babies_shutterstock_144900970

With the evidence still uncertain, where to next for interventions for new parents?

The first three years of life have long been recognised as fundamental to a child’s future development, and the role of parents in those early years is widely acknowledged as being critical.

For the new parent, there is an abundance of information on parenting babies both in the popular media and from health and social service agencies.

Yet how much of this is evidence-based and how much do we really know about what interventions work for parents of under threes?  Although there are still many gaps in our knowledge about parenting interventions for older children, these are minor compared to those for parents of babies.

Triple P is a widely known evidenced-based parenting intervention, and while there is support for its effectiveness in the toddler and pre-schooler years (for example, Morawska & Sanders, 2006) and into the primary school years, there is still limited evidence for interventions that target parents of babies.

This is not unique to Triple P. Most parenting programs target older children, and the majority of evidence-based, widely disseminated programs such as Triple P and Incredible Years is for older children.

Addressing the gap

To address this significant gap in supporting parents in the early years of parenting we developed Baby Triple P. Baby Triple P was designed as a comprehensive, preventative, group-based approach to support parents at the transition to parenthood, and targets known risks factors common across the transition (i.e., early parenting confidence and behaviour, parental coping, and supporting the couple relationship).

Our efforts to evaluate the efficacy of Baby Triple P are ongoing but to date findings have been mixed and largely not supportive of the efficacy of the program.

Interestingly, a recently published pre-post trial of Incredible Years Parents and Babies found limited evidence of effectiveness (Jones, Erjavec, Viktor, & Hutchings, 2016). Incredible Years, like Triple P, is based on social learning principles and has a strong evidence base, so it is intriguing that this version of the program has also shown few positive outcomes.

Four randomised controlled trials to date for Baby Triple P (Mihelic, Morawska, & Filus, 2016b; Seah & Morawska, 2016; Spry, 2013; Tsivos, Calam, Sanders, & Wittkowski, 2015) have shown two things: parents really like the intervention and yet report no or very limited change in any of the outcomes assessed. Each of these trials had significant limitations. For example, the sample in Spry (2013) was older, more educated, better off financially and better adjusted than the general population, thus causing ceiling effects on all outcome measures at baseline.

Several large-scale studies are currently ongoing in Australia and Scotland with more high-risk and vulnerable families. These studies will provide more definitive evidence pertaining to longer term effects of Baby Triple P.

Parents clearly like Baby Triple P

What we do know currently, however, is that parents clearly like Baby Triple P and find it highly acceptable, including families with premature babies (Ferrari, Whittingham, Boyd, Sanders, & Colditz, 2011), mothers in a psychiatric unit (Butler, Hare, Walker, Wieck, & Wittkowski, 2014), and mothers suffering from postnatal depression (Tsivos, Calam, Sanders, & Wittkowski, 2015).

Many parents and practitioners continue to ask for the program, often noting that there simply are no available parenting programs for them. One randomised trial even had to be discontinued because parents so desperately wanted the information in the program (Popp & Schneider, 2015).

Parents of babies clearly want evidence-based parenting programs. Practitioners tell us that few options are available and are very keen to know when Baby Triple P will become available.

verticle babyHowever, the research evidence for all parenting interventions targeting new parents suggests that all existing approaches to date have had limited effects.

Systematic reviews of specifically targeted interventions have found limited evidence of positive effects for outcomes such as infant sleep for babies under 6 months of age (Douglas & Hill, 2013).

Our own recent meta-analysis of interventions targeting early infant and parenting behaviours (Mihelic, Morawska, & Filus, 2016a), found only five studies that examined parenting competence and confidence. This means that while parenting skill and their confidence in their own ability as parents are recognised as important (Mihelic, Filus, & Morawska, 2016), few interventions actually aim to help parents enhance these.

A meta-analysis of more than 140 early parenting interventions, starting during pregnancy or the first six-months postpartum, found very small to small intervention effects and only for some outcomes (Pinquart & Teubert, 2010). The authors found that shorter, more targeted interventions, and older studies tended to show stronger effects.

The fact that older studies tend to show larger effect sizes might suggest that parents these days have access to much more information at their fingertips, making it more difficult for modern-day studies to show effects. However, we are still a long way from knowing whether or not this is the case. What we do know that despite this abundance of information, parents still clearly want an intervention such as Baby Triple P.

So where to now for Baby Triple P, a program that has been much anticipated by many people familiar with the Triple P system of programs?

We think the theoretical approach we have taken is sound, and the specific strategies incorporated into Baby Triple P are appropriate, but we have begun rethinking how we design the intervention and how we target delivery to parents with specific needs.

Perhaps we have tried to target too many varied factors within the existing intervention, making the job of detecting the effects on a specific outcome, such as baby crying, too difficult? Our next efforts will involve more targeted interventions, focusing on parents with identified needs.

At the same time, we will continue to work with parents and examine the theoretical literature to determine how best to tailor the program.

Parenting in infancy matters and we need to make sure we design and test effective programs for parents. And although it can be tempting to disseminate a program that parents and practitioners are asking for, Baby Triple P has not yet been disseminated.

We will continue to develop and test interventions for parents of babies in an effort to support those fundamental early days and months of development.

 

Other references:

 

Mihelic, M., Morawska, A., & Filus, A. (2016a). Effects of early parenting interventions on parents and infants: A meta-analytic review. Under review.

Mihelic, M., Morawska, A., & Filus, A. (2016b, 22-25 June). How effective is Baby Triple P for parenting confidence and the mother-infant relationship? . Paper presented at the 8th World Congress of Behavioural and Cognitive Therapies, Melbourne, Australia.

Seah, C. K. F., & Morawska, A. (2016). Does Baby Triple P increase responsive parenting, efficacy and reduce parental stress? A randomized controlled trial of an early parenting intervention. Under review.

