The Effectiveness and Acceptability of a Parenting Group on Perceived Stress, Parental Self-

Regulation and Child Emotional and Behavioural Problems: Investigating the Impact of

Parental Adverse Childhood Experiences on Outcomes

John Burke

Department of Psychology, University of Limerick

Thesis submitted to the University of Limerick in fulfilment of the requirements for the

degree of Doctor of Clinical Psychology (PhD in Clinical Psychology), Department of

Psychology, University of Limerick.

6th April 2020

Dr. Barry Coughlan, Course Director, Doctoral Programme in Clinical Psychology

Supervised by:

Dr. Sharon Houghton, Assistant Director, Doctoral Programme in Clinical Psychology;

Prof. Dónal Fortune, Professor of Clinical Psychology.

PARENTING GROUP OUTCOMES AND ACES 2

Declaration

I hereby declare that this project is entirely my own work, other than the counsel of my supervisors. Any contributions made by other authors have been recognised appropriately. The work herein has not been submitted for any academic award or part thereof at this or any other establishment.

Signed: ______

John Burke

Psychologist in Clinical Training

Candidate for the PhD in Clinical Psychology, University of Limerick

6th April 2020

PARENTING GROUP OUTCOMES AND ACES 3

Acknowledgements

I would like to sincerely thank the participants who contributed their time and insights for the purpose of this research.

Thank you to the Primary Care Child Psychology Services in Carlow and Kilkenny who facilitated the groups. A special thank you to Dr. Mark Fitzhenry who helped to conceptualise the project and was supportive from the outset.

I also wish to extend my gratitude to Dónal and Sharon for their support, guidance and supervision throughout the process.

PARENTING GROUP OUTCOMES AND ACES 4

Abstract

Many children experience some form of adversity in their childhood. These adverse childhood experiences (ACEs) can have long-term implications without the protective buffer of supportive parenting. Parenting group interventions were designed to support parents who struggle to act as the protective buffer against adversity. Despite the wide-ranging impacts of

ACEs, their influence on parenting intervention outcomes is relatively unknown. The

Understanding your Child’s Behaviour Programme (UYCBP) is a 10-week parenting group founded on the Solihull Approach which adopts a relational approach and explores a parents’ own experiences of being parented. This study used a pre-post repeated measures, mixed- methods design to evaluate the acceptability and effectiveness of the UYCBP in an Irish- based sample for the first time. Cumulative parental ACE scores were gathered to investigate their effects on outcomes. The group was experienced as ‘acceptable’ based on the

‘Experience of Service Questionnaire’, attendance rates and qualitative findings. Perceived stress (‘Perceived Stress scale’) and parental self-regulation (‘Me as a Parent’) showed significant improvements. Child emotional and behavioural improvements (‘Strengths and

Difficulties Questionnaire’) were observed on categorical data only. There was no significant effect of ACEs at baseline or on intervention outcomes. Qualitative data revealed salient themes of “Seeing” the child; Parental self-regulation; and Experiences of being parented.

Research and clinical implications including the importance of adopting broader, more sensitive methods of researching ACEs as well as tracking parent progression over longer periods are discussed.

Keywords: Understanding Your Child’s Behaviour, Solihull Approach, adverse childhood experiences, ACEs, parental self-regulation, perceived stress, child emotional and behavioural problems

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Table of Contents

Declaration ...... 2 Acknowledgements ...... 3 Abstract ...... 4 Table of Contents ...... 5 List of Tables and Figures ...... 8 Tables ...... 8 Figures ...... 9 List Of Appendices ...... 10 Glossary of Terms ...... 11 Chapter 1: Introduction ...... 12 1.1 Clinical Area ...... 12 1.2 The Parent-Child Relationship ...... 13 1.3 Conceptual Framework – The Solihull Approach ...... 14 1.4 Aims of Current Research ...... 15 1.5 Thesis Structure ...... 15 Chapter 2: Literature Review ...... 16 2.1 Chapter Overview ...... 16 2.2 Literature Search Strategy ...... 16 2.3 Good Enough Parenting ...... 16 2.3.1 Parenting Styles ...... 17 2.4 Adverse Childhood Experiences ...... 19 2.4.1 Critiques of the ACEs Score ...... 23 2.4.2 The Pair of ACEs ...... 23 2.4.3 Resilience ...... 24 2.4.4 ACEs and Parenting ...... 26 2.5 Parental Characteristics ...... 27 2.5.1 Parental Stress ...... 28 2.5.2 Parental Self-Regulation ...... 29 2.6 Emotional and Behavioural Difficulties in Children ...... 30 2.6.1 The Prognosis of EBD ...... 32 2.6.2 The Parent-Child Relationship and EBD ...... 33 2.7 Parenting Interventions ...... 33 2.7.1 Behavioural Parenting Programmes ...... 35 2.7.2 Relational Parenting Programmes ...... 35

PARENTING GROUP OUTCOMES AND ACES 6

2.7.3 Integrative Parenting Programmes ...... 36 2.8 ACEs Impact on Parenting Interventions ...... 37 2.9 The Understanding Your Child’s Behaviour Programme ...... 40 2.9.1 Research for UYCBP Effectiveness ...... 42 2.10 Gap In The Literature ...... 43 2.11 Research Questions ...... 44 Chapter 3: Methodology ...... 47 3.1 Chapter Overview ...... 47 3.2 Research Study Design ...... 47 3.3 Epistemology and Ontology ...... 48 3.4 Participants ...... 48 3.5 Procedure ...... 52 3.6 Consent & Ethical Issues ...... 53 3.7 Instruments ...... 53 3.7.1 ACEs Questionnaires ...... 53 3.7.2 Cohen’s Perceived Stress Scale (PSS) ...... 54 3.7.3 Strengths and Difficulties Questionnaire (SDQ) ...... 54 3.7.4 ‘Me as a Parent’ (MaaP) ...... 55 3.7.5 Experience of Service Questionnaire ...... 55 3.7.6 Focus Group Schedule ...... 56 3.8 Data Analysis Overview ...... 56 3.8.1 Quantitative Analysis Overview ...... 56 3.8.2 Data Preparation and Treatment ...... 57 3.8.3 Normality Testing ...... 58 3.9 Qualitative Analysis ...... 60 Chapter Four: Results ...... 61 4.1 Chapter Overview ...... 61 4.2 Quantitative Results ...... 61 4.2.1 Research Question One: Parental ACE Scores and Dependent Variables at Baseline ...... 61 4.2.2 Research Question Two: Evaluate the acceptability of the UYCBP ...... 62 4.2.3 Research Question Three: Effect of the Group on Dependent Variables ...... 62 4.2.4 Research Question Four: Parental ACEs Association with Group Effectiveness .. 66 4.3 Qualitative Results ...... 68 4.4 Group Acceptability ...... 69 4.4.1 Facilitation Expertise and Flexibility ...... 70 4.4.2 Non-Judgemental, Safe Space ...... 71

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4.4.3 Support and Validation Through Shared Experiences ...... 72 4.5 “Seeing” the Child ...... 74 4.5.1 Noticing and Recognising ...... 74 4.5.2 Taking the Child’s Perspective ...... 75 4.5.3 Facilitating Reciprocity ...... 76 4.6 Parental Self-Regulation ...... 77 4.6.1 Increasing Capacity for Managing Stress ...... 77 4.6.2 “Stepping Back” ...... 78 4.6.3 Feeling More “At Home” as a Parent ...... 79 4.7 Experiences of Being Parented ...... 80 4.7.1 Behavioural Intergenerational Transmission ...... 81 4.7.2 Emotional Intergenerational Transmission ...... 82 4.8 Results Summary ...... 84 Chapter 5: Discussion ...... 86 5.1 Chapter Overview ...... 86 5.2 Summary of Key Findings ...... 86 5.3 Acceptability of the UYCBP ...... 87 5.4 UYCBP Effectiveness ...... 90 5.5 Parental ACE Scores and Intervention Outcomes ...... 95 5.6 Research Implications ...... 99 5.7 Clinical Implications ...... 102 5.8 Strengths and Limitations ...... 107 5.9 Conclusion ...... 108 Chapter 6. Critiquing the Conceptual Frame and Design – Guiding Future Research ...... 110 6.1 Chapter Overview ...... 110 6.2 The Challenges of Evaluating Programmes Novel to a Health Service ...... 110 6.3 Recruitment Issues ...... 111 6.4 Follow-Up Data ...... 114 6.5 Integrating Conceptual Frameworks to Address a Specific Research Issue ...... 114 6.6 Mixed Methodology – Merits and Challenges ...... 116 6.7 ACE Implementation in Clinical Practice ...... 118 6.8 Future Research Planning ...... 121 6.8.1 Specific Design Amendments for Future Research ...... 123 References ...... 126 Appendices ...... 164

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List of Tables and Figures

Tables

Table 2.1: Parenting Styles And Associated Parenting Behaviours ...... 18

Table 2.2: Understanding Your Child’s Behaviour Weekly Session Content ...... 41

Table 3.1: Descriptive Statistics For Participants Attending The UYCBP ...... 51

Table 3.2: Correlation Matrix For Variables Included In Analysis ...... 59

Table 4.1: Independent T-Tests Comparing High And Low ACE Scores On Dependent

Variables ...... 61

Table 4.2: Paired Samples T-Tests Comparing Time Point One To Time Point Two Scores On

Dependent Variables ...... 63

Table 4.3: ANCOVA Comparing Time Point One And Time Point Two Scores On Dependent

Variables Across Low And High ACE Scores ...... 67

Table 4.4: Mean Difference Between Time Point One And Time Point Two On Low And High

ACE Scores ...... 68

Table 4.5: Summary Of Results – Research Questions, Hypotheses And Outcomes ...... 85

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Figures

Figure 2.1: Types Of Adverse Childhood Experiences Specified Within The Original Research

Paper (Felitti et al., 1998) ...... 20

Figure 2.2: Model Of ACE Impacts Across The Life Course (Adopted From Bellis et al.,

2016) ...... 21

Figure 2.3: The Pair Of ACEs (Adopted From Ellis & Dietz, 2017) ...... 24

Figure 2.4: The Solihull Approach Conceptual Triad (Douglas & Ginty, 2001) ...... 40

Figure 3.1: Flowchart For Participants From Initial Referral To Post-Intervention ...... 50

Figure 3.2: Number Of Children With Each Referral Reason As Reported By Attendees At

Baseline ...... 51

Figure 3.3: Number Of Children With Diagnoses As Reported By Attendees At Baseline ...... 52

Figure 4.1: Graphic Of Categorical Change In Number of Participants On SDQ From Time

Point One To Time Point Two On Completer (Left) And ITT (Right) Data ...... 65

Figure 4.2: Graphic Of Categorical Change In Number of Participants On PSS From Time

Point One To Time Point Two On Completer (Left) And ITT (Right) Data ...... 65

Figure 4.3: Graphic Depiction Of Themes And Subdomains Extracted From Dataset ...... 69

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List Of Appendices

Appendix 1.1: Systematic Review Search Terms ...... 164

Appendix 3.1: Information Sheet ...... 165

Appendix 3.2: Informed Consent Form ...... 167

Appendix 3.3: Pre-Intervention Questionnaire ...... 169

Appendix 3.4:Post-Intervention Questionnaire ...... 174

Appendix 3.5: Participant Debriefing Sheet ...... 176

Appendix 3.6: Interview Schedule ...... 177

Appendix 3.7: Missing Data Analysis ...... 178

Appendix 6.1: Reference List Compiled For Supplementary References In Chapter 6 ...... 179

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Glossary of Terms

ACEs Adverse Childhood Experiences

EBD Emotional and behavioural problems

SA Solihull Approach

UYCBP Understanding Your Child’s Behaviour Programme

PC Primary Care

Q’naire Questionnaire

PI Principal Investigator

ITT ‘Intention-to-treat’

PSS Perceived Stress Scale

MaaP ‘Me as a Parent’ Questionnaire

SDQ Strengths and Difficulties Questionnaire

SDQ_Tot Total score for Strengths and Difficulties Questionnaire

SDQ_Int Internalising Problems score on the Strengths and Difficulties Questionnaire

SDQ_Ext Externalising Problems score on the Strengths and Difficulties Questionnaire

ESQ Experience of Service Questionnaire

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Chapter 1: Introduction

1.1 Clinical Area

Seventy-five percent of children experience some form of stressful life event before the age of nine (Kelly, 2019). In some cases, the quality and chronicity of these stressful life events can lead to negative long-term outcomes (Bellis et al., 2016). The seminal piece of research by

Felitti and colleagues (1998) that demonstrated the potential long-lasting impacts of adverse childhood experiences (ACEs) on many facets of life has greatly influenced the outlook and implementation of healthcare globally. ACEs refer to neglectful or abusive experiences in childhood occurring within the household. Research emphasises the cumulative effect of these

ACEs, in that experiencing more ACEs results in more deleterious effects enduring throughout adulthood (Hughes et al., 2018).

One significant challenge that has emerged is tackling the intergenerational transmission of ACEs. This phenomenon refers to the impact of parents’ ACEs on their offspring in two distinct pathways. Firstly, children of parents’ who have endured ACEs are more likely to experience similar adversity and be subjected to the associated negative outcomes (Lin et al., 2019). Secondly, parents who have endured more ACEs are more likely to engage in harsh parenting styles, experience higher levels of perceived stress and have reduced capacity to self-regulate when managing their own stress and the stresses of their child

(Pereira et al., 2018). Parents who struggle in these areas often have insecure attachments with their children (Clarkson Freeman, 2014). Some families find it a greater challenge to overcome adversity in an adaptive manner and maintain a positive trajectory of development across the lifespan (Mersky et al., 2017). These difficulties often precede childhood onset of emotional and behavioural problems (EBD; Dretzke et al., 2009). Prevalence rates in Ireland suggest that between 21 and 24% of children under 9 years old experience EBD at some point in their

PARENTING GROUP OUTCOMES AND ACES 13 childhood (Growing up in Ireland Team, 2018), with approximately 15% of all Irish children experiencing considerable levels of EBD (McGilloway et al., 2012). This figure is comparable to global estimated prevalence rates of between 10 and 20% (Emerson & Einfield, 2010). Given the frequency of EBD and disruptions in the parent-child relationship, researchers and clinicians have attempted to unravel the underlying processes that lead to ruptures in the parent- child relationship.

1.2 The Parent-Child Relationship

There have been over 30,000 publications related to the parent-child attachment relationship, highlighting its pervasive importance in many aspects of human development

(Hughes, 2017). In the right circumstances, the parent-child relationship provides a buffering effect against childhood adversity (Shonkoff et al., 2012). Creating this positive parent-child relationship is no small task. Parenting can be stressful. The parent is required to have sufficient resources to care for their own emotions, whilst also holding those of their child (Evans & Kim,

2013). For parents who have endured ACEs, this task is even harder. Psychological interventions have been developed to support parents to meet the challenge of nurturing a positive relationship whilst maintaining appropriate boundaries for their children. Interventions are often in the format of parenting groups based on two main perspectives of relationship enhancement and behaviour management (Leijten et al., 2018). Relational parenting programmes have been employed as preventative and treatment measures to ‘break the cycle’ or reduce the intergenerational transmission of ACEs. The Understanding Your Child’s

Behaviour programme (UYCBP) is one such programme. It focuses on building the parent- child relationship, whilst also acknowledging how parents’ own experiences of being parented influence how they parent (Bateson et al., 2008). The literature available suggests that the

UYCBP is an effective programme in the United Kingdom (UK) but it has yet to be evaluated

PARENTING GROUP OUTCOMES AND ACES 14 in an Irish context. The UYCBP draws upon the integrative Solihull Approach (SA; Douglas

& Ginty, 2001) which conceptualises a unique way of working with families.

1.3 Conceptual Framework – The Solihull Approach

The SA was initially conceptualised in 1996, drawing from other models of psychotherapeutic intervention (Daws, 1993). The SA is a relationship-based method of working with families. It was developed in response to observations of some families

(primarily with children under five) who were struggling to make improvements with common challenges, such as sleeping, eating or toileting. The cornerstones of the model are adopted from different disciplines: the psychoanalytic concept of containment (Bion, 1959), the child neurodevelopmental concept of reciprocity (Brazelton et al., 1974), and learning theory’s understanding of behaviour management (Watson, 1930).

The model suggests that if parents feel a sense of regulation or containment over their own anxieties and concerns, they will have more resources available to facilitate a more attuned relationship with their child. Through this reciprocal relationship, parents can then attend to the thoughts, feelings and developmental perspective of their child to understand what they are trying to communicate. Parents begin to look at their child’s behaviour from a different perspective, recognising behaviour as a form of connection-seeking, as opposed to attention- seeking (Speer & Trees, 2007). Parents are then able to more effectively implement sensitive behaviour management strategies that support their child to process emotions, regulate and regain the capacity to reason. With these components, the SA has the potential to reduce the intergenerational transmission of ACEs by improving parental mental health, attachment relationships and parenting practice (Douglas & Ginty, 2001).

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1.4 Aims of Current Research

This research aims to address two areas lacking sufficient research in the existing literature base. A mixed-methods design was employed to allow for qualitative illustration of quantitative data collected. While research has specified the acceptability and effectiveness of the UYCBP in UK-based evaluations, no evaluation has been conducted in an Irish sample.

This thesis first investigated the acceptability of UYCBP in an Irish context. To align with the core principles of the SA measures of parental self-regulation, parental perceived stress and child emotional and behavioural difficulties were employed to assess effectiveness of the

UYCBP.

The UYCBP has previously demonstrated efficacy in improving the parent-child relationship, which is a significant protective factor against well-documented and wide-ranging deleterious effects of ACEs. However, little is known about the influence of parental ACEs in outcomes experienced after participating in the UYCBP, or other parenting programmes.

Therefore, the second aim of this research was to investigate the association between parents’

ACEs and outcomes after completing the UYCBP.

1.5 Thesis Structure

Chapter 2 outlines research associated with parenting practices and ACEs. Parenting interventions are brought into focus and literature describing the influence of ACEs on parenting programmes is outlined. Chapter 3 describes the research design, methodology and data analysis procedures. Quantitative results are shown and qualitative findings illustrated by quotations extracted from data are presented in Chapter 4. Chapter 5 discusses the findings in the context of predefined research questions and the existing literature base. Research and clinical implications are then explored. Finally, the strengths, limitations, and conclusions drawn from the research are outlined.

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Chapter 2: Literature Review

2.1 Chapter Overview

This chapter outlines literature that provides context and rationale for the current study.

It first focuses on parenting, highlighting the different styles and their associated outcomes for children. ACEs are then described and long-term outcomes of higher ACE scores are explored.

The impact of ACEs on parenting, specifically on levels of stress and self-regulation abilities is brought into focus. The association between parental characteristics and childhood EBD is summarised to emphasise the intergenerational transmission of ACEs. Parenting interventions

(including the UYCBP) to address these issues are described. The research questions and hypotheses are then presented.

2.2 Literature Search Strategy

Articles were sourced using a robust strategy that was conducted for each term or topic of relevance to the current study. Included search terms can be found in Appendix 1.1. A combination of each of these search terms were used to obtain relevant research articles during the systematic process. Databases reviewed included PsychoInfo, PsychArticles, Web of

Science, Cochrane Database and Google Scholar. Titles and abstracts were first reviewed to determine relevance and full articles were obtained for significant papers. Reference lists from each article identified were also reviewed and relevant articles were included in the literature review.

2.3 Good Enough Parenting

Psychological research has historically recognised the importance of attachment relationships in promoting positive development in children. The psychoanalytic concept of the good enough mother (Winnicott, 1953) remains of core relevance for parenting in the modern era. Research since its conceptualisation has made many attempts to operationalise

PARENTING GROUP OUTCOMES AND ACES 17 what good enough parenting looks like. One example is supportive parenting which is a multidimensional construct comprised of parenting behaviours such as sensitivity, responsivity, language/cognitive stimulation, positive regard, positive emotional affect, and joint attention (Halle et al., 2011; Mortensen & Mastergeorge, 2014). Historically, it was recognised that good enough parents are ‘in sync’ or respond to their infants in an attuned manner 30% of the time (Tronick, 1986). Recent research estimated that attachment security is promoted when parents soothe their distressed or dysregulated infant 50% of the time

(Woodhouse et al., 2019). The multidimensional nature of supportive parenting underlines the challenge of maintaining a good enough standard for children to thrive, even if only required for a fraction of all interactions. Parents have the responsibility of adjusting to the fluctuating needs of their child as they develop. Shortcomings in any aspect of supportive parenting has been associated to early onset of EBD (Odgers, 2008). Typical parenting behaviours are often grouped within parenting styles, and supportive parenting is closely related to an authoritative parenting style.

2.3.1 Parenting Styles

Parenting styles reflect a parent’s approach to interacting with their child in terms of control or demandingness and affective warmth or responsiveness (Baumrind, 1978).

Demandingness refers to the level of expectations and demands a parent holds of their child

(Baumrind, 1978). Responsiveness relates to the extent to which a parent can respond to a child’s needs in a supportive and accepting manner. Using these two concepts, four main parenting styles are currently recognised. Pinquart (2017) provides a useful summary for the main parenting styles in terms of demandingness and responsivity. These are summarised in

Table 2.1 below. Parenting styles mediate childhood EBD in a variety of ways, including through social modelling, through interruptions in attachment security and by compromising emotional regulation (Plant et al., 2018).

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Table 2.1

Parenting Styles and Associated Parenting Behaviours

Authoritative

High behavioural control High warmth

Firm boundaries Positive affect and open communication

Inductive discipline – help child to understand (Sanders, 2008)

why a behaviour is wrong (Choe et al., 2013). Self-regulation and cooperation encouraged

(Baumrind, 1991)

Authoritarian

High/harsh behavioural control Low warmth

Clearly structured rules and environment Directive and intrusive

Harsh or critical discipline Rules implemented without explanation

Negative reinforcement (Darling, 1999) Coercive interactions (Hurlburt et al., 2013).

Permissive

Low behavioural control High warmth

Lax and inconsistent boundaries Children self-regulate without support

Lenient and avoidant of confrontation Expected to display mature behaviours

More delinquent behaviours (Kiesner et al., without support (Pinquart, 2017).

2010).

Uninvolved/Neglectful

Low behavioural control Low warmth

Uninvolved/no boundaries Emotional rejection of child

Associated with child maltreatment (Darling,

1999).

PARENTING GROUP OUTCOMES AND ACES 19

Children with authoritative parents tend to achieve more academically (Pinquart, 2016), as parents provide the necessary emotional support to help them achieve on expectations

(Aram, 2007). This is in contrast to the lack of emotional responsiveness in authoritarian parent styles, and limited boundary-setting in permissive parenting (Bingham et al., 2014).

Authoritarian and permissive parenting styles have been associated with greater displays of externalising behaviour difficulties, more withdrawn behaviours and other difficulties classed as EBD (Knutsonet al., 2005). Mothers with higher ACE scores tend to have more permissive or authoritarian parenting styles (Leslie & Cook, 2015).

Parenting styles are differentially associated with a child’s social behaviours. For example, aggression towards peers is more common with negative parenting styles (Kawabata et al., 2011), while prosocial behaviours are more common in positive parenting styles (Alink et al., 2009). Beliefs about different parenting behaviours appear to mediate the association between parenting styles and child behaviours (Smetana, 2017). If authority is viewed as

‘illegitimate’ the response is more likely to be negative, for example involvement pertaining to privacy or personal preferences. Authoritative or supportive parenting is associated with stronger legitimacy beliefs, as these parents are more sensitive to the child’s needs (Trinkner et al., 2012).

2.4 Adverse Childhood Experiences

Research highlighting the influence of stressful conditions in childhood for later development (Rutter, 1989) existed prior to the inception of the seminal ACEs study (Felitti et al., 1998). However, the ACEs study paved the way for the substantial increase in publications mentioning ‘Adverse Childhood Experiences’ specifically in the title from one in 1985, to over two hundred in 2019 (Kelly-Irving & Delpierre, 2019). The definition of ACEs has been challenged and altered with numerous iterations proposed by different stakeholders. The latest definition describes ACEs as, “experiences which require significant adaptation by the

PARENTING GROUP OUTCOMES AND ACES 20 developing child in terms of psychological, social and neurodevelopmental systems, and which are outside of the normal expected environment” (Lacey & Minnis, 2019, p.2). There were ten adverse experiences included in the original ACEs study; five involved direct harm to a child and five that affected the childhood household environment (Figure 2.1). Bellis and colleagues published the first UK-based incidence study (2014a). The most recent research identified that approximately half of the population reported at least one ACE, with 10% at the other end of the spectrum reporting four or more (Bellis et al., 2014a). ACE scores are disproportionately higher in low-income samples in which many of the outcomes mentioned above are also more prevalent (Mersky et al., 2017). Rates of ACEs reported in at-risk populations are substantially higher, such as those in the justice system (Levenson et al., 2016), homeless individuals (Larkin

& Park, 2012) and psychiatric treatment samples (Fox et al., 2015).

Figure 2.1

Types of Adverse Childhood Experiences Specified Within The Original Research Paper (Felitti et al., 1998)

PARENTING GROUP OUTCOMES AND ACES 21

ACEs exact their impact through toxic stress, or “major unrelieved stress over prolonged periods of time” (Felitti & Anda, 2014, p. 208). The human physiology is sensitive during childhood and has the unique ability to respond both physically and psychologically to environmental changes during this time. When children are exposed to severe, prolonged adversity without adult support, a range of body systems are impacted, including immune and endocrine responses, epigenetics and brain development (Shonkoff et al., 2012). When ACEs occur during critical periods of brain development, parts of the brain associated with ‘survival’, such as fear, anxiety and impulse response overproduce neural connections. Other parts dedicated to reasoning, logic, planning and behavioural control receive less stimulation as a result. While changes in biology are a normal part of development, biological mechanisms involving stress response systems (Ridout et al., 2018) are a key factor in understanding the association between ACEs and health in later life (Kelly-Irving & Delpierre, 2019). A model to illustrate how each of these factors impact an individual over the life course is displayed in

Figure 2.2 (Bellis et al., 2016).

Figure 2.2

Model of ACE Impacts Across The Life Course (Adopted From Bellis et al., 2016)

PARENTING GROUP OUTCOMES AND ACES 22

Research is continuing to elucidate the long-term implications of ACEs, many of which allude to the concept of intergenerational transmission. ACEs are linked to increased involvement in violence, substance use, early unplanned pregnancy, incarceration and unemployment (Brown & Shilling, 2017). These risky behaviours of parents place their children at higher risk of being exposed to ACEs (Bellis et al., 2014b). Many poor health outcomes experienced by parents are simultaneously experienced as new ACEs by their children, thus highlighting the potential for intergenerational transmission of these ACEs

(Smith, 2018). Other mediating processes have been suggested, such as maladaptive cognitive models or dysfunctional coping behaviours, unhealthy peer associations, and attachment impairments (Finkelhor, 2018). Intergenerational transmission is also influenced by genetic predispositions to ill-health due to factors affecting previous generations in their family. This means that the child or parent themselves may not have experienced trauma, but their genetic predisposition has been altered as a result of previous generations who have been exposed to trauma (NHS Highland, 2018).

Epidemiological research on ACEs has demonstrated its utility in informing population-level policies. With the growing knowledge of how influential ACEs are for health, social, educational and criminal justice priorities, there has been a drive to address ACEs from multiple stakeholders (Ford et al., 2019). Public health campaigns in the UK such as being

‘ACE-aware’ and ‘trauma-informed practice’ (Oral et al., 2016) have been devised to increase public awareness, guide services in supporting a population who have experienced ACEs, and ultimately reduce the incidence of ACEs (Shonkoff et al., 2012).

The ACE score has many strengths that have contributed to the significant increase in attention it has received. It is simple to calculate and understand, thus making it a useful tool for engaging audiences from non-academic backgrounds on how early life experiences and social circumstances might have long-term impacts on health (McLaughlin & Sheridan, 2016).

PARENTING GROUP OUTCOMES AND ACES 23

ACEs tend to demonstrate a cumulative impact: higher scores result in more detrimental health effects (Evans et al., 2013). ACEs may have some ability in identifying people at the highest risk of poor outcomes, by recognising the high levels of co-occurring ACEs (Crouch et al.,

2019). Additionally, ACEs offer the potential to highlight the buffering effect of relationships against the ‘toxicity’ of ACEs (White et al., 2019).

2.4.1 Critiques of the ACEs Score

Critiques have argued that the ACE score does not adequately represent the full extent of adversity experienced (Kelly-Irving & Delpierre, 2019; McEwen & Gregerson, 2019; Lacey

& Minnis, 2019). The ACE score represents binary categories of each experience and does not include detail on severity, or personal relevance of experiences, assuming they are equal in their ability to predict later outcomes for the person. The ACEs specified in the original paper also exclude several potentially significant experiences in childhood that may have lasting impacts. These include adversities relating to friends and peers, such as bullying or rejection.

It does not account for individual circumstances where ACEs may be protective, for example, divorce when a parent was abusive (McEwen & Gregerson, 2019). The timing, chronicity and discontinuity of adversities, or impact of mitigating or protective factors are also not accounted for in the ACE score (Ford et al., 2019). While these shortcomings are acknowledged, the existing research provides strong evidence that ACE scores provide a powerful way of condensing a broad range of experiences into a meaningful metric.

2.4.2 The Pair of ACEs

To address the shortcomings of the ACE score, The Pair of ACEs framework was developed to conceptualise how household ACEs are connected with the Adverse Community

Environments of societal circumstances (Ellis & Dietz, 2017; Figure 2.3). It posits that ACEs are symptoms of the individual’s environment. The framework highlights that individuals need

PARENTING GROUP OUTCOMES AND ACES 24 access to support in order to prevent long-term consequences of ACEs whilst preventative measures are implemented at governmental, societal and policy level (Taylor-Robinson et al.,

2018). This framework is particularly useful within a Primary Care (PC) setting as it recognises the necessity for population-level awareness and education to reduce socially derived adversities (McEwen & Gregerson, 2019). It also recognises the need to support ‘at risk’ populations (Rose et al., 2008) in addition to targeted interventions for those who have experienced ACEs.

Figure 2.3

The Pair of ACEs (Adopted From Ellis & Dietz, 2017)

2.4.3 Resilience

Families endure adversity to varying degrees across the world. These stressful experiences are therefore essential for building resilience, which is the ability to biologically and psychologically adapt to stress (Hughes et al., 2018). Evidence suggests that many exposed

PARENTING GROUP OUTCOMES AND ACES 25 to ACEs develop positive or neutral outcomes (Knerr et al., 2013), primarily due to their resilience to adversity.

This differential response is central to the diathesis-stress model of vulnerability

(Ingram & Luxton, 2005). This model postulates that some individuals are at a heightened risk of experiencing psychological disturbance because of their genetic make-up (Belsky et al.,

2009). Other individuals who do not possess the same genetic vulnerability will not succumb to psychological difficulties when faced with the same adversity (Belsky & Pluess, 2009). The latest research contends that these genetic influences may also be advantageous, in that these individuals can experience greater benefits from environmental experiences absent from adversity (Stoltz et al., 2017). Researchers have referred to this phenomenon as ‘biological sensitivity to context’ (Boyce & Ellis, 2005). This research tells us that parents and children who have endured negative psychological impacts of ACEs, are potentially more likely to benefit from positive, nurturing changes in their environment to a greater extent than those who have not experienced adversity at all. With this theoretical basis, an individual’s history of connectedness is a better predictor of their life course than their adversities (Hambrick et al.,

2019).

In line with this theory, an individual’s history of connectedness is a better predictor of their life course than their adversities (Hambrick et al., 2019). As ACEs cannot be completely eradicated, building resilience is essential. By fostering resilience, toxic stress can be transformed into tolerable stress (Shonkoff et al., 2012). A robust parent-child relationship is one effective method of protecting against adversity and promoting resilience (Hughes et al.,

2018). As Gerhardt aptly put, “You need to have an experience with someone first – then you can reproduce it” (2014, p. 131). In other words, a parent must demonstrate resilience and coping with adversity before children can do the same. This can be modelled at any stage of development. However, ACEs can disrupt a parent’s ability to model this for their children.

PARENTING GROUP OUTCOMES AND ACES 26

2.4.4 ACEs and Parenting

The specific pathways through which ACEs impact parenting are multifaceted. They are interrelated, cumulative, relational, both unidirectional (involving parent or child-based effects only), bidirectional (involving interplay between parent and child influences) and often occur through unconscious processes. ACEs are sometimes considered “ghosts in the nursery”, where the “unremembered past” plays a significant role in how parenting behaviours develop and are maintained through generations (Fraiberg et al., 1975).

Parents who have experienced childhood adversity are at a greater risk of a broad range of adverse parenting practices that range in severity from lack of sensitivity to abusive behaviours (Pasalich et al., 2019). Parental sensitivity and responsivity is specifically impacted by childhood trauma (Vaillancourt et al., 2017). These parents are more likely to engage in harsher or permissive parenting practices making them less likely to have the capacity to maintain sensitive, attuned and empathic engagements with children (Grasso et al., 2016). Some of these parents have experienced interpersonal maltreatment or trauma in the context of close relationships which taints their ability to develop trusted attachments, thus implicating their relationship with their children (Muzik et al., 2013).

