A public health approach to reach all parents in a community to enhance parental competence and prevent or alter dysfunctional parenting practices, thereby reducing family risk factors both for child maltreatment and for children's behavioral and emotional problems.
Blueprints: Promising
Crime Solutions: Effective
OJJDP Model Programs: Effective
Social Programs that Work:Near Top Tier
Triple P America
E-mail: contact.us@triplep.net
Phone: (803) 451-2278
Web: www.triplep.net/glo-en/home/
Matthew Sanders, Ph.D.
The University of Queensland
The Triple P Positive Parenting Program is designed as a comprehensive population-level system of parenting and family support for famlies having at least one child in the birth to 12-year-old range. The multilevel system includes five intervention levels of increasing intensity and narrowing population reach. The system is designed to enhance parental competence and prevent or alter dysfunctional parenting practices, thereby reducing an important set of family risk factors, both for child maltreatment and for children's behavioral and emotional problems. In the Triple P system, a media and communication strategy is utilized extensively in a sophisticated and strategic manner to normalize and acknowledge the difficulties of parenting experiences, to break down parental sense of social isolation regarding parenting, to de-stigmatize getting help, to impart parenting information directly to parents, and to alter the community context for parenting.
In a population level version of Triple P, the existing workforce crossing several disciplines and settings (such as family and social support services, preschool/child-care settings, elementary schools, and other community entities with direct contact with families) is trained to deliver the Triple P system of interventions. They in turn deliver Triple P to parents in 1-10 or more sessions tailored to the severity of the family's dysfunction and/or child's behavioral problems.
The Triple P Positive Parenting Program is a multi-level preventive intervention system designed for families having at least one child in the birth to 12-year-old range (the core programs). All programming levels of Triple P have carefully developed intervention manuals, systematic training regimens for providers/practitioners, and coordinated resource materials for parents (videos, workbooks and tip sheets). The 5 core principles of positive parenting that are invoked throughout the multi-level Triple P system to promote social competence and emotion self-regulation in children are: (1) ensuring a safe, engaging environment, (2) promoting a positive learning environment, (3) using assertive discipline, (4) maintaining reasonable expectations, and (5) taking care of oneself as a parent. The emphasis is on parents learning how to apply these skills to different behavioral, emotional and developmental issues in children, ranging from common child-rearing challenges to more intense challenges. The five positive parenting principles translate into 35 specific strategies and parenting skills that fit into several major categories: parent-child relationship enhancement, encouraging desirable behavior, teaching new skills and behaviors, managing misbehaviors, preventing problems in high-risk situations, self-regulation skills, parental mood management and coping skills, and partner support and communication skills. Triple P provides developmentally tailored menu options that facilitate parental goal setting and self-regulation. Parents learn how to apply those techniques and strategies that are relevant to their child, the parent's goals and the family situation.
Universal Triple P (Level 1): The Universal facet of the Triple P intervention involves the implementation of media and informational strategies pertaining to positive parenting. These strategies are intended to destigmatize parenting and family support, make effective parenting strategies readily accessible to all parents, and facilitate help-seeking and self-regulation by parents who need higher intensity intervention. Universal Triple P includes use of radio, local newspapers, newsletters at schools, mass mailings to family households, presence at community events, and website information. Use of local newspapers takes three forms: positive parenting articles written by Sanders (program creator) on specific topics of interest to parents; local press releases on human interest stories that link with Triple P activities; and stories generated by reporters with whom the publicity team has developed working relationships.
Selected Triple P (Level 2): The Selected Triple P program has utility for many parents and is intended to normalize parenting interventions. There are two delivery formats for Selected Triple P: brief and flexible consultation with individual parents; and parenting seminars with large groups of parents. The brief and flexible consultation format involves one to two consultation contacts (20 minutes each) and is designed for parents whose children have relatively minor and fairly discrete problem behaviors that do not require more intensive levels of intervention. The intervention can be provided in the context of well childcare, daycare and preschool settings, and in other settings where parents may have routine contact with service providers and other professionals who regularly assist families. Selected Triple P can be viewed as a form of anticipatory development guidance. The parenting seminar format of Selected Triple P involves three 90-minute sessions designed for delivery to large groups of parents. The seminar series includes specific seminars on the following topics: The Power of Positive Parenting; Raising Confident, Competent Children; Raising Resilient Children. The three seminars are independent of each other so that parents can attend any or all of them and still benefit. Seminars are used to promote awareness of Triple P and as brief and informative sessions for any parent. Each seminar includes a presentation, a question and answer period, distribution of a parenting tip sheet, and availability of practitioners at the end of the session to deal with individual inquiries and requests for further assistance.
Primary Care Triple P (Level 3): The Primary Care Triple P program, like Selected Triple P, is appropriate for the management of discrete child problem behaviors that are not complicated by other major behavior management difficulties or significant family dysfunction. The key difference is that provision of advice and information is supported by active skills training for those parents who require it to implement the recommended parenting strategies. This program level is especially appropriate for parents of infants, toddlers and preschoolers with respect to common child behavior problems and parenting challenges. Level Three involves a series of four brief (20 minute) consultations that incorporate active skills training and the selective use of parenting tip sheets covering common developmental and behavioral problems of pre-adolescent children. This brief and flexible consultation modality also builds in generalization enhancement strategies for teaching parents how to apply knowledge and skills gained to non-targeted behaviors and other children in the family.
Standard and Group Triple P (Level 4): The Level 4 program benefits indicated populations of children who have detectable problems but who may or may not yet meet diagnostic criteria for a behavioral disorder, and parents who are struggling with parenting challenges. Parents learn a variety of child management skills and how to apply these skills both at home and in the community. Level 4 combines the provision of information with active skills training and support, as well as teaching parents to apply skills to a broad range of target behaviors in both home and community settings with the target child and siblings.
Enhanced Triple P (Level 5): Enhanced Triple P is an optional augmentation of Standard (Level 4) Triple P for families with additional risk factors that might need to be addressed through the intervention. It includes optional intervention modules on partner communication, mood management and stress coping skills for parents, and additional practice sessions addressing parent-child issues.
The Triple P system has a standard training and quality-promotion protocol that is used worldwide. Professional training courses delivered by professional trainers involves attendance in a multi-day training program (2 or 3 days, depending on course level), intensive self-review of intervention materials, competency practice and feedback at a day-long session, and completion of accreditation requirements. The training process includes didactic instruction, modeling by the trainer, video examples of discrete skills, small-group exercises for active skills practice, and group discussions of key issues.
Population System Approach: In a population level system trial, the existing workforce are trained to deliver the Triple P system of interventions. Service providers may include family support services (social workers and therapists affiliated with county health centers, mental health centers, and schools), social services (family services, social workers), preschool and child-care settings (directors, teachers), elementary schools (parent educators, guidance counselors, kindergarten teachers), early childhood workers, child abuse prevention, private sector practitioners, health centers (primary healthcare providers), and other community entities having direct contact with parents and families. In the population trial that was evaluated, 649 service providers participated in Triple P professional training in 9 counties. Sixty-four percent of county providers were trained in only Levels 2/3, and 36% were trained in Level 4 or above. About a third of the latter group also received training in Levels 2/3. The mean per-county number of Triple P trained individuals was 38.8 providers per 50,000 population. Based upon interviews with trained service providers, it is estimated that between 8,883 and 13,560 families participated in some level of Triple P across the 9 counties.
Primary Evidence Base for Certification
Study 1
Prinz et al. (2009, 2016) found that, compared to the control counties, the intervention counties had significantly
Primary Evidence Base for Certification
Of the two studies Blueprints has reviewed, one (Study 1) meets Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). The study was done by the developer.
Study 1
Prinz et al. (2009, 2016) conducted a randomized trial that examined 18 medium-sized U.S. counties in a southeastern state. After randomly assigning countries to intervention and control conditions, the study examined county measures of child maltreatment for children under eight years of age.
