Parenting
interventions for
complex problems
Matthew R Sanders, Ph.D
Professor of Clinical Psychology and Director
Parenting and Family Support Centre
The University of Queensland
October, 2011
At a glance
Role of
parenting
Parenting
interventions
with complex
problems
Challenges
ahead
Process issues
in delivery
parenting
programs
Parental influence is pervasive
Language,
communication
Influences
key risk and
protective
factors
Social skills and
peer
relationships
Emotion
regulation
Physical health
and well being
Sustained
attention and
problem solving
Coping with
adversity and
life transitions
School
achievement
Reduced social, emotional and health problems
Programs concurrently address
multiple problems
Child
Parent
Who benefits
Risk of child
Depression
Parental
Depression
Disruptive
behavior
Maltreatment;
Parental
anger
Substance
abuse
Couple
conflict
Delinquent
behaviors
Poor work
functioning
Better health
Better health
Parental access has increased
• Thousands of practitioners have been trained
in evidence-based interventions (e.g. UK, The
Netherlands, Belgium, Australia, NZ, Canada,
US)
• Millions of children and parents worldwide
now reap the benefit when programs
implemented properly
• At the same time there has been a
proliferation of NEBP’s
• Little work in LMIC’s
Information explosion on the webGoogle search “Parenting” yields 209,000,000 hits
Media sites
Commercial
sites
Government
sponsored
sites
Social
Networking
sites
Research
project sites
Apps for
smartphones
Practitioner
sites
It’s so confusing to parents
Parents want
programs that work
Focus of parenting support
Not a “one size fits all” approach
Universal Triple P
Level One
Selected Triple P
Level Two
Primary Care Triple P
Level three
Standard Triple P
Level four
More complex
problems
Enhanced Triple P
Level five
Principles of Positive Parenting
Safe,
engaging
environment
Taking care
of yourself
as a parent
Reasonable
expectations
Positive
learning
environment
Assertive
discipline
17 Core Parenting Skills
Promoting
positive
relationships
Brief quality
time
Talking to
children
Affection
Encouraging
desirable
behaviour
Praise,
positive
attention
engaging
activities
Teaching
new skills
and
behaviours
Modelling,
Incidental
teaching
Ask-say-do
Behaviour
charts
Managing
misbehaviour
Ground rules
Directed
discussion
Planned
ignoring
Clear, calm
instructions
Logical
consequences
Quiet time
Time-out
Parental
Self regulation
Selfmanagement
Self-efficacy
Minimally
Sufficient
Intervention
Personal
agency
Selfsufficiency
Reduced need for support
Use Self Regulation Framework
How does Triple P stack up?
300
First population
level data
published
240 Total papers
Triple P
International
begins
200
175 Evaluation
studies
150
100
Program
development
begins
Program is
given a name
65 Conceptual
papers
50
0
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2010
2011
No. of published papers
250
271 authors
Year
The development context
22 million
308 million
Many different authors have
contributed
N = 271
…in different evaluation sites
Number of research institutions=59
Number of independent evaluations=61
•
•
•
•
•
•
Australia (University of Queensland,
Curtin University, University of Sydney)
New Zealand (University of Auckland,
Waikato University, University of
Canterbury, Victoria University of
Wellington)
Germany (Technical University of
Braunschweig, University of Bielefeld)
Scotland (Glasgow Caledonian
University, University of Glasgow)
England (University of Manchester,
Oxford University, Cambridge
University, University of East Anglia)
US (University of South Carolina,
Oregon Research Institute, California
State University, University of North
Carolina)
•
•
•
•
•
•
Belgium (University of Antwerp,
University of Brussels)
The Netherlands (Trimbos
Institute, NjI)
Switzerland (University of
Fribourg)
Canada (University of Manitoba,
University of Ottawa, UBC,
University of Calgary)
Middle East (Medical University
of Tehran)
Asia (Hong Kong Polytechnic
University, University of Tokyo)
Plus 13 others
Growth of Triple P Training
(1996-2011)
4500
Number of training Courses
70000
Number of practitioners trained
4000
60000
3500
50000
3000
2500
2000
40000
PFSC
starts
30000
1500
Triple P
International
starts
20000
1000
10000
500
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
Slide no.18
1996
0
0
Role of
parenting
Parenting
interventions
with complex
problems
Challenges
ahead
Types of child problems tackled
to date
Child
maltreatment
Conduct
problem/
ADHD
Recurrent
pain
syndromes
Type of
child
problem
Anxiety
Disorders/
Trauma
Obesity
Feeding
disorders
Developmental
disability
Applications to meet the needs of
vulnerable parents
Separated
and divorced
couples
Indigenous
Parents
Parents who
are offenders
Foster
Parents
Couple in
conflict
Core
Triple P
Program
Parents with
history of
domestic
violence
Parents at
risk of abuse
Parents of
children with
special needs
Clinically
depressed
parents
Ultimate Outcome Question:
Adapted from Paul (1966). Behavior Therapy: Appraisal and Status. McGraw-Hill, NY
• What type of intervention
works?