 

whitehouse_web

Triple P goes to the White House

Representatives from Triple P America, the organisation licensed to disseminate Triple P in the United States, will attend the event at the invitation of the White House Office of Social Innovation and My Brother’s Keeper (MBK).

UQ Vice-Chancellor and President Professor Peter Høj said Triple P’s invitation to the White House showed a welcome belief that the pursuit of quality research could help overcome persistent global problems, such as a lack of opportunity for young men and boys of colour.

“The continued development and evaluation of Triple P internationally is an outstanding example of how research conducted in direct response to social need can inform the development of programs designed to improve the lives of individuals and  families while also providing community-wide benefits,’’ Professor Høj said.

Triple P founder and UQ Parenting and Family Support Centre director Professor Matt Sanders said the invitation to present at the White House was a strong endorsement for the program.

“The My Brother’s Keeper What Works presentation at the White House aims to give communities and the philanthropic and corporate sectors guidance on the type of quality, evidence-based programs they can be considering as part of this wonderful initiative,’’ Professor Sanders said.

“Internationally, and particularly in the US, we have seen that Triple P used in partnership with other evidence-based programs means great things can happen to provide opportunities for children and youth.’’

My Brother’s Keeper was established two years ago by US President Barack Obama to ensure all young people in the US reached their full potential.

Nearly 250 communities spanning all 50 US states have accessed $1.6 billion in private sector and philanthropic grants and low-interest financing as part of the initiative.

Triple P America Chief Executive Officer Bradley Thomas said Triple P had been invited to participate because its programs had been identified as being able to support the first of six My Brother’s Keeper milestone areas which encourage positive outcomes across the lifespan.

This milestone was ‘Getting a healthy start and entering school ready to learn’.

“Triple P America’s invitation to the White House is an indication of the strong evidence base of the Triple P system, as well as the outstanding results being obtained by sites rolling out the program in the United States,’’ Mr Thomas said.

The event can be viewed at https://www.whitehouse.gov/live

Home-visiting program plus Triple P shows significant improvements for children’s early cognitive development

Cute Toddler Child - 3

One of the most extensively conducted randomised controlled trials of an early childhood intervention program in Europe has shown that a home visiting program combined with the Triple P – Positive Parenting Program improved children’s cognitive development.

Results of a University College Dublin evaluation of the Preparing for life program include a finding that children in the high treatment group whose families participated in the full intervention had a 10-point IQ gap over children in the low treatment group.

Previous evidence of positive impacts of home visiting programs on children’s cognitive development before starting school has been limited.

As the study’s evaluation report states:

Only a small number of studies have found favourable intervention effects during the early years . .  However, the results are mixed and there is much variation in the effect sizes found by different programmes (Filene et al., 2013).

Preparing for Life (PFL) is a community-led initiative operated by the Northside Partnership in North Dublin and was evaluated over a seven-year period by the UCD Geary Institute under the direction of Dr Orla Doyle, an economist who has been awarded the Barrington Medal for her work in the economic and social sciences.

More than 200 families in designated disadvantaged areas of Dublin were involved in the trial, with the program aiming to help parents develop skills to help their children in five domains of school readiness:

  • cognitive development
  • physical health and motor skills
  • social, emotional & behavioural development
  • approaches to learning
  • language development and literacy

Parenting and Family Support Centre director and Professor of Clinical Psychology, Professor Matt Sanders, said PFL home-visiting mentors were trained to offer parents information about parenting and child development over a period of five years. They were also trained to deliver Triple P.

“Consequently, the principles and techniques of Triple P influenced the way in which mentors encouraged parents to interact with their children,” Professor Sanders said.

Access to a baby massage program was also available as well as access to additional Triple P programmes, such as Group Triple P.

The home visits started with mothers during pregnancy at 21 weeks and continued until the child started school at age four or five.

As part of the trial, a high treatment group received the full intervention, compared to a low-treatment group which did not receive the mentoring program, additional Triple P access or the baby massage program.

According to the final evaluation report, by school entry, the PFL program had a significant and large impact on children’s cognitive development. Children who received the high treatment supports had better general cognitive functioning, spatial abilities, non-verbal reasoning skills, and basic numeracy skills. This means that they were better at understanding information, seeing patterns, solving problems, and working with numbers.

 

overall-cognitive-development

Major impacts when the children were at school entry age included:

  • children in the high treatment group had a 10 point IQ gap over children in the low treatment group
  • 25 per cent of high treatment children had above-average verbal ability, compared to eight  per cent of low treatment children
  • High treatment children were better able to control their attention
  • 25 per cent of high treatment children were not on track in their social competence compared to 43 per cent of low treatment children
  • High treatment children had better gross and fine motor skills

More specifically, the program was shown to have a significant and large impact on:

  • Children’s overall verbal ability
  • Expressive and receptive language skills
  • Communication and emerging literacy skills

verbal-ability

PFL had some impact on how children approached learning. Children who received the high treatment supports were better able to manage their attention.

PFL had a significant impact on:

  • Reducing children’s hyperactivity
  • Reducing inattentive behaviours
  • Improving social competencies and autonomy

 

approached-learning

The program had a significant impact on reducing the amount of hospital services the children used and improved how families used these services. And children in the high treatment group were less likely to:

  • Visit the hospital for urgent reasons
  • Experience fractures
  • Visit the orthopaedics, physiotherapy, paediatrics, ocular and plastic surgery outpatient departments

 

hospital-services

 

PFL also had a significant impact on

  • Children’s gross motor skills
  • Children’s fine motor skills
  • Physical independence

(Graphics used in this blog post have been sourced with permission from the final evaluation of Preparing for life by University of College Dublin’s Geary Institute.)