Evidence

[Narrator and text on screen] 

One in ten young children struggle with managing their emotions and behaviour. This can have an impact on them now and in the future. Parents can make a big difference, but it’s important they have the tools and support to help them. 

The Healthy Start, Happy Start Study tested whether a program called VIPP 

[Text on screen] Video-Feedback Intervention to Promote Positive Parenting could help reduce children’s challenging behaviour. 

300 families with young children took part. Health professionals visited half the families at home and videoed parents playing with their children. They reviewed the videos with the parents, providing feedback highlighting moments of positive parenting. The other half of the families continued as normal. 

We followed these families over two years, we found that children whose families received VIPP had less challenging behaviour compared to those who did not. 

VIPP is one of the first programs delivered through the NHS that helps improve behaviour and strengthen mental health in young children 

[Text on screen] Happy Start, Health Start 

To get in touch contact us at Pedal@educ.cam.ac.uk 

HappyStart.org.uk 

This study is funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme grant (13/04/33). 

The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. 

[Logos on screen] 

Imperial College London 

Supported by NIHR (National Institute for Health Research) 

PEDAL (Play in Education Development and Learning) 

VU University Amsterdam 

Erasmus University Rotterdam 

University of Oxford 

The University of Warwick 

King’s College London 

University of Cambridge Faculty of Education 

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This is a plain English summary of an original research article

An intervention to help parents manage behaviour problems in young children had a lasting benefit. Researchers videoed parents and children at home, then provided detailed feedback on their interactions. They found improvements in the children’s behaviour that lasted for at least 2 years.

Young children with behaviour problems may be restless, aggressive or impulsive. These behaviours have been linked with mental and physical health problems, social difficulties and delays in learning. Early intervention could address behaviour problems before they become established.

This study included 1 and 2 year olds who had early signs of behaviour problems. All received standard care from GPs and health visitors. But in addition, half were assigned to the video feedback (VIPP) group. This meant 6 home visits from healthcare professionals, who filmed parents and children doing activities together. The professionals then provided parents with feedback. They aimed to promote parents’ sensitivity, ability to identify their child’s behaviour and respond appropriately, and provide sensitive, consistent discipline.

At 5 months, researchers found fewer behaviour problems in the group who received video feedback. This effect was largely sustained 2 years later. The researchers say the approach could be an effective part of routine NHS care.

Further information on child behaviour problems is available on the NHS website.

What’s the issue?

As many as 1 in 10 children have behaviour problems. They can make up 30% of a GP’s consultations with children, and account for almost half (45%) of children’s referrals to community services.

Behaviour problems can have a long-term impact. They are associated with mental and physical health problems, as well as learning and social difficulties. They also cause distress within the family. In the long-term, these childhood problems can have broader costs. They increase the risks of criminality, antisocial behaviour, and unemployment.

The quality and style of care given by parents can influence children’s behaviour. Young children whose parents are less sensitive, and use harsh discipline, can be at risk of developing behaviour problems. Most parenting programmes therefore address sensitivity and discipline.

Early behaviour problems can be spotted in 1-2 year olds. Intervening quickly, before problems become established, might therefore increase the impact of behaviour programmes. However, few effective interventions are available for parents and very young children.

This study is part of the ‘Healthy Start, Happy Start’ project. The video feedback was intended to help parents become more ‘in tune’ with their child, and to understand subtle behaviour cues. It aimed to encourage parents to empathise with their child, and respond sensitively.

The study aimed to find out whether video feedback could be used routinely within the NHS.

What’s new?

The study was carried out at 6 NHS Trusts in England. A brief screening questionnaire identified children with behaviour problems who were, for example, restless, aggressive, impulsive or had tantrums. The study included 300 children, aged 1 or 2 years old.

All parents had access to usual care. This was often advice from a GP or health visitor, or support from children’s mental health services. In addition, half the parents had 6 sessions of video feedback. Professionals (health visitors, nursery nurses and psychologists, or others working in child health who had been trained to provide the intervention) visited homes every 2 weeks.

In the first half of the session, the parent was filmed reading, playing, eating with their child, or doing other everyday activities together. In the second half, parents received feedback prepared from the previous visit.

The researchers carried out a structured interview with parents at the end of the 5-month programme. Parents also answered questionnaires.

At 5 months:

  • structured interviews found that children in the video feedback group had fewer behaviour problems than those receiving usual care; the average difference corresponded to mild tantrums (shouting) rather than severe (breaking things), or happening once or twice a week rather than daily
  • parent questionnaires rated children’s behaviour better in the video feedback group than in usual care group
  • the programme had more impact on behaviour such as hitting and tantrums (conduct) than on restlessness (hyperactivity), which is thought to be more ingrained and difficult to change with psychological treatments
  • the programme had most impact on those who received at least 4 sessions, and in those with more severe behaviour problems.