• For whom? When? and
• Under what circumstances?
• How does it come about?
Strongest evidence relates to early
years but parenting continues
across the lifespan
Weak
evidence
Transition to
parenthood
Strongest evidence
3-10 years
Parenting of
toddlers and
preschoolers
Parenting of
primary
school aged
children
Weaker evidence
11-18
Sandwich/club
sandwich generation
Parenting of
young
teenagers
Parenting of
older
teenagers
Parenting of
young adults
no children
Grand
Parenting/
Great
Grand
parenting
Greatest return on
investment 0-3 years
Areas of relative neglect
Characterizing the type
of intervention
What works?
Triple P is NOT a single
program
What level of
intensity?
•Universal
•Selected
•Primary care
•Standard
•Enhanced
•Full system
What mode of
delivery?
•Individual
•Group
•Over the Phone
•Media based
•Web based
•Self directed
What variant?
•Core program
•Teen
•Stepping Stones
•Lifestyle
•Resilience
•Workplace
•Fear-less
Characterizing the children and
families we serve
For whom?
What child?
•Prematurity
•Low birth weight
•Developmental
disability
•Internalising
•Externalising
•Type and severity
of behavior problem
What parent?
•Depressed
•Highly stressed
•Unhappy couples
•Abusive
•Substance abusing
•Minority parents
•Indigenous
•Grandparents
•Foster/adoptive
What family?
• Unhappy couples
• Separated/divorced
• Incarcerated
• Step/blended family
• Single parent
•Teen parent
• Extended family
Characterizing Providers and
System of Care
What delivery
system?
What
provider?
•No single discipline
delivers Triple P
•Government/NGO/
private providers
•Web/Self directed
What setting?
•Home
•Clinic (inpatient,
outpatient, hospital)
•School/Preschool
•Child care
•At work
•Over the phone
•Web-based
What funding
context?
•Recurrent funding
•Policy setting
•Mainstreamed
•Prevention or
Treatment service
•Workplace support
Evaluation strategy
Phase 1
Building
foundations
Testing levels of
Triple P in isolation
Phase 2
Testing multiple
levels as a
system
Phase 3
Improving reach to
high need and
hard to engage
families
Mean effect sizes on Child Behavior
Outcomes (ECBI Intensity Scores)
Based on 29 published RCTs; excludes N=1 studies, quasi experimental, pre-post service
based evaluations, or RCT’s under review
1.2
Cohen’s d= .64
1
0.8
0.6
0.4
N=6
N=3
N=1
0.2
N=15
0
Level 2
Level 3
Level 4
Level 5
Sanders, Kirby, Tellegen, & Day (2011). A Meta-Analysis exploring level by level
effects for the Triple P-Positive Parenting Program
Mean Effects sizes of Parenting
Outcomes
(PS)
1.2
Cohen’s d= .69
1
0.8
0.6
0.4
0.2
0
Level 2
Level 3
Level 4
Level 5
Sanders, Kirby, Tellegen, & Day (2011). A Meta-Analysis exploring level by level
effects for the Triple P-Positive Parenting Program: Preliminary Findings.
Some important milestones
Themes guiding our work
Increased consumer or
end user focus
Strengthening
the public
health
approach
Concurrent
targeting of
breadth and
intensity
Adapting and tailoring to
needs of high risk families
Building a stronger
workforce
Increased enduser or consumer
focus
Under what circumstances?
