A Public Health Perspective inthe Delivery of Evidence-Based

Parenting Intervention

Parenting Intervention:Benefits and Challenges

Matthew R Sanders, Ph.D

Parenting and Family Support Centre

The University of Queensland

Australia

December, 2009

At a glance

• Why parenting support and education is vital to child well-being

• Why a public health approach is necessary• Re-AIM formula applied to parenting

intervention• How prevention and less intensive programs

can make a difference• Cost-benefits to this approach

The need to make effective parenting programs widely

available is now firmly established

Support for a public health approach gaining momentum

“…. a substantial body of well designed, controlled-trial research shows that a small number of parenting programs can produce significant and durable positive changes by increasing positive family relationships, reducing child behavior problems and reducing future rates of child maltreatment”….

“Scientific support is sufficient to warrant the implementation of these evidence based parenting practices in demonstration projects at community health centers “

Source: APA (2009). Effective strategies to support positive parenting in community health centers: Report of the Working Group of Child Maltreatment Prevention. Washington, DC: Author.

Policy level advocacy for evidence based parenting programs

Groups Examples of policy statements• Institute of Medicine revised report on

Preventing Mental, Emotional and behavioural disorders among young people (IOM, 2009)

• Council of Europe Positive Parenting in Contemporary Europe (2007)-declaration calling on 46 member states to implement positive parenting programs

• UN’s report on Family skills training programmes and drug abuse prevention (2009)

• UK Government establishes National Academy for Parenting Practititoners (2007)

Far too many children continue to develop preventable social,

emotional, behavioral and health problems

Behavioral and emotional problems are common

Percentage of children with emotional or behavioral problems in the clinical range

20% clinical

80% nonclinicalSource: World Health Organization (2003). Caring for children and adolescents with mental disorders. Geneva: World Health Organization, 2003)

These problems are very costly

• The annual cost in the US in 2007 was estimated to be $247 billion

Source: IOM (2009) Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities

The quality of parenting children

receive really matters and affects every

aspect of their development

Significant improvements in the health and well being of children at a population level cannot be achieved without strengthening

the skills, knowledge and confidence of parents in the task of raising their children

How can we achieve a population level effect

Glasgow et al (2001)

Create leverage using the RE-AIM formula

Slide courtesy Dr Dennis Embry, Paxis Institute (2006)

Reach X Efficacy X Adoption X Implementation X Maintenance=Population level impact

Slide courtesy Dr Dennis Embry, Paxis Institute (2006)

Achieving population level Impact

Reach

What has been done to improve

population reach?

Develop interventions that

have a better “ecological fit” to the concerns of

parents

Listen to professionals and parents

Triple Pvariants

Pathways

Children with asthma*

Stepping Stones

Resilience*

Gifted & TalentedBaby*

Lifestyle

Workplace

Media series

Indigenous

* Under development

Test different delivery formats

Delivery formats

Individual

Web *

Self directed

TVseries

Over the phone

Small Group

Large group

* Under development

Delivery contexts

Hospital inpatient

Religious organizations

Child care

Workplace

Preschools/Schools

Mental health services

GP practices

Home

visiting

Community

centres

Use many service delivery settings and

providers

Efficacy

What can be done to improve

efficacy?

We have come a long way

From small beginnings

The evidence92 studies

13Single case experiments

46Efficacy

trials

27Effectiveness

trials

2Population

trials

4Meta

analyses

Building an evidence base takes time

as at November, 2009

25 further trials in

progress

Triple P Intervention Studies

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

0

20

40

60

80

100

120

Cumulative No. of Triple P Intervention Studies

Cumulative No. Intervention Stud-ies

Year we gave Triple P a

Name

No

. O

f s

tud

ies

Year

Year Triple P International

began

Some important milestones

Become much more consumer

focused

Adopt a self regulation framework

Collaborate with parents in waysthat empower them

Ultimate goal is parental

independence and autonomy

Parent decides on goals,

strategies and values

Parent has plan, monitors ,

evaluates outcome and

revises accordingly

Provide parent with support

and advice to “minimally sufficient”

degree needed

Our goal has been to develop and test

interventions that have a better “ecological fit” to

the concerns and preferences of parents as

consumers

Test different delivery formats

Delivery formats

Individual

Web *

Self directed

TVseries

Over the phone

Intensive Small Group

“Light touch” large group

“Light touch” small group

“Light touch” interventions for common problems to

reach many parents

Triple P Media Interventions

Television programsFamilies

DMDM 1&2

8 sessionTriple P on

line

Weekly Triple P Radio

broadcastsand podcasts

10 episodeTriple P

Parenting Media series

Adopting a consumer perspective helps to…

Example: Using consumer input on program content and cultural acceptability

• 158 ethnically diverse parents of 3-6 year children viewed “Making Shopping Fun” episode