Study 1
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The U.S. Triple P System population trial. Prevention Science, 10, 1-12.
Family: Family conflict/violence, Parent stress, Poor family management, Psychological aggression/discipline, Violent discipline
Individual: Coping Skills
Family: Attachment to parents, Nonviolent Discipline, Parent social support
*
Risk/Protective Factor was significantly impacted by the program
See also: Triple P System Logic Model (PDF)
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
Study 1 (Prinz et al.,m 2009, 2016) did not report the race, ethnic, or gender composition of the county populations. It reported statistics only for the providers participating in the intervention: 91.7% female, 57% European American (not Hispanic), 38.3% African American, 1.3% Hispanic, and 3.4% other ethnic/racial groups.
Level 2: Selected Triple P:
The minimum qualification level for the lead practitioner of Level 2 Selected Triple P is QCF Level 4/5 (Certificate C Level/Intermediate I Level) and the recommended qualification level is QCG Level 6 (Honours H Level).
Lead practitioners of Level 2 Seminar Triple P are expected to have some knowledge of child development, the impact parenting can have on children, and some experience working with families.
Training is provided by accredited Triple P Trainers in intensive face-to-face workshop of 1-day training (7.5 hours) and then half a day accreditation. There is no accreditation quiz. The practitioner must have been trained and accredited in either a Level 3 or Level 4 Triple P program as a prerequisite before beginning Level 2 Selected training.
Training
Attend a Selected Triple P Provider Training Course.
Triple P is designed for use by a variety of health, education and welfare professionals who consult with parents about children's behavior and development. It is assumed that practitioners using Triple P will have a basic professional qualification in either psychology, psychiatry, pediatrics, medicine, nursing, special education, social work or counseling. Practitioners delivering the Triple P Seminar Series should have a good working knowledge of child development, be familiar with major types of child psychopathology, and have skills in the application of social learning principles to child behavior and emotional problems.
To be accredited as a Selected Triple P provider, completion of a structured Triple P accreditation process is required. For information about Triple P practitioner training visit the Triple P website (www.triplep.net). For information about the Triple P Practitioner Network for accredited practitioners visit www.triplep.org.
Practitioners interested in completing Triple P training to deliver the Triple P Seminar Series can complete the following:
Level 3: Primary Care Triple P:
The minimum qualification level for the lead practitioner of Primary Care Triple P is QCF Level 4/5 (Certificate C Level/Intermediate I Level) and the recommended qualification level is QCG Level 6 (Honours H Level).
Lead practitioners of Primary Care Triple P are expected to have some knowledge of child development, the impact parenting can have on children, and some experience working with families.
Training is provided by accredited Triple P Trainers in intensive face-to-face workshops of 2 days duration followed by a one-day accreditation.
Training
Attend a Primary Care Triple P Provider Training Course.
A full Primary Care Triple P Provider Training Course consists of two parts. The first part consists of attending a Level 3 Primary Care Triple P Provider Training Course 2 x 7.5 hour days of workshops. The second part involves a day of accreditation. This course provides a specific focus on process issues and practical implementation of Primary Care Triple P. For facilitators who have already completed Group Triple P, the Primary Care Triple P course can be taken as a one-day extension course with an additional day for accreditation.
Following completion of the Primary Care Triple P components, participants will have acquired advanced skills in the following additional areas:
Accreditation involves practitioners passing a multiple-choice exam and displaying a set of core competencies in a face-to-face small group accreditation session. Peer support groups and pre-accreditation workshops provide practitioners with a means to practice before the accreditation session is attended.
Level 4: Group and Standard Triple P:
The minimum qualification level for the lead practitioner of Group and Standard Triple P is QCF Level 4/5 (Certificate C Level/Intermediate I Level) and the recommended qualification level is QCG Level 6 (Honours H Level).
Lead practitioners of Group and Standard Triple P are expected to have some knowledge of child development, the impact parenting can have on children, and some experience working with families.
Training is provided by accredited Triple P Trainers in intensive face-to-face workshops of 3 days duration followed by a one-day accreditation.
Training
Attend training sessions (typically consists of 3 x 7.5 hour days of workshops, but does depend on the combination of training courses the practitioner attends).
Training for Standard or Group Triple P provides an introduction to the field of behavioral family intervention and detailed information on the application of positive parenting strategies to a variety of child behavior problems. Following completion of Group Triple P training, participants have enhanced knowledge and skills in the following areas:
The onus is on the practitioner to complete background reading and professional skills development in this area. To become a formally accredited Triple P provider, completion of a structured Triple P accreditation process is required.
Accreditation involves practitioners passing a multiple-choice exam and displaying a set of core competencies in a face-to-face small group accreditation session. Peer support groups and pre-accreditation workshops provide practitioners with a means to practice before the accreditation session is attended.
Level 5: Enhanced Triple P:
The minimum qualification level for the lead practitioner of Enhanced Triple P is QCF Level 4/5 (Certificate C Level/Intermediate I Level) and the recommended qualification level is QCG Level 6 (Honours H Level).
Lead practitioners delivering Level 5 Enhanced interventions should have sound knowledge of child development and psychopathology, have skills in the application of social learning principles to child behavior problems, and have experience in the use of cognitive behavioral techniques in individual and couples programs for adults.
Training is provided by accredited Triple P Trainers in intensive face-to-face workshops of a minimum of 2 days duration (depending on the facilitators' prior training), and this is followed by a half day accreditation.
Training
Attend a Level 5 Enhanced Triple P Provider Training Course.
Attend training sessions (typically consists of 2 x 7.5 hour days of workshops and a half-day accreditation). However, practitioners must have completed Group or Standard Triple P prior to completing this training. This can be accomplished separately or over five consecutive days of training, plus two half days of accreditation.
Accreditation involves practitioners passing a multiple-choice exam and displaying a set of core competencies in a face-to-face small group accreditation session. Peer support groups and pre-accreditation workshops provide practitioners with a means to practice before the accreditation session is attended.
Stepping Stones Triple P: Standard:
The minimum qualification level for the lead practitioner of Stepping Stones Triple P is QCF Level 4/5 (Certificate C Level/Intermediate I Level) and the recommended qualification level is QCG Level 6 (Honours H Level).
Lead practitioners delivering Stepping Stones Triple P interventions should have sound knowledge of child development and psychopathology, have skills in the application of social learning principles to child behavior problems, and have experience in the use of cognitive behavioral techniques in individual and couples programs for adults.
Training is provided by accredited Triple P Trainers in intensive face-to-face workshops of 3 days duration (depending on the practitioner's prior training), and this is followed by a half day accreditation.
Training
Training in Standard Stepping Stones Triple P consists of 3 x 7.5 hour day workshops.
Training for Standard Stepping Stones Triple P provides an introduction to the field of behavioral family intervention and detailed information on the application of positive parenting strategies to a variety of developmental issues for parents of a child with a disability. Following completion of the training, participants have enhanced knowledge and skills in the following areas:
Accreditation involves practitioners passing a multiple-choice exam and displaying a set of core competencies in a face-to-face small group accreditation session. Peer support groups and pre-accreditation workshops provide practitioners with a means to practice before the accreditation session is attended.
All Levels:
Supervision
Triple P adopts a unique peer support self-regulation approach to supervision. The aim is to promote reflective practice and tailoring of the intervention to the needs of parents, while maintaining fidelity to the intervention model. It involves practitioners meeting regularly to discuss cases and issues arising from the delivery of the program. It is ideal for practitioners to make a video or audio recording of their program delivery and review this during supervision with small groups of peers. This small group format provides a forum for self-evaluation and peer feedback to enhance and maintain clinical skills and program integrity. When Triple P is used as part of a clinical service, provision should be made to ensure some supervision is available to practitioners using the program. Regular supervision can help reduce burnout and lead to more competent service delivery.