Parents with a history of ACEs display a different trajectory of change in parental sensitivity through their child’s stages of development (Fuchs et al., 2015). The change in how a toddler begins to explore the world and their increased desire for autonomy challenges a parent. Parents with a history of abuse are more likely to have insecure attachments to their children (Pasalich et al., 2016). Their insecure relationship may trigger dysfunctional attributions about their toddler’s emerging independence, such as a perceived loss of control

(Fuchs et al., 2015). This assertion has been supported in parents who experienced physical or sexual abuse, but emotional abuse has received less empirical attention (Hughes & Cossar,

2016). The relationship between cumulative ACEs and parenting practices has also been

PARENTING GROUP OUTCOMES AND ACES 27 explored (Lange, 2019; Steele et al., 2016). These parents are more likely to experience continued adversity throughout their adult life, which further compromises their mental and emotional capacity to provide sensitive, supportive parenting to their children (Gustafsson et al., 2015). Children of parents who experience these problems often display more EBD

(Clarkson Freeman, 2014). Much of the intergenerational transmission of ACEs can be explained through poor parenting practices and parental history of mental illness (Dixon et al.,

2005).

2.5 Parental Characteristics

2015 saw the World Health Organisation declare maternal mental health a major public health concern (Lin et al., 2019) and acknowledge it as one of the most neglected aspects of care (O’Donnell & Meaney, 2016). Parents who have experienced more ACEs during their own childhood will be more susceptible to maternal distress, including psychiatric disorders

(Nanni et al., 2012). Psychiatric disorders affect one in four women across pregnancy and in the first year postpartum alone, but this subpopulation is not more likely to seek support for the difficulties (Vesga-Lopez et al., 2008).

Parental distress experienced during the early years of a child’s life results in compromised emotional and behavioural adjustment (Toth et al., 2009). The timing of parental distress is also influential. Some parents with psychiatric diagnoses can be more critical, and less emotionally containing for their children (Johnson et al., 2006). Environmental adversity, such as economic deprivation, unemployment and low educational and occupational attainments (Furlong et al., 2010) may sustain this distress (Plant et al., 2018). This can have significant implications for the parent-child attachment and expose offspring to more ACEs

(Dutton et al., 2011). Numerous studies have demonstrated that parental affective distress mediates the relationship between maternal childhood maltreatment and EBD in children (Plant

PARENTING GROUP OUTCOMES AND ACES 28 et al., 2018). Maternal distress therefore, represents a key pathway through which ACEs and other trauma can be transmitted intergenerationally.

2.5.1 Parental Stress

Parental stress is one form of distress that is captured within this research. Parents’ own patterns of perceived stress can be transmitted to their offspring through parental mental health and caregiving behaviours (Bowers & Yehuda, 2016). Parental stress can result in harsher, more critical and less sensitive, responsive ways of managing behaviour (Leslie & Cook,

2015). These responses are associated with greater levels of conflict and less closeness in the parent-child relationship (Berthelot et al., 2015). As a result, the child displays more EBD, further increasing parental stress (Furlong et al., 2010).

Higher cumulative ACE scores have a positive association with parental stress (Lange et al., 2019; Steele et al., 2016). Biological and epigenetic pathways have identified how parental stress can implicate offspring (Moog et al., 2018). The neuropsychological impacts of

ACEs also impact the ‘social brain’ (DeGregorio, 2013) and parents with higher ACE scores typically have less supportive social networks. Social support does not offer the same buffering effect against stress as it might for other parents who have not experienced ACEs (Vranceanu et al., 2007). In an Irish based study, both harsh parenting styles and mothers reporting high levels of stress were the best predictors of children having EBD (Kelly, 2019).

Managing parental stress represents a key challenge when improving child outcomes and is closely influenced by a parent’s ability to regulate and tolerate negative emotional states

(Verrault et al., 2014). Affective dysregulation is a core feature for many psychiatric disorders, including anxiety and stress-related disorders (Merrick et al., 2014). Several meta-analyses have identified that childhood adversity increases the level of affective dysregulation experienced across the lifespan (Dvir et al., 2014). Parents with a history of ACEs endure more

PARENTING GROUP OUTCOMES AND ACES 29 pronounced periods of dysregulation, and have less coping strategies to tolerate it (Dvir et al.,

2014). Parental stress and other mental health difficulties are more likely to impact their offspring negatively without the ability to self-regulate.

2.5.2 Parental Self-Regulation

The skill of self-regulation involves a parent learning to adjust their behaviour and problem solve independently in order to facilitate family relationships (Karoly, 1993). Self- regulation is often associated with the concept of parental self-efficacy (Bandura & Walters,

1977), which refers to a parent’s belief or judgements about their competency or ability to be successful as a parent (Hess et al., 2004), whilst acknowledging their affective and physiological state (Bandura, 1982). Self-regulation considers a parent’s emotional capacity, which is a significant factor in forming a parent’s beliefs and shaping their behaviours.

Emotional dysregulation is described as inappropriately adjusting expressed emotions or mismatching regulatory strategies to circumstances, resulting in emotions getting in the way of goal-directed behaviours (Beauchaine, 2015). Emotional dysregulation is prevalent in EBD and is associated with vulnerability for psychopathology across the lifespan (Weissman et al.,

2019). For parents, the skill of self-regulation is an essential protective factor against many of these negative outcomes for themselves, and also for their children (Evans & Kim, 2013).

However, the skill of self-regulation typically develops across childhood (Crowell et al., 2015) and this may have been interrupted for parents who have experienced trauma (Ostlund et al.,

2019). There is evidence suggesting that parents exposed to ACEs lack adaptive emotion regulation skills, as they may have been punished or rejected for emotional expression (Kim &

Cicchetti, 2010). Their parents may also have modelled maladaptive strategies rather than promoting and scaffolding self-regulation skills (Glover, 2014).

PARENTING GROUP OUTCOMES AND ACES 30

Research across childhood and adolescence has provided evidence for the potential of intergenerational transmission of neurodevelopmental outcomes that are specifically associated with the stress response system (Leen-Feldner et al., 2013). Children of trauma- exposed parents are significantly more at risk of developing EBD (Hipwell, 2019). These effects are particularly pronounced when children are exposed to toxic stress during critical periods of heightened neuroplasticity, as both neurobiological and physiological systems are implicated (Cicchetti & Banny, 2014).

Environments in which trauma and abuse occurs encourage a sustained state of hypervigilance for potential threats. This contributes to regulatory patterns that tend towards self-preservation rather than self-regulation (Frankenhuis & Del Giudice, 2012). Parental self- regulation is an essential component captured within supportive parenting that facilitates children to reach their potential and protects against the intergenerational transmission of stress reactivity and its negative associations (Calkins et al., 2019), including EBD.

2.6 Emotional and Behavioural Difficulties in Children

Behaviours and presentations encapsulated under the umbrella term ‘EBD’ have been divided into externalising and internalising behaviours. Externalising problems can include disruptive or aggressive behaviour, negative interactions with adults and non-compliance with instructions or requests. They can also include an unwillingness or inability to perform schoolwork, poor social skills or difficulties interacting with peers and school refusal.

Internalising behaviours refer to emotional difficulties that can be less visible, such as low self- esteem and poor emotional control or difficulty managing feelings, difficulties concentrating or paying attention, as well as symptoms of anxiety, low mood or depression. These difficulties exist on a continuum, ranging from subclinical levels to the more severe levels. Presentations meeting certain criteria that result in significant levels of behavioural disruption are eligible for clinical diagnoses of Conduct Disorder and Oppositional Defiant Disorder. These presentations

PARENTING GROUP OUTCOMES AND ACES 31 can be comorbid with or closely related to other neurodevelopmental diagnoses such as

Attention Deficit/Hyperactivity Disorder or Attention Deficit Disorder (Fairchild et al., 2019).

A child’s temperament, levels of impulsivity and deficits in verbal intelligence or social information processing are influential in child behaviour and associated parenting strategies

(Furlong et al., 2010). Factors such as siblings, friends, school and family environments also play an important role (Kawabata et al., 2011). Often the association between parent and child behaviour is interpreted as a unidirectional phenomenon, focusing solely on the influence of parent behaviour on child behaviour. However, there is evidence that this relationship may be bidirectional in nature in some cases (Neece et al., 2012). For example, adolescent behaviours had a much stronger unidirectional effect on parenting styles.

These effects appear to vary depending on parenting styles. For example, child effects are more commonly associated with permissive parenting, and bidirectional effects are more frequently observed in authoritarian parenting (Smetana, 2017). Interestingly, no bidirectional effects were observed in authoritative parenting, suggesting that supportive parenting necessitates less feedback from the child as there is a more robust and agreeable parent-child relationship (Moilanen et al., 2015). Some genetic explanations may illustrate the potential bidirectional nature, as the same genes may account for dysfunctional parenting and a child’s aggression (Tackett et al., 2009).

More evidence exists for externalising behaviours in contrast to internalising behaviours, though recent research is attempting to bridge this gap (Rose et al., 2018). One explanation for this may be that internalising difficulties tend to start at a lower rate and increase through the life course, while externalising behaviours follow the opposite trajectory

(Hipwell et al., 2019). While this discrepancy in research is a concern, both externalising and internalising behaviours have similar antecedents, and also respond to similar interventions

(Tandon et al., 2009). Empirical evidence has been mixed (Herman et al., 2011), with some

PARENTING GROUP OUTCOMES AND ACES 32 meta-analyses finding more modest significant improvements on internalising behaviours compared to externalising behaviours (Buchanan-Pascall et al., 2018). This highlights the need for more effective interventions that hold internalising behaviours as a primary target (Coyne,

2013).

2.6.1 The Prognosis of EBD

Estimates of between 11 and 12% of a sample of young children and adolescents in

Ireland present with EBD (Kelly, 2019). Earlier onset of EBD is more strongly associated with more negative and more severe outcomes (Jones et al., 2015). EBD in childhood is associated with poor outcomes that endure into adulthood including antisocial and criminal behaviour

(Dretzke et al., 2009), emotional difficulties, psychiatric disorders and substance misuse, higher rates of hospitalisation and mortality, higher rates of school dropout and lower levels of academic attainment, along with greater unemployment and family breakdown (Farrington,

2007). Children with conduct problems are more likely to require additional support in educational settings, utilise PC and emergency services more regularly (McGroder & Hyra,

2009) and be in contact with legal authorities during adolescence (Hughes et al., 2017).

The prevalence of EBD, and particularly conduct problems has risen exponentially in the last century (Furlong et al., 2010), bringing with it considerable cost to society. By the age of 28, the cost of children aged 10 meeting the criteria for a conduct disorder (€104,416;

Fergusson, 2005) has been estimated to be approximately ten times higher than those with no conduct problems. More recent estimates accounting for productivity losses along with medical, criminal justice, special education and welfare costs are over €187,000 (Fang et al.,

2012). These estimates demonstrate the substantial economic and monetary costs of EBD to society. It is also an issue for communities, as healthcare and educational systems are placed under more pressure, antisocial behaviour will increase and additional support is required in areas of greater deprivation where EBD are more common (Mersky et al., 2017). These EBD

PARENTING GROUP OUTCOMES AND ACES 33 have been observed to be transmitted across generations (Dretzke et al., 2009) highlighting the influence of the parent-child relationship in either negating or accentuating these problems.

2.6.2 The Parent-Child Relationship and EBD

The management of EBD places strain on a family unit, particularly on caregivers, as they are tasked with managing these difficulties on a daily basis. This can be a significant source of stress for a parent and parents who are predisposed to stress have less resources to engage in effective behaviour management strategies (Pereira et al., 2018). This can increase the levels of conflict between the parent and child (Berthelot et al., 2015), which is a significant predictor of EBD (Kelly, 2019).

In Ireland, up to 22% of parents report issues of conflict with their child. In addition, ratings of parent-child closeness were also reduced for up to 21% of parents at some point in this period (Growing up in Ireland Team, 2018). Both conflict and relationship closeness tend to deteriorate over time when difficulties arise earlier in childhood (Growing up in Ireland

Team, 2018). EBD are more likely to develop in relationships with low closeness and high conflict (O’Donnell et al., 2014). These difficulties are thought to explain a significant proportion of EBD referrals to psychological services (Furlong et al., 2010). In robust parent- child attachment relationships, EBD are less common because stressors are adaptively managed using positive coping strategies modelled by the parent and internalised by the child

(Steele & McKinney, 2019). Parenting interventions support parents to build this adaptive parent-child relationship.

2.7 Parenting Interventions

Meta-analyses have evaluated the long-term effects of various parenting interventions and found that positive effects may be maintained for up to 20 years following intervention

(Sandler et al., 2011). Early intervention has been championed as the best antidote to longer-

PARENTING GROUP OUTCOMES AND ACES 34 term impacts (Duncan et al., 2017). The child’s brain is more malleable in early development and requires less intensive intervention to have significant impacts (Gardner et al., 2019). This evidence has encouraged the development of more PC-based parenting groups (Leslie et al.,

2016). PC parenting groups have demonstrated comparable effects to those in more specialised services, highlighting the promise for their implementation to reduce the long-term health impacts resulting from the occurrence of maltreatment (Moon et al., 2018).

While parenting groups targeting EBD were often conducted in higher socioeconomic areas (Karjalainen et al., 2019), recent studies show positive results across a range of parenting measures including parenting-child interactions and parenting practices in low to middle income countries (Knerr et al., 2013). Treatment and prevention programmes require different content (Leijten et al., 2013). Parenting programmes have been implemented in many countries, across varying cultures and in diverse populations (Leijten et al., 2016). Researchers found that homegrown and imported interventions based on the same principles lead to similar outcomes, which suggests that parenting groups can be selected based on their evidence base, with less focus on cultural specificity (Leijten et al., 2016). Several research publications have outlined the essential components of treatment parenting groups (Bateson et al., 2008). The most effective groups:

• Are time-limited (usually between 8 and 12 sessions). Briefer interventions tend to

outperform longer interventions, as teaching more skills is sometimes associated with

weaker program effects (Walton, 2014).

• Have a structure with a curriculum based on a theoretical framework.

• Include role play during the delivery of sessions and homework between sessions.

• Assist parents to identify their own goals.

• Employ behaviour management strategies tailored to each family’s specific needs.

• Teach positive reinforcement and nonviolent disciplinary techniques.

PARENTING GROUP OUTCOMES AND ACES 35

• Teach principles that are empowering for parents in a variety of situations rather than

context-specific techniques.

• Include strategies for enhancing the parent-child relationship and offer support to the

parent-child dyad (Mortensen & Mastergeorge, 2014).

• Teach parents stress reduction and self-regulation skills (Leijten et al., 2018).

• Are facilitated by appropriately trained and skilled clinicians who are supervised and

are capable of building appropriate alliances with parents who attend (NICE, 2017).

• Maintain a focus on strengthening protective factors (Browne, 2014).

Parenting groups are built on two main perspectives: relationship enhancement and behaviour management (Sanders, 2008). Both methods have empirical evidence supporting their benefits (Gardner & Leijten, 2017; Mingebach et al., 2018).

2.7.1 Behavioural Parenting Programmes

Programmes adopting a behavioural perspective draw on learning theory and posit that disruptive behaviours develop as a result of parents inadvertently reinforcing negative behaviours instead of positive behaviours. These programmes aim to teach parents the skills of positive reinforcement such as praise and rewards, whilst also preventing negative reinforcement strategies such as ‘time out’ or ignoring. By improving these skills, parents significantly reduce the coercive cycles underlying the maintenance of disruptive child behaviour and redirect parents’ attention towards their child’s positive behaviours (Leijten et al., 2018). When children become less disruptive it is easier for parents to express warmth, sensitivity and responsiveness (Combs-Ronto et al., 2009).

2.7.2 Relational Parenting Programmes

Groups based on a relationship enhancement perspective believe that disruptive behaviours result from a lack of sensitivity and responsiveness in the parent-child relationship

PARENTING GROUP OUTCOMES AND ACES 36

(Kochanska et al., 2005). These programmes aim to teach parents skills to improve how they relate to their child, and repair distressed parent-child relationships (Havighurst et al., 2013).

Relational experiences that parents carry over from the attachment relationship with their own parent are also considered (Bakermans-Kranenburg et al., 2005).

Relational programmes are more frequently offered to socioeconomically disadvantaged families (Carta et al., 2012), families where children are at risk of maltreatment

(Mulcahy et al., 2014), and families struggling to develop supportive parent-child relationships

(Whittaker et al., 2011). Several meta-analyses have identified relational group programmes as moderately effective in improving the parent-child relationship (Gilmour, 2018), parental self- regulation abilities, and in reducing EBD (Mortensen & Mastergeorge, 2014).

2.7.3 Integrative Parenting Programmes

The combination of both behaviour management and relational principles was first conceptualised by Hanf (1969) and has since been adopted by many parenting programmes

(Kaehler et al., 2016). This approach has a foundation in empirical evidence as parental behaviour management and the parent-child relationship are associated with the development of EBD (Pinquart, 2017). Therefore, teaching parents skills from both domains can be more effective than a singular method (Leijten, et al., 2013).

Treatment samples tend to have children with more significant EBD that cause greater disruption in the parent-child relationship and may require an integrated approach that focuses on both aspects (Leijten et al., 2018). Difficulties addressed in many parenting groups are often preceded by ACEs. However, much less evidence is available that informs practice about the impact of parental ACEs on engagement in parenting groups.

PARENTING GROUP OUTCOMES AND ACES 37

2.8 ACEs Impact on Parenting Interventions

There is a dearth in research examining parenting intervention outcomes for parents exposed to ACEs (Levey et al., 2017). Research appears instead to have focused on populations with low resources as a whole rather than parents who have histories of abuse or adversities specifically (Levey et al., 2017), though these populations are likely to have higher incidences of ACEs (Knerr et al., 2013). The literature that does exist is of varying quality and has evaluated various types of interventions.

Three home-visit interventions have been evaluated in families who have experienced childhood adversity (Pasalich et al., 2019). Parent-child interactions have been the primary outcome measured, and only one study has focused on child-based outcomes (Moran et al.,

2005). Parents with more childhood adversity tend to show greater deficits in specific parenting domains at baseline (Oxford et al., 2016; Theise et al., 2014). Findings suggest that sensitivity in parents who have experienced childhood maltreatment can reach comparable levels of improvement to parents without histories of maltreatment following parenting interventions

(Ammerman et al., 2016; Moran et al., 2005; Hurlburt et al., 2013; Shenk et al., 2017). Histories of physical abuse appear to be most strongly associated with lower parental sensitivity

(Vaillancourt et al., 2017) but this is also more amenable to improvement following parenting interventions (Ammerman et al., 2016; Pasalich et al., 2019). These findings support the concept of examining specific types of ACEs when predicting the trajectory of outcomes such as parental sensitivity following interventions (Muzik et al., 2017).

Parenting group interventions that have evaluated the impact of parental ACEs found similar patterns identified in home-visiting programmes. Parents with higher ACE scores (≥4) had higher levels of baseline impairments (Blair et al., 2019). Parents with lower ACE scores were more likely to rate their children’s behaviour in the non-clinical range before and after the intervention. Parents with higher ACE scores reported significant decreases in EBD overall,

PARENTING GROUP OUTCOMES AND ACES 38 while parents with lower ACE scores did not. Similar studies have found no significant differences in intervention effects for parents with and without a history of childhood maltreatment (Hurlburt et al., 2013). While one study found that family risk was mostly reported as a nonsignificant moderator (Shelleby & Shaw, 2014), parental exposure to cumulative adversity was not examined. When cumulative exposure was examined, parents with higher ACE scores benefited most from parenting groups (Rosenblum et al., 2017), particularly on measures of parent-child interactions (Pearl et al., 2012). Initial research suggested that exposure to trauma may impact negatively on parents’ response to treatment

(Heim et al., 2004). The research outlined above challenged this belief, identifying that parents with higher ACE scores experience greater baseline impairment but also experience greater improvements.

As parenting stress increased in long-term follow up of some parents with a history of trauma (Shenk et al., 2017), other potential confounding factors on outcomes were explored.

There is evidence to suggest that the extent to which a parent has ‘resolved’ their own trauma can have a significant impact on intervention outcomes (Siegal, 2015). A parent who has been able to process trauma from their own history is more likely to have the capacity to support their children to process emotions in a more adaptive manner.

Few studies have extrapolated the extent to which parents’ ACEs have been resolved either before, or through the process of intervention (Lange et al., 2020). Another important factor was that engagement in these programmes can be a challenge for parents who have experienced trauma (Muzik et al., 2015). Overwhelming levels of stress, unstructured daily routines, lack of knowledge about available services and negative previous experiences with the healthcare system are often mentioned as contributing factors to reduced engagement

(Muzik et al., 2016).

PARENTING GROUP OUTCOMES AND ACES 39

Parenting groups have historically had difficulties associated with high drop-out rates, despite high levels of enrolment. Making programmes easier to access for parents as well as investing and building relationships with the parents were two important aspects for reducing drop-out (Axford et al., 2012).

For trauma-exposed parents, there are additional barriers to engagement (Muzik et al.,

2013; Muzik et al., 2015). Excessive and prolonged exposure to trauma across their childhood has implicated the core capabilities that adults require to navigate life, work and parenting tasks effectively (Rayce et al., 2017). Trauma exposed parents can have less efficient skills in domains of planning, self-control and flexibility, which makes it more difficult for them to follow through on tasks that help them reach their goal (Center on Developing Child, 2016).

Attending a group intervention to better support their child is one example of a parent’s goal.

Doing so requires a strong level of executive functioning. Parents may have to re-organise their weekly schedule over a 10-week period, tolerate changes to their usual routine, manage unforeseen challenges that arise each week. They also have to attend and engage with the content and people in the group. This can be a challenge for any parent, and can be difficult to sustain for trauma-exposed parents (Rayce et al., 2017).

These parents require a safe and non-judgemental environment that provides flexible and respectful treatment to accommodate the challenges they face. While these are components most parents need when seeking support, it is especially important for trauma-exposed parents as their experience of trauma may have changed their perceptions of what can be considered safe and trustworthy, thus changing how they access healthcare (Liang et al., 2005). The

UYCBP is built on a foundation (the core SA principles) that emphasises the importance of implementing many of the strategies described throughout the group intervention, making it appropriate for parents with a history of ACEs.

PARENTING GROUP OUTCOMES AND ACES 40

2.9 The Understanding Your Child’s Behaviour Programme

The UYCBP has been developed based on the SA and aims to instil the importance of three core principles of containment, reciprocity and behaviour management (Douglas &

Ginty, 2001; Figure 2.4).

Figure 2.4

The Solihull Approach Conceptual Triad (Douglas & Ginty, 2001)

This programme is considered an integrative parenting programme, including relational components, attachment components and behavioural management strategies. This integrated framework is of particular importance when considering the impact of ACEs on parenting. The

UYCBP considers the impact of ACEs on parenting by exploring the attachment relationship of the parent during their own childhood experiences and addresses how this may influence their own parenting style now (Douglas & Ginty, 2001). The UYCBP has been implemented and evaluated in various areas by different services and is now considered an established programme, recommended within the NICE guidelines for behavioural difficulties in children

PARENTING GROUP OUTCOMES AND ACES 41

(NICE, 2017). In Ireland, implementation is in its infancy. The Health Service Executive plans to roll the UYCBP out nationally as a treatment method within PC Psychology Services. The

10-week programme is outlined in Table 2 below.

Table 2.2

Understanding Your Child’s Behaviour Weekly Session Content

Session Number Title

Session 1 Introduction

Session 2 How are you and your child feeling?

Session 3 Tuning into your child’s development

Session 4 Responding to your child’s feelings

Session 5 Different styles of parenting

Session 6 Parenting child partnership – having fun together

Session 7 The rhythm of interaction and sleep

Session 8 Self-regulation and anger

Session 9 Communication and attunement – how to recover when things go wrong

Session 10 Celebration

The programme is implemented for two hours each week across a 10-week period. Each session includes a break with refreshments. Course content includes presentations, role plays, group discussions and videos, and each facilitator follows programme guidelines in a manual to ensure fidelity to the programme. The group is facilitated by two practitioners who are typically health visitors, school nurses or other mental health clinicians such as psychotherapists or psychologists who have received the 2-day SA foundation course, in

PARENTING GROUP OUTCOMES AND ACES 42 addition to 1-day training in the facilitation of the parenting group. Facilitators are required to have used the SA in their practice for at least three months prior to facilitating the group.

2.9.1 Research for UYCBP Effectiveness

Studies have been conducted evaluating the UYCBP using various methodologies and outcome measures. Parents reported that they enjoyed the programme, indicating it was acceptable amongst attendees (Bateson et al., 2008). A mixed-methods evaluation found qualitative evidence supporting the successful implementation of the three core principles of containment, reciprocity and behaviour management throughout the programme (Johnson &

Wilson, 2012). Parents appeared to benefit from the theoretical model of the SA as a method of understanding their child’s behaviour (Vella, Butterworth, Johnson, & Urquhart Law, 2015).

Researchers also found parents were able to relax, share experiences and make changes in their parenting behaviours having increased their knowledge (Johnson & Wilson, 2012). The

UYCBP was acceptable in numerous research samples (Appleton et al., 2016), including a

‘father only’ group (Dolan, 2014). The UYCBP has been translated to an online course, with initial findings comparable to the original format (Johnson, 2018).

An initial pilot study found positive outcomes in parental well-being, specifically depression and anxiety symptoms and child behaviours, with the greatest improvements in externalising behaviours. Parents improved their confidence and self-esteem, reduced their levels of anxiety and observed better family relationships (Cabral, 2013). Parents engaged with their children using more reflective parenting styles that contributed to improved behaviour management (Vella et al., 2015). Parents felt calmer and more confident, and began to enjoy parenting more (Appleton, Douglas, & Rheeston, 2016). Parents were more nurturing and authoritative, thus reducing EBD (Cabral, 2013). Improvements in child behaviour, parental well-being and in the parent-child relationship were maintained at follow-up (Smith, 2013).

PARENTING GROUP OUTCOMES AND ACES 43

Many of the studies have been conducted using uncontrolled groups, which may have confounded the findings. However, most recently, a randomised controlled trial demonstrated significant improvements in parental emotional health and the parent-child relationship, along with reductions in measures of child behaviour (Douglas & Johnson, 2019). To the author’s knowledge, there are no studies that examine factors (such as ACE scores) that may alter the intervention outcomes for parents.

2.10 Gap In The Literature

Drawing on research that indicates parenting programmes are generally transferrable between cultures (Gardner, Montgomery, & Knerr, 2016), there are promising indications that the UYCBP can be effective in an Irish-based sample. However, there is currently no evidence for the UYCBP in terms of acceptability and effectiveness in an Irish-based PC sample.

Parental perceived stress levels and self-regulation abilities play a significant role in a child’s development, particularly in the likelihood that children will display externalising or internalising behaviours. Based on this association, parental stress, self-regulation and child internalising and externalising behaviour are important outcomes for measuring the effectiveness of a parenting intervention.

Few studies have evaluated the extent to which ACE scores influence the effectiveness of parenting programmes, even for interventions such as the UYCBP that explores the influence of parental ACEs on current parenting strategies. This highlights a significant gap in our understanding of how effective parenting groups are for parents with different ACE scores.

Given the significant impact of cumulative ACEs on parenting and child outcomes, it is important to identify their prevalence in the clinical sample, their impact on initial presentation, and how they might impact treatment. The current study aims to address these gaps in the literature.

PARENTING GROUP OUTCOMES AND ACES 44

2.11 Research Questions

The current study’s research questions and hypotheses are outlined below.

1. What is the relationship between parental ACE scores and both parent-based and child-

based dependent variables at baseline?

At baseline, compared to parents with lower ACE scores (≤ 1), parents with higher

ACE scores (≥ 2) will report:

H1a: significantly higher scores on perceived stress.

H1b: significantly lower self-regulation abilities.

H1c: their child displaying significantly more internalising and externalising difficulties

combined.

H1d: their child displaying significantly more internalising difficulties.

H1e: their child displaying significantly more externalising difficulties.

2. Is the UYCBP acceptable based on experience and attendance in an Irish-based sample?

H2a: Parents’ satisfaction will rate their overall experience at comparable levels to

existing normative data on the Experience of Service questionnaire.

H2b: Parents will show a strong rate of attendance to the UYCBP, defined as 70% (or

seven out of 10) of sessions (based on guidelines specified by Furlong et al., 2013).

To assess varying degrees of acceptability in terms of attendance, the following hypothesis was developed:

H2c: Parents with higher ACE scores will attend significantly fewer sessions when

compared to parents with lower ACE scores.

3. Is the UYCBP effective in improving both parent-based and child-based variables?

The UYCBP will produce:

H3ai: significant reductions in parents’ perceived level of stress.

PARENTING GROUP OUTCOMES AND ACES 45

H3aii: significant reductions in the proportion of scores within the “very high” category

for perceived stress.

H3b: significant improvements in parents’ self-regulation abilities.

H3ci: significant reductions in a child’s internalising and externalising difficulties

combined.

H3cii: significant reductions in the proportion of scores within the “very high” category

for combined internalising and externalising difficulties.

H3d: significant reductions in children’s internalising difficulties.

H3e: significant reductions in children’s externalising difficulties.

4. Do parental ACEs impact the effectiveness of the UYCBP?

Following the UYCBP, compared to parents with lower ACE scores, parents with higher ACE scores will report:

H4a: significantly greater reductions in levels of perceived stress.

H4b: significantly greater improvements in parental self-regulation.

H4c: significantly greater reductions in their child’s combined internalising and

externalising difficulties.

H4d: significantly greater reductions in their child’s internalising difficulties.

H4e: significantly greater reductions in their child’s externalising difficulties.

5. Does the UYCBP impact on parents’ perception, insight and understanding of their

child’s behaviour?

The UYCBP will give parents:

H5a: a better understanding of the behaviours of their children, identified through

qualitative analysis.

PARENTING GROUP OUTCOMES AND ACES 46

H5b: an insight into how their experiences of being parented impact their child’s

behaviour, identified through qualitative analysis.

PARENTING GROUP OUTCOMES AND ACES 47

Chapter 3: Methodology

3.1 Chapter Overview

Chapter 3 describes the methodological framework underpinning the research.

Participants characteristics are outlined. Research procedures and ethical considerations are outlined. The measures utilised and an overview of the associated data analyses are detailed.

3.2 Research Study Design

A repeated measures within-group, mixed-methods design was employed. In line with previous evaluations of the UYCBP, a pre-post research design was adopted. Change between timepoints was measured on dependent variables of parental perceived stress, parental self- regulation and child internalising and externalising problems. The parental ACE score was the covariate. As this was the first study to evaluate the UYCBP in an Irish setting, participant sampling was restricted to one community health organisation area. This ensured controlled and consistent programme implementation was maintained, thus reducing the influence of potentially confounding factors introduced with broader samples. Acceptability of the UYCBP to participants was assessed using both quantitative and qualitative measures. Written qualitative feedback was gathered and a focus group was conducted after the intervention to gain a more in-depth understanding of participants’ experience. This qualitative component was also used to gather information about changes in parents’ perception and understanding of their children’s behaviour and the possible consequences of participants’ own experiences of being parented. This also served to further illustrate statistical findings using participants’ own words. Sample size requirements and saturation is an on-going debate in qualitative research, with some suggestions that saturation can never truly occur as new data will always bring new interpretations with certain analytic approaches (Clarke & Braun, 2018). However, there is a

PARENTING GROUP OUTCOMES AND ACES 48 consensus that four to six participants is sufficient to generate overarching themes (Guest et al., 2006; Hennick et al., 2020).

3.3 Epistemology and Ontology

My ontological position is one of relativism. I believe reality exists through subjective observation and interpretation and as such, is experienced differently from person to person

(Scotland, 2012). My epistemological stance is interpretivism, whereby I believe that one’s knowledge of the world exists only through the lens of their perceptions, beliefs and subsequent interpretations (Ormston et al., 2014). As I engage in reflexive thematic analysis, my interpretation of the data is presented through these ontological and epistemological positions.

It is not possible for the qualitative data to be interpreted entirely objectively or ‘value-free’. I acknowledge that I am personally engaged in the analysis; that themes are not recognised and do not simply ‘emerge’. Instead, they are purposefully generated through the interaction of my interpretations within the underpinning theoretical framework devised by the research question and the raw data (Braun & Clarke, 2019). Similarly, I assume that interpretations of quantitative data are filtered through my understanding of the existence and production of knowledge and meaning in the world.

