Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009
Richard P. Barth
Are Multifaceted Campaigns That Include Parent Training Programs Effective?
For more than thirty years, public health policy has emphasized the importance of multifaceted campaigns using approaches that range from media efforts to group work to individual counseling to address complex health behavioral problems.51 Beti Thompson and her colleagues conclude, in their wide-ranging review of community interventions, that these campaigns continue to be a compelling approach to changing health behaviors and that the modest but important effects they show at the population level can have large effects on disease.52 Some interventions in the field of parent training—such as Family Connections and others described above—address co-occurring problems, and some new approaches also include multifaceted campaigns.
The most widely disseminated and tested of these campaigns is the Triple P-Positive Parenting Program, a multi-level evidence-based intervention designed to strengthen parenting. Designed in Australia by Matthew Sanders and several colleagues, it has since been used in many countries including the United States.53 Triple P includes five levels of intervention, each building on the same language and concepts but featuring a different means of delivery and intensity of service. Universal Triple P, level 1, is an overall media campaign that informs parents about parenting issues and gets them involved in parenting programs like Triple P. Selected Triple P, level 2, targets one topic, such as toilet training or bedtime, about which parents may either receive direct or phone contact with a trainer or therapist or attend a seminar. Primary Care Triple P, level 3, is directed toward parents who are concerned about their children’s development or behavior. Parents attend four brief programs, each about eighty minutes in length, to learn how to manage their children’s behaviors. Some parents may have either phone or direct contact with a primary care practitioner if needed. Standard Triple P, level 4, is for parents of children with more severe behavioral problems, like conduct disorder or aggression, who want to learn effective parenting skills. These parents attend twelve sessions of about an hour each, with a choice of group or individual sessions. Parents also may have phone contact with a primary care practitioner. Finally Enhanced Triple P, level 5, is for parents who have children with behavioral problems and who have dysfunction within their family. These parents attend about eleven one-hour individual sessions that are specific to their needs. Practitioners may also conduct home visits to ensure that parents are using the skills they are being taught.54
The framework for Triple P, very much like that of other leading American parent training programs, is squarely based on social learning theory. Triple P is based on five principles that are imperative in teaching positive parenting: ensuring a safe and engaging environment, creating a positive learning environment, using assertive discipline, having realistic expectations, and taking care of oneself as a parent.55 The conceptual underpinning of Triple P is that the parent must be “self-regulatory,” meaning that she believes that she can improve the behavior of her child through her own actions and is confident in making decisions and problem solving to do so.56
Triple P is now undergoing a major trial in South Carolina with a slightly different configuration. Though the principles are the same, some of the levels differ slightly. Selected Triple P, for example, is delivered as a “one-time seminar” to a group. All levels include a specific session for teen children. Group Triple P is similar to level 2 but it targets more specific behavioral and emotional problems and is given to a smaller group. Level 4, Standard Triple P, also includes Group Triple P, a Group Teen Triple P, and Standard Stepping-Stones Triple P. The latter level is for parents who have a developmentally disabled child. Both Group Triple P and Group Teen Triple P are administered to groups of parents. Standard Triple P and Standard Stepping-Stones Triple P are administered individually to parents in a home or clinic setting. Finally, level 5 includes Enhanced Triple P, which is directed to families with several problems, and Pathways Triple P, which is for parents who are at risk for child abuse. Both level 5 programs are administered individually, at home or in a clinic.57
The results of this first major U.S. Triple P trial are quite promising. After training more than 600 primary care practitioners in Triple P, and implementing the universal media strategies in half of eighteen counties randomly assigned to Triple P in South Carolina, Ronald Prinz found that administering Triple P to families in a population of 100,000 children under the age of eight resulted in 340 fewer cases of maltreatment, 240 fewer children being removed from their homes, and 60 fewer injuries from maltreatment requiring medical attention.58 To estimate the potential for more widespread use of the Triple P System of Interventions, the U.S. trial queried 448 service providers who were trained for more than two and a half years in their use of Triple P methods.59 As a group, the service providers reported becoming more effective in delivering parenting consultation based on the Triple P approach. Months of setup work by Triple P staff were typically required to gain access to the service providers and to determine the most appropriate level of training for the providers. As a result of the training process, service providers in the U.S. Triple P trial demonstrated significant improvement in confidence and competence in delivering this evidence-based parenting awareness and training program. After completing training, most service providers reported a high degree of confidence and skill in delivering parent consultations.60