Technical Assistance
Triple P has an exclusive technical and consultation support process that can be accessed by trained and accredited providers through the Triple P Practitioner Network (www.triplep.org). There are also implementation guidelines for agencies wishing to implement Triple P, manager briefings, and an annual Triple P Conference (Helping Families Change Conference - www.helpingfamilieschange.com).
For information on Triple P training and accreditation contact: Triple P America, Inc., PO Box 12755, Columbia, SC 29211. Tel: (803) 451 2278 Email: contact.us@triplep.net Website: www.triplep.net.
Training Trainers
Triple P Trainers are masters- or doctorate-level professionals (mainly clinical or educational psychologists) who are recruited and trained to train practitioners (Triple P providers) to implement Triple P programs with the parents with whom they work.
Professionals invited to become Triple P trainers undergo an intensive two-week training program. After initial induction, trainers are provisionally accredited and can begin conducting training under supervision from TPI. To be considered fully trained, trainers have to complete a skills-based accreditation process. Trainers do not work independently and use standardized materials, which serves to ensure that program integrity is protected. Although many agencies favor a train-the-trainer model, such an approach can lead to substantial program drift and poorer client outcomes. Program disseminators can quickly lose control of the training process and, as a result, can find it harder to efficiently incorporate revisions and changes when ongoing research indicates they are required. Maintaining control over the initial training of providers, although not without its challenges (when the demand for a program occurs in different cultural contexts), is achievable and helps to promote quality standards.
Maintaining Training Quality
To prevent program drift, all Triple P Trainers use standardized materials (including participant notes, training exercises, and training DVDs demonstrating core consultation skills) and adhere to a quality-assurance process; trainers become part of a trainer network, and maintenance of their accreditation is required by the completion of professional development activities over designated 2-year periods. Triple P International manages all aspects of the training program, including the initial training, post-training support, and follow-up technical assistance.
Technical and Consultation Support
The Triple P team encourages organizations and practitioners to access ongoing back-up consultative advice post training. Triple P staff members have ongoing email contact, teleconferences, and staff meetings as well as update days to address administrative issues (e.g., data management, performance indicators), logistical issues (e.g., avoidance of accreditation workshops due to anxiety, referral strategies), and clinical issues (e.g., dealing with specific populations, clinical process problems) identified by practitioners. These contacts actively engage agency staff in troubleshooting. An online practitioner network has also been established to provide ongoing technical support to practitioners using Triple P (http://www.triplep.org). This network provides practitioners with downloadable clinical tools and resources (e.g., monitoring forms, public domain questionnaires, and session checklists), updates of new research findings, and practice tips and suggestions. An international practitioner network for accredited providers enables Triple P practitioners to keep up to date with the latest developments in the world of Triple P, including recent research findings and new programs being released.
Encouraging Reflective Practice through Supervision
Practitioners who access supervision and workplace support post-training are more likely to implement Triple P. A self-regulatory peer-assisted approach is the preferred method of supervision in the dissemination of Triple P (see Sanders & Murphy-Brennan, 2010a, Sanders et al. 2002, Turner et al., 2011). The self-regulation approach to supervision is an alternative to more traditional, hierarchically based group or individual clinical supervision with an experienced, expert supervisor who provides mentoring, feedback, and advice. The self-regulation model utilizes the power and influence of the peer group to promote reciprocal learning outcomes for all participants in supervision groups. Under this model, peers become attuned to assessing the clinical skills of fellow practitioners and provide a motivational context to enable peer colleagues to change their own behaviors, cognitions, and emotions so they become proficient in delivering interventions.
Program Benefits (per individual):
$2,375
Program Costs (per individual):
$305
Net Present Value (Benefits minus Costs, per individual):
$2,070
Measured Risk (odds of a positive Net Present Value):
71%
Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.
Initial training is offered for 4 levels of the Triple P System. Again, the costs are based upon preparing a site to serve 100,000 families.
Brief Interventions
Level 2 Selected Seminars - 14 courses (20 participants per course) at $11,450 per course = $160,300
Level 3 Primary Care - 20 courses (20 participants per course) at $23,555 per course = $537,900 (includes $66,800 for Pre-Accreditation Cost)
Intensive Intervention
Level 4 Group - 10 courses (20 participants per course) at $26,760 per course = $301,000 (includes $33,400 for Pre-Accreditation Cost)
Level 4 Standard - 7 courses (20 participants per course) at $26,760 per course = $210,700 (includes $23,380 for Pre-Accreditation Cost)
Level 4 Standard Stepping Stones - 1 course (20 participants per course) at $28,815 per course = $32, 155 (includes $3,340 for Pre-Accreditation Cost)
Adjunctive Support
Level 5 Enhanced - 4 courses (20 participants per course) at $20,435 per course = $81,740
Please note.
All prices are exclusive of Sales Tax. Sales Tax will be charged where appropriate at the prevailing rate.
Prices are firm to 31 March 2013, please contact Triple P America (contact.us@triplep.net) for pricing.
Total for Training & Pre-Accreditation Workshops: $1,323,795
Included in training costs.
None.
Training costs do not include venue hire, catering or additional travel expenses if the training occurs in a remote location. There may be additional costs related to practitioner travel for training, accreditation and support days.
The time investment by practitioners to familiarize themselves with the program and prepare for accreditation (in addition to attending training, pre-accreditation workshop, and accreditation) is approximately 30½ hours.
A suitably qualified and experienced person should be appointed as project coordinator within the organization.
Implementation resources (such as workbooks and tipsheets) are required for working with families. The cost of these resources to reach 100,000 families in the programs detailed previously is $723,598 (including freight and handling).
Please note.
All prices are exclusive of Sales Tax. Sales Tax will be charged where appropriate at the prevailing rate.
Prices are firm to 31 March 2013, please contact Triple P America (contact.us@triplep.net) for pricing.
Triple P is designed to train an existing workforce to deliver the program to parents.
There could be space costs if the program is not offered space in the sponsor facility or other donated space. If included, the Stay Positive Communications Campaign would cost $3.20 per family per year.
Clinical Support Days provide an opportunity for practitioners to meet with fellow practitioners to discuss cases, problem solve, plan for future delivery, and receive expert feedback for professional development. Clinical Support Days cost $3,340 each. A phone model is also available.
Agencies/organizations are encouraged to set up peer support groups for their Triple P providers. Individual providers are encouraged to attend peer support groups (in-person or via teleconference when necessary). These peer support groups provide practitioners an opportunity to discuss their current Triple P cases, as well as common process issues that may arise for the group as a whole. It is recommended that practitioners use the self-regulatory approach in discussion of cases and process issues.
All Triple P programs are structured around robust resources that guide the practitioner to deliver programs in a consistent and coherent way. These include manuals for the practitioner with comprehensive session guides, video examples to be shown to parents at pre-determined times during each program, and parent workbooks and tip sheets that provide exercises and discussions designed to ensure parents receive the programs as they were designed and evaluated.
Session checklists are provided for each Triple P intervention and can be utilized by practitioners to monitor their own fidelity to the program, and agencies/organizations that are leading Triple P rollouts in communities may also collect these measures from practitioners as a measure of fidelity to the program. Practitioners and organizations are encouraged to use the checklists to assist in their self-regulation and continuous quality improvement
External fidelity checks may be seen as expensive and intrusive and are not routinely offered. Agencies are also encouraged to identify local sources of expertise in conducting independent evaluations of program outcomes on a larger scale. Triple P America does not typically undertake such evaluations but can assist in identifying suitable research groups if requested.
None.
