We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Hello and welcome to the Mind the Kids podcast series. I'm Mark Tebbs. I'm your host for today. I've kind of spent my whole career working in mental health, from frontline services through to Director of Mental Health Commissioning in the charity sector, NHS and social care. I'm currently chief executive of an infrastructure charity. So I'm really interested in how we support grassroots organisations and that kind of Community Impact. And I guess that background in commissioning kind of makes me really interested in around how we understand, need, lived experience, evidence, practise and how we really measure impact and value for money. And I'm also a parent and I've seen the system from a parent's perspective too. So I'm really delighted to be hosting the podcast. In these episodes, we have the opportunity to talk to researchers and practitioners about their research. It's an opportunity to talk and shine a light on some of the latest developments in child and adolescent mental health research. Today, I'm really delighted to be talking to Dr. Nathan Hodson from the University of Warwick, who's the lead author of the paper entitled Systematic Review and Meta-analysis, Financial Incentives Increase Engagement with the Parenting Programme for Disruptive Behaviour Problems. Nathan, really lovely to be speaking to you. Let's start with some introductions. Maybe if you could say a little bit about your background, maybe your research interests and a little bit about your career today. Hi, Mark. I'm a specialty doctor in child and adolescent psychiatry in Nuneaton in Central England. And that means that every day I work with families who benefit from parenting work, which is really what my research is about. I'm really excited about parenting support because it's really hard to change parenting style, but when you can, the outcomes can be amazing. So over the last five years or so, that's been my research focus, focusing on applying principles from behavioural economics to help people to use their parenting skills. And so part of that, I went to the USA. I did a master's where I worked with Cass Sunstein, who wrote the book Nudge. And since then, I've been working on research to get more people to use their parenting skills, using techniques like Nudges and others. So thanks for having me today. Brilliant. I'm really excited about our conversation. Really interesting topic. So before we get into it, do you want to give a bit of a name check? Because I think you work with some colleagues on the paper. Yeah, this is a paper I worked on with colleagues from the UK and the USA. So the senior author is Professor Rinad Beidas, who's an expert in combining behavioural economics with implementation science and especially in children's mental health. She leads the Medical Social Sciences Department at Northwestern University in Chicago. Professor Eileen Graham, Professor Dan Mroczek from Northwestern were also involved in the paper. Dr. Madiha Majid, the psychiatrist diversity of Nottingham, and she was involved. And so was medical librarian Richard James Delaware. So, a big team. Yeah, brilliant. Excellent. So no pressure, but this is your 30-second elevator pitch. So if you're just briefly summarising what the paper entailed, how would you summarise it? Well, I wanted to know whether giving people money made them come to parenting programmes. So we looked at all the research in financial incentives for parents. And what we did was we ran a systematic review of that meta-analysis and found that they work. So let's go into a little bit more detail then. So the cohort was children with disruptive behaviour disorders. Could you tell us a little bit about that? How prevalent that is? What kind of impact do disruptive behavioural disorders have on children's mental health as they grow up? So among children, disruptive behaviour disorders are some of the most common mental health problems that we come across. I'm talking about conduct disorders, oppositional defiant disorders. And they're really common behaviour problems. They probably affect 5% or more of children, more boys than girls. And they just lead to massive problems at home and at school. And the whole family is affected by it, brothers, sisters, as well as parents trying to sort out what they can do to support their children. Excellent. The study focuses on parenting programmes. So what is a parenting programmes? If I was going on one, what would be my experience? What would be the type of things that would be happening? So in general, these parenting programmes, they last about 10 to 16 weeks. And they tend to involve maybe 12 or more parents who will meet weekly with a group leader who's coaching them every week. And what that group leader will talk about is a topic or two about stuff that they can do to support their child. They'll have a chance to share their own experience of how they've been getting on with their child, what struggles they're having, and work through those with the group. But the group leader will suggest skills, evidence-based skills for them to incorporate into their parenting and will help them do role plays together, where they actually get to practise doing the skills, where one of them will be the parent and perhaps the group leader will be the child who's not doing what they're told and similar situations. And that helps them build these skills. But over the weeks, they'll build a really firm foundation where they start off working on skills like praising their child, building their child's confidence, doing child led play with the child, which is all stuff that isn't obvious. And you can build these skills really well. And once they've established that firm foundation where their child's really confident and their child believes that-- in their parents' unconditional love for them, then the parent can start practicing trying to change behaviour, trying to ignore unwanted behaviour, not rewarding it with attention, trying to distract away from behaviours they don't want to see. Building up to setting age appropriate consequences for their child. Setting up to using quiet times to help their child deal with emotions that are getting too much. So the key is that parents are equipped with a skill set that is effective at giving their child clear boundaries, whilst also knowing that they're loved. And so the programmes are amazing because parents learn loads, they build friendships, they see that others going through the same things as them, they see lasting changes. And the practitioners are just amazing fonts of wisdom. It's a huge privilege when I get to work with them. Across the UK, most of these are run by local councils. And they offer lots of modern programmes, which are advice as evidence-based, as well as offering evidence-based classic programmes, like incredible years at Triple P, developed in the '80s and '90s. And generally, is the evidence base good in