Written evidence submitted by Triple P UK (CYP0070)

Executive Summary

• The mental health of children and young people is of great importance. Mental health problems are common among young people, affecting one in six school-aged children[1], or an average three in every classroom[2].

• One in twenty (4.6%) five to 19-year-olds has a behavioural disorder, with rates higher in boys than girls.1 In 2020, one in six (16.0%) children aged five to 16 years were identified as having a probable mental disorder, including anxiety and depression, increasing from one in nine (10.8%) in 2017.[3]

• The Government must act to limit the deterioration of children’s mental health, and in particular, the effects COVID-19 has had on young people’s mental health, to ensure we are not at risk of losing a generation of young people to poverty and poor mental health.

• Triple P – Positive Parenting Program® is designed to improve the health and wellbeing of communities by supporting the development of more resilient and nurturing families.4 It is the most extensively evaluated parenting intervention system in the world.[4]

• Triple P UK have worked with Local Authorities across the country for many years and have seen first-hand the challenges children face, in turn innovating new, unique, and dynamic ways to support families, particularly in the face of COVID-19. 

• To support children, help prevent the negative impact of isolation and social distancing from following young people into their later life, and support the increased level of clinical need we have seen in recent years, the Government should invest in evidence-based parenting programmes. Such programmes have the potential to create healthier communities by improving children’s and parents’ mental health, cultivating stable home environments, reducing parental conflict, and reducing child abuse and neglect.

Introduction to Triple P

1. This is a submission by Triple P UK to the Health and Social Care Committee of the House of Commons’ Inquiry into the mental health of children and young people.

2. Triple P UK is a social enterprise providing training, resources, and implementation support to organisations across the UK and Ireland seeking to create healthier communities by improving children’s and parents’ mental health, cultivating stable home environments, reducing parental conflict, and reducing child abuse and neglect.[5]

3. The Triple P – Positive Parenting Program® - is designed to improve the health and wellbeing of communities by supporting the development of more resilient and nurturing families.4 It is one of the most extensively evaluated parenting interventions in the world.4

4. The Triple P evidence base has been growing for over 40 years, with more than 690 published papers across 35 countries, including 349 evaluation papers, 170 of which are randomised controlled trials (RCTs).

5. Triple P is a system of 25+ evidence-based interventions. Triple P programmes are classified through a five-level system that addresses service intensity (i.e. the level of support parents may need) and how parents access this support (e.g. one-to-one, groups, online). 

6. Triple P is NICE guideline compliant for the prevention and treatment of antisocial behaviour and conduct disorder[6], ADHD[7], and challenging behaviour in children with learning disabilities[8]. These conduct problems in children are regarded as perhaps the most reliable early indicator of adult mental health problems.[9]

7. We have worked extensively across different government departments, including the Department for Health and Social Care (DHSC), Department for Work and Pensions (DWP) and Department for Education, as well as targeted work with Local Authorities, NHS Trusts and Clinical Commissioning Groups.

8. We operate in more than half of England’s Local Authorities, and offer a wide range of delivery models, including group sessions, seminars, individual support, and online training.

Why we are submitting to this consultation

9. Triple P UK fully recognises the ways in which COVID-19 has exacerbated existing mental health issues and triggered additional problems in children and young people.

10. We believe that the best way to counteract this in the short, medium, and long-term is to fully commit to evidence-based approaches and provide a framework which supports young people and families throughout every stage of childhood and adolescence.

11. We are encouraged by the increased focus on evidence-based programmes, and the DHSC’s commitment to increasing the breath and depth of its evidence base, but believe this needs to be accelerated to meet the burgeoning demand being placed on mental health services across the UK in the wake of COVID-19.

12. Triple P has also experienced first-hand the need to adapt quickly to the changing landscape, requiring technological solutions, and have responded to this to meet the need to reach vulnerable young people and families.

Government progression in addressing children and young people’s mental health, including but not limited to:

The ambitions laid out in the 2017 Green Paper

13. As the Mental Health Green Paper described, the links between mental ill-health and Adverse Childhood Experiences (ACEs) are stark, in turn estimating that 45% of looked after children have a diagnosable mental disorder (compared to 10% of all children).[10]

14. This number has increased, with the Centre for Mental Health now estimating that 75% of children in care have a diagnosable mental health problem[11].