Two years later, structured interviews showed that children in the video feedback group still had lower levels of behaviour problems than those who had received usual care. The difference between the groups was only slightly less than in the earlier assessment. The effect remained stronger on behaviour than on hyperactivity. The programme did not affect parents’ mood, anxiety, or functioning as a couple.

The researchers looked at the cost-effectiveness (value for money) of the programme. They found that the video intervention cost £1466 per family (£1450 more than standard care). The question is therefore, how much commissioners are willing to pay to help parents manage their children’s behaviour.

Why is this important?

This study shows that it is possible to provide a video feedback programme as part of routine NHS care. It was effective in 1 and 2 year olds showing early signs of behaviour problems. Differences in behaviour could still be seen 2 years later, which suggests that intervening early could stop problems getting worse.

Behaviour problems were identified using a simple, brief screening questionnaire. This approach that could be used routinely by health visitors and others working to help young children and their families. However, the NHS does not currently have standard care pathways for early-onset behaviour problems.

The research supports the idea that those with particularly high levels of behaviour problems may benefit most, and that more sessions lead to better outcomes.

The analysis of costs was not conclusive. Costs related to programme (such as visits to the GP) can be measured. But the long-term impact on society (including criminality, poor health and employment), could not be quantified. It may be that long-term benefits for society would outweigh the immediate costs of the programme.

What’s next?

The researchers are now following children up 5 years after the original study. They hope this will provide more information for policy makers about long-term benefits and value for money of the intervention. The intervention is not used routinely, but some services have already adopted it.

It would be helpful to identify the groups of children who may benefit most. Other research is testing the programme in different groups, including foster parents. More parents in this study had post-school qualifications than in the average population. It would be useful to see if the programme is as effective in the general population.

This programme focused on sensitivity and discipline and was most effective at decreasing conduct problems. The researchers would like to better understand the aspects of the programme which brought benefits.

They would also like to explore whether booster sessions or additional interventions later in childhood could enhance the benefits of this early programme.  

You may be interested to read

This NIHR Alert is based on: O’Farrelly C, and others. A video-feedback parenting intervention to prevent enduring behaviour problems in at-risk children aged 12-36 months: the Healthy Start, Happy Start RCT. Health Technology Assessment 2021;25:29

Results of the main trial: O’Farrelly C, and others. A brief home-based parenting intervention to reduce behavior problems in young children: a pragmatic randomized clinical trial. JAMA Pediatrics 2021;175:6

A news piece from the University of Cambridge's Faculty of Education: Video-led feedback programme reduces behaviour problems in children as young as 12 months.

The researchers' blog for health visitors about the study.

A video on the Healthy Start, Happy Start study.

Funding: This research was funded by the NIHR Health Technology Assessment programme.

Additional funding also came from the NIHR Biomedical Research Centre at Imperial College Healthcare NHS Trust and Imperial College London.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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Comments

Study author

It has been recognised for a long time that we should be worried about early behaviour problems in children. We wanted to look at the best approach in young children, before problems become entrenched.

The feedback parents get is positive and focuses on things that are going well. It’s about helping the parent notice the communication of the child and respond appropriately.

Interventions such as this don’t always do well in trials. It was encouraging to find an effect straight away, and then to see that it looks like that effect is sustained.

Paul Ramchandani, Professor of Play in Education, Development and Learning at the University of Cambridge

Family support group

Being a parent can be both rewarding and challenging, and all parents will benefit from others coming alongside them as they bring up their children. As a charity whose work supports parents of children in the early years, we welcome the development of early engagement with families to promote positive, sensitive caregiving and develop strong, healthy family relationships.

Early intervention has the potential to benefit the child throughout their life in terms of their healthy development and mental well-being, and to improve the parent’s fulfilment and depth of relationship with their child. However it can also deliver economic benefits for society, through a reduction in criminal activity, substance misuse and mental health difficulties.

As the paper observes, intervening earlier in childhood could be effective both clinically and economically, provided that there is reliable identification of children at risk. It would be good to see this explored further, together with more research into early childhood to assess targeted interventions and also proactive, universal engagement with families. Such early support for parents could be highly significant in preventing the development of harmful behaviours and mental health difficulties.

Mark Chester, Parent Support Manager, Care for the Family

Member of the public

Children with behaviour problems affect the education of all our children. As a member of a Schools Admissions Appeals Panel, I see the impact of chaotic families, and children at risk, on schools.

Further research may be helpful to look at whether different behaviour problems should be managed differently and whether different ages should be managed differently. More targeted and specific interventions and guidance may prove to be still more costly. But this needs to be measured against further improvements in success rates and the accompanying long-term benefits for all.

Public Contributor

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