Objectives Despite a large evaluation literature for interventions aiming to improve the lives of families affected by parent substance misuse, very few studies have examined how families change when engaged with treatment. This study examines the interactive process of change in parent psychopathology and mindful parenting during participation in the Parents under Pressure (PuP) program for parents engaged in community addiction services. Methods Parents ( n = 164) provided baseline, mid- and end-treatment measures of parent psychopathology and mindful parenting. Cross-lagged modelling was used to examine therapeutic process of change. Results Parent psychopathology decreased, and mindful parenting increased from baseline to end-treatment ( p s < .001). Less psychopathology at mid-treatment predicted higher levels of overall mindful parenting upon completion of the PuP program ( p = .005). Examination of the mindful parenting dimensions revealed variation in the therapeutic process of change. While higher levels of Non-Judgemental Acceptance of Parental Functioning (NJAPF) at baseline predicted lower psychopathology at mid-treatment ( p = .03), higher levels of Compassion for Child (CC) at baseline predicted greater psychopathology at mid-treatment ( p = 0.004). Higher levels of NJAPF mid-treatment predicted lower psychopathology upon treatment completion ( p = .023), yet higher levels of Emotional Awareness of Child (EAC) at mid-treatment predicted greater psychopathology upon treatment completion ( p = .023). Lower parent psychopathology at mid-treatment predicted higher levels of LFA, EAC, Self-Regulation in Parenting and NJAPF upon completion of the PuP program ( p s < .05). Conclusions The findings highlight the importance of reducing parent psychopathology as a precursor to more mindful parenting and also provide new evidence regarding the way in which variation in mindful parenting dimensions influences the therapeutic process of change.

This study presents the feasibility and pilot evaluation of the Reflective Fostering Programme (RFP), a recently developed, group-based program to support foster carers, based on the concept of “reflective parenting.” This innovative development follows calls by the National Institute for Health and Clinical Excellence and other organizations to help improve outcomes for children in care by providing better support to their carers. This study aimed to establish whether it is possible to implement the RFP and to gather preliminary data on the acceptability and effectiveness of the program. Twenty-eight foster carers took part in the study. Results indicate that training and delivery of the RFP were feasible; the program was felt to be relevant and meaningful to both foster carers and social care professionals delivering it. Preliminary pre-post evaluation showed a statistically significant improvement in foster carers’ stress, their achievement of self-defined goals and child’s emotion lability and overall strengths and difficulties. There were no statistically significant changes in carers’ reflective functioning, although some foster carers reported on changes in reflective capacity during focus groups. Preliminary findings about the feasibility of training and delivery of the RFP, as well as the acceptability and effectiveness of the program, are encouraging, but further impact evaluation is needed.

We argue that major health and social care policy initiatives are not too complex for randomised controlled trial (RCT) methodology and illustrate this using the example of the Best Services Trial (BeST?): a RCT of an infant mental health intervention for maltreated children. We suggest that qualitative research, as a core part of the trial process from conception and development through to implementation and evaluation, is crucial in building, understanding and strengthening the partnership required to drive such a complex trial. Data pertinent to trial implementation demonstrate the iterative nature of the process whereby stakeholders are consulted and their views influence the conduct of the trial. Here we reflect on the bi‐directional relationship between qualitative data collection and partnership‐working in a trial. For very complex trials to be possible, significant resource needs to be available for the qualitative component.Key Practitioner Message: • Qualitative research is key to understanding, building and strengthening partnership approaches to researching complex interventions; • Qualitative research is vital to supporting randomised controlled trials involving multiple sectors; • Qualitative research provides essential explanatory power to outcome data in research.

Despite knowledge about the profound effects of child abuse and neglect, we know little about how best to assess whether maltreated children should return home. The effectiveness of the New Orleans Intervention Model (NIM) is being tested in a randomized controlled trial where the comparison is social work ‘services as usual.’ The future trial results will tell us which approach produces the best outcomes for children; meanwhile qualitative process evaluation is generating intriguing findings about the perceived impact of NIM on decision-making about childrens’ futures. Interviews and focus groups were conducted with social workers, foster carers, legal decision-makers and the NIM team (n=63). Data were analysed thematically. Findings suggest that NIM is seen as bringing greater influence (‘clout’) to decision-making due to its depth of focus, provision of treatment for the family, health professional input and perceived objectivity. Simultaneously, the NIM approach and the detailed information it produces potentially throws judgments into doubt in the legal system. Clout/doubt perceptions permeate opinions about NIM and are inter-related with a historical discourse about ‘health versus social’ models of information gathering, with implications for assessment of child abuse and neglect that extend beyond the study context. The juxtaposition of ‘clout versus doubt’ both highlights and is strengthened by an intense focus among social workers and legal professionals on how evidence will be regarded within legal fora when making decisions about children. There is continuing uncertainty in the child welfare system about the best ways of assessing maltreated children, underscoring a continued need for the trial.

