[MUSIC PLAYING] This podcast is brought to you by the Association for Child and Adolescent Mental Health, ACAMH, for short. You can find more podcasts and other resources on our website, www.acamh.org, and follow us on social media by searching ACAMH. Hello. Welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH, for short. I'm Joe Calo, a freelance journalist with a specialism in Psychology. Today, I am interviewing Professor Catherine Ward of the Department of Psychology at the University of Cape Town, South Africa and winner of ACAMH's Journal of Child Psychology and Psychiatry Journal Best Paper award 2021. The JCPP is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces JCPP Advances and the CAMH. If you're a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review, and do share with friends and colleagues. Catherine, welcome. Thank you for joining me. Can you start with a bit of background about who you are and what you do? Sure. Thanks for having me, Joe. So, I'm trained as a clinical psychologist. And I think that that's shaped my interest in my research. I like to do very applied research that will make a difference in the lives of children and adolescents and their families. I am very interested in violence prevention. That's the main area in which I'm working. And how that tracks back to children and adolescents is that I started my career looking at youth violence but very quickly realized that child maltreatment is a risk factor for later violence by the children who have been maltreated. And so, in fact, you have to start looking at violence in the family if you want to prevent youth violence. And of course, violence in the family, the perpetrators are the parents against the children. And so preventing that form of child maltreatment, then, should have knock-on effects to preventing youth violence as well. So that's what's brought me, perhaps, full circle in a way to the clinical origins of youth violence and to intervening in the lives of parents and families. So what we have been working on in my group-- and just to say that that best paper award is very much a group award. I just happen to be the first name on it-- is looking at parenting programs to prevent violence against children. So that's what I've been working on with other colleagues around the world for the last few years. Well, congratulations on winning the award, which I appreciate is a group award. Just to recap, you won ACAMH's 2021 award for JCPP Journal Best Paper. This was for a paper published in 2020. Catherine, what did winning the award mean for you? Gosh, it was such a-- I mean, I sat through the awards meeting listening to all these wonderful pieces of research that were being done. And when they got to our award, I thought, no, surely there's no chance. But it was such a delight and such an honor. And I also want to compliment ACAMH on the way the whole awards ceremony was done. Because that kind of big reveal, even in an online meeting, was hugely meaningful for us. And aside from the sort of fun we had with the big reveal and the surprise of the moment, it's lovely to have our work recognized by colleagues and especially colleagues who edit a prestigious journal. So it was lovely to get it published in the journal and then even more lovely to have our work recognized in this way. And I suppose, I think that sometimes we fear that the applied work is going to be overlooked. But it was very clear in the speech from ACAMH explaining why they had awarded it, that applied work is close to everyone's heart, along with the more basic theoretical work as well, which, of course, is equally important and shapes our work too. Well, let's take a look at the award-winning paper. This was "Parenting for Lifelong Health for Young Children, a randomized controlled trial of a parenting program in South Africa, to prevent harsh parenting and child conduct problems". Catherine, it was a standout paper in which you described a trial of a parenting program carried out in extremely resource-poor areas. What, in your view, made the trial itself and also the paper so successful? In the Parenting for Lifelong Health group, which is a group of academics at the University of Oxford, the UCT, and now more broadly in other universities as well, but this particular paper was the Oxford UCT team, we have a big commitment to low and middle income countries and under-resourced areas. Because when we started doing this work, we wanted to use the best and most evidence-based parenting programs for children and families. Because we think that in low resource contexts, there really is no room for anything less than evidence-based and having high quality evidence. Because there are so few resources, they really can't be wasted. Now, I'm quite sure that my colleagues who are listening in high-income countries will tell me that resources, even in high-income countries, can't be wasted. And certainly that is true. We shouldn't be wasting resources anywhere. And I think there's a particular ethical imperative in low-resource contexts to make sure that we really do do rigorous science and make sure that the children and families are getting the very best that we have to offer. So we made a commitment to doing the rigorous science. And so I think part of-- and this was mentioned in the award introduction from ACAMH. Part of what we did was we committed ourselves to rigorous science. So we did a very careful randomized controlled trial. We did a one year follow up, which is relatively unusual in the parenting field and I hope increasingly will