15. More so, as pointed out in the Green Paper, a study by SafeLives showed 52% of children who witness domestic abuse experienced behavioural problems and issues with social development and relationships.10

16. In conjunction with high rates of mental ill-health among children, there are difficulties accessing those who need support. The Centre for Mental Health estimates that 75% of children and young people experiencing a mental health problem do not currently access treatment.

17. Clearly, the prevention of ACEs is a central tenet to any strategy to support the mental health for children and young people, and the stark increase in young people with diagnosable mental health problems demonstrates that more must be done to prevent ACEs in young people’s lives. Triple P’s programmes have a long established and evidenced history of combatting ACEs through a system of prevention and early intervention.[12]

18. The Green Paper said it would “look to test how teams can effectively link to social care services, youth offending teams and troubled families’ teams to provide alternative points of entry and better continuity of support to the most vulnerable.”10

19. Triple P has welcomed this integrated approach and has seen a notable increase in the quality and quantity of referrals it has received.

20. The Paper also confirmed it would “commission further research into interventions that support parents and carers to build and/or improve the quality of attachment relationships with their babies.”10

21. Triple P has been closely involved with this, having spoken at length with officials in DHSC, as well as through ‘Deep Dive’ sessions alongside Andrea Leadsom MP, Tim Loughton MP and Miriam Cates MP.

22. We have also developed Baby Triple P, an eight-session programme delivered through four group sessions, and four individual sessions, for parents during their transition to parenthood or with babies up to 12 months.

23. Baby Triple P targets the following areas:
• Positive parenting skills to promote secure attachment and reduce parent and infant distress.
• Improve partner and social support to increase overall family well-being.
• Increase parental coping resources to reduce the risk of mental health problems developing.

24. The randomised controlled trial (RCT) outcomes of Baby Triple P indicate programme participation can significantly enhance child development when compared to usual care. Improvements include:
• Babies around six-months of age are awake and content more often, with less periods of inconsolable crying.[13]
• At two years of age, pre-term children have significantly higher cognitive function and motor skills, with slightly better language skills. [14]

The programme also has a positive impact for parents when compared to usual care groups:

• Mothers with post-natal depression report favourable improvements in happiness, self-regulation, subjective bonding, and depression.[15]
• First time mothers report significantly lower levels of depression and first-time fathers report significantly lower levels of anxiety.[16]

25. We have also undertaken a review of other comparable programmes and found that overall, Baby Triple P:
• Has more robust evidence with positive findings in the UK context.
• Has a low programme dose (nine hours), which translated to potential for cost-effectiveness and reduced participant and provider burden.
• Has flexibility to deliver in-person, remotely or via the telephone.
• Is designed to support during both antenatal and postnatal periods, providing continuity of care as families transition across community support touchpoints.
• Positive outcomes for both mothers and fathers.
• Evidence of acceptability across high- and low-risk populations.13, 15, 16, [17],[18], [19]

26. We are encouraged by the steps that the Department is taking to support the mental and physical health of children in the early years and stand ready to support the findings and outcomes of Leadsom’s report into Early Years in the coming months.

27. Triple P worked extensively with the Department for Work and Pensions (DWP) on its ‘Reducing Parental Conflict’ programme. The programme has made significant in-roads into highlighting the impact of parental conflict and raising awareness within the wider children and families workforce by testing a small number of interventions that have robustly demonstrated the ability to improve parents’ mental health, co-parent acrimony and communication during separation and divorce.[20]

28. As NHS England’s recent survey on the mental health of children and young people showed, among 11- to 16-year-old girls, 63.8% with a probable mental disorder had seen or heard an argument among adults in the household.3 This highlights the damaging impact of unstable home lives to young people and underlines the importance of placing parenting support at the centre of attempts to support young people’s mental health.

29. One of Triple P’s programmes is Family Transitions Triple P, an intensive intervention for parents experiencing difficulties as a consequence of separation or divorce. The programme is rated as one of the few robustly evidenced interventions in this space by the Early Intervention Foundation (EIF).[21]

30. The programme aims to:
• Improve parents’ personal coping skills in managing transition through separation or divorce.
• Increase parents’ competence and confidence in raising children.
• Reduce parents’ level of emotional distress (including depression, stress, anxiety, anger).
• Improve parents’ communication about co-parenting issues.
• Reduce the use of coercive and punitive methods of disciplining children.
• Improve the parent–child relationship.