No information is available
No information is available
To summarize the costs above, which represent the Year One investment in a Triple P Program serving 100,000 families, see below:
| Training courses | $1,323,795.00 |
| Implementation costs | $723,598.00 |
| Stay Positive Communications Campaign | $320,000.00 |
| Total One Year Cost | $2,367,393.00 |
The total dollar value of $2,367,393 represents a cost of $23.67 per family in a community serving 100,000 families. All prices are exclusive of Sales Tax, to be charged where appropriate at the prevailing rate. Prices are firm to 31 March 2013, please contact Triple P America (contact.us@triplep.net) for pricing.
Given the complexity of Triple P, with its diverse approaches and interventions, it should not be surprising that many funding approaches have been used to fund various components. These will be introduced without attempting to tie each to a specific component of Triple P.
When parenting programs are already in use and they do not have a strong evidence base, Triple P should be considered as a proven alternative that could be funded with a re-direction of existing funds.
State and local funding has been used to support many components of Triple P. It has been funded by local school districts when used in schools, by the health sector when offered in hospitals and primary care clinics, by social services in the family resource center arena and by mental health funding for community mental health clinics. It is thus important to approach Triple P funding with a willingness to explore options broadly. In addition, state and local funds have provided matches required for federal entitlement programs.
Entitlements: Triple P has been funded with both Medicaid and Title IV-E dollars. Medicaid is used to fund Triple P when offered as either a health or a mental health service. Title IV-E has been used to obtain reimbursement for training costs related to components of Triple P that address child abuse issues through parent education.
Formula Funds: Title I grants to school systems have been used to train teachers and counselors in Triple P. TANF and Title IV-B social services funding can be used for training and interventions through parenting programs.
Discretionary Grants: Discretionary grants from the federal government can be sought from a wide array of federal agencies, including the Departments of Education, the Centers for Disease Control, National Institutes of Health, Centers for Medicare and Medicaid Services and the WIC Program. Again, a wide-ranging review of federal grant opportunities will be important for sites considering Triple P.
Many foundations and United Ways support Triple P. With the many different targets of the Triple P intervention, interest can be garnered from a variety of foundations, especially those with priorities including child abuse, health and mental health care and parenting education. An Opportunity Compact can be considered when Triple P is being employed as an alternative to undesirable, expensive programs such a foster care.
Debt financing should be considered as a source of funding for initial implementation of Triple P. This is particularly true when the program targets a population at risk of an expensive remedial intervention in the absence of Triple P. An example of this is the use of Triple P as child abuse prevention that could prevent the removal of children from their parents for placement in foster care.
New revenue can be useful for both start-up costs and sustaining Triple P, particularly when the intervention desired does not have an already existing funding source. A range of approaches can be considered, from fund raising efforts to sin taxes to tax form check-offs and children's trust funds. Again, an openness to exploring new options for realizing new revenue should be brought to the effort.
All information comes from the responses to a questionnaire submitted by the purveyor, Triple P America, to the Annie E. Casey Foundation and Blueprints.
Matthew Sanders, Ph.D.DirectorThe University of QueenslandSchool of PsychologyParenting and Family Support CenterBrisbane, QLD 4072AUSTRALIA+61 (7) 3365 7290info@triplep.netmatts@psy.uq.edu.au www.pfsc.uq.edu.au">http://www.pfsc.uq.edu.au">www.pfsc.uq.edu.au
A public health approach to reach all parents in a community to enhance parental competence and prevent or alter dysfunctional parenting practices, thereby reducing family risk factors both for child maltreatment and for children's behavioral and emotional problems.
Uses a public health approach to reach all parents in a community. Specifically, parents with a child in the birth to 12 year age range are targeted by the core programs of Triple P. In the population trial, the referent target were parents with children below age 8.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
Study 1 (Prinz et al.,m 2009, 2016) did not report the race, ethnic, or gender composition of the county populations. It reported statistics only for the providers participating in the intervention: 91.7% female, 57% European American (not Hispanic), 38.3% African American, 1.3% Hispanic, and 3.4% other ethnic/racial groups.
Family: Family conflict/violence, Parent stress, Poor family management, Psychological aggression/discipline, Violent discipline
Individual: Coping Skills
Family: Attachment to parents, Nonviolent Discipline, Parent social support
*Risk/Protective Factor was significantly impacted by the program
The Triple P Positive Parenting Program is designed as a comprehensive population-level system of parenting and family support for famlies having at least one child in the birth to 12-year-old range. The multilevel system includes five intervention levels of increasing intensity and narrowing population reach. The system is designed to enhance parental competence and prevent or alter dysfunctional parenting practices, thereby reducing an important set of family risk factors, both for child maltreatment and for children's behavioral and emotional problems. In the Triple P system, a media and communication strategy is utilized extensively in a sophisticated and strategic manner to normalize and acknowledge the difficulties of parenting experiences, to break down parental sense of social isolation regarding parenting, to de-stigmatize getting help, to impart parenting information directly to parents, and to alter the community context for parenting.
In a population level version of Triple P, the existing workforce crossing several disciplines and settings (such as family and social support services, preschool/child-care settings, elementary schools, and other community entities with direct contact with families) is trained to deliver the Triple P system of interventions. They in turn deliver Triple P to parents in 1-10 or more sessions tailored to the severity of the family's dysfunction and/or child's behavioral problems.
The Triple P Positive Parenting Program is a multi-level preventive intervention system designed for families having at least one child in the birth to 12-year-old range (the core programs). All programming levels of Triple P have carefully developed intervention manuals, systematic training regimens for providers/practitioners, and coordinated resource materials for parents (videos, workbooks and tip sheets). The 5 core principles of positive parenting that are invoked throughout the multi-level Triple P system to promote social competence and emotion self-regulation in children are: (1) ensuring a safe, engaging environment, (2) promoting a positive learning environment, (3) using assertive discipline, (4) maintaining reasonable expectations, and (5) taking care of oneself as a parent. The emphasis is on parents learning how to apply these skills to different behavioral, emotional and developmental issues in children, ranging from common child-rearing challenges to more intense challenges. The five positive parenting principles translate into 35 specific strategies and parenting skills that fit into several major categories: parent-child relationship enhancement, encouraging desirable behavior, teaching new skills and behaviors, managing misbehaviors, preventing problems in high-risk situations, self-regulation skills, parental mood management and coping skills, and partner support and communication skills. Triple P provides developmentally tailored menu options that facilitate parental goal setting and self-regulation. Parents learn how to apply those techniques and strategies that are relevant to their child, the parent's goals and the family situation.
Universal Triple P (Level 1): The Universal facet of the Triple P intervention involves the implementation of media and informational strategies pertaining to positive parenting. These strategies are intended to destigmatize parenting and family support, make effective parenting strategies readily accessible to all parents, and facilitate help-seeking and self-regulation by parents who need higher intensity intervention. Universal Triple P includes use of radio, local newspapers, newsletters at schools, mass mailings to family households, presence at community events, and website information. Use of local newspapers takes three forms: positive parenting articles written by Sanders (program creator) on specific topics of interest to parents; local press releases on human interest stories that link with Triple P activities; and stories generated by reporters with whom the publicity team has developed working relationships.
Selected Triple P (Level 2): The Selected Triple P program has utility for many parents and is intended to normalize parenting interventions. There are two delivery formats for Selected Triple P: brief and flexible consultation with individual parents; and parenting seminars with large groups of parents. The brief and flexible consultation format involves one to two consultation contacts (20 minutes each) and is designed for parents whose children have relatively minor and fairly discrete problem behaviors that do not require more intensive levels of intervention. The intervention can be provided in the context of well childcare, daycare and preschool settings, and in other settings where parents may have routine contact with service providers and other professionals who regularly assist families. Selected Triple P can be viewed as a form of anticipatory development guidance. The parenting seminar format of Selected Triple P involves three 90-minute sessions designed for delivery to large groups of parents. The seminar series includes specific seminars on the following topics: The Power of Positive Parenting; Raising Confident, Competent Children; Raising Resilient Children. The three seminars are independent of each other so that parents can attend any or all of them and still benefit. Seminars are used to promote awareness of Triple P and as brief and informative sessions for any parent. Each seminar includes a presentation, a question and answer period, distribution of a parenting tip sheet, and availability of practitioners at the end of the session to deal with individual inquiries and requests for further assistance.
