(p. 32) Emergence of a Population Approach to Evidence-Based Parenting Support
The emergence of an evidence-based population approach to the provision of parenting and family support services represented a major change in how parenting programs have been deployed (Prinz & Sanders, 2007; Sanders, 1999). Traditionally, empirically supported parenting programs based on social learning theory, applied behavior analysis, cognitive-behavioral principles, and developmental theory were delivered as individual or group treatments and primarily offered to parents of children with clinical-level behavior problems (McMahon, 1999). This approach was, and remains, an outstanding success in providing effective family intervention to assist parents of children with conduct problems.
Despite the clear value of the approach variously known as behavioral parent training (McMahon & Forehand, 2005), parent management training (Kazdin, 2008), and behavioral family intervention (Sanders & Dadds, 1982), these parenting programs have not been used widely enough by practitioners or mental health and family support agencies. Intervention provided active “coaching” to parents in how to apply positive parenting strategies and included strategies for both rearranging antecedents (e.g., providing engaging activities and giving clear, calm, instructions) and the application of contingent consequences to change children’s prosocial behavior (e.g., descriptive praise and positive attention) and problem behavior (e.g., planned ignoring, a logical consequence such as removing a toy, nonexclusionary and exclusionary time-out). The interventions were primarily applied to disruptive behavior and conduct disorders. Over time, it became clear that problematic or dysfunctional parenting practices were implicated in the origins and maintenance of a wider range of child problems (including internalizing behavior), and that the techniques of behavior change, when used appropriately, could also be successfully applied by parents to prevent or manage many of these problems.
(p. 33) We begin this chapter with a brief overview of the historical context that led to the emergence of population-based strategies. We then describe the Triple P system as an exemplar of a population-based approach to providing parenting support that involves using an integrated multilevel system of parenting interventions. We discuss the essential criteria that need to be met for a population approach to work in practice and some of the distinguishing features of the Triple P system as a model. Finally, we discuss implications for policy, research, and practice derived from large-scale dissemination of the Triple P system.
Historical Foundations of the Population Approach to Parenting Support
Behavioral parent training has its roots in the early 1960s (Hanf & Kling, 1973; Patterson, 1976; Tharp & Wetzel, 1969; Wahler, 1969), when major changes were beginning to take place in the field of mental health. The prevailing paradigm of psychoanalytic and other intrapsychic assumptions about the origins of mental health disorders was beginning to give way to a new paradigm focused on the role of the environment. Child mental health witnessed this shift more quickly than the adult area, perhaps because it was easier to recognize the impact of the family environment on children. Accordingly, mental health professionals began to call on parents as active “therapists” to alter the social-environmental conditions and contingencies operating at home and elsewhere in their children’s lives. This approach to treatment, namely behavioral parent training, emerged from social learning theory and applied behavior analysis, eventually becoming the cornerstone of clinical child psychology (O’Dell, 1974).
By the 1990s, behavioral parent training specifically, and evidence-based treatments more generally, had become mainstream. The benefits to children and families with social, emotional, and behavioral problems were well documented, but a strong interest in prevention began to emerge. There are several compelling reasons to pursue prevention as it applies to children, youth, and their families. Intervening early in a developmental trajectory before children’s problems rise to a dysfunctional level is less costly in both economic and human terms (Arruabarrena & De Paúl, 2012). Furthermore, letting problems continue without intervention until adolescence can make the intervention task more difficult because family processes might have significantly deteriorated and youth problems become more serious and intransigent.
In the child maltreatment area, prevention is essential because (a) many parents engage in problematic parenting that does not usually trigger official involvement of the child welfare system; (b) waiting until child protective services become involved before intervening often results in the accumulation of adverse consequences for children, families, and society; and (c) the cost of child maltreatment is high, and the return on investment in prevention not only offsets this cost but also yields other economic and societal benefits (e.g., associated with gains in child development productivity and reduction in child protection and juvenile justice involvement; Christian & Schwarz, 2011). Finally, in comparison with treatment, prevention strategies have a greater potential to reach large numbers of families (Altafim & Linhares, 2016).
The result of research and application over several decades is a broad and cogent approach to parenting and family intervention. A generic term to describe this approach is evidence-based parenting support (EBPS), which denotes a process of change that aims to positively influence the prosocial development, including social, emotional, and physical well-being, (p. 34) of children and youth through corresponding changes in those aspects of the family environment implicated in the development, maintenance, and alteration of children’s behavior and capabilities. EBPS involves the systematic application of data-based principles and techniques derived from social learning theory, public health, and relevant behavioral, affective, and cognitive change strategies, with an emphasis on reciprocity of change and relationship building among family members.
What Is the Triple P System?
The Triple P—Positive Parenting Program (Sanders, 2008, 2012) is a unique, multilevel system of parenting support derived from social learning theory, applied behavior analysis, cognitive-behavioral principles, developmental theory, and population health principles discussed previously. It extends traditional population health models through a unique blending of universal and targeted parenting programs and covers the full spectrum of interventions, including universal, selected, and indicated prevention; early intervention; and treatment. The specific parenting and behavior change principles and strategies employed in the Triple P system are outlined by Sanders and Mazzucchelli in Chapter 4 of this volume.
Goals of the Triple P System
The overarching aim of the Triple P system is to reduce the prevalence rates of serious social, emotional, and behavioral problems in children and the level of child maltreatment in the community. It seeks to achieve these outcomes by making high-quality EBPS programs widely available to all parents. The specific parent and child outcomes that the population approach to parenting support seeks to accomplish are as follows:
1. To increase the number of parents who have the necessary knowledge, skills, and confidence to parent their children and adolescents well by increasing the number of parents who complete an evidence-based, culturally appropriate parenting program.
2. To increase the number of children and adolescents who are thriving socially, emotionally, and academically.
3. To decrease the number of children and adolescents who develop serious social, emotional, and behavioral problems.
4. To decrease the number of children and adolescents who are maltreated or at risk of being maltreated by their parents.
Defining a Population Approach to Parenting Support
The Triple P system builds on the principles of population health articulated by Rose (2008). There are two separate, but related, aspects to the population approach used in Triple P. The (p. 35) first relates to targeting prevalence rates of child and parent problems and using population indicators to judge impact. The second aspect involves conceptualizing the intervention needed in terms of how larger segments of the community are engaged (in contrast to a typical clinical intervention that is conceptualized in terms of action with one family at a time). The goals are to move the population distribution curve of a targeted child outcome (e.g., social, emotional, and behavioral problems or child maltreatment), a risk factor (e.g., coercive parenting), or a protective factor (e.g., positive parenting) toward healthier levels of functioning and to decrease the distribution of the targeted problem, enabling a higher proportion of the eligible population to be within healthy limits. In the population approach, if the population mean for a target problem and its standard deviation can be shifted toward healthier positive functioning by a defined amount (e.g., one half to one third of a standard deviation on a reliable population measure), many more children and families will benefit as a result compared to an approach that exclusively targets only the most disadvantaged (e.g., children in the bottom quintile of the income distribution). The study of distribution curves to identify, on measures at a population level, the proportion of a population above and below the clinical diagnosis threshold before and after an intervention differentiates the population approach from a clinical treatment approach (Sarkadi, Sampaio, Kelly, & Feldman, 2014).
Principles of Positive Parenting
Triple P has five basic principles of positive parenting designed to promote children’s development by teaching them the social and emotional skills they need to thrive: (a) ensuring a safe, engaging, and healthy environment for children; (b) having a positive learning environment; (c) using assertive, consistent, and nonviolent discipline; (d) having reasonable expectations of children and oneself as a parent; and (e) taking care of oneself. These principles are applied through a range of specific techniques to change behavioral and emotional problems and promote child development (e.g., brief quality time, incidental teaching, descriptive praise, quiet time). The specific techniques applied vary depending on the developmental level of the child and the type of problem or parenting focus (see Chapter 4, this volume, for a description of these principles and how they are operationalized into parenting skills).
The Multilevel System Explained
Triple P uses a multilevel system of parenting support rather than a single “one-size-fits-all” program as parents differ in terms of their needs, the type of problems they experience, and the type of help they require and prefer. The system includes programs of varying intensity, ranging from very “light-touch” single-session programs through to more intensive multiweek group or individual programs. Different resources are available for all developmental periods, from infants, toddlers, preschool, elementary, or primary school–aged children to adolescents. Different delivery modalities have also been developed for some levels to enhance population reach, including individual, group, self-directed, telephone-based, and web-based delivery formats. Figure 3.1 summarizes the multilevel system of intervention and identifies different modes of delivery available at each level.
