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Keywords:

  • Preventive intervention;
  • school-based;
  • social-emotional health

Abstract

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References

Background:  Children with poor social-emotional health are at risk of failing to reach their potential.

Method:  The impact of the Pyramid Club year 3 preventive intervention on children's social-emotional health was investigated. Children were allocated to an intervention or non-problem comparison group.

Results:  Post-intervention both groups had improved Total Difficulty scores (Strengths and Difficulties Questionnaire) with the Pyramid group showing a significantly stronger effect size (r = .71) than the non-problem comparison group (r = .44).

Conclusions:  The Pyramid Club intervention improves the social-emotional health of vulnerable children. The need to evaluate such interventions and to extend research are discussed.


Key Practitioner Message:

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References
  •  Development of children's social skills and emotional competence is essential for successful social interaction
  •  Pyramid after-school clubs are designed to develop social skills and confidence in Year 3 children identified as vulnerable
  •  An evaluation of Pyramid clubs suggests that Pyramid children show improved social-emotional well-being in comparison to non-problem children
  •  Future research should examine the durability of social-emotional improvements and the extent to which improvements may lead to development in other areas such as academic performance

Introduction

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References

The development of social skills and emotional competence in middle childhood is essential for children to negotiate successful social interaction throughout their lives (Robins & Rutter, 1990). Furthermore, children whose interactive skills are limited are less likely to be rated favourably by their teachers and perceived as likeable by their peers (Eisenberg et al., 1995). These children can be viewed as more vulnerable to developing low self-esteem and at risk of failing to reach their potential as such difficulties can limit educational and career opportunities as well as affect relationships and physical and mental well-being (Flouri, Buchanan, & Bream, 2000).

The importance of early intervention to promote social-emotional health is increasingly acknowledged (Aviles Anderson, & Davila, 2006; Flouri et al., 2000; Prilleltensky & Nelson, 2000). This development reflects a shift from an emphasis on acute care, which may be expensive, to early preventive interventions which have the potential to reduce the demand for acute care (Munoz, Mrazek, & Haggerty, 1996). The shift to incorporate a preventive focus and the responsibility for social and emotional well-being are clearly identifiable within current UK government policy. The national framework proposed by Every Child Matters: Change for Children (Department for Education and Skills [DfES], 2003) describes five main outcomes that it maintains are every child's right in the passage to adulthood: being healthy; staying safe; enjoying and achieving; making a positive contribution, and achieving economic well-being. These outcomes are underpinned by successful social interactions built on social skills and emotional competence. Against this background, it has been argued (Buchanan, 2000) that there is a moral responsibility for society to ensure the social-emotional well-being of its children. Furthermore, there is a growing realisation that schooling may focus too strongly on academic measures in an effort to raise academic standards (Faupel, 2003). This emphasis has downplayed the importance of ‘that essential human wholeness’ (Faupel, 2003) which incorporates emotional health and social well-being.

A diverse range of school-based social-emotional interventions exists. These vary along many dimensions including the aim of the intervention, type of intervention activities, type of child and behaviour targeted, intervention length and delivery mode. One of the longest established primary school-based social-emotional interventions within the UK is the Pyramid Club programme. Pyramid was founded in the early 1980s by social worker Katrin Fitzherbert to provide interventions to improve self-esteem and social skills in children who present as withdrawn, socially isolated and at risk of emotional and psychological vulnerability. Thus, the intervention is selective and preventive (Munoz et al., 1996). In 1993 a charitable trust was set up to disseminate the Pyramid intervention model and the organisation now provides a geographically widespread intervention programme in partnership with local authorities and other voluntary agencies. There are currently 42 Pyramid Club schemes across England, Wales and Northern Ireland involving over 3,000 children.