Primary Care Triple P (Level 3): The Primary Care Triple P program, like Selected Triple P, is appropriate for the management of discrete child problem behaviors that are not complicated by other major behavior management difficulties or significant family dysfunction. The key difference is that provision of advice and information is supported by active skills training for those parents who require it to implement the recommended parenting strategies. This program level is especially appropriate for parents of infants, toddlers and preschoolers with respect to common child behavior problems and parenting challenges. Level Three involves a series of four brief (20 minute) consultations that incorporate active skills training and the selective use of parenting tip sheets covering common developmental and behavioral problems of pre-adolescent children. This brief and flexible consultation modality also builds in generalization enhancement strategies for teaching parents how to apply knowledge and skills gained to non-targeted behaviors and other children in the family.
Standard and Group Triple P (Level 4): The Level 4 program benefits indicated populations of children who have detectable problems but who may or may not yet meet diagnostic criteria for a behavioral disorder, and parents who are struggling with parenting challenges. Parents learn a variety of child management skills and how to apply these skills both at home and in the community. Level 4 combines the provision of information with active skills training and support, as well as teaching parents to apply skills to a broad range of target behaviors in both home and community settings with the target child and siblings.
Enhanced Triple P (Level 5): Enhanced Triple P is an optional augmentation of Standard (Level 4) Triple P for families with additional risk factors that might need to be addressed through the intervention. It includes optional intervention modules on partner communication, mood management and stress coping skills for parents, and additional practice sessions addressing parent-child issues.
The Triple P system has a standard training and quality-promotion protocol that is used worldwide. Professional training courses delivered by professional trainers involves attendance in a multi-day training program (2 or 3 days, depending on course level), intensive self-review of intervention materials, competency practice and feedback at a day-long session, and completion of accreditation requirements. The training process includes didactic instruction, modeling by the trainer, video examples of discrete skills, small-group exercises for active skills practice, and group discussions of key issues.
Population System Approach: In a population level system trial, the existing workforce are trained to deliver the Triple P system of interventions. Service providers may include family support services (social workers and therapists affiliated with county health centers, mental health centers, and schools), social services (family services, social workers), preschool and child-care settings (directors, teachers), elementary schools (parent educators, guidance counselors, kindergarten teachers), early childhood workers, child abuse prevention, private sector practitioners, health centers (primary healthcare providers), and other community entities having direct contact with parents and families. In the population trial that was evaluated, 649 service providers participated in Triple P professional training in 9 counties. Sixty-four percent of county providers were trained in only Levels 2/3, and 36% were trained in Level 4 or above. About a third of the latter group also received training in Levels 2/3. The mean per-county number of Triple P trained individuals was 38.8 providers per 50,000 population. Based upon interviews with trained service providers, it is estimated that between 8,883 and 13,560 families participated in some level of Triple P across the 9 counties.
Although Triple P uses social learning principles, the trial described here is based on the following conceptual framework:
Primary Evidence Base for Certification
Of the two studies Blueprints has reviewed, one (Study 1) meets Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). The study was done by the developer.
Study 1
Prinz et al. (2009, 2016) conducted a randomized trial that examined 18 medium-sized U.S. counties in a southeastern state. After randomly assigning countries to intervention and control conditions, the study examined county measures of child maltreatment for children under eight years of age.
Primary Evidence Base for Certification
Study 1
Prinz et al. (2009, 2016) found that, after 2 years of intervention, randomly surveyed households in the Triple P System counties showed significantly higher proportion of awareness regarding Triple P than did those in control counties. The comparison of Triple P System and control conditions revealed differential and positive effects on the Triple P System counties for rates of substantiated child maltreatment, child out-of-home placements, and hospitalizations or emergency-room visits for child maltreatment injuries.
Primary Evidence Base for Certification
Study 1
Prinz et al. (2009, 2016) found that, compared to the control counties, the intervention counties had significantly
One study meets Blueprints standards for high-quality methods with strong evidence of program impact (i.e., "certified" by Blueprints): Study 1 (Prinz et al., 2009, 2016). The sample for studies included families with at least one child under eight years of age.
Study 1 took place in a southeastern U.S. state and compared the intervention group to a services-as-usual control group.
Additional Studies (not certified by Blueprints)
Study 2 (Sanders et al., 2008)
Sanders, M. R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S., & Bidwell, K. (2008). Every family: A population approach to reducing behavioral and emotional problems in children making the transition to school. The Journal of Primary Prevention, 29,197-222.
Blueprints: Promising
Crime Solutions: Effective
OJJDP Model Programs: Effective
Social Programs that Work:Near Top Tier
Nicole Young
First 5
Santa Cruz, CA
Email: nicole@opti-solutions.com
Phone: (831) 594-1498
Website: first5scc.org/families-are-strong/triple-p
Barbara Sheppard
Cabarrus Health Alliance
Cabarrus County, NC
Email: Barbara.Sheppard@cabarrushealth.org
Phone: (704) 920-1367
Website: www.cabarrushealth.org/153/Triple-P-Positive-Parenting_Program
Triple P America
E-mail: contact.us@triplep.net
Phone: (803) 451-2278
Web: www.triplep.net/glo-en/home/
Certified Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The U.S. Triple P System population trial. Prevention Science, 10, 1-12.
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(3), 410-416.
Sanders, M. R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S., & Bidwell, K. (2008). Every family: A population approach to reducing behavioral and emotional problems in children making the transition to school. The Journal of Primary Prevention, 29, 197-222.
Summary
Prinz et al. (2009, 2016) conducted a randomized trial that examined 18 medium-sized U.S. counties in a southeastern state. After randomly assigning countries to intervention and control conditions, the study examined county measures of child maltreatment for children under eight years of age.
Prinz et al. (2009, 2016) found that, compared to the control counties, the intervention counties had significantly
Evaluation Methodology
Design: The U.S. TPSPT (Triple P System Population Trial) consists of the stratified random assignment of 18 medium-sized counties (population between 50,000 and 175,000) in a southeastern state to dissemination and control conditions, controlling for county population size, county poverty rate, and county child abuse rate. Population size was the main factor in selecting counties to arrive at units that were reasonably comparable by eliminating very small counties that would not have sufficient population to implement the preventive interventions and detect effects, and by eliminating very large counties that would individually account for too much of the overall variance.
The population indicators chosen for this trial met several criteria: (1) standardized across counties and delivered to a central repository; (2) measure of child maltreatment or its immediate consequence; (3) associated with significant human and financial costs; and (4) recorded by personnel not involved in the dissemination of the preventive intervention in the population trial. Substantiated child maltreatment was chosen over reports because the former is associated with real and potentially costly sequelae beyond the initiation of an evaluation or investigation. The three population indicators chosen for the study had the added benefit of being derived from three separate systems (i.e., Child Protective Services, Foster Care System and hospitals), which allowed for relatively independent corroboration and documentation of possible preventive effects.
The conditions were: (1) Triple P System, which involved implementation of the core Triple P system with the existing workforce; and (2) Control, which meant services as usual without implementation of Triple P. Prevention of child maltreatment in this design is defined by three population indicators evaluated after a 2-year period of intervention dissemination controlling for the pre-intervention level. The pre-post randomized design builds in a 2-year period deemed to be necessary to train a sufficient number of service providers in the participating counties and to allow a sufficient amount of time for these providers to deliver the preventive interventions to many families. Using the three control variables for stratified random assignment was intended to reduce initial between-condition differences with respect to population size, which could be correlated with services available to families; poverty rate, which might make it more difficult to achieve intervention success; and child abuse rate, which is related to the outcomes of interest.
