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The Triple P Positive Parenting Program Matthew R Sanders, Ph.D Professor of Clinical Psychology The University of Queensland
The case • Parenting has a pervasive impact on children’s development (Collins et al, 2000) • Parenting programs benefit both children and parents • Potential impact is diminished because they reach relatively few parents
Clear documentation of unmet need
1
The problem
A disturbingly large number of children develop significant social, behavioral and emotional problems that are preventable
Significance of the Problem Percentage of children with emotional or behavioral problems in the clinical range
15% clinical
(Sawyer et al, 2000)
85% nonclinical
Percentage of children in each family income band Highest proportion of children developing problems come from low income families
Which parents should we target? 84 % of cases are not from low income families
No group has a monopoly on either coercive or positive parenting practices
It’s little wonder parents are stressed • Many parents reported experiencing high levels of personal stress (52%) • Many parents reported being depressed (23%) • 31% had sought professional help for their child’s behavioural or emotional problems. • Only a minority of parents (14%) had completed a parenting program
Sanders, M. R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S., et al. (2008). Every family: A population approach to reducing behavioral and emotional problems in children making the transition to school. Journal of Primary Prevention, 29(3), 197-222.
An explicit theoretical framework
2
The Challenge
Increase the number of parents who complete evidence-based parenting programs
To enhance parenting competence and confidence at a population level
To reduce the prevalence of child social, emotional and behavioural problems
Theoretical Basis of Triple P • Social learning models of parent-child interaction • Developmental research on parenting in everyday contexts and social competence • Social information processing models • Developmental psychopathology research • Public health framework
Self Regulation Framework
Parental Self regulation
Selfmanagement
Self-efficacy
Personal agency
Selfsufficiency
Principles of Positive Parenting
Ensuring a safe, engaging environment
Taking care of yourself as a parent
Having realistic expectations
Creating a positive learning environment
Using assertive discipline
17 Core Parenting Skills
Promoting positive relationships
Brief quality time Talking to children Affection
Encouraging desirable behaviour
Praise, positive attention, engaging activities
Teaching new skills and behaviours
Modelling, Incidental teaching Ask-say-do Behaviour charts
Managing misbehaviour Ground rules Directed discussion Planned ignoring Clear, calm instructions Logical consequences Quiet time Time-out
What makes Triple P any different?
A whole of population approach
Suite of evidence based programs (from infancy through to adolescence-5 levels, 4 delivery modalities)
Blends universal and targeted programs
Concurrently implements multiple levels
What makes Triple P any different?
Applies concept of the minimally sufficient intervention
Effective with diverse problems
Multidisciplinary
Acceptable and effective in diverse cultural contexts
Focus of parenting support Universal Triple P Level One
Selected Triple P Level Two
Primary Care Triple P Level three
Standard Triple P Level four
Enhanced Triple P Level five
A strong evidence base and allowing a program to evolve in the light of new evidence
3
Building an evidence base to justify population level application takes time Last updated August, 2008
Strength of evidence Efficacy trials have been conducted using i) a series of single case experiments
Supporting evidence 12 studies
ii) randomised controlled trials (RCT) methodology
47 studies
Effectiveness trials have been conducted under conditions of usual service delivery that demonstrate positive outcomes for children and parents
28 studies
Independent meta analyses Total evaluation studies
4 studies 91 studies Evidence list www.pfsc.uq.edu.au
Independent meta analyses •
•
•
•
de Graaf, I., Speetiens, P., Smit, F., de Wolff, M., & Tavecchio, L. (2008). Effectiveness of the Triple P-Positive Parenting Program on behavioral problems in children: A meta-analysis. Behavior Modification, 32(5), 714-735. de Graaf, I., Speetiens, P., Smit, F., de Wolff, M., & Tavecchio, L. (in press). Effectiveness of the Triple P Positive Parenting Program on parenting: A meta-analysis. Journal of Family Relations. Nowak, C., & Heinrichs, N. (2008). A comprehensive meta-analysis of Triple P-Positive Parenting Program using hierarchical linear modeling: Effectiveness and moderating variables. Clinical Child and Family Psychology Review. Thomas, R., Zimmer-Gembeck, M.J. (2007). Behavioral outcomes of parent-child interaction therapy and Triple P-Positive Parenting Program: A review and meta-analysis. Journal of Abnormal Child Psychology, 35, 475-495.
Examples of tailoring undertaken with high need groups • • • • • • • • • •
Parents at risk of abuse (Sanders et al, 2004) Depressed parents of children with conduct problems (Sanders & McFarland, 2000) Parents who have separated or divorced (Stallman & Sanders, 2007) Maritally discordant parents (Dadds, Schwartz & Sanders, 1987) Parents of children with ADHD (Hoath & Sanders, 2004) Parents of children with developmental disabilities (Plant & Sanders, 2007) Parents of children with chronic illnesses (Morawska & Sanders, 2008) Parents of children with feeding disorders (Sanders & Turner, 2000) Parents of children with recurrent pain syndromes (Sanders et al, 1994) Parents of gifted and talented children (Morawska & Sanders, 2007)
Current international trials – – – – – – – – – – – –
Belgium (University of Antwerp) The Netherlands Trimbos Institute) Sweden (University of Uppsala) Germany (University of Braunschweig) Switzerland (University of Friborg) Canada (University of Manitoba; UBC) USA (Oregon Research Institute, USC) England (University of Manchester, Oxford University, Cambridge University, University of Birmingham) NZ (University of Auckland, University of Waikato, University of Canterbury) Iran (Medical University of Tehran) Japan (University of Tokyo, University of Wakayama) Hong Kong (DOH)
Evidence is shaped by and interpreted by multiple stakeholders
The Evidence
Policy makers
Researchers
Providers
Consumers
Funders
Involve consumers to fine tune program
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A range of program variants to meet the needs of different parents Family Transitions Triple P
Infant Triple P
Pathways Triple P
Indigenous Triple P
Core Triple P Program
Stepping Stones Triple P
Lifestyle Triple P
Workplace Triple P
Teen Triple P
Use consumer preference data to tailor programs more effectively Sanders, Haslam, Stallman, Calam & Southwell (in prep)
Preferred delivery formats
What type of program features are important to parents? Survey Item
Rank % responding ‘important’
or ‘very important’ The program has been demonstrated to be effective
1
94.0%
The program is conducted by trained practitioners
2
90.3%
The program addresses personally relevant issues
3
90.1%
Resources are professionally produced and presented
4
85.2%
Participants are encouraged to set and achieve their own goals
5
75.5%
Parent preferences re delivery mode Metzler, Sanders et al (2008)
Preferred delivery modalities
%
TV program
73
On Line
61
Written material
56
Workbook
46
One time parenting group
46
Resource Centre
39
Parenting group over weeks
27
Therapist
21
Home Visit
17
Establish achievable participation targets
Where we need to be
Where we are now
Design cost effective interventions that reach many parents
5
Levels of access to parenting support
•
Selected Triple P (Level 2) helps many parents and normalises parenting interventions. There are two delivery formats: Brief and flexible consultation (about 20 minutes each) by existing, Triple P trained workforce with individual parents for; and Parenting seminars with large groups of parents for 90 minutes on selected topics: The power of positive parenting, Raising confident competent children Raising resilient children
Selected Triple P Level Two
Triple P Seminar Series Tipsheets
Triple P Parent Discussion Groups Examples only • Infants-sleeping • Toddlers-disobedience • Preschoolers-Hassle Free Shopping • Primary Schoolers-homework • Teens-communicating with teens
Hassle Free Shopping 2 hour large group session plan • Taking shopping with children • Activity 1: Shopping hassles • Why do children misbehave on shopping trips? • Activity 2: Parent traps • Activity 3: How to prevent shopping problems • Activity 3: How to manage shopping problems • Activity 4: Getting started • If problems persist
Effects on Child Behaviour Joachim, Sanders & Turner (in prep) .Hassle-free shopping with children- Evaluation of a brief Triple P parent discussion group
130
ECBI Intensity Scores
120 110 100 90 80 70 60 50 40 Intervention PreIntervention
Control Post Intervention
Follow Up
• Fewer shopping specific problems (d=1.6) • Lower levels of dysfunctional parenting (d=.72) • Increased task specific self efficacy (d=1.31) • High consumer satisfaction (M = 34.3; SD = 5.80) d=.75
Lessons learned • Brief interventions can be effective (Sanders, Pryor & Ralph, 2008; Sanders et al, 2007;Joachim et al, under review) • Help to destigmatize and normalize parenthood preparation • Extremely cost effective
Use diverse access points
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Effects of Work-Family Conflict on functioning at work • Occupational stress and burnout • Lower job satisfaction and organizational commitment • Low productivity • Increases absenteeism • Industrial accidents • Higher turnover • Skills shortage in the workforce
Workplace Triple P • Run in the workplace or with colleagues • Specifically targets the needs of working parents • 8 session parenting program – 5, 2-hour group sessions or 2 day intensive option – plus 3 phone consults
Effects on Parental Mood Sanders, Stallman & McHale (under review)
N=64
N=64
• Increased work commitment • Increased work satisfaction • Increased work self efficacy • Effect size: Cohen’s d=.37-.83
Use more intensive programs sparingly
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Strengthen social structures that support good parenting
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Universal Triple P Level One
•
•
The Universal (Level One) of Triple P uses media and informational strategies to promote positive parenting and normalize help seeking by families as a part of everyday life. Universal Triple P includes use of radio, local newspapers, newsletters at schools, mass mailings to family households, presence at community events, and website information.
Reality parenting? • Reality parenting programs are now part of the popular culture (Supernanny, Nanny 911) • 43% of parents of 4-7 year olds have watched supernanny • Very little is known about the effects of these parenting programs
Reality ITV Series on Parenting • • •
•
“Driving Mum and Dad Mad” Series captures the emotional journey of the families undertaking Group Triple P 5 families (9 parents, 5 target children between 3-7, 6 siblings) All had severe conduct problems (ODD, CD) complicated by additional difficulties (profound deafness, ADHD, chronic sleep disturbance, encopresis, physical health problems) Poor parenting complicated by other factors including marital conflict, depression, anger management problems, sleep deprivation, and unemployment
Acknowledgement: Research funded by the Home Office (UK). Respect Task Force
Main Findings Both Standard TV and Enhanced TV groups showed ↓ Child behavior problems (ECBI-Intensity and Problem scores) ↑ Parental task specific self efficacy (PSBC) ↓ Dysfunctional parenting (PS Laxness, overreactivity, verbosity, Total) ↓ Parental anger (PAI) ↓ Parental depression-DASS-depression) ↓ Parental stress (DASS-stress) Calam, Sanders, Liversidge et al (2008). Journal of Child Psychology and Psychiatry
Enhanced condition families reported greater improvements than families in the standard condition on the following: ↓ Child behaviour difficulties (ECBI Intensity and Problem scores) ↓ Dysfunctional parenting strategies (PS:laxness, overreactivity and total score) ↓ Parental anger (PAI-problem score) ↓ Parental disagreements about discipline (PPCIntensity and problem scores) ↑ Consumer satisfaction
Lessons learned • DMDM attracted wide range of parents from different SES backgrounds who had children with significant problems who were not seeing anyone • Some of the most needy parents require some professional support to complete a self help parenting programme • New NIDA funded trial examining enhanced media series involving attributional retraining, expectancy enhancement, social support, mindfulness elements
Develop a sustainable system of dissemination to enable program to “go to scale”
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Same training model is used everywhere Triple P operates Australia New Zealand Scotland England USA Canada Germany Ireland
The Netherlands Switzerland Iran Hong Kong Singapore Japan Belgium Curacao Sweden
“User friendly” parent and practitioner tools and resources • Standardised training and accreditation process • Needs to be financially viable
The differences between users and non users? • Have completed accreditation (Seng, Prinz & Sanders, 2006) • Have greater line management support (Turner, Nicholson & Sanders, 2005) • Identify fewer barriers to program implementation (Seng et al, 2006)
Lessons learned • Program use related to the post training environment of service providers • Agency optimization strategies needed • Quality assurance mechanisms
Collect population level outcome data on policy relevant concerns
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10 Step Blueprint Clear documentation of need
Use diverse access points
An explicit theoretical framework
Use intensive programs sparingly
Build a strong evidence base
Involve consumers to shape program Design cost effective interventions
Strengthen social structures to support parenting Sustainable system of dissemination Population level outcome data relevant to policy
Triple P system population-level trial to prevent child maltreatment • Sponsored by the US Centers for Disease Control and Prevention •
Source: Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (Accepted for publication). Population-based prevention of child maltreatment: The U.S. Triple P System Population Trial. Prevention Science.
Randomized study of 18 counties •
Counties between 50,000 and 175,000 people.
•
Counties matched on level of childmaltreatment, poverty, and size.
•
Counties randomly assigned to Triple P or care as usual.
• •
About 85,000 in all the Triple P counties. This is the first-ever randomized control study at a population-level to prevent child maltreatment.
Translation of effect sizes into human terms • Assume a population with 100,000 children under 8 years of age • With the observed effects, there were……. – 688 fewer substantiated cases of child maltreatment per year – 240 fewer child out-of-home placements per year – 60 fewer hospitalized or ER treated children with child-maltreatment injuries per year
Ecological model of Every Family Sanders, M. R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S., et al. (2008). Every family: A population approach to reducing behavioral and emotional problems in children making the transition to school. Journal of Primary Prevention, 29(3), 197-222.
Media strategy
Level 1 Universal Triple P
Divisions of General Practice Level 2 Selected Triple P Level 3 Primary Care Triple P
Community Child Health Services
Level 2 Seminars Level 4 Group Triple P Level 4 Standard Triple P Level 5 Enhanced Triple P
Preschools and Schools
Parents and children
Parentline
Telephone support services
Level 2 Seminars Level 4 Group Triple P Triple P Newsletters
Workplace Intervention Workplace Triple P
Every Family: Population Impact Every Family impact on children’s emotional and behavioural problems:
Comparable Australian National Tobacco Campaign impact on smoking:
Every Family: Population Impact Every Family impact on children’s behavioural and emotional problems: 22% reduction
Comparable National Tobacco Campaign impact on smoking: 7% reduction
Policy that supports good parenting is essential to improve the well being of children and young people “The soul of a nation is defined by the
treatment of its children” (Nelson Mandela)
Take home message • Triple P is an example of how psychological science knowledge can be combined with epidemiology, and public health to tackle a major social problem • Good parenting should be the centrepiece of population level efforts to prevent child maltreatment, major mental health, social and educational problems in children and young people
Practitioner Update Matthew R Sanders, Ph.D Parenting and Family Support Centre University of Queensland
Overview • What’s new • Recent findings • Studies under way – Triple P Media series (Metzler et al, 2009) – Bipolar Parents Project
• Newly developed programs – Primary Care Stepping Stones Triple P – Baby Triple P + Prem Baby Triple P
– UD Triple P system Population Trial (Prinz et al, 2009) – Every Family population trial (Sanders et al. 2008) – Lifestyle Triple P (West & Sanders, 2009) – Family transitions Triple P – Primary Care Group Triple P – Triple P for grandparents – Foster Parents Triple P