31. Throughout the Green Paper, there are calls to increase the breadth and depth of the department’s evidence-base, which in turn would inform what provision would be supported in the future.10 Though there have been notable successes, we believe that greater faith needs to be placed in the commissioning of evidence-based programmes.

32. The Green Paper stated an ambition to “encourage local areas to improve their existing support of families… [through] evidence-based commissioning of interventions aimed at supporting parents and carers.”10

33. As has been argued by The Early Intervention Foundation[22], the Centre for Mental Health[23] and Social Mobility Commission[24], there are still steps to go to ensure that this commitment to evidence-based commissioning becomes embedded in Local Authorities’ processes.

Provision of mental health support in schools

34. One of our most recent programmes, Fear-Less Triple P, teaches parents positive ways to respond to children’s anxiety and supports parents to learn new cognitive behavioural strategies to help children manage their own anxiety.

35. This programme has been rolled-out through the Better Finglas centre in Dublin, Ireland, and has already seen extremely positive outcomes.

36. A recent newsletter from Barnardos[25] noted that the nearly 40% (38.7%) of children whose parents received Fear-Less Triple P were free from any anxiety disorder in comparison with just 3.4% whose parents received no intervention.[26]

37. Researchers found that Fear-Less Triple P was “more accessible, shorter and cheaper than the average CBT programme for anxiety experiencing children in Australia,” where the intervention originated, while still offering “comparable” recovery rates reported when evaluating individual child-focused CBT.25, 26

38. Barnardos concluded that Fear-Less Triple P is “a promising alternative to child-only based therapies, offering greater access through community roll out, fewer barriers to participation (waiting lists and costs) and actively empowering parents by teaching them the CBT strategies that they can then model and teach to their children.” 25,

Improving access to mental health services

39. Since February 2020, there has been a near five-fold increase in the level of targeted online support Triple P has been asked to provide, something which speaks to the clear demand for parental support and the ways in which our blended delivery models can help support this.

40. Triple P recognises that the impact of COVID-19 will extend far beyond the end of this current national lockdown and will place additional strain on mental health services.

41. The Department must do more to support the impact the pandemic has had on the mental health of young people and children. In order to address the increased level of need, the Department must look at models which reach parents and young people at pace and scale, to reduce waiting times and provide adequate support, which reduces referrals.

42. Triple P has been able to reach a significant number of families during COVID-19 thanks to their self-guided web-based intervention, Triple P Online.

43. Triple P Online was the first online parenting programme to be used in a randomised controlled trial that demonstrated sustained improvements in child and family outcomes.[27] It has been available since 2011 and has comparable outcomes to face-to-face delivery.[28]

44. Positive research outcomes have been demonstrated in seven randomised controlled trials (in the UK, Australia, New Zealand, and the US), including for parents of children with ADHD symptoms.27, [29], [30], [31], [32], [33], [34] 

45. Triple Online has been evaluated in a number of studies and has been shown to improve several parent and child outcomes, with effects largely being maintained at follow-up. Positive outcomes include:

• Improved child behaviour, reduced child conduct and emotional problems, or reduced ADHD symptoms 27, 29-34
• Improved parenting style, practices or use of positive parenting strategies27, 29-33
• Improved parental sense of competence, confidence, satisfaction or self-efficacy27, 29, 30, 32, 34
• Reduced parental anger, stress or depression27, 29, 31, 34
• Decreased risk of child maltreatment and inter-parental conflict, both maternally and paternally[35]

46. The Early Intervention Foundation (EIF) has reviewed the evidence for Triple P Online and given it an ‘evidence of efficacy’ ranking – it is also the only online programme on the EIF Guidebook rated to have evidence of efficacy.[36] The EIF Guidebook also recognises Triple P Online as low-cost to set up and deliver.

47. The EIF’s recent ‘COVID-19 and early intervention: Evidence, challenges and risks relating to virtual and digital delivery’ report highlights Triple P Online as one of the very few digital interventions that has robust evidence.[37]

48. Triple P Online is a vitally important tool that would create a significant increase in reach and access of evidence-based parenting support to help meet demand, and support the needs of heightened stress in families juggling children, working and schooling at home as well as other significant stressors (e.g. financial, relationship, personal, parenting).