TSPST: Specific modifications to the Triple P design for the population trial are as follows:
After randomization to condition, recruitment of service providers and organizations took place in the nine Triple P System counties. Service providers were recruited through many settings that provided services to families to participate in Triple P professional training courses. The dissemination staff identified and contacted stakeholders at both the state and local (county) levels in support services for parents of young children, including representatives from a wide range of provider systems such as education, school readiness, childcare, mental health, social services, and health. The staff introduced the Triple P system of interventions to each stakeholder group and organization and then worked with each entity to consider training needs and the ability to deliver parent consultation services. Providers who served families in the Triple P System counties were invited to training courses, and providers in other counties (including the Control counties) were not permitted to participate.
Sample:
Counties: All of the 18 counties selected for the TPSPT had population sizes between 50,000 and 175,000 and none of the counties had any prior exposure to Triple P at the start of the population trail. The counties ranged in demographics from rural to semi-urban. In terms of broader context, the agencies and services in these counties had suffered significant funding cuts over several years. The counties appeared to have little or no prior exposure to evidence-based parenting programs of any kind.
Families: The referent population in the 18 counties was all families with at least one child under 8 years of age (though because this was a population-level trail, no families formally entered the trial). In the Triple P System counties, this is approximately 85,000 families in any given year. The birth to 8 years child group refers to the target age for assessing preventive effects on child maltreatment and was chosen because this is the period of greatest risk for child maltreatment selected by the funder (CDC) for the initiative.
Service Providers: A key facet of the population-based dissemination of the Triple P system involves the engagement, training, and support of a broad array of service providers from several disciplines and settings including: family support services (social workers and therapists affiliated with county health centers, mental health centers, and schools), social services (family services, social workers), preschool and child-care settings (directors, teachers), elementary schools (parent educators, guidance counselors, kindergarten teachers), non-governmental organizations (e.g., early childhood NGOs, child-abuse prevention NGOs), private sector practitioners, health centers (primary healthcare providers), and other community entities having direct contact with parents and families. For the 2-year intervention period pertinent to this report, 649 service providers participated in Triple P professional training courses. Demographically, 91.7% of the providers were female, 57% European American (not Hispanic), 38.3% African American, 1.3% Hispanic, and 3.4% other ethnic/racial groups, with a mean age of 44.5. Most (81%) of the providers had already been engaged in parent consultation work for at least 5 years prior to Triple P training, and 59% had over 10 years of such experience.
Measures:
Public awareness of Triple P - A random telephone survey of households was conducted pre-intervention and again at post-intervention to determine relative growth in public awareness of Triple P in the two sets of counties. The surveys were based on random-dialing sampling of population databases of households where children resided. Response rates for the two administrations of the survey were 42.6% and 49.7%, respectively. Respondents who identified themselves as primary caregivers for at least one child under 8 years of age were asked whether they had heard of each of a number of parenting programs, including Triple P. The number of respondents in the Triple P System counties was 1,794 at pre-intervention and 1,854 at post intervention; 1,836 and 1,826 respectively in Control counties.
Estimated number of families participating in Triple P - Follow-up telephone interviews with Triple P trained service providers were used to estimate the number of families to whom programming was delivered. Six months after participating in Triple P professional training, providers were contacted and asked about the number of families they served with Triple P (a) in the most recent 4-week period and (b) during the time since participation in Triple P training. The responses to these two interview questions were converted to annualized figures, which provided an upper and lower estimate of the number of families who providers indicated had participated in Triple P programming. These estimates are considered to be rough projections, which on the one hand could be overestimates because there is an assumption of constant rate of programming by any given provider, but on the other hand are likely to be underestimates because the data are extrapolated to a 12-month period even though the intervention period was actually 24 months.
Population outcome indicators - Three population indicators related to child maltreatment served as the outcome variables for this study and were derived from independent data-collection systems deposited with a state-run statistical division. The first indicator was substantiated child maltreatment recorded by child protective services staff. These data were unduplicated such that no child maltreatment case was counted more than once in a given year. The second was child out-of-home placements recorded through the foster care system. The third was child hospitalizations and emergency room visits due to child maltreatment injuries, which were recorded by medical staff in compliance with mandatory state reporting requirements for hospitals, regardless of whether or when Child Protective Services was involved. All three population indicators were computed as annual rates per 1,000 children in the birth to 8-year-old range.
Analysis: Prior to conducting the primary pre-post analyses, preliminary analyses of the three population indicators for the 5 years prior to the TPSPT were undertaken retrospectively to determine if the two clusters of counties showed any pre-study trends or differences. Each population indicator was subjected to a County Cluster x Time repeated measures analysis of variance. For each of the indicators, post-intervention rates for the Triple P System and Control conditions were compared, controlling for pre-intervention rate from the year just prior to the initiation of intervention.
In an addendum published separately (Prinz et al., 2016), the researchers used ANCOVA with averages of the baseline population outcome variables for the five years prior to initiation as controls. The analysis was done at the county level, the unit of randomization, and had a sample size of 18.
Outcomes
Pre-intervention demographic characteristics of the counties - The two sets of counties were compared with respect to pre-intervention demographic characteristics. At pre-intervention, the Triple P System counties did not differ significantly from the Control counties with respect to county population, percentage of the population in poverty, and racial composition, and were quite comparable. Pre-intervention levels for the three outcome indicators, calculated as an average of the 5-year period prior to the study for each indicator, also did not differentiate the two sets of counties. Prinz et al. (2016) confirmed the lack of condition differences using 5-year baseline averages.
After 2 years of intervention, randomly surveyed households in the Triple P System counties showed significantly higher proportion of awareness regarding Triple P than did those in Control counties. Consistent with this observation, the Triple P System counties showed significant growth in proportion of Triple P awareness from a mean of 4.8% to a mean of 17.1%, while Control counties did not show significant change from a mean of 4.5% to a mean of 5.5%. Based on follow-up telephone interviews with Triple P service providers, it was estimated that between 8,883 and 13,560 families participated in Triple P within the Triple P System counties. Between 71% and 75% of these families were reported to have received Levels 2/3 Triple P, and the remainder Level 4 Triple P and above.
Population Outcomes - The unit of randomization - county - was the unit of analysis for the three population outcome indicators: substantiated child maltreatment, child out-of-home placements and hospitalizations or emergency room visits for child maltreatment injuries. The comparison of Triple P System and Control conditions revealed differential and positive effects on the Triple P System counties for rates of substantiated child maltreatment, child out-of-home placements, and hospitalizations or emergency-room visits for child maltreatment injuries.
In an addendum published separately (Prinz et al., 2016), the researchers repeated population outcome analyses using outcome variable averages for the 5 years prior to implementation as baseline outcome controls. In doing so, they found comparable results to where only a single year was used as baseline outcome control. As compared to the control group, the treatment counties showed a significant positive difference for substantiated child maltreatment cases (p = .04, d = 1.20) and marginally significant positive differences for out-of-home placements (p = .10, d = .87) and for child maltreatment injuries (p = .06, d = 1.01).
Summary
Sanders et al. (2008) conducted a quasi-experimental study that examined 20 Australian communities. The communities were non-randomly selected for intervention and control conditions. Surveys of families in the communities examined child distress and behavior problems.
