Calls for evidence-based parenting programs to be made available to all as part of medical services in US

pediatric settingsAccess to parenting programs in primary care settings should be removed from an “at-risk’’ funding framework in the United States and be made universally available in pediatric settings, an article in the American Medical Association journal, JAMA Pediatrics, recommends.

The article, Parenting as Primary Prevention, is the latest in a string of recommendations calling for evidence-based parenting interventions to be integrated into services provided by US medical services.

Last month The University of Queensland-developed Triple P – Positive Parenting Program was included in an American Academy of Pediatrics policy recommendation to reduce the toxic effects of poverty on children’s health.

In the JAMA Pediatrics article, authors Dr Ellen Perrin, Dr Laurel Leslie, and Dr Thomas Boat argue that programs such as Triple P – , Family Check-Up, Incredible Years and Parent-Child Interaction Therapy have traditionally been located in the US under a mental health funding framework but this needed to change.

Locating funding for parenting interventions under a mental health framework meant that a child’s behaviour needed to be identified as “pathological’’ or the parents’ parenting style or other family characteristics have to be identified as “at risk’’ before families can access services, they argue.

“Parents report hesitation in accepting such referrals because of the stigma attached to their children’s behaviour and their own effectiveness,’’ the authors write.

Founder of Triple P and director of The University of Queensland’s Parenting and Family Support Centre Professor Matt Sanders said the development of the Triple P system of programs, designed to support large numbers of families across the population with varying degrees of needs, had gone a long way to destigmatise the notion of parenting support.

However, in Australia funding for parenting programs in primary care settings require parents access a mental health care plan before they qualify for support.

Professor Sanders said because a wealth of evidence showed that all parents can benefit from evidence-based parenting support, that support should be available to all in the same way as early child health care is available to every child.

 

Why work might actually be good for you and your chronically ill child, and why you might want to cut yourself some slack

Parents juggling the guilt and pressure of work and family life might be pleased to know research shows keeping down a job is actually good for children.

Income from work can create better outcomes and well-being for children while other research suggests working parents are modelling a positive work ethic for their kids.

Unfortunately, such facts don’t appear to be helping the stress levels of most Australian parents.

In a recent Australian survey, nearly half (47%) of employed men with children under 15 said they felt as if they were always or often rushed or pressed for time. Unsurprisingly, more women (62%) felt the same way.

Despite the advantages that working parents provide for their children, balancing work, family and life in general clearly comes at a cost for parents.

Most of us know we should try to limit the overflow of home life into the workplace and vice-versa. But that’s a lot easier said than done.

Most of the time, parents are often just questioning themselves about whether they are doing the right thing at any given moment, such as missing a child’s doctor’s appointment, or answering that late-night work email.

We all try to make sacrifices and accommodations to keep both worlds afloat. Yet at some point, something on either side has to give, a spill-over called work-family conflict. And this conflict can do harm.

Undoing the gains

When we don’t manage work-family conflict, we risk undoing the gains we might have made by working in the first place by contributing to poorer health and wellbeing for ourselves and our children.

While most parents experience some level of work and family conflict, there are some families who experience much higher levels. Individuals who work longer hours and those who are carers often fall in this category.  What we don’t know is how do these experiences play out in parents who have even more demands and burdens placed upon them because their child is suffering from one or more of Australia’s common chronic illnesses.

The reality is that most chronic conditions require ongoing medical care and management.

And with extra expenses and costs, these parents – more than most – need to work to ensure the best possible outcomes for their children while juggling the needs of being a fulltime carer.

Research shows that chronically ill children whose parents work have statistically better outcomes because their parents can afford to get them to hospital for treatment, for example.

But what kinds of pressures does the work-family dynamic place on these families and do these additional pressures pose a health risk for these parents and their children?

Given the consequences family stress and conflict might be having on chronically ill children, along with the fact that childhood diagnoses of asthma, diabetes and eczema are on the rise, the need to understand parents’ experiences has become ever more pressing.

In order to understand the impact that work-family conflict might be having on families of chronically ill children, we are asking all parents of children aged between 5-12 years to complete a short questionnaire, regardless of whether they are caring for a chronically ill child or not.

We hope to determine whether parents of chronically ill children have higher levels of work and family conflict than parents of healthy children and to examine the impact of work and family conflict on the quality of life of both parents and children.  If you would like to contribute to this important research click here.