When the system is delivered at a population level, it is expected that the majority of parents with mild-to-moderate problems will participate in brief, low-intensity parenting support programs. These light-touch programs include accessing information (simple tips and parenting advice) through a communications campaign known as Stay Positive (Level 1; Chapter 35, this volume). Parents can also access parenting tip sheets through one to four brief consultations with a primary care provider (Levels 2–3). They can attend one or more large-group parenting seminars (Level 2), one or more smaller group topic-specific discussion group (Level 3). Families who have children with more serious problems or if parenting is complicated by other family problems are more likely to need a more intensive multisession program. At Level 4, more intensive programs include Group Triple P or Group Teen Triple P (8 sessions), Standard Triple P (10 sessions), Triple P Online (8 modules), Group Stepping Stones Triple P for families with a child with a disability (8 sessions), or Group Lifestyle Triple P for families of children with obesity or health issues (14 sessions). At Level 5, additional program modules can be added to address broader family issues, as in Enhanced Triple P for families with parental adjustment or relationship difficulties (up to 12 sessions), Pathways Triple P for families at risk of child maltreatment (up to 9 sessions), or Family Transitions Triple P for parents going through separation or divorce (up to 12 sessions). Table 3.1 provides a summary of Triple P intervention levels and formats.
Table 3.1: Triple P System Programs, Contexts, and Delivery Modes
Level of Intervention
All parents interested in information about parenting and promoting their child’s development.
Coordinated communications strategy raising awareness of parent issues and encouraging participation in parenting programs. May involve electronic and print media (e.g., brochures, posters, websites, television, talk-back radio, newspaper and magazine editorials).
Typically coordinated by communications, health or welfare staff.
Health promotion strategy/brief selective intervention
Parents interested in parenting education or with specific concerns about their child’s development or behavior.
Health promotion information or specific advice for a discrete developmental issue or a child’s minor behavior problem. May involve a group seminar format or brief (up to 20 minutes) telephone or face-to-face clinician contact.
Practitioners who provide parent support during routine well-child health care (e.g., health, education, allied health, and child care staff).
Parents of children with disabilities, with concerns as above.
A parallel program with a focus on disabilities.
Same as above.
Narrow-focus parent training
Parents with specific concerns as above who require consultations or active-skills training.
Brief program (about 80 minutes over four sessions or 2-hour discussion groups) combining advice, rehearsal, and self-evaluation to teach parents to manage a discrete child problem behavior. May involve telephone contact.
Same as for Level 2.
Parents of children with disabilities, with concerns as above.
A parallel program with a focus on disabilities.
Same as above.
Broad focus parent training
Parents wanting intensive training in positive parenting skills. Typically parents of children with behavior problems such as aggressive or oppositional behavior.
Broad focus program (about 10 hours over 8–10 sessions) focusing on parent–child interaction and the application of parenting skills to a broad range of target behaviors. Includes generalization-enhancement strategies. May be self-directed; online; involve telephone or face-to-face clinician contact; group sessions.
Intensive parenting intervention workers (e.g., mental health and welfare staff and other allied health and education professionals who regularly consult with parents about child behavior).
Parents of children with disabilities who have or are at risk of developing behavioral or emotional disorders.
A parallel series of tailored programs with a focus on disabilities.
Same as above.
Intensive family intervention
Parents of children with behavior problems and concurrent family dysfunction, such as parental depression or stress or conflict between partners.
Intensive individually tailored program with modules (60- to 90-minute sessions), including practice sessions to enhance parenting skills, mood management and stress coping skills, and partner support skills.
Intensive family intervention workers (e.g., mental health and welfare staff).
Parents at risk of child maltreatment. Targets anger management problems and other factors associated with abuse.
Intensive individually tailored or group program with modules (60- to 120-minute sessions depending on delivery model), including attribution retraining and anger management.
Same as above.
Parents of overweight or obese children. Targets healthy eating and increasing activity levels as well as general child behavior.
Intensive 14-session group program (including telephone consultations) focusing on nutrition, healthy lifestyle, and general parenting strategies. Includes generalization enhancement strategies.
As above plus dieticians/nutritionists with experience in delivering parenting interventions.
Parents going through separation or divorce.
Intensive 12-session group program (including telephone consultations) focusing on coping skills, conflict management, general parenting strategies, and developing a healthy coparenting relationship.
Intensive family intervention workers (e.g., counselors, mental health and welfare staff).
Parents enter the system of parenting support at the level most appropriate to their needs, preferences, and capacity to engage in the requirements of the specific program. The system is not linear. Parents do not need to start at the least intensive level of intervention and move progressively toward the more intensive levels. The system is designed so that parents participate in as little or as much as they require to address their current parenting concerns. The model is based on the assumption that most parents (with some professional guidance when necessary) can choose between the level of support and mode of delivery they need. Providing flexibility for parents to select a program appropriate to their needs avoids expensive population screening to identify families considered at risk or providing only intensive programs. (p. 38) (p. 37)
(p. 39) The system of support is designed so that parents can enter, exit, and reenter the system on multiple occasions depending on the family’s needs and current circumstances (Figure 3.2 and 3.3). For example, a parent of a toddler or preschooler might complete the eight-session Group Triple P, then participate in a brief program on a specific issue, such as a 2-hour Triple P Discussion Group (e.g., Managing Fighting and Aggression) when the child is in elementary or primary school and then, if needed, a Teen Triple P program for any concerns in adolescence. Figure 3.2 illustrates an example of a family engaging in tailored Triple P interventions at two separate developmental stages. The approach assumes that parenting support needs to be continuously accessible throughout childhood and adolescence as new problems can emerge or old ones reemerge at any time in a child’s development. It is expected that a lower proportion of parents who have had an effective early intervention will need intensive later intervention, but they may wish to access lighter touch programs relating to later phases of development.
To effect change on population-level indicators of child functioning or well-being, a significant proportion of the population of eligible parents with children in a target age group must be reached. Participation in parenting programs is not socially normative in most countries (after almost-universal engagement in birthing or antenatal classes in Western countries). In many communities, relatively few parents complete an EBPS program (Sanders, Markie-Dadds, Rinaldis, Firman, & Baig, 2007; Sanders et al., 2008). To achieve a meaningful reduction in the prevalence rates of children who develop serious problems, specific outreach and engagement strategies are needed to ensure that a sufficient number of parents complete evidence-based prevention and intervention programs.
(p. 40) Self-Regulation Framework
The principle of self-regulation was a central construct in the design of the Triple P system from the beginning (Sanders & Glynn, 1981). Self-regulation is a process whereby individuals are taught skills to change their own behavior and become independent problem-solvers in a broader social environment that supports parenting and family relationships (Karoly, 1993; Sanders, 2008; Sanders & Mazzucchelli, 2013). The approach to self-regulation used in Triple P is derived from social cognitive theory. According to Bandura (1986, 2000), the development of self-regulation is related to personal, environmental, and behavioral factors; these factors operate separately but are interdependent.
Self-regulation is a central skill in building parental competence and confidence. In the context of Triple P, this involves teaching parents strategies to modify their own ways of thinking (p. 41) and behaving that enable them to become independent problem-solvers (Karoly, 1993). The aim is for parents to become self-sufficient (parent effectively, trust their judgment, seek support if they need it); have self-efficacy (believe they can effectively deal with parenting situations); self-manage (set goals, choose strategies to try, and self-evaluate their success); have a sense of personal agency (attribute positive changes to their own or their child’s efforts); and be able to problem-solve (define a problem, identify potential solutions, develop a tailored parenting plan, try it out, review, and refine as necessary). The success of a parenting intervention is not only parents’ ability to resolve current issues but also their capacity to address a diverse range of family challenges over time with relative autonomy (Sanders & Mazzucchelli, 2013).
To further operationalize the concept of self-regulation as it applies to parenting, consider the characteristics of a parent who has strong self-regulatory capability. Such a parent (e.g., a mother) would have a clear sense of the sorts of behaviors, skills, and values she wishes to manifest in herself as a parent and adult, instill in her child, and foster in her home and broader community. She would have realistic expectations of herself, of others in a caring role for her child, and knowledge regarding what she could reasonably expect of her child at different points of his or her development. Monitoring her performance against these standards would be automatic, rather than conscious or deliberate (Papies & Aarts, 2011). On detecting a discrepancy between a personal standard and current performance (be it performance of herself, her child, or a significant other), goal-relevant habitual behavior would be brought under her volitional control. Deliberately attending to these behaviors would provide information from which she develops hypotheses about why the discrepancy has come about and clarity with regard to her objectives.
The parent would have a rich repertoire of knowledge and skills from which to draw when formulating options and developing a plan or new way of responding. These would include not only parenting and interpersonal skills (such as clear instructions, descriptive praise, and planned ignoring), but also personal management skills (such as verbal self-cueing, attentional control, and ideas on how to arrange her environment to prompt and reinforce her own behavior). The parent would proceed to execute the plan and evaluate the outcome, revising the plan as required until a desirable outcome has been achieved. At this point, the parent would allow the new behavior(s) to come under the control of new environmental stimuli—that is, her behavior would again become automatic.
