Positive Parenting Program - Springer Link

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(Sanders et al., 2000b). Apart from improving parent- ing skills, the program aims to increase parents' sense of competence in their parenting abilities, improve.

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C 2002) Prevention Science, Vol. 3, No. 3, September 2002 (°

The Development and Dissemination of the Triple P—Positive Parenting Program: A Multilevel, Evidence-Based System of Parenting and Family Support Matthew R. Sanders,1,2 Karen M. T. Turner,1 and Carol Markie-Dadds1

This paper describes the theoretical and empirical basis of a unique multilevel system of parenting and family support known as the Triple P—Positive Parenting Program. The program incorporates five levels of intervention on a tiered continuum of increasing strength and narrowing population reach. The self-regulation framework of the program is discussed and an ecological or systems-contextual approach to dissemination of the program to service providers is highlighted. Implementation issues to consider in effective program dissemination are discussed including managing the “politics” of family support, strategies for coping with changes in government, maintaining quality, balancing cost and sustainability, and remaining data responsive. Future research directions are identified. KEY WORDS: dissemination; Positive Parenting Program; multilevel; family support.

The Triple P—Positive Parenting Program was developed as a system of parenting and family support to assist parents to promote their children’s social competence and manage common developmental and behavioral problems. Although parenting interventions based on social learning principles (Patterson, 1982) are the most effective parenting programs available (Kazdin, 1991; McMahon & Wells, 1998), they are not widely used, expensive to deliver, and most importantly, have made little impact on the prevalence of behavioral disorders in children (Sanders, 2001). Many of the parent training and family intervention programs developed to date have been delivered as remedial treatment after serious conduct problems have developed or as early interventions for high-risk children already showing signs of behavioral disorder. As dysfunctional parenting is related to a wide range of health, social and educational problems in children and young people, we believed a population

approach that sought to improve parental competencies in the community was needed. This paper describes the Triple P system of intervention, its conceptual and empirical base and discusses issues relevant to its successful dissemination and implementation at a population level. WHAT IS TRIPLE P? The Triple P model of parenting and family support is a contemporary behavioral family intervention (BFI) that aims to prevent severe behavioral and emotional disturbances in children. A unique characteristic of Triple P is that rather than being a single program it is a multilevel system of parenting support on a tiered continuum of increasing intensity. The Triple P system aims to promote positive, caring relationships between parents and their children and to help parents develop effective management strategies for dealing with a variety of childhood behavior problems and common developmental issues (Sanders et al., 2000b). Apart from improving parenting skills, the program aims to increase parents’ sense of competence in their parenting abilities, improve couples’ communication about parenting, and reduce

1

Parenting and Family Support Centre, School of Psychology, The University of Queensland, St. Lucia, Australia. 2 Correspondence should be directed to Matthew Sanders, Director, Parenting and Family Support Centre, School of Psychology, The University of Queensland, McElwain Building, Room SS-S226A, St. Lucia, QLD 4072, Australia.

173 C 2002 Society for Prevention Research 1389-4986/02/0900-0173/1 °

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174 parenting stress. The acquisition of specific parenting competencies results in improved family communication and reduced conflict that in turn reduces the risk that children will develop a variety of behavioral and emotional problems. Although the original research on Triple P focused on conduct problems in children, many of the same social learning principles and processes within families (e.g., contingent positive support for adaptive, prosocial or incompatible behaviors, use of effective consequences to decrease maladaptive behaviors) are relevant to other childhood disorders, and have been successfully applied to an increasingly diverse range of childhood problems such as depression, anxiety, feeding difficulties, habit disorders, and recurrent pain syndromes (see Sanders, 1996, 1998; Sanders et al., 1994). The Triple P model is based on the principle of sufficiency. That is, amongst parents who are concerned about their child’s behavior, there are individual differences in the severity of problems experienced (mild to severe), breadth of knowledge, motivation, access to support, and the presence of additional family stresses (e.g., relationship conflict, financial difficulties). It is therefore unlikely that any single family intervention program will cater for the requirements of all parents. The Triple P model assumes that the differing needs of parents will require differing levels of support. Consequently, Triple P allows the strength of the intervention to be tailored to the assessed needs and preferences of individual families. It incorporates five levels of intervention (see Table 1) for parents of preadolescent children from birth to 12 years, with recent extensions of the program for parents of teenagers. The application of the principle of sufficiency means that the same content (e.g., a specific parenting plan for managing fighting or aggression) can be provided with different intensities of skills training and practitioner support (e.g., a tip sheet plus video demonstrating the strategy versus a tip sheet plus video plus behavioral rehearsal and coaching with a practitioner). Level 1, a universal parent information strategy, provides all interested parents with access to useful information about parenting through a coordinated media and promotional campaign using print and electronic media, as well as user-friendly parenting tip sheets and videotapes that demonstrate specific parenting strategies. This level of intervention aims to increase community awareness of parenting resources and receptivity of parents to participating in parenting programs, and to create a sense of optimism by depicting solutions to common behavioral

Sanders, Turner, and Markie-Dadds and developmental concerns. Level 2 is a brief, one- to two-session primary health care intervention providing early anticipatory developmental guidance to parents of children with mild behavior difficulties. Level 3, also a brief primary health care intervention (up to 80 min of contact), targets children with mild to moderate behavior difficulties and includes active skills training for parents. Level 4 is an intensive 10-session individual or 8-session group parent training program for children with more severe behavioral difficulties. Level 5 is a 5- to 11-session enhanced BFI program for families where parenting difficulties are complicated by other sources of family distress (e.g., relationship conflict, parental depression, or high levels of stress). It builds on Level 4, with additional modules targeting home practice of parenting skills, coping skills, and partner support skills. This multilevel model has considerable flexibility and enables parents to participate in the program at different levels of intensity depending on the parent’s assessed need (e.g., parenting concerns alone versus parenting concerns plus marital conflict) and parental availability. In the case of universal level intervention the goals are to normalize and destigmatize parenthood preparation. Many of the issues that are relevant to parents (e.g., parental consistency, having engaging supervised activities for children, positive attention) can be depicted at all levels of the intervention, however the intensity of intervention support will vary (e.g., number of sessions required, amount of practice, and feedback provided to the parent). Furthermore, parents may enter the system (for the first time) or re-enter the system for subsequent parenting support at any level (e.g., at a later developmental phase or with other siblings) for booster sessions. THEORETICAL BASIS OF TRIPLE P Triple P is a contemporary form of behavioral family intervention. Across the five levels of the intervention the Triple P system draws on: (i) Social learning models of parent–child interaction that highlight the reciprocal and bi-directional nature of parent–child interactions (e.g., Patterson, 1982); (ii) Research in child and family behavior therapy that has identified many useful behavior change techniques (Sanders, 1992, 1996); (iii) Developmental research on parenting in everyday contexts that has identified children’s competencies in naturally occurring

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Development and Dissemination of Triple P

Table 1. The Triple P Model of Parenting and Family Support Level of intervention

Target population

Intervention methods

Program resources

Possible target areas

1. Universal Triple P media-based parenting information campaign

All parents interested in information about parenting and promoting their child’s development

Guide to Triple P Triple P media and promotions kit (including promotional poster, brochure, radio announcements, newspaper columns)