Obtaining informed consent can be challenging in stressful and urgent circumstances. One example is when potential participants have recently had their child removed into care; intervention is urgent and mandatory whereas participation in associated research is voluntary. Using a nested qualitative study, we examined experiences of consent processes in a randomised controlled trial of a family assessment and intervention service for maltreated young children. Some potential participants found it difficult to use information; some believed consenting might influence the return of their child. In response to these ethical challenges, we propose reversing the typical process of securing consent, so that randomisation to an intervention occurs before inviting potential participants to consider the trial. This will avoid delays, delineate research from intervention, and make it easier to consider information. We suggest that this innovation could be useful in trials across service areas that incorporate urgent and complex interventions.

Young mothers living in low-income urban settings often are exposed to significant and chronic environmental difficulties including poverty, social isolation and poor education and typically also have to cope with personal histories of abuse and depression. Minding the Baby® (MTB) is an interdisciplinary home-visiting programme developed to support first-time young mothers, which integrates primary care and mental health approaches into a single intensive intervention from the last trimester of pregnancy until the child’s second birthday. The primary aim of the intervention is to promote caregiver sensitivity, and, secondarily, to promote both child and maternal socioemotional outcomes.

Macdonald G, Livingstone N, Hanratty J, et al. The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis. Southampton (UK): NIHR Journals Library; 2016 Sep.(Health Technology Assessment, No. 20.69.)

Macdonald G, Livingstone N, Hanratty J, et al. The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis. Southampton (UK): NIHR Journals Library; 2016 Sep.(Health Technology Assessment, No. 20.69.)

Background Child maltreatment is a substantial social problem that affects large numbers of children and young people in the UK, resulting in a range of significant short- and long-term psychosocial problems. Objectives To synthesise evidence of the effectiveness, cost-effectiveness and acceptability of interventions addressing the adverse consequences of child maltreatment. Study design For effectiveness, we included any controlled study. Other study designs were considered for economic decision modelling. For acceptability, we included any study that asked participants for their views. Participants Children and young people up to 24 years 11 months, who had experienced maltreatment before the age of 17 years 11 months. Interventions Any psychosocial intervention provided in any setting aiming to address the consequences of maltreatment. Main outcome measures Psychological distress [particularly post-traumatic stress disorder (PTSD), depression and anxiety, and self-harm], behaviour, social functioning, quality of life and acceptability. Methods Young Persons and Professional Advisory Groups guided the project, which was conducted in accordance with Cochrane Collaboration and NHS Centre for Reviews and Dissemination guidance. Departures from the published protocol were recorded and explained. Meta-analyses and cost-effectiveness analyses of available data were undertaken where possible. Results We identified 198 effectiveness studies (including 62 randomised trials); six economic evaluations (five using trial data and one decision-analytic model); and 73 studies investigating treatment acceptability. Pooled data on cognitive–behavioural therapy (CBT) for sexual abuse suggested post-treatment reductions in PTSD [standardised mean difference (SMD) –0.44 (95% CI –4.43 to –1.53)], depression [mean difference –2.83 (95% CI –4.53 to –1.13)] and anxiety [SMD –0.23 (95% CI –0.03 to –0.42)]. No differences were observed for post-treatment sexualised behaviour, externalising behaviour, behaviour management skills of parents, or parental support to the child. Findings from attachment-focused interventions suggested improvements in secure attachment [odds ratio 0.14 (95% CI 0.03 to 0.70)] and reductions in disorganised behaviour [SMD 0.23 (95% CI 0.13 to 0.42)], but no differences in avoidant attachment or externalising behaviour. Few studies addressed the role of caregivers, or the impact of the therapist–child relationship. Economic evaluations suffered methodological limitations and provided conflicting results. As a result, decision-analytic modelling was not possible, but cost-effectiveness analysis using effectiveness data from meta-analyses was undertaken for the most promising intervention: CBT for sexual abuse. Analyses of the cost-effectiveness of CBT were limited by the lack of cost data beyond the cost of CBT itself. Conclusions It is not possible to draw firm conclusions about which interventions are effective for children with different maltreatment profiles, which are of no benefit or are harmful, and which factors encourage people to seek therapy, accept the offer of therapy and actively engage with therapy. Little is known about the cost-effectiveness of alternative interventions. Limitations Studies were largely conducted outside the UK. The heterogeneity of outcomes and measures seriously impacted on the ability to conduct meta-analyses. Future work Studies are needed that assess the effectiveness of interventions within a UK context, which address the wider effects of maltreatment, as well as specific clinical outcomes. Study registration This study is registered as PROSPERO CRD42013003889. Funding The National Institute for Health Research Health Technology Assessment programme.

Macdonald G, Livingstone N, Hanratty J, et al. The effectiveness, acceptability and cost-effectiveness of psychosocial interventions for maltreated children and adolescents: an evidence synthesis. Southampton (UK): NIHR Journals Library; 2016 Sep.(Health Technology Assessment, No. 20.69.)

Key Practitioner Messages SafeCare is a structured training programme for parents, developed in America for families where there were concerns about possible neglect or abuse. SafeCare has been implemented in six NSPCC sites. An evaluation is considering whether and how it can contribute to the prevention and amelioration of child neglect in the UK. The service development and early implementation experiences are outlined, including the varying practitioner responses to the implementation of a structured, manualised programme.