The self-regulating parent would have positive expectations that she could successfully enact her plan and bring about future positive outcomes. She would be self-reflective, open to and capable of identifying personal strengths and weaknesses, successes and failures, without being unhelpfully critical. Her self-evaluations and attributions would be constructive and serve to increase her competence and confidence for addressing future challenges. As parents attempt to achieve their goals, they are frequently confronted with potentially emotion-arousing situations.
Affect is naturally linked to goal-directed behavior. Diverse feeling states arise as a result of success, failure, frustration, slowing, or delay in the pursuit of goals (Carver & Scheier, 2011). But, feelings can also be elicited by stimuli as a result of respondent conditioning. The self-regulating parent would be capable of accepting, ignoring, or downregulating emotions that might otherwise interfere with successful goal pursuit (Koole, van Dillen, & Sheppes, 2011). However, and importantly, rather than ploughing through life with a stony grimness, the parent would mostly enjoy the process. Having genuinely high self-regulatory capacity, the parent would have the ability to deploy conscious self-regulation skills when required and suspend them when they are not required. On occasion, the parent would let go of end-state cognitions to enjoy the moment and experience contentment (Csikszentmihalyi, 1990).
(p. 42) Logic Model for the Triple P System
Figure 3.4 presents Triple P’s logic model as it has been applied to reducing the prevalence of child maltreatment (Chapter 39, this volume). To produce sustained improvements in child outcomes, changes are predicted to occur at the child, parent, and family levels and wider community and policy levels.
What Is Required for a Population Approach to Work?
Consistent Theoretical Framework
The content and structure of the program components need to be theoretically based and consistent and make sense at all levels of the intervention. Characterizing the theoretical base of a system of parenting support is not straightforward. Triple P is not easy to pigeonhole into a simplistic grouping, such as a behavioral, cognitive-behavioral, attachment-based, or public health group. While the theoretical foundations of Triple P evolved from a broad body of basic and applied research on principles of learning, cognitive, and behavior change, over time the model has evolved to become a population approach to parenting support. This shift from individuals to populations demanded a different and expanded theoretical base. As a consequence, Triple P is best characterized as a transtheoretical model that integrates empirically supported principles of behavioral, cognitive, and affect change at a population level.
This integrative approach allowed new knowledge, principles, and understandings from different areas of research in experimental and applied psychology and, more broadly, the social and behavioral sciences that are relevant to enhancing human potential over the life span to be incorporated. For example, recent advances in cognitive neuroscience, epigenetic, and developmental research highlighting the importance of early brain development, developmental plasticity, and the quality of early parent–child relationships provides further theoretical justification for Triple P’s historically strong emphasis on the importance of self-regulation in both parents and children. Developmental research on the importance of early learning, in particular language, has informed Triple P’s emphasis on the important role of communication interactions to promote school readiness (Hart & Risley, 1995). Marmot’s (2010) important work on the social determinants of health and the concept of “proportionate universalism” provides theoretical justification for adopting a whole-of-population approach, and research on the adverse long-term effects of poverty and social disadvantage continues to inform Triple P’s research and development work on how to better serve vulnerable, marginalized, socially disadvantaged, and socially excluded groups. Organizational theories and advances in implementation science have informed how Triple P is disseminated to organizations.
An integrated population health approach that draws on the principle of minimal sufficiency refers to the process whereby parents receive the minimally sufficient or “just enough” level of intervention support needed to resolve the problem and to enable the parents to parent their children confidently, competently, and independently.
With an evidence-based system of intervention, it almost goes without saying that each of the program components should have well-established efficacy and effectiveness. The system for professional training and supervision also needs to be empirically validated and able to produce a well-trained and supported workforce (Chapter 34, this volume).
To be in a position to achieve population-level change, EBPS programs need broad appeal for a variety of parents, taking into account their needs and preferences. There are many needs that EBPS can serve, including, but not limited to, improvement of school readiness, early intervention for children’s problems, prevention of child maltreatment, and reduction of risk for subsequent adverse outcomes (such as substance abuse, academic difficulties or school dropout, teen parenthood, and delinquency). Similarly, parental preference for different modes of program delivery can be met by providing a variety of options, such as individual, group, telephone, online, and brief formats.
Access and Reach
Quality and breadth of programming are necessary but not sufficient for a population approach to work. Access and reach are also important. Access can be optimized by involving many delivery venues and settings across a broad range of service sectors (e.g., health, education, mental health, and community nongovernmental organizations); drawing on program personnel from several professional disciplines, and utilizing a range of delivery formats couched in destigmatized contexts. Reach is critical as well. A cogent population approach needs to ensure that enough parents participate to reduce the prevalence rates associated with parenting difficulties and child problems while increasing parental confidence and efficacy. Having a system that engages large numbers of eligible parents is key to prevalence reduction. Strategies that destigmatize parental participation in a parenting and family program help to eliminate barriers to broad community reach. Normalizing such participation via various strategies (e.g., framing, media messages, modeling) can help take the stigma out of seeking parenting support.
Another important consideration pertains to universal preventive intervention. Sometimes, the field intimates that universal versus targeted prevention is a forced choice, and that the two (p. 45) intervention approaches are mutually exclusive. An alternative is blended prevention, by which universal and targeted interventions are integrated into a combined approach. The universal representations of the program are less intensive and more appealing to a broader parental audience, while targeted programming can include more intensive intervention and can serve the specialized needs associated with narrower segments of the parent and child population (e.g., parents with mental health problems, parents of children with a disability). The notion of “proportionate universalism” is apropos here, which emphasizes the resourcing and delivering of universal programming at a scale and intensity proportionate to the degree of need. Proportionate universalism speaks to the criticism by social justice advocates, who worry that universal interventions might leave those with the greatest need without adequate support.
Favorable Policy Environment
Finally, a supportive policy and funding environment is critical to the sustainability of a population approach to EBPS (Kirp, 2012). Without policy support, programs that have been introduced in the context of a funded trial cannot be sustained without securing additional funding to continue.
Distinguishing Features of Triple P
In addition to taking a population approach to providing EBPS, Triple P differentiates itself from other evidence-based parenting programs because it is a comprehensive tiered system of parenting support covering a wider range of ages than most other evidence-based programs. Some of its key characteristics that collectively define its uniqueness are outlined next.
Although Triple P began as a home-delivered intervention with parents of preschool-aged children with disruptive behavior problems (Sanders & Glynn, 1981), the approach gradually evolved to include interventions covering infancy through to adolescence. A life-span perspective emphasizes both continuities (love, care, attention, time, age-appropriate activities, consistency, monitoring) and discontinuities (increasing importance of peers, independence, conflict management, negotiation and problem-solving skills) at different phases of the life cycle. It also emphasizes the importance of the parent–child relationship and the need for parenting support at every stage of parenting, including for grandparents.
Multiple Levels and Different Delivery Modalities
As noted, the multilevel system of Triple P is based on an assumption that the type of support parents need varies as a function of the severity and complexity of a child’s or parent’s problems. For example, more intensive support, such as Standard Stepping Stones Triple P (10 individual sessions), may be initially needed for a parent of a preschool child with severe challenging behavior in the context of a developmental disability. This allows for one-on-one support and skill development tailored to the family’s unique needs. If the intervention is successful, the same (p. 46) parents might later benefit from a briefer (2-hour) Triple P Discussion Group to address peer relationship difficulties once their child is at school. In this model, as the same child may face new or additional challenges at a later stage of development, parents may require a “booster” to refine their strategies for a new developmental phase, which can be achieved using a brief intervention format. This brief contact avoids burden on the family and reinforces parenting skills, and the group format provides a supportive environment for parents to share concerns, ideas, and successes.
Extensive Consumer and End-User Feedback to Ensure Contextual Relevance
Sanders and Kirby (2014) argued that programs are more likely to be adopted, implemented, and sustained if there is meaningful engagement with consumers (parents) and end users (practitioners). Consumer and end-user engagement can occur through focus groups or participation in consumer advisory groups to help program implementers tackle issues such as how best to engage parents, particularly in vulnerable, hard-to-reach, marginalized, or high-risk groups. This engagement process can include conducting online surveys and focus groups with target parents to determine the cultural relevance and acceptability of Triple P with ethnically diverse populations (Chapter 28, this volume).
Demonstrated Effectiveness Across Different Cultural Groups
The population approach seeks to share basic positive parenting principles and strategies with the entire population of parents. For the approach to work, it has to be culturally relevant and acceptable to all parents to enable engagement in the program in large numbers. Over time, a wealth of quantitative and qualitative evidence has shown that Triple P’s core principles and parenting techniques are considered culturally acceptable to a wide range of parents both with individual countries and across continents (Chapter 30, this volume). For example, a range of parents from different cultural and language backgrounds have rated Triple P strategies favorably (Morawska et al., 2011). Cultural acceptability studies have been conducted in Australasia (Australia, New Zealand); in the United Kingdom and Ireland; in Europe (Germany, the Netherlands, Belgium, Switzerland, Sweden, Turkey); in North America (United States, Canada), Central America (Panama), and South America (Chile); in the Caribbean (Curaçao); and in Africa (South Africa, Kenya); South East Asia (Singapore, Indonesia); North Asia (Japan, China); and the Middle East (Iran). These countries range from individualist cultures in Western Europe, North America, and Australasia to more collectivistic cultures in Asia, Latin America, Africa, and the Middle East. Taken together, these studies showed a remarkable consistency across cultures and language groups in the acceptability of the basic positive parenting methods used in Triple P. However, for specific programs to work in a local context, practitioners need to ensure that the examples used to illustrate principles and strategies are locally relevant.