General parenting issues Common every day behavioral and developmental issues

2. Selected Triple P information and advice for a specific parenting concern

Parents with specific concerns about their child’s behavior or development

Guide to Triple P Positive parenting booklet Triple P tip sheet series Every parent video series Developmental wall chart

Common behavior difficulties or developmental transitions, such as toilet training, bedtime problems

3. Primary care Triple P narrow focus parenting skills training

Parents with specific concerns about their child’s behavior or development who require consultations or active skills training Parents wanting intensive training in positive parenting skills. Typically targets parents of children with more severe behavior problems Parents of children with concurrent child behavior problems and family dysfunction

A coordinated information campaign using print and electronic media and other health promotion strategies to promote awareness of parenting issues and normalize participation in parenting programs such as Triple P. May include some contact with professional staff (e.g., telephone information line) Provision of specific advice on how to solve common child developmental issues and minor child behavior problems. May involve face-to-face or telephone contact with a practitioner (about 20 min over two sessions) or (60–90 min) seminars A brief program (about 80 min over four sessions) combining advice with rehearsal and self-evaluation as required to teach parents to manage discrete child problem behavior. May involve face-to-face or telephone contact with a practitioner

Level 2 materials Practitioner’s manual for primary care Triple P Consultation flip chart

Discrete child behavior problems, such as tantrums, whining, fighting with siblings

Levels 2 and 3 materials Every parent Practitioner’s manual for standard Triple P and every parent’s family workbook Facilitator’s manual for group Triple P and every parent’s group workbook Every parent’s self-help workbook

Multiple child behavior problems Aggressive behavior Oppositional defiant disorder Conduct disorder Learning difficulties

Levels 2–4 materials Practitioner’s manual for enhanced Triple P and every parent’s supplementary workbook

Concurrent child behavior problems and parent problems (e.g., relationship conflict, depression, stress)

4. Standard Triple P group Triple P self-directed Triple P broad focus parenting skills training

5. Enhanced Triple P behavioral family intervention

A broad focus program (up to 12 one-hour sessions) for parents requiring intensive training in positive parenting skills and generalization enhancement strategies. Application of parenting skills to a broad range of target behaviors, settings and children. Program variants include individual, group or self-directed (with or without telephone assistance) options An intensive individually tailored program (up to 11 one-hour sessions) for families with child behavior problems and family dysfunction. Program modules include home visits to enhance parenting skills, mood management strategies and stress coping skills, and partner support skills

Source: Reproduced with permission from Sanders, M. R., Markie-Dadds, C., & Turner, K. M. T. (2001). Practitioner’s manual for standard Triple P (p. 4). Brisbane, Australia: Families International.

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Sanders, Turner, and Markie-Dadds situations, particularly work that traces the origins of social, language, and intellectual competence to early parent–child interactions (Hart & Risley, 1995); (iv) Research from the field of developmental psychopathology that has identified specific risk and protective factors linked to the development of psychopathology in children (Emery, 1982; Grych & Fincham, 1990; Rutter, 1985). Targeted risk factors include coercive parent–child interaction, marital conflict, and parental depression; (v) Social information processing models that highlight the important role of parental cognitions such as attributions, expectancies, and beliefs as factors that contribute to parental self-efficacy, decision making, and behavioral intentions (e.g., Bandura, 1977, 1989, 1995); (vi) Population health research on changing health risk behaviors among the population that has been applied within a mental health framework (e.g., Becker et al., 1992).

In essence, it is hypothesized that effective parenting is a common protective pathway to reduce the risk that children and adolescents will develop serious mental health problems (including both externalizing and internalizing problems). When parents are competent and confident (self-efficacious) in managing the day-to-day tasks of raising children and learn adaptive ways of responding to maladaptive or dysfunctional behaviors, children are less likely to develop severe behavioral or emotional disorders. In families where parents communicate well with their children, provide plenty of positive attention, and who use consistent nonviolent disciplinary methods in a low conflict environment, children are less likely to develop significant problems. However, parenting occurs in a broader sociocultural context. Parents are more likely to adopt positive parenting methods when the importance of parenting skills is publically supported by the broader community within which a parent lives. INTERVENTION METHODS The core features of the Triple P system involve creating supportive environments for parents where parents can readily learn the skills they need to get on well with their children. This involves creating easily accessible learning environments for parents

that facilitate skills acquisition. Hence, Triple P uses the media, primary care services, schools, telephone counseling services, and the workplace as contexts which enable parents to access program support. Triple P teaches parents strategies to encourage their child’s social and language skills, emotional selfregulation, independence, and problem-solving ability. It is hypothesized that attainment of these skills promotes family harmony, reduces parent–child conflict, fosters successful peer relationships and prepares children to be successful at school. To achieve these child outcomes, parents are taught a variety of child management skills including: monitoring problem child behavior; providing brief contingent attention for appropriate behavior; arranging engaging activities in high-risk parenting situations; using directed discussion and planned ignoring for minor problem behavior; giving clear, calm instructions; and backing up instructions with logical consequences, quiet time (nonexclusionary time-out) and time-out. Parents learn to apply these skills both at home and in the community. Specific strategies such as planned activities training are used to promote the generalization and maintenance of parenting skills across siblings, settings, and over time. Triple P interventions combine the provision of quality parenting information with active skills training and support. At each level of intervention active skills training methods are used to promote skill acquisition. For example, in Universal Triple P, media strategies are used that involve the realistic depiction of possible solutions to commonly encountered parenting situations (e.g., bedtime problems). These potential solutions can be illustrated through various mediums including television programs, community service announcements, talk-back radio, newspaper columns, and advertising. The messages are optimistic and promote the idea that even the most difficult parenting problems are solvable and or preventable. In more intensive levels of intervention (e.g., Levels 3, 4, and 5) information is supplemented by the use of active skills training methods that include modeling, rehearsal, feedback, and between-session practice tasks. Segments from videotapes (e.g., Sanders et al., 1996) can also be used to demonstrate positive parenting skills. Several generalization enhancement strategies are incorporated into the system of intervention (e.g., training with sufficient exemplars until parents can generalize skills to an untrained situation, and training loosely with varied target behaviors and children) to promote the transfer of parenting skills

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Development and Dissemination of Triple P across settings, siblings, and time. Practice sessions can be conducted at home or in the clinic during which parents self-select goals to practice, are observed interacting with their child and implementing parenting skills, and subsequently review their performance and receive feedback from the practitioner. For families with additional modifiable risk factors, such as parental distress or relationship conflict, intervention can be expanded to include a focus on mood management, stress coping, communication or partner support skills. The Triple P model of intervention argues that to reduce the prevalence of inadequate or dysfunctional parenting a contextual approach is required to create a broader social environment that supports and acknowledges the importance of parenting and normalizes the process of parenthood preparation. Social institutions that are in a position to provide preventively-oriented early intervention need to be adequately trained and resourced to provide effective brief parent consultation. These institutions include primary health care providers and schools. In addition to the provision of early intervention, these institutions can serve a triage function to appropriately refer nonresponders and more complex cases with additional family risk factors to services offering more intensive programs. The major differences between the universal level of Triple P and the more intensive levels of intervention include the wider reach of the universal program, the lower “dosage” level of intervention provided, the lower per parent cost of delivery of the intervention, the focus of shifting community attitudes and values about parenting, and increasing the awareness of parents of where they can access additional support if needed. Exposure of parents to the universal level is viewed as helpful and facilitatory but nonessential for parents to benefit from other levels of intervention. Universal Triple P is seen as promoting a healthier ecological context for parenting. It supports all other levels of intervention in promoting program participation and in potentially providing after-care for families who have already completed one or more of the intensive levels of intervention. The Triple P model is not designed to involve sequential exposure of parents to more intensive intervention. Parents may enter the system of parenting support either with a low intensity exposure and move towards more intensive exposure as required, or receive a high-level intervention initially and then move to universal level support for maintenance or booster exposure.