become a standard. Because you really want the effects of your intervention to sustain over a very lengthy period. Otherwise, there's no point in using the program, if it don't sustain for a long time. So I think it was that combination of our commitment to rigorous science, a thorough trial design, very good statistics-- and I want to thank the statistics reviewer from JCPP. Because whoever it was really pushed us to do our very best work there. And so I think it was a combination of a really good trial design, a commitment to low-resource contexts, and really good statistical work that probably led to it being a best paper. And as you've described, your work involves evidence-based approaches designed to reduce the likelihood of children becoming aggressive. Can you share some recent highlights from this work? What feels important to mention? Thanks. That's a nice question. Because Parenting for Lifelong Health is bigger than this program. And we actually have four programs in the family. One program intended to promote attachment, so it's aimed at pregnant women in the period just before and just after birth. There's another program, which is dialogical book sharing, which obviously provides cognitive stimulation, but we're also shown there's a host of other benefits for children. Vocabularies improve marvelously. There are signs that their ability to pay attention improves. There are signs that their theory of mind-- so that's the rudiments of empathy-- improve. And then we have Parenting for Lifelong Health for Young Children. And we have a very similar Parenting for Lifelong Health for Teens, teens and their parents. So in the teen program, the teens and the parents have a number of joint sessions where they work together on things. And just to say that those last two programs are intended to reduce not only child conduct problems but also violence against children. So it's child maltreatment and child conduct problems. There's several exciting things. We have a number of colleagues who are using the programs vary widely across Africa, in particular. So the program has been used at scale in about a dozen African countries. The government of Montenegro has taken the program for young children and is busy integrating that into government services. The same is true in Thailand and in the Philippines. And to see governments valuing our commitment to both rigorous science and making things as affordable as possible for low-resource contexts has been enormously gratifying. I mean, in a sense, it's lovely to win an award. But it's much better if my work is actually supporting children and families. And so we're very gratified in the team to have that happening and also grateful for our colleagues in the countries around the world where they are doing this. So there's that. So that's enormously gratifying. The other thing that I'd like to mention, that sort of emerging evidence, and there's other colleagues in the team have been more involved in than me, but with the start of the pandemic, my colleague Lucy Kruger looked at her two young children-- I think they were then aged 2 and 4-- who were running around the house madly one morning, and she found herself wondering how she was going to cope during lockdown. So Britain had not yet gone into a lockdown at that point. And so there was a massive pivot to the digital. What we started with was COVID-19 parenting tips, which people around the world very kindly translated into over 100 languages. And so you can go to covid19parenting.com and download the tips. And then we discovered that colleagues we're starting to use these unusual sorts of ways, these parenting tips. And out of that has emerged the notion of facilitated groups being delivered on apps like WhatsApp and WeChat and Viber and so on. All of these have got the capacity to have a facilitator pull together a group, send up the parenting tips, and then facilitate an online discussion about the parenting tips. And we've just collected some preliminary data from a pilot test of this. And that's actually showing itself to be quite positive. And so that has spurred us on towards developing apps. So we've got Parent Chat, which is using things like WhatsApp and WeChat. We're working on Parent App, which will be using an app that can be used offline, a bit more like doing the program on your own but could also be used in a group sort of format if you've got access to an online system, and then Parent Text, which is interacting with a chat bot, even more low-resource. And so in fact, the pandemic has spurred us onto a whole new set of innovations that, given our current data are looking pretty promising, we haven't yet done the rigorous randomized controlled trials. We're hoping to start those next year. So we're excited about that. Yeah, what do you imagine is the timescale? At what point will users come to benefit, do you imagine? All of these things are using our existing material, which has the evidentiary support. So it's more the process, I think, that's going to be tested in the new trials, as in does this work if it's not on WhatsApp? So a randomized controlled trials will start next year and go into the following year. A number of those trials-- I mean, the other exciting thing about digital is you can have very big sample sizes, because you can do everything online. And it's much easier to do than with an in-person parenting program. So I'm expecting that we will be able to have good data on this by 2023. I'm going to ask you more about dissemination and translation of research in a moment. But