• Their engagement in the episode (interesting, entertaining and usefulness) and its watchability (would watch it on TV)– 92% found it somewhat, quite or very engaging– 70% said they would probably or definitely watch it on

TV• Parents of children with greater problem behavior

reported greater likelihood that they would watch it• SES and ethnicity did not predict outcomes

Source: Metzler, et al (in prep). Triple P Media Series.

How do parents want to receive information about effective parenting?

Source: Metzler et al (in prep)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Percent indicating "quite" or "very interested" in receiving parenting information in each of nine formats

clinical nonclinical

Programs with

strongest evidence

Develop “light touch” interventions for common problems to reach many

parents

Parent discussion groups Group Primary Care Triple P

• Preschoolers•Toddlers•Infants

•Elementary school age•Teenagers

Test different delivery formats

Delivery formats

Individual

Web *

Self directed

TVseries

Over the phone

Intensive Small Group

“Light touch” large group

“Light touch” small group

Primary Care Group Triple P Parent Discussion Groups

Hassle Free

Shopping

Fighting and

aggression

Disobedience Bedtime

Hassle Free Shopping with children 2 hour group session

Content• Activity 1: Shopping

hassles

• Activity 2: Parent traps

• Activity 3: How to prevent shopping problems

• Activity 3: How to manage shopping problems

• Activity 4: Getting started

Process• Trained Triple P facilitator• Use of DVD footage on

common shopping problems

• Group activity to identify common parent traps (causes/attributions)

• Watch and discuss “Making Shopping fun” DVD

• Discussion/planning

Effects on Child BehaviourJoachim, Sanders & Turner (2009).Hassle-free shopping with children- Evaluation of a brief Triple P parent discussion group . Journal of Child Psychiatry and Development.

d=.75

• Fewer shopping specific problems (d=1.6)

• Lower levels of dysfunctional parenting (d=.72)

• Increased task specific self efficacy (d=1.31)

• High consumer satisfaction (M = 34.3; SD = 5.80)

Primary Care Group Triple P Parent Discussion Groups

Hassle Free

Shopping

Fighting and

aggression

Disobedience Bedtime

Study 2: Effects on Child Behaviour

• Fewer conduct problems (d=1.14)

• Lower levels of dysfunctional parenting (d=.71)

• Increased task specific self efficacy (d=1.01)

• 6 month follow ups underway

Improve engagement

strategies

Who participates in Triple P when it is offered universally?

• Child had behavioural or emotional problem (47.8%)

• SDQ Conduct Score-borderline or clinical (2 times more likely to participate)

• Mothers (86.8%)• Highly stressed in previous 2 weeks (52.9)• Parent of a boy (59.5%)

Sanders, et al (2007). Every family: A public health approach to positive parenting. The University of Queensland

Engagement

• More disadvantaged parents less likely to know about, participate or complete parenting programs

• Participating parents benefit regardless of background (Leung et al., 2006; McTaggart & Sanders, 2007)