3.4 Participants

Participants were referred to the PC Child Psychology Service in two locations within the same community health organisation. Their suitability for the UYCBP was assessed in an initial consultation session facilitated by Clinical Psychologists as part of routine clinical practice. No randomisation was carried out to prevent any impact of the research on typical service provision. All parents who attended the group were offered the opportunity to participate in the research. To maintain a clinically representative sample, exclusion criteria were kept to a minimum. Clinical judgement was used to decide if attendees met exclusion

PARENTING GROUP OUTCOMES AND ACES 49 criteria specified as: (1) The research was considered overburdensome for a participant, or (2)

The research placed the participant at increased risk of distress or harm. Figure 3.1 details the number of participants at each time point from initial referral to the group, through to post- intervention research completion. No participants met the exclusion criteria at screening, and

43 participants were referred to four separate UYCBPs facilitated within 2019. Thirty-four participants attended the first session, with 30 participants agreeing to participate in the research. Participant characteristics are displayed in Table 3.1. The sample was predominantly female, married and unemployed mothers of Irish origin. The average age of attendee was

45.85 (± 10.83), with the average age of the referred child being 7.6 (± 2.72). Families had an average of 2.6 (± 1.1) children in their family, ranging from the youngest age of 6.03 (± 2.78) to the oldest age of 11.73 (± 6.24). ACE scores were 1.97 ± 1.95 for complete responses, and

1.77 ± 1.91 when missing questionnaire responses were scored as 0. The reason for referral is displayed in Figure 3.2, with quantitative representation of any formal diagnoses reported by parents portrayed in Figure 3.3.

PARENTING GROUP OUTCOMES AND ACES 50

Figure 3.1

Flowchart For Participants From Initial Referral To Post-Intervention

PARENTING GROUP OUTCOMES AND ACES 51

Table 3.1

Descriptive Statistics For Participants Attending The UYCBP

N M ± SD Range Age of attendee 30 45.85 ± 10.83 26 – 54 (28) Youngest child age 30 6.03 ± 2.78 1 – 11 (10) Oldest child age 30 11.73 ± 6.24 3 – 31 (28) Age of referred child 30 7.6 ± 2.72 3 – 14 (11) Children in family 30 2.6 ± 1.10 1 – 5 (4) ACE score Fully complete 26 1.96 ± 1.95 Missing items = 0 30 1.77 ± 1.91 Employment Status Employed Unemployed 10 20 Attender Gender Male Female 2 28 Attender Nationality Irish Irish/British Polish 28 1 1 Relationship Status* Single Relationship LwP Married Sep/Div 7 1 1 16 4 Relationship to child Mother Father Foster Carer 22 2 6 Note. n = number of participants in each group; M ± SD = mean ± standard deviation; ACE score Missing items = 0 = Items with no response scored as 0 and included in total scores; Relationship = in a relationship; LwP = living with partner; Sep/Div = separated or divorced; ACE score Fully complete = all items completed on questionnaire. * One participant did not declare their relationship status

Figure 3.2.

Number Of Children With Each Referral Reason As Reported By Attendees At Baseline

21

10

3 2 2 2

AGGRESSION/ EMOTIONAL IMPULSIVITY/ SOCIAL SENSORY REDUCED ANGER WELLBEING HYPERACTIVITY DIFFICULTIES REGULATION DANGER AWARENESS

PARENTING GROUP OUTCOMES AND ACES 52

Figure 3.3

Number Of Children With Diagnoses As Reported By Attendees At Baseline

4

2 2 2

1

LEARNING ATTACHMENT SENSORY EMOTIONAL OR ADHD DIFFICULTIES (I.E. DISORDER REGULATION BEHAVIOURAL DYSLEXIA) DISORDER DISTURBANCE

3.5 Procedure

Participants were informed about the research in an initial consultation session implemented as standard clinical practice to assess suitability for the UYCBP. Each individual had until the first group session to review the research information provided and reflect on the opportunity to take part in this research. Information about the research was reiterated before the first group session (Appendix 3.1), prior to obtaining informed consent using the form devised (Appendix 3.2). If participants provided informed consent, they completed the questionnaires (Appendix 3.3). This procedure was completed before the intervention began, lasting approximately 10-15 minutes in duration. The post-intervention data was collected at the end of the final UYCBP session in week 10 (Appendix 3.4) and this took approximately 10 minutes to complete. Participants were provided with a debrief sheet (Appendix 3.5) describing the research aims in more detail once they had completed the questionnaire. The focus group was held immediately after the final session of the first programme, lasting approximately 50 minutes. The Principal Investigator (PI) facilitated the focus group and emphasised that their role was specifically in a research capacity, meaning they were not directly affiliated with the

PARENTING GROUP OUTCOMES AND ACES 53 clinical service. The focus group schedule was briefly introduced by outlining the goal which centred on obtaining information about participants’ experience of attending the group.

Reflective notes were made immediately after the focus group which were used to inform the interpretation of data gathered. Full transcription of the focus group was conducted at a later date by the interviewer.

3.6 Consent & Ethical Issues

Ethical approval for this study was obtained from the Research Ethics Committee, HSE

South East (Available on request). The consent process approved by this committee ensured that participants were aware that they could withdraw from the research at any stage and that their participation, or decision not to participate would not impact their treatment or care within the service in any way (Appendix 3.2). As the participants were being recruited from a clinical population, risk was monitored throughout the research procedure. Clinical judgements made by clinical psychologists on a person’s suitability for the research were observed, and the clinical psychologists facilitating the group also monitored risk on an on-going basis as the group progressed. To maintain participant confidentiality, the PI was the only individual who had access to participant data throughout the research process.

3.7 Instruments

3.7.1 ACEs Questionnaires

The ACEs questionnaire (Felitti et al., 1998) is a well-established questionnaire that has been used extensively in large-scale research. It requires participants to answer binary

“yes” or “no” questions to retrospectively determine if they have had specific experiences in childhood. This measure was administered at baseline and used to obtain a sum of event occurrences during the parents’ experiences from birth to 18 years of age. Based on population data (Bellis et al., 2014a), experiencing up to one ACE is considered average, and ACEs scores

PARENTING GROUP OUTCOMES AND ACES 54 of two or more were considered the cut-off for potential increased risk of difficulty in the present study. Missing items (N = 14) was coded as ‘no’ in the data, and total scores for each individual was summed including these items.

3.7.2 Cohen’s Perceived Stress Scale (PSS)

The PSS (Cohen et al., 1983) is a 10-item questionnaire measuring the frequency of feelings and thoughts considering life uncontrollable, unpredictable and overloading within the last month on a 5-point Likert scale ranging from “never” to “very often”. Four positively- worded were reverse-scored in the analyses. Higher scores on the PSS are indicative of greater perceived stress. The PSS has been subjected to extensive review and utilisation in the literature and satisfies the necessary internal reliability requirements for perceived stress (a = .85) and test-retest reliability up to twelve weeks (a = .85; Lee, 2012). Normative data gathered from large-scale validation studies were used as a standard of comparison for mean and categorical scores of perceived stress (Cohen & Janicki-Deverts, 2012).

3.7.3 Strengths and Difficulties Questionnaire (SDQ)

The SDQ was used to measure child emotional and behavioural difficulties (Goodman,

1997). It is a 25-item scale with a 3-point Likert scale completed by a parent or guardian about their child. There are four problem subscales of conduct problems, hyperactivity, emotional symptoms, peer relationship difficulties, and a pro-social behaviour scale. The four problem scales are summed to calculate a total difficulties score, as well as two separate internalising

(emotional symptoms and peer relationship difficulties) and externalising (conduct problems and hyperactivity) problem scores. It is validated for use with children aged between three and

16 years and demonstrated strong internal consistency (a = .75) and adequate test-retest reliability over 3-month periods required for the current group duration (Goodman, 1997). The

PARENTING GROUP OUTCOMES AND ACES 55 scale has been used in many PC samples with similar presenting concerns to the present study

(e.g. Goodman & Goodman, 2011).

3.7.4 ‘Me as a Parent’ (MaaP)

The MaaP scale contains 16 items scored on a 5-point Likert scale that measures parental self-regulation. Parental self-regulation is a construct that captures different terminologies employed in research to date (Hess, 2004). Each of these share overlapping definitions but parental self-regulation is a broader explanation of parental efficacy, which captures four concepts of personal agency, self-efficacy, self-management, and self- sufficiency. Parental self-regulation refers to the extent that parents perceive themselves to be competent and efficacious, with abilities of independent problem-solving, self-direction and adapting parenting goals to different parenting challenges they are faced with (Sanders, 2008).

It has been linked with many of the positive parent-child outcomes discussed previously

(Barlow et al., 2010). A systematic review of measures of parental self-efficacy informed the decision-making process to identify the MaaP as the most suitable measure when considering the current research questions (Wittkowski et al., 2017). The initial development study for the

MaaP (Hamilton et al., 2015) identified adequate convergent validity compared to well- established scale measuring parental competence (r = .61). The scale also demonstrated test- retest reliability across a 3-month time period (r = .71), which sufficiently covers the 10-week

UYCBP.

3.7.5 Experience of Service Questionnaire

The 12-item Experience of Service – Parent version (ESQ; Attride-Stirling, 2003) was utilised to measure satisfaction with treatment. It was designed for use with parents or carers who have used a psychological service for issues relating to their child. Two constructs are measured: Satisfaction with care (9 items), and satisfaction with environment (3 items). Lower

PARENTING GROUP OUTCOMES AND ACES 56 scores indicate higher satisfaction. Open-ended questions are included to allow participants to expand on their experience. The measure demonstrates adequate construct validity within a child mental health service similar to the current study (Brown et al., 2014).

3.7.6 Focus Group Schedule

The focus group schedule was designed with a specific focus on the research questions posed by this study. The questions were formulated in accordance with guidance for qualitative research with focus groups (Massey, 2011) and guidelines for thematic analysis in focus groups

(Clarke et al., 2015; Braun et al., 2019). Qualitative questions from the ESQ were used as a basis for constructing further questions about the participants’ experiences of the group.

Quantitative questionnaires were reviewed and open-ended questions related to the hypotheses were drafted. The additional questions aimed to gather a qualitative understanding of parents’ participation in the group and asked if parents’ perceptions of their child’s behaviour had changed. They were also designed to explore if parents’ own experiences of being parented had impacted on their current parenting behaviours. To ensure the interview schedule was sufficient to provide relevant data but also brief enough to fit within the time constraints, the drafted list of questions was reviewed and one question was dedicated to each hypothesis. The final version of the interview schedule (Appendix 3.6) consists of nine questions including follow-up prompts.

3.8 Data Analysis Overview

3.8.1 Quantitative Analysis Overview

Quantitative data was analysed using SPSS v26. Baseline descriptive data was analysed to provide a profile of parents who attended the UYCBP. Significance was set at p < 0.05

(Feise, 2002) and effect sizes were calculated using Cohen’s d (Cohen, 1988). Using results outlined by previous studies evaluating the UYCBP as a basis (Bateson et al., 2018), a large

PARENTING GROUP OUTCOMES AND ACES 57 effect size (d = 1) with p-value of 0.05 significance levels were input to determine required sample sizes using G*Power software (Faul et al., 2007).

Independent sample t-tests were used to analyse differences between high and low ACE scores at baseline. Baseline independent sample t-tests for analysing differences between high and low parental ACE scores on the dependent variables required 34 participants to detect a large, two-tailed effect size. Repeated measures t-tests were used to analyse pre to post- intervention differences. 16 participants were required for adequate power in two-tailed repeated measures t-tests. Chi-square analysis were carried out on the SDQ total score and the

PSS total score to analyse categorical change across categories obtained from existing normative data. No post-hoc analyses were conducted given the data spread and insufficient cell count observed. Analysis of covariance (ANCOVA) procedures were utilised to investigate the relationship of parental ACE scores to pre and post-intervention scores on each dependent variable, requiring 33 participants for sufficient power. Acceptability was measured using mean and standard deviations on the ESQ care and environment scales, with lower scores indicating greater acceptance of the care and environment.

3.8.2 Data Preparation and Treatment

Incomplete questionnaires were handled as specified by authors of the specific measures where possible. Data was assessed using Little’s Missing Completely at Random

(MCAR; 1986) test prior to proration and imputation of missing items (Appendix 3.7). For the

MaaP and PSS scales, missing items were replaced by the individual average score on the total scale to compute a reliable total score for questionnaires with less than two missing items. For the SDQ, missing items were replaced with prorated scores calculated using other item scores within the questionnaire subscales, as specified by the questionnaire author’s validation study

(Goodman, 1997). For missing items on the ACE questionnaire, it was not possible to impute

PARENTING GROUP OUTCOMES AND ACES 58 missing values given the binary nature of each question. Missing values were coded as a “no” response and total scores were calculated to include missing items.

Two sets of analyses were completed. The first was defined as “research completers”.

These were participants who completed both pre and post-intervention questionnaires as specified by the research protocol. The second analysis evaluated the “intention-to-treat”

(ITT) sample, which included any participant who completed the pre-intervention questionnaire but did not complete the post-intervention questionnaire. Multiple imputation was carried out for missing data at the second time point as outlined by best practice guidelines for missing data (Lee & Carlin, 2010; Schafer, 1999). Little’s MCAR was not significant for any of the dependent variables gathered at pre and post timepoints, indicating the data was missing completely at random. As a result, multiple imputation was conducted. All dependent variable items from time point one were included as predictors in the multiple imputation model. Eight participants’ post-intervention data was imputed. There were no significant differences between the research completer and ITT data on all dependent variables (all p’s >

.083). Variable correlations are displayed in Table 3.2, in line with quantitative research reporting guidelines (Coolican, 2017).

3.8.3 Normality Testing

A series of normality tests were conducted for each dependent variable used in t-tests at baseline, and dependent and independent variables used in both t-tests and ANCOVAs

(Howitt & Cramer, 2017). A difference score between timepoints was calculated to assess the assumption of normality (Howitt & Cramer, 2017). Violations are outlined in the text.

3.8.3.1 T-Test Assumptions.

Boxplots were inspected to identify outliers in the dataset, with the criteria for outliers set at 1.5 box lengths from the edge of the box. Quantitative analysis of normality was also

PARENTING GROUP OUTCOMES AND ACES 59 conducted using Shapiro-Wilk’s test (p > .05). Visual observations of Q.Q plots and histograms were made in order to identify normal distribution.

3.8.3.2 ANCOVA Assumptions.

Linear relationships between ACE groups were assessed through scatterplot observation. Interaction terms were inspected to assess for homogeneity of the regression slope, and normality was assessed using Shapiro-Wilk’s test on standardised residuals extracted from the dependent variables. Homoscedasticity was visually assessed from standardised residuals plotted against predicted values. Homogeneity of variances was assessed using Levene’s test

(Howitt & Cramer, 2017). Outliers were also identified as standardised residual scores greater than ± 3 standard deviations.

Table 3.2

Correlation Matrix for Variables Included in Analysis

1 2 3 4 5 6 7 8 9

[1] PSST1 [2] PSST2 .62** [3] MaaPT1 -.52** -0.17 [4] MaaPT2 -0.38 -.46* 0.42 [5] SDQT1 0.31 0.28 -.37* 0.08 [6] IntT1 0.24 0.39 -0.13 -0.01 .89** [7] ExtT1 0.28 -0.05 -.57** 0.16 .74** 0.35 [8] SDQT2 0.12 0.24 0.01 -0.13 .61** .52* 0.37 [9] IntT2 0.06 0.20 0.19 0.00 .57** .66** 0.11 .84** [10] ExtT2 0.15 0.22 -0.13 -0.20 .51* 0.30 .50* .91** .54** Note. PSST1, PSST2 = Perceived Stress Scale time point 1, time point 2; MaaPT1, MaaPT2 = Me as a Parent scale time point 1, time point 2; SDQT1, SDQT2 = Strengths and Difficulties questionnaire total score time point 1, time point 2; IntT1, IntT2 = Strengths and Difficulties questionnaire internalising score time point 1, time point 2; ExtT1, ExtT2 = Strengths and Difficulties questionnaire externalising score time point 1, time point 2. *p < .05. **p < .01.

PARENTING GROUP OUTCOMES AND ACES 60

3.9 Qualitative Analysis

A reflexive thematic analysis (TA) was conducted on qualitative data using guidelines provided by Braun and Clarke (2016, 2019), whilst maintaining principles of good practice in qualitative analysis (Elliott et al., 1999). TA is flexible in its theoretical basis and basing the analysis within theory suitable for the specific research question is important. Two main theoretical frameworks were drawn upon throughout the analysis. The first was the SA’s triad of containment, reciprocity and behaviour management as core principles for positive parenting approaches. The second was attachment theory and its explanation of how parental difficulties are transmitted to offspring. The PI’s subjectivity was utilised as a resource to create narratives from the data and provided a context for meaning-making (Clarke & Braun, 2018). Reflective notes were maintained throughout data collection and analysis to reduce the potential for bias in interpretation (Smith, 2006).

Raw data included a written transcript of the focus group, qualitative responses from the ESQ questionnaire and additional feedback forms gathered after each session. The primary author initially familiarised themselves with the raw data through multiple readings, from which initial codes were generated. A framework of topics was created from the initial codes and the distinct topics were categorised into domains that were deemed representative of the data. Subthemes were devised to reflect discrete aspects within each theme. The analysis was continually reviewed across several iterations to ensure it accurately represented the narratives interpreted from the data. The structure of the analysis was also assessed to ensure it fit within the guidelines of the TA framework. The proposed themes and subdomains were modified to ensure they accurately described the amended categorisation of the data. Finally, relevant quotations were presented in report format to depict the themes and subdomains.

PARENTING GROUP OUTCOMES AND ACES 61

Chapter Four: Results

4.1 Chapter Overview

Chapter 4 presents quantitative results, outlining manipulations made to the data in

preparation for each test procedure. The qualitative analysis is then illustrated using participant

quotations extracted from the data gathered.

4.2 Quantitative Results

4.2.1 Research Question One: Parental ACE Scores and Dependent Variables at Baseline

The normality testing revealed that the MaaP measure at baseline was significant on

the Shapiro-Wilk’s test, with the data appearing positively skewed. Logarithmic transformation

was performed to produce normality in the data. There no discernible differences between

transformed and original variable analysis. As independent samples t-test are robust enough to

tolerate skewed data (Howitt & Cramer, 2017), original data analysis was interpreted in the

present results. Table 4.1 displays results of the independent samples t-test analyses conducted.

Table 4.1

Independent T-Tests Comparing High and Low ACE Scores on Dependent Variables

LACE (N=17) HACE (N=13) Mean M ± SD M ± SD diff. 95% CI t df p d

PSS 21.29 ± 6.60 22.23 ± 6.21 0.94 -3.92 to 5.79 0.40 28 .70 0.15 MaaP 55.66 ± 7.56 52.92 ± 7.34 -1.74 -7.37 to 3.89 -0.65 28 .52 0.37 SDQ_Tot 22.84 ± 5.35 23.69 ± 5.33 0.85 -3.18 to 4.89 0.43 28 .67 0.16 SDQ_Int 10.24 ± 3.50 10.54 ± 4.26 0.30 -2.59 to 3.20 0.21 28 .83 0.08 SDQ_Ext 12.6 ± 2.80 13.15 ± 2.34 0.55 -1.42 to 2.52 0.57 28 .57 0.21 Note. LACE = Low ACE score; HACE = High ACE score; N = number of participants in each group; M ± SD = Mean ± Standard deviation; Mean Diff. = Mean difference; 95% CI = 95% confidence interval; t = t value; df = degrees of freedom; p = p-value; d = Cohen’s d effect size; PSS = Perceived Stress Scale; MaaP = Me as a Parent scale; SDQ_Tot = SDQ total score; SDQ_Int = SDQ internalising score; SDQ_Ext = SDQ externalising score.

PARENTING GROUP OUTCOMES AND ACES 62

Individuals with higher ACE scores displayed a profile of greater difficulties on all dependent variables when compared to those with lower ACE scores. However, this difference did not reach statistical significance. Mean scores for both high and low ACE scores were within the “moderate” range of perceived stress and “very high” on the SDQ.

4.2.2 Research Question Two: Evaluate the acceptability of the UYCBP

Little’s MCAR was significant for the ESQ Satisfaction with Care scale (Appendix

3.7). However, this related to one missing item only. Validity data and proration guidelines outlined by the questionnaire authors were consulted. The questionnaire was deemed robust enough to sufficiently account for the missing item. Mean score analyses revealed high satisfaction with care received (M = 8.6 ± 1.08) and high satisfaction with the environment

(M = 3.59 ± 1.26). These scores compare with previous research conducted in similar services in which participants typically endorsed the most favourable outcome rating for each item

(Brown et al., 2014). Attendance data was also considered within the research question relating to acceptability. The mean number of sessions attended was 6.73 ± 2.60. Individuals with lower

ACE scores attended more sessions 7.21 ± 2.26 than those with higher ACE scores 6.33 ± 2.77, but this difference was not significant, t(28) = 1.53, p = .14, d = 0.55.

4.2.3 Research Question Three: Effect of the Group on Dependent Variables

Outliers were identified using boxplots for the SDQ Internalising scale and the PSS scale, but inspection of their values did not reveal them to be extreme and they were retained for analysis to preserve power. This was also justified by comparing t-test analyses with and without the outliers which revealed no significant differences. Shapiro-Wilk’s test was significant for the PSS scale. This scale was analysed using the rank test as a non-parametric alternative that is robust enough to tolerate violation of the normality assumption and data that is not symmetrically distributed (Field, 2009). Table 4.2 shows paired samples t-test results for both completer and ITT analysis. In completer analysis, the PSS scale was the only variable

PARENTING GROUP OUTCOMES AND ACES 63

showing significant change. Three participants were observed to have disimproved on the PSS

scale, with the remaining 19 making improvements from pre (Mdn = 23) to post (Mdn = 16)

intervention, with a median reduction of 3.0, p = .004. Assumptions were met for each

dependent variable in ITT data. In ITT analysis, both MaaP (p = .005) and PSS (p < .000)

scores showed significant positive change with moderate effect sizes across timepoints.

Table 4.2

Paired Samples T-Tests Comparing Time Point One to Time Point Two Scores On Dependent

Variables

T1 M ± SD T2 M ± SD Mean diff. 95% CI t df p d

Completer N = 22 MaaP 55.15 ± 7.56 59.06 ± 9.11 3.91 (9.06) -0.1 – 7.93 2.03 21 .056 .73 SDQ_Tot 23.01 ± 4.34 22.27 ± 6.30 -0.74 (5.03) -2.97 – 1.49 -0.69 21 .50 .14 SDQ_Int 10.23 ± 3.38 9.32 ± 3.12 -0.91 (2.71) -2.11 – .29 -1.58 21 .13 .28 SDQ_Ext 12.78 ± 2.38 12.95 ± 4.04 0.17 (3.52) -1.4 – 1.73 0.23 21 .82 .05 PSS* 23 16 -3.0 .004** ITT N = 30 MaaP 54.91 ± 7.39 59.57 ± 7.64 4.66 (8.46) 1.50 – 7.82 3.01 29 .005** .62 SDQ_Tot 23.21 ± 5.27 22.57 ± 5.58 -0.64 (5.76) -2.79 – 1.51 -0.61 29 .55 .12 SDQ_Int 10.37 ± 3.77 9.47 ± 2.86 -0.90 (3.51) -2.21 – 0.41 -1.41 29 .17 .27 SDQ_Ext 12.84 ± 2.58 13.1 ± 3.57 0.26 (3.4) -1.01 – 1.53 0.42 29 .68 .08 PSS 21.70 ± 6.34 17.33 ± 4.79 -4.37 (5.38) -6.38 – -2.36 -4.45 29 <.000** .78 Note. T1 = Time point 1; T2 = Time point 2; M ± SD = Mean ± Standard deviation; Mean Diff. = Mean difference; 95% CI = 95% confidence interval; t = t value; df = degrees of freedom; p = p-value; d = Cohen’s d effect size; ITT = ‘Intention to treat’; MaaP = Me as a Parent scale; SDQ_Tot = SDQ total score; SDQ_Int = SDQ internalising score; SDQ_Ext = SDQ externalising score; PSS = Perceived Stress Scale; Exact Sign = Exact sign test alternative to paired samples t-test; Standard = Standardised score; Sign = Sign test score. * PSS scores are reported as median T1, median T2 and median difference instead of means, as required by the Exact sign test conducted. ** p < .005.

PARENTING GROUP OUTCOMES AND ACES 64

A chi-square test of independence was carried out to determine if there was significant categorical change across timepoints on the SDQ and PSS normative categories. Expected cell frequencies were less than five in a number of instances. The analysis was continued but the statistical results are considered in the context of this assumption violation. Post-hoc analyses were not conducted because of low cell counts (Howitt & Cramer, 2017). There was a statistically significant categorical change between time point one and two for SDQ completer data χ2(6) = 25.79, p = .006, with a large association size (Cohen, 1988), Cramer’s V = .77.

Figure 4.1 shows a decrease of four (18%) from the most severe category downwards along the categorical continuum of severity, with an increase of two (9%) in both the “slightly raised/slightly lowered” and “high/low” categories. ITT analysis was also significant χ2(9) =

20.76, p = .01, with a moderate association size, Cramer’s V = .48. Figure 4.1 displays a decrease of two (7%) from the category of most severe difficulties with combined externalising and internalising problems, an increase of two (7%) in the “high/low” category, an increase of one (3%) in the “slightly raised/slightly lowered” category, and a decrease of one (3%) in the

“close to average” category.

Chi-square tests of independence between PSS categories at time point one and two revealed statistically significant categorical changes for completer data χ2(4) = 14.11, p =

0.007, with a large association size, Cramer’s V = .57 (Figure 4.2). There was a reduction of four (18%) participants from the “high” stress group, with two (9%) participants moving to the

“low” stress and two (9%) to “moderate” stress categories. ITT analysis was also significant

χ2(9) = 12.76, p = .013, with a moderate association size, Cramer’s V = .46. There was a decrease of five (17%) from the highest category, an increase of four (13%) in the “low” stress category and an increase of two (7%) in the moderate stress category between pre and post intervention.

PARENTING GROUP OUTCOMES AND ACES 65

Figure 4.1

Graphic of Categorical Change in Number of Participants on SDQ from Time Point One to

Time Point Two on Completer (Left) and ITT (Right) Data

18 18 24 22 16 T1 T1I 14 20 14 T2 T2I 12 15 10 8 10 6 5 3 5 4 2 5 3 1 1 2 2 2 0 1 1 0 0

/Low /Low

High /Very Low High /Very Low

Close to average Close to average Very High Very High

Slightly raised/slight lowered Slightly raised/slight lowered

Figure 4.2

Graphic of Categorical Change in Number of Participants on PSS from Time Point One to

Time Point Two on Completer (Left) and ITT (Right) Data

23 22 T1 T1I 20 20 T2 T2I 17 15 15 15

10 10

6 6 5 5 4 5 2 2 1 1 0 0 Low Moderate High Low Moderate High

PARENTING GROUP OUTCOMES AND ACES 66

4.2.4 Research Question Four: Parental ACEs Association with Group Effectiveness

In completer analysis, the assumption of linearity was violated for all dependent variables except the SDQ internalising scale. The PSS also violated Shapiro-Wilk’s test (p =

.037). In ITT analysis, the SDQ Internalising scale showed one outlier, and the SDQ

Internalising and Externalising scales violated the assumption of homogeneity of regression slopes. As the ANCOVA is robust to deviations from normality, the analysis was continued in each instance (Rutherford, 2011). No significant differences were observed across time points between low and high ACE scores in completer or ITT analysis, as displayed in Table 4.3.

Mean scores on the SDQ remained within the ‘very high/very low’ category and within the

‘moderate’ category for parents with both low and high ACE scores.

Table 4.4 below displays mean differences between low and high ACE scores. None of these changes were statistically significant. In completer analysis, individuals who had higher

ACE scores made bigger changes in a positive direction on all scales except the SDQ internalising scale. In ITT analysis, parents with higher ACE scores made bigger changes in a positive direction on the SDQ total score, the MaaP and the SDQ internalising scale. Parents with higher ACE scores made smaller improvements on the PSS, and showed slightly larger deterioration on the SDQ externalising scale compared to lower ACE scores.

PARENTING GROUP OUTCOMES AND ACES 67

Table 4.3

ANCOVA Comparing Time point One and Time Point Two Scores on Dependent Variables

Across Low and High ACE Scores

T1 M ± SD T2 M ± SD F df p η2

Completer N = 22 Low High Low High PSS 21 ± 6.65 23.13 ± 7.28 16.64 ± 4.55 18.63 ± 6.35 .003 1, 20 .95 0 MaaP 56.59 ± 8.05 52.63 ± 6.30 58.95 ± 9.37 59.26 ± 9.27 1.14 1, 20 .30 .05 SDQ_Tot 22.8 ± 4.31 23.38 ± 4.66 22.43 ± 6.65 22 ± 6.07 0.19 1, 20 .66 .01 SDQ_Int 10.5 ± 2.65 9.75 ± 4.56 9.79 ± 3.09 8.5 ± 3.21 0.19 1, 20 .66 .01 SDQ_Ext 12.3 ± 2.67 13.62 ± 1.60 12.64 ± 4.32 13.5 ± 3.7 0.09 1, 20 .77 .004 ITT N = 30 PSS 21.29 ± 6.60 22.23 ± 6.21 16.71 ± 4.34 18.15 ± 5.38 .064 1, 28 .81 .002 MaaP 55.66 ± 7.56 53.92 ± 7.34 59.64 ± 8.46 59.46 ± 6.75 .242 1, 28 .63 .009 SDQ_Tot 22.84 ± 5.35 23.69 ± 5.33 22.82 ± 6.13 22.23 ± 5.00 .456 1, 28 .51 .016 SDQ_Int 10.24 ± 3.50 10.54 ± 4.26 10.06 ± 2.95 8.69 ± 2.66 1.71 1, 28 .20 .058 SDQ_Ext 12.60 ± 2.80 13.15 ± 2.34 12.76 ± 3.91 13.54 ± 3.15 .031 1, 28 .86 .001 Note. T1 = Time point 1; T2 = Time point 2; Low = Low ACE score; High = High ACE score; M ± SD = Mean ± Standard deviation; F = F value; df = degrees of freedom; p = p- value; d = Cohen’s d effect size; MaaP = Me as a Parent scale; SDQ_Tot = Strengths and Difficulties questionnaire total score; SDQ_Int = Strengths and Difficulties questionnaire internalising score; SDQ_Ext = Strengths and Difficulties questionnaire externalising score; PSS = Perceived Stress Scale.

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Table 4.4

Mean Difference Between Time Point One and Time Point Two on Low and High ACE

Scores

Mean Difference M ± SD Completer ITT Low (N = 14) High (N = 8) Low (N = 17) High (N = 13) PSS -4.36 ± 5.68 -4.50 ± 5.37 -4.59 ± 5.35 -4.08 ± 5.62 MaaP 2.36 ± 9.98 6.64 ± 6.93 3.98 ± 9.60 5.54 ± 6.98 SDQ_Tot -0.38 ± 5.66 -1.38 ± 3.96 -0.15 ± 5.91 -1.46 ± 5.68 SDQ_Int -0.71 ± 2.79 -1.25 ± 2.71 -0.18 ± 3.32 -1.85 ± 3.65 SDQ_Ext 0.34 ± 3.85 -0.13 ± 3.09 0.16 ± 3.67 0.38 ± 3.15 Note. Low = Low ACE score; High = High ACE score; M ± SD = Mean ± Standard deviation; MaaP = Me as a Parent scale; SDQ_Tot = Strengths and Difficulties questionnaire total score; SDQ_Int = Strengths and Difficulties questionnaire internalising score; SDQ_Ext = Strengths and Difficulties questionnaire externalising score; PSS = Perceived Stress Scale.

4.3 Qualitative Results

The focus group was conducted with six participants for a duration of 50 minutes.

Written qualitative data from the ESQ form was obtained from 20 participants, yielding a total of 120 responses. Data from individual session feedback totalled 13 responses, and qualitative data obtained from the overall feedback forms yielded 21 responses. To maintain anonymity,

‘Psychologist’ and ‘Child’ were substituted for identifiable information throughout the quotations. Where possible, participants were credited for their quotations; those without credit were taken from anonymised feedback forms. TA revealed four themes across the dataset:

Group acceptability; “Seeing” the child; Parental self-regulation; and Experiences of being parented (Figure 4.3).

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Figure 4.3

Graphic Depiction Of Themes And Subdomains Extracted From Dataset

4.4 Group Acceptability

Establishing participants’ perspectives on their experience of the group process and content was an important aspect of this research, particularly as the UYCBP had not been previously evaluated in an Irish-based sample. Overall, the content of the group process and delivery was well-received, and the content of the group was relatable for participants.

“It was well-delivered, always felt supported and not pressurised”.

Participant 20

“It kept all our attention; it was relaxed and fun at times”.

Participant 7

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4.4.1 Facilitation Expertise and Flexibility

Participants valued the expertise facilitators brought to the group. This expertise extended from the relaying of important concepts clearly, to understanding participant narratives and offering alternative ways of thinking at appropriate moments:

“They gave great explanations, they explained it well, they let us talk among ourselves, and in certain situations they gave us a different outlook”.

Participant 3

As it was aptly put by one participant:

“Life really gets in the way”

Participant 1

The facilitators being attuned to the group’s practical and logistical needs was recognised. For example, facilitators adjusted the start time to accommodate issues for parents such as dropping their children to school or finding a childminder. They were also accepting of unforeseen circumstances preventing attendance such as funerals, hospitalisations and car accidents. It appeared that finding a balance between providing a sense of flexibility whilst maintaining some consistency was important for parents.

