through a play and oral language development programme. Subsequently, when the child reaches 18 months, the Incredible Years Parent and Toddler Programme (IY-PTP) will be delivered.
The goals of the programme are to: enhance parent-infant relationships and encourage secure attachment; empower parents, strengthen parent competency and build social support networks; encourage prevent child injury; promote cognitive and pre-literacy skills; prevent conduct-disordered behaviour; and enhance infant socio-emotional development.
The programme is being implemented as part of the Area Based Childhood (ABC) programme in two separate sites in Ireland: Clondalkin, Co. Dublin and Drogheda/Dundalk, Co. Louth. Both areas are characterised by significant socioeconomic disadvantage. The programme is expected to be delivered at any one time point to two to three groups of parents (each group will comprise approximately ten parents) in cycles over the course of one year. Programme delivery began in January 2015 in Clondalkin, whilst roll-out in Drogheda and Dundalk will commence in September 2015.
The ENRICH research evaluation
The ENRICH research programme involves a methodologically rigorous, multi-method evaluation comprising three interlocking studies including: (1) a longitudinal, controlled before-and-after impact evaluation to assess the effectiveness of the new programme; (2) a process evaluation to explore programme implementation and the contextual factors that influence or shape implementation; and (3) an economic analysis designed to assess the cost-effectiveness and longer-run cost-benefits of the programme.
The specific objectives are as follows:
• To analyse the impact of the programme on parent and infant outcomes including parental competencies, parental psychological wellbeing, parent-child interactions, the home environment and child development and socio-emotional wellbeing, and to compare outcomes in the short to medium term between families who receive wraparound supports and those receiving services as usual.
• To document how the intervention was developed and examine in detail the implementation processes and mechanisms, including the extent to which the intervention was delivered as intended (e.g. implementation fidelity; theoretical fidelity).
• To describe the patterns of parental engagement with, and response to, the programme and to explore, in parallel, contextual factors which may facilitate or inhibit effective implementation processes.
• To investigate patterns of service utilisation, calculate the costs of service delivery and combine data on outcomes and costs to estimate the programme’s cost-effectiveness, as well as longer-run cost-benefits.
A significant proportion of Irish children are at risk of adverse early experiences which, in turn, may undermine their ability to achieve their full potential (Williams et al., 2009). However, there remain significant barriers to ensuring that vulnerable children and families receive high quality prevention and early intervention services (Horwitz et al., 2010). In the context of an increasing commitment to public investment in early years services, it is imperative that high quality research is conducted to identify and evaluate programmes which meet the complex needs of vulnerable families and to help articulate how such services can be embedded within mainstream settings in Ireland. The first set of findings emerging from this research programme should be available in early 2016 and it is envisaged that this study will provide important information about the implementation, effectiveness and cost-effectiveness, of a new wraparound model of service provision for parents and infants. The research will also generate valuable insights into the factors which facilitate or impede the effectiveness of early years parenting supports.
Another important element of this research will involve the development of a model of knowledge transfer based on an analysis of barriers and facilitators to the transfer of research evidence into child health and social care policy and practice. The aim of this strand of work is to enhance the utilisation of a high quality evidence base that has been, and continues to be, generated by many early childhood-focused researchers in collaboration with practitioners and service providers throughout Ireland.
We are grateful to the Health Research Board for supporting the ENRICH research programme through its new Collaborative Applied Research Grants scheme.
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Dr Gráinne Hickey is Research Programme Manager on the ENRICH team. Her research interests include child development, prevention and early intervention, evidence-based practice, evaluation and public health research.
Dr Sinéad McGilloway is the Principal Investigator of the ENRICH programme and Director of the Mental Health and Social Research Unit at Maynooth University Department of Psychology. She has research interests in child and adult mental health, /mental health services, research evaluation, early intervention and prevention, systematic reviews and palliative care.
Shane Leavy is a Research Assistant and Data Manager with the ENRICH team. He holds an MSc in Applied Social Research and has worked on a range of research projects with the Economic and Social Research Institute.
Yvonne Leckey is a Researcher/Fieldwork Coordinator on the ENRICH programme. She holds an MA in Anthropology and has research interests in child development and mental health, early intervention and evidence-based practice, substance misuse and related health outcomes.
Dr Mairéad Furlong is a postdoctoral researcher with the ENRICH team. Her research interests include early intervention and evidence-based practice, systematic reviews, mixed methods and health and social inequities.
Siobhan O’Connor is a Doctoral Fellow on the ENRICH research programme and is working to develop a knowledge transfer model to address the use of research evidence in policy and practice within child health and social care.