(p. 47) Culturally Informed Delivery
Within any culture, there are individual differences across the community in views relating to raising children (e.g., use of corporal punishment in disciplining children), and based on cultural and religious beliefs, individual parents and practitioners may have strongly held views on practices and expectations across the developmental spectrum (e.g., the benefits of co-sleeping with young children or the acceptability and timing of adolescent behaviors associated with dating and relationships). The use of a self-regulation framework greatly facilitates cultural acceptability as parents are encouraged to formulate their own goals informed by their culture, history, traditions, and priorities.
The Triple P model embraces cultural diversity and has made numerous efforts over the past two decades to facilitate the participation of parents from different cultural and ethnic groups. For example, Turner et al. (Chapter 28, this volume) have developed and tested a collaborative partnership adaptation model (CPAM) as a cultural adaptation process that can be applied to determine the relevance and cultural acceptability of existing Triple P resources and delivery formats. CPAM is a multistage process that involves working collaboratively with communities (elders, professionals, parents) to gain knowledge and a clear understanding of the specific local context. Focus groups with parents and with practitioners have been used effectively to explore the perceived usefulness, relevance, and cultural acceptability of the program; these groups have included specific parenting techniques, types of group activities, and audiovisual and written material used in the program. Changes are not made to the existing program if there is little evidence suggesting that the program is culturally unacceptable. Core Triple P program resources (e.g., parent workbooks, slide presentations, video resources) have been translated into and successfully used in approximately 20 languages across 27 countries (at time of writing), but have required little alteration other than language. It is important to note that not all English resources are available in every language.
The CPAM process aims to identify possible changes that need to be made (if any) to core program materials to increase consumer acceptability where there may be a significant barrier to participation, executing these changes through revisions of program materials, then testing the modified or adapted program in a robust evaluation, such as conducting a randomized controlled trial (RCT) (Frank, Keown, Dittman, & Sanders, 2015). Finally, if trial outcomes are successful using culturally adapted materials, the recommended changes can be made to program resources, materials, and the delivery of professional training. Such changes are not undertaken lightly as they need to be funded and can be expensive (e.g., reshooting material for a DVD). Tailored resources and delivery have been successfully developed for Australian indigenous communities, and additional cultural resources have been developed for Māori communities in New Zealand.
The model of intervention seeks to involve all parents and parental figures in a caring role with children. This includes mothers, fathers, step-parents, grandparents, and other relevant extended family members and caregivers who have a caring responsibility for a child. True inclusiveness requires practitioners to be able to tailor program delivery sensitively for the unique needs of (p. 48) diverse community groups (e.g., parents with mental health or substance abuse problems; parents with low literacy; migrant and refugee families).
Research on parenting shows that mothers are far more likely to participate in a parenting program than fathers. There is less evidence available relating to the effects of Triple P and other parenting programs with fathers than mothers (Chapter 16, this volume). Although the meta-analysis by Sanders, Kirby, Tellegen, and Day (2014) found positive outcome effects for fathers, the effect sizes were larger for mothers than fathers. In the past 5 years, a concerted effort to increase father participation in Triple P has taken place. For example, Frank et al. (2015) conducted focus groups and a web survey with fathers to identify parenting topics and issues that were particularly relevant to fathers and to identify barriers and enablers to their participation. These father-relevant topics were then systematically introduced into the delivery of Group Triple P for a mixed group of mothers and fathers. Both mothers and fathers reported positive outcomes on child behavior, parenting, and conflict over parenting and a high level of consumer satisfaction. Other efforts to increase father engagement have been the offering of Triple P Online and delivering versions of Triple P in the workplace (see Haslam, Sanders, & Sofronoff, 2013).
There have also been several trials showing grandparents benefit from participating in Triple P (Kirby & Sanders, 2014), and a new variant of Triple P for Early Child Educators (Chapter 21, this volume) is currently being evaluated.
Principle of Proportionate Universalism to Reduce Social Disparities
Universal programs have been criticized on the basis that parents who function well or are socioeconomically advantaged will consume scarce resources that are desperately needed to assist more vulnerable or disadvantaged families. Rather than decreasing inequality, universal interventions are seen as increasing social disparities. It should be noted that parenting difficulties and child social, emotional, and behavioral problems exist across all socioeconomic groups; however, the risk of disproportionate assistance can be mitigated by applying the principle of proportionate universalism (Marmot, 2010) in population rollouts. When this principle is applied correctly, special efforts are made to engage the most vulnerable parents. Having tailored programs for specific types of children and families (e.g., Family Transitions Triple P for families going through separation or divorce, Indigenous Triple P, and Pathways Triple P for families at risk of maltreatment) and having outreach and engagement strategies that specifically target vulnerable and hard-to-reach families helps ensure the neediest families have the opportunity to participate. Successful examples of this include offering Triple P to incarcerated parents, through organizations that support parents with mental illnesses, and through services for immigrant and refugee families.
Measurement and Promotion of Fidelity
Like all EBPS programs, positive outcomes are unlikely if a program at any level is not implemented with fidelity by competent, well-trained practitioners, as has been evident in a small number of studies that have failed to achieve positive outcomes with Triple P (e.g., Little et al., 2012). In an effort to promote program fidelity, each program has a detailed practitioner manual that outlines session-by-session procedures for monitoring a practitioner’s adherence to (p. 49) core intervention protocols and for measuring client outcomes (e.g., Sanders, Markie-Dadds, & Turner, 2001). Sanders and Kirby (2015) developed an observational tool for assessing both session content (material covered) and process fidelity (quality of the delivery).
Flexible Tailoring of Content and Process
To ensure that practitioners tailor interventions to the specific needs of individual families, Mazzucchelli and Sanders (2010) developed guidelines to encourage practitioners to vary the content and process of their delivery in certain circumstances. Low-risk variations to content included changing examples to make them more salient (e.g., for fathers or for parents from a specific cultural background), whereas high-risk variations included leaving out a core procedure or skill altogether (e.g., how to use time-out effectively). Low-risk variations to process included extending or shortening the length of sessions based on the observed skill of the parent. Other variations to process were considered high risk (e.g., not practicing a core skill such as descriptive praise or preparation for and use of time-out). Practitioners are encouraged to use their judgment, experience, and knowledge of the client population to tailor program delivery to the needs of participating parents while ensuring the core content and session activities are delivered.
Program Coordination and Management
Achieving population-level change requires interagency collaboration, local alliances, and partnerships to support the promotion and implementation of the program and to ensure trained practitioners deliver agreed intervention targets. A program director or manager appointed from a lead agency is needed to manage and coordinate the logistics associated with the entire rollout, including the organization of training and supervision of the multidisciplinary, multisector, or agency workforce. The best examples of the successful implementation of the Triple P system have all paid close attention to the importance of forming effective partnerships and alliances (e.g., Chapter 40, this volume; Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009; Sanders et al., 2008).
Routine Evaluation of Outcomes
Each Triple P variant includes a set of recommended measures that can be used to evaluate the outcomes achieved by parents. We recommend the use of measures that are in the public domain and can be used free of charge by agencies. Outcomes are generally assessed at four levels—child outcomes, parenting outcomes, family adjustment outcomes, and consumer satisfaction (Chapter 36 in this volume for details). In some programs, behavioral diaries and behavior-monitoring forms are also recommended to track child or parent progress through the intervention (Level 3–5 programs). The Triple P Provider Network includes an Automated Client Scoring and Reporting Application (ASRA) to enable practitioners to track and monitor client outcomes using a selection of child, parent, and family outcome measures. ASRA is available to all accredited Triple P practitioners to enable individual client data to be entered and scored and to produce a profile of the assessment results. When data collection procedures become routinized and embedded in the way programs are delivered, higher rates of assessment form completion by parents are more likely.
(p. 50) Child Well-Being Indicators Tracked at a Population Level
Beyond the clinical assessment of outcomes for individual families, the hallmark of a population approach is having suitable population-level indicators of child outcomes to track changes in prevalence rates over time. Different kinds of population-level data can be used for this purpose. Prinz and colleagues (2009) used routinely collected state government administrative data to evaluate the effects of the Triple P system on aggregate county-level rates of child maltreatment, emergency room visits due to child maltreatment–related injuries and out-of-home placements. Fives, Purcell, Heary, NicGabhainn, and Canavan (2014) used in-person household surveys to assess the prevalence of child social and emotional problems, whereas Sanders and colleagues (2008) used a random digit dialing telephone survey to assess behavioral problems and parenting practices at a population level.