“With me, I’ve the four kids and only one that’s not in school so it was helpful for me to know well, Mam, are you going to be here this time for the next ten weeks”.

Participant 5

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The element of consistency aligns with the containment principle of the SA and data gathered suggests it is supportive of a positive group experience.

4.4.2 Non-Judgemental, Safe Space

Participants felt that the UYCBP represented a space they could share their thoughts and experiences of parenting without judgement.

“I never felt under pressure here, it was very clear that if you had a bad day you could say you had a bad day, and if you didn’t want to talk about something you didn’t have to, you don’t have to if you don’t want to”.

Participant 3

The safe space gave participants an opportunity to share some of the trials and tribulations they experienced as a parent, without repercussions or judgement from others. It was also notable that parents did not feel obliged to share experiences, but that the opportunity was always there and it would be met without judgement. This non-judgemental space offered by the group appeared to be of greater importance because of participants’ experiences outside of the group.

“It’s like a safe place, you can say anything, and you know no one is going say, ‘sure it’s your fault’ or, ‘sure why are you letting them do it’ and things like that”.

Participant 1

The experience of being judged outside of the group was a common theme for parents, particularly through ‘school-gate judgement’, which ranged from ‘looks’ to over questioning of their parenting decisions and behaviours. These experiences were invalidating for parents

PARENTING GROUP OUTCOMES AND ACES 72 who were already finding it a challenge to manage their child’s behaviours appropriately and effectively.

4.4.3 Support and Validation Through Shared Experiences

All participants made reference to the supportive group experience throughout the 10- week journey. Participants valued hearing others’ experiences, as it validated their own struggles with different aspects of parenting.

“Having other people in the kind of same situation, that know what you’re going through”.

Participant 1

“Shared experiences, and knowing that we all had problems with our children – no supermums!”

Participant 8

Sharing experiences was helpful for participants.

“[I felt] more relaxed”

Participant 4

“You’d feel like a weight was lifted off your shoulders coming out”.

Participant 5

Such statements are impactful because they highlight the distinct pressure on participants to meet the expectations of being a ‘good enough’ parent. The group offered a place where these expectations could be explored and discussed, which ultimately reduced the

PARENTING GROUP OUTCOMES AND ACES 73 burden of them on attendees. By creating a contained atmosphere for parents, the group allowed for more reflective thought and action for parents when engaging with their child. The group created an opportunity to model reciprocity between parents in their interactions with each other within the group setting, another core principle of the SA.

“The group was split and then we had to come up [with suggestions]. It was nice to see that even though one half was there, one half was here, that when [the facilitators] put up their charts, they were actually similar, do you know, and that was really helpful to know”.

Participant 5

Giving participants the opportunity to problem-solve in their own groups provided a sense of hope that each parent could draw upon their experience to find appropriate solutions to scenarios each of them were facing. The supportive nature of the group provided a space where participants were more open to receiving advice and guidance:

“somebody says to you that this worked for me, you could try this, you know, and you go home, and you just give it a go like, it kind of makes you more hopeful well it worked for her like, so we’ll give it a go”.

Participant 6

Advice received from group members who faced similar situations as a parent came from a more empathic stance than they might have experienced outside of the group. This was a powerful influence that inspired a sense of hope and intention in participants.

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4.5 “Seeing” the Child

4.5.1 Noticing and Recognising

Parents are encouraged to observe their child and try to notice small but significant changes that might be indicative of certain behaviours. For some parents, this was a new skill and may have required a change in their previously held beliefs about certain behaviours or emotional states.

“Before I wouldn’t [have] really recognised that as anxiety to be quite honest. Now I can see when she’s starting to [get] work[ed up]. There’s certain signs there that I would have missed the first time, and I’m able to recognise now and I’m able to put a stop to it before it begins and get her back to her happy place”.

Participant 3

This parent gives an insight into her own perception of how anxiety looked in her daughter. Her participation in the group allowed her to challenge this belief, notice different behaviours that were related to her daughter’s anxiety, and intervene appropriately. Parents referenced how they noticed different behaviours of their children, which allowed them to pre- empt situations that may have escalated into more challenging situations previously:

“I can pick up now before he has the outbursts I can tell when he’s kinda getting ‘arrrgh’ and

I can stop it before he does have a big meltdown basically”.

Participant 1

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4.5.2 Taking the Child’s Perspective

One significant change for parents who attended the group was to better acknowledge their child’s perspective. The arduous trial of parenting resulted in a ‘fire-fighting’ approach to managing their child’s behaviour that neglected their child’s perspective.

“Learning that they [our children] have the same feelings as us. You know, you wouldn’t like somebody to send us to our rooms… I wouldn’t calm down if someone sent me to my room!

So yeah, it’s just to learn that you have to teach them the same, you have to treat them the same as an adult”.

Participant 6

For this parent, the realisation that her child has emotions and feelings just as she does was a powerful one. It allowed her to step into her child’s shoes and wonder what it might feel like. The statement reflects how the parent now realises the benefits of including their child as an active participant in the behaviour management process; one that has changeable moods, emotional states and perspectives, all of which they can now explore together. Other parents had similar realisations that resulted in practical changes to how they manage challenging situations with their child.

“Yes, I don't just always give out, I will give him time to talk about how he is feeling and time to cool down”.

Participant 14

This parent has learned that taking their child’s perspective opens up a new form of communication to explore. They are already acknowledging their child’s emotional state by giving them time to ‘cool down’ so the child can better articulate how he is feeling. This mirrors

PARENTING GROUP OUTCOMES AND ACES 76 the principle of containment that the SA posits as a central component in successful parent- child relationships. Another parent outlined each of the important aspects of developing reciprocity in the parent-child relationship:

“Empathy - how I communicate, the child's development stage, changes may be affecting them, and to give them ‘lookaway’ time so we can open up better then”.

Anonymous

This parent recognises how empathy is of core importance when communicating with their child. The group content explores the ‘dance of reciprocity’, which offers ‘lookaway’ time as a way for parents to support their children. This parent has been able to use the group to develop a better understanding of the unique individuality of her own child. They used this technique to regulate their child before exploring changes affecting them. The parent then understood how acknowledging their child’s perspective can help to find solutions.

4.5.3 Facilitating Reciprocity

Parents reported that they have learned the importance of facilitating reciprocity in the parent-child relationship, and also described ways in which they learned to do so. Closely linked to taking the child’s perspective, one parent noticed that they have to dedicate time and attention to their child to build a reciprocal relationship where the child feels comfortable to interact with the parent.

“It’s the attention like when they come to you with a problem, you could be getting the dinner ready… it’s the stopping what you’re doing and the turning and looking at them, and letting them see that you’re interacting with them”.

Participant 5

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Another parent has learned new ways of facilitating conversations with her daughter, having learned the importance of opening the opportunity for conversation:

“I’d normally leave her down there. Now I just give her 5 minutes and I go down and I talk to her and she’s beside me and she’ll talk to me”.

Participant 3

Some parents noted their concern about phrasing things the right way to help their child to open up and engage in conversation. One parent used their child’s interests as a ‘way in’ when beginning to facilitate a more reciprocal relationship.

“I focus on sending messages to her to make sure she is OK - on her phone - to know I am thinking of her”.

Participant 29

4.6 Parental Self-Regulation

4.6.1 Increasing Capacity for Managing Stress

Many parents recognised changes in how they manage stressful situations:

“[I am] calmer”.

“I think before I act”.

“I check myself now and my tone and body language whenever possible”.

Anonymous

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These parents are more attuned to their own levels of stress than before. They recognise that this impacts on their own behaviours and those of their children. They are more mindful of using strategies to manage their stress, thus affording them greater capacity when stressful situations arise. One parent has developed an increased ability to manage stressful situations and this has contributed to an increased sense of competence in their ability to resolve their child’s moments of emotional dysregulation.

“To be a lot calmer like instead of just snapping straight away at them like it’s kind of like okay well I know what’s going on here to be able to speak to them and bring them back down and whereas before I wouldn’t have even tried to talk to them but it’s just like just go to your room whereas now I was like I can talk to them and figure out what’s going on”.

Participant 1

4.6.2 “Stepping Back”

Many of the parents found themselves overwhelmed when trying to decide the best course of action to deescalate a situation. However, the UYCBP helped participants to realise that sometimes taking a step back was the best way to move forward. Participant 1 describes this process:

“You’re stressed and they’re stressed and everyone’s stressed out… it’s us learning when we are stressed as well and we have to take our time to look after us, as hard as it is…in the last few weeks I’ve made that time for me, and I’m more at ease with them, and the whole house seems more at ease, because they pick up on your emotions too… so it’s knowing and saying well look I need to be chilled, but it is it’s taking that step back”.

Participant 1

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While parents were aware that taking the step back was important, there was a sense of guilt for some parents if they did so.

“You’re more aware of why I’m feeling guilty I mean I know I’m always the bad guy and I’m one parent, if you sit down and think about how you’re going to react to a certain situation, it not only gives you a bit of clarity, but you start to feel well look I’m doing the best I can in situations that are just out of my control, and the child is obviously frustrated like the only way you can deal with it is if you allow yourself that few minutes, turn the guilt off and turn the brain on”.

Participant 3

Only when the guilt was ‘turned off’, could this parent’s their problem-solving abilities be accessed. Encouraging parents to give themselves permission to take the step back was essential, because it allowed them to consider the situation rationally, plan appropriately and reduce the impact of emotional dysregulation on their own responses.

4.6.3 Feeling More “At Home” as a Parent

The UYCBP has helped parents feel more comfortable in the parenting role. This represents a shift from previous experiences where they may not have been assured in their parenting abilities, particularly as they experienced judgement in how they parented.

“I feel more at ease as a parent”;

“I have gained more confidence as a parent. I am more aware of my child’s feelings. I am more calmer and use a more calmer approach to my child”.

Anonymous

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The combination of skills that parents have built upon throughout the group has given them a sense of competence in their abilities, perhaps helped by the group members all sharing similar stories and normalising different challenges faced as a parent.

“I feel more hopeful and positive as a mother, that I'm not alone in what goes on day to day and that I'm more aware and equipped to deal with it”.

Anonymous

The group also highlighted the parenting abilities they already have, extracting the many positives that they may not have given themselves credit for previously.

“It just kind of helps you to realise you know what you can do, to make it better you know at home”.

Participant 6

4.7 Experiences of Being Parented

“As bad as it sounds at all but like I realise that I don’t want to be the same kind of mother as my mother… I want to be the opposite”.

Participant 1

As this participant poignantly expressed, the group brought about a difficult realisation that her experiences of being parented have very significantly shaped her own values as a parent, specifically providing an antithesis to the parenting template she hoped to follow. There are two important interpretations of this quote. Firstly, it demonstrates how the participant has developed insight into how her own experiences of being parented have shaped her own

PARENTING GROUP OUTCOMES AND ACES 81 parenting style. Second, it portrays the level of comfort this participant felt within the group format, highlighting that the group was successful in creating a safe space for sharing vulnerability.

4.7.1 Behavioural Intergenerational Transmission

Participants identified several instances where their current behaviour as parents were directly linked with their own childhood experiences of being parented.

“It’s only actually in the group that I realised that I was just giving him everything that I didn’t have, like beforehand I wouldn’t be thinking twice about that. He has about 10 pairs of runners and … he really doesn’t [need them] but I know it’s only because I never had it growing up”.

Participant 1

This parent identified how she tended to be more generous in her parenting behaviours, as a method of ensuring her children would never experience the same negative emotions she associated with not having things she desired as a child. By developing an awareness of this transfer across generations, she was able to acknowledge that she was over-compensating for her own unfulfilled needs of childhood and adjust her behaviour accordingly. Parents also talked about the differences between generations and how this has challenged them as a parent.

“When we were playing like there was 11 of us, and then you’d have your cousins behind us and there was 10 of them, so it was like a whole football team out in the field so like there was no fears that you could go out… But it is different now again like the 14-year old is so bored at the moment… she’s completely bored and doing my head in”.

Participant 3

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This parent acknowledged that playing in a field isn’t recognised as ‘fun’ or

‘enjoyment’ for her own children. This was a difficult evolution to tolerate, as their own childhood experiences are so behaviourally different to what their own children experience now. The result is a tension in the relationship, with the parent feeling frustrated by their child’s boredom and their inability to provide for this.

4.7.2 Emotional Intergenerational Transmission

The changes of environment between generations also implicates how emotions continue across family generations. Parents felt that the current social scene meant they had no choice but to restrict the freedom of their children, which contradicted their own childhood experiences:

“It’s not safe to just let them out these days”.

Participant 1

“Now you can’t let them out of your sight like even at 14 you’re nervous of them going into town”.

Participant 2

Parents described how they were allowed to independently run free in fields, and adopted a different level of responsibility from a younger age, highlighted by one participant:

“when I was 12 I had my first part-time job”.

Participant 3

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This excessive independence experienced in childhood has potentially transmitted across generation to the opposite behaviour: a perception that there is an increased need for vigilance of their child’s safety.

“To be quite honest I was completely anxious all day that I text the child all day… ‘Where are ya, what are you doing, how are ya, how’s the movie’. Just to make sure”.

Participant 3

The phrase, “Just to make sure” highlights how this parent’s level of vigilance is a measure of the significant level of anxiety some parents experience when grappling with the balance between freedom, independence, and safety. Other participants described how emotions appear to transmit across three generations, particularly when there is an increased level of contact in these relationships.

“That will never go away, like when I came in here I had to text [my mother] to let her know that I arrived safe and I’ll have to ring her when I’m leaving and then I’m heading to her straight away after anyway… My mam is just a worrier… [My son] like my mum, very much, and my mum’s around every day, he asks me now who’s driving when I’m going somewhere, ‘oh don’t get Grandma to drive you drive mammy you’re a better driver’. He’s picked up on my Mum’s worries and anxieties”.

Participant 5

This mother has developed an awareness of how patterns of navigating the world and emotional responsivity do not develop in isolation, rather they are in part a product of the child’s social influences and the social environment they develop within. Acknowledging that

PARENTING GROUP OUTCOMES AND ACES 84 these patterns have developed is an essential part of breaking the cycle to reduce negative emotional reactions such as excessive anxiety fostered in this family across generations.

4.8 Results Summary

Table 4.5 portrays a summary of results in terms of original hypotheses and associated outcomes. At baseline, parents with higher ACE scores showed greater difficulty, but differences compared to lower ACE scores were not statistically significant. The UYCBP was well-accepted and well-attended. Pre to post-intervention analysis revealed significant results for perceived stress only in completer analysis, with significant results showing moderate effect sizes for both perceived stress and parental self-regulation in ITT analysis. Improvements were observed for the remaining dependent variables, with the exception of externalising behaviours, which showed slight deterioration. These differences were not statistically significant. There was significant categorical improvement for perceived stress and combined internalising and externalising behaviour scores. Parents with higher ACE scores made greater improvements from pre to post-intervention measurement, but these improvements were not statistically significant compared to parents with lower ACE scores.

Qualitative analysis identified that participants identified several benefits from core aspects of the SA employed. Participants greatly benefited from a perceived improvement in self-regulation, which allowed them to feel less overwhelmed, and more competent in the face of similar parenting challenges they faced before the group. This competence developed despite the fact that reported levels of internalising and externalising behaviours were similar at pre and post intervention. Participants also identified how their own experiences of being parented played an important role in shaping behavioural and emotional responses of their children.

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Table 4.5

Summary of Results – Research Questions, Hypotheses and Outcomes Hypotheses Outcome Q1 What is the relationship between parental ACE scores and both parent-based and child-based dependent variables at baseline? Unmet At baseline, compared to parents with lower ACE scores (≤ 1), parents with higher ACE scores (≥ 2) will report: H1a Significantly higher scores on perceived stress Unmet H1b Significantly lower self-regulation abilities Unmet H1c Their child displaying more internalising and externalising difficulties Unmet H1d Their child displaying significantly more internalising difficulties. Unmet H1e Their child displaying significantly more externalising difficulties. Unmet Q2 Is the UYCBP acceptable based on experience and attendance in an Irish-based sample? Unmet H2a* Parents’ will rate their overall experience positively (ESQ questionnaire, and identified qualitative analysis). Met H2b Parents will show a strong rate of attendance to the UYCBP (70%). Met H2c Parents with higher ACE scores will attend significantly fewer sessions when compared to parents with lower ACE scores. Unmet Q3 Is the UYCBP effective in improving both parent-based and child-based variables? Partially Met H3ai Significant reductions in parents’ perceived level of stress Met H3aii Significant reductions in the proportion of scores within the “very high” category for perceived stress. Met H3b Significant improvements in parents’ self-regulation abilities. Met H3ci Significant reductions in a child’s internalising and externalising difficulties combined. Unmet H3cii Significant reductions in number of scores within the “very high” category for combined internalising and externalising difficulties. Met H3d Significant reductions in children’s internalising difficulties. Unmet H3e Significant reductions in children’s externalising difficulties. Unmet Q4 Do parental ACEs impact the effectiveness of the UYCBP? Unmet Following the UYCBP, compared to parents with lower ACE scores, parents with higher ACE scores will report: H4a Significantly greater reductions in levels of perceived stress. Unmet H4b Significantly greater improvements in parental self-regulation. Unmet H4c Significantly greater reductions in their child’s combined internalising and externalising difficulties. Unmet H4d Significantly greater reductions in their child’s internalising difficulties. Unmet H4e Significantly greater reductions in their child’s externalising difficulties. Unmet Q5 Does the UYCBP impact on parents’ perception, insight and understanding of their child’s behaviour? Met H5a* Parents will have a better understanding of the behaviours of their children (post-intervention) identified through qualitative analysis Met H5b* Insight into how their experiences of being parented impact their child’s behaviour, identified with qualitative analysis Met Note. * = Hypothesis was addressed either fully, or partially using qualitative data. Remaining hypotheses were addressed using quantitative data

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Chapter 5: Discussion

5.1 Chapter Overview

This chapter begins by summarising the findings of the current study which evaluates the UYCBP for the first time in an Irish context and examines parental ACEs as a covariate in outcomes. Findings associated with each research question are addressed sequentially. The implications for research and clinical practice for parenting, parenting interventions and ACEs research in the context of the wider research on the UYCBP, parenting and ACEs are then outlined. Strengths and limitations of the study are reported before concluding remarks.

5.2 Summary of Key Findings

The UYCBP was experienced as acceptable. Average attendance was seven sessions out of 10 (70%), which is above average for a parenting group (Axford et al., 2012).

Participants valued the non-judgemental and safe space provided by the group, along with the support and validation received through sharing experiences. Facilitation expertise and flexibility were also important. Pre to post-intervention analyses revealed significant reductions in perceived stress (completer and ITT analysis) and increases in parental self- regulation (ITT analysis only). Non-significant improvements were observed for the remaining dependent variables, with the exception of externalising behaviours which showed a slight increase. These findings indicate improvements in proximal, parent-based factors but not distal, child-based factors (Lindsay, 2019). This is consistent with other recent research evaluating the UYCBP, which observed a similar pattern (Douglas & Johnson, 2019). There was a significant reduction between timepoints in the proportion of parents in the most severe categories for perceived stress (Completer 18%; ITT 17%) and internalising and externalising problems (Completer 18%; ITT 7%).

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At baseline, parents with higher ACE scores (≥ 2) reported greater difficulties on dependent variables than parents with lower ACE scores at baseline, but these differences were non-significant. Mean ACE scores were approximately one point higher than the average population (1.97 ± 1.95 for complete responses; 1.77 ± 1.91 when missing responses were scored as 0; Bellis et al., 2014a). Mean scores were within the “moderate” range for perceived stress, and the “very high” range for internalising and externalising problems for parents in both low and high ACE score categories. Parents with higher ACE scores made greater changes than parents with lower ACEs across timepoints on all variables excluding externalising behaviours (completer analysis) and on all variables excluding perceived stress and externalising behaviours (ITT analysis). These differences were non-significant.

Reflexive TA produced three salient themes alongside the theme of ‘Group acceptability’ discussed above. The theme of ‘“Seeing” the child’ aligned with the reciprocity principle of the SA, with subthemes of ‘noticing and recognising’, ‘taking the child’s perspective’ and ‘facilitating reciprocity’ identified. Aligning with SA’s containment principle, the ‘Parental self-regulation’ theme included subthemes of ‘increasing capacity for managing stress’, “Stepping back”, and ‘feeling more “at home” as a parent’. The last theme named

‘Experiences of being parented’ contained subthemes of ‘behavioural intergenerational transmission’ and ‘emotional intergenerational transmission’. This theme highlighted intergenerational influences for certain behavioural and emotional reactions.

5.3 Acceptability of the UYCBP

Quantitative and qualitative evaluation suggests the group is acceptable in an Irish- based, PC sample of participants. The format of the UYCBP was engaging for participants.

Noticeably, some parents enjoyed the aspects that involved group involvement as it gave them a sense of empowerment beyond what was experienced through informational sessions previously attended primarily involving didactic teaching alone. Previous research identified

PARENTING GROUP OUTCOMES AND ACES 88 that empowering parents is an essential component of effective parenting programmes (Walton,

2014).

There is a wealth of research identifying the many barriers to attending parenting groups (e.g. Lindsay, 2019). Qualitative analysis conducted in the current study suggests that the UYCBP was able to reduce these barriers to participation for parents in a number of ways.

Firstly, facilitators found an appropriate balance between flexibility with practicalities of the group and the core SA component of containment. They were flexible enough to reduce practical barriers to attendance by changing the time, and scheduling the group around school holidays to avoid busy periods for parents. Parenting programmes that were more accessible for attendees have lower drop-out rates (Axford et al., 2012), and this research provided further support for these findings.

The facilitators’ expertise was evident in how they maintained an element of flexibility, but also harboured a containing atmosphere, where participants felt safe to share their experiences in a non-judgemental space. The value participants placed on this aspect of the group highlighted the stark contrast it presented to their daily lives. They faced constant scrutiny and judgement from unsupportive family members, other parents, and through

‘school-gate judgement’. This perceived judgement brought about a sense of shame for parents and acted as a significant barrier to perceived parental competence and subsequent positive parenting practices (Mintz, Etengoff, & Grysman, 2017). The safe space provided by the

UYCBP supported parents to feel a sense of togetherness, which contrasted the isolation felt through perceived judgment outside of the group. This space allowed parents to experience more reciprocal ways of relating to people, without the judgement, shame or guilt some of them had become accustomed to in many aspects of their daily lives. These factors were especially important for trauma-exposed parents (Muzik et al., 2015), as their template of what can be considered safe and trustworthy is often a significant barrier to accessing healthcare (Liang et

PARENTING GROUP OUTCOMES AND ACES 89 al., 2005). Fostering relationships within parenting programmes improves attendance (Axford et al., 2012) and the current UYCBP allowed these relationships to develop on a foundation of containment. Results indicate that the UYCB increased accessibility and invested in relationships throughout the intervention. This significantly reduced barriers to engagement and positively influenced attendance levels.

There is a long-standing issue with parenting programmes having high rates of attrition

(Furlong et al., 2013). This reduces the ‘dose’ of the intervention they receive, meaning many parents do not attend enough sessions to achieve positive outcomes (Whittaker & Cowley,

2012). The current study observed an average attendance of approximately seven out of 10 sessions, which suggests that the UYCBP can achieve good levels of attendance in an Irish sample. The confounding factor is the disparity between parents referred and parents who attended. Thirty research participants were recruited from the 43 parents initially referred to the group (70%). It is more challenging to find methods of reducing drop-out for the 30% of referrals who did not initially attend the group, or take part in the research. However, this study demonstrated that many of the effective strategies intended to reduce drop out were employed by the UYCBP successfully.

Previous research evaluating the UYCBP has separated families into age categories, or implemented a separate programme for foster carers (Madigan et al., 2017). Six (20%) of the current attendees identified as foster carers. By including this broad spectrum of attendees, the

UYCBP shows its efficacy for a diverse range of participants within an Irish sample, representing a wide variety of age and familial backgrounds (Leijten et al., 2016). This supports existing evidence which suggests that parenting programmes are transferable across cultures

(Gardner et al., 2016). However, 20% represents a significant portion of the research sample, and it is likely that including this proportion of foster carers had a significant impact on the overall effectiveness of the group, despite it being experienced as acceptable.

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It has been a challenge to establish the effectiveness of parenting programmes in more disadvantaged areas when the referral reason was related to EBD. Most referrals in disadvantaged areas were associated with maltreatment, rather than EBD (Furlong &

McGilloway, 2015). While the current sample was recruited from PC psychology services, many of the areas recruited from were classified as ‘disadvantaged’ on deprivation indices, relative to other areas of Ireland (Haase & Pratschke, 2017). Based on this data, it is reasonable to assume that the UYCBP was acceptable for families struggling with EBD in more disadvantaged areas.

5.4 UYCBP Effectiveness

The UYCBP demonstrated significant positive effects for proximal factors, including perceived stress and parental self-regulation. Results suggested there was a change in parents’ own perceptions of their child as a result of the group experience. The findings were non- significant on distal factors relating to their child’s internalising and externalising problems.

There are a number of potential explanations for this discrepancy and some important considerations can be drawn from these results.

The group itself modelled important aspects of parenting which translated to parents’ own practices with their child. In a supportive group environment, with appropriate structure and containment, parents reduced their perceived stress and increased their self-regulation abilities concurrently. These improvements are essential protective factors against negative outcomes of EBD for themselves and their children (Evans & Kim, 2013). Parents brought this containment into the parent-child relationship, as they talked about taking a “step back” in response to behavioural challenges they faced. The ability to step back was a new skill for some parents. This skill is developed across childhood and the process of learning self-regulation is more likely to be disrupted when ACEs occur (Ostlund et al., 2019). This skill allowed for attuned caregiving and sensitive responding, rather than emotive reacting that escalated the

PARENTING GROUP OUTCOMES AND ACES 91 situation which often occurs when children display EBD (Leslie & Cook, 2015). This method of behavioural management is empowering, as the potential for change is placed within the parent, and not on an external reliance on their child’s behaviour to change. Instilling this sense of empowerment in parents has been an important component for effectiveness in parenting programmes (Walton, 2014).

Parents demonstrated aspects of reciprocity during the sessions when they acknowledged each other’s viewpoints, listened to each other and problem-solved together.

The group provided an opportunity for parents to ‘practice’ these behaviours. Parents could bring this element of reciprocity into their relationship with their children. This was evidenced in the subtheme of ‘taking the child’s perspective’. This represented a significant modification in some parents’ perspectives of their child’s behaviour and emotions. They may have previously held the belief that children did not have the same feelings as adults. After their participation in the group, it was evident that parents were able to facilitate a more reciprocal relationship that acknowledged their child’s needs. This closely aligned with the reciprocal processes of the SA, which was intended to positively influence the parent-child relationship

(Speer & Trees, 2007).

One of the most important improvements was in parents’ perceived parental competence. When parents were able to draw on an internal sense of competence that assured them they are handling a challenging situation appropriately, it reduced the impact of external factors outside of their control, such as perceived judgements or child temperament. Parents also began to realise their potential as a parent through the successes and achievements they experienced during the group which may have been forgotten through many instances of perceived failure before the group. Repeated exposure to successful experiences of managing their child’s behaviour allowed them to feel more ‘at home’ as a parent. This increased their sense of competence in their parenting abilities, which is essential in the management of EBD

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(Fuchs et al., 2015). Behaviours associated with supportive parenting occurs more regularly in parents who are comfortable in their role (Pinquart, 2017). A parent’s sense of competence and control over behaviour is an essential component in reducing conflict (Kelly, 2019). Secure attachments are promoted when a child is regulated sensitively in 50% of interactions, reducing conflict; and increasing the frequency of supportive behaviours was an important development for parents in the current study (Woodhouse et al., 2019).

One parent was able to notice that their child needed ‘lookaway time’ at certain periods during the day as a method of regulating themselves and reduced the conflict in the relationship.

The ‘lookaway time’ was introduced through the ‘dance of reciprocity’ during the group, which is a core facet of the SA. Reducing conflict is important because it is a risk factor for EBD

(Kelly, 2019). This positive change has been achieved through several very important steps.

First, the parent was able to notice and recognise their child’s distress as a result of their broadening perception of how their child communicates distress. Next, the parent developed an improved ability to regulate themselves which increased their problem-solving capacity.

This in turn enabled them to provide a more attuned response to their child’s needs – which in this case was ‘lookaway time’. The child was then allowed time and space to regulate after experiencing an attuned response. The dance of reciprocity concept appeared to resonate with parents and provided an effective behaviour management strategy that could be used consistently in future situations.

Cumulative ACEs compromise the stress reactivity biology in childhood, which made self-regulation a challenge for some parents (Hipwell et al., 2019). Introducing a pattern of consistency provided a further sense of self-efficacy and empowerment for the parent when similar situations arise in the future. These experiences of positive coping can be learned and internalised by the child (Steele & McKinney, 2019). It also provided a sense of containment for the child, which helps to shift from a ‘survival’ response to one of reason, logic and

PARENTING GROUP OUTCOMES AND ACES 93 behavioural control (Ridout et al., 2019). This example exemplifies the SA in practice: containment facilitated reciprocity in the parent-child relationship, which shaped more attuned behaviour management strategies (Vella et al., 2015).

It is important to draw attention to the apparent incongruence between some of the quantitative and qualitative results. Quantitative data analysis revealed that children’s problematic behaviours did not reduce in frequency or intensity after participation in the

UYCBP. However, qualitative analysis illustrated how parents felt much more capable of understanding and consequently managing their child’s different behaviours and emotions.

One potential explanation for this finding is that parents were more attuned to their child’s behaviours after the group, and as a result were better able to identify internalising behaviours that they may not have previously recognised as anxiety. This was reflected in the

‘noticing and recognising’ subtheme of the qualitative analysis. After the UYCBP, they perceived behaviours differently and therefore were more aware that certain behaviours are more likely to be a sign of emotional distress in their child. This awareness may have increased the frequency of internalising behaviours reported at post measurement.

A significant proportion of the group identified as foster carers (20%). Foster children often present with more significant EBD and require more intensive intervention given the disruption in attachment relationships (Vanderfaeillie et al., 2013). Behaviour may be less amendable to change in short periods of time for these children. This is likely to have significantly impacted the overall effectiveness on child behaviours in the current study.

The UYCBP focused on fostering relational components in order to improve behaviour management. The SA posits that it is through containment and reciprocity that behaviour management is achieved. Following this theory, child-based factors may improve as parents engage in more consistent responses over a period of time. In this sense, 10 weeks may not be

PARENTING GROUP OUTCOMES AND ACES 94 sufficient to fully capture the change in a child’s pattern of behaviour as a result of this intervention. Similar patterns have been observed in a study comparing behavioural and non- behavioural or relational programmes across a two-year follow up (Högström et al., 2016).

Behavioural programmes produced more rapid reductions in externalising behaviours, but in relational programmes, they continued to improve after the intervention. It is possible that parents attending the UYCBP experienced similar patterns of improvement in EBD that were not recognised without a follow-up component.

The SA acknowledges that challenging behaviours may be a child’s only method of communicating their needs based on their developmental stage. This is an especially relevant approach when considering other individual factors, such as a child’s temperament or underlying neurological conditions that may prevent children from altering their behaviours

(Furlong et al., 2010). How children communicate their needs will change frequently as they develop. Previous research also identifies how the relationship between parent and child behaviours gradually becomes bidirectional in nature as children get older (Neece et al., 2019).

Parenting involvement can be viewed as more illegitimate without the foundation of a robust parent-child relationship (Smetana, 2017). However, child behaviours, and perceived illegitimacy of parental involvement is less likely to produce negative outcomes in supportive parent-child relationships (Milanen et al., 2015). The relational components of containment and reciprocity protect against these challenges. These changes contribute to effective behaviour management and lay the foundations for long-lasting change in the parent-child relationship (Symeou & Georgiou, 2017).

Families that foster a positive parent-child relationship in early childhood sow the seeds for lasting benefits. This focus equips parents with skills that help them to navigate the changing behaviours as their child develops (Steele & McKinney, 2019). The SA uses this rationale in their approach to behaviour management strategies by focusing on parent-based

PARENTING GROUP OUTCOMES AND ACES 95 responses to behaviour, rather than child-based behaviour reduction. In line with previous qualitative research on the UYCBP (Vella et al., 2015), the current study provides evidence to suggest that these core principles were effectively communicated and received by the majority of parents at the programme.

5.5 Parental ACE Scores and Intervention Outcomes

Parental ACE scores showed no significant effects as a covariate at baseline or in repeated measures analysis. This is consistent with other research evaluating the effects of ACE scores on home visit interventions (Pasalich et al., 2019). Baseline scores were more impaired for parents with high ACE scores, but the difference was not significant, which contrasts findings of previous research (Oxford et al., 2016). A series of conclusions can be drawn from these findings and further unanswered questions are posed by the data. No information was gathered about participants who did not attend, or dropped out of the group or the research.

Research has already identified the difficulties of engagement for individuals who are compromised by ACEs (Muzik et al., 2015). It is possible that those with higher ACEs were less likely to attend in the first place. There is also the possibility that the constructs evaluated, along with the measures used to assess these constructs were less affected by parental ACEs.

