Mark Tebbs: 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 kind of director of mental health commissioning in the charity sector, NHS and social care. I'm currently chief executive of a infrastructure charity. So I'm really interested in how we kind of support grassroots organizations 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 of practice, and how we really measure impact and value for money. And I'm also a parent and, have seen the system from a kind of 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 children adolescent mental health. Today, I'm absolutely delighted to be talking to Dr. Lucy Tully, who's the lead author of the JCPP Journal paper entitled, An Online Father Inclusive Parenting Intervention for Reducing Child Conduct Problems, A Randomized Controlled Trial of Family Man. And Simon Rice, who's the global director of Movember Institute of Men's Health. Welcome, really glad to be speaking to you both today. Let's start with some introductions. So if we go with Lucy first, if you could tell us a little bit about yourself, maybe your research interests and a little bit about your career today.
Dr. Lucy Tully: Yeah, absolutely. So I'm a psychologist and I'm a senior lecturer in the School of Psychology at the University of Sydney. I've worked for over 20 years, mainly in clinical research on child mental health and evidence-based parenting interventions. So I work in a clinic at the university called the Child Behaviour Research Clinic, and we provide evidence-based parenting programs for parents of children with conduct problems. Now, in terms of my research interests, I'm really passionate about improving child mental health and supporting parents from very early on in a child's life. So we know that half of mental health problems start before the age of 14 and many mental health problems even start to emerge by the age of five. So it's really important to intervene early and the best way to improve child mental health in the early years is to support parents in their parenting efforts through evidence-based parenting programs. So I'm particularly interested in researching parenting programs that are easily accessible to parents. Now, there are a lot of parenting programs available, but many are lengthy and delivered face-to-face, which requires a practitioner. And these sorts of programs are really costly to deliver, which means that not everyone can participate. So my research focuses on easy-to-access parenting programs like brief programs and online programs. And I'm also really interested in research in fathers. So one of the most important gaps in the field of parenting is that programs have been developed mainly for mothers and tested mostly with mothers. So I've worked on a number of projects that have aimed to understand why fathers don't participate and to develop strategies and programs to increase father engagement in parenting programs.
Mark Tebbs: Thanks Lucy and do you want to just give a little name check for the colleagues you worked with on the paper?
Dr. Lucy Tully: Absolutely. So this paper was a product of a wonderful collaboration between the team of researchers at the University of Sydney and the Movember Institute of Men's Health. So at the University of Sydney, my co-authors were Adrienne Turnell, Bronte Morgan, Professor Mark Dadds and Professor David Hawes. And it's especially important for me to acknowledge the really hard work of the project coordinator for this study, Adrienne Turnell, who managed the recruitment and data collection for this study. At Movember, Jenny Anderson and Anna Kean were also co-authors on the paper. And I also wanted to say that there are a lot of other staff at Movember who helped support this research in so many ways. So it's really important for me to acknowledge their wonderful efforts too.
Mark Tebbs: Brilliant, thanks, Lucy. And to you Simon. Likewise, if you could introduce yourself and say a little bit about the work of the Institute.
Dr. Simon Rice: Thanks Mark. So my name is Simon Rice. Like Lucy, I have a clinical background. I'm a clinical psychologist and I also have an honorary professorial role at the University of Melbourne. And I have the fantastic honour of leading the Movember Institute of Men's Health, which we stood up, Movember stood up in November of 2023 as our vehicle to be speeding up our work in generating impact across men's health. And for us to have a much far reach into influencing men's health policy and government support for men's health at a local level, at an international level, we recognise that we have a way to go in better policies to be supporting men's health. And when it comes to the area of fathers involvement in caregiving, we've definitely got a long way to go there. So it's been amazing that Movember has been able to be involved with supporting the family man work that Lucy's been so skilled at leading.
Mark Tebbs: Brilliant, really looking forward to this conversation. Let's turn to the paper. So could you set the scene for us,
Dr. Lucy Tully: Yeah, absolutely. So the paper aimed to examine the effectiveness of an online father-inclusive parenting program called Family Man, which was developed by the November Institute of Men's Health and Researches at the University of Sydney. So Family Man is a very brief, self-directed parenting program, and by self-directed we just mean that parents work through the content on their own, at home, at their own pace without the help from a practitioner. So the program was designed for parents wanting help with managing child behavior problems, which we call conduct problems. And in this study, we tested the effects of Family Man in a randomized control trial. So eligible families were randomly allocated to Family Man or to a waitlist group. And those in the waitlist group just waited for four weeks before receiving Family Man. So participants in the research were Australian families of children three to nine years who wanted help for their child's challenging behavior. And what we were looking at in this research was whether those who receive Family Man reported significantly greater improvements in child conduct problems and other aspects of parenting and family functioning relative to the waitlist group. And we also wanted to examine whether or not there were differences between mothers and fathers in their outcomes, really to find out if fathers achieved the same benefits as mothers from participating in the program.