EFFECTIVENESS OF TRIPLE P The evaluation of the Triple P system is very much a work in progress. Although there is considerable existing evidence demonstrating the benefits of various levels of intervention and modes of delivery, Triple P as a population level approach is subject to ongoing evaluation. Early efficacy trials focused on the effects of core intervention procedures. The Triple P interventions that form the core of the system are derived from over 25 years of experimental clinical research that has established the efficacy and effectiveness of intervention strategies for reducing children’s behavior problems in a variety of populations including children from maritally discordant homes (Dadds et al., 1987), children of depressed parents (Sanders & McFarland, 2000), children in stepfamilies (Nicholson & Sanders, 1999), children with persistent feeding difficulties (Turner et al., 1994), children in socially disadvantaged areas (Sanders et al., 2000a; Williams et al., 1997), and children with developmental disabilities (Sanders & Plant, 1989). These parenting skills training methods also have been evaluated independently in other groups with mildly and moderately intellectually disabled children (e.g., Harrold et al., 1992). The major findings from group trials in the Triple P series of research are detailed in Table 2. In summary, this research shows that when parents change problematic parenting practices, children experience fewer problems, are more cooperative, get on better with other children, and are better behaved at school. Parents have greater confidence in their parenting ability, have more positive attitudes toward their children, are less reliant on potentially abusive parenting practices, and are less depressed and stressed by their parenting role. The interested reader is referred to Sanders (1999) for a thorough review of the empirical basis of Triple P. Inspection of Table 2 shows that the sample sizes used in various trials are quite varied (N = 16– 1615). These studies represent the progression of the evidence base from efficacy trials to effectiveness trials and finally to studies examining the dissemination of the program. The approach to evaluation to date has been to evaluate each level of intervention and different delivery modalities within levels. These outcome studies have included both efficacy trials conducted within a university clinical research setting (e.g., Sanders & McFarland, 2000) and effectiveness trials conducted within regular health services in the community (e.g., Williams et al., 1997).

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RCT comparing Triple P television segments (12 episodes) and a wait list control. Parents reporting concerns about disruptive child behavior

RCT comparing selected Triple P, primary care Triple P, and a wait list control. Parents with concerns about discrete child behavior problems

Sultana et al., 2000

50 (SE nil; PC nil; WL 38%)

56 (Int nil; WL nil)

1–5

2–8

3–9

3

Child disruptive behavior, parenting style, and parental adjustment

Child disruptive behavior, parenting style and confidence, parental adjustment and parenting conflict

Child disruptive behavior, parent–child interaction, parenting confidence and parental adjustment

Child disruptive behavior, parent–child interaction, parenting style and confidence, parental adjustment, parenting conflict and relationship satisfaction Child disruptive behavior, parent–child interaction, parenting style and confidence, parental adjustment, parenting conflict and relationship satisfaction

Both intervention programs were associated with significantly lower parent-reported child behavior problems and dysfunctional parenting and significantly greater parenting confidence than the WL condition. Enhanced Triple P was also associated with significantly less observed disruptive child behavior than the WL condition. Results were maintained at 1-year follow-up. Both interventions produced significant reductions in children’s comorbid disruptive behavior and attention problems Children in the three intervention conditions showed greater improvement on mother-reported disruptive behavior than the WL control, however only those in the enhanced Triple P and standard Triple P conditions showed significant improvement on observed disruptive child behavior and father reports. Parents in the two practitioner assisted programs also showed significant reduction in dysfunctional parenting strategies (self-report) for both parents. No intervention effects were found for observed mother negative behavior toward the child or for parent adjustment, conflict or relationship satisfaction. Mothers in all three intervention conditions reported greater parenting confidence than controls. At 1-year follow-up, children receiving self-directed Triple P had made further improvements on observed disruptive behavior and all intervention groups were comparable on measures of child behavior and parenting style Both interventions were effective in reducing observed and parent reported disruptive child behavior, as well as mothers’ and fathers’ depression. Both interventions also significantly increased parental confidence. Intervention results were maintained at 6-month follow-up, with more mothers in the enhanced Triple P intervention experiencing concurrent clinically reliable reductions in disruptive child behavior and maternal depression Mothers in the television intervention condition reported significantly lower levels of disruptive child behavior and higher levels of parenting confidence than controls following intervention. No changes were found on parenting strategies, conflict or parental adjustment. Results for the intervention group were maintained at 6-month follow-up Parents in the primary care Triple P condition reported significantly fewer child behavior problems and dysfunctional parenting strategies than the WL controls. Moderate positive changes in child and parent behavior were found for selected Triple P, however these did not differ significantly from controls. No differences were found on parent adjustment measures. Results for the intervention groups were maintained at 4-month follow-up

Outcomes

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47 (ST 21%; EN 13%)

305 (ST 17%; SD 19%; EN 24%; WL 8%)

3

Measures

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RCT comparing standard Triple P, self-directed Triple P, enhanced Triple P, and a wait list control. Parents of children with clinically elevated disruptive behavior, and at least one family adversity factor (e.g., low income, maternal depression, relationship conflict, single parent)

Sanders et al., 2000

87 (ST 28%; EN 42%; WL 16%)

Age range (years)

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RCT comparing standard Triple P and enhanced Triple P. Parents of children with oppositional defiant disorder or conduct disorder, and mothers with major depression

RCT comparing standard Triple P, enhanced Triple P, and a wait list control. Parents of children with comorbid significantly elevated disruptive behavior and attention problems

Bor et al., in press

Sample size (attrition at post)

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Method/population

Authors

Table 2. Behavioral Family Intervention Outcomes From Group Design Studies in the Triple P Research Series

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RCT comparing behavioral parent training and standard dietary education. Parents of children with persistent feeding problems

Turner et al., 1994

21 (BPT nil; SDE 11%)

44 (Int 11%)

1–5

7–14

3–4

Child dietary intake, anthropometrics, mealtime behavior, disruptive behavior, parent–child mealtime interaction, parenting confidence, and parental adjustment

Child pain intensity, adjustment, and parent observations of pain behavior

Child disruptive behavior, parenting style, parental adjustment, parenting conflict and relationship satisfaction

Child disruptive behavior, parenting style and confidence, and parental adjustment

Child disruptive behavior and adjustment (depression, anxiety, self-esteem), and parenting conflict