More specific parental behaviours or measures that assessed the parental impact of trauma (Roy

& Perry, 2004) may have been more appropriate to evaluate the impact of ACEs on group effectiveness. Alternatively, it may be the case that the majority of children referred to a PC psychology service experience demonstrate “high” levels of EBD, regardless of parental ACE score. Mean ACE scores were two, which is higher than the average population, but 50% of participants still had an “average” ACE score.

A significant percentage (20%) of participants were foster carers. For these parents, there is no intergenerational transmission from their own experiences and their foster children.

These parents may report significantly different childhood experiences to that of their foster

PARENTING GROUP OUTCOMES AND ACES 96 children. This presents a significant discrepancy within the data that impacted the assessment of ACEs and their relationship with child EBD.

Some participants were recruited from areas that are considered more deprived than other areas in Ireland (Haase & Pratschke, 2017). The group potentially experienced more difficulties associated with ACEs than relatively more affluent populations. Evidence suggests that ACEs disproportionately affect more disadvantaged populations (Mersky et al., 2017).

Some areas of Carlow are considered ‘disadvantaged’ or ‘very disadvantaged’ and much of the county is below the national average. Kilkenny has some areas considered ‘disadvantaged’, but has a broader range of deprivation from disadvantaged to affluent (Haase et al., 2017). The PC population recruited from the two locations may have represented heterogenous samples. Some participants may have had more significant histories of ACEs, while others with no reported history of ACEs at all.

Evidence highlights how those with lower ACE scores typically reported their child’s behaviours within the non-clinical range before and after parenting interventions (Hurlburt et al., 2013). The majority of parents reported their child’s EBD within the most severe category at both timepoints, suggesting that certain parents may have had more significant experiences of trauma than the cumulative ACE score suggests.

There is also evidence suggesting that individuals tolerate such adversity differently

(Crouch et al., 2019). While participants of this study required a referral for psychological intervention to support their child, they may have had sufficient resilience to protect against further deleterious effects of ACEs. This may have prevented the difficulties from progressing into more significant concerns that warranted a referral to more specialist services. Therefore,

ACE scores may not have been a significantly differentiating factor for predicting greater difficulties within this clinical population, as ACE scores were closer to the general population than other specialist services. Other studies that investigated the effects of ACE scores used a

PARENTING GROUP OUTCOMES AND ACES 97 significantly higher threshold (ACEs ≥ 4; Blair et al., 2019), signifying a more compromised childhood compared to most of the participants in the current study recruited from a PC service.

While ACE scores did not significantly impact group outcomes, the exploration of the parents’ perceptions of their own experiences in childhood produced some novel realisations for some of the participants. This was evident through the qualitative piece, in which some participants highlighted discrete and individual experiences in their childhood that they could specifically relate to their current parenting behaviours. For example, one participant linked their own experience of poverty in childhood to their endeavours to provide excessively for their child. There is evidence that such compensatory behaviours are not entirely individual.

For example, childhood financial hardship has significant wide-ranging impacts that endure across the lifespan (Spence, Nunn, & Bifulco, 2019) and can impact parenting practices (Stacks et al., 2014). This realisation provided a framework for this parent to understand how her own behaviours impacted her interactions with her children, through the lens of her own experiences as a child.

Most of the parents had not considered how this generational component impacted on their own and their child’s behaviours and emotions before the group. This highlighted the benefit of introducing initiatives such as being ‘ACE-aware’ and ‘trauma-informed practice’

(Oral et al., 2016) to increase public awareness of their impact on parenting behaviours.

Developing an awareness of how these negative patterns of EBD and emotional dysregulation are carried across generations is the first step to reducing their negative impact and breaking the cycle of intergenerational transmission (Shonkoff et al., 2012). The UYCBP dedicated time within the 10-week period to explore these patterns and provided a safe space for parents to relieve some of the guilt and shame they felt when making such powerful realisations. Current findings suggested that the UYCBP was successful in elucidating these insights from participants, and parents greatly benefitted from it.

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The experiences parents discussed were not singular, significant events typically considered ‘big traumas’ named in the ACE questionnaire employed. Instead, parents referred to smaller traumas experienced chronically throughout their childhood. Participants talked about the warmth, or lack of warmth in the relationship with their parents. One participant developed new insights in that she wanted to be the ‘opposite’ to her own mother. The pressure and stress this experience had placed on this parent’s own expectations of themselves as a parent is significant (Pereira et al., 2018). This suggests that ‘small t’ traumas were equally as impactful on some parenting behaviours as more distinct ACEs for some parents. This aligns with research suggesting chronic ‘small t’ traumas in childhood can endure into adulthood and impact parenting behaviours as adults (Kim et al., 2013). The UYCBP provided a space to explore this and it brought the impact of these childhood traumas into the parent’s conscious awareness. Developing this insight increased the parent’s ability to tolerate stress, self-regulate and engage in the important aspects of parenting in a more attuned and reciprocal manner.

The qualitative data gathered indicated that these adversities are often individual, discrete, and must be interpreted through the person’s own perspective. This extends to the experience of ‘school-gate judgement’ described by parents in the current analysis, whereby other parents’ judgements were more critically perceived because of their ACEs. It may also relate to parent’s experience of excessive freedom as children, which has made them more anxious or protective over their own children now.

The ACEs questionnaire represents a crude measure of adversity experienced as a child.

However, there are several criticisms associated with the use of singular ACE scores (e.g.

Lacey & Minnis, 2019). The current findings supported the notion that an ACE score does not fully capture a person’s experience of childhood adversity. There are updated ACE questionnaires currently in development that attempt to better capture the range of adversity experienced in childhood which are more related to systemic and societal issues (Bethell et al.,

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2017). However, the types of ACEs captured in the narratives of the current study’s participants required more in-depth exploration, which focused on the meaning each individual inferred from the experiences themselves. Identifying incidence alone represents only a fraction of the bigger picture. The key piece of information that researchers and clinicians need to extrapolate is each parent’s individual perspective and felt impact of the ACEs.

5.6 Research Implications

There are several implications specific to future research that were highlighted by the present study’s findings. Firstly, the variables employed must be scrutinised. There may be an argument that the measures utilised were not sensitive enough to accurately capture change in this PC sample after taking part in this group. The short period between measurements already discussed may have confounded the assessment of distal, child-based variables evaluated using the SDQ. Follow-up measures extending beyond the length of the programme may have provided more accurate analysis. Other UYCBP research has found significant effects by analysing more discrete subscales devised within the SDQ, such as the ‘conduct problems’ subscale (Douglas & Johnson, 2019). This level of analysis was not possible given the sample size of the current study, but may have been more illustrative of children’s behavioural changes observed by parents. On proximal factors, a similar phenomenon may have been observed. The

MaaP is a relatively new measure of self-regulation, which encompasses several important factors of positive parenting. Analysing individual subscales within the total score may have yielded more significant findings with larger effect sizes.

Categorical change on the SDQ and PSS measures showed significant results.

Evaluating change across categorical severity may potentially hold clinical utility compared to a reduction on overall scale scores. Mean internalising and externalising scores were within the

“high” range at the beginning. Even significant reductions on continuous total scores did not equate to a clinically meaningful change in the level of behaviour displayed by children.

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Evaluating categorical change is especially relevant in a clinical setting where supporting participants’ return to tolerable levels of distress is the goal.

There was a discrepancy between the mean ACE score calculated from completed data, and mean ACE score calculated when missing items were scored as zero. This discrepancy may have significantly impacted on the analysis. However, it does highlight concerns about employing the ACE questionnaire in certain research contexts. A total of 14 items responses were omitted on the questionnaire, which was a significantly higher omission rate than any other questionnaire. Given the sensitive nature of the questions posed, it appeared that participants chose not to provide an answer for some of the questions. This was entirely understandable, given there is no rapport developed between the researcher and participants when they completed the questionnaire. Finding more sensitive ways to gather this information is important to improve accuracy of the information, and to ensure participants feel safe when asked about such sensitive topics. Accuracy and sensitivity could be increased by asking these questions through a clinical interview, or by introducing an interrater reliability component by asking therapists to score the questionnaire after conducting a clinical interview as part of routine clinical practice, for example.

Categorising the ACE scores as “high” and “low” may not distinguish the groups sufficiently. Introducing another category of “below average” (ACEs = 0) may have provided more illustrative results. The sample size in the current sample did not allow for a three-level classification. Alternatively, future research could consider raising the criteria for “high” ACE scores similar to previous studies (ACEs ≥ 4; Blair et al., 2019) This categorisation would make it difficult to gather equal distribution from one service alone. Specialised services would see a greater number of parents with higher ACE scores and other PC services are likely to have an ACE score distribution similar to this study. Conducting cross-service evaluations of

PARENTING GROUP OUTCOMES AND ACES 101 a parenting group would be a more comprehensive approach to evaluate the influence of ACEs on parenting group outcomes.

It is still vitally important to acknowledge that parents endure difficult social circumstances, contending with challenging family dynamics that have maintained the issues up to this point that consequently warranted referral to the PC psychology services. The expressed experiences of the current cohort were testament to the difficulties endured by many families, regardless of the cumulative ACE score they are assigned based on a binary questionnaire.

As discussed previously, the ACE questionnaire utilised asks about specific, significant experiences in childhood. The current data emphasises the idea that “small t” traumas experienced in childhood can be equally as influential in parenting behaviours, particularly due to their potential chronic existence in childhood (Larkin et al., 2014). The parent’s own perceptions about their childhood experiences were salient. Future research evaluating the impact of ACEs on parenting should find more extensive methods of capturing discrete detail that cannot be effectively gathered by a binary response questionnaire. This will likely require a qualitative component given the complexity of each individual’s perception of an event, the timing and chronicity of such events, the impact of protective factors and the differences in how parents relate these events to their current parenting behaviours (Ford et al., 2019).

The lack of a control or comparison group prevents us from drawing assertions about

ACEs impact group effects compared to matched pairs. There are different patterns of improvement in distal factors following completion of behavioural and relational programmes

(Högström et al., 2016). Therefore, comparing the effectiveness of the UYCBP to a behavioural-focused parenting programme with a longer follow-up period is important. This would address an important gap in our understanding of how parents progress over time after

PARENTING GROUP OUTCOMES AND ACES 102 completing the UYCBP and determine if this programme provides comparable long-term benefits on a child’s behaviour to behavioural-focused programmes.

5.7 Clinical Implications

The UYCBP was beneficial for the majority of research participants who attended. The benefits primarily related to parent-based factors rather than child behavioural improvements, though parents felt better able to manage behavioural problems when the group concluded. The

SA considers the parent to be the primary catalyst for change, and considers child behaviour primarily as a product of the parent-child interaction, notwithstanding a child’s developmental level and communication abilities. This may partially explain why child behaviour showed no significant quantitative improvements after the group (Douglas & Ginty, 2001). However, there is sufficient evidence from other quantitative variables and from qualitative analysis that the group was successful in many respects. Parent-based changes are important because these are protective against difficulties in the future and provide a change in the parent-child relationship which is sustainable over longer periods (Steele & McKinney, 2019). This has already been discussed in greater detail. The theory that proximal changes in the short-term alone are valuable enough to classify the UYCBP as successful, compared with distal, child-based behavioural improvements has been unpacked in the research (Leijten et al., 2018). This important question must be addressed using longer-term data, tracking progress of parents and children over several years, rather than the duration of a parenting programme. This is especially important given the variation in patterns of improvement observed in parents following parenting programmes of different orientations (Högström et al., 2016) and the changing demands parents must manage across childhood (Fuchs et al., 2015). Determining proximal and distal effects from the child’s perspective could also provide a novel insight into change that occurs. This would align with the ethos of the SA, which advocates for acknowledging the child as an active participant in the relationship, and in subsequent change.

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However, the discrepancy between quantitative and qualitative findings raises the question from a service-based perspective of what constitutes ‘sufficient change’. Participants of the current group still represent a vulnerable population, as many still remain in the

“moderate” or “high” range of perceived stress and are supporting children who display “high” levels of EBD. Without the on-going support of the group, these parents may find it difficult to continue their progress, in spite of the improvements they have experienced. These participants may require further support to navigate through difficulties as their children grow older and parenting demands change. This is especially the case for parents who have a history of trauma (Pasalich et al., 2016). The research has identified how a child’s development can considerably impact on parental sensitivity, as a child’s emerging independence can trigger dysfunctional attributions, leaving parents feeling a loss of control (Fuchs et al., 2015).

Additionally, a child’s behaviour has a stronger effect on parenting styles in later childhood and adolescence (Smetana, 2017) and this bidirectional effect is stronger when parenting behaviours are less sensitive in a child’s earlier years (Kelly, 2019). However, if a parent has greater self-regulatory abilities, they are more likely to manage these behaviours better. It will be essential to determine if improving proximal, parent-based factors is sufficient to give parents the ability to alter patterns of challenging behaviours over time, or if parents need more focused support to do so.

There is also the consideration that parents with greater cumulative exposure to adversity benefit from relational groups more (Pearl et al., 2012). Perhaps participants in this study were below this threshold of cumulative adversity and may have experienced greater benefits from a behavioural focused intervention as a result. An additional confounding factor identified in previous research is the type of trauma experienced by the parent. This may have altered how parents responded to the UYCBP, as certain types of maltreatment and trauma accentuated effects (e.g. history of interpersonal trauma; Rosenblum et al., 2017) and other

PARENTING GROUP OUTCOMES AND ACES 104 types showed no significant effects on treatment (Hurlburt et al., 2013). The present study was not designed to identify any such patterns, but they remain an important factor when considering the clinical implications of future referrals to the UYCBP.

It is important to emphasise the contained and reciprocal atmosphere fostered within the group. Parents shared experiences and allowed themselves to be vulnerable in front of others. This experience has a powerful healing effect for parents who may not have had supportive relationships throughout their lives. An individual’s history of connectedness is a better predictor of their resilience to adversity than any history of trauma in childhood

(Hambrick et al., 2019). The UYCBP facilitates this connectedness by enabling the development of relationships (NHS Highland, 2018).

Participants expressed their satisfaction with their overall group experience. There are some confounding factors worthy of discussion with regard to the acceptability of the group in clinical practice. One issue is that the majority of parents who attended were female. Female- dominant attendance is often observed in parenting programmes (Bayley, Wallace, &

Choudhry, 2009). Attempting to engage both parents may be an important method of consolidating progress, working on family dynamics, which ensures both parties benefit from the support and validation provided by the group. However, involving both parents can introduce unnecessary barriers to engagement for some families (Huntington & Vetere, 2016) and this requires services to be flexible and accommodating to the practical aspects of each family’s involvement. UK-based studies have evaluated the UYCBP with a father-only sample and the results bear strong resemblance to the experiences of parents in the current study

(Dolan, 2013). This shows further promising signs that the UYCBP performs similarly across diverse population samples.

The current study evaluated a clinically representative sample of parents who attended the UYCBP. The programme was offered to a more diverse group of parents, including foster

PARENTING GROUP OUTCOMES AND ACES 105 carers, who made up 20% of the overall sample. Findings suggest that the group was acceptable even with this more diverse group of parents. This is important for service delivery as it provides evidence that the group can be offered to a diverse group of parents without losing the core components of the SA. While the group was acceptable for a more inclusive population, this diversity may have impacted on the overall effectiveness of the group.

There are still 17% of individuals who did not engage in the research, most of which did not attend the group. It is a pertinent clinical issue to find ways of engaging the parents who are experiencing barriers to participating in such interventions. The current findings suggest the group can provide a supportive space that reduces barriers to engagement, but helping parents attend initially may be a more significant issue to ensure all suitable parents are benefitting from the UYCBP (Axford et al., 2012). This is a significant problem for many services delivering parental support. The current study has provided evidence that the UYCBP was successful in reducing drop-out through implementing essential factors outlined in research (Muzik et al., 2015). However, the findings did not extend to investigate factors associated with parents who did not attend the group at all.

The exact number of sessions of the UYCBP a parent is required to attend to achieve clinically significant outcomes is relatively unknown. Previous studies suggested that parents may require close to full attendance to grasp the concepts being presented in the content

(Johnson & Wilson, 2012). Current findings suggest that participants have gained an awareness of the three core principles proposed by the SA with an average attendance of seven sessions.

However, there is likely to be huge variability in this ‘dose-response’ relationship for parents, as each of them battle with similar, but distinct challenges. Diverse parenting experiences, different coping mechanisms and a range of social circumstances are all influential factors.

Their children have unique temperaments, diverse behaviours and many different ways of displaying their emotions. Finding a reliable ‘dose’ that accurately caters for any constellation

PARENTING GROUP OUTCOMES AND ACES 106 of these factors is a challenge even for the most heavily researched parenting programmes

(Axford et al., 2017). Research does outline that programmes should be time-limited and within these guidelines, better attendance does appear to improve outcomes for the UYCBP (Johnson

& Wilson, 2012) and for other parenting programmes (Walton, 2014).

Disseminating the SA to the wider population of parents is a broader clinical goal.

Parenting programmes in clinical populations act as a treatment for the consequences of on- going societal issues such as poverty and social disadvantage that undermine positive parenting practices. Many of these are included as causal factors in the Pair of ACEs framework (Ellis &

Dietz, 2017). In Ireland, providing this support in a timely manner is often a challenge. PC services do not have the capacity to correct societal injustices that exist; this must come at governmental policy level. This is the premise on which the Pair of ACEs framework was designed. Introducing a preventative approach would, in theory, reduce the impact that poor parenting practices have on the young population (Taylor-Robinson et al., 2018). The unfortunate reality is that children who are impacted by the intergenerational transmission of

ACEs, through parenting practices and their own traumatic experiences do not get the support they require (Rose et al., 2008). However, introducing a model of positive parenting, such as the SA, may be one way of providing evidence-based information for parents at population level. This would help to reduce the stigma associated with parenting programmes. Attending parenting programmes is often considered synonymous with being a ‘bad’ parent. Introducing universal parenting programmes would diminish this negative association and may encourage more parents to engage with the targeted interventions (such as the UYCBP). This type of population intervention has been successful in other countries, including the UK and were well received by participants (Lindsay & Totsika, 2017). This type of implementation provides the supportive and validating aspect (Prinz, 2019) that participants of the current study experienced as greatly beneficial and valuable in their group experience.

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5.8 Strengths and Limitations

There are several strengths of the current study design. Participants were recruited from only two sites, reducing the variability in programme delivery. The programme was implemented as routine practice and was not impacted by the research, thus allowing the data to provide a representative reflection of true clinical practice (Boswell et al., 2015). Risk was minimised through the consistent presence of a clinician who monitored participants’ suitability for involvement in the research study. Quantitative statistical analysis methods were conducted using a systematic and thorough procedure to ensure data was managed appropriately and test assumptions were adequately met. A mixed-methods design provided more in-depth evaluation of the group. Where statistical analysis was not sufficiently powered, the qualitative component compensated by gaining an insight into participants’ experiences from their own perspective to further extrapolate meaning from the data.

Some limitations were also evident. The research did not utilise a control group, which was consistent with previous evaluations of the UYCBP (e.g. Appleton, Douglas, & Rheeston,

2016). However, more recent evaluations (Douglas & Johnson, 2019) have implemented a controlled trial and future research in Irish-based samples should endeavour to duplicate this design to improve the quality of evidence supporting the positive effects of the group.

Introducing a follow-up element would also augment existing evidence for the longer term impacts of the UYCBP. This would provide more conclusive evidence to address the debate on whether proximal improvements are sufficient when no distal, child-based behavioural improvements are observed. Longitudinal designs across multiple services could also establish if PC samples are more resilient and resourced to manage difficulties compared to referrals to specialised services for the same issues. While efforts were made to maintain treatment fidelity by collecting data in two locations only, there were three different pairs of facilitators

PARENTING GROUP OUTCOMES AND ACES 108 delivering the four UYCBP groups. This may have impacted on effectiveness and acceptability of the group.

ACEs scores were relatively low compared to previous studies evaluating ACE scores.

This made it more difficult to assess the effect of ACEs on outcomes. Recruiting samples from specialised services who likely report higher cumulative ACE scores would allow for more accurate assessment of ACEs impact on treatment outcomes. Missing responses on the ACE questionnaire at baseline may have compromised the analysis. As this is a difficult topic to ask participants to engage openly and honestly with, future studies need to find more sensitive ways of gathering this information. The conceptual understanding of what constitutes an ‘ACE’ may need to be expanded on, given the unique adversities described by participants of this study. Though the qualitative analysis did gather written qualitative data from the entire cohort, a focus group was conducted with six participants of one group. Employing focus groups for each cohort would allow qualitative analysis to examine patterns that might emerge across different groups and participants. Finally, participants who did not complete the post- intervention questionnaire represent the group who may guide researchers and clinicians alike in shaping the UYCBP to better accommodate the needs of participants who did not complete the group. Finding methods of evaluating these participants’ experiences in future research would provide a more insightful perspective which could improve and increase engagement of the UYCBP.

5.9 Conclusion

The UYCBP was acceptable for a diverse group of participants, though an increase in diversity has the potential to reduce the overall effectiveness for attendees. Group effects were observed mainly on proximal as opposed to distal factors. This may be a result of the relational approach adopted by the UYCBP, or because of the characteristics of the PC population.

However, it must be acknowledged that this PC sample still represents a disadvantaged group

PARENTING GROUP OUTCOMES AND ACES 109 that face many obstacles in their parenting practices. Finding more clinically relevant ways of measuring change is also an important consideration for future research. There were no significant impacts of ACEs observed, which may have been related to the low mean ACE score of the group overall. More importantly, the issue of how adversity is truly measured was highlighted. Findings suggest that qualitative exploration represents the most sensitive way of measuring adversity and its individual impacts. Bringing such adversities into parents’ awareness, specifically in how they influenced their parenting practices was a significant realisation for some participants, with positive impacts.

The UYCBP offered Irish parents an opportunity to connect and relate with other parents experiencing similar difficulties. Parents experienced a supportive, contained environment where judgement was left outside the door, allowing space to explore difficult topics and experiences that brought them to the group. The UYCBP enlightened parents to hold broader perspectives of their own history of adversity, their child’s behaviours and on the importance of fostering a sensitive parent-child relationship. Parents carried these contained, reciprocal group experiences into interactions with their children. They used insights gained to better manage behaviour that previously challenged their identity as a parent. Adversity will visit every parent at some point in their life and the UYCBP acted as a guiding light on these parents’ journey to feel more “at home” in their parenting role.

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Chapter 6. Critiquing the Conceptual Frame and Design – Guiding Future

Research

6.1 Chapter Overview

The author has engaged in reflective practice throughout the process of conducting this piece of research. This reflective practice began in the initial conception of the research idea, continuing through the design and execution of the research project. These reflections contain important points of critique and may provide valuable insights for future research projects that have similar or related research aims to the current project. The following chapter articulates elements of the author’s reflective process to provide a critique of significant challenges faced and guidance on how these can be resolved in future related research projects.

6.2 The Challenges of Evaluating Programmes Novel to a Health Service

Research projects are designed to provide novel additions to the literature. The UYCBP had not been implemented, or evaluated in an Irish sample prior to the current research project.

However, this novelty brings challenges when designing and executing effective research

(Boswell et al., 2015). The UYCBP had been recently introduced to a Health Service. Services require facilitators to obtain a certain level of training, designate the requisite time period to facilitate the group, adjust service provision strategies to incorporate a different programme into the service and also allocate sufficient time to screen parents for suitability of group attendance. For many services that are introducing a new programme into their service, research can appear to add another element of complexity to an already resource-intensive endeavour (Hunter, 2013). Many of these factors can be preclusive to doctoral research which has a specified end date. The current research represents some of the difficulties that arise when amalgamating the collection of practice-based evidence with new service provisions.

PARENTING GROUP OUTCOMES AND ACES 111

One example is that research may not be the first priority when new programmes are being piloted in services and as a result, uptake for research can be reduced. Research may be prioritised when new services have been successfully integrated into ‘normal’ service provision.

The novelty of the programme meant that services did not have the opportunity to consider potential clinical implications of including a diverse population. This can impact on measures of effectiveness (Bauer et al., 2015). When services have experience facilitating the groups, they can make more accurate clinical judgements about the suitability of parents for the intervention. Services implementing a novel programme may need to adjust the prescribed method of delivering and facilitating the programme to suit their demographic, which can vary between catchment areas. Evaluating a programme at the early stages does not allow a service to make these adjustments prior to the research evaluation.

While these considerations and adjustments are synonymous with many interventions, there is also value in evaluating programmes at this stage of their implementation. The current research provides, at a minimum, a baseline evaluation of effectiveness and acceptability for the UYCBP. This can act as a comparison for future implementations of the programme, following appropriate amendments, informed by clinical practice and these research findings.

6.3 Recruitment Issues

Recruitment issues are often encountered when conducting research in conjunction with standard clinical practice (Hunsley, 2007). The current study was designed to account and control for potential recruitment challenges without impacting on routine clinical practice, but faced significant challenges nonetheless.

The literature relating to attendance rates to the UYCBP (e.g. Douglas & Johnson,

2019) and parenting interventions in general (Furlong et al., 2013) was consulted to ensure an

PARENTING GROUP OUTCOMES AND ACES 112 adequate number of groups were being evaluated to meet power requirements. Using information from the literature, it was established that including four groups in the research would meet sufficient power requirements for all research questions. This estimate also accounted for expected attrition and non-attendance rates. However, additional recruitment issues arose beyond those anticipated. Some participants attended adequate numbers of sessions, but did not attend the first session and therefore, did not complete the pre-intervention questionnaire. A small, but significant number of participants could not be included in the quantitative analysis for this reason. Additionally, the service found it a challenge to recruit parents who were deemed suitable for the programme. This meant the prescribed number of attendees was less than expected, thus reducing the overall pool of potential research participants.

The decision to contain the recruitment to a single service provision area was made to maintain a more homogenous group that would allow for more accurate assertions to be made about the data collected (Dewa et al., 2004). However, the data gathered suggested that the group was more heterogenous than expected. This heterogeneity within the sample negated the benefits of maintaining a more controlled population for recruitment. This method of sampling meant that unanticipated attrition rates could not be compensated for within the research sample.

The limited number of participants also made it more difficult to compensate for more discrete or modest effects that may have been captured with a wider sampling method, primarily because of the potential for increasing recruitment. The sample recruited was identified as a heterogenous one, with 20% of the sample identifying as foster parents. The neurodevelopmental and biological relationship for these parents and children is different

(Ridout et al, 2018). A number of in-utero, prenatal and perinatal factors are absent, which reduces the potential for intergenerational transmission of adversity described in the literature

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(Bowers & Yehuda, 2016). By including a significant proportion of foster families in the analysis, it is likely that effects would have been more modest than in previous samples published in the literature, because of the differences outlined.

The qualitative component of the research was designed to add context to the quantitative data gathered. It was successful in providing more in-depth data that contextualised the quantitative findings. However, it may have been beneficial to recruit a focus group from each group facilitated, as opposed to one group that was intended to represent the entire sample. This would have provided an element of comparison within the data and may have elucidated patterns relating to certain demographics or levels of difficulties reported.

Recruiting a case-matched control sample would have increased confidence in the evidence gathered (Des Jarlais et al., 2004). This could be obtained from the service waiting list to control for transient improvement potentially observed in similar cases. Additionally, given the on-going debate in the literature regarding behavioural and relational programmes, a non-inferiority randomised control trial could be implemented to determine if parents benefit differentially from programmes using distinct approaches (Hahn, 2012). Finally, to further assess the specific impact of trauma on outcomes, research could evaluate the UYCBP in services of more specialised need, where ACE scores are typically higher, and adversity in childhood is more prominent. This would provide a more robust method of evaluating the impact of parental childhood trauma on intervention effects.

The time restrictions associated with doctoral research can introduce additional issues with sampling and adequate recruitment. These time limits imposed prevented the current research from making adaptations to improve recruitment. Future research should strongly consider a multi-site recruitment design, including a control group for reasons outlined above.

Multi-site recruitment would also ensure the population is nationally representative,

PARENTING GROUP OUTCOMES AND ACES 114 sufficiently powered to uncover more discrete effects and have the capacity to facilitate contingency planning if recruitment issues arise.

6.4 Follow-Up Data

The pattern of data collected in the current study aligns with existing literature for parenting programmes with a relational focus (Mortensen & Mastergeorge, 2014). The literature suggests a delayed pattern of improvement for distal factors, as it takes some time for these patterns to produce change beyond the parent who attends the group (Steele & McKinney,

2019). When considering these factors, a follow-up component would have improved the current project’s research design. By introducing a follow-up component into the research design, any hypotheses about the trajectory of improvement for measures employed would have been substantiated by data.

A follow-up component would also provide the opportunity of assessing whether the parent-based improvements are maintained, whether they facilitate greater change or if there is regression in progress made throughout the group as time passes. Follow-up at three months would provide provisional data to evaluate this trajectory. Extending the time period for follow- up would allow further exploration of the relationship of the post-intervention trajectory and future service usage, for example.

6.5 Integrating Conceptual Frameworks to Address a Specific Research Issue

The current study was founded in the conceptual framework proposed by the Solihull

Approach (SA), and attempted to integrate the extensive ACEs literature to form a coherent narrative that led sensibly to the research questions and hypotheses outlined. To summarise briefly, the SA aims to support parents to engage in more sensitive, reciprocal relationships with their children to facilitate improved attachment, improved parental self-regulatory abilities and consequently, better parenting practices (Douglas & Ginty, 2001). The link drawn

PARENTING GROUP OUTCOMES AND ACES 115 between ACEs and the SA lies in the prolonged exposure to toxic stress that is produced by adversity in childhood (Felitti & Anda, 2014). This toxic stress has implications for brain development and stress response systems of parents who experienced trauma (Shonkoff, 2012).

These implications have been demonstrated to transmit intergenerationally through numerous pathways including (but not limited to) dysfunctional coping behaviours and attachment impairments (Finkelhor, 2018). These aspects are specific targets for improvement within the

SA.

Combining overlapping but distinctive conceptual frameworks brings its challenges

(Fassinger, 2005). Firstly, different frameworks may have distinct operational definitions for similar constructs. This presents difficulties in interpreting data (both quantitative and qualitative), as interpretations may change depending on how constructs are defined.

Combining frameworks also complicates the conclusions drawn about your findings, as your research questions are based on the framework and therefore, results are premised on the framework being valid and coherent. However, it is difficult to combine different theoretical frameworks whilst maintaining the same level of validation each might have individually. That said, it is the role of the researcher to ‘construct’ their theoretical framework by critiquing relevant literature that may be biased with assumptions embedded in existing frames, and tailoring the conceptual frame appropriately for the research aims (Adom et al., 2018). Future research may intend to ‘pilot’ the goodness-of-fit for their constructed theoretical frame through qualitative exploration as a method of validation. Researchers can then make appropriate amendments prior to proceeding with investigations of the research questions. The benefits of doing so were borne out in the qualitative research gathered. For example, parents described how more discrete traumas experienced in childhood were influential in their parenting behaviours. By gathering this information in an initial pilot, it may have altered the method of gathering information on trauma used in the current study.

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The literature review presented in the current study delved into both frameworks in detail. In doing so, it attempted to outline the distinctive features of each, but also the overlapping aspects. However, the current research did not adequately depict the conceptual frame through which these existing frameworks would be integrated.

In the current study, the ACEs is primarily focused on describing problems, trauma and adversity, whereas the SA is focused on making change as a result of these difficulties. For example, trauma or adversity occurs (ACE concept), thus disrupting neurodevelopment (ACE and partial SA concept), resulting in the need for containment, reciprocity and sensitive behaviour management strategies (SA concepts). In this simplified example, the conceptual frameworks overlap, but are also distinct in their position in the model envisaged throughout the conception of the current study.

By explicitly formulating the framework, the research may have been more convincing in portraying a meaningful theoretical basis from which research questions and hypotheses were developed. The current study may have introduced ACEs as a potentially causal factor for the issues that the SA was formulated to intervene against. Future research should focus on being distinctive about the relationship between SA and ACEs, extricating the salient components of each and describing the main points of integration. Some of this may be guided by pilot exploration studies discussed above.

6.6 Mixed Methodology – Merits and Challenges

The current study was designed to answer a number of distinct research questions that related to group acceptability and group effectiveness. The UYCBP adopts a focus on exploring how parents’ own experience of being parented might have influenced their current parenting practices and the potential impact childhood adversity may have had on their own parenting styles (Douglas & Ginty, 2001). The importance of mixed methods in research pertaining to

PARENTING GROUP OUTCOMES AND ACES 117 childhood trauma has been highlighted elsewhere (Boeije et al., 2013). Evaluating the parents’ perceptions of how their childhood experiences influenced their current parenting practices following the intervention was therefore included as a research question. Based on these research questions, it was deemed most appropriate to employ mixed methodology to provide the necessary data to answer these questions. Reflecting on the process of the research, this allowed the authors to make important conclusions that would not have been possible by employing quantitative or qualitative methods alone. There are two distinct examples that can be extracted from the data to highlight the benefits of employing mixed-methods, outlined below.