49. The national availability of Triple P Online for vulnerable families in the United Kingdom has also been recommended by a report produced by the Behavioural Insights Team, funded by the Joseph Rowntree Foundation.[38] The report, ‘Poverty and Decision Making: How behavioural science can improve opportunity in the UK’, made the following recommendation:

“The government should provide families in or near poverty with free access to online parenting programmes that are supported by rigorous evaluations (Asmussen, Feinstein, Martin, & Chowdry, 2016; Nieuwboer, Fukkink, & Hermanns, 2013). For example, RCT evidence supports the effectiveness of the Triple P Positive Parenting Program and recent research has shown that an online version provides similar benefits in terms of reductions in child behaviour problems and decreases in parents’ use of ineffective parenting strategies (Day & Sanders). We recommend giving schools, health services and Jobcentres in the UK the ability to refer high risk families to free support of this kind. Additional benefits could be gained by testing behaviourally informed text messages to prompt parents to remain engaged with the programme.”

50. As Triple P evidenced through its submission to the Education Select Committee’s inquiry into the impact of COVID-19 on education and children’s’ services, increased flexibility in delivery has had manifold positive impacts.

51. Sharon Williams, Supporting Families Parenting Coordinator for Dudley MBC, commented:

“…speaking with one of the Intensive Family Support workers in the Edge of Care Team. She has been telling me that the best element of working remotely has been the Online Teen Triple P!!! The team have found it amazing and want to continue promoting and using this after the lockdown. She gave me two examples [previously parents hadn’t made progress] … The changes she says in both families has been almost instant. The one family is a couple, but dad never got involved due to work, but he is also using the Online programme and gets involved in the weekly telephone sessions the worker has with them. She says the programme has made them more accountable, she feels the weekly sessions are now more effective.”

wider changes needed in the system as a whole to reorient towards early intervention to prevent development and progression of severe mental illness in children and young people

52. Triple P’s programmes are rooted in prevention and early intervention, and, importantly, offer support to young people and families from the Early Years, through childhood and into adolescence.

53. We believe that this end-to-end system is the most effective way of recognising, monitoring and supporting mental ill-health.

54. Our work was recently applauded by Dianne Farmer MP, Minister for Child Safety, Youth and Women and Minister for the Prevention of Domestic and Family Violence for the Queensland Government in Australia.[39]

55. In October 2020, Ms Farmer said she was “delighted to hear that more than 417,000 Queenslanders have accessed Triple P,” since the State began utilising Triple P in 2015, having commented in September 2018 that “there has been a 24 per cent drop in the number of children re-entering the child protection system”, thanks to our programmes.39 This shows just how effective evidence-based programmes can be when deployed at scale.

56. We firmly believe that a commitment to evidence-based approaches will have manifold economic and social benefits. The Early Intervention Foundation’s (EIF) November 2020 report suggested that we can only ‘Level Up’ Britain through ensuring high-quality local family services which start in the maternity and run all through childhood, such as the support we can offer.[40]

57. The EIF’s report40 also concluded that “there is a need to go further in making evidence-based interventions the foundation of local approaches,” and we believe that this would go a long way to creating a system which provides support from the Early Years, through childhood and into adolescence. This, in turn, will provide multiple opportunities for early intervention.

58. The Social Mobility Commission advocated for increased funding and availability of evidence-based support through its 2017 ‘Time for Change’ report, in turn suggesting that “parenting support today is little better now than it was in 1997” due to real-terms cuts to parenting programmes.[41]

59. The report therefore called on the Government to “restore funding for [evidence-based] parenting programmes and experiment with online classes to achieve scale without undermining quality.” 41

60. Research estimates that every £1 spent on evidence-based parenting support results in at least £3 of annual savings to health, education, and social care.[42]

61. This has been echoed by the British Medical Association, who found through their own research, that the Triple P system generates returns of £5.05 for every pound invested, in areas related to reductions in distributive behaviour disorder symptoms, child abuse and neglect, crime, and substance abuse, and increases in high school graduation and employment.[43]

62. The BMA’s recent report on ‘Supporting a Healthy Childhood’ also “highlights insufficient investment in England across a range of services to support a healthy childhood, with funding for a number of different services being cut in recent years. This lack of resource is likely to have an adverse impact on child health in England.” [44]

63. Though Triple P recognises that Public Finances are understandably stretched, we believe that investing in quality solutions will be a necessity in the months and years to come. Investing in programmes which are not evidence-based, but cheaper, is a false economy.