 

Translating research into practice. Five-year evaluation of Triple P in California shows why helping parents can improve the health and wellbeing of the community

Part of my role as founder of the Triple P – Positive Parenting Program involves delivering masterclasses to practitioners who have been trained to deliver the program.

For the past five years, I have been travelling to California. Last Friday, I was back in California again. Only this time, I was there to support the launch of First 5 Santa Cruz County’s five-year evaluation report into the impacts Triple P has made in the community.

Santa Cruz was one of the first counties in California to implement Triple P following publication of our population trial which demonstrated that the Triple P system could help stem rising rates of child maltreatment.

In collaboration with partner organisations, First 5 decided to invest in Triple P to help local children reach their full potential after child abuse rates rose in the county in the years leading up to 2008.

The aim of First 5 is to ensure that family-friendly services and education are available so that each child reaches their fifth year of life healthy, ready and able to learn, and emotionally well developed.

Supported in training and implementation by our commercial partner, Triple P America, First 5 Santa Cruz County decided to provide the full Triple P system of programs at low- or no-cost, in English and Spanish, to local families with children aged up to 16.

The program is delivered by a number of local organisations and individuals through a partnership between First 5 Santa Cruz County, the Santa Cruz County Health Services Agency (via the Mental Health Services Act) and the Santa Cruz County Human Services Department.

Each year, Santa Cruz have conducted an evaluation of their work to see what level of impact Triple P is having. The launch I attended on Friday was the culmination of five years of those evaluations. And the report produced is an outstanding illustration of how Triple P can work with other policies and programs to make an impact on population-level indicators of child maltreatment.

The Santa Cruz model shows how effective a population-health approach to the provision of parenting support can be and is a superb example of how to translate research into everyday practice.

Their service-based evaluation found that:

  • Triple P is an effective and universal public health parenting intervention, reaching a broad population of parents
  • Triple P’s simple, practical parenting strategies are changing families’ lives for the better
  • Triple P is responsive to the needs of diverse families
  • Brief, “light touch” Triple P services are effective
  • Triple P has staying power, long after services have ended

It was enormously gratifying to hear county officials describe Triple P and its effects.

“Triple P is an invaluable partner for the Human Services Department,” Cecilia Espinola, Director of the Santa Cruz County Human Services Department and a Commissioner for First 5 Santa Cruz County, said.  “We share a common goal to strengthen families and improve outcomes for children.”

David Brody, Executive Director of First 5 Santa Cruz County, said:

“We have no doubt that the widespread, local availability of Triple P has been a vital contributor in the effort to help more children grow up in safe, stable, and nurturing families. Five-year data shows that Triple P has helped turn the curve on children’s health and well-being at a population level.’’

Dr Salem Magarian, Pediatric Director for Santa Cruz Community Health Centers and a Commissioner for First 5 Santa Cruz County, described Triple P as an outstanding model for helping parents:

“It’s an evidence-based program that’s been around for many years. It’s not just an industry standard, it’s a life standard to provide this kind of support, and it’s for all families.”

Cultural responsiveness and a common language

The five-year report suggests that both English and Spanish-speaking families, as well as both men and women, found the Triple P strategies relevant and helpful, indicating the cultural responsiveness of the Triple P model and the common language of positive parenting.

Evaluation data also showed that Triple P’s parenting strategies became tools that gained traction and usefulness with parents as they continued to learn, practice and self-evaluate their progress.

On average:

  • The majority of parents who completed in-depth Triple P services reported improvements in their children’s behaviors (80%), overall parenting style (77%), and level of stress (63%)
  • 95% of survey respondents reported they continue to use the Triple P strategies they learned, long after services have ended
  • 98% of Triple P participants surveyed reported they would recommend Triple P to their family and friends

The report, Strengthening Families in Santa Cruz County, 5-Year Report 2010-2015, is available here.

Turkish researchers show Group Triple P can treat anxiety in children

Turkish researchers have become the first to show that The University of Queensland’s Triple P – Positive Parenting Program can successfully target and treat clinical levels of anxiety in children.

Triple P is one of the world’s most extensively researched parenting interventions and is estimated to have reached millions of families.

However, much of the previous research of the past three decades has focused on prevention and treatment of early onset mental health problems in children such as disruptive behaviour problems.

“Traditionally treatments for anxiety and depressive disorders have focused on the individual child and it’s only been in recent years that research has focused on what role parents can have,’’ program founder and director of UQ’s Parenting and Family Support Centre, Professor Matt Sanders, said.