Each data source has its own advantages and limitations. The International Parenting Survey (Lee et al., 2014) is a web-based population survey instrument used to gain information on child behavior, parenting practices, parent participation on parenting programs, and parent preferences concerning how they wish to access parenting information. This survey can be used to measure population-level outcomes relating to parenting. However, it should be noted that currently there is no widely accepted or used measure of parenting that is routinely collected at the population level. Such an instrument would be extremely valuable but would need to be validated in multiple countries to facilitate cross-cultural comparisons.
Developments in implementation science and practical learnings from large-scale rollouts of Triple P have highlighted the critical importance of adequate preparation of organizations involved in the implementation of Triple P before, during, and after staff have been trained to implement new evidence-based practices (McWilliam, Brown, Sanders, & Jones, 2016). Purveyor organizations responsible for the dissemination of interventions have increasingly incorporated principles of implementation science and organizational change (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005) in working with organizations interested in adopting a population approach. The Triple P Implementation Framework, developed by Triple P International, provides a framework of support for communities and organizations through five phases of implementation: engagement, commitment and contracting, implementation planning, training and accreditation, and implementation and maintenance.
Delivery and Participation Targets
A major challenge for all population-based rollouts is to ensure trained practitioners and the agencies employing them honor their commitments to deliver programs to an agreed number of parents over a defined period (e.g., a 3-year plan). The targets negotiated with agencies need to be realistic given competing commitments and demands. Targets are more likely to be achieved when the programs that staff are being trained in are organized and advertised in (p. 51) advance of practitioners undertaking training so that practitioners can begin delivery as soon as possible after training is completed. Having too great a delay between training and starting program implementation can erode practitioners’ confidence and decrease the likelihood of implementation.
Sustained Investment in Research and Development
There has been a sustained commitment over almost four decades of ongoing research and development to improve Triple P. The commitment to building a strong scientific foundation for each component in the system has ensured that Triple P has kept evolving (informed by evidence of outcomes) in an effort to remain relevant to the contemporary needs of parents. This ongoing search for innovation has led to the development and evaluation of new program variants following the development of the core five-level system. These additional programs included programs for parents of adolescents (Teen Triple P), parents of a child who has a disability (Stepping Stones Triple P), parents at risk of child maltreatment (Pathways Triple P), parents experiencing separation and divorce (Family Transitions Triple P), parents of overweight and obese children (Lifestyle Triple P), a suite of online programs (Triple P Online and Triple P Online Brief), and two programs under development for parents of children with chronic health problems (Positive Parenting for Healthy Living Triple P) and parents of infants (Baby Triple P). Each of these variants is discussed in Parts 2 and 3 of the current volume.
How Effective Is Triple P?
Evaluating a multilevel system of parenting support is complex. Each level can be evaluated as well as the system as a whole. The traditional effectiveness question needs to be reworked for a multilevel system to ask, What intervention is effective with which child problems at what age, delivered by which delivery modality, at what level of intensity, to which type of parent and family, in what community context, and how does the intervention effect come about? The evidence base supporting different aspects of the Triple P system has evolved gradually over almost decades and is now quite extensive, but never complete. Space precludes a thorough overview of the evidence supporting Triple P, and readers are referred to various meta-analyses that have been conducted on Triple P (e.g., Nowak & Heinrichs, 2008; Sanders et al., 2014). A comprehensive database of Triple P studies is maintained by the Parenting and Family Support Centre (https://www.pfsc.uq.edu.au/research/evidence).
Evidence relating to the effectiveness of Triple P should also be considered in the wider context of the substantial evidence relating to the effectiveness of social learning approaches to parent intervention (e.g., Dretzke et al., 2009; Lundahl, Tollefson, Risser, & Lovejoy, 2008). At the time of writing, 137 RCTs and 261 total evaluations of Triple P have been conducted around the world, with a further 20 trials in progress that we know of, making it the most extensively studied parenting program yet developed.
A search of the Triple P evidence base conducted in February 2017 revealed that a total of 773 papers have been written on Triple P. Of those, 499 were theoretical or conceptual papers, and 274 were evaluation papers (comprising 137 RCTs). The vast majority of (p. 52) evaluation studies showed positive findings for Triple P (95%). There were 13 papers with null findings for Triple P (5%). A total of 134 papers (49%) had no developer involvement. This research is truly international and has involved researchers from 30 different countries, 1,187 individual researchers from 358 academic or research institutions across multiple cultures and 20 languages. The Triple P evidence base involves a mix of developer-involved and independent studies. Approximately 49% of all Triple P evaluation studies have been independent of developers, with positive effects obtained for both independent and developer-involved studies (Sanders et al., 2014). Of the few papers (13) with null findings, 63% involved the developer. A more detailed discussion of the importance of both developer-led and independent-of-developer studies are discussed in more detail by Sanders and Kirby (Chapter 43, this volume).
The evaluation philosophy adopted has been to critically evaluate every element of the Triple P system. Only programs that have sufficient evidence of effectiveness are included in the system. Programs that have failed to reach this evidence threshold are not disseminated. The strength of evidence required for a program to be included since 2000 is the successful completion and publication of the results of a randomized clinical trial, robust quasiexperimental evaluation, or a series of well-conducted single-subject experiments (Sanders, 2012).
The first outcome studies were published in the early 1980s as single-subject experiments for an individually administered intervention now known as Standard Triple P, a Level 4 intervention (Sanders & Dadds, 1982; Sanders & Glynn, 1981). A number of different approaches to evaluation have been employed, including single-subject experiments, RCTs, meta-analyses, quasiexperimental evaluations, uncontrolled service-based evaluations, economic analyses, and qualitative studies using focus group and survey methodology (Sanders, 2012). Several studies have use mixed methods combining RCTs and qualitative evaluation. The most recent and comprehensive meta-analysis of Triple P involving 101 studies and over 16,000 parents (Sanders et al., 2014) showed that each level of the intervention was associated with significant positive intervention effects for child social, emotional, and behavioral problems; parental self-efficacy and satisfaction; positive parenting; family conflict; and parental distress.
In addition, three large-scale population-level evaluations have been conducted of the implementation of the multilevel system. The most comprehensive of these deployed a place-based randomized design (Prinz et al., 2009; Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2016) and found implementation of the Triple P system produced meaningful reductions in founded cases of child maltreatment, hospital-treated child maltreatment–related injuries, and out-of-home placements, with statistically significant and large Cohen d effect sizes ranging from 1.01 to 1.61.
A more recent evaluation of the population-level effects of the Triple P system in Midland counties in Ireland (Fives et al., 2014) showed, based on an epidemiological household survey of parents with children aged 3–8 years, that counties implementing the Triple P system, compared to a county receiving services as usual, experienced a 37% reduction in the number of borderline and clinically elevated cases of children with social and emotional problems. This finding was consistent with findings showing population effects on a measure of child adjustment from an earlier large-scale population trial in Australia that used a similar approach (Sanders et al., 2008).
(p. 53) Several other large-scale replication studies are in progress that will add further important information about outcomes achieved with a population approach. There have been insufficient numbers of studies to conduct systematic review or meta-analysis of the population effects of implementing the Triple P system. All population trials have targeted young children, aged 3–9 years, and no population trials have been conducted with very young children (under 3 years) or with adolescents. Ways of further strengthening the evidence base are discussed in chapters 45 and 46 in this volume.
Challenges in Making a Population Approach Work
As a population approach to parenting support is still novel, only a few population trials have been published to date. However, much has been learned about how to best deploy the Triple P system to achieve outcomes at a population-level change. This section discusses these challenges and ways of addressing them.
Implementation With Fidelity
Population-level change is unlikely if programs are not implemented with fidelity. It is important that staff who deliver Triple P are competent. Unskilled, inadequately trained, and poorly supervised staff are unlikely to produce satisfactory outcomes with families. Indeed, a poorly delivered parenting program can have adverse effects on children and parents (Scott, Carby, & Rendu, 2008). It is therefore essential that funds are allocated to ensure necessary technical assistance and support are available to the implementation team and supervision is provided to practitioners delivering programs. The routine use of the peer-assisted supervision and support (PASS) model of supervision offers opportunities for practitioners to improve their consultation skills in working with parents and should be extensively used in population rollouts of any program (McPherson, Sanders, Schroeter, Troy, & Wiseman, 2016; Sanders & Murphy-Brennan, 2013). Access to supervision is particularly important in low-resource settings (Chapter 29, this volume), where the available workforce is unlikely to have graduate-level professional training. This situation characterizes many low- and middle-income countries; many indigenous communities, particularly in regional and remote areas; and parents living in impoverished neighborhoods in large cities.