Discrimination
Refugee status
Parental mental
health
Enablers & barriers
Acculturation
Parental concern
about child behavior
Perceived vulnerability
Severity of child problem
Level of parental distress
Family friendly
policies
Poverty
Employment
status
Type of
Neighborhood
Motivation
Program itself
Perceived need
Anticipated
benefits/costs
Available incentives
Competing demands
Type of message
Provider ethnicity/skills
Cost/Accessibility
Program format
Cultural Acceptability
Social
infrastructure
Outcomes
Cognitions or
Affect
Social influence
In home support
Extended family
support,
Community and
neighborhood support
Expectation of benefit
Parental self-efficacy
Access to role models
Parental attributions
Gender/age of parent
Prior help
seeking
Level of
violence
Family of origin
experiences
Immigration
status
Culturally normative
parenting practices
Available parenting
services
Connectedness to
community
Education /literacy
Laws
Ensure our programs are
culturally acceptable
Minority, refugee, or
indigenous parents are
less likely to participate
Adopting an end-user perspective
helps to…
Tailor content to needs and aspirations
of target group
Optimize program delivery
Improve engagement
Enablers & barriers
Parental concern
about child’s behavior
Perceived vulnerability
Severity of child problem
Level of parental distress or
anxiety
Program variables
Motivational
variables
Perceived need
Anticipated benefits/costs
Incentives
Competing demands
Engagement
Message
Providers-ethnicity,
experience, skills
Cost/ accessibility
Program format
Acceptability of
parenting advice
Cognitive/
Affective variables
Social influence
Variables
Expectancies of benefit
Parental self efficacy
Access to models
In home support
Extended family support,
Community and
neighborhood support
Parental attributions
10
9
8
7
6
5
4
3
2
1
0
Time Out
Quiet Time
Logical…
Giving Instructions
Planned Ignoring
Directed Discussion
Ground Rules
Behaviour Charts
Ask, Say, Do
Incidental Teaching
Set a Good…
Engaging Activities
Attention
Praise
Show Affection
Talking with child
Quality Time
Usefulness
Minority parents and professionals
views on cultural appropriateness
Practitioner
Parent
Tailoring to needs of parents
Grandparents
Foster parents
Using
epidemiology
and
qualitative
methods to
tailor program
to needs
Working
parents
Parents of
children with CP
Parents of
multiples
Parents of
children with
ASD
Tailoring
content
or
process
(as needed)
Testing
efficacy
of
adapted
version
Consumer input  Research
Program modification
Grandparent Triple P (Kirby & Sanders, in prep)
Consumer Input through
focus groups
Research
Arguments over parenting
“There are arguments around
discipline, about how we as
grandparents treat the grandkids I
suppose versus how the parents do
it.”
Concerns over grandparent role
taking
“I just get the feeling that sometimes
my son is starting to take me a little
bit more for granted. And that
becomes overwhelming and
frustrating.”
Parents dislike unsolicited
parenting advice from own
parents (Thomas, 1990)
Grandparents report finding
the role exhausting and
demanding (Fitzpatrick &
Reeve, 2003)
Program Modification
Inclusion of module centered
on effective communication
skills and problem solving
Session 4: How to build a
positive parenting team (e.g.,
dealing with emotional
distress, page 88)
Inclusion of strategies to
manage emotional distress
Session 5: Grandparent
survival skills (e.g., Exercise 6
ways to look after yourself,
page 108)
Tailoring Process
Knowledge
gained from
consumers
Research
evidence
Tailored
variant
ready for
empirical
testing
Using more intensive
individual and group
programs with vulnerable
families
Why focus on parental attributions
• An attribution is a causal explanation individuals
use to explain events that occur to them.
• Parents at risk of child maltreatment are more
likely to blame their child for the child’s
misbehaviour.
• Parents’ misattributions for children’s behaviour
can lead to poor parent-child attachment and an
increased risk of child maltreatment.
What is Pathways Triple P?