Mark Tebbs: Right, let's kind of roll back a little bit. just unpacking what child conduct problems are and how common are they and what are some of the impacts on later mental health?
Dr. Lucy Tully: Absolutely. So child conduct problems involve behaviors like temper tantrums, noncompliance and aggression. So these behaviors are very common. They tend to start very early in life and they can range from quite mild to much more severe. So at the milder end, we all know that temper tantrums and defiance are part of the terrible twos and threes. And behaviors at this age are really developmentally normal and can be quite transient and often just simply improve as children grow and develop their communication skills and their skills in regulating their emotions and behaviors. But it's important to know that these contact problems can be more severe and can really impact on child and family functioning, even from a very young age. And when these problems are much more frequent and severe, they're much more likely to persist over time. So they can lead to a diagnosis of mental health disorders like oppositional defiant disorder, or conduct disorder or other mental health disorders. Now around about five to 10 % of children in the community have conduct problems at the more moderate to severe end. And these problems tend to be much more common in boys than in girls. Now in terms of impact, the Dunedin Longitudinal Study in New Zealand, which is one of the longest running longitudinal studies of child mental health and development, showed that childhood conduct problems were part of the developmental trajectory leading to all mental health problems, including depression, anxiety. So it really does show that these childhood conduct problems are an important risk factor for poor mental health problems in adulthood. And it's not just poor mental health either. There's evidence that childhood conduct problems can lead to negative outcomes in other areas too. So poor educational outcomes like school dropout, involvement in crime, all of which are quite costly to society.
Mark Tebbs: So, yeah, so relatively common and with potentially very significant impacts. So, parenting interventions are often talked about as a way to address conduct problems. What does the research say about how effective they normally are?
Dr. Lucy Tully: Yeah, well parenting interventions or parenting programs are really the gold standard treatment to address childhood conduct problems. So these interventions tend to focus on teaching parents evidence-based strategies, such as strategies to encourage positive behavior and strategies to effectively manage challenging behavior. Now it is important just to emphasize here that it's not that parenting causes contact problems, but oftentimes what happens in families where children have these problems is that parents and children get caught up in this coercive cycle of interaction. And oftentimes they end up using more ineffective parenting strategies, which can increase contact problems. Also, children with contact problems tend to respond well to certain types of parenting. And this is parenting which is very positive, involves a calm response to problem behavior and consistent limit setting and discipline. Now the evidence shows that parenting programs are pretty effective. So overall about two thirds of children whose parents participate in a program will show clinically significant improvements in their child's behavior. Now, as I mentioned earlier, much of the research on parenting programs has been done with mothers and we know much less about how effective these programs are for fathers. It is also important to say that traditional parenting programs can be quite lengthy. So they can be typically around eight to 10 sessions in length but even as many as 20 or 30 sessions. And there tends to be high dropout rates. So busy families find it really difficult to make their time to attend these long programs. So we really need to develop much briefer programs so that families can easily fit these programs into their lives.
Mark Tebbs: Brilliant. So you mentioned earlier in the instructions that fathers in particular haven't always engaged as much in those kind of traditional parenting interventions. Why is that? What's the research behind that?
Dr. Lucy Tully: Yeah, it's really interesting because we've done a few studies to try and identify why fathers don't engage as much. And we found that there's a lot of factors that may lead to fathers being less involved than mothers. So we did a survey a few years back with a thousand fathers and we found that cost of the service was the most frequently rated barrier, which is quite surprising given that many of parenting programs in the community are provided free of charge. But this is likely to relate to costs for private practitioners, such as seeing a psychologist or seeing a pediatrician. But some of the other barriers identified by fathers included work commitments. So simply not being able to attend programs during working hours. And most face-to-face programs are still offered only sort of in that nine to five window. Other factors included simply not being aware of parenting programs. So this really suggests the importance of offering free programs offering programs that are available outside of working hours and having media campaigns to direct fathers to the availability of these parenting programs. We also did a survey with 200 practitioners who work with families to find out their perspectives on father engagement. And the main barriers that these practitioners reported were fathers not having time again, fathers discomfort in receiving parenting assistance, and also fathers feeling like it's a mother's role to parent the children. We also found that factors such as practitioner confidence and competence in engaging fathers and whether or not the organization was supportive of father engagement were also important factors for getting fathers involved. So we actually went on to develop a training program for practitioners focused on improving their skills and competence in how to engage fathers. And we tested that training program in a study. And we found that practitioners who received that training had significant improvements in their competencies. So really this shows the importance of providing training programs to practitioners. Now we also know that most parenting programs are developed and tested for mothers and really don't meet the needs of fathers. And there's a bit of research to show that when fathers hear the term parenting program, they equate it with a mothering program. So it definitely seems important to advertise that programs are suitable for both fathers and mothers.