Lessons learned from local and international best practice

64. Triple P is rated as the number one parenting programme in the world for its evidence-base by the UN4, and has been shown to improve child, family, and community functioning through more than 340 evaluations worldwide.

65. Triple P’s suite of more than 25 flexible programmes have been implemented across the world, meaning we are able to glean vital lessons from their implementation.  

66. Recent research evaluated a national roll out of parent training interventions in Scotland, delivered in early years services through the Psychology of Parenting Project (PoPP). They report some very positive outcomes, including:[45]
• An overall positive effect in reducing behavioural difficulties in children in Scotland, achieved through evidence-based parenting interventions and scaled to a size comparable to controlled trials.
• Children with ‘low’ and ‘moderate’ behavioural problems benefited more from Triple P than other programmes in the evaluation, with 75-80% of these children moving out of ‘high risk’ range for poor outcomes post-intervention.
• The effectiveness of the parenting interventions implemented within the PoPP framework suggested the potential for considerable long-term savings, given the long-term costs often associated with conduct disorders.

67. The U.S. Triple P system population trial saw 18 counties in a south-eastern state randomly assigned to either dissemination of the Triple P – Positive Parenting Program® system or to a business-as-usual control condition.[46]

68. Dissemination involved Triple P professional training for the existing workforce (over 600 service providers), as well as universal media and communication strategies.46

69. Large effect sizes were found for three independently derived population indicators: substantiated child maltreatment, child out-of-home placements, and child maltreatment injuries.46

70. This 2009 study was the first to randomise geographical areas and show preventive impact on child maltreatment at a population level using evidence-based parenting interventions.46

71. As the report concluded: “The real-world magnitude of the observed effects can be derived from the data. In a community with 100,000 children under 8 years of age, these effects would translate into 688 fewer cases of Child Maltreatment (CM), 240 fewer out-of-home placements, and 60 fewer children with injuries requiring hospitalization or emergency room treatment.” 46

72. As our evidence shows, and as DHSC, has noted, ensuring a stable familial environment is vital in fostering positive mental health in children and young people. Investment in evidence-based approaches at all stages of life facilitates not only successful early intervention, but effective prevention of ACEs, a key factor in preventing mental ill-health in later life. 

recommendations

73. Triple P UK therefore makes the following recommendations:

74. Evidence-based parenting support is established as the first step of support for families who are supporting children with signs of mental health conditions or challenges.

75. As part of the Government’s response to support children and young people’s mental health, they should prioritise implementing an evidence-based programme which directly deals with the heightened anxiety and stress in children and parents, and provides parents with enhanced skills to support their children to prevent and manage mental health conditions. The data suggests children’s mental health will continue to deteriorate and it is therefore vital to equip all parents with the ability to support their children’s mental health and wellbeing and ensure children have the crucial skills to be resilient in challenging circumstances. Parents should be given support using evidence-based online resources, through schools, and as members of the local community.

76. Evidence-based programmes should be made available at every stage of a child or young person’s life and done so in a variety of accessible formats. As Triple P’s programmes show, children and their parents benefit from manifold mental health benefits when accessing specialised support, such as Baby Triple P, Fear-Less Triple P and Family Transitions Triple P, and excel when they can do so on their own terms, such as through Triple P Online. Choice should be viewed as a necessity, not a luxury, as it will increase the likelihood of supporting the hardest to reach and most vulnerable young people and families in the UK.

77. A national communications and engagement plan to change social norms around parenting is run concurrently to remove barriers to engagement in parenting programmes, with parents given access to an online evidence-based behavioural family intervention, such as Triple P Online, as the first step of care to support the increased clinical need of children’s mental health services.

78. National ring-fenced funding for evidence-based parenting programmes is made available across a range of funding mechanisms, such as education, social care, and health care to ensure the delivery of evidence-based parenting support.

79. Local authorities are encouraged to collaborate to provide a systems-wide approach to the provision of evidence-based parenting support, using a digital intervention such as Triple P Online to go to scale, and integrating support for face-to-face delivery around a centralised website. As part of this, core teams can be trained to work with parents, deliver services in schools, and engage with other service delivery organisations. This will integrate delivery across the community to reach vulnerable sections of the population to improve children’s and parents’ mental health, protect children from harm, and improve children’s social mobility.

references