Qualitative data suggested that parents experienced the group as highly beneficial. They described several salient themes which indicated the positive impact the group has had on them and their child. With qualitative data alone, we would assume that there were improvements across the board, in both parent and child-based factors. However, quantitative data showed that the benefits were primarily observed in measures relating to the parent only. By combining both quantitative and qualitative methods, we can understand the parents’ experiences better.

There was a discrepancy between the quantitative and qualitative data in terms of the occurrence, relevance and impact of adversity the parents experienced in childhood. Overall, quantitative data suggests that trauma did not significantly impact on baseline difficulties, nor did it significantly impact on outcomes of the parenting group. However, the qualitative piece provided more nuanced experiences of trauma that were not captured by quantitative questionnaires, but were clearly influential in parenting practices. The qualitative data also revealed that by exploring these in the group, some parents became more aware of the associated parenting behaviours, which reduced the negative impact these experiences had on their parenting practices.

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The research would have been strengthened by increased numbers in the quantitative analysis and the use of more focus groups. While the qualitative data did provide context for understanding and making sense of the quantitative data, this cannot fully compensate for some of the statistical analyses being underpowered. Qualitative interpretations could have been more accurate when combined with sufficiently powered quantitative analyses on all tests conducted. An additional confounding factor was the issue of implementing only one focus group in the research design. This potentially introduced bias towards one group and may not fully represent all attendees. Facilitating focus groups for each intervention programme would provide a more representative method of implementing a qualitative component to the design.

While there are clear benefits to introducing mixed methodology to the current research, this design also posed some challenges (Bryman, 2006). Integrating both quantitative findings and qualitative data was not possible given the broader scope of the qualitative data gathered. Future studies may decide to be more specific in what they obtain from the qualitative data. For instance, focusing specifically on the research question of intervention effectiveness, or the mechanisms through which participants experienced change throughout their participation. Another potential method of utilising mixed methodology could relate to the exploration of trauma in childhood: Investigating its incidence, how it was experienced, and determining whether exploring this impacted on their progression through the group intervention. This would map more closely onto the implementation of the ACEs measure in this study. Facilitating individual interviews may be more appropriate to adequately explore this subject, given the sensitive content.

6.7 ACE Implementation in Clinical Practice

The ACE was originally designed as a demographic tool that appealed to many researchers and clinicians because it provided a method of evaluating the impact of complicated and difficult experiences in a simple format (Bellis et al., 2014a). The appeal of

PARENTING GROUP OUTCOMES AND ACES 119 the ACE score in its simplicity is also a source of criticism. Many argue that the ACE score simplifies complex topics into a number, whilst overlooking key factors such as the severity, the chronicity and the personal meaning associated with any type of trauma (Ford et al., 2019).

This argument is certainly valid and one that the primary author considered heavily when initially deciding on the most suitable measures to implement in the research design. Other quantitative methods of capturing trauma in childhood were considered. There are many other options (McDonald et al., 2014). However, they all have similar limitations (Danese, 2020).

ACE has a distinct benefit in that it carries a large evidence-base indicating a clear dose- response relationship with ACE scores and many negative health outcomes (Bellis et al.,

2014a). The outcomes resulting from such adversities are largely due to the toxic stress that develops in many situations where ACEs occur (Felitti & Anda, 2014), providing a theoretical basis which underlies and relates to clinical issues.

The ACE score was employed in the current study to gather information about potential adversities that elicit the toxic stress response and which contribute to disrupted attachment relationships both in parents’ own childhood, and with their own offspring. Several studies exist in the literature that draw on similar paradigms and employ the ACE score (e.g. Knerr et al., 2013; Levey et al., 2017), or other similar quantitative methods of evaluating childhood trauma and adversity (see Roy & Perry, 2004 for review) to make assertions about clinical programme engagement and intervention outcome associations.

While the current author acknowledged that there are more accurate methods of evaluating trauma in childhood, the ACE score was deemed the measure with the most compelling evidence base, and had also been utilised in previous research evaluating similar constructs with a similar design (Blair et al., 2019; Hurlburt et al., 2019). Having completed each stage of the research process, the primary author has made some reflections on the use of

PARENTING GROUP OUTCOMES AND ACES 120 the ACE tool in the current study. Each of these reflections is underlined by the realisation of the complexity of measuring trauma in research (McDonald et al., 2014).

Firstly, there are newer adaptations of the ACE score that encompass more discrete elements of childhood trauma that could be employed in future research. Additionally, there are now similar questionnaires that capture the Pair of ACEs referred to throughout the study.

This measures societal adversities that are influential in producing the toxic stress responsible for many negative outcomes. This measure also places the emphasis of adversity within the society and environment the person lives in, rather than the person themselves. This is important as it highlights how societal disparity can shape someone’s current and future life

(McEwen & McEwen, 2017) something which is not captured with the ‘classic’ ACE questionnaire employed in the current study. The obvious downside to this questionnaire is that it lacks the same level of evidence outlining the dose-response relationship of the ACE score and negative outcomes. However, it is likely that similar patterns will be exposed, given the existing research that highlights societal deprivation as a precipitant of adversity in itself

(Walsh et al., 2019).

It is clear from the qualitative data that parents consider trauma and adversity as much more discrete moments in childhood than the ACE score denotes. The qualitative data highlights the limitations of all quantitative measures of childhood trauma, as it appears that the personal relevance of certain situations is what is important for some parents in the current study. The reality is that no quantitative questionnaire can accurately and reliably capture all individuals discrete experiences of trauma and their potential implications for each person. This raises the question of finding more reliable ways of capturing trauma. There are structured clinical interview methods that can be employed, though these methods are not always suitable to research given the extensive time requirement to complete these. However, the balance between parsimony of measurement and accuracy of data collection is of great relevance to the

PARENTING GROUP OUTCOMES AND ACES 121 current study, and future studies evaluating similar constructs. Additionally, the current study showed that in some cases, there was incomplete or missing data gathered on the ACE questionnaire. The sensitive nature of the questions asked by the ACE questionnaire may account for some of the incomplete data gathered.

Future studies may need to amalgamate quantitative data with qualitative data when assessing trauma and its impact. For example, the updated ACE questionnaire that includes additional adversities while also assessing societal adversities could be employed as a self- report measure. In addition, as a method of validating the data gathered, a psychologist or therapist could provide a rating of trauma or adversity experienced following the in-depth clinical assessment conducted as part of the initial screening process for programme suitability.

This has been utilised in similar research (e.g. Bernstein et al., 2003). By introducing the therapist as an intermediary in assessment of the trauma, it allows for more discrete elements of trauma to be captured, as well as the person’s own personal interpretation of how relevant and influential the trauma was for them. This may represent a much more in-depth and reliable measure of trauma experiences in childhood over and above the use of a quantitative measure alone.

6.8 Future Research Planning

Based on the reflections outlined above, a series of considerations for future research are proposed below.

• Evaluating clinical interventions at their novel stages of implementation can produce

challenges for research, as outlined above. Future research projects aiming to use the

UYCBP in research projects may benefit from evaluating the UYCBP when it has been

successfully integrated into typical service provision. This may provide more valuable data

upon which reliable conclusions and recommendations can be drawn about the programme.

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• Future research should ensure that recruitment strategies are robust enough to tolerate

recruitment challenges that typically arise when evaluating interventions in clinical

practice. Recruiting using a multi-site model would provide a more flexible approach that

can be refined and adjusted to manage issues with recruitment. This method would allow

for larger sampling that is more representative of the overall population in qualitative data,

and provide requisite statistical power to draw inferences from quantitative data more

confidently.

• Introducing control groups, from case-matched waitlists or from alternative, equivalent

interventions is a priority for advancing the effectiveness research relating to the UYCBP.

Research focusing on the impact of parental childhood trauma on outcomes will benefit

from broadening the recruitment to more specialised service where trauma experiences are

likely more prominent and can provide a broader sample across the range of experiences.

• Follow-up data is an essential component of any future research project as it will provide

evidence for hypotheses made based on data gathered in the current study. Follow-up data

will help to plot the trajectory for parents who engage with the UYCBP.

• Integrating conceptual frameworks successfully is an important component for coherent

research. The present study encountered challenges in making convincing arguments for

the integration of related, but distinct frameworks. Qualitative data identified the value of

parents’ own voices in guiding how these frameworks could be more effectively assessed

and evaluated. Future studies would benefit from including a pilot ‘exploration’ study to

guide the integration of overlapping conceptual frames. This would also contribute to more

specific, accurate and appropriate methods of assessing research questions considered

within this framework.

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• Mixed methods research can provide valuable insights from differing perspectives.

However, it also presents challenges when considering how to integrate both qualitative

and quantitative methods effectively into the research design. Future research should ensure

both methods are adequately powered individually prior to integration. Potential bias in

sampling could be protected against by extracting a representative qualitative sample from

quantitative data. Qualitative aspects of the research may be more effective if the focus is

more specific to one research question, rather than addressing all simultaneously.

Qualitative aspects of similar research may be adapted to align more specifically with the

experience of childhood trauma, its relationship with later parenting behaviours and

subsequent outcomes of parenting interventions.

• Assessing trauma is a sensitive and complex task. Employing standardised quantitative

measures to assess trauma is subject to significant criticism which is sufficiently justified.

The current study employed the ACE questionnaire in isolation, but qualitative data

demonstrated how this does not accurately capture all forms of experiences in childhood

that may be interpreted as adversity or trauma. Future studies should aim to employ newer

quantitative measures of trauma that have aimed to address some of the flaws with their

original design (e.g. the Pair of ACEs questionnaire). They should also employ other ways

of assessing trauma to ensure it is captured more reliably, such as introducing therapist

ratings of trauma and adversity following clinical assessments. This provides a combination

of both quantitative and qualitative trauma assessment and is likely to produce more

accurate and reliable measurement of the extent of adversity experienced in childhood.

6.8.1 Specific Design Amendments for Future Research

The considerations detailed in this critique are outlined as specific points of inclusion for future research projects below.

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1. Ensure that the intervention has been piloted by a sufficient number of services and has

been implemented by services who have made progress in integrating the delivery of the

UYCBP into typical service provision.

2. Implement a multi-site recruitment strategy to ensure sufficient statistical power, greater

national representation and provide more flexibility in resolving recruitment issues.

3. Ensure that recruitment for the qualitative component is conducted on a multi-site basis

and representative of the overall sample. This would involve conducting focus groups with

each intervention group.

4. Implement a case-matched control group to increase confidence and reliability of

conclusions drawn from the research. This could be recruited from a waiting list group, or

alternatively compared to a behavioural intervention as a non-inferiority trial. Future

research investigating the effects of parental childhood trauma on outcomes should recruit

from more specialised services where these occurrences are more prominent.

5. Introduce a follow-up component to inform progression post-intervention. Consider 3-

month follow-up at a minimum. Additional data points over extended periods would

provide further, novel data on the trajectory of parents after the intervention.

6. Employ a pilot exploration study to guide the integration of conceptual frameworks and

provide a form of conceptual validity. Use the data gathered to inform the specific

methodology and measures employed to investigate the research question considered

within the overall framework.

7. Consider specifying more distinct research questions for qualitative research components.

Group-related questions may warrant the use of focus groups. Questions specific to trauma

may require more sensitive, individual qualitative interviews.

PARENTING GROUP OUTCOMES AND ACES 125

8. Consider using more detailed quantitative measures of adversity in childhood (e.g. the Pair

of ACEs questionnaire). Ensure that trauma is assessed sensitively and thoroughly.

Consider including therapist ratings post-clinical interviewing as a cross reference to

increase accuracy. Consider qualitative assessment of trauma, as this remains the most

accurate and sensitive method available.

PARENTING GROUP OUTCOMES AND ACES 126

References

Adom, D., Hussein, E. K., & Agyem, J. A. (2018). Theoretical and conceptual framework:

Mandatory ingredients of a quality research. International Journal of Scientific

Research, 7(1), 438-441. Retrieved from:

https://www.researchgate.net/publication/322204158

Alink, L. R., Mesman, J., Van Zeijl, J., Stolk, M. N., Juffer, F., Bakermans‐Kranenburg, M.

J., ... & Koot, H. M. (2009). Maternal sensitivity moderates the relation between

negative discipline and aggression in early childhood. Social Development, 18(1), 99-

120. doi: 10.1111/j.1467-9507.2008.00478.x

Ammerman, R. T., Peugh, J. L., Teeters, A. R., Putnam, F. W., & Van Ginkel, J. B. (2016).

Child maltreatment history and response to CBT treatment in depressed mothers

participating in home visiting. Journal of Interpersonal Violence, 31(5), 774-791. doi:

10.1177/0886260514556769

Appleton, R., Douglas, H., & Rheeston, M. (2016). Taking part in ‘Understanding your

child’s behaviour’ and positive changes for parents. Community Practitioner, 89(2),

42-8. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27164802

Aram, D. (2007). Sensitivity and consistency of maternal writing mediation to twin

kindergartners. Early Education and Development, 18(1), 71-92. doi:

10.1080/10409280701274733

Attride-Stirling, J. (2003). Development of methods to capture users’ views of child and

adolescent mental health services in clinical governance reviews (Project evaluation

report). London: Commission for Health Improvement. Retrieved from:

https://www.corc.uk.net/media/1215/chi_projectevaluationreport.pdf

PARENTING GROUP OUTCOMES AND ACES 127

Axford, N., Bywater, T., Blower, S., Berry, V., Baker, V., & Morpeth, L. (2017). Critical

factors in the successful implementation of evidence-based parenting programmes:

Fidelity, adaptation and promoting quality. In L. Dixon, D. Perkins, C. Hamilton‐

Giachritsis & L. Craig (Eds.), Critical factors in the successful implementation of

evidence‐based parenting programmes (pp. 349–366). Hoboken, NJ: Wiley.

Axford, N., Lehtonen, M., Kaoukji, D., Tobin, K., & Berry, V. (2012). Engaging parents in

parenting programs: Lessons from research and practice. Children and Youth Services

Review, 34(10), 2061-2071. doi: 10.1016/j.childyouth.2012.06.011

Bakermans‐Kranenburg, M. J., Van IJzendoorn, M. H., & Juffer, F. (2005). Disorganized

infant attachment and preventive interventions: A review and meta-analysis. Infant

Mental Health Journal: Official Publication of The World Association for Infant

Mental Health, 26(3), 191-216. doi: 10.1002/imhj.20046

Bandura, A. (1982). The assessment and predictive generality of self-percepts of

efficacy. Journal of Behavior Therapy and Experimental Psychiatry, 13(3), 195-199.

doi: 10.1016/0005-7916(82)90004-0

Bandura, A., & Walters, R. H. (1977). Social learning theory (Vol. 1). Englewood Cliffs, NJ:

Prentice-hall.

Barlow, J., Smailagic, N., Ferriter, M., Bennett, C., & Jones, H. (2010). Group‐based parent‐

training programmes for improving emotional and behavioural adjustment in children

from birth to three years old. Cochrane Database of Systematic Reviews, 3. doi:

10.1002/14651858.CD003680.pub2

Bateson, K., Delaney, J., Pybus, R. (2008). Meeting expectations: the pilot evaluation of the

Solihull Approach parenting group. Community Practitioner, 81(5), 28-31. Retrieved

PARENTING GROUP OUTCOMES AND ACES 128

from:

https://pdfs.semanticscholar.org/e500/8750dbbcf490e616292b5ccca0648871157c.pdf

Bauer, M. S., Damschroder, L., Hagedorn, H., Smith, J., & Kilbourne, A. M. (2015). An

introduction to implementation science for the non-specialist. BMC Psychology, 3(1),

32. doi: 10.1186/s40359-015-0089-9

Baumrind, D. (1978). Parental disciplinary patterns and social competence in children. Youth

& Society, 9(3), 239-267. doi: 10.1177/0044118X7800900302

Baumrind, D. (1991). Effective parenting during the early adolescent transition. In Cowan,

P., Hetherington, M. (Ed.) Family transitions, 2(1), 1. Hillsdale, NJ: Lawrence

Erlbaum

Bayley, J., Wallace, L. M., & Choudhry, K. (2009). Fathers and parenting programmes:

barriers and best practice. Community Practitioner, 82(4).Retrieved from:

https://europepmc.org/article/med/19397081

Beauchaine, T. P. (2015). Future directions in emotion dysregulation and youth

psychopathology. Journal of Clinical Child & Adolescent Psychology, 44(5), 875-

896. doi: 10.1080/15374416.2015.1038827

Bellis, M. A., Ashton, K., Hughes, K., Ford, K. J., Bishop, J., & Paranjothy, S.

(2016). Adverse childhood experiences and their impact on health-harming

behaviours in the Welsh adult population. Public Health Wales NHS Trust. Retrieved

from

http://researchonline.ljmu.ac.uk/id/eprint/2648/1/ACE%20Report%20FINAL%20%2

8E%29.pdf

Bellis, M. A., Hughes, K., Leckenby, N., Perkins, C., & Lowey, H. (2014a). National

household survey of adverse childhood experiences and their relationship with

PARENTING GROUP OUTCOMES AND ACES 129

resilience to health-harming behaviors in England. BMC medicine, 12(1), 72. doi:

10.1186/1741-7015-12-72

Bellis, M. A., Lowey, H., Leckenby, N., Hughes, K., & Harrison, D. (2014b). Adverse

childhood experiences: retrospective study to determine their impact on adult health

behaviours and health outcomes in a UK population. Journal of Public Health, 36(1),

81-91. doi: 10.1093/pubmed/fdt038

Belsky, J., Jonassaint, C., Pluess, M., Stanton, M., Brummett, B., & Williams, R. (2009).

Vulnerability genes or plasticity genes? Molecular Psychiatry, 14(8), 746-754. doi:

0.1038/mp.2009.44

Belsky, J., & Pluess, M. (2009). Beyond diathesis stress: differential susceptibility to

environmental influences. Psychological Bulletin, 135(6), 885-908. doi:

10.1037/a0017376

Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., ... &

Zule, W. (2003). Development and validation of a brief screening version of the

Childhood Trauma Questionnaire. Child Abuse & Neglect, 27(2), 169-190. doi:

10.1016/S0145-2134(02)00541-0

Berthelot, N., Ensink, K., Bernazzani, O., Normandin, L., Luyten, P., & Fonagy, P. (2015).

Intergenerational transmission of attachment in abused and neglected mothers: The

role of trauma‐specific reflective functioning. Infant Mental Health Journal, 36(2),

200-212. doi: 10.1002/imhj.21499

Bethell, C. D., Carle, A., Hudziak, J., Gombojav, N., Powers, K., Wade, R., & Braveman, P.

(2017). Methods to assess adverse childhood experiences of children and families:

toward approaches to promote child well-being in policy and practice. Academic

Pediatrics, 17(7), S51-S69. doi: 10.1016/j.acap.2017.04.161

PARENTING GROUP OUTCOMES AND ACES 130

Bingham, G. E., Jeon, H. J., Kwon, K. A., & Lim, C. (2017). Parenting styles and home

literacy opportunities: Associations with children's oral language skills. Infant and

Child Development, 26(5), e2020. doi: 10.1002/icd.2020

Bion, W. R. (1959). Attacks on linking. In Second thoughts. London: Karnac.

Blair, K., Topitzes, J., & Mersky, J. P. (2019). Do parents’ adverse childhood experiences

influence treatment responses to parent-child interaction therapy? An exploratory

study with a child welfare sample. Child & Family Behavior Therapy, 41(2), 73-83.

doi: 10.1080/07317107.2019.1599255

Boeije, H., Slagt, M., & van Wesel, F. (2013). The contribution of mixed methods research to

the field of childhood trauma: a narrative review focused on data integration. Journal

of Mixed Methods Research, 7(4), 347-369. doi: 10.1177/1558689813482756

Boswell, J. F., Kraus, D. R., Miller, S. D., & Lambert, M. J. (2015). Implementing routine

outcome monitoring in clinical practice: Benefits, challenges, and

solutions. Psychotherapy Research, 25(1), 6-19. doi: 10.1080/10503307.2013.817696

Bowers, M. E., & Yehuda, R. (2016). Intergenerational transmission of stress in

humans. Neuropsychopharmacology, 41(1), 232. doi: 10.1038/npp.2015.247

Braun, V., & Clarke, V. (2016). (Mis) conceptualising themes, thematic analysis, and other

problems with Fugard and Potts’ (2015) sample-size tool for thematic

analysis. International Journal of Social Research Methodology, 19(6), 739-743. doi:

10.1080/13645579.2016.1195588

Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative

Research in Sport, Exercise and Health, 11(4), 589-597. doi:

10.1080/2159676X.2019.1628806

PARENTING GROUP OUTCOMES AND ACES 131

Braun, V., Clarke, V., Hayfield, N., & Terry, G. (2019). Thematic analysis. In Liamputtong,

P. (Ed.), Handbook of research methods in health social sciences, 843-860.

Singapore, Springer.

Brazelton, T. B., Koslowski, B., & Main, M. (1974). The origins of reciprocity: The early

mother-infant interaction. Retrieved from https://psycnet.apa.org/record/1974-22730-

007

Brown, A., Ford, T., Deighton, J., & Wolpert, M. (2014). Satisfaction in child and adolescent

mental health services: Translating users’ feedback into measurement. Administration

and Policy in Mental Health and Mental Health Services Research, 41(4), 434-446.

doi: 10.1007/s10488-012-0433-9

Brown, S. M., & Shillington, A. M. (2017). Childhood adversity and the risk of substance use

and delinquency: The role of protective adult relationships. Child Abuse &

Neglect, 63, 211-221. doi: 10.1016/j.chiabu.2016.11.006

Browne, C. H. (2014). National Quality Improvement Center on Early Childhood. Zero to

Three, 35(1), 2-9. Retrieved from https://eric.ed.gov/?id=EJ1125256

Bryman, A. (2006). Integrating quantitative and qualitative research: how is it

done? Qualitative Research, 6(1), 97-113. doi: 10.1177/1468794106058877

Buchanan-Pascall, S., Gray, K. M., Gordon, M., & Melvin, G. A. (2018). Systematic review

and meta-analysis of parent group interventions for primary school children aged 4–

12 years with externalizing and/or internalizing problems. Child Psychiatry & Human

Development, 49(2), 244-267. doi: 10.1007/s10578-017-0745-9

Cabral, J. (2013). The value of evaluating parenting groups: a new researcher’s perspective

on methods and results. Community Practitioner, 86(6), 30-33. Retrieved from:

https://pdfs.semanticscholar.org/5060/b5fa87cc2717f92e7f38b887e92f65c7323b.pdf

PARENTING GROUP OUTCOMES AND ACES 132

Calkins, S. D., Dollar, J. M., & Wideman, L. (2019). Temperamental vulnerability to emotion

dysregulation and risk for mental and physical health challenges. Development and

Psychopathology, 1-14. doi: 10.1017/S0954579419000415

Carta, J., Greenwood, C., Baggett, K., Buzhardt, J., & Walker, D. (2012). Research-based

approaches for individualizing caregiving and educational interventions for infants

and toddlers in poverty. Infants, Toddlers and Families in Poverty, 333-349.

Retrieved from https://psycnet.apa.org/record/2012-25305-014

Center on the Developing Child (2016). Building core capabilities for life: The science

behind the skills adults need to succeed in parenting and in the workplace.

https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-

content/uploads/2016/03/Building-Core-Capabilities-for-Life.pdf

Choe, D. E., Olson, S. L., & Sameroff, A. J. (2013). The interplay of externalizing problems

and physical and inductive discipline during childhood. Developmental

Psychology, 49(11), 2029. doi: 10.1037/a0032054

Cicchetti, D., & Banny, A. (2014). A developmental psychopathology perspective on child

maltreatment. In Lewis M., Rudolph K. (Eds.) Handbook of developmental

psychopathology (pp. 723-741). Springer, Boston, MA.

Clarke, V., & Braun, V. (2018). Using thematic analysis in counselling and psychotherapy

research: A critical reflection. Counselling and Psychotherapy Research, 18(2), 107-

110. doi: 10.1002/capr.12165

Clarke, V., Braun, V., & Hayfield, N. (2015). Thematic analysis. In Smith, J. (Ed.),

Qualitative psychology: A practical guide to research methods, 222-248. Sage.

PARENTING GROUP OUTCOMES AND ACES 133

Clarkson Freeman, P. A. (2014). Prevalence and relationship between adverse childhood

experiences and child behavior among young children. Infant Mental Health

Journal, 35(6), 544-554. doi: 10.1002/imhj.21460

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale,

NJ: Erlbaum.

Cohen, S., & Janicki‐Deverts, D. E. N. I. S. E. (2012). Who's stressed? Distributions of

psychological stress in the United States in probability samples from 1983, 2006, and

2009 1. Journal of Applied Social Psychology, 42(6), 1320-1334. doi: 10.1111/j.1559-

1816.2012.00900.x

Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived

stress. Journal of Health and Social Behavior, 385-396. doi: 10.2307/2136404

Combs-Ronto, L. A., Olson, S. L., Lunkenheimer, E. S., & Sameroff, A. J. (2009).

Interactions between maternal parenting and children’s early disruptive behavior:

Bidirectional associations across the transition from preschool to school

entry. Journal of Abnormal Child Psychology, 37(8), 1151. doi: 10.1007/s10802-

009-9332-2

Coolican, H. (2017). Research methods and statistics in psychology. Psychology Press.

Coyne, J. (2013). Parenting from the outside-in: Reflections on parent training during a

potential paradigm shift. Australian Psychologist, 48(5), 379-387. doi:

10.1111/ap.12010

Crouch, E., Radcliff, E., Strompolis, M., Srivastav, A. (2019). Safe, stable, and nurtured:

Protective factors against poor physical and mental health outcomes following

exposure to adverse childhood experiences (ACEs). Journal of Child & Adolescent

Trauma 12, 165–173 (2019). doi: 10.1007/s40653-018-0217-9

PARENTING GROUP OUTCOMES AND ACES 134

Crowell, S. E., Puzia, M. E., & Yaptangco, M. (2015). The ontogeny of chronic distress:

Emotion dysregulation across the life span and its implications for psychological and

physical health. Current Opinion in Psychology, 3, 91-99. doi:

10.1016/j.copsyc.2015.03.023

Danese, A. (2020). Annual Research Review: Rethinking childhood trauma‐new research

directions for measurement, study design and analytical strategies. Journal of Child

Psychology and Psychiatry, 61(3), 236-250. doi: 10.1111/jcpp.13160

Darling, N. (1999). Parenting style and its correlates. ERIC Digest. Retrieved from

https://eric.ed.gov/?id=ED427896

Daws, D. (1993). Feeding problems and relationship difficulties: therapeutic work with

parents and infants. Journal of Child Psychotherapy, 19(2), 69-83. doi:

10.1080/00754179308259389

DeGregorio, L. J. (2013). Intergenerational transmission of abuse: Implications for parenting

interventions from a neuropsychological perspective. Traumatology, 19(2), 158-166.

doi: 10.1177/1534765612457219

Des Jarlais, D. C., Lyles, C., Crepaz, N., & Trend Group. (2004). Improving the reporting

quality of nonrandomized evaluations of behavioral and public health interventions:

the TREND statement. American Journal of Public Health, 94(3), 361-366. doi:

10.2105/ajph.94.3.361

Dewa, C. S., Butterill, D., Durbin, J., & Goering, P. (2004). No matter how you land:

Challenges of a longitudinal multi-site evaluation. The Canadian Journal of Program

Evaluation, 19(3), 1-28. Retrieved from:

https://search.proquest.com/openview/b78f3381f3bf542c835d0c87cce43d76/1?pq-

origsite=gscholar&cbl=44049

PARENTING GROUP OUTCOMES AND ACES 135

Dixon, L., Hamilton‐Giachritsis, C., & Browne, K. (2005). Attributions and behaviours of

parents abused as children: A mediational analysis of the intergenerational continuity

of child maltreatment (Part II). Journal of Child Psychology and Psychiatry, 46(1),

58-68. doi: 10.1111/j.1469-7610.2004.00340.x

Dolan, A. (2014). ‘I’ve learnt what a dad should do’: the interaction of masculine and

fathering identities among men who attended a ‘dads only’ parenting

programme. Sociology, 48(4), 812-828. doi: 10.1177/0038038513511872

Douglas, H., & Ginty, M. (2001). The Solihull Approach: changes in health visiting

practice. Community Practitioner, 74(6), 222-224. Retrieved from

http://s571809705.websitehome.co.uk/Images2/changes-in-health-visiting-

practice.pdf

Douglas, H. and Johnson, R. (2019). The Solihull Approach 10-week programme: a

randomised controlled trial. Community Practitioner, 9(7), 45-47. Retrieved from

https://www.communitypractitioner.co.uk/resources/2019/09/randomised-controlled-

trial-solihull-approach-ten-week-group-parents-

Dretzke, J., Davenport, C., Frew, E., Barlow, J., Stewart-Brown, S., Bayliss, S., ... & Hyde,

C. (2009). The clinical effectiveness of different parenting programmes for children

with conduct problems: a systematic review of randomised controlled trials. Child and

Adolescent Psychiatry and Mental Health, 3(1), 7. doi: 10.1186/1753-2000-3-7

Duncan, K. M., MacGillivray, S., & Renfrew, M. J. (2017). Costs and savings of parenting

interventions: results of a systematic review. Child: Care, Health and

Development, 43(6), 797-811. doi: 10.1111/cch.12473

PARENTING GROUP OUTCOMES AND ACES 136

Dutton, D. G., Denny-Keys, M. K., & Sells, J. R. (2011). Parental personality disorder and its

effects on children: A review of current literature. Journal of Child Custody, 8(4),

268-283. doi: 10.1080/15379418.2011.620928

Dvir, Y., Ford, J. D., Hill, M., & Frazier, J. A. (2014). Childhood maltreatment, emotional

dysregulation, and psychiatric comorbidities. Harvard Review of Psychiatry, 22(3),

149-161. doi: 10.1097/HRP.0000000000000014

Elliott, R., Fischer, C. T., & Rennie, D. L. (1999). Evolving guidelines for publication of

qualitative research studies in psychology and related fields. British Journal of

Clinical Psychology, 38(3), 215-229. doi: 10.1348/014466599162782

Ellis, W. R., & Dietz, W. H. (2017). A new framework for addressing adverse childhood and

community experiences: The building community resilience model. Academic

Pediatrics, 17(7), S86-S93. doi: 10.1016/j.acap.2016.12.011

Emerson, E., & Einfield, S. (2010). Emotional and behavioural difficulties in young children

with and without developmental delay: A bi-national perspective. Journal of Child

Psychology and Psychiatry, 51, 583–593. doi:10.1111/j.1469-7610.2009.02179.x

Evans, G. W., & Kim, P. (2013). Childhood poverty, chronic stress, self‐regulation, and

coping. Child Development Perspectives, 7(1), 43-48. doi: 10.1111/cdep.12013

Evans, G. W., Li, D., & Whipple, S. S. (2013). Cumulative risk and child

development. Psychological Bulletin, 139(6), 1342. doi: 10.1037/a0031808

Fairchild, G., Hawes, D. J., Frick, P. J., Copeland, W. E., Odgers, C. L., Franke, B., ... & De

Brito, S. A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 1-25.

doi: 10.1038/s41572-019-0095-y

PARENTING GROUP OUTCOMES AND ACES 137

Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A. (2012). The economic burden of

child maltreatment in the United States and implications for prevention. Child Abuse

& Neglect, 36(2), 156-165. doi: 10.1016/j.chiabu.2011.10.006

Farrington, D. P. (2007). Childhood risk factors and risk-focused prevention. In M. Maguire,

R. Morgan, & R. Reinder (Eds.), The Oxford handbook of criminology (4th ed., pp.

602-641). Oxford University Press.

Fassinger, R. E. (2005). Paradigms, praxis, problems, and promise: Grounded theory in

counseling psychology research. Journal of Counseling Psychology, 52(2), 156. doi:

10.1037/0022-0167.52.2.156

Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G* Power 3: A flexible statistical

power analysis program for the social, behavioral, and biomedical sciences. Behavior

Research Methods, 39(2), 175-191. doi: 10.3758/BF03193146

Feise, R. J. (2002). Do multiple outcome measures require p-value adjustment? BMC Medical

Research Methodology, 2(1), 8. doi: 10.1186/1471-2288-2-8

Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., ... &

Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to

many of the leading causes of death in adults. American Journal of Preventive

Medicine, 14(4). doi: 10.1016/S0749-3797(98)00017-8

Felitti, V. J., & Anda, R. F., (2014). The lifelong effects of adverse childhood experiences. In

D. L. Chadwick (Ed.), Child maltreatment: Sexual abuse and psychological

maltreatment, volume 2 (4th ed., pp. 203 – 216). STM Learning.

Fergusson, D., Doucette, S., Glass, K. C., Shapiro, S., Healy, D., Hebert, P., & Hutton, B.

(2005). Association between suicide attempts and selective serotonin reuptake

PARENTING GROUP OUTCOMES AND ACES 138

inhibitors: systematic review of randomised controlled trials. British Medical

Journal, 330(7488), 396. doi: 10.1136/bmj.330.7488.396

Field, A. P. (2009). Discovering statistics using SPSS (and sex and drugs and rock 'n' roll).