Mark Tebbs: So Simon, guess this is where kind of Movember came in with Family Man. So what was your motivation behind kind of developing and funding the program?
Dr. Simon Rice: Well, I think Lucy's really hit the nail on the head with so many points there that so many dads, so many fathers perceive parenting or a parenting program to be directed at the mum and that that is the mother's role to be engaging in that. And there are very, few examples of programs or interventions which are framed with the needs of men in mind, so that the needs of a dad primarily. Family man is a rare exception to that from all elements of it through to the name, through to the design, through to how it looks and feels that it has purposefully been built to engage men to be engaging to fathers. And so it clearly communicates that this is something that has been built with you very clearly in mind as the end user and the expectation that it's going to be really effective to engage with you as a dad struggling with many of the challenges that many dads and many parents do with difficult early childhood behaviours. So I think it's in sensitising it, in making it much more responsive to the needs of men lies where its success is. We sometimes see that in our field of mental health, if we develop an intervention that's more focused towards women, the likelihood of men or young men engaging with that intervention is very low. Conversely, if we build it more with the gender neutral or focus on engaging men, we tend to do much better engaging men and it often will do pretty well at engaging women as well. So it's a useful steer to us to be thinking through multiple lenses. Obviously we need our evidence-based interventions to be top quality, but we need the marketing to be really good as well.
Mark Tebbs: So how would it look like if I was using Family Man? How would it be different to a of a traditional package or program?
Dr. Lucy Tully: Well, so it's the first parenting program that I'm aware of that has an animated format, which is really engaging. It's also very funny with lots of laugh out loud moments and the central characters that appear in the program are fathers, which really highlights and models the important role of fathers in parenting. It also includes this choose your own adventure style of format which asks what the user thinks the parent depicted in the program should do next in a certain situation. And then it shows what happens based on what the user selects, eventually going on to show and explain what the correct choice is and why. So by doing this, the user is learning in a really engaging way why certain parenting responses are more effective than other types of responses. Now the whole program is only three episodes in length and each episode can be completed in less than 20 minutes. The focus is really on how to encourage the positive behavior and how to manage the challenging behavior effectively, both in the home and then in difficult situations outside the home. So the whole program can be done in less than an hour. And as I said earlier, traditional programs are typically eight to 10 sessions. They can be as long as 30 session. So it really is a very brief or what we call a light touch program. It's also quite different from traditional approaches due to the father-focused branding, of course, which Simon mentioned. It's called Family Man. So the program is directly appealing to fathers. As Simon said, mothers are still welcome and encouraged to participate. And it's been really interesting to find that the name of the program does not seem to deter mothers from participating. It's also different from traditional programs due to it being online. So it's very accessible to fathers who want to participate in these programs outside of work hours. And our survey of fathers showed that fathers much prefer these online programs to face-to-face programs. They also prefer brief programs to lengthy programs. So it really does meet the needs and preferences of fathers in terms of its format and delivery.
Mark Tebbs: Yeah, I had a look at it earlier actually, it's really easy to find and it was really informative and engaging. But yeah, there was lots of kind of challenging bits there too. It was really, you know, was very impressed. It very, very good. So could we just like turn back to the kind of methodology of the study?
Dr. Lucy Tully: Yeah, well we really wanted to conduct a randomized control trial because they're considered the gold standard in research and really kind of the best research designed to show evidence of effectiveness. So we decided on this random allocation to either the family man group or the waitlist group and we included a two-month follow-up for the family man group just to examine whether or not the effects of the program continue or last over time. Now in terms of conducting the study, we recruited families Australia-wide through various methods, including social media, outreach to preschool schools, and even through our own university child behaviour research clinic. Overall, took us about six months to recruit the sample and we had 103 families participating in the research.