Sanders et al. (2008) found that, compared to the control participants, intervention participants reported significantly greater reductions in
Evaluation Methodology
Design : As trial funders, the Beyondblue organization was interested in determining the "real world" effects of a public health approach to mental health promotion and prevention using evidence-based interventions delivered through regular services. This meant utilizing and upskilling the existing workforce and building upon existing referral networks and delivery mechanisms. A pragmatic evaluation plan was required to track population level auditing or monitoring of parents in a defined catchment area to gauge program effects. The design involved repeated assessment of randomly drawn samples of parents from the catchment areas, rather than attempting to follow individual parents over time. Although this made it harder to detect intervention effects, this design had the advantage of assessing change in a population of parents over time. It was not possible to randomize geographic catchment areas receiving Triple P within the same city to different conditions, as the implementation of a comprehensive media strategy would have meant substantial local across condition leakage. Hence, the evaluation approach involved 10 intervention communities in southern Brisbane that implemented all five levels of the TPS (Triple P System). These communities were compared to 10 non-randomly assigned care as usual (CAU) communities; five in Melbourne, and five in Sydney.
Household interviews were conducted using a computer-assisted telephone interviewing system (CATI). Trained telephone interviewers and a supervisor were employed to conduct the interviews. A total of 6003 surveys were conducted; 2999 at Time 1 (1499 with parents in the intervention city and 1500 in CAU cities), and 3004 at Time 2 (1504 in the intervention city and 1500 in the CAU cities). Time 1 surveys took place in July 2003; follow-up surveys at Time 2 were conducted in April 2006. Surveys were conducted at pre-intervention and then again at post-intervention two years later. Both times, a randomly drawn sample of parents in the selected catchment areas was asked to participate in the survey and to report on their own and their children's behavior.
As schools and preschools were the major focal points for the children whose parents were to be surveyed, these settings were used to generate the units of analysis. Schools were ranked on the Index of Relative Socio Economic Disadvantage (IRSED). The IRSED was constructed from 20 variables collected at the 1996 Census of Population and Housing and describes the population of each census Collection District in terms of employment/unemployment, income, education, family structure, housing characteristics, Aboriginality and English language fluency. A school's score is an average of the index weighted by enrollments taking into account the geographical location of the student population. Schools were plotted on a map of the catchment area and placed into clusters on the basis of geographical proximity, similar IRSED scores and number of students. Attention was also given to major geographical boundaries such a major highways, rivers, railway lines and industrial areas. To maximize geographical separation, clusters were arranged so that a buffer region was between them whenever possible. Ten clusters were developed, with the mean number of target children estimated to be an average of 385 in each cluster. To achieve 1500 completed surveys, the minimum number in each cluster was 150. Clusters were then ordered on the basis of school's IRSED scores to represent broad socioeconomic variability.
Ten catchment areas in suburban Melbourne and Sydney were identified to provide the CAU comparison samples. Australian Bureau of Statistics criteria were used to identify suburban catchments with a similar range of sociodemographic diversity in order the match the Queensland clusters as closely as possible. Catchments were constructed to ensure similar numbers of children of the target age resided there. In order to obtain telephone numbers for the CATI, school catchment areas were estimated based on geographical and transportation criteria. A list of telephone numbers was then obtained based on relevant suburban postcodes and census districts, and numbers were dialed at random within these catchment areas. When a household had at least one 4-7 year old child, CATI survey staff asked to interview the primary caregiver who was able to understand basic English. A household was considered unreachable after 15 attempts. Mean interview time was 25 minutes. In the baseline CATI, 39% of eligible calls resulted in a completed interview; this yielded 2,999 participants. In the post-assessment CATI, 35% of eligible calls resulted in a completed interview with a total of 3,004 parents. In the second CATI, 22% of respondents were identified as having been interviewed previously in the baseline survey.
Triple P was implemented as a whole population approach that blended universal and indicated program elements. A coordinated media and community education campaign involving social marketing and health promotion strategies was used to promote the use of positive parenting practices in the community; increase the receptivity of parents towards participating in Triple P and other family/child interventions; de-stigmatize and normalize the process of seeking help for children with behavioral and emotional problems; increase the visibility and reach of the various interventions; and, counter the often alarmist, sensational or parent-blaming messages in the media. The target communities were provided with information about common behavioral, developmental and mental health problems in children and their families, the value of positive parenting in preventing and reducing these problems, and ways to obtain further information, advice and support. They received access to low-cost, high-quality written resources through a range of venues in the community and access to a telephone support service with Triple P-trained counselors through a statewide telephone counseling service for parents.
Existing partnerships with local media outlets and new partnerships with community-based media outlets were used to support the media campaign. A cross-promotional media strategy comprising both print and electronic media was employed. Media activities included a positive parenting segment on national and local radio, positive parenting messages for broadcast on radio, and a series of positive parenting community service announcements on a major local television channel.
Parents could participate in a Triple P Seminar Series conducted in local preschools, schools and community facilities by accredited Triple P providers. Parents were invited to attend up to three 90-minute seminars on topics related to the prevention of emotional and behavioral problems in children. The introductory seminar (The Power of Positive Parenting) was followed by two seminars dealing with common emotional and behavior problems in young children (Raising Confident, Competent Children and Raising Resilient Children). The second and third seminars in the series were designed to build on the foundations of the introductory seminar and show parents how to apply positive parenting principles in practical ways. Tip sheets were provided to parents and included information related to formulating individual solutions to the issues or problems addressed. Topics included promoting self-esteem in children, helping children confront their fears, partner support, coping with stress, helping children do well at school, helping children make friends, dealing with bullying, and dealing with disobedience.
Parents whose children attended school received six Triple P Newsletters throughout the intervention period. This newsletter included tips and suggestions about positive parenting strategies designed to support their child's education, social competence, coping skills and development of self-esteem. It also provided information on how and where to access other levels of parenting advice and assistance.
Parents could also enroll in a more intensive program that provided active skills training in a group format. Group Triple P is an eight hour program completed in either four weekly 2 hour sessions or a condensed one day program. It employed an active skills training process to help parents acquire new knowledge and skills across a wide range of child management topics via observation, discussion, practice and feedback. Positive parenting skills were demonstrated with videotapes and modeled by service providers. These skills were then practiced in small groups and parents received constructive feedback in an emotionally supportive context. The program also offered three optional weekly follow-up individual telephone consultations of up to 30 minutes to promote transfer and generalization of learning.
Schools were invited to participate in a professional development program for teachers based on Workplace Triple P, a variant of Triple P aimed at assisting teachers in dealing with life stressors and difficult situations in the school environment. Participation also provided teachers with an opportunity to become familiar with the Triple P principles and strategies that were introduced to parents attending the school. Such an approach was designed to encourage a collaborative approach between home and schools so that teachers and parents would develop a more consistent approach in managing children. School staff also received briefings about Every Family from project managers and project officers. These 30-minute briefings were designed to provide an overview of the program and a snapshot of what was involved in Workplace Triple P for teachers.
Primary care practitioners offered indicated intervention programs requiring participation in 3-4 sessions. Primary Care Triple P is a brief 4-session intervention specifically tailored to the primary care environment. Typically the sessions, each 20-30 minutes long, are delivered over a 4-6 week period. The program employs an active skills training process to help parents acquire new knowledge and skills about a specific child management issue or problem via discussion, practice and feedback. Positive parenting skills are demonstrated on videotape and modeled by practitioners. Information and advice about developing a specific parenting plan are provided to parents by health professionals selecting from a series of 46 tip sheets covering different developmental and behavioral topics. Parents then practice implementing the plan at home between sessions. Practitioners were offered training and accreditation in Primary Care Triple P, as well as support and supervision, as part of this project.
Existing referral pathways were also reviewed and streamlined to facilitate communication and timely access to the appropriate level of care. Existing staff from the educational and health sector played a crucial role in consulting and liaising with local stakeholders and in promoting collaboration among them, in order to optimize communication and referral pathways and strengthen linkages across the community. Local mental health service and family intervention specialists' providers from Queensland Health serving the catchment areas were offered training in an advanced level Triple P training. This was to ensure they were familiar with Triple P and were in a position to provide consultative backup and receive appropriate referrals of parents and children requiring the most intensive levels of intervention.