Anxiety is one of the most common mental health problems in adulthood and the second most common mental health disorder experienced by children and adolescents in Australia after ADHD. An estimated 6.9 per cent children and adolescents are estimated to be affected, latest government surveys suggest.

In their paper published in the Journal of Child and Family Studies, the Turkish authors point out that studies of humans as well as primates have shown that anxious children – or offspring – are particularly sensitive to the impacts of parenting, citing a study by Suomi (1997).

Parents who use harsh punishment, shouting and anger were likely to produce fear reactions in children, the authors, led by Gonca Özyurt, of the Child and Adolescent Psychiatry Clinic, in Nevsehir State Hospital, write.

Other parental factors such as anxious modelling, an over-controlling parenting style, ineffective disciplinary methods and child vulnerability factors such as their temperament, the way they think, and their age can also contribute to the likelihood of a child developing anxiety problems.

The children who participated in the Turkish study were on a waiting list at the Child and Adolescent Department outpatient unit at the School of Medicine in Dokuz Eylul University and were evaluated to have an anxiety disorder by a child psychiatrist.

“We aimed to evaluate the effectiveness of Triple P on childhood anxiety disorders and to assess its effects on behavioural and emotional problems, general anxiety level, severity of the disorder and general psychosocial functioning,’’ the authors write.

They also looked at the effects of the program on anxiety and psychological well-being of the parents.

This was a randomised controlled trial with parents of the Triple P group participating in Group Triple P for eight weeks, with the two groups compared just before and four months after the intervention.

Turkish-speaking practitioners were trained in the delivery of the program by UQ Associate Professor Alan Ralph and the program was delivered with Turkish-translated resources.

The authors conclude that “children’s anxiety level and severity of the disorder significantly decreased and the child’s functionality significantly improved with applying Triple P to children’s parents’’.

Although limited because of the size of the study (50 parents), they concluded that Triple P may be an effective and useful method of treatment for children and adolescents who have anxiety symptoms or anxiety disorders.

Sometimes a light touch is all it takes: Triple P Seminars show benefits for Indonesian parents and their children

A randomised controlled trial involving Indonesian parents has shown a low-intensity parenting program can significantly improve children’s behavioural problems and parents’ confidence while reducing dysfunctional parenting practices and parents’ stress.

The delivery of the Triple P seminar series to 143 parents in Surabaya, Indonesia, is the first study to show that an evidence-based parenting program can be both effective and culturally acceptable for Indonesian parents.

It is also the first to show that a light-touch intervention can be effective in a developing country and one of only a few studies worldwide to have done so, regardless of the level of the intervention.

The Triple P – Positive Parenting Program takes a population health approach to parenting support with a multi-level system of programs available, from light-touch programs to more intensive, treatment-based approaches.

Professor Matt Sanders, director of the Parenting and Family Support Centre, said the finding was further support for a central tenet of this population approach, the principle of minimal sufficiency.

“We now have a significant body of work that shows that families, whether they are in Indonesia, China, Japan, or Australia, can derive real benefit from having parenting support that is adjusted and delivered in a dose that is appropriate to their needs,’’ Professor Sanders said.

“These were families with moderate problems yet the program still showed effects. It shows that reaching large numbers of parents with a low-intensity program that is both cost-effective and time-efficient is a practical as well as a particularly effective preventative health approach to take in low-resource settings.’’

A graduate of The University of Queensland’s Parenting and Family Support Centre, Dr Agnes Sumargi, currently a lecturer with Widya Mandala Catholic University in Surabaya, conducted significant research work in the lead up to publication of this study in the journal, Child Psychiatry and Human Development.

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Dr Agnes Sumargi.

An initial survey of 273 Indonesian parents living in Indonesia and Australia conducted in 2013 indicated that Indonesian parents often struggle with ineffective parenting practices such as making children apologise for misbehaviour, lecturing or shouting. And a large majority (78 per cent) said if help was available they would attend a parenting program.

In 2014, Dr Sumargi trialled the 90-minute Triple P seminar, The Power of Positive Parenting, with 30 Indonesian parents living in Australia. She delivered the seminar in Indonesian and results of the pilot showed the program was both culturally acceptable and likely to lead to less emotional and behavioural problems in children and less permissive parenting styles.

Then, in the randomised controlled trial published last year, Dr Sumargi invited Surabayan parents of a typically developing child between the ages of 2-12 years to attend the three 90-minute Triple P seminars: The Power of Positive Parenting, Raising Confident, Competent Children, and Raising Resilient Children, once a week. The seminars were delivered in Indonesian and most parents (88 per cent) attended all three seminars.