Mark Tebbs: and were there any particular sort of challenges or hurdles you faced in that kind of research process?
Dr. Lucy Tully: Yeah, what was really interesting here is that we found it difficult to engage fathers directly. So mothers were the main instigators of help seeking in this study. Although it's really important to point out that in this study, we needed to conceal the name of the program from potential participants since the Family Man program was already freely available at the time of the study. So we didn't want the wait list participants to know this find the Family Man website and participate in the program during the waitlist period, which of course would have interfered with the study and the findings. So this meant that we couldn't say the program name Family Man in the advertising materials, which may have attracted more fathers if we were able to do so. However, we did advertise that the program was for fathers and mothers, and even then less than 10 % of our inquiries were from fathers. But despite this, we did have an overall good participation rate from fathers. So more than 80 % of available fathers participated in that study. But this was a result of indirect engagement by mothers. So mothers prompting or encouraging fathers to participate rather than this more direct engagement. And other researchers have also found that mothers seem to be the main instigator of help seeking when help is needed for their child's mental health. So there does seem to be these gender role stereotypes regarding seeking help and mental health. And we need more research to understand this and to examine strategies to encourage fathers to reach out and to instigate help seeking.
Mark Tebbs: Right, so what were the kind of key findings of the work?
Dr. Lucy Tully: Yeah, well, we found that those who participated in the Family Man program showed significant improvements in parent reports of child conduct problems relative to those in the waitlist group at the post-assessment. We also found improvements in Family Man and the waitlist for all the other outcomes we looked at. So these outcomes included things like negative parenting practices, parent mental health and wellbeing parenting self-efficacy, which is the extent to which parents feel like they're doing a good job as parents. Also conflict between parents over parenting and even chaos in the home environment. And these improvements at post in the Family Man Group were also maintained at this two month follow-up. So when I say maintained, I just mean the improvements did not deteriorate or go backwards and there were no further improvements. But this is really good news because sometimes what you expect is that deterioration happens in these really short programs. And we didn't find this, but instead found that these positive effects really lasted over time. And we also didn't find a different pattern of results for mothers and fathers. So it seems both parents are really benefiting to this same extent from participation in the program. We also found that satisfaction rates for the program were high and they also didn't differ for mothers and fathers, which was great to find.
Mark Tebbs: So how could this research make a difference for families or practitioners working in the field?
Dr. Lucy Tully: Yeah, well look, our research shows that even a very brief online self-directed program can have these great effects. And it can change the way we offer parenting support. So not all parents need these costly and resource intensive face-to-face programs. Certainly some families will require this, but many parents can benefit from doing these online programs on their own with no practitioner involvement. Also these brief online programs like Family Man, can and are being used as a waitlist management strategy. So what we mean here is that some face-to-face services for child mental health have really long waitlists, waitlists as long as six to 12 months. And programs like Family Man can be offered to parents who are waiting to face-to-face services. So many families will benefit enough that they no longer then need the face-to-face services. And then only those who need help at the end of the program are then stepped up to more intensive practitioner-based programs. So this really allows more cost-effective use of practitioner time and resources.
Mark Tebbs: I'm wondering what the Institute are doing in terms of the promotion and support of the kind of rollout of Family Man.
Dr. Simon Rice: Well, it's fantastic that the results of the Family Man RCT are so strong. And so we've got a really robust evidence base that the program has built on. that's specific to the results of the RCT, but also the underpinning work coming into that that Lucy and her team have done over many years. We at the Institute, the Movember Institute of Men's Health, want to make sure that we're able to promote this and maximise the number of families and especially dads who are able to engage with it. So the Family Man resource is available for anyone to use. It's free on the internet, familyman.movember.com. People can come, test it out. The user experience is really strong. It's engaging. It offers something of significant value, especially because it's free as well. So it takes away that barrier. And it... to the points that we've talked about, it really has been built with the needs of men and dads and new dads in particular. recently, the outgoing US Surgeon General in America, Dr. Vivette Murphy, was talking about statistics in the range of 41 % of parents being so stressed out that they can barely cope. And that relates to about 20 % of...non-parents in the general population. we are seeing trends where parents are experiencing significant strains and challenges on their mental health, the way in which they manage difficult and challenging behaviours in the young people they're looking after can contribute to that. And so we want to make sure that we do our part, that Movember can do our part in upskilling dads to be able to be the best dads they can be, because that caregiving role is just so important in a family's developmental trajectory.