terms of their efficacy and impact? Yeah, there's really good evidence that these programmes, particularly the old ones that I mentioned, incredible years in Triple P, have long lasting impacts for families. When you get those parents along-- when I say long lasting, I mean that parents will go when their children are under 10 and you'll see the benefits lasting through teenage years with improvements. And loads of social outcomes, better educational outcomes, reduced contact with criminal Justice Services. You see a huge impact on those families potentially. So your study particularly focused on engagement parts. So getting parents involved in the first place. So could you just tell us a little bit about previous studies and what strategies have been used to encourage participation in the parenting programme? Yeah, I think everyone agrees that this is a challenge, and that getting people engaged is really important. There's a couple of approaches we mentioned in the paper. So motivational interviewing is one option. One study did find that there was a 15% increase in parent attendance when they provided motivational interviewing. Other studies have found no effect of that. Really, it's quite difficult to get motivational interviewers to see every single parent who we want to go along to these groups. Overall, it's worth thinking about what barriers people are facing before deciding what interventions to do to get them to engage better. It's not that people are unmotivated to attend the groups. Parents with children experiencing disruptive behaviour disorders aren't oblivious to the problems they're facing. They face these practical issues every day. So another approach that we've thought about is running groups online, which has been attempted by lots of people. And there's two ways of doing it online. One is getting people together on a Teams call and doing the group that way, or another way is getting people to do a sort of e-learning style. But these online programmes, again, have engagement problems. In fact, in the biggest study, only 7% of people who were referred went on to finish the programme. And it seems like, really, e-learning just isn't engaging people because it's quite tough going on your own. It's lonely. You don't get those social benefits. But also anecdotally, what I'm hearing is that lots of people struggle with online groups as well. They get distracted at home. They're doing other things at the same time as the group. It's hard to really get people together in that way. So those online approaches don't seem to quite address the barriers people are facing either. Another approach I'm hearing about is people trying to compress programmes. So rather than doing 16-week programme, bring it down to two or three sessions, squeeze all the content into just long days. And that way parents can get along to those. And that's great, but we don't know whether that works yet. I want to tell you about the way we thought about engagement in this study, which is the CAPE model, which has been published in the past, which stands for connecting, which is registering to come to the programme, attending, which is turning up to the sessions, participating, which is talking in the groups, bringing your problems and doing the homework, and then enacting, which is actually changing your behaviour style as a parent, changing how you react to your child. With the final part that we could add to that is also sustainment. Do you stick with this into the future, or does it stop? And so that's the way that we wanted to think about engagement in this paper. Yes, it's a really nice model actually to break it down into those different stages. You explored the role of financial incentives in improving engagement on the online parenting programmes. What were the specific research questions you were aiming to explore? The main things we wanted to explore was whether incentives increased connection, attendance, participation and enacting. And we had three other questions, one related to equity. Did financial incentives increase engagement among groups experiencing structural inequalities, like racism or poverty? Next, did different incentives have different outcomes, that is cash versus vouchers, lotteries or guaranteed prizes, large and small prizes? And then finally, we wanted to know if there was any evidence that financial incentives had a downstream effect on the thing we really care about, which is child behaviour and outcome. Because I guess the prize is, if you can get more engagement with online parenting programmes, then it's a much less resource intensive way of delivering these programmes. That's potentially a huge advantage. It also saves parents a lot of time getting down there. It saves parents thinking about their childcare. So online programmes have a massive potential advantage. Yeah. Cool. So what did you find? So the key takeaway was that parents who are offered incentives are more likely to attend groups. So we found that they work. And that's the main thing for people to remember. I think offering financial incentives gets more parents along to groups and an odds ratio of 2.5. It's not small. Wow. OK. So that's a really big impact. So was there any part of the results that surprised you? Were there any kind of nuances in the results that you'd like to share? Yeah, I think there were a couple. The first was that the incentives seemed to work before people even turned up to their first session. So we've got those four stages, connection, registering with the programme, then attending and turning up every week, then doing the participation and then changing your parenting style at home. But people were only getting incentives for stage 2, for attendance at the group, not for connecting, not for registering with the group. Interestingly, we found that parents connected more when they knew that the attendance was going to be incentivized. We saw that there was an odds ratio of 1.4. It was statistically significant at the 0.05 level, which, interestingly, seems to show that people register for parenting programmes when there's going to be an incentive for them. That's not how incentives are meant to work. You're meant to do the thing that's being incentivized, not sign up to do them later. OK. Was there any difference in terms of the type of incentives? You mentioned, vouchers or financial. Was there any difference in terms of the type of incentive? Yeah, there was a difference in the size of incentives. So some people were just given that they had to buy a book to attend the group. And the incentive was that they got $16, which was the cost of the book back at the end of their eight sessions. And that was one of the studies where there was no effect of the incentive. There was another study where people were getting small sums of money at $3 or $5 at a time, a little more later on in the programme. But those payments were quite delayed because of difficulties with their finances in the