Dr Sumargi, and co-authors A/Prof Kate Sofronoff and A/Prof Alina Morawska, of the Parenting and Family Support Centre, point out this trial shows that a brief parenting program should now be tested with a wider audience in a community setting.

“Holding the seminar series in community sites, such as child care centres, schools, health care centres and religious sites may be especially beneficial as it can increase parents’ accessibility to and participation in the program.’’

They also suggest that not all parents require an intensive level of intervention, and this research demonstrates that providing a brief parenting program is effective for parents from diverse cultures.

 

 

 

 

Meta-analysis finds Triple P effective in preventing antisocial behaviour and delinquency

More evidence has come to hand that parenting programs are an effective evidence-based strategy to prevent antisocial behaviour and delinquency.

A meta-analysis update on the effects of early family/parent training programs on antisocial behaviour and delinquency (Piquero et al., 2016) is an excellent and timely study which shows the huge value that evidence-based parenting programs represent.

If you think about the costs of violent and anti-social behaviour to society, for very little outlay, parenting programs reward investors many times over.

The study, published in the Journal of Experimental Criminology, updates and replicates Alex Piquero’s previous work published in 2009 which found that early family/parent training “is an effective intervention for reducing behaviour problems among young children’’.

The authors conclude:

“In short, early family/parent training programs are an important evidence-based strategy that deserves continued application and expansion as part of a more general strategy for building a safer society.’’

In comparing different interventions, the review authors place Triple P’s effect size of 0.56 midway between Parenting-Child Interaction Therapy (0.98) and The Incredible Years (0.37).

This is an extremely encouraging finding given that PCIT adopts a treatment approach, focusing on more difficult cases with “more room to move’’.

PCIT and, to a lesser extent, The Incredible Years are targeted, treatment interventions for families with children with well-established conduct problems.

In contrast, the Triple P multilevel system of parenting support is based on a population-based public health model which seeks to shift prevalence rates across the community.

Triple P’s approach blends early intervention, light touch programs designed with prevention in mind with more enhanced, targeted treatment options.

The Triple P studies reviewed by Piquero et al. included a mix of different delivery modalities such as over-the-phone, self-directed, and television programs – representing a mixture of brief, low-intensity prevention interventions (Sanders, Montgomery & Brechman-Toussaint) – and more intensive enhanced interventions (Sanders, Markie-Dadds, Tully & Bor).

Prevention interventions usually have lower base rates of problems and therefore less room to “improve” whereas treatment interventions such as PCIT typically have higher base rates and much greater capacity to show change over time as well as larger effect sizes.

An intensive intervention with multiple sessions (12 or more) may produce larger effect sizes than briefer interventions (eight or less sessions) but a brief intervention may have greater impact because it’s less expensive to deliver with more families able to be seen with the same allocation of practitioner time.

Generally meta-analyses of parent training have not looked at these issues of cost and population reach that an intervention can achieve.

Both treatment and prevention approaches are important and both need to be incorporated in any effort to treat and prevent anti-social behaviour and delinquency.

However, issues such as practitioner availability and the amount of time that parents can dedicate to participation are important factors that agencies need to weigh up when considering how to implement a prevention health approach.

Social media a force for families

Social media and electronic gaming strategies can have an extremely positive influence on the lives of impoverished families, a study of The University of Queensland’s Triple P Online program has found.

A version of Triple P Online, the web-based version ofUQ’s Triple P – Positive Parenting Program, was ramped up with social media and gaming smarts and made available to disadvantaged families in Los Angeles.

Triple P founder Professor Matt Sanders said the enhanced version – called Triple P Online Community – was designed to encourage parents to participate in the program and share knowledge about what they had learnt.

He said the study included 155 disadvantaged high-risk parents in Los Angeles.

“Of these, 76 per cent had a family annual income of less than $US15,000, 41 per cent of parents had been incarcerated, 38 per cent were in drug and/or alcohol treatment and 24 per cent had a child removed due to maltreatment,” Professor Sanders said.

The study, led by Dr Susan Love of California State University Northridge, set out to test if gaming and social media could successfully engage this traditionally hard-to-reach population, and show benefits to both parents and children.

“The program’s 50 per cent retention rate of participants was extraordinary, given the stress the participating families would have been under just to manage daily life,” Professor Sanders said.