(6th ed.) Los Angeles, Thousand Oaks, California: Sage Publications.

Finkelhor, D. (2018). Screening for adverse childhood experiences (ACEs): cautions and

suggestions. Child Abuse & Neglect, 85, 174-179. doi: 10.1016/j.chiabu.2017.07.016

Ford, K., Hughes, K., Hardcastle, K., Di Lemma, L. C., Davies, A. R., Edwards, S., & Bellis,

M. A. (2019). The evidence base for routine enquiry into adverse childhood

experiences: A scoping review. Child Abuse & Neglect, 91, 131-146. doi:

10.1016/j.chiabu.2019.03.007

Fox, B. H., Perez, N., Cass, E., Baglivio, M. T., & Epps, N. (2015). Trauma changes

everything: Examining the relationship between adverse childhood experiences and

serious, violent and chronic juvenile offenders. Child Abuse & Neglect, 46, 163-173.

doi: 10.1016/j.chiabu.2015.01.011

Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic

approach to the problems of impaired infant-mother relationships. Journal of the

American Academy of Child Psychiatry, 14(3), 387-421. doi: 10.1016/S0002-

7138(09)61442-4

Frankenhuis, W. E., & Del Giudice, M. (2012). When do adaptive developmental

mechanisms yield maladaptive outcomes? Developmental Psychology, 48(3), 628.

doi: 10.1037/a0025629

Fuchs, A., Möhler, E., Resch, F., & Kaess, M. (2015). Impact of a maternal history of

childhood abuse on the development of mother–infant interaction during the first year

of life. Child Abuse & Neglect, 48, 179-189. doi: 10.1016/j.chiabu.2015.05.023

PARENTING GROUP OUTCOMES AND ACES 139

Furlong, M., & McGilloway, S. (2015). Barriers and facilitators to implementing evidence-

based parenting programs in disadvantaged settings: A qualitative study. Journal of

Child and Family Studies, 24(6), 1809-1818. doi: 10.1007/s10826-014-9984-6

Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Donnelly, M., Smith, S. M., &

O'Neill, C. (2010). Behavioural/cognitive-behavioural group-based parenting

interventions for children age 3-12 with early onset conduct problems. The Cochrane

Library, 1, 1-14. doi: 10.1002/14651858.CD008225

Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S. M., & Donnelly, M.

(2013). Cochrane review: behavioural and cognitive‐behavioural group‐based

parenting programmes for early‐onset conduct problems in children aged 3 to 12

years. Evidence‐Based Child Health: A Cochrane Review Journal, 8(2), 318-692.

Gardner, F., & Leijten, P. (2017). Incredible Years parenting interventions: Current

effectiveness research and future directions. Current Opinion in Psychology, 15, 99-

104. doi: 10.1016/j.copsyc.2017.02.023

Gardner, F., Leijten, P., Melendez‐Torres, G. J., Landau, S., Harris, V., Mann, J., ... & Scott,

S. (2019). The earlier the better? Individual participant data and traditional meta‐

analysis of age effects of parenting interventions. Child Development, 90(1), 7-19.

doi: 10.1111/cdev.13138

Gardner, F., Montgomery, P., & Knerr, W. (2016). Transporting evidence-based parenting

programs for child problem behavior (age 3–10) between countries: Systematic

review and meta-analysis. Journal of Clinical Child & Adolescent Psychology, 45(6),

749-762. doi: 10.1080/15374416.2015.1015134

Gerhardt, S. (2014). Why love matters: How affection shapes a baby's brain. Routledge.

PARENTING GROUP OUTCOMES AND ACES 140

Guest, G., Bunce, A., & Johnson, L. (2006). How many interviews are enough? An

experiment with data saturation and variability. Field Methods, 18(1), 59-82. doi:

10.1177/1525822X05279903

Gilmour, K. A. (2018). A Systematic Review of Caregiver Interventions in Infancy to Enable

Responsive Caregiving and Secure Attachment in Low and Middle-Income

Countries (Doctoral dissertation, University of Cape Town). Retrieved from:

https://open.uct.ac.za/bitstream/handle/11427/29875/thesis_hsf_2018_gilmour_kirsty

_a.pdf?sequence=1&isAllowed=y

Glover, V. (2014). Maternal depression, anxiety and stress during pregnancy and child

outcome; what needs to be done. Best Practice & Research Clinical Obstetrics &

Gynaecology, 28(1), 25-35. doi: 10.1016/j.bpobgyn.2013.08.017

Goodman, R. (1997). The Strengths and Difficulties Questionnaire: a research note. Journal

of Child Psychology and Psychiatry, 38(5), 581-586. doi: 10.1111/j.1469-

7610.1997.tb01545.x

Goodman, A., & Goodman, R. (2011). Population mean scores predict child mental disorder

rates: validating SDQ prevalence estimators in Britain. Journal of Child Psychology

and Psychiatry, 52(1), 100-108. doi: 10.1111/j.1469-7610.2010.02278.x

Grasso, D. J., Dierkhising, C. B., Branson, C. E., Ford, J. D., & Lee, R. (2016).

Developmental patterns of adverse childhood experiences and current symptoms and

impairment in youth referred for trauma-specific services. Journal of Abnormal Child

Psychology, 44(5), 871-886. doi: 10.1007/s10802-015-0086-8

Growing Up in Ireland Study Team (2018). Key Finding No. 4, Cohort ’08 at Nine Years:

Relationships & Socio-Emotional Well-Being. Dublin: ESRI/DCYA. Retrieved

PARENTING GROUP OUTCOMES AND ACES 141

from https://www.growingup.ie/pubs/Growing-Up-in-Ireland-Relationships-and-

Socio-emotional-Well-being.pdf

Gustafsson, H. C., Coffman, J. L., & Cox, M. J. (2015). Intimate partner violence, maternal

sensitive parenting behaviors, and children’s executive functioning. Psychology of

Violence, 5(3), 266. doi: 10.1037/a0037971

Haase T, Pratschke J (2017) The 2016 Pobal HP Deprivation Index for small areas (SA).

Retrieved

from: https://www.pobal.ie/Publications/Documents/The%202016%20Pobal%20HP

%20Deprivation%20Index%20-%20Introduction%2007.pdf

Hahn, S. (2012). Understanding noninferiority trials. Korean Journal of Pediatrics, 55(11),

403. doi: 10.3345/kjp.2012.55.11.403

Halle, T., Anderson, R., Blasberg, A., Chrisler, A., & Simkin, S. (2011). Quality of

caregiver–child interactions for infants and toddlers (QCCIIT): A review of the

literature (OPRE 2011-25). Washington, DC: U.S. Department of Health and Human

Services, Administration for Children and Families, Office of Planning, Research and

Evaluation.

Hambrick, E. P., Brawner, T. W., Perry, B. D., Brandt, K., Hofmeister, C., & Collins, J. O.

(2019). Beyond the ACE score: Examining relationships between timing of

developmental adversity, relational health and developmental outcomes in

children. Archives of Psychiatric Nursing, 33(3), 238-247. doi:

10.1016/j.apnu.2018.11.001

Hamilton, V. E., Matthews, J. M., & Crawford, S. B. (2015). Development and preliminary

validation of a parenting self-regulation scale: “Me as a parent”. Journal of Child and

Family Studies, 24(10), 2853-2864. doi: 10.1007/s10826-014-0089-z

PARENTING GROUP OUTCOMES AND ACES 142

Hanf, C. (1969). A two stage program for modifying maternal controlling during mother-

child (MC) interaction. In Paper presented at the Western Psychological Association

Meeting, Vancouver, BC, 1969.

Havighurst, S. S., Kehoe, C. E., & Harley, A. E. (2015). Tuning in to teens: Improving

parental responses to anger and reducing youth externalizing behavior

problems. Journal of Adolescence, 42, 148-158. doi:

10.1016/j.adolescence.2015.04.005

Heim, C., Plotsky, P. M., & Nemeroff, C. B. (2004). Importance of studying the contributions

of early adverse experience to neurobiological findings in

depression. Neuropsychopharmacology, 29(4), 641. doi: 10.1038/sj.npp.1300397

Hennink, M., Hutter, I., & Bailey, A. (2020). Qualitative research methods. SAGE

Publications Limited.

Herman, K. C., Borden, L. A., Reinke, W. M., & Webster-Stratton, C. (2011). The impact of

the Incredible Years parent, child, and teacher training programs on children's co-

occurring internalizing symptoms. School Psychology Quarterly, 26(3), 189. doi:

10.1037/a0025228

Hess, C. R., Teti, D. M., & Hussey-Gardner, B. (2004). Self-efficacy and parenting of high-

risk infants: The moderating role of parent knowledge of infant development. Journal

of Applied Developmental Psychology, 25(4), 423-437. doi:

10.1016/j.appdev.2004.06.002

Hipwell, A. E., Tung, I., Northrup, J., & Keenan, K. (2019). Transgenerational associations

between maternal childhood stress exposure and profiles of infant emotional

reactivity. Development and Psychopathology, 1-12. doi:

10.1017/S0954579419000324

PARENTING GROUP OUTCOMES AND ACES 143

Högström, J., Olofsson, V., Özdemir, M., Enebrink, P., & Stattin, H. (2017). Two-year

findings from a national effectiveness trial: Effectiveness of behavioral and non-

behavioral parenting programs. Journal of Abnormal Child Psychology, 45(3), 527-

542. doi: 10.1007/s10802-016-0178-0

Howitt, D., & Cramer, D. (2017). Introduction to Statistics in Psychology (5th ed.). Harlow:

Pearson Education.

Hughes, D. (2017). Dyadic Developmental Psychotherapy (DDP): An attachment-focused

family treatment for developmental trauma. Australian and New Zealand Journal of

Family Therapy, 38(4), 595-605. doi: 10.1002/anzf.1273

Hughes, M., & Cossar, J. (2016). The relationship between maternal childhood emotional

abuse/neglect and parenting outcomes: A systematic review. Child Abuse

Review, 25(1), 31-45. doi: 10.1002/car.2393

Hughes K, Ford K, Davies A, Homolova L, Bellis M. (2018). Sources of resilience and their

moderating relationships with harms from adverse childhood experiences (Report 1).

Retrieved from the Public Health Wales NHS Trust website:

http://www.wales.nhs.uk/sitesplus/documents/888/ACE%20&%20Resilience%20

Report%20(Eng_final2).pdf

Hunsley, J. (2007). Addressing key challenges in evidence-based practice in psychology.

Professional Psychology: Research and Practice, 38(2), 113 – 121. doi:

10.1037/0735-7028.38.2.113

Hunter, B. (2013). Implementing research evidence into practice: some reflections on the

challenges. Evidence Based Midwifery, 11(3), 76-80. Retrieved from

http://orca.cf.ac.uk/59062/

PARENTING GROUP OUTCOMES AND ACES 144

Huntington, C., & Vetere, A. (2016). Coparents and parenting programmes: do both parents

need to attend? Journal of Family Therapy, 38(3), 409-434. doi: 10.1111/1467-

6427.12092

Hurlburt, M. S., Nguyen, K., Reid, J., Webster-Stratton, C., & Zhang, J. (2013). Efficacy of

the Incredible Years group parent program with families in Head Start who self-

reported a history of child maltreatment. Child Abuse & Neglect, 37(8), 531-543. doi:

10.1016/j.chiabu.2012.10.008

Ingram, R., & Luxton, D. (2005). Vulnerability-stress models. In B. L. Hankin & J. R. Z.

Abela (Eds.), Development of psychopathology: A vulnerability-stress perspective

(pp. 32–46). Thousand Oaks, CA: Sage Publications, Inc.

Johnson, R. (2018). Improvements in parenting achieved with innovative online programme:

Preliminary evaluation of ‘Understanding Your Child—Online’(UYC-OL): A

Solihull Approach course for parents and carers. Educational and Child Psychology,

35(1), 40-50. Retrieved from: https://psycnet.apa.org/record/2018-25158-003

Johnson, J. G., Cohen, P., Kasen, S., & Brook, J. S. (2006). Maternal psychiatric disorders,

parenting, and maternal behavior in the home during the child rearing years. Journal

of Child and Family Studies, 15(1), 96-113. doi: 10.1007/s10826-005-9003-z

Johnson, R., & Wilson, H. (2012). Parents' evaluation of 'understanding your child's

behaviour', a parenting group based on the Solihull Approach. Community

Practitioner, 85(5), 29-34. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/22792842

Jones, D. E., Greenberg, M., & Crowley, M. (2015). Early social-emotional functioning and

public health: The relationship between kindergarten social competence and future

PARENTING GROUP OUTCOMES AND ACES 145

wellness. American Journal of Public Health, 105(11), 2283-2290. doi:

10.2105/AJPH.2015.302630

Kaehler, L. A., Jacobs, M., & Jones, D. J. (2016). Distilling common history and practice

elements to inform dissemination: Hanf-model BPT programs as an example. Clinical

Child and Family Psychology Review, 19(3), 236-258. doi: 10.1007/s10567-016-

0210-5

Karjalainen, P., Kiviruusu, O., Aronen, E. T., & Santalahti, P. (2019). Group-based parenting

program to improve parenting and children's behavioral problems in families using

special services: A randomized controlled trial in a real-life setting. Children and

Youth Services Review, 96, 420-429. doi: 10.1016/j.childyouth.2018.12.004

Karoly, P. (1993). Mechanisms of self-regulation: A systems view. Annual Review of

Psychology, 44(1), 23-52. doi:10.1146/annurev.ps.44.020193.000323

Kawabata, Y., Alink, L. R., Tseng, W. L., Van Ijzendoorn, M. H., & Crick, N. R. (2011).

Maternal and paternal parenting styles associated with relational aggression in

children and adolescents: A conceptual analysis and meta-analytic

review. Developmental Review, 31(4), 240-278. doi: 10.1016/j.dr.2011.08.001

Kelly, F. (2019). Identifying early indicators of Emotional and Behavioural Difficulties in

Irish children and testing the feasibility of an online parenting intervention for

improving child mental health (Doctoral dissertation, Department of Pharmacology

and Therapeutics, School of Medicine, Trinity College Dublin). Retrieved from

http://www.tara.tcd.ie/bitstream/handle/2262/86150/Final%20Thesis%20April%2020

19-signed.pdf?sequence=1

PARENTING GROUP OUTCOMES AND ACES 146

Kelly-Irving, M., & Delpierre, C. (2019). A critique of the adverse childhood experiences

framework in epidemiology and public health: uses and misuses. Social Policy and

Society, 18(3), 445-456. doi: 10.1017/S1474746419000101

Kiesner, J., Poulin, F., & Dishion, T. J. (2010). Adolescent substance use with friends:

Moderating and mediating effects of parental monitoring and peer activity

contexts. Merrill-Palmer Quarterly (Wayne State University. Press), 56(4), 529. doi:

10.1353/mpq.2010.0002

Kim, H. Y. (2017). Statistical notes for clinical researchers: chi-squared test and Fisher's

exact test. Restorative Dentistry & Endodontics, 42(2), 152-155. doi:

10.5395/rde.2017.42.2.152

Kim, J., & Cicchetti, D. (2010). Longitudinal pathways linking child maltreatment, emotion

regulation, peer relations, and psychopathology. Journal of Child Psychology and

Psychiatry, 51(6), 706-716. doi: 10.1111/j.1469-7610.2009.02202.x

Kim, P., Evans, G. W., Angstadt, M., Ho, S. S., Sripada, C. S., Swain, J. E., ... & Phan, K. L.

(2013). Effects of childhood poverty and chronic stress on emotion regulatory brain

function in adulthood. Proceedings of the National Academy of Sciences, 110(46),

18442-18447. doi: 10.1073/pnas.1308240110

Kochanska, G., Forman, D. R., Aksan, N., & Dunbar, S. B. (2005). Pathways to conscience:

Early mother–child mutually responsive orientation and children's moral emotion,

conduct, and cognition. Journal of Child Psychology and Psychiatry, 46(1), 19-34.

doi: 10.1111/j.1469-7610.2004.00348.x

Knerr, W., Gardner, F., & Cluver, L. (2013). Improving positive parenting skills and reducing

harsh and abusive parenting in low-and middle-income countries: A systematic

review. Prevention Science, 14(4), 352-363. doi: 10.1007/s11121-012-0314-1

PARENTING GROUP OUTCOMES AND ACES 147

Knutson, J. F., DeGarmo, D., Koeppl, G., & Reid, J. B. (2005). Care neglect, supervisory

neglect, and harsh parenting in the development of children’s aggression: A

replication and extension. Child Maltreatment, 10(2), 92-107. doi:

10.1177/1077559504273684

Lacey, R. E., & Minnis, H. (2019). Practitioner Review: Twenty years of research with

adverse childhood experience scores–Advantages, disadvantages and applications to

practice. Journal of Child Psychology and Psychiatry, 61(2), 116-130. doi:

10.1111/jcpp.13135

Lange, B. C., Callinan, L. S., & Smith, M. V. (2019). Adverse childhood experiences and

their relation to parenting stress and parenting practices. Community Mental Health

Journal, 55(4), 651-662. doi: 10.1007/s10597-018-0331-z

Lange, B. C., Condon, E. M., & Gardner, F. (2020). Parenting among mothers who

experienced child sexual abuse: A qualitative systematic review. Qualitative Health

Research, 30(1), 146-161. doi: 10.1177/1049732319882914

Larkin, H., Felitti, V. J., & Anda, R. F. (2014). Social work and adverse childhood

experiences research: Implications for practice and health policy. Social Work in

Public Health, 29(1), 1-16. doi: 10.1080/19371918.2011.619433

Larkin, H., & Park, J. (2012). Adverse childhood experiences (ACEs), service use, and

service helpfulness among people experiencing homelessness. Families in

Society, 93(2), 85-93. doi: 10.1606/1044-3894.4192

Lee, E. H. (2012). Review of the psychometric evidence of the perceived stress scale. Asian

Nursing Research, 6(4), 121-127. doi: 10.1016/j.anr.2012.08.004

PARENTING GROUP OUTCOMES AND ACES 148

Lee, K. J., & Carlin, J. B. (2010). Multiple imputation for missing data: fully conditional

specification versus multivariate normal imputation. American Journal of

Epidemiology, 171(5), 624-632. doi: 10.1093/aje/kwp425

Leen-Feldner, E. W., Feldner, M. T., Knapp, A., Bunaciu, L., Blumenthal, H., & Amstadter,

A. B. (2013). Offspring psychological and biological correlates of parental

posttraumatic stress: review of the literature and research agenda. Clinical Psychology

Review, 33(8), 1106-1133. doi: 10.1016/j.cpr.2013.09.001

Leijten, P., Melendez-Torres, G. J., Knerr, W., & Gardner, F. (2016). Transported versus

homegrown parenting interventions for reducing disruptive child behavior: A

multilevel meta-regression study. Journal of the American Academy of Child &

Adolescent Psychiatry, 55(7), 610-617. doi: 10.1016/j.jaac.2016.05.003

Leijten, P., Melendez‐Torres, G. J., Gardner, F., Van Aar, J., Schulz, S., & Overbeek, G.

(2018). Are relationship enhancement and behavior Management “The golden

couple” for disruptive child behavior? Two Meta-analyses. Child Development, 89(6),

1970-1982. doi: 10.1111/cdev.13051

Leijten, P., Raaijmakers, M. A., de Castro, B. O., & Matthys, W. (2013). Does

socioeconomic status matter? A meta-analysis on parent training effectiveness for

disruptive child behavior. Journal of Clinical Child & Adolescent Psychology, 42(3),

384-392. doi: 10.1080/15374416.2013.769169

Leslie, L. A., & Cook, E. T. (2015). Maternal trauma and adolescent depression: Is parenting

style a moderator? Unpublished article. Retrieved from

http://hdl.handle.net/1903/19662

Leslie, L. K., Mehus, C. J., Hawkins, J. D., Boat, T., McCabe, M. A., Barkin, S., ... & Brown,

R. (2016). Primary health care: potential home for family-focused preventive

PARENTING GROUP OUTCOMES AND ACES 149

interventions. American Journal of Preventive Medicine, 51(4), S106-S118. doi:

10.1016/j.amepre.2016.05.014

Levenson, J. S., Willis, G. M., & Prescott, D. S. (2016). Adverse childhood experiences in

the lives of male sex offenders: Implications for trauma-informed care. Sexual

Abuse, 28(4), 340-359. doi: 10.1177/1079063214535819

Levey, E. J., Gelaye, B., Bain, P., Rondon, M. B., Borba, C. P., Henderson, D. C., &

Williams, M. A. (2017). A systematic review of randomized controlled trials of

interventions designed to decrease child abuse in high-risk families. Child Abuse &

Neglect, 65, 48-57. doi: 10.1016/j.chiabu.2017.01.004

Liang, B., Goodman, L., Tummala-Narra, P., & Weintraub, S. (2005). A theoretical

framework for understanding help‐seeking processes among survivors of intimate

partner violence. American Journal of Community Psychology, 36(1-2), 71-84. doi:

10.1007/s10464-005-6233-6

Lin, B., Kaliush, P. R., Conradt, E., Terrell, S., Neff, D., Allen, A. K., ... & Crowell, S. E.

(2019). Intergenerational transmission of emotion dysregulation: Part I.

Psychopathology, self-injury, and parasympathetic responsivity among pregnant

women. Development and Psychopathology, 31(3), 817-831.

doi: 10.1017/S0954579419000336

Lindsay, G. (2019). Parenting programmes for parents of children and young people with

behavioural difficulties. Counselling and Psychotherapy Research, 19(1), 3-7. doi:

10.1002/capr.12192

Lindsay, G., & Totsika, V. (2017). The effectiveness of universal parenting programmes: the

CANparent trial. BMC Psychology, 5(1), 35. doi: 10.1186/s40359-017-0204-1

PARENTING GROUP OUTCOMES AND ACES 150

Little, R. J. (1988). A test of missing completely at random for multivariate data with missing

values. Journal of the American Statistical Association, 83(404), 1198-1202. doi:

10.2307/2290157

Madigan, S., Paton, K., & Mackett, N. (2017). The Springfield Project service: evaluation of

a Solihull Approach course for foster carers. Adoption & Fostering, 41(3), 254-267.

doi: 10.1177/0308575917719373

Massey, O. T. (2011). A proposed model for the analysis and interpretation of focus groups

in evaluation research. Evaluation and Program Planning, 34(1), 21-28. doi:

10.1016/j.evalprogplan.2010.06.003

McDonald, M. K., Borntrager, C. F., & Rostad, W. (2014). Measuring trauma:

Considerations for assessing complex and non-PTSD criterion a childhood

trauma. Journal of Trauma & Dissociation, 15(2), 184-203. doi:

10.1080/15299732.2014.867577

McEwen, C. A., & Gregerson, S. F. (2019). A critical assessment of the adverse childhood

experiences study at 20 years. American Journal of Preventive Medicine, 56(6), 790-

794. doi: 10.1016/j.amepre.2018.10.016

McEwen, C. A., & McEwen, B. S. (2017). Social structure, adversity, toxic stress, and

intergenerational poverty: An early childhood model. Annual Review of Sociology, 43,

445-472. doi: 10.1146/annurev-soc-060116-053252

McGilloway, S., Mhaille, G. N., Bywater, T., Furlong, M., Leckey, Y., Kelly, P., ... &

Donnelly, M. (2012). A parenting intervention for childhood behavioral problems: a

randomized controlled trial in disadvantaged community-based settings. Journal of

Consulting and Clinical Psychology, 80(1), 116. doi: 10.1037/a0026304

PARENTING GROUP OUTCOMES AND ACES 151

McGroder, S. M., & Hyra, A. (2009). Developmental and economic effects of parenting

programs for expectant parents and parents of preschool-age children. The

Partnership for America’s Economic Success, 9, 1-20. Retrieved from

https://rhyclearinghouse.acf.hhs.gov/sites/default/files/docs/18064-

Developmental_and_Economic_Effects_of_Parenting_Programs.pdf

McLaughlin, K. A., & Sheridan, M. A. (2016). Beyond cumulative risk: A dimensional

approach to childhood adversity. Current Directions in Psychological Science, 25(4),

239-245. doi: 10.1177/0963721416655883

Merrick, M. T., Ports, K. A., Ford, D. C., Afifi, T. O., Gershoff, E. T., & Grogan-Kaylor, A.

(2017). Unpacking the impact of adverse childhood experiences on adult mental

health. Child Abuse & Neglect, 69, 10-19. doi: 10.1016/j.chiabu.2017.03.016

Mersky, J. P., Janczewski, C. E., & Topitzes, J. (2017). Rethinking the measurement of

adversity: Moving toward second-generation research on adverse childhood

experiences. Child Maltreatment, 22(1), 58-68. doi: 10.1177/1077559516679513

Mingebach, T., Kamp-Becker, I., Christiansen, H., & Weber, L. (2018). Meta-meta-analysis

on the effectiveness of parent-based interventions for the treatment of child

externalizing behavior problems. PloS One, 13(9), e0202855. doi:

10.1371/journal.pone.0202855

Mintz, G., Etengoff, C., & Grysman, A. (2017). The relation between childhood parenting

and emerging adults’ experiences of shame and guilt. Journal of Child and Family

Studies, 26(10), 2908-2920. doi: 10.1007/s10826-017-0778-5

Moilanen, K. L., Rasmussen, K. E., & Padilla‐Walker, L. M. (2015). Bidirectional

associations between self‐regulation and parenting styles in early

PARENTING GROUP OUTCOMES AND ACES 152

adolescence. Journal of Research on Adolescence, 25(2), 246-262. doi:

10.1111/jora.12125

Moog, N. K., Entringer, S., Rasmussen, J. M., Styner, M., Gilmore, J. H., Kathmann, N., ... &

Buss, C. (2018). Intergenerational effect of maternal exposure to childhood

maltreatment on newborn brain anatomy. Biological Psychiatry, 83(2), 120-127. doi:

10.1016/j.biopsych.2017.07.009

Moon, D. J., Damman, J. L., & Romero, A. (2018). The effects of primary care–based

parenting interventions on parenting and child behavioral outcomes: a systematic

Review. Trauma, Violence, & Abuse, 1524838018774424. doi:

10.1177/1524838018774424

Moran, G., Pederson, D. R., & Krupka, A. (2005). Maternal unresolved attachment status

impedes the effectiveness of interventions with adolescent mothers. Infant Mental

Health Journal: Official Publication of The World Association for Infant Mental

Health, 26(3), 231-249. doi: 10.1002/imhj.20045

Mortensen, J. A., & Mastergeorge, A. M. (2014). A meta‐analytic review of relationship‐

based interventions for low‐income families with infants and toddlers: Facilitating

supportive parent–child interactions. Infant Mental Health Journal, 35(4), 336-353.

doi: 10.1002/imhj.21451

Mulcahy, G., Badger, J., Wright, H., & Erskine, C. (2014). ‘What happened next’: a study of

outcomes for maltreated children following care proceedings. Adoption &

Fostering, 38(4), 314-330. doi: 10.1177/0308575914553362

Muzik, M., Ads, M., Bonham, C., Rosenblum, K. L., Broderick, A., & Kirk, R. (2013).

Perspectives on trauma-informed care from mothers with a history of childhood

PARENTING GROUP OUTCOMES AND ACES 153

maltreatment: A qualitative study. Child Abuse & Neglect, 37(12), 1215-1224. doi:

10.1016/j.chiabu.2013.07.014

Muzik, M., Kirk, R., Alfafara, E., Jonika, J., & Waddell, R. (2016). Teenage mothers of black

and minority ethnic origin want access to a range of mental and physical health

support: a participatory research approach. Health Expectations, 19(2), 403-415. doi:

10.1111/hex.12364

Muzik, M., Morelen, D., Hruschak, J., Rosenblum, K. L., Bocknek, E., & Beeghly, M.

(2017). Psychopathology and parenting: An examination of perceived and observed

parenting in mothers with depression and PTSD. Journal of Affective Disorders, 207,

242-250. doi: 10.1016/j.jad.2016.08.035

Muzik, M., Rosenblum, K. L., Alfafara, E. A., Schuster, M. M., Miller, N. M., Waddell, R.

M., & Kohler, E. S. (2015). Mom Power: preliminary outcomes of a group

intervention to improve mental health and parenting among high-risk

mothers. Archives of Women's Mental Health, 18(3), 507-521. doi: 10.1007/s00737-

014-0490-z

Nanni, V., Uher, R., & Danese, A. (2012). Childhood maltreatment predicts unfavorable

course of illness and treatment outcome in depression: a meta-analysis. American

Journal of Psychiatry, 169(2), 141-151. doi: 10.1176/appi.ajp.2011.11020335

National Institute for Health and Clinical Excellence (NICE) (2017). Antisocial behaviour

and conduct disorders in children and young people: recognition and management

(Report No. 158). Retrieved from https://www.nice.org.uk/guidance/cg158

Neece, C. L., Green, S. A., & Baker, B. L. (2012). Parenting stress and child behavior

problems: A transactional relationship across time. American Journal on Intellectual

and Developmental Disabilities, 117(1), 48-66. doi: 10.1352/1944-7558-117.1.48

PARENTING GROUP OUTCOMES AND ACES 154

NHS Highland (2018). Adverse Childhood Experiences, Resilience and Trauma Informed

Care: A Public Health Approach to Understanding and Responding to Adversity.

Retrieved from https://www.nhshighland.scot.nhs.uk/Publications/Documents/DPH-

Annual-Report-2018_(web-version).pdf

Odgers, C. L., Moffitt, T. E., Broadbent, J. M., Dickson, N., Hancox, R. J., Harrington, H., ...

& Caspi, A. (2008). Female and male antisocial trajectories: From childhood origins

to adult outcomes. Development and Psychopathology, 20(2), 673-716. doi:

10.1017/S0954579408000333

Oral, R., Ramirez, M., Coohey, C., Nakada, S., Walz, A., Kuntz, A., ... & Peek-Asa, C.

(2016). Adverse childhood experiences and trauma informed care: the future of health

care. Pediatric Research, 79(1-2), 227. doi: 10.1038/pr.2015.197

Ormston, R., Spencer, L., Barnard, M., & Snape, D. (2014). The foundations of qualitative

research. In J. Ritchie, J. Lewis, C. Nicholls & R. Ormston (Eds.), Qualitative

research practice: A guide for social science students and researchers (pp. 1-25). Los

Angeles: Sage.

Ostlund, B. D., Vlisides-Henry, R. D., Crowell, S. E., Raby, K. L., Terrell, S., Brown, M. A.,

... & Buchi, K. F. (2019). Intergenerational transmission of emotion dysregulation:

Part II. Developmental origins of newborn neurobehavior. Development and

Psychopathology, 1-14. doi: 10.1017/S0954579419000440

O'Donnell, K. J., Glover, V., Barker, E. D., & O'Connor, T. G. (2014). The persisting effect

of maternal mood in pregnancy on childhood psychopathology. Development and

Psychopathology, 26(2), 393-403. doi: 10.1017/S0954579414000029

PARENTING GROUP OUTCOMES AND ACES 155

O’Donnell, K. J., & Meaney, M. J. (2016). Fetal origins of mental health: the developmental

origins of health and disease hypothesis. American Journal of Psychiatry, 174(4),

319-328. doi: 10.1176/appi.ajp.2016.16020138

Oxford, M. L., Marcenko, M., Fleming, C. B., Lohr, M. J., & Spieker, S. J. (2016).

Promoting birth parents' relationships with their toddlers upon reunification: Results

from Promoting First Relationships® home visiting program. Children and Youth

Services Review, 61, 109-116. doi: 10.1016/j.childyouth.2015.12.004

Pasalich, D. S., Cyr, M., Zheng, Y., McMahon, R. J., & Spieker, S. J. (2016). Child abuse

history in teen mothers and parent–child risk processes for offspring externalizing

problems. Child Abuse & Neglect, 56, 89-98. doi: 10.1016/j.chiabu.2016.04.011

Pasalich, D. S., Fleming, C. B., Spieker, S. J., Lohr, M. J., & Oxford, M. L. (2019). Does

parents’ own History of child abuse moderate the effectiveness of the Promoting First

Relationships® intervention in child welfare? Child Maltreatment, 24(1), 56-65. doi:

10.1177/1077559518809217

Pearl, E., Thieken, L., Olafson, E., Boat, B., Connelly, L., Barnes, J., & Putnam, F. (2012).