No differences were found between the therapist-directed and self-directed programs. Children in the intervention groups showed significant reductions in parent reported disruptive child behavior (with smaller changes for the wait list group on one measure only). Significant reductions in parenting conflict were reported by parents and stepparents in the intervention conditions only. All children showed reductions in anxiety and increases in self-esteem Only children in the intervention group showed significant reductions in parent reported disruptive child behavior. Significant reductions in dysfunctional parenting styles, increases in parenting confidence, and decreases in depression and stress were reported by mothers (but not fathers) in the intervention group. Results for the intervention group were maintained at 4-month follow-up Parents in the intervention group had significantly higher preintervention levels of dysfunctional parenting strategies, which decreased significantly following intervention and although slightly increased, remained lower at 12- and 24-month follow-up than control parents who showed a gradual decline in dysfunctional parenting over time. Children in the intervention group showed significant decreases in parent-reported disruptive child behavior following intervention, which maintained at 12and 24-month follow-up. Two years following universal intervention, there was a 37% decrease in prevalence of child behavior problems in the intervention region. Although poorer than controls at pre, parental adjustment (depression, anxiety, and stress) and marital adjustment also improved significantly for intervention families. This was maintained at 12- but not 24-month follow-up. The same pattern was found for parenting conflict, however this did not maintain at follow-up assessments Both intervention conditions resulted in significant improvements on measures of pain intensity and pain behavior, which maintained at 6- and 12-month follow-up. Children receiving BFI had higher rates of complete elimination of pain, lower levels of relapse at follow-up assessments and lower levels of interference with usual activities due to pain. Significant improvements on measures of child adjustment were found for both conditions, which maintained at both follow-up assessments Children in both intervention conditions showed significant improvements on observed and home mealtime behavior. There was a significant increase in observed mother positive mother–child interaction at mealtimes in the behavioral parent training group only. Results are maintained at 3-month follow-up. At follow-up, children in both conditions also showed a significant increase in the variety of foods eaten. No changes were observed on measures of children’s weight or height for age, or measures of child or parent adjustment

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1615 (GR 11%; CON 4%)

2–6

7–12

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Sanders, et al., 1994

Nonrandom two-group concurrent prospective observation design evaluating group Triple P in one high-risk health region with a comparable region as control. All parents of children in the age-range

24 (SD nil; WL 8%)

60 (EN 36%; SD 43%; WL 6%)

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RCT comparing enhanced Triple P (for stepfamilies), enhanced self-directed Triple P (for stepfamilies), and a wait list control. Parents and stepparents of children with oppositional defiant disorder or conduct disorder in stepfamilies RCT comparing self-directed Triple P with telephone sessions and a wait list control. Parents of children with clinically elevated disruptive behavior living in a rural area

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RCT comparing habit reversal, differential reinforcement of other behavior and a wait list control. Children with thumb-sucking behavior and their parents Group design with crossed factors of marital type and intervention type, evaluating Standard Triple P and Standard Triple P with a partner support module. Parents of children with oppositional defiant disorder or conduct disorder (split according to relationship discord)

Christensen and Sanders, 1987

180 20 (CMT nil; ST nil)

2–7

Child disruptive behavior and parent–child interaction

Child disruptive behavior, parent–child interaction, and relationship satisfaction

Child thumb-sucking and disruptive behavior

Child pain intensity, adjustment, parent–child interaction, and parent and teacher observations of pain behavior

The intervention group reduced their self-reported levels of pain and mother observed pain behavior quickly, with significant decreases occurring in phase 2 if the intervention (working directly with the child on coping strategies). Both groups had improved significantly on pain measures by 3-month follow-up. However, intervention group effects also generalized to the school setting, and a significantly larger proportion were completely pain free by follow-up. Both groups also showed decreases in parent-reported disruptive behavior, which maintained at follow-up. No effects were found for observed mother or child behavior, although baseline levels of observed disruptive child behavior approximated those of a normal comparison group Both interventions effectively reduced thumb-sucking in a training setting and two generalization settings, and intervention effects were maintained at 3-month follow-up. No changes were observed in the WL controls. However, both interventions were associated with some temporary increases in disruptive child behavior and elimination rates were low All groups showed a significant improvement on observed and parent-reported disruptive child behavior, and observed mother implementation of targeted strategies and aversive parenting. However, a relapse effect was found for parents with relationship discord who received only the standard program without partner support training. The partner support training added little to the maintenance of change for parents without relationship distress, however it produced gains over standard Triple P for the discordant group. There was an increase in marital satisfaction for all parents following intervention, although by follow-up this had relapsed for mothers and fathers in the distressed group who did not receive partner support training Both interventions were associated with significant reductions in observed child disruptive behavior and mother aversive behavior and increased use of targeted parenting strategies in all observation settings. Results were maintained at 3-month follow-up. At follow-up, rates of disruptive child behavior were not significantly different from a group of nonproblem controls

Outcomes

Note. EN = Enhanced Triple P (Level 5); ST = Standard Triple P (Level 4); SD = Self-directed Triple P (Level 4); GR = Group Triple P (Level 4); PC = Primary care Triple P (Level 2); SE = Selected Triple P (Level 2); Int = Intervention as detailed; WL = Wait list; CON = Control; BPT = Behavioral parent training (re-mealtime management); SDE = Standard dietary education; HR = Habit reversal; DRO = Differential reinforcement of other behavior; CMT = Child management training (i.e. standard Triple P without planned activities training).

Sanders and Christensen, 1985

2–5

4–9

6–12

Measures

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30 (HR nil; DRO nil; WL nil)

16 (Int nil; WL nil)

Age range (years)

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RCT comparing child management training (without planned activities training) and standard Triple P. Parents of children with oppositional behavior

RCT comparing cognitive behavioral family intervention and a wait list control. Children with recurrent abdominal pain and their parents

Sanders et al., 1989

Sample size (attrition at post)

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Dadds et al., 1987

Method/population

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Table 2. Continued

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Development and Dissemination of Triple P An effectiveness trial evaluating the full implementation of the multilevel system with tracking of population level outcomes will be the ultimate test of the benefits of the population approach advocated. Such an evaluation trial is being planned at time of writing. Our current research activity also includes studies evaluating the efficacy of our approach to the dissemination of Triple P into regular clinical services.

TRAINING AND DISSEMINATION MODEL Since 1996, Triple P has been widely disseminated in Australia to health, education, and welfare professionals. At the time of writing, over 10,500 professionals have received training in Triple P and the system has been implemented statewide in five of the eight states and territories in the country, with training also conducted in the remaining three, but on a lesser scale. As opposed to the exposure of the parenting population to the program through the services provided by professionals trained in its use, we refer to dissemination in terms of our efforts to disseminate program variants to professionals through our professional training programs and consultative services to agencies adopting and using the Triple P system. The criterion for success of program dissemination relates primarily to program uptake and use by service providers, rather than outcomes with parents achieved by service providers. We have taken an ecological approach to the dissemination of Triple P that views changing professionals’ consulting practices as being a complex interaction between the quality of the intervention itself (i.e., Triple P), the quality of the skills training and the nature of the practitioner’s post-training environment. The dissemination process used combines two complementary perspectives: (1) a systemscontextual organizational intervention that aims to promote and support practitioners’ program use; and (2) a self-regulatory approach that promotes professional behavior change through self-directed learning. The systems-contextual approach views the attitudes, knowledge, receptivity to innovation, and consulting practices of professionals as being embedded within the broader organizational environment within which the practitioner works (Biglan et al., 1999). Specifically, professional change is thought more likely to occur when supervisors, managers, and professional colleagues support the adoption or