I just want to touch on another key strand of your work. This is the focus on preventing child maltreatment and understanding the epidemiology risk factors faced by South African children. Catherine, what can you tell us about this aspect of your work? I was privileged to lead a large nationally representative study of violence against children in South Africa funded by the UBS Optimus Foundation and along with colleagues Patrick Burton and [INAUDIBLE]. So we were then able to map out the enormous amount of violence that South African children face. And it was the first nationally representative study of South African children. So I believe that colleagues are finding that very useful for advocacy and so on. And its intent was very similar to what UNICEF has been doing with their violence against children surveys, which have now been carried out in a number of other countries around the world. And so those are also very helpful to us in Parenting for Lifelong Health when we are using them, for instance, to advocate for the need for a parenting program. We can draw on both understanding the kinds of violence that children face, how much of it is in the home, or like for instance, sexual violence against children, it may occur in the home, but it might occur outside the home. But we know that parents who monitor their children's whereabouts, know who their friends are, help them choose the right friends, and have warm relationships with their teens, those children are far less likely to be sexually abused. And so parenting interventions, again, can help with that. And so it all works together to help us marshal evidence for the uptake of parenting programs quite widely. You recently co-authored the edited volume, Youth Violence Sources and Solutions in South Africa. I'm wondering how applicable that is, that kind of resources for other countries, and also how you go about adapting this kind of evidence base to have a global reach. It was really editing of Youth Violence Sources and Solutions that spurred me into realizing that we needed to look at child maltreatment and the parenting that would prevent child conduct problems. So in a sense, for me and my thought process, that was a really important book. We tried to write the book so that it would be applicable in other low-resource contexts. It was very much focused on South Africa, and it was by South African authors. But actually the science translates very well to other contexts. And what we found-- so perhaps to give you an example with Parenting for Lifelong Health-- I mean, I've already mentioned that it's being used quite widely around the world. Yes. The substantive material of Parenting for Lifelong Health programs, the kinds of skills that we teach parents, we have not needed to alter in any context In any context, raising your children for doing things that you want them to do, talking things out with them, setting up a good household routine and structure so that everybody knows where they stand, using consequences when children do something wrong. It is applicable. We haven't yet found a culture where that's not applicable. Sometimes parents might say that they've never done this before, and it feels alien to them. But when they are encouraged to try it at home, they generally come back astounded at the effects. So the substandard material, we haven't needed really to adapt the substance of the parenting programs. What we do do, and that we've got, at the moment, two organizations that are accredited in delivering training for the Parenting for Lifelong Health program for young children. And that's an NGO called Clowns Without Borders South Africa, which is based here in South Africa and then Judy Hutchings' organization, [INAUDIBLE] training, which is based in Wales. They will be in charge of the more surface level adaptations. And so for instance, to keep the programs suitable for resource-poor contexts, we decided not to use videos showing families delivering the skills. Because, obviously, you need then to have a video machine or a computer. You need to have a projector and so on. So we went with cartoons. Cartoons in the original version called Sinovuyo in South Africa, it gets different names in other countries according to whatever is appropriate. The Sinovuyo is a [INAUDIBLE] word, which means we have happiness. So it's what we're aiming for in the family. But to give you an idea of a surface adaptation, Parenting for Lifelong Health Sinovuyo in South Africa has got pictures of African families using African names and doing African things, such as growing maize. When it's translated to the Philippines or Thailand, we change the pictures so that the names are familiar to people, people look like Thai people or Filipino people, and they are doing things that the Thai and Filipino families would recognize. And that's a very surface adaptation. I just have one question in terms of parenting programs where you mentioned using consequences when the child does something wrong. What does that mean? Give a very basic example, if a child knocks over the milk on the kitchen table, rather than shouting at them and hitting them, you ask them to mop it up. And what we're aiming to do is to teach children-- so very often the more punitive strategies teach children what you don't want them to do, but they don't tell the child what you do want them to do. And actually if you think of parenting as training a child in the direction you want it to go, most of your parenting strategies, all of our parenting strategies need to tell children what to do