• A Level 5 intervention
• additional modules, 2 sessions in each module
–
–
Module 1: Attribution retraining (2 hours) Avoiding parent traps
Module 2: Anger management (2 hours) - Coping
with anger
plus
–
Module 3: Maintenance and closure (2 hours)
Pathways Triple P
Delivery Options
Intake interview
1 individual session
Group Triple P
4 group sessions
Standard Triple P
6 individual sessions
Pathways Triple P
Module 1 and 2
4 group sessions
Pathways Triple P
Module 1 and 2
4 individual sessions
Closure session
1 group session
Closure session
1 individual session
Main findings
Sanders, Pidgeon et al (2004)
Both conditions showed significant improvements
over time on all key outcome measures
•
Observed disruptive behavior (FOS)
•
Disruptive child behaviour (ECBI scores)
•
Parental anger (PAI and STAXI)
•
Dysfunctional discipline (Parenting Scale)
Pathways Triple P showed additive
benefits on the following measures
• Lower dysfunctional parent expectations (POQ)
• Lower child abuse potential (CAPI abuse scale)
• Less dysfunctional attributions for own
behaviour
• Less dysfunctional attributions for child’s
behaviour
Positive
Parenting after
separation
or divorce
Relationship breakdown
• Relationship breakdown is a major life
stressor for parents, children, and their
extended families
• Although declining 40% of all marriages
end in divorce1
• Half of all divorces involve parents
• Divorce impacts on 44, 000 Australian
children each year.
Source: Australian Bureau of Statistics (2007). Divorces Australia. Canberra, Australia.
Program Content
•
•
•
•
•
12 week program
Divorce – a Family
Transition
Coping with Emotions
Managing Conflict
Balancing work, family,
and play
Positive Parenting
Outcomes
↓ Fewer behavioural and
emotional problems
↓Dysfunctional parenting
practices
↓Parental Expressed and
Trait Anger
Parents of children
who are bullied
Bullying
Anxiety
Loss of
friendships
Behaviour
problems
Suicide
School
bullying has
severe
consequences
Health
problems
Lower
self-esteem
Depression
School
absenteeism
Increased long-term risk
of severe mental health problems,
school dropout, involvement in
criminal justice system
What is Facilitative Parenting?
Talks to
child about
issues
Facilitative
Parenting
Enjoys
child’s
company
Facilitates
peer
interaction
Communicates
well with child’s
teacher
Helps child
resolve
conflicts
Not aggressive
to others in
defense of
child
Avoids over
protectiveness
Encourages
appropriate
independence
Resilience Triple P
Facilitative parent
training
LESS Peer
Victimisation
Social and emotional
skills for children
Australian Research Council
funded RCT under way
Role of
parenting
Parenting
interventions
with complex
problems
Challenges
ahead
Need responsive program delivery
Flexibility
vs fidelity
Content
variations
Low risk
Process
variations
High
risk
Low
risk
High
Risk
Mazzucchelli, T. & Sanders, M.R. (2010). Facilitating Practitioner Flexibility Within an Empirically Supported Intervention: Lessons From a System of
Parenting Support. Clinical Psychology Research and Practice, 17, 238-252.
Process Variations
Low Risk
More sessions
High Risk
Advice to use or not to use
specific strategies
Session length
Session location
No agenda or session
structuring
School contact
No review of homework
Switch to briefer version
Repeated abandoning of
agenda
Individual prep before group
Always proving answers
More emphasis on practice
and DVD
Giving feedback without
Content Variations
Low Risk
Modify examples to make more
relevant to target group
High Risk
Withholding information about
certain strategies
Modify steps from a tipsheet in a Suggest parent stray from
parenting plan
principles underlying the
recommended parenting
Changing focus of session to
strategy
partner support
Combining a selection of Triple
P strategies with programs
Triple P keeps evolving
Work in progress
More Intensive
Less intensive
Population level
Other
Taking Care Triple P
for foster carers
Lifestyle Triple P
Seminar seriesPositive Parenting for
Healthy Living
(Obesity prevention)
Stepping Stones as a
public health
intervention for
children with a
disability
PASS model of
supervision trial
Group Triple P for
children with
language delay
Workplace Triple P
(EAP)
Emotion-focused
Group Triple P for
children with disruptive Brief 4 session online
behaviour problems
Primary Care
intervention
Triple P for teachers
Seminar series
and child care
(Prevention of CD)
providers
Pathways Group Triple
P for offenders
International Triple P
Research Network
• Complex problems don’t always require
complex solutions
• Parenting programs can be effectively applied to
a wide range of clinical problems in children and
young people
• Parenting programs are also useful with a
diverse range of adults including those with
serious mental health problems
• Benefits are typically intergenerational
A final word
Significant investment in
parenting programs
makes good sense.
Parenting programs can
be tailored to a wide
range of disorders and
problem behaviors
Thank you for your attention
For further information on Triple P
Research: www.pfsc.uq.edu.au
Training and materials: www.triplep.net