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181 change process (Backer et al., 1986; Parcel et al., 1990); when peer supervision, feedback, and support is available (Henggeler et al., 1997); and where computer technologies such as the Internet and e-mail services are used to support and provide consultative backup to professionals (Sanders, 2001). As argued by Ash (1997), in organizations where a culture of innovation is supported by management through the provision of resources and attention, a greater success in establishing and implementing new projects is predicted. Consequently, an effective dissemination process must strategically form alliances with key administrative and management staff and other key stakeholders to ensure that the adoption process is supported by administrators and staff (Backer et al., 1986; Parcel et al., 1990; Webster-Stratton & Taylor, 1998). This process involves development of specific strategies for informing and educating administrators about the distinguishing features of the intervention, the potential benefits and responsibilities, and costs of adoption. Central to this process is the identification of an internal advocate. This involves identifying at least one internal champion from an organization who can be engaged in interpersonal contact with key dissemination staff in order to foster internal support for the program (Webster-Stratton & Taylor, 1998). According to Backer et al. (1986) and Rogers (1995), recruiting an internal advocate is particularly important for disseminating innovative psychosocial preventive interventions. Subsequently, the internal advocate(s) has the potential to positively influence the adoption of innovation and to foster administrative support for the new innovation. There is extensive literature showing that adoption of new innovation is more likely to occur when leaders in an organization support the innovation (Backer et al., 1986; Parcel et al., 1990; WebsterStratton & Taylor, 1998). Networking with key administrators and providing information about the program to these individuals is a common practice in the diffusion of innovation (Webster-Stratton & Taylor, 1998). Triple P has introduced a range of systematic support strategies into the broader contextual post-training environment such as orientation of supervisors and managers to the program and to the training and accreditation process, the provision of materials for program promotion, and access to ongoing back-up consultative advice post-training. The Triple P team endeavors to provide information and support specific to the needs of the agency requesting support. Depending on geographical location and

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length of intended consultation, these consultations may involve face-to-face contact, telephone, and electronic or video link-ups. Examples of the type of support offered are presented below. Examples of Agency Support Information and technical support • Attending staff meetings to address clinical and administrative issues generated by practitioners. • Informing others about Triple P’s strong evidence base, wide applicability, philosophy, and target population; and clarifying expectancies about what is involved in implementing Triple P. • Distributing to agencies a copy of the Triple P: Procedures and Guidelines Manual. This resource provides an overview of a range of administrative and organizational activities for implementing Triple P from providing descriptions of Triple P training programs and strategies for organizing supervision networks to strategies for encouraging parents to complete clinical questionnaires. • Providing information to facilitate the establishment and maintenance of peer support networks across agencies. • Providing regular Triple P updates to agencies and practitioners via a biannual newsletter and web pages (e.g., www.triplep.net). • Maintaining a question and answer forum with the State Program Coordinator via e-mail to address administrative and procedural issues. • Providing information on common strengths and barriers in implementing the program and ways to overcome potential barriers. Consultation backup • Maintaining relationships with agency representatives through regular contact via e-mail, telephone, and fax. • Troubleshooting and providing logistical support as needed (e.g., tips on gaining media coverage, strategies for dealing with referrals). • Providing assistance to agency representatives to maintain peer support networks. • Troubleshooting staff issues as required, such as nontrained staff using the program and staff being anxious about attending accreditation workshops.

Periodic reviews of agency implementation • Identifying strengths and barriers in implementing the program at each agency via regular telephone- or video-conferencing or faceto-face meetings. • Where data is provided, reviewing each agency’s progress towards meeting performance indicators. Research has also identified the importance of ongoing supervision and support to practitioners as a procedure in psychological practice for promoting greater utilization of the training undertaken by a practitioner (Holloway & Neufeldt, 1995) and as a means of maintaining program fidelity beyond initial training in a dissemination strategy (e.g., Henggeler et al., 1997). Effective supervision of agency staff involved in a program dissemination effort includes strategies of peer support and mentoring of practitioners who are new to the program (Webster-Stratton & Taylor, 1998). In the dissemination of Triple P, a self-regulatory approach to supervision has been adopted. A self-regulatory perspective involves the promotion of personal responsibility for self-directed change (e.g., Karoly, 1993). The self-regulatory perspective to dissemination involves training practitioners to use self-directed learning strategies such as self-monitoring and self-evaluation, personal goal setting, and self-reward for goal attainment (Halford & Sanders, 1994). These self-regulatory skills enable practitioners to direct their own learning, skill acquisition, and problem solving subsequent to participating in skills training workshops. The Triple P model of dissemination proposes that practitioners will be more receptive and motivated to use self-regulatory skills in organizational environments that support and encourage staff to do so. As the universal aspects of Triple P form part of a comprehensive multilevel system, when the program is disseminated to agencies or service providers, program support (e.g., media resources and promotional material) is offered to enable tailored implementation of a media strategy to local needs to promote program awareness and recruitment of parents. However, the scope of this element depends greatly on agencies allocating some resources to support the coordination of a media campaign. The model of dissemination we have adopted to promote the use of Triple P within organizations is similar to the conceptual framework underpinning our approach to working with parents. Namely, to motivate practitioners to adopt and implement

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Development and Dissemination of Triple P evidence-based programs a collaborative approach is required in which practitioners’ broader employment context is considered. The availability of a supportive work context with program resources that have a good ecological “fit” to the environment where the program is used will facilitate subsequent program use. In this model, practitioners’ self-efficacy (or confidence in their ability to implement a program) is proposed to be the primary predictor of program uptake and implementation. We are currently undertaking a study to explore the relationship between program uptake, self-efficacy, and training, program and workplace variables (Turner & Sanders, 2002).

KEY ISSUES TO CONSIDER IN PROGRAM DISSEMINATION Recruitment and Engagement Strategies A number of strategies are employed to promote program awareness and to engage families in Triple P interventions, although the specific strategy has varied depending on the delivery context. These methods have included: referrals from practitioners and agencies; advertising materials such as brochures, flyers, posters, business cards and sign-up sheets displayed at schools, child care centers, and community centers; press releases to radio, television, and newspapers; feature stories by journalists in local newspapers; radio interviews; and current affairs stories on television. In the state of Queensland where there has been statewide government adoption of the program, a population survey of 4,010 Queensland families with a child under the age of 12 years (Sanders et al., 2002), revealed that 43% of parents had heard of Triple P and 15% of parents reported having participated in at least one level of the intervention system. The most common way in which parents reported hearing of Triple P was through school or preschool newsletters, word of mouth, and television coverage. This survey also showed that there was greater awareness of Triple P amongst higher income and better educated parents. These findings highlight the need to develop additional program recruitment strategies for engaging more disadvantaged low-income families. Towards this end, further strategies have been used such as 15 and 30 s television commercials providing simple positive parenting messages with a call to action for parents to contact a telephone counseling service, as well as talk-back radio, and the establishment of collaborative partnerships with services and agencies

that directly work with the most disadvantaged sectors of the population. Many parents entering Triple P interventions report hearing about the program through multiple sources (e.g., personal invitation from teacher or other professional, word-of-mouth testimonials from friends completing a program, and advertising of the program). In our experience, an active outreach campaign is needed to recruit and engage sufficient numbers of families to achieve a population level benefit. At present we do not have accurate data available on the proportion of parents with a child in the eligible age range who have participated in Triple P. However, as an indication of impact, according to Queensland Health records from Community Child Health between 1999 and 2002 over 120,000 families received either a group or an individual Triple P intervention and 1,500 Queensland Health Staff underwent Triple P professional training. A large number of government and nongovernment services have been involved in the implementation of Triple P. The approach we have found most successful in promoting engagement has been to respond to requests for information about the program. Enquiries have often occurred in the first instance as a result of hearing scientific presentations about the program at professional forums such as scientific meetings. The dissemination of an annual report from our center has also stimulated interest and awareness of the program and professionals have increasingly accessed information about Triple P via the internet (www.triplep.net).