rather than what not to do. So if you knock something over, you must mop it up. And you know it's a small example, but there are similar things that one can enact. You know, if a child comes in-- an older child who comes in, for instance, late from playing with their children, or say there was a house-- with their friends. Say there was a household rule that you need to be home by 6 o'clock if you've been playing with your friends. And the child comes home at 7:00, the consequence would be, you've just shown us that you are not actually able to handle the responsibility of coming home at 6 o'clock. And so the consequence for that is that you are not going to be able to play with your friends after school for another week. And you agree the consequence with the child up front so that everybody knows where they stand. That's really helpful. Is it worth mentioning about the substantive adaptations? Yeah. So would be a substantive adaptation? We have a couple of substantive adaptations already where we've integrated more content around HIV prevention into our programs, particularly at the teen level. We are working on integrating material related to reducing intimate partner violence into the home and improving co-parenting. Because we realized that our definition of child maltreatment was originally quite narrow and that actually exposure to intimate partner violence in the home into parents arguing can be very threatening for children. And so we're working to include that now. And so we've got some rather exciting work on the go there. So those are the kinds of things that we work on with partners to test the new material and to develop. And then, I think that kind of substantive alteration is absolutely fine. Sometimes parties come back to us-- and I think this is a very legitimate concern-- and they say-- for instance, the young children program was designed originally to be 12 sessions-- and they say that's just too long. Can we do the sessions twice a week? And then we would say, actually no, we don't think that will work, because parents in each session are given homework. So for instance in the week where we talk about praising your children, they're asked to go home and praise their children for everything that they do right. And if you have children that you're annoyed with, it's quite hard to get that right. And so it can be quite a shift for parents. And they need the time to bid that skill down. So if you move through the material too fast, we don't think that will work. But what we have done, just to follow on from that, is working with colleagues in Eastern Europe in Romania, Moldova, and North Macedonia, we've actually done a test of a five session version of the program versus a 10 session version of the program. So we've done the rigorous science again. And we found that the five session version was more cost effective. We're going to explore the reasons behind that and who benefits from the 10 session program versus the five session program, if we can identify them from the front. And so that a five session program is much more scalable. And we've done we've done the rigorous science. We've discovered that the five session program was cost effective. And we're just finishing up the RCT of the five session version. And I'm afraid I don't know the results myself, so I can't give them to you. But please watch the space. Yeah, so there is a more substantive adaptation. We'd say either, like with a twice a week thing, we don't think that's a good idea. We think it would really undermine parents capacity to learn. Or if you don't mind slightly longer time frame, please work with us to test this. And then if we find that it's still effective, you're welcome to use the shorter version or the adapted version. Having a wide reach, especially including the involvement of public health, is key to what you do. You've said something about how you translate evidence-based research into practice. But can you say a little more about how you really make a difference at the sharp end? What we want is our programs to be used widely. And we are enormously gratified by the uptake. And this is-- it was a little scary at the beginning, to be honest, because we published the papers, and then suddenly had a whole lot of requests for training and Clowns Without Borders. And [INAUDIBLE] wasn't on board at that point. And Clowns Without Borders South Africa was just quite swamped. But they did an amazing job of rising to the challenge. And part of that I think was recognition of the value of this kind of program by funding bodies, such as USAID, who made it one of their mandated programs for partners in their dreams initiative and some of their other initiatives to use. I think where we are is that our work on keeping things as low cost as possible and making all our materials open source, supporting adaptations for the local context, those surface adaptations that I've talked about, and even, in fact, supporting some of the science when people want more substantive adaptations, I think that that's paid off. Because a number of organizations are using the programs very widely. So when I say public health in that sense, what I'm talking about is very widespread. But to use public health in it's more narrow sense, what we're also seeing-- and this is in Thailand-- it is the Ministry of Public Health, which has picked up the program and is rolling out training to a number of-- they have village health volunteers who will be delivering the program. And that's an existing system in Thailand for delivering public health