organisation. So they weren't getting to the people. And again, that had a much reduced effect. Whereas what we found was there were other programmes where people were just being given sums that were comparable to their minimum wage in the USA at the time, which was much more likely to motivate people to change their behaviour. So that's one of our recommendations, is if you're going to bother doing incentives, make them promptly paying a minimum wage style amount of money. So I'm just thinking about the practical implications of this. So I'm just wondering how this could be applied in the field, I guess. So I think it tells us a couple of things about parenting groups that we might then apply, because it doesn't necessarily tell us, all right, everybody needs to be given a cash reimbursement for telling a parenting group. But it does tell us that there's a significant group of people who aren't opposed to parenting groups, but still don't turn up. So they're happy to go if there's a small incentive there. And some people might think, oh, well, those parents who don't turn up, they don't want to go. They can't tolerate the idea that they need parenting help. They don't believe they need any support. But that's not really what this suggests. It shows that those parents were willing to go and get some advice on their parenting and willing to say, yeah, I'm here to get some help, but they weren't going to do it unless there was something else going on to make this programme work for them. And in this case, that happened to be the money. There's also a significant group of people who find that the cash sways them. So maybe we need to think about money related reasons for non-attendance. Is it that people can't afford transport to and from something that will be familiar to anyone working in a campus department? Is it that people actually have to spend their whole evening out there? So they're going to have to go and get a takeaway on the way home because they're missing the chance to cook a healthy hot meal. Or is it that maybe they were going to do a shift at work? And I talked to lots of parents who work-- who have to skip shifts at work to get to their parenting programmes. We're asking a lot of people to miss work at the moment. Maybe replacing some of that money is what just allows people to justify to themselves why they're turning up. So I think we've got to think really hard about those specific barriers that seem to be emerging from this. And we could deal with every specific barrier per person. We could say, all right, well, for the people who don't have transport, we'll sort out a taxi. For the people who don't have food, we'll sort out cooking for them. For the people who should be at work, we'll write a letter to their boss saying, please, can you just pay them anyways to not be there to hand off work. But overall, it might just be easier for us to give people a cash incentive if it works. So I think there's a policy option there, but it also makes us think a bit harder about the lives of people who are turning up to programmes. Yeah, I think that's a really useful framing, because I can imagine that there being some kind of political sensitivities around payments. So yeah, I think that framing in terms of payments to enable engagement is a really helpful one. So whilst we're thinking about policies. So if you could influence policy based on your research, what changes would you be advocating for? So I don't want to overstate our findings, and I don't think that our study shows that we should be rolling out incentives across the country to everyone, because we don't know whether people are changing their parenting style. We didn't have good evidence of that. So it's actually still possible that people are participating in groups, but not enacting their new learning, not keeping any changes up afterwards. And maybe the incentives actually just don't replace real motivation. So we need to look at a big cluster RCTs that require high level policy support that says, we are going to try this. And we're going to give it a good go. But if it doesn't work, we're not going to follow it up. I do want to come back to the finding that people will turn up when programmes are changed slightly, though. We've got people turning up, not because we changed the core idea that you need to change your parenting style to improve your child's mental health. That's not the thing we changed. What we changed was just giving people some incentives alongside it. So it could be that the incentive is the thing we need to change. It could be that there's other things that we can change in a parenting programme to get that message across. So I think we should be thinking about wider ways to make these 20th century parenting programmes suits 21st century parents. So that leads us on quite nicely about whether you are planning any further studies. Maybe explore some of those questions. Yeah. So since you ask, I'll mention the Pause App. This is an app we've made at Warwick University to support parents to use their parenting skills during programmes and after programmes. So that's really based on the idea of improving the enact stage and improving the participate stage, as well as hopefully ensuring sustainment by giving people lasting, personalised toolkit of the skills that they've been learning during their group. So that's just another way of making parenting skills fit for the modern world, rather than expecting parents to learn in the same way that their own parents did a generation or two back. So we can think about those kinds of approaches. And we're setting up a pseudo randomised controlled trial at the moment to study that. But I also think there's work to do around whether financial incentives themselves are acceptable. And working with staff in local authorities in the UK, in the councils that are providing these to understand their priorities about whether to give people financial incentives for engagement is another key area there. And we've got early signs that that's possible. But following that up is another key area for research. Yeah, really interesting. I'm just wondering, is there a key message for the listeners? I guess the key message for me is that families are missing out. We've got the tools to change this, whether that's incentives or something similar. But getting evidence-based parenting skills, ideas out to family, that's the key thing that we need to work on. And we can change that. But we need to be determined to find an acceptable way of doing that. Great. Thank you so much. It's been a really interesting and thought provoking conversation. I think there's a lot of really important work there. Thanks so much for the conversation. If listeners would like more details on Dr. Nathan Hodson from the University of Warwick, please visit the ACAMH website, which is www.acamh.org. Don't forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review, and do share with friends and colleagues.