The Pyramid Club year 3 intervention comprises a 10 week group programme in which children take part in an after-school club that runs on one day a week for one and a half hours. Pyramid Clubs focus on ‘building confidence and an improved sense of well-being, encouraging friendship skills and allowing the children to feel, perhaps for the first time in their lives, that they truly belong’ (National Pyramid Trust, 2005). Identification of children considered suitable to attend a Pyramid Club is generally a two-stage and universal process. Firstly, the whole year group within a school is screened, usually using the Goodman Strengths and Difficulties Questionnaire ([SDQ] Goodman, 1997). Secondly, there is a multi-disciplinary meeting within the school of all professionals (teachers, social workers, educational psychologists) who may have responsibility for the children. The clubs are organised and run by volunteers who have received training in Pyramid's intervention methods, and have undergone checks via the Criminal Records Bureau Enhanced Disclosure system. Thus the clubs provide children with an opportunity to rehearse and develop their social skills in a safe, relaxed and supportive environment.

The necessity to evaluate mental health promotion programmes has been strongly argued (Stallard et al., 2007; Weare & Gray, 2003). However, no outcome evaluations of Pyramid Clubs have been published in peer-reviewed literature, although the ‘grey’ literature provides preliminary evidence of Pyramid's impact on children's social-emotional well-being. An evaluation (Skinner, 1996) of Pyramid Clubs at 16 schools over a period of four months found a significantly greater improvement in depressive symptoms, social withdrawal and immaturity in children who had attended a Pyramid Club than in those who had not. In addition, the Pyramid children rated themselves as more popular and happier after attending a Pyramid Club than before. Another short-term evaluation (Davies, 1999) found that teachers at three schools rated children who attended Pyramid Clubs as showing greater improvements than non-attenders in relation to emotional problems and peer problems. This study also indicated that Pyramid children's writing ability improved more than that of non-attenders as measured by story content and a sentence generation task (Davies, 1999). The findings of both Skinner (1996) and Davies (1999) suggest a beneficial effect on Pyramid attendees that might not be attributable to normal developmental progress alone. However, these positive outcomes require replication as the studies appear to have methodological and reporting limitations such as small sample size (Davies, 1999), and insufficient information about the comparison group (Skinner, 1996) and effect sizes (Davies, 1999; Skinner, 1996). Moreover, to improve evidence-based practice, it is important that intervention evaluations are reviewed and disseminated to practitioners (Stallard et al., 2007). Therefore, this paper addresses these issues by reporting a more robust evaluation of the impact of the Pyramid Club year 3 intervention on children's social-emotional health.

Method

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References

Design and assessment

The impact of the Pyramid Club year 3 intervention on children's social-emotional health was investigated using a pre-post intervention design. Social-emotional health was assessed on two separate occasions: prior to allocation of the children to either the Pyramid Club intervention or a non-problem comparison group (Time 1), and at the end of the 10 week Pyramid Club intervention (Time 2). On both occasions the children's class teacher completed the SDQ T4-16, the teacher-completed version of the SDQ for children aged 4–16 (Goodman, 2005), for all children in the year 3 cohort. Children were allocated to the Pyramid Club intervention or non-problem comparison group following a multi-agency review of their scores on the SDQ T4-16 and professional assessment of the extent of their emotional and/or peer relationship problems.

The SDQ T4-16 comprises 25 items divided into five scales of five items. Four scales measure potential ‘difficulties’ (emotional symptoms, conduct problems, hyperactivity/inattention, and peer relationship problems). Each scale has a scoring range of 0–10 contributing to a Total Difficulties (TD) score with a range of 0–40 and a higher score indicating a greater level of difficulty. A fifth scale of five items measures pro-social behaviour, is termed a ‘strength’, and has a range of 0–10 with a higher score indicating greater pro-social behaviour. The SDQ can be used to define caseness of mental health disorders using combinations of scores from the scales. The case bandings for the teacher report SDQ Total Difficulties score are normal (0–11), borderline (12–15), and abnormal (16–40) (Meltzer et al., 2000). In this study the SDQ TD score only has been used to assess the children's change in social-emotional difficulties.

Participants

The participants were year 3 school children attending four West London primary schools (three schools were two-form entry and one school was one-form entry). Parental permission was obtained for 105 children (43 Pyramid participants and 62 non-problem comparison children) to take part: 51 girls and 54 boys with an age range of 8–9 years. Parental permission was not withdrawn for any of the children once the study had begun.

The Pyramid Club year 3 intervention

Stage one: Whole class screening to assess social-emotional need.  Class teachers screened the whole year group to assess social-emotional need using the SDQ T4-16 (Goodman, 2005). Class teachers initially identified children who may be suitable for Pyramid Clubs based on the children's scores on the peer relationship problems and emotional symptoms scales along with their knowledge of children who they considered to have socio-emotional problems.

Stage two: Multi-agency meeting.  The children identified as presenting a cause for concern at stage one were discussed at a multi-agency meeting attended by the class teachers, head teacher or assigned link teacher, Special Educational Needs Co-ordinator, local Pyramid co-ordinator and other professionals involved with the children concerned. The SDQ scores were reviewed and knowledge shared regarding children who were experiencing particular emotional or peer relationship problems. This information was used to identify children who were suitable to attend a Pyramid Club. All children who were considered suitable to attend a Pyramid Club were offered a place. Any remaining children who gave cause for concern but were not considered suitable for a Pyramid Club were referred to the Special Educational Needs Co-ordinator at each school for further referral if necessary.

Stage three: The Pyramid Clubs.  A course of 10 weekly sessions comprising activities designed to develop social skills, confidence and emotional expression took place. The clubs were run by trained volunteer leaders who planned and ran each session in line with Pyramid's manualised club programme (Pyramid, 2007). Volunteers were trained to deliver Pyramid activities (circle time, club naming) and to practise basic behavioural techniques (to reward positive behaviour, give proximal praise, and act as positive role models). Intervention fidelity was ensured by ongoing supervision provided by the Pyramid Co-ordinator who visited each club at least twice during its 10 week programme to ensure clubs adhered to the Pyramid ethos and intervention. The volunteer training programme has been accredited by the Council for Awards in Children's Care and Education (http://www.cache.org.uk) and is regularly updated to reflect current policy and best practice. It comprises the first module in the CACHE Level 3 Certificate in Promoting Children's Social and Emotional Development and is usually delivered over three days (Pyramid, 2007). Figure 1 describes the main elements of a year 3 Pyramid Club.

image

Figure 1.  Main elements of the Pyramid Club year 3 intervention

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Each session incorporated circle time, team building activities and opportunities for the children to rehearse their social skills in a safe, relaxed and supportive atmosphere. The first of the 10 week sessions included naming of the club and the setting of four or five simple rules by the children, guided by the club leaders, with the aim of encouraging children's ownership of the club. Throughout the course of the clubs, the leaders endeavoured to ensure an established routine of activities to create a secure environment for the attendees.

Post-Pyramid Club intervention meeting.  At the end of the 10 week period, a post-intervention multi-agency meeting was held so that teachers, other professionals and Pyramid Club leaders could discuss the progress of the whole year 3 cohort and refer any who remained a cause for concern for further help. In this study there were two Pyramid attendees at one school who were subsequently referred to social services.

Results

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References

The four difficulty scales of the SDQ T4-16 were totalled to form a Total Difficulty (TD) score for each child at Time 1 and Time 2. Eleven participants (one intervention group and 10 non-problem comparison group participants) had incomplete data and were removed from the analysis. Therefore, TD scores were available at both baseline and 10 week follow-up for 94 children forming a Pyramid Club intervention group of 42 children (44.7%) and a non-problem comparison group of 52 children (55.3%). As expected, the Pyramid Club group baseline mean TD score (mean = 13.93, SD = 4.06) was higher than that of the non-problem comparison group (mean = 9.52, SD = 2.00). However, at 10 week follow-up, both groups showed a decrease in TD mean scores: Pyramid Club group mean = 9.24, SD = 5.00; non-problem comparison group mean =7.00, SD = 5.00 as displayed in Table 1.

Table 1.   Means (standard deviations) of Total Difficulty scores at baseline and 10 week follow-up
 Baseline Total Difficulty scores10 week follow-up Total Difficulty scores
M (SD)M (SD)
Pyramid attendee group (n = 42)13.93 (4.06)9.24 (5.00)
Non-problem group (n = 52)9.52 (2.00)7.00 (5.00)

To analyse the changes in children's TD scores, a two-way mixed model analysis of variance (ANOVA) was carried out with group (Pyramid Club or non-problem comparison) as a between-subjects variable and time-point (baseline or 10 week follow-up) as a within-subjects variable. There was a significant group × time-point interaction, F (1, 92) = 4.25, p = .042, indicating that the change in TD scores in the Pyramid Club group was significantly different to the change in TD scores in the non-problem comparison group. The interaction is illustrated in Figure 2.

image

Figure 2.  Total Difficulty scores: group × time-point interaction

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Tests for simple effects were conducted to examine the interaction. There was a significant decrease over time for the Pyramid Club group (t (41) = 6.47, p < .001) which generated a strong effect size (r = .71). There was also a significant decrease over time for the non-problem comparison group (t (51) = 3.54, p = .001) which generated a moderate effect size (r = .44). Comparison of these correlation coefficients showed that the Pyramid Club group effect size was significantly stronger than the non-problem comparison group effect size (z = 1.93, p = .044). These results show that, whilst the mean scores for both groups decreased over the time period, the decrease in the Pyramid Club intervention group TD scores was significantly greater than the decrease in the non-problem comparison group TD scores.

The mixed model ANOVA also revealed a significant main effect for time-point, F (1, 92) = 49.12, p < .001, indicating that the 10 week follow-up TD scores were significantly lower than TD scores at baseline. The effect for group was also significant (F (1, 92) = 23.8, p < .001). However, these effects were not explored further due to the significant group × time-point interaction.

The impact of Pyramid on attendees was assessed on an individual basis by comparing each child's pre-intervention and post-intervention SDQ case banding category. At baseline 15 of the 42 Pyramid attendees (35.7%) were in the abnormal range; 12 (28.6%) were in the borderline range, and 15 (35.7%) were in the normal range. As shown in Table 2, 20 children (47.6%) had an improved post-intervention banding; 20 children (47.6%) remained in the same banding, and two children (4.8%) had a lower banding. Specifically, of the 15 children in the baseline abnormal range, three (20%) remained in the abnormal range at 10 week follow-up, three (20%) moved to the borderline range, and nine (60%) moved to the normal range. For the 12 children in the baseline borderline range, four (33%) remained in the borderline range at 10 week follow-up, and eight (67%) moved to the normal range. For the 15 children in the normal range at baseline, 13 (86.7%) remained in the normal range, and two (13.3%) moved to the borderline range.

Table 2.   Number (%) of children in each Strengths and Difficulties Questionnaire (SDQ) category for Total Difficulties at baseline (T1) and 10 week follow-up (T2) with number (%) of children changing SDQ category
SDQ category (scoring range)Pyramid Club Attendee group (n = 42)Non-problem comparison group (n = 52)
T1T2T1T2
No (%)No (%)No (%)No (%)
Abnormal (16–40)15 (35.7)3 (7.1)0 (0)3 (5.8)
Borderline (12–15)12 (28.6)10 (23.8)6 (11.6)3 (5.8)
Normal (0–11)15 (35.7)29 (69.1)46 (88.4)46 (88.4)
SDQ category change at T2No (%)No (%)
Improved20 (47.6)4 (7.7)
No change20 (47.6)44 (84.6)
Lower2 (4.8)4 (7.7)