A total of 375 practitioners were trained as part of Every Family, with 73% becoming fully accredited by the training organization, across different levels of Triple P. All participants underwent a standardized training process consisting of 2-5 days training and a further 1-2 days accreditation. The training program employed active skills training procedures, detailed participant notes, practitioner manuals, part workbooks and videotape training material.
Parents residing in CAU communities could access usual mental health, primary health care, welfare, and school-based services, and participate in any parenting programs available in their community. Although no specific integrated multilevel Triple P intervention was provided by the project team, some existing services may have exposed parents to Triple P if those services had service providers who had been previously trained in the program.
Sample: Based on the 2001 Australian Bureau of Statistics (ABS) Census data, there were 12,874 children ages 4-7 years in the 10 Brisbane catchment areas. This comprised the total population of children whose parents were eligible to participate in the intervention and provided the pool from which the Brisbane survey sample was drawn. Participants were primary caregivers living in Brisbane, Sydney or Melbourne, with at least one child aged between 4 and 7 years at the Time 1 survey. Almost all caregivers were parents; parents were ineligible to participate if they were less than 18 years of age, did not speak English sufficiently well, had a mental or physical impairment that prevented them from being able to take part in a telephone interview, were staying in the contacted dwelling but did not usually live there, or did not have a child in the desired age range.
Measures: The measurement plan consisted of a mix of well-validated parent report measures and specific individual questions assessing known risk and protective factors using Likert-type scales. A range of sociodemographic information was collected which included the age and sex of children and parents, respondent's employment status, education level, marital status, annual household income and ethnic background.
The Strengths and Difficulties Questionnaire (SDQ) was used as the primary outcome variable to assess the nature and extent of children's emotional and behavioral problems as reported by parents. There are 25 items in the SDQ, with each subscale consisting of 5 items. The SDQ provides a total problem score that is generated by summing the scores from all scales except the prosocial scale. The SDQ also yields a score on the emotional subscale, the conduct subscale, the hyperactivity subscale, peer problems subscale and the prosocial subscale. Scores on the SDQ can be classified as normal, borderline and abnormal. Parents were also asked whether they considered their child to have had any emotional or behavioral problems over the past 6 months.
As parental depression and high levels of parenting stress have been shown to be related to behavioral and emotional problems in children, parental adjustment was assessed. Parents rated how stressed and depressed they had felt over the two-week period prior to the survey on a 5-point Likert scale.
To assess the presence of parental risk and protective factors, parents were asked about their use of specific parenting strategies for encouraging positive behavior and dealing with misbehavior. Parents were also asked about their use of parenting strategies when their child became anxious or distressed. The parenting strategies for encouraging positive behavior included: praising the child by describing what was pleasing; giving a treat, reward or fun activity; or giving attention such as a hug or wink when the child engaged in positive behavior. Strategies for dealing with misbehavior were divided into two groups. The first set of strategies has been shown to be effective in managing misbehavior and included ignoring the problem behavior, telling the child to stop misbehaving, using a consequence that fits the situation, sending the child to quiet time or time-out, and calling a family meeting to work out a solution. The second set of strategies has been associated with coercive or ineffective discipline and included a single smack with the hand, smacking more than once with hand or with an object other than hand, shouting or becoming angry, and threatening to do something the child would not like but not necessarily following through with it. The strategies for dealing with anxious or distressed behaviors included ignoring the distress by not giving attention; holding, cuddling or using physical contact to settle or calm the child; telling the child to stop being so silly; talking to the child in a soothing way until the fear has passed; allowing the child to avoid the thing he/she is scared of; and encouraging the child to be brave. For each of the parenting strategies, parents were asked to consider how likely they were to use each strategy based on a 4-point Likert scale.
Parents were asked to consider how consistent they were in dealing with their child's behavior using a 5-point Likert scale. Parents were also asked how confident they had felt in the last 6 months to undertake their responsibilities as a parent to their 4-7 year old child using a 5-point Likert scale. To assess the availability of practical and emotional support for parents, respondents were asked to rate on a 5-point Likert scale how much they had felt supported in parenting by family, friends or neighbors over the past 6 months. To gauge parental awareness and participation in Triple P, parents were read a list of 5 commonly used parenting programs and asked if they had heard of each of them. To assess potential false positive recognition of parenting programs, one of the program options was fictional. Parental awareness of Triple P was assessed by asking parents whether they had heard or seen anything about Triple P in the past 12 months, and if so, where they had heard about it from a range of options including: friend, relative, neighbor, radio, television, newspaper, school newsletter, etc. If a parent indicated that they had been involved in a Triple P intervention, they were asked how they were involved: attended a brief seminar, had 1-4 brief meetings with a professional, attended group sessions with other parents, had individual sessions of about an hour each, had telephone contact only or some other way.
Analysis: Logistic regression was used to examine differences between the conditions at Time 1 for each of the key child outcome variables, parent outcome variables, and parenting strategy variables. For each of the variables, change from Time 1 to Time 2 was then assessed by calculating odds ratios and 95% confidence intervals separately for each condition. Tarone's statistics were calculated to test for the equality of odds ratios between the TPS and CAU conditions. This test allowed for statistical comparison of the odds ratios representing change over time when significant change was observed in at least one of the conditions.
Outcomes
The TPS and CAU caregivers were similar in terms of the relationship of the participant to the target child, participant age distribution, and child gender, age and school status. Compared to the TPS group, the CAU group was more likely to be older, married, identify with an ethnic group, and have a higher income and education.
At post-intervention the household survey showed that significantly more parents in the TPS (81.8%) than the CAU (46%) condition were aware of Triple P, and more than three times as many parents in the TPS (7.5%) as in the CAU (2.1%) condition had participated in a Triple P intervention.
From pre- to post-intervention in the TPS condition, the proportion of children who were clinically elevated on SDQ Emotional Symptoms decreased significantly, whereas in the CAU condition, no significant change was observed. Improvements over time for these children were significantly greater for the TPS condition than the CAU condition. Similarly, children in the TPS condition who were clinically elevated on SDQ Total Difficulties decreased significantly from Time 1 to Time 2, whereas in the CAU condition the proportion did not change significantly. When looking at SDQ Conduct Problems, children in the CAU condition who were clinically elevated decreased significantly from pre- to post-intervention while the proportion for TPS children only approached significance, and odds ratios revealed no significant difference between the conditions. Between Time 1 and Time 2, the proportion of children with Behavioral and Emotional Problems decreased significantly in both the TPS and CAU condition; no significant difference was observed between the conditions in the level of change over time. No significant changes or differences between groups were observed between TPS and CAU in regards to SDQ Hyperactivity or SDQ Prosocial Behavior.
From Time 1 to Time 2, the proportion of parents in the TPS condition with a "high" score for depression decreased significantly, while in the CAU condition, no change over time was observed. Conversely, from Time 1 to Time 2, the proportion of parents in the TPS condition with a "high" stress score did not change, while in the CAU condition, the proportion increased significantly; thus the increase over time for stress was significantly greater for the CAU condition than the TPS condition. No significant changes were observed from Time 1 to Time 2 in the proportion of parents who were high scorers on confidence, nor on support.
From Time 1 to Time 2, the proportion of parents in the TPS condition likely to use appropriate parenting strategies for child misbehavior did not change, while in the CAU condition, the proportion increased significantly. When looking at inappropriate parenting strategies for child misbehavior, parents in both conditions likely to use such strategies decreased significantly from Time 1 to Time 2, however the magnitude of pre- to post-intervention change between conditions was significantly greater for the TPS condition than the CAU condition. No change over time or significant differences between TPS and CAU was found for appropriate parenting for fearful/anxious behavior, inappropriate parenting for fearful/anxious behavior, positive parenting or parenting consistency.