“More importantly, both parents and their children showed improvements likely to lead to better developmental outcomes for those children and potentially more stability and less stress in the lives of the parents.

“Participation in evidence-based parenting programs has also been shown to reduce risk factors for child maltreatment.

“A program able to engage highly vulnerable families and produce outcomes such as these shows just how important it is that researchers think creatively when it comes to finding solutions for families.”

Triple P Online Community was designed by Dr Love, former UQ-based project manager Marianne Maurange and Triple P authors at UQ’s Parenting and Family Support Centre, as well as researchers at the University of South Carolina and the Oregon Research Institute in the US.

Dr Love said one of the most rewarding aspects of the study was finding that parents in the Triple P Online Community actively encouraged each other.

“Parents in the study shared parenting tips and strategies, not just with each other, but with other family members, their friends, teachers and day care workers,’’ Dr Love said.

“They also were far more engaged than the typical social media audience, far exceeding the 90-9-1 social media rule – the idea that 90 per cent of people watch but don’t contribute to social media, nine per cent contribute occasionally and one per cent of users participate a lot.

“In our study, 50 per cent of our parents ‘lurked’ online, 32 per cent shared occasionally and 17 per cent shared frequently.’’

The study is online in the journal Child Abuse and Neglect.

To adapt or not to adapt: Paper finds Group Triple P has ‘social validity’ with African American fathers

shutterstock_219865159Practitioners should not hesitate to use Triple P with African American fathers, a paper co-authored by US researcher Patricia Kohl, of the George Warren Brown School of Social Work at Washington University in St Louis, concludes.

The study, published in Best Practice Mental Health, looks at the engagement of African American fathers in Group Triple P by comparing a group which was shown limited Triple P materials, including video resources, with a group who received the full intervention.

Conducted with the use of focus groups and interviews, the study found that providing fathers with only a small amount of information from program resources could actually be a barrier to potential participation – or at least perceptions of the value of the program.

Many of the fathers involved in the study spoke about initial concerns that program materials did not provide examples using African American fathers or urban settings similar to their own. However, fathers who participated in Group Triple P had a much more detailed perspective and could identify with many of the scenarios of daily life presented.

“For fathers who were exposed to the complete intervention, it appears to be a socially valid intervention,’’ Dr Kohl and co-author Kristen Seay, of the College of Social Work of the University of South Carolina, write. “However, when Triple P is used with this population, it is important to tailor examples to the circumstances of culturally diverse groups and to use language with which urban African American fathers relate.’’

The paper points out that since the early 1990s, the diversity of mothers involved in Triple P research has increased but this has not been the case for African American fathers who, until this study, remained almost completely absent from the Triple P evidence base.

The authors also describe how the highly segregated, disadvantaged urban communities in which African American fathers often must parent their children present very difficult circumstances such as high crime rates, drugs, gang violence, and few resources. But assumptions should not be made about a program’s social validity without actually asking the fathers, and those who work to support them, what they think.

“It is essential that practitioners or researchers considering the adaptation of an ESI (evidence supported intervention) to a new culturally diverse population do not make assumptions about how the target population views the intervention or about the fit between the population and the ESI,’’ the authors argue. “The voices of the target population, as well as those of other key stakeholders such as those providing services to the population, must be heard in this process (McKleroy et al, 2006).’’

Interviews with fathers from the two groups are highly contrasted in the paper. After watching a snippet of the Triple P DVD, several fathers across all five focus groups who did not participate in Triple P felt that they could not identify with several aspects of the intervention. One father said:

“When an urban neighborhood has a big crime rate, your kids don’t come home like that. Your mom ain’t cooking at home like that… . If you look at this program, you’d be like it’s not like that in this environment… . It’s a different environment.”

In contrast, fathers who received the complete intervention were far more positive. A number of examples were supplied in interviews of how they recognised themselves in the material and how they applied that information to their lives and saw a difference. One father said:

“I used to be more aggressive with them but now I am just calming down.”

After recognising his role in his child’s behavior for the first time, another said:

“After that session last week, I just went home and I just thought about everything that was going on, and I came to the conclusion that it wasn’t really so much as my kids that were giving me the problem—it was really myself that was causing all the problems.’’

The authors write: “That is a very powerful statement given that the parent is the change agent in BPT interventions. It is through changing the parent’s behavior that children’s behavior improves.’’

They conclude that more efforts are needed to understand the transportability of Triple P to African American fathers and to further explore the acceptability of Triple P by non-traditional service settings, such as father support agencies.