Quality of Implementation We have also employed a number of strategies to increase the likelihood that practitioners will use Triple P interventions in a way that is likely to be effective. A standardized training program has been developed for each level of the intervention. This ensures that at first point of exposure practitioners throughout the world receive the same training experience. High quality training materials, practitioner resources, and parent materials have been developed to ensure that the program is easy to follow, accessible, and culturally appropriate. Practitioners participating in Triple P training are encouraged to establish or join peer support/supervision networks to review clinical cases and to prepare for the accreditation process. Accreditation as a Triple P provider requires practitioners to demonstrate a set of core competencies defined for each level of the program. We have also developed

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184 protocol adherence checklists to guide practitioners through the session content of each Triple P intervention within the system. Refinement of Intervention Guided by Theory As the Triple P system is strongly committed to a scientist–practitioner perspective, any level of the system is revised in the light of new data, theory, and feedback from program users and consumers. This feedback is incorporated into revised editions, program extensions, and program derivatives (e.g., Stepping stones Triple P which targets parents of children with disabilities). Economic Analysis The Triple P model addresses cost-effectiveness through its differing levels of intervention intensity and flexible delivery modalities tailored to meet families’ individual needs. The only formal costing of the program, which was for the universal delivery of group Triple P, indicated a total program cost of AU$296 per family. This figure included staff training, salaries, supervision, materials, childcare, and transport costs. The self-directed format costs as little as the price of a parent workbook, around AU$20 per family, or AU$145 if telephone consultations are included. This compares to the cost of AU$1950 for a course of treatment for a child with conduct problem behavior at a Child and Youth Mental Health Service in the same community. At time of writing, the Australian dollar equivalent is approximately US0.55 cents, although it would be inaccurate to directly translate the cost of delivery in Australia to cost of implementation in the United States. Further work is required to determine the program costs when implemented as a complete system of intervention within a defined geographical community. Researcher–Practitioner Collaboration Triple P has established a Scientific and Professional Advisory Committee that provides a context for identifying research questions and project ideas for future evaluations. This mechanism encourages clinically relevant research questions about the system to be identified and is a useful context for identification of Masters and PhD level dissertation topics. Feedback from practitioners and agencies is viewed as being extremely important in progressing the ev-

Sanders, Turner, and Markie-Dadds idence base underpinning Triple P. Direct contact with program developers has also been made possible through a Triple P Practitioner Network for trained and accredited providers. Members of this network have access to a web site that provides downloadable clinical tools and promotional materials, program updates, a questionnaire scoring program, referral details of other providers, and a question and answer forum.

TROUBLE SHOOTING DISSEMINATION OBSTACLES The development, evaluation, dissemination into regular clinical services, continued implementation, and ongoing evaluation and refinement of Triple P has challenged us as clinical researchers to move well beyond the traditional concerns of teams conducting clinical trials. We have needed to examine and develop strategies to address the broader ecological and organizational context within which clinical services are delivered. In the section below we discuss the nature of the ecological issues we have faced and solutions we have found helpful.

Managing the “Politics” of Supporting Families Over the past 5 years there has been a significant increase in worldwide policy debate on how governments can best support families. Within an Australian political context, both major political parties (Labor Party and the Liberal/National Party Coalition) have developed policies at state and federal levels that aim to support parents to do a better job in raising their children. For example, the State and Territory Governments of Queensland, Victoria, New South Wales, Western Australia, and South Australia have initiated information campaigns to make parenting information and advice more accessible to the public. Various national policy statements have identified parenting as being important in areas as varied as suicide prevention, drug abuse, and crime prevention (e.g., Commonwealth Department of Health and Aged Care, 2000a,b). However, the desire by government to support “family-friendly” policies is often not matched by a commitment to adequately fund evidence-based solutions. Nevertheless, there is much greater recognition of the importance of supporting parents and families than in the past. Our center has been actively involved in trying to inform the policy debate. Activities have included

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Development and Dissemination of Triple P making verbal and written presentations to senior policy advisors and government agencies on evidencebased practice and findings from recent clinical trials (e.g., Sanders, 1995), as well as developing innovative forms of communication about Triple P that can be easily accessed by policy makers (e.g., web sites and newsletters). We have served on several national committees, prepared briefings on research findings on family intervention, appeared before state-based inquiries into parent education, and sought government sponsorship for scientific conventions promoting better links between research and practice in relation to family functioning. Our center has an annual “Helping Families Change” conference for researchers, practitioners, and policy makers. Although these activities take considerable time, research centers have an important role in advocating for the adoption of evidence-based prevention initiatives that can influence funding priorities.

Coping With Changes of Government We are now well aware that a funding commitment from one government to implement a program such as Triple P can easily be overturned with a change of government. For example, in 1995 the Labor Government made a commitment to implement Triple P statewide, only to lose power 6-months later in a bielection. This change of government led to the defunding of the program for the next 3 years. A return to a Labor government in 1998 saw the reinstatement of the earlier commitment to implement the program. It is ill-advised for a program to become politically aligned as it immediately becomes vulnerable with a change of government. The “new broom” approach taken by new administrations often involves wanting to be seen to introduce something new or different from the previous administration. Alignment with one political party can be minimized by ensuring program activities are communicated broadly across the political spectrum in an effort to gain bipartisan support.

Continuity Despite Changes of Key Personnel The departure of key personnel from various government departments or divisions within departments or agencies is inevitable. The consequence of this mobility is that new policy advisors and program managers need to be educated about the program, the

agency’s history of involvement with the program, and the benefits of providing continuing support. Fighting Misinformation and Myths As an intervention becomes better known it is inevitable that it will develop critics. Not only does the Triple P approach to working with families challenge existing practices but it can also affect the funding of other programs. The phenomenon of the “tall poppy syndrome” means that successful programs engender a certain amount of resentment and professional rivalry, particularly if substantial government funding is received at the expense of competing programs. We have developed myth-debunking strategies to address myths about Triple P that have come to our attention. Often these myths (e.g., “It only works with middle-class families,” “It’s inflexible,” “It’s too behavioral”) are perpetuated on the basis of hearsay, in the absence of supporting evidence, or indeed in the face of contrary evidence. Criticism is often made when knowledgeable program staff members are not present and therefore unable to respond. Despite trialing Triple P with large samples of high risk, multiproblem families, myths perpetuate regarding its ability to benefit families with low income, low literacy or low education levels. The approach we have generally taken in addressing myths is to be open, nondefensive and wherever possible let the data do the talking. We have often debunked myths in training by presenting factual information on the issue at hand (e.g., data illustrating that family income does not predict intervention outcomes). It can be difficult to address criticisms from those with no direct knowledge or experience of the intervention. To deal with this, it is useful to train practitioners implementing the program to respond with evidence when these criticisms are voiced. When individuals other than the program developers defend the program with strong arguments or data, critics may be disarmed. It is also important to determine whether it is worth the time and effort required to address criticism. Generally we make a judgment about whether to respond on the basis of a critic’s capacity to influence the survival of the program. In most instances they do not have this capacity. Maintaining Quality Assurance One important threat to the effectiveness of programs like Triple P is when practitioners significantly

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186 drift away from using the evidence-based clinical protocols developed during the trialing of a program. The maintenance of program integrity is difficult once a program has been disseminated and is being widely used by service providers. We have developed a variety of strategies to reduce the likelihood of program drift. Many problems can be avoided by having high quality, professionally developed resources, and parent materials that are easy to use and designed to have a good ecological fit with the practice environment within which the program is being used. In addition, we have developed a standardized accreditationbased professional training program for all five levels of the intervention, as well as a training and accreditation program for new trainers. Another aspect of quality assurance is the development of supervision and administrative guidelines (described earlier) that support the practical implementation of the program in an agency.