Critics of EBPS have expressed concern that programs that apply social learning and cognitive-behavioral principles are trying to eliminate diversity in parenting, fearing that everyone will start to parent their children in the same way and that children will become too similar. This is an understandable but unfounded concern. The adoption of a self-regulation framework where parents choose their own personal goals, and the parenting strategies they wish to apply in achieving those goals, means that different parents completing the same program have a unique (p. 54) experience. Parents are encouraged to acknowledge individual temperament-based differences in children and to focus on teaching children the social and emotional skills they need to achieve success in education, relationships, and life goals.
A “Home” for the Delivery of Evidence-Based Parenting Programs
The population model underpinning Triple P is based on an assumption that there is no single service delivery context for the provision of EBPS. The task of supporting good parenting is a shared community responsibility that is inherently multidisciplinary and must involve multiple agencies and settings. There are considerable advantages of having parenting services and programs better coordinated and having a shared community vision focused on prevalence rate reduction of problems through competent parenting. Better coordination and planning between services about delivery of Triple P ensure greater efficiency and better access for parents, avoid unnecessary duplication or overservicing, and ensure more cost-effective utilization of scarce resources. The American Academy of Pediatrics (2016) has argued that pediatric practices can function as a “medical home” for the provision of coordinated parenting advice and education. Similar arguments can be made for use of the early childhood education settings and schools as a point of wide (if not universal) access to parents in a destigmatized context.
Role of Parenting Programs in Addressing Adverse Childhood Experiences
A great deal of focus is currently being placed on the importance of services being trauma sensitive. This emphasis stems from the findings by Felitti et al. (1998) and others, who have documented the links between exposure to adverse and potentially traumatic experiences in childhood (e.g., child verbal, physical, emotional or sexual abuse or neglect or a household involving substance abuse, mental illness, incarceration, domestic violence, or family breakup) and adverse physical and mental health in adulthood. Having four or more categories of childhood exposure has been linked to a 4- to 12-fold increase in health risks such as alcoholism, drug abuse, depression, and attempted suicide; a 2- to 4-fold increase in smoking, poor self-rated health, 50 sexual partners or more, and sexually transmitted disease; and a 1.4- to 1.6-fold increase in physical inactivity and severe obesity.
Triple P has developed programs that can be used to minimize children’s exposure to adverse family experiences and to assist parents with significant adjustment difficulties. Of the 10 categories of adverse experiences in the Adverse Childhood Experiences (ACEs) Index (Felitti et al., 1998), five relate to child maltreatment. The implementation of the Triple P system has been shown to reduce the level of maltreatment in the community (Prinz et al., 2009), and Pathways Triple P directly addresses anger management and attribution retraining for parents at risk of maltreatment. In relation to the other categories, Family Transitions Triple P seeks to minimize the adverse effects of separation and divorce; Group Triple P, Enhanced Triple P, and Triple P Online have been shown to reduce adult parental mental health and substance abuse problems. Group Triple P and Pathways Triple P have also been successfully implemented in prisons for both men and women, although there are no controlled outcome data available at this time.
(p. 55) Implementing Parenting Programs in Low-Resource Settings
Fewer parents raising children in low-resource environments compared to high-resource environments have access to evidence-based parenting programs. Most research on parenting programs has been conducted in a handful of the richest countries in North America, Western Europe, and Australasia. Fortunately, there is growing evidence that existing evidence-based programs can transport well to other cultures with relatively little adaptation.
There are numerous challenges to be addressed before evidence-based programs can be implemented in low- and middle-income countries, including lack of funds, a trained workforce to deliver parenting programs, and basic health, mental health, and family support services. A major challenge is to ensure that relevant programs that do work can be delivered and scaled effectively in low-resource settings. This is likely to require alternative, lower cost ways of providing professional training, program delivery, and technical and consultation support in these settings to enable programs to be implemented in a sustainable way (Ward, Sanders, Gardner, Mikton, & Dawes, 2016).
Implications for Policy, Research, and Practice
Influencing Policy and Securing Funding
Despite clear evidence that the quality of parenting that children receive affects many important life course outcomes and that EBPS can positively influence children’s development and is highly cost-effective, investments in parenting typically target the most vulnerable and disadvantaged parents with significant preexisting problems. Agencies and organizations that might deliver preventively focused parenting programs require additional funding to undertake this work. Securing necessary funds to implement a population-based program properly is a major challenge in many countries. The wheels of government can move slowly, and it is common for advocates and champions of the population approach to take years to secure the necessary resources to commence implementation. Some organizations use a “bootstrapping” approach to secure funds to deliver one or two levels of the Triple P system (often the more intensive levels), then gradually work to secure additional braided funding to extend the program to other levels to eventually become a multilevel system.
A mix of strategies is often needed to influence policy decisions. Strategies that have been employed include submitting programs for review to influential evidence-based lists of empirically supported interventions, such as Blueprints for Heathy Youth Development (Mihalic & Elliott, 2015); policy statements by professional groups (e.g., American Academy of Pediatrics, 2016; National Academies of Science Engineering and Medicine, 2016); direct lobbying of politicians and policy advisors; advocacy from consumers and end users of programs; media coverage of important new research findings; and responding in a timely and helpful manner to requests for information from government, community organizations, and media. Undertaking a careful analysis of policy statements that links specific program outcomes to publicly stated policy aspirations or commitments is a useful approach when engaging with government.
(p. 56) An Integrated System or a Patchwork of Multiple Programs?
The model of parenting support that Triple P employs is designed as a fully integrated, internally consistent, multilevel suite of related programs using a common theoretical framework. Having a named program or a “brand” that has a clear public identity raises issues relating to restriction of consumer choice and concerns that home-grown or preexisting programs sometimes based on different theoretical models will be threatened and their funding cut. However, the introduction of the Triple P system often fills gaps not covered by local services, and it can complement and work comfortably alongside any other evidence-based parenting program. The main advantage of adopting an integrated multilevel system is that it facilitates agencies working together in partnership with a shared vision, common language and approach to parenting, and a commitment to achieving population-level change.
Funding of Parenting Services and Programs
Funding models for supporting the implementation of EBPS programs are extremely varied, and a number of different mechanisms are used. Typically, there is a lack of a funding model that is consistently applied even within the same country. Funding can include specific allocation of funds by governments to provide parenting programs through government-funded services in health, mental health, education, and welfare services. Many not-for-profit organizations delivering parenting programs use braided funding models from multiple sources (e.g., grants, donations, service contracts). Medical or health insurance schemes sometimes allow EBPS programs if a child or parent has a specific clinical diagnosis, but rarely to support preventive work. Some provider groups deliver Triple P as part of workplace employee assistance programs or through block grants to schools for mental health programs. Others deliver Triple P as part of a clinical practice in psychology, social work, nursing, or pediatrics. The lack of a consistent funding mechanism or pathway to support parenting programs is a fundamental limitation on the growth of EBPS programs.
Need for Additional Population Trials
The few large-scale population trials of the full Triple P system conducted to date have been promising. These trials have identified a range of practical and logistical programming, organizational, and implementation issues that must be addressed to ensure that an integrated system of EBPS works in practice and reaches families most in need of parenting support. Further large-scale place-randomized trials are needed to specifically clarify the population effects of the Triple P system on subgroups of disadvantaged and vulnerable families.
The current Every Family population trial targeting parents of 3- to 8-year-olds is using Australian federal and state administrative data on child development outcomes to specifically examine intervention effects in 33 low-socioeconomic areas in the state of Queensland, with matched comparison areas in other states that are not receiving the Triple P System. This trial will help to determine whether existing programming efforts to activate community change processes to support competent parenting across an entire community will be successful in engaging the most vulnerable families living in socioeconomically disadvantaged circumstances.
(p. 57) Mediators and Moderators of Population-Level Effects
Little is known about how to explain population-level effects. In a complex multilevel system like Triple P that has many moving parts, it is unclear how best to explain intervention effects. The mechanisms used to explain improvements in child behavior in RCTs such as changes in positive parenting or parental efficacy, reduced harsh or negative parenting, more consistent discipline, and reduced interparental conflict are likely to be inadequate in explaining population-level effects. Possible additional candidates include activation of a “parent-to-parent” social contagion by which participating parents become champions and influence other parents to participate; increased parental awareness and participation; changing social norms and expectations; reduced stigma about participation in parenting programs; increased access to and completion of evidence-based programs; and policy-based changes that could affect how parenting programs are funded.
Differential Susceptibility to Environmental Influence
An evolutionary biology perspective underpins the contention that children vary in their developmental plasticity and susceptibility to environmental influence. The Pluess and Belsky (2010) differential susceptibility hypothesis states that children have varying biological sensitivity to differences in social context. Specifically, they contended that children who are most adversely affected by adversity and stressors are the same children who respond most positively to environmental support and enrichment (including positive parenting). Biologically based individual differences in plasticity mean positive parenting may be especially valuable for those children with difficult temperaments, who are impulsive, and who have poor self-regulation over behavior and emotions compared to other less temperamentally difficult children. A twin study that measured both increases in positive prosocial behavior and reductions in problem behavior in relation to varying dosages of positive parenting programs (low vs. high intensity) would be particularly valuable to determine how active manipulation of the strength of environmental influence through parenting interacts with genetic or biological vulnerability.