In contrast and as expected due to the screening process, the non-problem comparison group (n = 52) had a greater proportion of children in the normal (n =46, 88.5%) and borderline ranges (n = 6, 11.5%) at baseline than the Pyramid Club group. At the 10 week follow-up, four children (7.7%) had an improved SDQ banding; 44 children (84.6%) remained in the same banding, and four children (7.7%) had a lower banding category. Specifically, of the six children in the baseline borderline range, two (33%) remained in the borderline range at 10 week follow-up, and four (67%) moved to the normal range. For the 46 children in the baseline normal range, 42 (91.3%) remained in the normal range, one (2.2%) moved to the borderline range and three (6.5%) moved to the abnormal range. Table 2 summarises the changes in children's SDQ bandings and shows that, in comparison to the non-problem comparison group, a greater proportion of Pyramid children than non-problem comparison group children showed improvement.

SDQ norms for British community samples show that 10%, 10% and 80% of children score within the abnormal, borderline and normal categories respectively (Meltzer et al., 2000). At baseline, norm comparisons showed a higher prevalence of abnormal and borderline scores for the total sample: 16% (n = 15) scored in the abnormal range, 19% (n = 18) scored in the borderline range, and 65% (n = 61) scored within the normal range. The post-intervention shifts in SDQ banding brought the children's SDQ banding in line with SDQ community norms: at 10 week follow-up 6.4% (n = 6) scored in the abnormal range; 13.8% (n =13) scored in the borderline range, and 79.8% (n = 75) scored in the normal range.

Discussion

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References

This study sought to examine further the impact of the Pyramid Club year 3 intervention on children's social-emotional health (Davies, 1999; Skinner, 1996). The significant decrease in the Pyramid children's SDQ TD scores (Goodman, 2005) indicates that the intervention had a beneficial effect on children's social-emotional health and elicited a strong effect size (r = .71). In this study, improvements were also evident in the non-problem comparison group children; however, the improvement was of a significantly lower magnitude (r = .44). The difference in effect size between the Pyramid attendees and the non-problem comparison group suggests that attending a Pyramid Club improves children's social-emotional health above that which may possibly be explained by developmental changes. These findings are consistent with those of Davies (1999) who reported that children who attended Pyramid Clubs showed greater decreases than controls in scores on the emotional symptoms and peer problems scales of the SDQ. Additionally, Skinner (1996) reported beneficial effects of the Pyramid intervention on children who displayed low self-esteem, depressive symptomology and social withdrawal.

Importantly, this study also indicates that running a selective intervention within the year 3 cohorts did not have a negative impact on the SDQ banding of the children who did not take part in Pyramid. All the children whose pre-intervention TD scores put them within the abnormal banding of the SDQ (n = 15) were selected to be Pyramid attendees and, post-intervention, the majority of these children's scores (n = 12) moved to an improved band. For the 52 non-problem comparison group children, 46 were in the normal band at baseline; only four of them showed a lower banding at follow-up in comparison to two of the Pyramid attendees. Indeed, when the combined sample of Pyramid and non-problem comparison children was examined post-intervention, it had moved from outside to within the parameters of the British SDQ community sample norms (Meltzer et al., 2000).

The use of volunteers as club leaders differentiates Pyramid Clubs from social-emotional interventions that use mental health and/or education professionals to deliver programmes e.g. FRIENDS (Stallard et al., 2007), Circle of Friends (Newton, Taylor, & Wilson, 1996), Incredible Years Classroom Dinosaur School Programme (Webster-Stratton, Reid, & Hammond, 2001). Pyramid volunteers are trained in basic behavioural techniques (to reward positive behaviour, give proximal praise, and to act as positive role models for the children). The finding that trained volunteers can successfully deliver a school-based behavioural intervention has important practice implications. In addition to minimising staff costs, use of volunteers can reduce demands made on teachers and thus increase the programme's acceptability to schools and its availability to children. The presence of non-teaching volunteers ensures that clubs maintain their focus on social-emotional issues. Furthermore, it is possible to run clubs with a low club leader to child ratio (1:3). This ensures that each child can be the frequent focus of the accepting and encouraging attention of an adult and has the opportunity to practise new positive behaviours in a small group setting. The small group nature of the intervention may also limit opportunity for disruptive behaviour thus adding to the successful cohesion of each club (Maddern et al., 2004).

