A parenting intervention, developed by the Mikhulu Trust, and successfully trialled in South Africa, holds great promise as early violence prevention initiative.
There is great concern about the level of violence in South Africa. In the 12 months to March 2016, there were 18,673 murders in South Africa, almost 5% more than in the previous year and almost 20% higher than four years previously. And rates of other violent acts, such as rape and domestic violence have been similarly alarming. Several agencies are tackling the question of what to do about this.
Clearly, intervention is needed at multiple levels, including dealing with the impact of poverty and poor housing, ensuring effective policing and an effective justice system, changing cultural norms about violence, reducing access to firearms, and tackling youth gang involvement and drug trafficking. But one area of risk for later violence that has received little attention in South Africa so far is the prevention of early child aggression.
Preventing early child aggression
Strikingly, within the normal lifespan, the time when people are most aggressive is when they are just two years old. Beyond this age, aggression typically reduces as children learn better ways of handling threat and managing frustration.
The challenge, therefore, is not how to prevent this ‘normal’ aggression arising, but how to help children to acquire adaptive ways of overcoming aggressive impulses. This is important, because aggression that becomes an established and persistent behaviour pattern by age three to four, is the strongest early personal risk factor for later violence and criminal behaviour. Indeed, longitudinal studies suggest that these persistently aggressive children account for at least half of all adolescent and adult crimes.
The risk factors for early aggression and conduct problems and their related consequences of violent delinquency and criminal offending are well-established. At the individual level, the critical risk factors are impulsivity and deficits in attention and low levels of general cognitive functioning.
Additionally, insecure attachment, together with associated poor social understanding and empathy have also been associated with behaviour problems. At the family level, the key risk factors include harsh or inconsistent discipline, poor cognitive stimulation and support, and unresponsive, insensitive parenting. The way in which these risks could interact during the early years of a child’s life, to cause increased risk for later violence, is shown schematically below:
What can we do? Secure child attachment, prosocial behaviours and positive parenting
It has yet to be demonstrated empirically that simultaneously targeting the three sets of parenting variables indicated in the figure has a substantial impact on rates of subsequent violence, but there is considerable encouraging evidence.
Interventions that enhance maternal sensitivity do lead to improvements in rates of secure child attachment, with associated reductions in adverse outcomes; and interventions that enhance child social understanding and increase empathy are associated with improved prosocial behaviours and with lower rates of behaviour problems.
Programmes that reduce harsh parental discipline are associated with reduced levels of child aggression. And supporting parents in stimulating child learning does improve child language and cognitive development, which, in turn, are associated with reduced rates of child behaviour disturbance. Further, the limited longitudinal evidence that does exist indicates that early parenting programmes are beneficial in reducing delinquency and crime in adolescence and early adulthood.
Brief parenting interventions for cost-effective implementation
The findings from these studies are very encouraging, but they present the South African policy maker with a problem. While there is good evidence from many of the relevant intervention programmes that, in the long term, they are cost effective – in terms of the substantial savings in policing, legal, and incarceration costs - in the short term they can be expensive.
For example, one of the most successful early intervention programmes is the Nurse Family Partnership (Olds et al, 2007), which has been shown to produce a 16% reduction in offspring crime levels and savings of twice the cost of the intervention itself. However, this programme is one in which trained nurses make bimonthly home visits for two years; and, notably, when para-professionals have been used as home visitors, the benefit to families was substantially reduced.
What is needed for South Africa, and other countries with high rates of violence and limited resources is a brief parenting intervention that can be delivered relatively inexpensively by lay personnel, that simultaneously targets the risk factors for child aggression shown in the figure above. One intervention that may satisfy these requirements is training carers in ‘dialogic’ book-sharing.
Dialogic, supportive book-sharing
Dialogic book-sharing is a process in which adults engage the child in an active exchange about a book, pitched to be sensitive to the child’s interest and cues, with a fluid interchange between them. There is good evidence from several studies, most carried out in the USA that this intervention is of considerable benefit to the development of children’s language.
A recent study carried out in Khayelitsha, South Africa - the first trial conducted in a low/middle-income country in which book-sharing training was provided to parents - confirmed this finding. In the context of a randomised controlled trial, over eight weekly sessions, parents of one-year-old children received a group-based training in book-sharing from a trained lay facilitator.