Effectiveness of community dissemination of parent–child interaction

therapy. Psychological Trauma: Theory, Research, Practice, and Policy, 4(2), 204.

doi: 10.1037/a0022948

Pereira, J., Ludmer, J. A., Gonzalez, A., & Atkinson, L. (2018). Mothers’ personal and

interpersonal function as potential mediators between maternal maltreatment history

and child behavior problems. Child Maltreatment, 23(2), 147-156. doi:

10.1177/1077559517734937

PARENTING GROUP OUTCOMES AND ACES 156

Pinquart, M. (2016). Associations of parenting styles and dimensions with academic

achievement in children and adolescents: A meta-analysis. Educational Psychology

Review, 28(3), 475-493. doi: 10.1007/s10648-015-9338-y

Pinquart, M. (2017). Associations of parenting dimensions and styles with externalizing

problems of children and adolescents: An updated meta-analysis. Developmental

Psychology, 53(5), 873. doi: 10.1037/dev0000295

Plant, D. T., Pawlby, S., Pariante, C. M., & Jones, F. W. (2018). When one childhood meets

another–maternal childhood trauma and offspring child psychopathology: A

systematic review. Clinical Child Psychology and Psychiatry, 23(3), 483-500. doi:

10.1177/1359104517742186

Prinz, R. J. (2019). A Population Approach to Parenting Support and Prevention. The Future

of Children, 29(1), 123-144. Retrieved from https://www.jstor.org/stable/26639559

Rayce, S. B., Rasmussen, I. S., Klest, S. K., Patras, J., & Pontoppidan, M. (2017). Effects of

parenting interventions for at-risk parents with infants: a systematic review and meta-

analyses. BMJ Open, 7(12), e015707. doi: 10.1136/bmjopen-2016-015707

Ridout, K. K., Khan, M., & Ridout, S. J. (2018). Adverse childhood experiences run deep:

toxic early life stress, telomeres, and mitochondrial DNA copy number, the biological

markers of cumulative stress. Bioessays, 40(9), 1800077. doi:

10.1002/bies.201800077

Rose, G. A., Khaw, K. T., & Marmot, M. (2008). Rose's strategy of preventive medicine: the

complete original text. Oxford University Press, USA.

Rose, J., Roman, N., Mwaba, K., & Ismail, K. (2018). The relationship between parenting

and internalizing behaviours of children: A systematic review. Early Child

Development and Care, 188(10), 1468-1486. doi: 10.1080/03004430.2016.1269762

PARENTING GROUP OUTCOMES AND ACES 157

Rosenblum, K. L., Muzik, M., Morelen, D. M., Alfafara, E. A., Miller, N. M., Waddell, R.

M., ... & Ribaudo, J. (2017). A community-based randomized controlled trial of Mom

Power parenting intervention for mothers with interpersonal trauma histories and their

young children. Archives of Women's Mental Health, 20(5), 673-686. doi:

10.1007/s00737-017-0734-9

Roy, C. A., & Perry, J. C. (2004). Instruments for the assessment of childhood trauma in

adults. The Journal of Nervous and Mental Disease, 192(5), 343-351. doi:

10.1097/01.nmd.0000126701.23121.fa

Rutherford, A. (2011). ANOVA and ANCOVA: a GLM approach. John Wiley & Sons.

Rutter, M. (1989). Pathways from childhood to adult life. Journal of Child Psychology and

Psychiatry, 30(1), 23-51. doi: 10.1111/j.1469-7610.1989.tb00768.x

Sanders, M. R. (2008). Triple P-Positive Parenting Program as a public health approach to

strengthening parenting. Journal of Family Psychology, 22(4), 506. doi:

10.1037/0893-3200.22.3.506

Sandler, I. N., Schoenfelder, E. N., Wolchik, S. A., & MacKinnon, D. P. (2011). Long-term

impact of prevention programs to promote effective parenting: Lasting effects but

uncertain processes. Annual Review of Psychology, 62, 299-329. doi:

10.1146/annurev.psych.121208.131619

Schafer, J. L. (1999). Multiple imputation: a primer. Statistical Methods in Medical

Research, 8(1), 3-15. doi: 10.1177/096228029900800102

Scotland, J. (2012). Exploring the philosophical underpinnings of research: Relating ontology

and epistemology to the methodology and methods of the scientific, interpretive, and

critical research paradigms. English Language Teaching, 5(9), 9-16. doi:

10.5539/elt.v5n9p9

PARENTING GROUP OUTCOMES AND ACES 158

Siegel, D. J. (2015). The developing mind: How relationships and the brain interact to shape

who we are. Guilford Publications.

Shelleby, E. C., & Shaw, D. S. (2014). Outcomes of parenting interventions for child conduct

problems: A review of differential effectiveness. Child Psychiatry & Human

Development, 45(5), 628-645. doi: 10.1007/s10578-013-0431-5

Shenk, C. E., Ammerman, R. T., Teeters, A. R., Bensman, H. E., Allen, E. K., Putnam, F. W.,

& Van Ginkel, J. B. (2017). History of maltreatment in childhood and subsequent

parenting stress in at-risk, first-time mothers: Identifying points of intervention during

home visiting. Prevention Science, 18(3), 361-370. doi: 10.1007/s11121-017-0758-4

Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L., ... &

Committee on Early Childhood, Adoption, and Dependent Care. (2012). The lifelong

effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.

doi: 10.1542/peds.2011-2663

Smetana, J. G. (2017). Current research on parenting styles, dimensions, and beliefs. Current

Opinion in Psychology, 15, 19-25. doi: 10.1016/j.copsyc.2017.02.012

Smith, L. (2018). Adverse Childhood Experiences (ACEs): interventions in education. IRISS.

Retrieved from: https://www.iriss.org.uk/sites/default/files/2018-04/iriss-esss-outline-

adverse-childhood-experiences-2018-4-23.pdf

Smith, R. (2013) An uncontrolled, pre, post and follow-up evaluation of the understanding

your child’s behaviour (UYCB) group: a parenting group intervention based on the

Solihull Approach. Doctorate in Clinical Psychology (Unpublished thesis) (Vol. 1):

University of Birmingham. Retrieved from https://etheses.bham.ac.uk//id/eprint/4741/

PARENTING GROUP OUTCOMES AND ACES 159

Smith, S. (2006). Encouraging the use of reflexivity in the writing up of qualitative

research. International Journal of Therapy and Rehabilitation, 13(5), 209-215. doi:

10.12968/ijtr.2006.13.5.21377

Speer, R. B., & Trees, A. R. (2007). The push and pull of stepfamily life: The contribution of

stepchildren's autonomy and connection-seeking behaviors to role development in

stepfamilies. Communication Studies, 58(4), 377-394. doi:

10.1080/10510970701648590

Spence, R., Nunn, S., & Bifulco, A. (2019). The long-term effects of childhood financial

hardship mediated by physical abuse, shame, and stigma on depression in

women. Maltrattamento e abuso all’infanzia. doi: 10.3280/MAL2019-001005

Stacks, A. M., Muzik, M., Wong, K., Beeghly, M., Huth-Bocks, A., Irwin, J. L., &

Rosenblum, K. L. (2014). Maternal reflective functioning among mothers with

childhood maltreatment histories: Links to sensitive parenting and infant attachment

security. Attachment & Human Development, 16(5), 515-533. doi:

10.1080/14616734.2014.935452

Steele, H., Bate, J., Steele, M., Dube, S. R., Danskin, K., Knafo, H., ... & Murphy, A. (2016).

Adverse childhood experiences, poverty, and parenting stress. Canadian Journal of

Behavioural Science, 48(1), 32. doi: 10.1037/cbs0000034

Steele, E. H., & McKinney, C. (2019). Emerging adult psychological problems and parenting

style: Moderation by parent-child relationship quality. Personality and Individual

Differences, 146, 201-208. doi: 10.1016/j.paid.2018.04.048

Stoltz, S., Beijers, R., Smeekens, S., & Deković, M. (2017). Diathesis stress or differential

susceptibility? Testing longitudinal associations between parenting, temperament, and

PARENTING GROUP OUTCOMES AND ACES 160

children's problem behavior. Social Development, 26(4), 783-796. doi:

10.1111/sode.12237

Symeou, M., & Georgiou, S. (2017). Externalizing and internalizing behaviours in

adolescence, and the importance of parental behavioural and psychological control

practices. Journal of Adolescence, 60, 104-113. doi:

10.1016/j.adolescence.2017.07.007

Tackett, J. L., Waldman, I. D., & Lahey, B. B. (2009). Etiology and measurement of

relational aggression: A multi-informant behavior genetic investigation. Journal of

Abnormal Psychology, 118, 722–733. doi: 10.1016/j.dr.2011.08.001

Tandon, M., Cardeli, E., & Luby, J. (2009). Internalizing disorders in early childhood: A

review of depressive and anxiety disorders. Child and Adolescent Psychiatric

Clinics, 18(3), 593-610. doi: 10.1016/j.chc.2009.03.004

Taylor-Robinson, D. C., Straatmann, V. S., & Whitehead, M. (2018). Adverse childhood

experiences or adverse childhood socioeconomic conditions?. The Lancet Public

Health, 3(6), e262-e263. doi: 10.1016/S2468-2667(18)30094-X

Theise, R., Huang, K. Y., Kamboukos, D., Doctoroff, G. L., Dawson-McClure, S., Palamar,

J. J., & Brotman, L. M. (2014). Moderators of intervention effects on parenting

practices in a randomized controlled trial in early childhood. Journal of Clinical Child

& Adolescent Psychology, 43(3), 501-509. doi: 10.1080/15374416.2013.833095

Toth, S. L., Rogosch, F. A., Sturge‐Apple, M., & Cicchetti, D. (2009). Maternal depression,

children’s attachment security, and representational development: An organizational

perspective. Child Development, 80(1), 192-208. doi: 10.1111/j.1467-

8624.2008.01254.x

PARENTING GROUP OUTCOMES AND ACES 161

Trinkner, R., Cohn, E. S., Rebellon, C. J., & Van Gundy, K. (2012). Don't trust anyone over

30: Parental legitimacy as a mediator between parenting style and changes in

delinquent behavior over time. Journal of Adolescence, 35(1), 119-132. doi:

10.1016/j.adolescence.2011.05.003

Tronick, E. (1986). Interactive mismatch and repair: Challenges to the coping infant. Zero to

Three, 6, 1-6. Retrieved from: https://psycnet.apa.org/record/1987-15272-001

Vaillancourt, K., Pawlby, S., & Fearon, R. P. (2017). History of childhood abuse and mother–

infant interaction: A systematic review of observational studies. Infant Mental Health

Journal, 38(2), 226-248. doi: 10.1002/imhj.21634

Vanderfaeillie, J., Van Holen, F., Vanschoonlandt, F., Robberechts, M., & Stroobants, T.

(2013). Children placed in long-term family foster care: A longitudinal study into the

development of problem behavior and associated factors. Children and Youth Services

Review, 35(4), 587-593. doi: 10.1016/j.childyouth.2012.12.012

Vella, L. R., Butterworth, R. E., Johnson, R., & Urquhart Law, G. (2015). Parents'

experiences of being in the Solihull Approach parenting group, ‘Understanding Your

Child's Behaviour’: an interpretative phenomenological analysis. Child: Care, Health

and Development, 41(6), 882-894. doi: 10.1111/cch.12284

Verreault, N., Da Costa, D., Marchand, A., Ireland, K., Dritsa, M., & Khalifé, S. (2014).

Rates and risk factors associated with depressive symptoms during pregnancy and

with postpartum onset. Journal of Psychosomatic Obstetrics & Gynecology, 35(3),

84-91. doi: 10.3109/0167482X.2014.947953

Vesga-Lopez, O., Blanco, C., Keyes, K., Olfson, M., Grant, B. F., & Hasin, D. S. (2008).

Psychiatric disorders in pregnant and postpartum women in the United

PARENTING GROUP OUTCOMES AND ACES 162

States. Archives of General Psychiatry, 65(7), 805-815. doi:

10.1001/archpsyc.65.7.805

Vranceanu, A. M., Hobfoll, S. E., & Johnson, R. J. (2007). Child multi-type maltreatment and

associated depression and PTSD symptoms: The role of social support and

stress. Child Abuse & Neglect, 31(1), 71-84. doi: 10.1016/j.chiabu.2006.04.010

Walsh, D., McCartney, G., Smith, M., & Armour, G. (2019). Relationship between childhood

socioeconomic position and adverse childhood experiences (ACEs): a systematic

review. Journal of Epidemiology and Community Health, 73(12), 1087-1093. doi:

10.1136/jech-2019-212738

Walton, G. M. (2014). The new science of wise psychological interventions. Current

Directions in Psychological Science, 23(1), 73-82. doi: 10.1177/0963721413512856

Watson, J. B. (1930). Behaviorism. Chicago: University of Chicago Press.

Weissman, D. G., Bitran, D., Miller, A. B., Schaefer, J. D., Sheridan, M. A., & McLaughlin,

K. A. (2019). Difficulties with emotion regulation as a transdiagnostic mechanism

linking child maltreatment with the emergence of psychopathology. Development and

Psychopathology, 1-17. doi: 10.1017/S0954579419000348

White, S., Edwards, R., Gillies, V., & Wastell, D. (2019). All the ACEs: A Chaotic Concept

for Family Policy and Decision-Making? Social Policy and Society, 18(3), 457-466.

doi: 10.1017/s147474641900006x

Whittaker, K. A., & Cowley, S. (2012). An effective programme is not enough: A review of

factors associated with poor attendance and engagement with parenting support

programmes. Children & Society, 26(2), 138-149. doi: 10.1111/j.1099-

0860.2010.00333.x

PARENTING GROUP OUTCOMES AND ACES 163

Whittaker, J. E. V., Harden, B. J., See, H. M., Meisch, A. D., & T’Pring, R. W. (2011).

Family risks and protective factors: Pathways to Early Head Start toddlers’ social–

emotional functioning. Early Childhood Research Quarterly, 26(1), 74-86. doi:

10.1016/j.ecresq.2010.04.007

Wittkowski, A., Garrett, C., Calam, R., & Weisberg, D. (2017). Self-report measures of

parental self-efficacy: A systematic review of the current literature. Journal of Child

and Family Studies, 26(11), 2960-2978. doi: 10.1007/s10826-017-0830-5

Winnicott, D. W. (1953). Transitional objects and transitional phenomena—a study of the

first not-me possession. International Journal of Psycho-Analysis, 34, 89-97. doi:

10.4324/9780429475931-14

Woodhouse, S. S., Scott, J. R., Hepworth, A. D., & Cassidy, J. (2019). Secure base provision:

A new approach to examining links between maternal caregiving and infant

attachment. Child Development, 91(1), 249-265. doi: 10.1111/cdev.13224

PARENTING GROUP OUTCOMES AND ACES 164

Appendices

Appendix 1.1

Systematic Review Search Terms

Psychology-related Psychology or psych* or psychology.tw Primary Care Setting Primary health care or primary healthcare or primary healthcare providers Reviews Systematic review or meta-analysis or literature review or review of literature Relationship focused groups Attachment or attachment based or attachment focused or relationship or relationship focused or relational Effectiveness Effectiveness or outcomes or impact or effects or impacts or consequences or influences or outcomes or efficacy Adverse childhood experiences ACEs or child abuse or child neglect or childhood trauma or parent adverse childhood experiences or parent ACEs or parent child neglect or parent childhood trauma or parent maltreatment or parent child abuse Child emotional and behavioural difficulties Child emotional difficulties or child emotion difficulties or child emotion or child behaviour or child behaviour difficulties or internalising behaviours or externalising behaviours Parental self-regulation Parental self-efficacy or parent self-efficacy or parent self-regulation or parental self- regulation or parent efficacy or parent regulation Relationship focused groups Attachment or attachment based or attachment focused or relationship or relationship focused or relational

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Appendix 3.1

Information Sheet

Study Title: ‘The impact of parental childhood experience on parental stress and competence and subsequent child behaviours: Breaking the cycle with a Parenting group intervention’. We are inviting you to take part in a research study. Depending on a parent’s childhood experiences, a parent’s ability to manage stressful situations on a daily basis may increase or decrease their sense of competence as a parent. Each of these factors play an important role in the behaviours that children display. This research study is intended to evaluate how effective a 10-week parenting group focused on improving parents’ relationships with their child is in reducing less desirable child behaviours, and also its impact on how parents manage stress and how competent they feel in their abilities as a parent. It is also hoping to find out information on how much parents’ own experiences in childhood impact on how well they are able to engage with the group. This study is being conducted by Mr. John Burke (Psychologist in Clinical Training) and Dr. Mark Fitzhenry (Clinical Psychologist). If you consent to take part in this study, you will be asked to complete a short questionnaire before and after the group. You will also be asked to take part in a focus group after the 10- week group, which will ask some questions about your experience and overall satisfaction with the group intervention.

How long will participation take? Your participation will take around 20 minutes in total, 10 minutes before and after the group intervention. Should you decide to participate in the focus group, this will last approximately 30-40 minutes. You will be provided information during your consultation session prior to the start of the group. You will have time between this consultation and the start of the group to consider your participation. Your decision to participate or not will have no impact on the treatment your receive whilst attending the service.

Do I have to participate? You may withdraw from this research at any time without impacting on support you receive from the Primary Care and Child Psychology Service in the future. Withdrawal from the study is an option until your data is anonymised (within one week of participation).

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What are the risks? Occasionally, some people may feel upset filling out a questionnaire about their visit to the clinic as it may remind them of the concern about their child that led them to attend. If you feel upset at any time you can change your mind and stop taking part. The Service can also help you find support if you are feeling upset.

What are the benefits? We hope that this study will help us understand more about parents’ experience of attending this group intervention. It will give us an insight into what kind of parents are attending the group, their stress and competence levels and how the group has changed their child’s behaviour. We can use this information to improve the service we offer parents when they attend groups like this in the future.

What happens to the information? Any information that we obtain from this study about you will be made anonymous and kept confidential. This will be complete after the focus group data has been transcribed. The information provided by each participant will be added to data from all participants for data analysis. Data will be destroyed once the research project has been completed.

Confidentiality: Occasionally, the researcher might be concerned by some of the information you provide. If we are concerned about the safety of yourself or someone else, or about any potential professional misconduct we are informed about, we are professionally responsible for reporting any allegations that may be disclosed during the interview.

Do I have to sign anything? You will be requested to provide a signature in order to confirm that you understand the information about the study and its procedure, By signing the consent form, it will allow us to use the information you give us as part of our overall dataset.

Ethical Approval: Obtained from the Research Ethics Committee, HSE, South East.

If you have any questions or would like further information, please feel free to contact John Burke via e-mail on [email protected]

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Appendix 3.2

Informed Consent Form

PLEASE READ CAREFULLY BEFORE SIGNING FOR INFORMED CONSENT

I am invited to take part in a study named, ‘The impact of parental childhood experience on parental stress and competence and subsequent child behaviours: Breaking the cycle with a Parenting group intervention’. This study is being conducted by Mr. John Burke (Psychologist in Clinical Training) and Dr. Mark Fitzhenry (Clinical Psychologist).

Please read the statements below, and tick each box to show that you understand each statement.

I understand that my participation is voluntary and that I can withdraw from the study at any time. ☐

I understand the procedure involved in participating in this study. ☐

I understand that the information I supply will be treated confidentially and no information that could lead to the identification of an individual participant will be reported. ☐

Informed Consent

If you understand the information outlined above and you agree to participate in this study, please sign below. By signing, you indicate that you are providing informed consent to participate and you may continue to fill out the questionnaire.

Participant’s Name: ______

Participant’s Signature: ______Date: ______

Signature of Researcher: ______

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DOCUMENT FOR YOUR OWN INFORMATION

I am invited to take part in a study named, ‘The impact of parental childhood experience on parental stress and competence and subsequent child behaviours: Breaking the cycle with a Parenting group intervention’. This study is being conducted by John Burke (Psychologist in Clinical Training) and Dr. Mark Fitzhenry (Clinical Psychologist).

I understand that my participation is voluntary and that I can withdraw from the study at any time.

I understand the procedure involved in participating in this study.

I understand that the information I supply will be treated confidentially and no information that could lead to the identification of an individual participant will be reported.

Informed Consent

I have provided informed consent signing that I understand each of the statements above and have agreed to participate in the study.

Signed as Principal Researcher: John Burke

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Appendix 3.3

Pre-Intervention Questionnaire

Demographic Questionnaire

Please fill in the questionnaire below to help us understand more about the people who attend this group. Some questions will require you to tick a box next to the most appropriate answer; some will require you to write down the answer.

What is your current employment Employed ☐ Retired ☐ status? Unemployed ☐ Student ☐ What is your age and gender? Age: ______Gender: ______

Single: ☐ Married: ☐ Please specify your relationship Status: Separated/Divorced: ☐ In a relationship: ☐ Living with a partner: ☐ Widowed: ☐ What is your nationality? ______

How many children are in your care ______in total?

What are the youngest and oldest Youngest: ______Oldest: ______ages of your children?

What age and gender is the child who you are attending this service Age: ______Gender: ______for?

What are the presenting concerns for your child? ______

Has your child received a diagnosis relating to their development, If yes, please specify: ______learning, behaviour, or emotional difficulties? What is your relationship to the Mother: ☐ Father: ☐ child you are attending this service for: Other: ☐ Please specify: ______

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Perceived Stress Scale

The questions in this scale ask you about your feelings and thoughts during the last month. In each case, you will be asked to indicate by circling how often you felt or thought a certain way. Almos Some- Fairly Very Never t times Often Often Never 1. In the last month, how often have you been upset because 0 1 2 3 4 of something that happened unexpectedly?

2. In the last month, how often have you felt that you were 0 1 2 3 4 unable to control the important things in your life?

3. In the last month, how often have you felt nervous and 0 1 2 3 4 “stressed”?

4. In the last month, how often have you felt confident 0 1 2 3 4 about your ability to handle your personal problems?

5. In the last month, how often have you felt that things 0 1 2 3 4 were going your way?

6. In the last month, how often have you found that you 0 1 2 3 4 could not cope with all the things that you had to do?

7. In the last month, how often have you been able to 0 1 2 3 4 control irritations in your life?

8. In the last month, how often have you felt that you were 0 1 2 3 4 on top of things?

9. In the last month, how often have you been angered 0 1 2 3 4 because of things that were outside of your control?

10. In the last month, how often have you felt difficulties 0 1 2 3 4 were piling up so high that you could not overcome them?

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“Me as a Parent” Questionnaire

The following questions are about parenting: How strongly do you agree or disagree with these statements (please tick): Item Strongly Disagree Mixed Agree Strongly disagree feelings agree 1. When something goes wrong between me and my child, there is little I can do ☐ ☐ ☐ ☐ ☐ to fix it 2. I know how to solve most problems ☐ ☐ ☐ ☐ ☐ that arise with parenting 3. I have confidence in myself as a parent ☐ ☐ ☐ ☐ ☐ 4. My child usually ends up getting their ☐ ☐ ☐ ☐ ☐ own way, so why try 5. I have the skills to deal with new ☐ ☐ ☐ ☐ ☐ situations with my child as they arise 6. When changes are needed in my family I am good at setting goals to ☐ ☐ ☐ ☐ ☐ achieve those changes 7. I can find out what’s needed to resolve ☐ ☐ ☐ ☐ ☐ any problems my child has 8. I meet my expectations for providing ☐ ☐ ☐ ☐ ☐ emotional support for my child 9. I often feel helpless about my child’s ☐ ☐ ☐ ☐ ☐ behaviour 10. I am good at making plans and arranging fun and educational activities ☐ ☐ ☐ ☐ ☐ for my child to engage in 11. I have all the skills necessary to be a ☐ ☐ ☐ ☐ ☐ good parent to my child 12. I know I am doing a good job as a ☐ ☐ ☐ ☐ ☐ parent 13. I know how to work out which situations my child is likely to be ☐ ☐ ☐ ☐ ☐ happiest in 14. I can stay focused on the things I need to do as a parent even when I’ve ☐ ☐ ☐ ☐ ☐ had an upsetting experience 15. My parenting skills are effective ☐ ☐ ☐ ☐ ☐ 16. How my child turns out is mainly due ☐ ☐ ☐ ☐ ☐ to luck

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Strengths and Difficulties Questionnaire

For each item, please mark the box for Not True, Somewhat True, or Certainly True. It would help us if you answered all of the items as best you can, even if you are not absolutely certain or the item seems daft! Please give your answers on the basis of the child’s behaviour over the last six months of the school year.

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ACES Questionnaire - Parent

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often … Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt? Yes No 2. Did a parent or other adult in the household often … Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured? Yes No 3. Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Try to or actually have oral, anal, or vaginal sex with you? Yes No 4. Did you often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other? Yes No 5. Did you often feel that … You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No 6. Were your parents ever separated or divorced? Yes No 7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes No 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No 9. Was a household member depressed or mentally ill or did a household member attempt suicide? Yes No 10. Did a household member go to prison? Yes No

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Appendix 3.4

Post-Intervention Questionnaire

Experience of Service Questionnaire

Your Name: ______Child’s Name: ______

Please note these details will be anonymised once these questionnaires have been matched to your questionnaires completed prior to the group beginning. Please think about the group you or your family have had at this service or clinic. For each item, please tick the box that best describes what you think or feel about the service (e.g.þ) Item Certainly Partly Not True Don’t

True True know

I feel that the people here listened to me

It was easy to talk to the people here

I was treated well by the people here

My views and worries were taken seriously

I feel the people here know how to help with the

Problem(s) I came for

I have been given enough explanation about the help

available here

The facilities here are comfortable (e.g. waiting area)

The appointments are usually at a convenient time

(e.g. don’t interfere with work, school)

It is quite easy to get to the place where the

appointments are

If a friend needed similar help, I would recommend

that he or she come here

Overall, the help I have received here is good

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Experience of Service – Qualitative Questionnaire

1. What was really good about the group? ______2. Was there anything you didn’t like or anything that needs improving? ______3. Has your perception of your child changed since attending the group? If so, in what way? ______4. Do you feel more able to manage the difficulties with your child that you first attended the group for? ______5. Have you noticed any changes in how your respond to stressful situations? ______6. Is there anything else you want to tell us about the service you received? ______

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Appendix 3.5

Participant Debriefing Sheet

Thank you for participating in this study: ‘The impact of parental childhood experience on parental stress and competence and subsequent child behaviours: Breaking the cycle with a Parenting group intervention’.

What is the study about? The group you have attended has evidence to suggest that it is effective in helping parents manage their child’s behaviour and emotional difficulties better in a UK-based sample. The present study investigated the effectiveness of the group programme with an Irish sample. It investigated the change, if any, on measures of parental stress and self-competence having engaged with the group. It also measures changes in child behavioural difficulties after you, their parents, have attended the group. The research also tried to find out some more information about how your own experiences of being parented as children has impacted your parenting style with your own child. Whether this had an effect on how much difference this group intervention made on the difficulties you first presented to the Psychology service with was also investigated. Lastly, we tried to find out your experience of the group overall and gain your perspective on what you found most useful, and least helpful throughout the 10 weeks. By finding out this information from the questionnaires and the interview, it can help us to improve the intervention for parents who attend in the future, and also will help to spread the group to other services and areas that are most in need of this type of intervention for parents. If any of the topics brought up in the questionnaire has caused you to feel distressed, please contact the Primary Care and Child Psychology Service and they will help you find appropriate support. Alternatively, if you wish to talk to someone in confidence, please contact Samaritans helpline on 116 123, or email [email protected]. If you have any further questions about this study or your participation in the study, please feel free to contact the Principal Investigator, John Burke via telephone on 076- 1082018 or via e-mail at [email protected] Your data will be treated in a confidential manner, will remain anonymous and will be stored in a secure place.

A summary of results of this study will be available upon study completion. If you would like to receive this, please contact the Principal Investigator John Burke on the above email.

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Appendix 3.6

Interview Schedule

1. What was really good about the group?

a. What specific skills that they learned were most useful from the group?

2. Was there anything you didn’t like or anything that needs improving?

a. What were the barriers to you attending?

b. Were there any barriers to completing the home activities?

3. Do you understand how your experiences in childhood have impacted your parenting

styles, if at all?

a. What was it like exploring these topics?

b. Was it new/useful information to you?

4. Do you understand your child better now?

5. Do you feel more able to manage the difficulties with your child that you first

attended the group for?

a. Would you say you are more confident in your abilities as a parent?

b. What part of the group in particular facilitated or made these changes

possible?

6. Have you noticed any changes in how your respond to stressful situations?

7. Is there anything else you want to tell us about the service you received?

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Appendix 3.7

Missing Data Analysis

Missing data analysis including Little’s Missing Completely at Random Analysis for baseline and repeated measures data

Little’s MCAR

Total pts. Items missing Chi-Square df P-value

PSST1 30 0 N/A

MaaPT1 30 1 19.899 15 .176

SDQT1 30 5 62.510 71 .754

ACEs 30 14 18.038 26 .874

ESQ_SwC 22 1 21.000 7 .004*

ESQ_SwE 22 0 N/A

PSST2 22 0 N/A

MaaPT2 22 5 44.921 43 .391

SDQT2 22 1 20.875 24 .646

Imputed data Total pts. People missing

PSST2 30 8 (imputed) 4.917 10 .897

MaaPT2 30 8 (imputed) 15.921 16 .459

SDQT2 30 8 (imputed) 15.970 24 .889

Note. PSST1, PSST2 = Perceived Stress Scale time point 1, time point 2; MaaPT1, MaaPT2 = Me as a Parent scale time point 1, time point 2; SDQT1, SDQT2 = Strengths and Difficulties questionnaire total score time point 1, time point 2; ACEs = Adverse childhood experiences Questionnaire; ESQ_SwC = Experience of Service – Satisfaction with Care scale; ESQ_SwE = Experience of Service – Satisfaction with Experience scale.

PARENTING GROUP OUTCOMES AND ACES 179

Appendix 6.1

Reference List Compiled for Supplementary References in Chapter 6

Adom, D., Hussein, E. K., & Agyem, J. A. (2018). Theoretical and conceptual framework:

Mandatory ingredients of a quality research. International Journal of Scientific

Research, 7(1), 438-441. Retrieved from:

https://www.researchgate.net/publication/322204158

Bauer, M. S., Damschroder, L., Hagedorn, H., Smith, J., & Kilbourne, A. M. (2015). An

introduction to implementation science for the non-specialist. BMC Psychology, 3(1),

32. doi: 10.1186/s40359-015-0089-9

Bernstein, D. P., Stein, J. A., Newcomb, M. D., Walker, E., Pogge, D., Ahluvalia, T., ... &

Zule, W. (2003). Development and validation of a brief screening version of the

Childhood Trauma Questionnaire. Child Abuse & Neglect, 27(2), 169-190. doi:

10.1016/S0145-2134(02)00541-0

Boeije, H., Slagt, M., & van Wesel, F. (2013). The contribution of mixed methods research to

the field of childhood trauma: a narrative review focused on data integration. Journal

of Mixed Methods Research, 7(4), 347-369. doi: 10.1177/1558689813482756

Bryman, A. (2006). Integrating quantitative and qualitative research: how is it

done? Qualitative Research, 6(1), 97-113. doi: 10.1177/1468794106058877

Danese, A. (2020). Annual Research Review: Rethinking childhood trauma‐new research

directions for measurement, study design and analytical strategies. Journal of Child

Psychology and Psychiatry, 61(3), 236-250. doi: 10.1111/jcpp.13160

Des Jarlais, D. C., Lyles, C., Crepaz, N., & Trend Group. (2004). Improving the reporting

quality of nonrandomized evaluations of behavioral and public health interventions:

the TREND statement. American Journal of Public Health, 94(3), 361-366. doi:

10.2105/ajph.94.3.361

PARENTING GROUP OUTCOMES AND ACES 180

Dewa, C. S., Butterill, D., Durbin, J., & Goering, P. (2004). No matter how you land:

Challenges of a longitudinal multi-site evaluation. The Canadian Journal of Program

Evaluation, 19(3), 1-28. Retrieved from:

https://search.proquest.com/openview/b78f3381f3bf542c835d0c87cce43d76/1?pq-

origsite=gscholar&cbl=44049

Fassinger, R. E. (2005). Paradigms, praxis, problems, and promise: Grounded theory in

counseling psychology research. Journal of Counseling Psychology, 52(2), 156. doi:

10.1037/0022-0167.52.2.156

Hahn, S. (2012). Understanding noninferiority trials. Korean Journal of Pediatrics, 55(11),

403. doi: 10.3345/kjp.2012.55.11.403

Hunsley, J. (2007). Addressing key challenges in evidence-based practice in psychology.

Professional Psychology: Research and Practice, 38(2), 113 – 121. doi:

10.1037/0735-7028.38.2.113

Hunter, B. (2013). Implementing research evidence into practice: some reflections on the

challenges. Evidence Based Midwifery, 11(3), 76-80. Retrieved from

http://orca.cf.ac.uk/59062/

McDonald, M. K., Borntrager, C. F., & Rostad, W. (2014). Measuring trauma:

Considerations for assessing complex and non-PTSD criterion a childhood

trauma. Journal of Trauma & Dissociation, 15(2), 184-203. doi:

10.1080/15299732.2014.867577

McEwen, C. A., & McEwen, B. S. (2017). Social structure, adversity, toxic stress, and

intergenerational poverty: An early childhood model. Annual Review of Sociology, 43,

445-472. doi: 10.1146/annurev-soc-060116-053252

PARENTING GROUP OUTCOMES AND ACES 181

Walsh, D., McCartney, G., Smith, M., & Armour, G. (2019). Relationship between childhood

socioeconomic position and adverse childhood experiences (ACEs): a systematic

review. Journal of Epidemiology and Community Health, 73(12), 1087-1093. doi:

10.1136/jech-2019-212738