Importantly for future investigation, volunteering may provide reciprocal benefits for the club leaders as possible mechanisms for improved general well-being in volunteers have been suggested (Wilson & Musick, 2000). The promotion of Pyramid as an ‘after-school club’ and its integration at the end of the school day is likely to increase its acceptance to parents, encourage attendance and reduce potential stigma associated with mental health issues. Indeed, our analysis of focus group data from children who attended Pyramid Clubs showed their enthusiasm for the clubs and no reporting of negative outcomes (Fox et al., 2006). It is through these programme attributes that the improved functioning of the Pyramid children is likely to have occurred although the mechanisms of this effect require investigation. Finally, Pyramid offers schools an opportunity to demonstrate that they are adopting evidence-based practice to contribute to government initiatives, such as Every Child Matters (DfES, 2003) and the Healthy School Standard (Health Development Agency, 2004). This is an important finding given the large number of children and schools who take part in Pyramid Clubs each year in the UK.

The conclusions of this study are limited by its use of one outcome measure based on teacher report alone of children's behaviour in school; use of a non-problem comparison group; limited follow-up period, and relatively small sample. The focus on social-emotional health as the sole outcome measure precludes the examination of the extent to which improvements in social-emotional health may be associated with improvements in other domains such as academic performance. However, use of the SDQ is supported by evidence of its value as both a screening tool and outcome measure (Goodman et al., 2000; Mathai, Anderson, & Bourne 2003) and, although this study is also limited by its use of teacher report only, research indicates that this has greater sensitivity to behavioural and social problems than parent report alone. Nevertheless it would be preferable to also measure parental report as both together have greater sensitivity than either report alone (Goodman et al., 2000). It would also be preferable to compare the Pyramid group with a waiting list control group rather than a non-problem comparison group. Waiting list controls would enable comparison with an equivalent group of children rather than children for whom the possibility of a reduction in problem behaviour is more limited due to their baseline non-problem behaviour. In this study, there were sufficient Pyramid places for all children identified as suitable for the intervention and, therefore, it was considered unethical to create a waiting list control group.

Whilst this study demonstrates a positive impact on the social-emotional health of the Pyramid attendees, a further limitation is that it does not indicate the durability of the effects or indeed a preventive effect upon development of future psychopathology. However, the present results are consistent with Durlak and Wells’ (1997) suggestion that it is important to value the positive impact of interventions in the short-term particularly with community samples, as well as focusing on prevention as a longer-term goal. Finally, this study is limited by its sample size. However, such large effects on relatively small numbers are worthy of further investigation using a sample size based on power calculations. Therefore, the authors are currently attempting to replicate the findings of this study with a larger cohort and a longer-term follow-up. Overall, these considerations limit the conclusions that can be drawn about the outcomes and indicate the need to replicate the findings in a study incorporating a wider range of outcome measures based on both parent and teacher reports, a longer-term follow-up to investigate the durability of the impact of the intervention, and a larger sample size incorporating a comparison group of children with equivalent social-emotional problems. Additionally, future research should examine the relative importance of components of the Pyramid model in order to explain how the intervention operates to have a positive impact on social-emotional well-being and the extent to which any social-emotional improvements may lead to improvements in other domains.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References

The authors would like to thank the schools, children and teachers who took part in the study, the volunteers who ran the Pyramid Clubs, and Pyramid for supporting the research.

In June 2006, Thames Valley University worked with Pyramid to carry out a focus group study, commissioned by the King's Fund, of children's views of taking part in various mental health initiatives. TVU's contribution to this study was carried out by Pauline Fox, Kathryn Mitchell and Maddie Ohl.

References

  1. Top of page
  2. Abstract
  3. Key Practitioner Message:
  4. Introduction
  5. Method
  6. Results
  7. Discussion
  8. Acknowledgments
  9. References
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