On the basis of blind independent assessment, as shown in the figure below, the intervention was found to be of considerable benefit to children’s language and attention (Vally et al, 2015). Notably, the impact of the intervention on these child outcomes was brought about by improvements in both maternal sensitivity and the reciprocity between parent and child (Murray et al, 2016).
Improving the parent-child relationship
A central feature of sensitive book-sharing is to become aware of one’s child’s focus of interest and to become engaged in an open exchange of thoughts and ideas about it with one’s child. This process appears to have a major beneficial effect on the quality of the parent-child relationship.
In current ongoing trials in Lesotho (Tomlinson et al, 2016) and Khayelitsha (Dowdall et al, 2017), we are examining the impact of this intervention on child socio-emotional understanding, emotion regulation and behaviour, as well as on parenting practices. The extent to which the parenting risk factors highlighted in the figure above are successfully tackled will become apparent.
It is possible that we will find that modifications to the programme will be necessary. For example, additional elements derived from a positive parenting programme might be required to have a more profound impact on the harsh parenting element of the model. If so, we will make these modifications and test out the efficacy of any revised programme.
Even if enhancing parental book-sharing skills were demonstrated to reduce the rate of persistent and pervasive aggression in children, the impact of this on the prevalence of adolescent and adult violence is likely to vary in relation to the presence of wider social risk factors.
For example, in a community where the social life of young people is seriously constrained by the operation of armed gangs, the normal continuity from childhood aggression to violence may be attenuated. However, the extent to which the protective factors set in place by an earlier intervention - such as secure attachment and good executive function skills - might prevent the emergence of violence, even in the most challenging circumstances, is a question that needs rigorous investigation.
We have developed manualised book-sharing training programmes for families of children from the age of one to five years. We have also developed a programme for use by those looking after groups of young children, such as ECD centre practitioners. We have versions of these programmes in isiXhosa, Sesotho, Afrikaans and English. Their dissemination is managed by a charity, the Mikhulu Trust (www.mikhulutrust.org).
- Prof. Peter Cooper is a professor of psychology at the University of Reading
- David Jeffery is the Director of Operations and Training at the Mikhulu Trust
- Dr. Joseph Murray is senior Research Associate at the Department of Psychiatry in Cambridge, and hold affiliate positions at the Universidade Federal de Uberlândia in Brazil.
- Prof. Mark Tomlinson is a professor in the Department of Psychology at Stellenbosch University.
- Nicholas Dowdall is a PhD candidate at Oxford University,
- Prof. Lynne Murray is a professor of psychology at the University of Reading.
Dowdall, N, Cooper, P.J., Tomlinson, M., Skeen, S., Gardner, F. & Murray, L. (2017) The Benefits of Early Book Sharing (BEBS) for child cognitive and socio-emotional development in South Africa: study protocol for a randomised controlled trial. Trials 18.1,118.
Murray, L, De Pascalis, L, Tomlinson, M, Vally, Z, Dadomo, H, MacLachlan, B, Woodward, C, Cooper, P.J. (2016) Randomized controlled trial of a book-sharing intervention in a deprived South African community: effects on carer-infant interactions, and their relation to infant cognitive and socio-emotional outcome. Journal of Child Psychology and Psychiatry, 57.12, 1370-1379.
Olds, D. L., Sadler, L., & Kitzman, H. (2007). Programs for parents of infants and toddlers: Recent evidence from randomized trials. Journal of Child Psychology and Psychiatry, 48(3–4), 355–391.
Tomlinson, M., Skeen, S., Marlow, M., Cluver, L., Cooper, P., Murray, L., Mofokeng, S., Morley, N., Makhetha, M., Gordon, S., Esterhuizen, T. & Sherr, L. (2016) Improving early childhood care and development, HIV testing, treatment and support, and nutrition in Mokhotlong, Lesotho: a cluster randomized control trial of an integrated intervention. Trials, 17.1, 538.
Vally, Z., Murray, L., Tomlinson, M., & Cooper, P. J. (2015). The impact of dialogic book‐sharing training on infant language and attention: a randomized controlled trial in a deprived South African community. Journal of Child Psychology and Psychiatry, 56(8), 865-873.