Mark Tebbs: I'd just like to also just think about maybe some of the policy implications. Are there any changes that you'd like to see on the back of the RCT results?
Dr. Lucy Tully: I think the main point is about engagement of fathers in services for child mental health. So fathers really need to be core business in services for children and families like mothers are, and every effort needs to be made to engage them. At the policy level, organizations really need to develop policies and practices about engaging fathers and conduct training on father engagement, since we know that that does make a difference to practitioner skills and confidence. Organizations should also record and track levels of father participation as evidence of success in their father engagement strategies. Now we previously did a study to try and benchmark levels of father engagement in different services for child mental health in Australia and we included 11 organizations and not one of those organizations was routinely keeping data on father engagement levels. So it's not something that's currently prioritized in clinical services but it definitely needs to be.
Mark Tebbs: Yeah. And same sort of question to you, Simon. Are there kind of policy changes that Movember are seeking that could improve father involvement in parenting?
Dr. Simon Rice: Movember definitely has a strong interest in supporting policies at a global level, at a national level that better enable men dads to be involved in the caregiving experience. so ranging from caregiver leave, paternity leave, which varies significantly from country to country. Many countries offer fantastic and significant leave and others differ in what they're able to provide. But we see that that has such a profound role in not only supporting gender equity, but deepening the bonds in which fathers can establish with their children and also challenging cultural norms. And I think there's a really strong piece here around that, that too many dads and men see that the parenting role needs to be deferred to women and to the expectations that women will be able to be the ones who can shoulder doing courses, up-skilling, when there is absolutely opportunity for that to be shared amongst all parents engaged in caregiving. So through instituting policies on a national level that are more engaging and supportive of father involvement, we can see a real shift there.
Mark Tebbs: It's so important on every level. I'm just wondering, is there any further work you're doing in the area, any kind of follow up research from this study?
Dr. Lucy Tully: Yeah, look, we would really like to follow up families in the Family Man Group in the longer term to see if the improvements are maintained. So we only included the two month follow-up and there's a really important question about whether or not the effects of these brief programs are sustained over longer periods of time or whether or not there's deterioration. So it would be great to do a one or a two year follow-up to see if these improvements continue. So we're just looking for funding at the moment to try and support that research. Now, also, as I said earlier, only two thirds of families tend to respond well to these types of parenting programs. And we're now doing a new program of research a new intervention that's called measurement-based care for the one-third who don't respond to these programs to see if that improves outcomes.
Mark Tebbs: So we're coming to the end of the podcast. So Lucy, is there like a final sort of take home message for our listeners?
Dr. Lucy Tully: Yeah, I've got three key points I want to make here. So first off, for practitioners who work with parents, it's really important to engage fathers as well as mothers. The program that you offer and provide is much more likely to be effective for children when you have all available parents participating. We know it's common for practitioners just to work with whoever shows up at the service, and that's usually mothers. But there are lots of ways to engage fathers. It may mean a phone call to the father to emphasize his expertise and engage him in the service then flexibility to engage him in different ways in the program. For researchers, it's very important to include fathers as well as mothers when doing research on parenting and parent interventions. It continues to be the case that most research is done with mothers. And it means that we are really just examining mothering rather than parenting. So new programs must be developed and tested with fathers as well as mothers. And finally, for parents of children, if you do have a child three to nine years,you're welcome to complete the Family Man program as Simon said. So Family Man can be helpful if you have concerns about your child's behavior, but even if you don't have any concerns and you're just keen for more information on effective parenting strategies, you're welcome to participate. So you can find the program at familyman.movember.com. It's free, it's suitable for all parents, and it's evidence-based.
Mark Tebbs: Right, and Simon, same question to you. Is there a take-home message for our listeners?
Dr. Simon Rice: The Movember Institute is very proud to have partnered with Lucy's team on the research component and the development of Family Man. We're really excited that it's an offering that will be available for many years to come. We really want to see more people use it, especially dads. And the Institute will be having a much stronger focus on supporting men's healthy relationships and effective relationships as a determinant of their mental health and the impact that they have on other people and we're that impact to be as positive as possible. It's very much our view that healthier men equal a healthier world and we see that the Institute's role, that we can play a small role at least in providing dads with good parenting advice through the Family Mania intervention.
Mark Tebbs: Lucy Simon, thank you so much for your time and for such an interesting conversation and letting us know about all of this important work. Don't forget to follow us on your preferred streaming platform. Let us know if you enjoy the podcast with a rating review and do share with friends and colleagues.