Managing Academic Responsibilities and Consultation With the Field Dissemination activity has received scant attention in the past partly because it has not been seen as core business of academic institutions. The academic system tends to reward research productivity (e.g., publishing and attracting grants), service to the university and, to a lesser extent, the quality of teaching. Little value is place on the importance of academics being directly involved in the dissemination of evidence-based interventions evaluated at the institution. As a consequence of this university reward structure, many potentially important clinical findings gather dust on library shelves, having been read by only a handful of people. To encourage clinical researchers and program developers to market and promote quality solutions, supportive mechanisms are needed. These include the development of technology transfer incentives for researchers that take into consideration the commercialization of intellectual property. Incentivizing the process of transferring programs into products that can be made available to the community is important if evidence-based solutions are to be fostered. Such incentives for program developers can include innovation grants, gaining teaching release time, developing appropriate royalty arrangements for contributing authors, providing research and development grants with industry partners to collaboratively develop and then disseminate the work.

Sanders, Turner, and Markie-Dadds Balancing Cost and Sustainability of Dissemination Efforts Dissemination efforts need to be funded. Our center is largely funded through research grants, contracts and service agreements, and as such, has not received any specific funds for program dissemination. To disseminate Triple P, we have established a selffunded training and dissemination operation. This operation was originally based within our research center. Although this initial arrangement worked satisfactorily when dissemination activities operated on a small scale, as the training program expanded, and particularly once international dissemination commenced, a more flexible operation was needed. Consequently, a business entity devoted to managing the dissemination of Triple P has recently been created. This company holds a license from The University of Queensland, which holds copyright for Triple P, to commercially develop all intellectual property invested in Triple P, including publishing, training, and dissemination. This approach is expected to ensure the financial viability of the training and dissemination operation. The clinical research and development of Triple P remains based in the university research center. The major function of this center is to develop, through rigorous research, evidence-based solutions that can then be disseminated through the commercial operation. Considering Cost Versus Quality Another issue we have had to contend with is the tension between ensuring a dissemination operation is financially viable and the desire to make the program available to agencies at a reasonable cost. Many of the agencies that could use Triple P have limited resources. There is thus an ongoing challenge to keeping costs down while ensuring the program is associated with quality resources and materials. Remaining Data Responsive For interventions to be truly evidence-based, they should continue to evolve and be modified in the light of new evidence related to the nature, causes, treatment or prevention of the problem(s) being targeted. In addition, once an intervention has been disseminated, practitioners can provide a rich source of ideas and feedback that can be used to refine the intervention. This includes adaptations of the program to new client groups. However, all derivative programs

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Development and Dissemination of Triple P need to be evaluated and the findings, as well as any program modifications, need to be communicated to practitioners and agencies using the program. Working With Different Populations Another aspect to being data responsive has involved trialing the program with different populations. Over the years we have had express interest from service providers and agencies working with different client groups (e.g., parents of teenagers, parents with anger management problems or child abuse notifications, parents and carers of children with disabilities, and Indigenous Australian families) that have engendered program adaptations, research trials, and further program development. This process has been guided by appropriate scientific and cultural reference groups, focus testing, and field trials. Promoting International Dissemination One of the more challenging and time consuming aspects of dissemination involves the development of a strategy for handling expressions of interest from other countries seeking to use the program in their own cultural context. While there are fewer obstacles for English-speaking countries, the culturally appropriate adaptation of the program into another country involves addressing several important issues. The use of Triple P in several Asian countries (e.g., Hong Kong and Singapore) and European countries (e.g., Germany and Switzerland) has initially involved pilot research to establish the effectiveness and acceptability of the program in different cultural contexts. Introducing the program into other countries also highlights new issues, such as considerable investment of time with no immediate return (e.g., up to 2 years contact to establish the program), and considerable financial outlay for translations and reverse translations to ensure the meaning of core program content is not lost. Low cost communication strategies such as e-mail have made it much easier to liaise with other countries where time-differences make telephone contact difficult, allowing regular consultation to occur.

FUTURE DIRECTIONS Triple P provides a flexible, evidence-based system of parenting and family support. As the core program has evolved to address the diverse needs of

families (e.g., parents of children at differing developmental levels from infancy to adolescence, special needs, as well as the needs of indigenous and migrant parents) it has been clear that the scientific basis of the parenting advice given to families, the methods of training parents and the strategies to disseminate the program to the field all require careful ongoing empirical scrutiny. Decision rules that have a stronger evidence-base are required to determine which families require different levels or intensities of intervention delivered through the various modalities of intervention. As the program extends to address other important clinical problems and disorders, a rich array of interventions become available to both practitioners and parents. This increased range of options also leads to greater complexity and sophistication in the clinical judgements required of practitioners. For example, practitioners have to determine whether a child’s parent requires a parenting intervention, and also which dose or level of intervention is required, through what delivery modality, in what delivery context and by whom. Such an approach creates considerably greater options for consumers to access quality parenting advice. The full scale implementation of parenting and family support strategies at a population level offers the greatest potential to address the task of reducing the prevalence of family and parenting risk factors associated with the development of serious behavioral, emotional, and social problems in children and adolescents. Prevention efforts targeting major problems such as juvenile crime, drug abuse, youth homelessness, or other social maladies of the young are unlikely to be successful if the central role of how families socialize and care for children are ignored. REFERENCES Ash, J. (1997). Organizational factors that influence information technology diffusion in academic health science centers. Journal of the American Information Association, 4, 102–111. Backer, T. E., Liberman, R. P., & Kuehnl, T. G. (1986). Dissemination and adoption of innovative psychosocial interventions. Journal of Consulting and Clinical Psychology, 54, 111–118. Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1989). Regulation of cognitive processes through perceived self-efficacy. Developmental Psychology, 25, 729–735. Bandura, A. (1995). Self-efficacy in changing societies. New York: Cambridge University Press. Becker, D. M., Hill, D. R., Jackson, J. S., Levine, D. M., Stillman, F. A., & Weiss, S. M. (1992). Health Behavior Research in minority populations: Access, design and implementation. U.S. Department of Health and Human Services. Biglan, A., Mrazek, P. J., & Carnine, D. (1999). Strategies for translating research into practice. Unpublished manuscript.