interventions. But we were able to show them that this was feasible and that it worked through doing the rigorous science that was led by Emily McCoy and Francis Gardner based at Oxford and Emily based in Thailand. They did the work to show through rigorous science that it was feasible to build it into the public health system and that it did have quite large effects. And so the Ministry actually picks it up and is integrating it into their public health system delivery. And in a similar way, although this is the Department of Social Welfare and Development in the Philippines, they also had an existing system for delivering a parenting program through their conditional cash transfer. So parents who need cash support are given that cash support conditional on a number of things. And one of them is attending a parenting program. And we've been able to show the Department of Social Welfare and Development-- and this is my colleagues Bernie Madrid and [INAUDIBLE] in the Philippines who led this. They've been able to show that it's feasible to integrate it into that delivery system and that it has enormous benefits for the families. And so the Philippines government has picked that up and is integrating it into that system. So in a sense, I was probably, when I wrote that, referring to public health in a very broad sense of wanting to reach people at scale. But there is also the sense in which we really want the programs to be integrated into existing systems so that they can reach lots and lots of people. And it's amazing to see the way in which those two governments and Montenegro are picking things up and running with it. So there are some excellent examples. I'm just wondering what more you would like to see done to disseminate and promote evidence-based research as it relates to child and adolescent mental health to include influencing policy makers. So my next a big project-- and we actually have the funding for this at the moment. Thanks very much to the OAK foundation and LEGO Foundation. My dream project spins off somebody in our Department of Health in the Western Cape here in South Africa who said to me, "I need a parenting program that costs no money and uses no resources." And that really is pie in the sky. But I have never forgotten Tracy [INAUDIBLE] comment. This pivot to the digital has really made it possible that we probably will be able to deliver a parenting program that costs, I won't say nothing, but costs incredibly little using digital resources. And so I will be working with the Department of Health here in the Western Cape to integrate the digital programs, if they're found to be effective, into the work of the Department of Health in such a way that every parent can have access to some support. And then those families who need more intensive support will get support at the level at which they need it. And all of this still has to be negotiated and worked out, because the funding has only just arrived. I'm really looking forward to that. Because to me, that's the, you know, can we make this so available that everybody can have some support? That to me is the Holy Grail for my career, basically. Absolutely. Good luck with that. Catherine, what else is in the pipeline for you that you'd like to mention? I've mentioned briefly the funding that the OAK foundation and the LEGO Foundation have very kindly given to us. And along with the World Childhood Foundation and the Human Safety Net Foundation, they're making it possible for us to get the thing that we're calling the global parenting initiative where there will be active research on the digital programs on this Holy Grail study that I've just described on integrating content on intimate partner violence into programs. It's working with colleagues largely in Africa and in Asia but also drawing in other colleagues in other contexts as occasion arises. There'll be a number of early career researchers that will be mentoring into doing rigorous parenting research. And that's also going to be exciting for them. And I'm really excited about that. So far the span is five years starting 1st of January 2022, and I think it's going to be an enormously exciting endeavor. Sounds wonderful. Catherine, finally, what is your take-home message for those listening to our conversation? You know, I think really the take home is that rigorous science is possible in low-resource contexts. And so for the scientists who are listening, go for it. Don't hold back on doing rigorous science in low-resource contexts. Because those contexts really need you, and the work really can have traction. And I think I mentioned this briefly too that one of the reasons our work has had so much traction is that we've had a big commitment to those low-resource contexts, to the rigorous science, but also to making our work as low cost as possible and open source. So our digital programs will be open source, and our in-person parenting programs are licensed with a Creative Commons license. And really, I think that you can conquer the world and change the world for child and adolescent mental health if you if you dare to dream big in that sense. Catherine, thank you so much. For more details on Professor Catherine Ward, please visit the ACAMH website, www.acamh.org and Twitter, @ACAMH. ACAMH is spelled A-C-A-M-H. And don't forget to follow us on iTunes or your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review and do share with friends and colleagues. [MUSIC PLAYING] This podcast was brought to you by the Association for Child and Adolescent Mental Health, ACAMH for short.