• Underrepresented groups– Fathers– Minority parents– Indigenous parents

Gender /age of parent

Education /literacy

Employment status

Poverty

Parental mental health

Connectedness

Discrimination

Neighborhood

Prior help

seeking

Family of origin

experience

Culturally

normative parenting practices

Immigration status

Family

friendly policies

Acculturation

Ecological Context

Enablers & barriers

Cognitive/Affective variables

Social influenceVariables

Program variables

Parental concern about child’s

behavior

Motivational variables Engagement

Enablers & barriers

Cognitive/Affective variablesExpectancies of benefit

Parental self efficacyAccess to models

Parental attributions

Social influenceVariables

In home supportExtended family support,

Community and neighborhood support

Program variablesMessage

Providers-ethnicity, experience, skillsCost/ AccessibilityProgram format

Acceptability of parenting advice

Parental concern about child’s behavior

Perceived vulnerabilitySeverity of child problem

Level of parental distress or anxiety

Motivational variables

Perceived needAnticipated benefits/costs

IncentivesCompeting demands

Engagement

Experimental manipulation

Motivational variables

• Expectancies of

benefit

• Parental self

efficacy

• Attributions

• Access to models

Engagement

No testimonial

Parent testimonial

Expert testimonial

Exp

erim

enta

l co

nd

itio

ns

vs

vs

Seek direct consumer input to ensure programs are culturally

acceptable

Connecting Communities ProjectBrisbane South Divisions of General Practice

Parenting and Family Support CentreThe University of Queensland

Funded byFACSIA, Commonwealth Government of

Australia

Acceptability of Triple P parenting strategies

Design interventions to

directly target high need, underserved

populations

Positive Parenting after separation

or divorce

Investigators:

Dr Helen Stallman

Prof Matt Sanders

Funded by Australian Research Council In collaboration with Relationships Australia (Qld)

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

Adoption

What can be done to increase

adoption?

17 Countries where Triple P has been disseminated

Australia

New Zealand

England

Scotland

Ireland

United States

Canada

Iran

Curacao

Germany

The Netherlands

Belgium

Switzerland

Sweden

Singapore

Japan

Hong Kong

Understanding the sociopolitical

context better

Public policy that supports good parenting remains essential to

improve the well being of children and young people

However policies concerning parenting and family support

rarely win elections

Seeking linkages to influence policy

• The Council of Australian Governments (COAG) Human Capital Agenda– Communiqué 10 Feb 2006 - Early Childhood Development

• The Council of Australian Governments (COAG) Indigenous Issues– Communiqué 13 April 2007

• Australian Government Attorney General’s Department –– Family Relationship Centres

• Australian Government Department of Family and Community Services and Indigenous Affairs – – Stronger Families and Communities– Raising children network (Australian parenting website)

• Indigenous Parenting and Family Wellbeing• Department of Veterans Affairs –

– Health and Wellbeing initiatives for the Veteran Community• National Mental Health Plan 2008-2011

A national roll out of Every Family?

• Costs of a national roll out of over 4 years – Equates to approximately $12.00 per child per

year, or $20.45 per family– Substantially less than the cost of a single GP visit

or to immunize a child

Although costs matters politically

% reduction in prevalence

Potential cost savings

48% $683,000,000

26% $370,000,000

20% $290,000,000

15% $210,000,000

2% $29,000,000

1% $14,000,000

Point at which Intervention pays for itself

Source: Mihalopoulos et al (2007). Is Triple P value for money? Australian and New Zealand Journal of Psychiatry

Winners are grinners however..

Politicians live in families themselves and are tuned into what their electorates say is important

and media scrutiny

Some criticism is inevitable

Dealing with it

professionally is NOT

Implementation

What can be done to increase

implementation?

Identify what promotes movement along this trajectory

Completes Initial training

Becomesaccredite

d

Starts to use

program

Continues to use

program

Being a high

impact parenting practitione

r

Strengthen organizational

support for good implementation

Challenges in upskilling a workforce in evidence based practice

Individual practitioner variables

• Workforce very diverse • Wide range of

experience and expertise

• Inadequate pre-service and in-service training in evidence based approaches

• Low self efficacy

Organizational variables• Non recurrent funding• Many poorly paid for the

type of work they do • Inadequately supervised• High occupational stress

and turnover• Organizational leadership• Delivery of parenting

programs not mainstream

Self regulation applies to all levels of the Triple P system

Program

developer

TrainerAgenc

yPractition

erParent/

s Child

Highlight the importance of

customizing delivery while maintaining program fidelity

Maintenance

What can be done to improve maintenance and

sustainability?

Allow the system to evolve through

responding to new evidence

Triple P as a work in progress

• Triple P parent discussion group • Grandparents and Group Triple P• Foster parents and Group Triple P• Parents of children with multiples• Triple P and parents of children with asthma• Baby Triple P (Prem Triple P)• Teen Triple P Seminar series• Primary Care Stepping Stones• Bipolar disorder and Triple P• Triple P and anxious children

Watch this space

Our major threats

Complacency and Not using the knowledge

we have

A final word

The widespread use of positive parenting will be to create a future generation of healthy, happy, resilient children with the life skills they need to contribute to the well being of our communities