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188 Bor, W., Sanders, M. R., & Markie-Dadds, C. (in press). The effects of the Triple P-Positive Parenting Program in preschool children with co-occurring disruptive behavior and attentional/hyperactive difficulties. Journal of Abnormal Child Psychology. Christensen, A. P., & Sanders, M. R. (1987). Habit reversal and DRO in the treatment of thumbsucking: An analysis of generalization and side effects. Journal of Child Psychology and Psychiatry, 28, 281–295. Commonwealth Department of Health and Aged Care. (2000a). National action plan for promotion, prevention and early intervention for mental health. Canberra: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care. Commonwealth Department of Health and Aged Care. (2000b). LIFE—Living is for everyone: A framework for prevention of suicide and self-harm in Australia. Canberra: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care. Connell, S., Sanders, M. R., & Markie-Dadds, C. (1997). Selfdirected behavioral family intervention for parents of oppositional children in rural and remote areas. Behavior Modification, 21(4), 379–408. Dadds, M. R., Schwartz, S., & Sanders, M. R. (1987). Marital discord and treatment outcome in the treatment of childhood conduct disorders. Journal of Consulting and Clinical Psychology, 55, 396–403. Emery, R. E. (1982). Interparental conflict and the children of discord and divorce. Psychological Bulletin, 9, 310–330. Grych, J. H., & Fincham, F. D. (1990). Marital conflict and children’s adjustment: A cognitive–contextual framework. Psychological Bulletin, 108, 267–290. Halford, K. W., & Sanders, M. R. (1994). Self-regulation in behavioral couples’ therapy. Behavior Therapy, 25, 431–452. Harrold, M., Lutzker, J. R., Campbell, R. V., & Touchette, P. E. (1992). Improving parent–child interactions for families with developmental disabilities. Journal of Behavior Therapy and Experimental Psychiatry, 23, 89–100. Hart, B. M., & Risley, T. R. (1995). Meaningful differences in the everyday experience of young American children. Sydney: Paul. H. Brooks. Henggeler, S. W., Melton, G. B., Brondino, M. J., Schereer, D. G., & Hanely, J. H. (1997). Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology, 65, 821–833. Holloway, E. L., & Neufeldt, S. A. (1995). Supervision: Its contributions to treatment efficacy. Journal of Consulting and Clinical Psychology, 63, 207–213. Karoly, P. (1993). Mechanisms of self-regulation: A systems view. Annual Review of Psychology, 44, 23–52. Kazdin, A. E. (1991). Effectiveness of psychotherapy with children and adolescents. Journal of Consulting and Clinical Psychology, 59, 785–798. McMahon, R. J., & Wells, K. C. (1998). Conduct problems. In E. J. Mash, R. A. Barkley, et al. (Eds.), Assessment of childhood disorders (2nd ed., pp. 111–207). New York: Guilford. Nicholson, J. M., & Sanders, M. R. (1999). Randomized controlled trial of behavioral family intervention for the treatment of child behavior problems in stepfamilies. Journal of Divorce and Remarriage, 30, 1–23. Parcel, G. S., Perry, C. L., & Taylor, W. C. (1990). Beyond demonstration: Diffusion of health promotion innovations. In N. Bracht (Ed.), Health promotion at the community level: Sage sourcebooks for the human services series, Vol. 15 (pp. 229– 251). Thousand Oaks, CA: Sage. Patterson, G. R. (1982). Coercive family process. Eugene, OR: Castalia.

Sanders, Turner, and Markie-Dadds Rogers, E. M. (1995). Diffusion of innovations (4th ed). New York: Free Press. Rutter, M. (1985). Family and school influences on behavioural development. Journal of Child Psychology and Psychiatry, 26, 349–368. Sanders, M. R. (1992). Every parent: A positive guide to children’s behaviour. Sydney, Australia: Addison-Wesley. Sanders, M. R. (Ed.). (1995). Healthy families, healthy nation: Strategies for promoting family mental health in Australia. Brisbane: Australian Academic Press. Sanders, M. R. (1996). New directions in behavioral family intervention with children. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology (pp. 283–330). New York: Plenum. Sanders, M. R. (1998). The empirical status of psychological interventions with families of children and adolescents. In L. L’Abate (Ed.), Family psychopathology: The relational roots of dysfunctional behavior. New York: Guilford. Sanders, M. R. (1999). The Triple P-Positive Parenting Program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clinical Child and Family Psychology Review, 2, 71–90. Sanders, M. R. (2001). Helping families change: From clinical interventions to population-based strategies. In A. Booth, A. C. Crouter, & M. Clements (Eds.), Couples in conflict (pp. 185– 219). Mahwah, NJ: Erlbaum. Sanders, M. R., & Christensen, A. P. (1985). A comparison of the effects of child management and planned activities training across five parenting environments. Journal of Abnormal Child Psychology, 13, 101–117. Sanders, M. R., Markie-Dadds, C., Rinaldis, M., Firman, D., & Baig, N. (2002). Strengthening families: A survey of Queensland families. Brisbane, Australia: Queensland Health. Sanders, M. R., Markie-Dadds, C., Tully, L. A., & Bor, W. (2000a). The Triple P—Positive Parenting Program: A comparison of enhanced, standard, and self-directed behavioral family intervention for parents of children with early onset conduct problems. Journal of Consulting and Clinical Psychology, 68, 624– 640. Sanders, M. R., Markie-Dadds, C., & Turner, K. M. T. (Producers/ Directors). (1996). Every parent’s survival guide [videotape and booklet]. Brisbane, Australia: Families International. Sanders, M. R., Markie-Dadds, C., & Turner, K. M. T. (2001). Practitioner’s manual for Standard Triple P. Brisbane, Australia: Families International. Sanders, M. R., Markie-Dadds, C., Turner, K. M. T., & BrechmanToussaint, M. (2000b). Triple P—Positive Parenting Program: A guide to the system. Brisbane, Australia: Families International. Sanders, M. R., & McFarland, M. L. (2000). The treatment of depressed mothers with disruptive children: A controlled evaluation of cognitive behavioral family intervention. Behavior Therapy, 31, 89–112. Sanders, M. R., Montgomery, D., & Brechman-Toussaint, M. (2000c). Mass media and the prevention of child behaviour problems. Journal of Child Psychology and Psychiatry, 41, 939– 948. Sanders, M. R., & Plant, K. (1989). Programming for generalization to high and low risk parenting situations in families with oppositional developmentally disabled preschoolers. Behaviour Modification, 13, 283–305. Sanders, M. R., Rebgetz, M., Morrison, M., Bor, W., Dadds, M., & Shepherd, R. W. (1989). Cognitive–behavioral treatment of recurrent nonspecific abdominal pain in children: An analysis of generalization, maintenance, and side effects. Journal of Consulting and Clinical Psychology, 57, 294– 300.

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Development and Dissemination of Triple P Sanders, M. R., Shepherd, R. W., Cleghorn, G., & Woolford, H. (1994). The treatment of recurrent abdominal pain in children: A controlled comparison of cognitive–behavioral family intervention and standard pediatric care. Journal of Consulting and Clinical Psychology, 62, 306–314. Sultana, C., Matthews, J., De Bortoli, D., & Cann, W. (2000, February). Outcome evaluation of the primary care level of the Positive Parenting Program implemented in a community setting by primary care practitioners. Paper presented at the Helping Families Change Conference: 2000 and Beyond, Brisbane, Australia. Turner, K. M. T., & Sanders, M. R. (2002, June). Dissemination of psychological innovation to primary care professionals: Effectiveness and program uptake. Paper presented at the 3rd International Conference on Child and Adolescent Mental Health, Brisbane, Australia.

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