Determining Fiscal Value
The key economic question is whether the benefits of the intervention are worth the implementation costs. To answer this, we need to know how much it costs to implement parenting programs, what benefits can be expected, and any effects the intervention might have on other costs (e.g., leading to increased or reduced use of other services). EBPS programs, including Triple P, are widely considered to have good fiscal value, as reflected in the economic analyses reported by the independent Washington State Institute for Public Policy (WSIPP; 2017) and underscored by the Institute of Medicine and National Research Council (2014). In their most recent report, the WSIPP (2017) indicated that the Triple P system has shown a return of $8.14 for each dollar of investment, and Level 4 Individual Triple P showed a return of $3.36 for each invested dollar.
(p. 58) Promoting Collaborative Interagency Partnerships
The successful implementation of a population approach requires coordinated multiagency involvement and ongoing collaboration (Fives et al., 2014; Chapter 40, this volume). Owens et al. (Chapter 40) describe a successful approach to partnership formation and maintenance that supported the implementation of the Triple P system in Ireland.
Training the Right People to Deliver Programs
To achieve sufficient population reach, an intervention needs to train a sufficient number of practitioners who can deliver the intervention with fidelity. It has become increasingly clear that not all trained practitioners have the capacity to become sustained implementers of a program. To increase the likelihood of sustained implementations, practitioners should be selected who meet the following criteria: (a) They have roles that enable them to devote a certain percentage of allocated time to actually deliver Triple P, so they have the capacity to deliver on participation targets; (b) they have line management support for program delivery and allocated work time to implement programs with families; (c) they are able to attend peer support supervision sessions; (d) they are fully accredited; (e) they are required to collect assessment data for all participating families so that an outcome is known for all cases; and (f) their agencies allocate resources to promote and socially market the program to ensure participation targets are reached.
Achieving Implementation Targets
When agencies enter into an agreement to deliver Triple P to a defined number of families per year, it should mean a major organizational undertaking to commit the necessary resources to ensure targets are reached. Service managers need to make staff available to deliver programs, to promote the availability of the programs to parents, and then to deliver programs in a manner required to ensure adequate fidelity of program delivery. If participation targets are not reached or trained practitioners simply do not deliver at all, the implementation team needs to address the issue with line managers. It is helpful for implementation consultants to work with trained staff as well to identify the source of the problem and to initiate a remedial plan to get practitioners active.
The development of the Triple P system as a comprehensive population-based approach and its subsequent dissemination, adoption, implementation, scaling up, and ongoing evaluation have been a major undertaking involving the sustained efforts of many people for almost four decades. As the population approach to parenting support is relatively new, Triple P remains a work in progress as new findings help refine the way the system is best implemented in different communities. From small beginnings as an in-home “coaching” model, using a self-management framework, single-subject experimental designs, and careful observation (p. 59) procedures to track child and parent behavior, Triple P has evolved into a suite of interrelated programs. EBPS as a population approach is an extremely promising strategy to achieve change on a large scale in parenting practices and child outcomes associated with inadequate or dysfunctional parenting.
• Problems of parenting are a major public health issue that is best tackled at a whole-of-population level.
• A self-regulation approach to positive parenting helps promote parenting independence in problem-solving and reduces dependency on others.
• A multilevel system of intervention such as Triple P has the greatest potential to ensure adequate population reach to achieve change in target problems at a population level.
• Adoption of the principle of “proportionate universalism” helps ensure that social equalities are addressed in any implementation plan.
• The field of implementation science is still in its infancy in relation to the establishment, evaluation, and long-term sustainment of universal population-level EBPS strategies, and Triple P is an early exemplar on which to build the knowledge base.
Altafim, E. R. P., & Linhares, M. B. M. (2016). Universal violence and child maltreatment prevention programs for parents: A systematic review. Psychosocial Intervention, 25, 27–38. doi:10.1016/j.psi.2015.10.003Find this resource:
American Academy of Pediatrics. (2016). Poverty and child health in the United States. Pediatrics, 137, 1–14. doi:10.1542/peds.2016-0339Find this resource:
Arruabarrena, I., & De Paúl, J. (2012). Early intervention programs for children and families: Theoretical and empirical bases supporting their social and economic efficiency. Psychosocial Intervention, 21, 117–127. doi:10.5093/in2012a18Find this resource:
Bandura, A. (1986). Social foundations of thought and action: a social cognitive theory/Albert Bandura. Englewood Cliffs, NJ: Prentice-Hall.Find this resource:
Bandura, A. (2000). Exercise of human agency through collective efficacy. Current Directions in Psychological Science, 9, 75–78.Find this resource:
Carver, C. S., & Scheier, M. F. (2011). Self-regulation of action and affect. In K. D. Vohs & R. F. Baumeister (Eds.), Handbook of self-regulation: Research, theory, and applications (2nd ed., pp. 3–21). New York, NY: Guilford Press.Find this resource:
Christian, C. W., & Schwarz, D. F. (2011). Child maltreatment and the transition to adult-based medical and mental health care. Pediatrics, 127, 139–145. doi:10.1542/peds.2010-2297Find this resource:
Csikszentmihalyi, M. (1990). Flow: The psychology of optimal experience. New York, NY: Harper Perennial.Find this resource:
Dretzke, J., Davenport, C., Frew, E., Barlow, J., Stewart-Brown, S., Bayliss, S., . . . Hyde, C. (2009). The clinical effectiveness of different parenting programmes for children with conduct problems: A systematic (p. 60) review of randomised controlled trials. Child and Adolescent Psychiatry and Mental Health, 3, 7. doi:10.1186/1753-2000-3-7Find this resource:
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14, 245–258. doi:10.1016/S0749-3797(98)00017-8Find this resource:
Fives, A., Purcell, L., Heary, C., NicGabhainn, S., & Canavan, J. (2014). Parenting support for every parent: A population-level evaluation of Triple P in Longford Westmeath. Final Report. Athlone, Ireland: Longford Westmeath Parenting Partnership.Find this resource:
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005). Implementation research: A synthesis of the literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, the National Implementation Research Network (FMHI Publication #231).Find this resource:
Frank, T. J., Keown, L. J., Dittman, C., & Sanders, M. R. (2015). Using father preference data to increase father engagement in evidence-based parenting programs. Journal of Child and Family Studies, 24, 937–947. doi:10.1007/s10826-014-9904-9Find this resource:
Hanf, C., & Kling, J. (1973). Facilitating parent-child interaction: A two-stage training model. Unpublished manuscript, University of Oregon Medical School, University of Oregon, OR.Find this resource:
Hart, B., & Risley, R. T. (1995). Meaningful differences in the everyday experience of young American children. Baltimore, MD: Brookes.Find this resource:
Haslam, D. M., Sanders, M. R., & Sofronoff, K. (2013). Reducing work and family conflict in teachers: A randomised controlled trial of Workplace Triple P. School Mental Health, 5, 70–82. doi:10.1007/s12310-012-9091-zFind this resource:
Institute of Medicine and National Research Council. (2014). Considerations in applying benefit-cost analysis to preventive interventions for children, youth, and families (workshop summary). Washington, DC: National Academy of Sciences. Retrieved from https://www.nap.edu/catalog/18708/considerations-in-applying-benefit-cost-analysis-to-preventive-interventions-for-children-youth-and-familiesFind this resource:
Karoly, P. (1993). Mechanisms of self-regulation: A systems view. Annual Review of Psychology, 44, 23–52. doi:10.1146/annurev.ps.44.020193.000323Find this resource:
Kazdin, A. E. (2008). Parent management training: Treatment for oppositional, aggressive, and antisocial behavior in children and adolescents. New York, NY: Oxford University Press.Find this resource:
Kirby, J. N., & Sanders, M. R. (2014). A randomized controlled trial evaluating a parenting program designed specifically for grandparents. Behavior Research and Therapy, 52, 35–44. doi:10.1016/j.brat.2013.11.002Find this resource:
Kirp, D. L. (2012). Kids first: Five big ideas for transforming children’s lives and America’s future. New York, NY: Public Affairs.Find this resource:
Koole, S. L., van Dillen, L. F., & Sheppes, G. (2011). The self-regulation of emotion. In K. D. Vohs & R. F. Baumeister (Eds.), Handbook of self-regulation: Research, theory, and applications (2nd ed., pp. 22–40). New York, NY: Guilford Press.Find this resource:
Lee, C. M., Smith, P. B., Stern, S. B., Piche, G., Feldgaier, S., Ateah, C., . . . Chan, K. (2014). The international parenting survey–Canada: Exploring access to parenting services. Canadian Psychology/Psychologie Canadienne, 55, 110–116. doi:10.1037/a0036297Find this resource:
Little, M., Berry, V., Morpeth, L., Blower, S., Axford, N., Taylor, R., . . . Tobin, K. (2012). The impact of three evidence-based programmes delivered in public systems in Birmingham, UK. International Journal of Conflict and Violence, 6, 260–272. doi:0070-ijcv-2012293Find this resource:
Lundahl, B. W., Tollefson, D., Risser, H., & Lovejoy, M. C. (2008). A meta-analysis of father involvement in parent training. Research on Social Work Practice, 18, 97–106. doi:10.1177/1049731507309828 (p. 61) Find this resource:
Marmot, M. (2010). Fair society, healthy lives: The Mamort Review; Strategic review of health inequalities in England post-2010. London, England: Marmot Review.Find this resource:
Mazzucchelli, T. G., & Sanders, M. R. (2010). Facilitating practitioner flexibility within an empirically supported intervention: Lessons from a system of parenting support. Clinical Psychology: Science and Practice, 17, 238–252. doi:10.1111/j.1468-2850.2010.01215.xFind this resource:
McMahon, R. J. (1999). Parent training. In S. W. Russ & T. H. Ollendick (Eds.), Handbook of psychotherapies with children and families (pp. 153–180). Boston, MA: Springer US.Find this resource:
McMahon, R. J., & Forehand, R. (2005). Helping the noncompliant child: Family-based treatment for oppositional behavior (2nd ed.). New York, NY: Guilford Press.Find this resource:
McPherson, K. E., Sanders, M. R., Schroeter, B., Troy, V., & Wiseman, K. (2016). Acceptability and feasibility of peer assisted supervision and support for intervention practitioners: A Q-methodology evaluation. Journal of Child and Family Studies, 25, 720–732. doi:10.1007/s10826-015-0281-9Find this resource:
McWilliam, J., Brown, J., Sanders, M. R., & Jones, L. (2016). The Triple P implementation framework: The role of purveyors in the implementation and sustainability of evidence-based programs. Prevention Science, 17, 636–645. doi:10.1007/s11121-016-0661-4Find this resource:
Mihalic, S. F., & Elliott, D. S. (2015). Evidence-based programs registry: Blueprints for Healthy Youth Development. Evaluation and Program Planning, 48, 124–131. doi:10.1016/j.evalprogplan.2014.08.004Find this resource:
Morawska, A., Sanders, M. R., Goadby, E., Headley, C., Hodge, L., McAuliffe, C., . . . Anderson, E. (2011). Is the Triple P-Positive Parenting Program acceptable to parents from culturally diverse backgrounds? Journal of Child and Family Studies, 20, 614–622. doi:10.1007/s10826-010-9436-xFind this resource:
National Academies of Sciences, Engineering, and Medicine. (2016). Parenting matters: Supporting parents of children Ages 0–8. Washington, DC: Academies Press. Retrieved from https://www.nap.edu/catalog/21868/parenting-matters-supporting-parents-of-children-ages-0-8Find this resource:
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, 11, 114–144. doi:10.1007/s10567-008-0033-0Find this resource:
O’Dell, S. (1974). Training parents in behavior modification: A review. Psychological Bulletin, 81, 418–433. doi:10.1037/h0036545Find this resource:
Papies, E. K., & Aarts, H. (2011). Nonconscious self-regulation, or the automatic pilot of human behavior. In K. Vohs & R. Baumeister (Eds.), Handbook of self-regulation: Research, theory, and applications (2nd ed., pp. 125–142). New York, NY: Guilford Press.Find this resource:
Patterson, G. R. (1976). The aggressive child: Victim and architect of a coercive system Behavior Modification and Families, 1, 267–316.Find this resource:
Pluess, M., & Belsky, J. (2010). Children’s differential susceptibility to effects of parenting. Family Science, 1, 14–25. doi:10.1080/19424620903388554Find this resource:
Prinz, R. J., & Sanders, M. R. (2007). Adopting a population-level approach to parenting and family support interventions. Clinical Psychology Review, 27, 739–749. doi:10.1016/j.cpr.2007.01.005Find this resource:
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The US Triple P system population trial. Prevention Science, 10, 1–12. doi:10.1007/s11121-009-0123-3Find this resource:
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2016). Addendum to “Population-based prevention of child maltreatment: The US Triple P system population trial.” Prevention Science, 17, 410–416. doi:10.1007/s11121-016-0631-xFind this resource:
Rose, G. (2008). Rose’s strategy of preventive medicine. New York, NY: Oxford University Press.Find this resource:
Sanders, M. R. (1999). 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. doi:10.1023/A:1021843613840 (p. 62) Find this resource:
Sanders, M. R. (2008). Triple P-Positive Parenting Program as a public health approach to strengthening parenting. Journal of Family Psychology, 22, 506–517. doi:10.1037/0893-3126.96.36.1996Find this resource:
Sanders, M. R. (2012). Development, evaluation, and multinational dissemination of the Triple P-Positive Parenting Program. Annual Review of Clinical Psychology, 8, 1–35. doi:10.1146/annurev-clinpsy-032511-143104Find this resource:
Sanders, M. R., & Dadds, M. R. (1982). The effects of planned activities and child management procedures in parent training: An analysis of setting generality. Behavior Therapy, 13, 452–461. doi:10.1016/S0005-7894(82)80007-5Find this resource:
Sanders, M. R., & Glynn, T. (1981). Training parents in behavioral self-management: An analysis of generalization and maintenance. Journal of Applied Behavior Analysis, 14, 223–237. doi:10.1901/jaba.1981.14-223Find this resource:
Sanders, M. R., & Kirby, J. N. (2014). A public-health approach to improving parenting and promoting children’s well-being. Child Development Perspectives, 8, 250–257. doi:10.1111/cdep.12086Find this resource:
Sanders, M. R., & Kirby, J. N. (2015). Surviving or thriving: Quality assurance mechanisms to promote innovation in the development of evidence-based parenting interventions. Prevention Science, 16, 421–431. doi:10.1007/s11121-014-0475-1Find this resource:
Sanders, M. R., Kirby, J. N., Tellegen, C. L., & Day, J. J. (2014). The Triple P-Positive Parenting Program: A systematic review and meta-analysis of a multi-level system of parenting support. Clinical Psychology Review, 34, 337–357. doi:10.1016/j.cpr.2014.04.003Find this resource:
Sanders, M. R., Markie-Dadds, C., Rinaldis, M., Firman, D., & Baig, N. (2007). Using household survey data to inform policy decisions regarding the delivery of evidence-based parenting interventions. Child: Care, Health and Development, 33, 768–783. doi:10.1111/j.1365-2214.2006.00725.xFind this resource:
Sanders, M. R., Markie-Dadds, C., & Turner, K. M. T. (2001). Practitioner’s manual for Standard Triple P (Revised ed.). Brisbane, Australia: Triple P International.Find this resource:
Sanders, M. R., & Mazzucchelli, T. G. (2013). The promotion of self-regulation through parenting interventions. Clinical Child and Family Psychology Review, 16, 1–17. doi:10.1007/s10567-013-0129-zFind this resource:
Sanders, M. R., & Murphy-Brennan, M. (2013). Triple P in action: Peer-assisted supervision and support manual. Milton, Australia: Triple P International.Find this resource:
Sanders, M. R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S. B., & Bidwell, K. (2008). Every family: A population approach to reducing behavioral and emotional problems in children making the transition to school. Journal of Primary Prevention, 29, 197–222. doi:10.1007/s10935-008-0139-7Find this resource:
Sarkadi, A., Sampaio, F., Kelly, M. P., & Feldman, I. (2014). A novel approach used outcome distribution curves to estimate the population-level impact of a public health intervention. Journal of Clinical Epidemiology, 67, 785–792. doi:10.1016/j.jclinepi.2013.12.012Find this resource:
Scott, S., Carby, A., & Rendu, A. (2008). Impact of therapists’ skill on effectiveness of parenting groups for child antisocial behavior. London, England: Kings College London, Institute of Psychiatry.Find this resource:
Tharp, R. G., & Wetzel, R. J. (1969). Behavior modification in the natural environment. New York, NY: Academic Press.Find this resource:
Wahler, R. G. (1969). Oppositional children: A quest for parental reinforcement control 1. Journal of Applied Behavior Analysis, 2, 159–170. doi:10.1901/jaba.1969.2-159Find this resource:
Ward, C., Sanders, M. R., Gardner, F., Mikton, C., & Dawes, A. (2016). Preventing child maltreatment in low- and middle-income countries: Parent support programs have the potential to buffer the effects of poverty. Child Abuse and Neglect, 54, 97–107. doi:10.1016/j.chiabu.2015.11.002Find this resource:
Washington State Institute for Public Policy. (2017). Benefit-cost results. Seattle, WA: Author. Retrieved from http://www.wsipp.wa.gov/BenefitCostFind this resource: