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Australian e-Journal for the Advancement of Mental Health (AeJAMH), Vol.

2, Issue 3, 2003 -1-


ISSN: 1446-7984

Triple P - Positive Parenting Program: A population approach to promoting


competent parenting

Matthew R. Sanders
Parenting and Family Support Centre, The University of Queensland, Brisbane, Australia

Abstract

Family conflict and poor parenting are generic risk factors associated with a wide variety of
adverse developmental outcomes in children including increased risk for conduct problems,
drug abuse, delinquency and academic underachievement. This paper makes the case for a
multi-level population based approach to the development of parental competence. Evidence
is reviewed showing that while parenting interventions based on social learning approaches
are effective, they have significant limitations in achieving a level of population reach that
will do enough to decrease the prevalence of dysfunctional parenting. A case is made for a
contextual approach targeting the media, primary care services, schools, and worksites as
basic institutions within the community which can potentially support the task of
disseminating more widely evidence-based approaches to parenting intervention. Evidence is
reviewed for the efficacy and effectiveness of the Triple P-Positive Parenting Program as a
comprehensive, multilevel system of parenting and family intervention. The evidence
reviewed shows significant effects across several trials on both child and parent mental
health outcomes. Challenges in disseminating empirically supported interventions and
possible future directions for family intervention research are discussed.

Keywords
Prevention, population, health, parent training, family intervention

Introduction Australia have mental health problems, with


similar results to earlier surveys. The
There is widespread concern amongst parents Queensland Health survey conducted in 1996 of
about the behavioural and emotional problems of 1218 parents revealed that 25% of parents
their children and youth. Australian prevalence reported that their child's behaviour was
surveys show between 14-18% of children and moderately to extremely difficult and 28%
adolescents show significant behavioural and perceived that their eldest child, less than 12
emotional problems (Sawyer, Arney, Baghurst et years, had an emotional or behavioural problem
al., 2000; Zubrick, Silburn, Garton et al., 1995). in the last 6 months (Sanders, Tully, Baade et
The recent report The mental health of young al., 1999).
people in Australia: The child and adolescent
component of the National survey of mental Epidemiological studies indicate that family risk
health and well-being (Sawyer et al., 2000) factors such as poor parenting, family conflict,
found that 14% of children and adolescents in and marital breakdown are powerful early

Contact: Matthew Sanders Ph.D, Parenting and Family Support Centre, University of Queensland, Brisbane, 4072
m.sanders@psy.uq.edu.au
Citation: Sanders, M.R., (2003). Triple-P - Positive Parenting Program: A population approach to promoting competent
parenting. Australian e-Journal for the Advancement of Mental Health 2(3)
www.auseinet.com/journal/vol2iss3/sanders.pdf
Published by: Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet) -
www.auseinet.com/journal
Received 14 August 2003; Revised 5 November 2003; Accepted 5 November 2003
Sanders

predictors for the development and maintenance it is argued that there would be a reduction in the
of behavioural and emotional problems in prevalence of behavioural and emotional
children and adolescents (eg. Cummings & problems in children and adolescents.
Davies, 1994; Dryfoos, 1990; Robins & Price,
1991). Specifically, lack of a warm, positive A comprehensive population based strategy is
relationship with parents; insecure attachment; required. This strategy needs to be designed to
harsh, inflexible, rigid, or inconsistent discipline enhance parental competence, prevent
practices; inadequate supervision of and dysfunctional parenting practices, promote better
involvement with children; marital conflict and teamwork between partners and thereby reduce
breakdown; and parental psychopathology an important set of family risk factors associated
(particularly maternal depression and high levels with behavioural and emotional problems in
of parenting stress), increase the risk that children. In order for such a population approach
children develop major behavioural and to be effective several scientific and clinical
emotional problems, including conduct criteria need to be met (Taylor, 1999):
problems, substance abuse, antisocial behaviour,
and participation in delinquent activities (e.g., Knowledge of the prevalence and incidence of
Coie, 1996; Loeber & Farrington, 1998; child outcomes being targeted. A number of
Patterson, 1982). studies in the US, Canada, United Kingdom,
New Zealand, Germany and Australia have
In contrast, supportive family relationships have established the prevalence rates of behavioural
been shown to be a significant predictor of and emotional problems in children, showing
positive adjustment in childhood and that about 18% of children experience
adolescence, and indirect evidence suggests that behavioural or emotional problems (eg. Zubrick
supportive family relationships are a protective et al., 1995). Parents themselves report a high
factor for conduct problems and adolescent level of concern about their child’s behaviour
adjustment problems (Cauce, Reid, Landesman and adjustment. For example, in a recent
& Gonzales, 1990; Cohen & Wills, 1985; epidemiological survey of Queensland parents,
Collins, 2000; Wills, Vaccaro & McNamara, when asked 'Do you consider your child to have
1992). a behavioural or emotional problem?' 28% said
yes (Sanders, Tully et al., 1999), reflecting the
The need for large scale parenting high degree of parental concern about children.
interventions
Knowledge of the prevalence and incidence of
Partly in response to this concern about children family risk factors. Some studies which have
and the prevalence of various family risk factors established the incidence and prevalence of child
in the community, greater attention is being behaviour problems have also examined
given to the importance of better preparation for parenting practices, disciplinary styles and
parents to undertake their role in raising marital conflict. For example, 70% of parents
children. Parents generally receive little under the age of 12 years reported they smack
preparation beyond the experience of having their children at least occasionally, 3% reported
been parented themselves, with most learning on hitting their child with an object other than their
the job through trial and error. However, only a hand, and 25% of parents reported significant
minority of parents participate in parent disagreements with partners about parenting
education programs and the more disadvantaged issues (Sanders, Tully et al., 1999).
the parent the less likely they are to participate
and the more likely they are to drop out Knowledge that changing specific family risk
(Sanders, Tully, et al., 1999). and protective factors leads to a reduction in the
incidence and prevalence of the target problem.
The challenge is to develop intervention An effective population level parenting strategy
strategies at a population level that can enhance must make explicit the kinds of parenting
the competence and confidence of parents in practices that are considered harmful to children.
raising their children. If this were to be achieved The core constructs believed to underpin

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competent parenting need to be articulated so responsibilities, predominant cultural beliefs and


that targets for intervention can be specified. The values, child raising practices and developmental
validity of any model of family intervention issues, sexuality and gender roles may be
would be greatly strengthened if improvements culturally specific and need to be addressed.
in child functioning were shown to be directly While there is much to learn about how to
related to the specific changes specified by the achieve this objective in a multicultural context,
model, such as decreased dysfunctional and sensitively tailored parenting programs can be
increased competent parenting variables. For effective with a variety of cultural groups. It is
example, there is now considerable evidence to important that the multicultural context within
support the proposition that teaching parents which assessment, intervention and research
positive parenting and consistent disciplinary programs operate is made clear in evaluations.
skills results in significant improvements in the There is an ethical imperative to ensure that
majority of oppositional and disruptive interventions designed to empower parents and
behaviours in children, particularly young children in the community’s dominant culture
children, attesting to the importance of reducing are not at the expense of language and other
coercive patterns of parent-child interaction competencies or values in the family’s own
(Patterson, 1982; Taylor & Biglan, 1998; culture.
Webster-Stratton & Hammond, 1997).
Interventions need to be widely available. A key
Having effective family interventions. A assumption of a population based approach is
population perspective requires a range of that parenting and other family intervention
effective family interventions to be available. strategies should be widely accessible in the
Family interventions must also be subjected to community. It is important that barriers to
comprehensive and systematic evaluation with accessing parenting and other family
rigorous scientific controls using either intervention programs are reduced. Inflexible
intrasubject replication designs or traditional, clinic hours may prevent working parents from
randomized, controlled clinical trials with participating in parenting programs. Families
sufficient statistical power to detect meaningful most in need of help with emotional and
differences between intervention and control behavioural problems often do not have or seek
conditions. To be effective a family intervention access to support services. Families who are
strategy should demonstrate that short-term socially, economically or geographically
intervention gains maintain over time, are cost disadvantaged are less likely to refer themselves
effective relative to no intervention, alternative for help. In addition, the family intervention
interventions or usual community care, and are services may be viewed as coercive and
associated with high levels of consumer intrusive, rather than helpful. Use of the internet,
satisfaction and community acceptance. It is not CD rom based applications and media
sufficient just to demonstrate that a strategy interventions all have the potential to increase
results in improvements in family interaction the reach of interventions to hard to access
based exclusively on parental reports, although groups, however such approaches require
this is a necessary first step. The mechanisms systematic evaluation.
purported to underlie the improvements in
family interaction must also be demonstrated to An ecological approach to supporting
change and be responsible for the observed
better parenting
improvements.
In order to achieve a significant improvement in
Family interventions must be culturally parenting competence a population health
appropriate. An effective population strategy perspective is needed. The concept of designing
should be tailored in such a way that it is 'family friendly' environments to support and
accessible, relevant and respectful of the cultural empower parents requires interventions that
values, beliefs, aspirations, traditions and target social contexts that influence parents on a
identified needs of different ethnic groups. day to day basis including the mass media,
Factors such as family structure, roles and primary health care services, child care and
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school systems, religious organisations, The program targets four different


worksites, and the political system. developmental periods from infancy to
preadolescence. Within each developmental
In an effort to develop a contextually meaningful period the reach of the intervention can vary
approach to supporting parents, the Triple P- from being very broad (targeting an entire
Positive Parenting Program, a multi-level, population) or quite narrow (targeting only high
preventively oriented, parenting and family risk children). This flexibility enables individual
support strategy has been developed by the practitioners to determine the scope of the
author and his colleagues at the University of intervention given their own service priorities
Queensland in Brisbane, Australia. The program and funding. Alternatively the program can be
aims to prevent severe behavioural, emotional delivered as a government funded service
and developmental problems in children by provided on a free to consumer basis.
enhancing the knowledge, skills, confidence and
teamwork of parents. The program has five Theoretical basis of Triple P
levels of intervention on a tiered continuum of
increasing strength (see Figure 1) for parents of Triple P is a form of behavioural family
children from birth to age 16. intervention based on social learning principles
(eg. Patterson, 1982). Triple P aims to enhance
The rationale for this tiered multilevel strategy is family protective factors and to reduce risk
that there are differing levels of dysfunction and factors associated with severe behavioural and
behavioural disturbance in children and that emotional problems in preadolescent children.
parents have differing needs and desires Specifically the program aims to: 1) enhance the
regarding the type, intensity and mode of knowledge, skills, confidence, self sufficiency
assistance they require. The multilevel strategy and resourcefulness of parents of preadolescent
is designed to maximize efficiency, contain children; 2) promote nurturing, safe, engaging,
costs, avoid waste and over servicing and to non-violent, and low conflict environments for
ensure the program has wide reach in the children; 3) Promote children’s social,
community. As the program is multidisciplinary emotional, language, intellectual, and
it involves better utilisation of the existing behavioural competencies through positive
professional workforce in the task of promoting parenting practices. The program content draws
competent parenting. on:

1) Social learning models of parent-child


interaction that highlight the reciprocal and
Breadth of reach bidirectional nature of parent-child interactions
(e.g. Patterson, 1982). This model identifies
learning mechanisms which maintain coercive
Low
Increasing Intensity

Indi
vidu ted
and dysfunctional patterns of family interaction
a direc
l Group Self- and predicts future antisocial behaviour in
Media and Communication strategy
children (Patterson, Reid, & Dishion, 1992). As
Level 1-Universal a consequence, the program specifically teaches
Brief parenting advice parents positive child management skills as an
Level 2-Selected
alternative to coercive parenting practices.
Narrow focus parent skills training
Level 3-Primary Care
Broad focus parent skills training 2) Research in child and family behaviour
Level 4-Standard
therapy and applied behaviour analysis which
High

Intensive family intervention has developed many useful behaviour change


Level 5-Enhanced
strategies, particularly research which focuses on
rearranging antecedents of problem behaviour
Figure 1: The Triple P System of Parenting and through designing more positive engaging
Family Support
environments for children (Risley, Clark &
Cataldo, 1976; Sanders, 1992; 1996).

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3) Developmental research on parenting in Markie-Dadds & Turner, 1998). Triple P also


everyday contexts. The program targets targets distressing emotional reactions of parents
children’s competencies in naturally occurring including depression, anger, anxiety and high
everyday contexts, drawing heavily on work levels of stress especially with the parenting role
which traces the origins of social and intellectual (Sanders, Markie-Dadds, & Turner, 1999).
competence to early parent-child relationships Distress can be alleviated through parents
(eg., Hart & Risley, 1995; White, 1990). developing better parenting skills, which reduces
Children’s risk of developing severe behavioural feelings of helplessness, depression and stress.
and emotional problems is reduced by teaching Enhanced levels of the intervention use
parents to use naturally occurring daily cognitive-behaviour therapy techniques such as
interactions to teach children language, social mood monitoring, challenging dysfunctional
skills and developmental competencies and cognitions and attributions and teaching parents
problem solving skills in an emotionally specific coping skills for high risk parenting
supportive context. Particular emphasis is placed situations.
on using child-initiated interactions as a context
for the use of incidental teaching (Hart & Risley, 6) A population health perspective to family
1975). Children are at greater risk for adverse intervention involves the explicit recognition of
developmental outcomes, including behavioural the role of the broader ecological context for
problems, if they fail to acquire core language human development (Biglan, 1995; Mrazek &
competencies and impulse control during early Haggerty, 1994; National Institute of Mental
childhood (Hart & Risley, 1995). Health, 1998). As pointed out by Biglan (1995)
the reduction of antisocial behaviour in children
4) Social information processing models which requires the community context for parenting to
highlight the important role of parental change. Triple P’s media and promotional
cognitions such as attributions, expectancies and strategy as part of a larger system of intervention
beliefs as factors which contribute to parental aims to change this broader ecological context of
self-efficacy, decision making and behavioural parenting. It does this by normalising parenting
intentions (eg., Bandura, 1977; 1995). Parents' experiences (particularly the process of
attributions are specifically targeted in the participating in parent education), by breaking
intervention by encouraging parents to identify down parents’ sense of social isolation,
alternative social interactional explanations for increasing social and emotional support from
their child’s behaviour. others in the community, and by validating and
acknowledging publicly the importance and
5) Research from the field of developmental difficulties of parenting. It also involves actively
psychopathology that has identified specific risk seeking community involvement and support in
and protective factors which are linked to the program by the engagement of key
adverse developmental outcomes in children community stakeholders (eg. community leaders,
(e.g. Emery, 1982; Grych & Fincham, 1990; businesses, schools and voluntary organisations).
Hart & Risley, 1995; Rutter, 1985). Specifically
the risk factors of poor parent management Self regulation and parental competence
practices, marital family conflict and parental
distress are targeted risk factors. As parental The Triple P approach to promoting parental
discord is a specific risk factor for many forms competence views the development of a parent’s
of child and adolescent psychopathology (Grych capacity for self-regulation as a central skill.
& Fincham, 1990; Rutter, 1985; Sanders & This involves teaching parents skills that enable
Markie-Dadds, 1997), the program fosters them to become independent problem solvers.
collaboration and teamwork between carers in Karoly (1993) defined self regulation as follows:
raising children. Improving couples’ 'Self-regulation refers to those processes, internal
communication is an important vehicle to reduce and transactional, that enable an individual to
marital conflict over child rearing issues, and to guide his/her goal directed activities over time
reduce the personal distress of parents and and across changing circumstances (contexts).
children in conflictual relationships (Sanders, Regulation implies modulation of thought,

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affect, behaviour, and attention via deliberate or own and their child’s behaviour they wish to
automated use of specific mechanisms and work on, to set goals for themselves, to choose
supportive metaskills. The processes of self- specific parenting and child management
regulation are initiated when routinized activity techniques they wish to implement, and to self
is impeded or when goal directedness is evaluate their success with their chosen goals
otherwise made salient (eg. the appearance of a against self determined criteria. Triple P aims to
challenge, the failure of habitual patterns; etc)…' help parents make informed decisions by sharing
(p25). This definition emphasises that self- knowledge and skills derived from contemporary
regulatory processes are embedded in a social research into effective child rearing practices.
context that not only provides opportunities and An active skills training process is incorporated
limitations for individual self directedness, but into Triple P to enable skills to be modeled and
implies a dynamic reciprocal interchange practiced. Parents receive feedback regarding
between the internal and external determinants their implementation of skills learned in a
of human motivation. From a therapeutic supportive context, using a self-regulatory
perspective self-regulation is a process whereby framework (see Sanders & Dadds, 1993);
individuals are taught skills to modify their own
behaviour. These skills include how to select 4) Personal agency: Here the parent increasingly
developmentally appropriate goals, monitor their attributes changes or improvements in their
child’s or their own behaviour, choose an situation to their own or their child’s efforts
appropriate method of intervention for a rather than to chance, age, maturational factors
particular problem, implement the solution, self or other uncontrollable events (eg. spouses’ bad
monitor their implementation of solutions via parenting or genes). This outcome is achieved by
checklists relating to the areas of concern, and to prompting parents to identify causes or
identify strengths or limitations in their explanations for their child’s or their own
performance and set future goals for action. behaviour.

This self-regulatory framework is Encouraging parents to become more self


operationalised to include: sufficient does not mean that parent's own social
support networks are unimportant (partners,
1) Self-sufficiency: As a parenting program is extended family, friends, child care supports).
time limited, parents need to become However, the broader ecological context within
independent problem solvers so they trust their which a family lives can not be ignored (poverty,
own judgment and become less reliant on others dangerous neighbourhoods, community,
in carrying out basic parenting responsibilities. ethnicity, culture). It is hypothesised that the
Self sufficient parents have the resilience, more self-sufficient parents become the more
resourcefulness, knowledge, and skills to parent likely they are to seek appropriate support when
with confidence; they need it, to advocate for children, become
involved in their child’s schooling, and to protect
2) Parental self-efficacy: This refers to a children from harm (eg. by managing conflict
parent’s belief that they can overcome or solve a with partners, and creating a secure low conflict
parenting or child management problem. Parents environment).
with high self efficacy have more positive
expectations about the possibility of change; Principles of positive parenting

3) Self-management: The tools or skills that Five core positive parenting principles form the
parents use to become more self sufficient, basis of the program. These principles address
include self monitoring, self determination of specific risk and protective factors known to
performance goals and standards, self evaluation predict developmental and mental health
against some performance criterion, and self- outcomes in children. These core principles
selection of change strategies. As each parent is translate into a range of specific parenting skills,
responsible for the way they choose to raise their which are outlined in Table 1.
children, parents select which aspects of their

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Table 1: Core parenting skills

Observation Parent-child Encouraging Teaching new Managing Preventing Self- Mood Partner
skills relationship desirable skills and misbehaviour problems in regulation management support and
enhancement behaviour behaviours high-risk skills and coping communication
skills situations skills skills
Monitoring Spending Giving Setting Establishing Planning and Setting Catching Improving
children’s quality time descriptive developmentally ground rules advanced practice unhelpful personal
behaviour praise appropriate preparation tasks thoughts communication
Talking with goals Using directed habits
Monitoring own children Giving non- discussion Discussing Relaxation
Self-
behaviour verbal Setting a good ground rules and stress Giving and
evaluation of
Showing attention example Using planned for specific management receiving
strengths
affection ignoring situations constructive
and
Providing Using incidental Developing feedback
weaknesses
engaging teaching Giving clear, Selecting personal
activities calm engaging coping Having casual
Setting
Using Ask, Say, instructions activities statements conversations
personal
Do
goals for
Using logical Providing Challenging Supporting each
change
Using behaviour consequences incentives unhelpful other when
charts thoughts problem
Using quiet Providing behaviour
time consequences Developing occurs
coping plans
Using time- Holding for high risk Problem solving
out follow-up situations
discussions Improving
relationship
happiness

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Core features of Triple P areas who typically have less access to
professional services.
There are several other distinctive features of
Triple P as a family intervention which are Principles of effective program
discussed below. development and implementation

Targets meaningful social contexts for parents. Principle 1: Use the media more effectively
Triple P aims to make parenting support
available in a variety of different contexts that One way to disseminate effective parenting
are part of the everyday lives of parents. These interventions more widely is by using the mass
include using the media, primary health care media. The mass media play an important role in
services, child care, school and work settings as providing health information for the general
a delivery and access point for parents. public (Egger, Donovan & Spark, 1993). The
goals of a media strategy include normalising the
Developmentally-sensitive information. The process of participating in parenting programs,
information resources used in parent and destigmatising the idea of getting assistance to
practitioner materials have been designed to be address parenting issues, increasing the
developmentally sensitive to the changing needs receptivity of parents to specific messages about
and competencies of children as they mature parenting and to promote self sufficiency in
from birth through to adolescence. parents. A comprehensive media strategy can
include television, radio, print and internet based
Principle of program sufficiency. This concept strategies.
refers to the notion that parents differ in the
strength of intervention they may require to Of all the media strategies, television has the
enable them to independently manage a problem. greatest potential as television acts as the
Triple P aims to provide the minimally sufficient primary vehicle for mass media in today's
level of support parents require to do their job. society. Television has been shown to have the
For example, parents seeking advice on a capacity to influence awareness and to change
specific topic (eg. tantrums) can receive clear, attitudes, beliefs and behaviours, making it
high quality, behaviourally specific advice in the potentially one of the most powerful educational
form of a parenting tip sheet on how to manage resources available at the present time
or prevent a specific problem. For such a parent (Hofstetter, Schultze & Mulvihill, 1992;
Levels 1 or 2 of Triple P would constitute a Zimmerman, 1996). For example, evidence from
sufficient intervention. the public health field has shown that televised
media strategies can successfully increase
Flexible tailoring. A number of different community awareness of the risk and protective
programs of varying intensity have been factors impacting upon health and well-being,
developed ranging from brief 1-2 session promote health preserving behaviours such as
consultations with a primary care provider to abstaining from drinking alcohol when driving,
more intensive interventions that target and be instrumental in modifying potentially
additional family risk factors, such as marital harmful behaviours such as cigarette smoking,
conflict, mood disturbance and high levels of poor diet and lack of exercise (Biglan, 1995;
stress. Sorenson, Emmons, Hunt & Johnston, 1998).
Although the mass media have been used widely
Varied delivery modalities. Several of the levels in the health promotion field, little is known
of intervention in Triple P can be delivered in a about resulting effectiveness in the field of
variety of formats, including individual face to family intervention. There are several potential
face, group, telephone assisted or self-directed advantages of using media strategies, such as
programs or a combination. This flexibility television, as an information source for parenting
enables parents to participate in ways that suit and family issues. Television has a pervasive
their individual circumstances and allows influence on modern families: adults watch
participation from families in rural and remote approximately three hours of television per day

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(Neilson, 1997); 47% of adults rate television as behaviours and gave specific skills-based
the best medium for accurate and reliable news; information, such as teaching mothers how to
61.8% choose to obtain news and information adequately prepare their infant's food. Similarly,
from television; and 79.6% report it to be the for the mass media to be a successful vehicle for
most influential advertising source (Federation the promotion of effective parenting skills and
of Australian Commercial Television Stations, the modification of parental behaviour,
1995). information about functional strategies for
promoting competence in children and for
A televised parent education program has the dealing with problem behaviour need to be
advantage of being able to be accessed in the provided. Behaviour change then requires
privacy of the home by a large proportion of the parents to adopt a self-regulatory approach that
population, some of whom, such as parents involves self-monitoring, self-identification of
living in rural and remote locations, may personal strengths and weaknesses and personal
otherwise be difficult to reach. It may also assist goal setting (Halford, Sanders & Behrens, 1994;
parents to recognise early warning signs of Webster-Stratton, 1992).
behavioural and emotional problems in children
and encourage them to seek professional advice A Universal Triple P health promotion strategy
early when a minimal level of intervention may was recently developed to include a media
be sufficient to address recent onset, discrete campaign on parenting based around a television
child behaviour problems (Sanders & Markie- series, Families, which was shown in prime time
Dadds, 1997). Moreover, a televised parent on a commercial television network in New
education program could promote and increase Zealand. The 13, 30-minute episode series was
community awareness of effective parenting in an 'infotainment' style to ensure the widest
strategies and understanding of the role family reach possible for Triple P. Such programs are
relationships play in the health and well-being of very popular and according to ratings data,
young children (Sanders, 1999). Media frequently attract around 20-35% of the viewing
interventions of this type have the capacity to audience (Neilson, 1997). The series used an
create a social milieu that is supportive of parent entertaining format to provide practical
education and family change (Flay, 1987) which information and advice to parents on a variety of
can be used to counter alarmist, sensationalised common behavioural and developmental
or parent blaming messages (Sanders, 1999). An problems in children as well as other parenting
added advantage of a televised parent education issues. The main segments were: a feature story,
program is that any behavioural change achieved which presented brief discussions on a number
by watching the program is likely to be of family issues (e.g. school involvement and the
attributed to one’s own efforts (Flay 1987), thus role of fathers); a segment in which a celebrity
increasing parents’ feelings of personal family discussed a range of issues about their
competence. family; family health care tips; animal care and
integrating a pet into family life; interesting facts
To be most effective as a mechanism of about the current state of families in society; and
behaviour change, rather than operating purely a Triple P segment.
as a strategy for raising public awareness, it has
been argued that a media intervention needs to A 5–7 minute Triple P segment each week
not only provide information about the problem enabled parents to complete a 13-session Triple
behaviour but also provide practical advice about P intervention at home. The Triple P segments
how to deal with it effectively (Andrews, provided brief examples of the causes of child
McLeese & Curran, 1995; Flay & Burton, 1990; behaviour problems from a social learning
Owen, Bauman, Booth, Oldenburg & Magnus, perspective, provided information on how to
1995). For example, Parloto, Green and Fishman monitor child behaviour, and presented clear
(1992) found that efforts to teach mothers about guidelines for using a range of parenting
the general principles of nutrition were less strategies designed to encourage desirable
successful in changing infant feeding patterns behaviour in children (e.g. descriptive praise,
than programs that pinpointed food-related positive attention), prevent problems from

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occurring (e.g. providing engaging activities), in the percentage of children from the media
and manage difficult behaviour (e.g. rule setting, condition who fell in the clinical range — from
directed discussion, planned ignoring, and the 46% prior to the intervention (over twice the
provision of clear instructions backed up by national average) to 14% remaining in the
logical consequences, quiet time or time-out). clinical range following the intervention.
These strategies were integrated into parenting Mothers in the media condition also reported an
plans for common problems (e.g. whining, increased sense of competence and satisfaction
disobedience, aggression and temper tantrums), in their parenting abilities relative to mothers in
for promoting children’s development (e.g. the control group. Anecdotally, many mothers
encouraging creativity and involvement in sport, reported that the realisation they were doing
and helping with homework), and for managing some things 'the right way' was one of the most
developmental issues (e.g. cooperative play, salient outcomes of the program. A strong trend
sleeping difficulties and eating difficulties). In was also indicated for mothers in the media
addition, each Triple P segment presented a condition to demonstrate a reduction in
modeled demonstration of suggested strategies. dysfunctional parenting styles (e.g. laxness,
overly harsh discipline, nagging) relative to the
A cross promotional strategy used radio and the mothers in the waitlist condition. All
print media to prompt parents to watch the intervention effects evident at post assessment
program and inform them of how to contact a were maintained at 4-6 months follow up.
Triple P telephone information line for more
information about parenting. The Families fact Although the up-front costs of establishing a
sheets (specifically designed parenting tip sheets media-based intervention program such as
providing a written version of the information Families is substantial, the reach may be wide
from the Triple P segment) were also available and the long term benefits to individuals and the
by writing to a Triple P Centre, calling the Triple community may far outweigh these initial costs.
P information line, or through a retail chain
store. As Triple P has been disseminated more widely
in the community, different kinds of media
To evaluate whether this form of media activities have been used to promote the program
intervention could significantly impact on family in the community. These activities have included
functioning, Sanders, Montgomery and the broadcast of Triple P positive parenting tips
Brechman-Toussaint (2000) randomly assigned (approximately 60 seconds each) on community
mothers with children aged between two and radio stations, a weekly newspaper column on
eight years either to a media intervention or positive parenting, editorial and feature articles
control group. Mothers in the intervention group on the program, 15-30-second television
were given the television series, in the format of commercials promoting the five key principles
videos and tip sheets. These mothers watched of positive parenting (a safe engaging
two episodes of the series (in their own home) environment, a positive learning environment,
each week, at a time convenient to them, and assertive discipline, reasonable expections, and
read the relevant tip sheets. Mothers in the taking care of ourselves as parents), positive
control group received no intervention for six parenting inserts in school newsletters, public
weeks. As predicted, mothers in the media lectures and presentations, news and current
condition reported significant reductions in child affairs stories on network television. These
behaviour problems post-treatment in treatments have generally tracked one or more
comparison to the control group. Reductions children through the intervention and have
occurred in both the intensity of problem promoted strong public interest in the program.
behaviour and the number of problems that
mothers were experiencing with their child. The These activities provide examples of ways in
percentage of children from the control condition which the media can be used to promote
falling in the clinical range for problem program awareness, which in turn can create
behaviour did not change from pre- to post- demand for evidence-based programs. Our
intervention, yet there was a significant decrease experience has been that it is important to

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develop appropriate referral networks and back- Only 2% saw a mental health specialist (Zubrick,
up services for more intensive interventions et al., 1995).
when required. For some families this is the only
participation they will have in a parenting In a national U.S. survey of over 2000 parents
program. Hence, designing a media campaign to with children under 3 years of age, Young,
ensure that messages are thematically consistent, Davis, Schoen & Parker (1998) highlighted
culturally appropriate, and practical is critical to parents’ concerns and the information they
ensure that messages are acceptable and have a would like to receive from their pediatric
positive impact. This level of intervention may physician or nurse. The majority of parents
be particularly useful for parents who have reported having a regular source of pediatric
sufficient personal resources (i.e. motivation, health care, which met their child’s health needs,
literacy skills, commitment, time and support) to yet many were not satisfied with the help they
implement suggested strategies with only brief received with regard to understanding their
parenting advice. However, a media strategy is child’s growth, development or care. Fewer than
unlikely to be effective on its own for parents one quarter had talked with their pediatric
who have a child with a severe behavioural clinician about discipline or promoting their
disorder or where a parent has few of the child’s development. Parents who had received
resources listed above, is depressed, in a this type of information were significantly more
conflictual relationship or suffering from major satisfied with their pediatric clinician than those
psychopathology. In these instances a more who had not. A majority of parents (79%)
intensive form of intervention is indicated. reported a desire for more information from their
pediatric clinician in at least one of six areas of
Principle 2: Enhance the capacity of primary child rearing (i.e. newborn care, sleep patterns,
care services to support parents crying, toilet training, discipline, and
encouraging early learning) and 53% wanted
The last decade has seen an increasing emphasis information in at least three areas. These data
on treating mental health problems at the suggest that personalised advice, in the context
primary care level (Giel, Koeter & Ormel, 1990). of an ongoing supportive relationship, is the
The family doctor or child health nurse is often need being expressed by parents.
the first point of contact for parents experiencing
behavioural difficulties with their young As they have regular contact with young
children. A large number of pediatric families, primary care services can undertake
consultations deal with parental concerns about several important tasks to promote children’s
their child’s behaviour, development or school mental health. Early detection of significant
achievement (Christopherson, 1982; Oberklaid, deviations from normal development and
Dworkin & Levine, 1979; Taylor & Biglan, provision of advice to parents seeking
1998; Triggs & Perrin, 1989). Primary care information about developmental issues should
professionals are well-positioned to provide become part of routine well-child care. Provision
parenting support and yet are commonly under- of brief behavioural counselling for child
resourced and under-trained for the provision of behaviour problems and increased access to
effective mental health programs for children early intervention on dysfunctional family
and families. interaction patterns could help to prevent later,
more serious problems. Primary care service
A recent parenting survey showed that doctors providers can perform a triage function for the
were the professionals most frequently consulted appropriate referral of moderate to severe child
by caregivers of children with an emotional or behaviour problems to specialised services. This
behavioural problem (Sanders, Tully, et al., would help match intervention strength to
1999). The Western Australian Child Health individual family needs and ensure the limited
Survey reported that 65% of parents of children funds available for specialist mental health
with behavioural and emotional problems services are directed where they are most
consulted a doctor during a 6-month period. needed. In the long term, widespread
implementation of such preventive primary care

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Sanders

interventions could function to decrease the advice). Participants were 50 families of children
number of children requiring specialist health aged between 18 months and 6 years with a
services. Through this type of primary care recent onset, mild to moderate behaviour
strategy, parenting support would become an problem. Results showed the Level 3
integral part of family health care provision. intervention produced significant reductions in
child behaviour problems and more appropriate
Two recent independent trials have assessed the discipline practices in comparison to the waitlist
impact of Triple P interventions in primary care control condition. Moderate positive parent and
settings. The first (Zubrick, Silburn, Teoh et al., child outcomes were achieved by families in the
1997) examined the effectiveness of specialised Level 2 intervention, however results did not
training and implementation of a group format, differ significantly from the waitlist control
intensive parenting skills training program condition. The Level 3 intervention proved
(Markie-Dadds, Turner & Sanders, 1997; superior to Level 2 on one measure of child
Turner, Markie-Dadds & Sanders, 1998) by behaviour problems (Parent Daily Report
primary care staff. The program was Checklist; Chamberlain & Reid, 1987), and in
administered as a selective prevention reducing conflict between parents over
demonstration project to reduce the prevalence parenting. These results provide further support
of conduct problems at a population level. The for the efficacy of primary care staff in offering
target population was all parents of 3–4 year old brief, early parenting support, resulting in
children living in a metropolitan area with high reduced child problem behaviour and improved
socioeconomic disadvantage and high child parenting practices.
abuse notification rates. The intervention was
relatively brief — four 2-hour group sessions Principle 3: Provide universal parenting
and four 15–30 minute individual telephone programs targeting entire populations at
consultations. Groups were facilitated by developmentally sensitive transition points
community health nurses. Three in five eligible
families attended the program and 85% of Triple P has also been used as a transitional
families completed at least 7 of the 8 program program targeting the parents of children in their
sessions. The program was successful in first year of school. McTaggart and Sanders
reducing dysfunctional parenting from twice the (2003, this issue) evaluated the effects of Triple
population average to general population levels P as a transition to primary school program.
and significantly reduced disruptive behaviour They randomly assigned 25 schools to receive
problems in the children of participating either Group Triple P and an information
families. This trial has shown not only extremely campaign or to a control group. At the end of
high community support for parenting programs Grade 1 in Triple P schools there were fewer
offered through primary care settings, it has children reported by teachers to have behaviour
demonstrated positive outcomes for parents and programs and a significant increase in self report
children. measures of parenting skills than in schools
where parents had not participated in Group
The second (Sultana, Matthews, De Bortoli & Triple P. A similar project using the adolescent
Cann, 2000) involved a randomised controlled version of Group Triple P is currently being
trial comparing two brief parenting interventions trialled in four Queensland state high schools.
(Level 2 and 3 Triple P; Turner, Sanders, & The encouraging preliminary finding from these
Markie-Dadds, 1999) implemented by maternal studies suggested that the school could be used
and child health nurses, in comparison to a as a community context to support the needs of
waitlist control condition. The study aimed to parents.
evaluate the impact of the Level 2 intervention
(involving self-administration of written Principle 4: Develop tailored more intensive
parenting advice following a 15 minute interventions for high risk parents and children
consultation) in comparison to the Level 3
intervention (involving four brief consultations There are always likely to be non responders to
supported by written and videotaped parenting universal parenting programs. These parents may

12
Sanders

require more intensive programs specifically employment policies increasingly advocated for
tailoured for their needs. An example of such within business organisations.
comes from our work with parents at risk of
child maltreatment. Sanders, Pidgeon, Principle 6: Promote better teamwork in
Gravestock, Brown, Connors and Young (in parenting
press) compared the effects of a standard Group
Triple P program with an enhanced program, There is increasing evidence that exposure to
Pathways Triple P which provided targeted, significant parental conflict is a risk factor for
additional attributional retraining and anger the development of behavioural problems in
management for parents. These parents all children. Marital conflict is also a risk factor for
reported significant anger management concerns. parents failing to implement parenting skills
Results showed that the enhanced training learnt in parent training programs. Dadds,
resulted in additional benefits in terms of Schwartz and Sanders (1987) developed a brief
reduced dysfunctional attributions of their form of marital communication skills training for
child’s behaviour, but similar levels of marital discordant couples with an oppositional
improvement on measures of child behaviour. child. A randomised controlled trial evaluating
This finding shows that a targeted adjunctive this intervention found that providing Partner
intervention designed to specifically address Support Training reduced the risk of relapse
specific risk factors that are frequently present in after successful parent training in these families.
parents at risk of child maltreatment enhances
overall treatment effects. Principle 7: Help parents manage their own
emotional distress
Principle 5: Develop interventions to enable
parents to manage work and family Although parenting interventions can reduce
responsibilities parental distress, when parenting problems are
complicated by more serious mental health
Many parents report difficulties balancing work problems tailored interventions to address the
and family responsibilities, and due to their work mental health problem may be required. Many
commitments can find it difficult to access treatments for adult depression ignore the
parenting programs. The development of interpersonal and family context of parental
parenting interventions as an employee distress. Sanders and McFarland (2000) showed
assistance program may be useful to enable that an integrated parenting and brief cognitive
workers who are parents to more effectively intervention targeting parenting situations was
balance work and home responsibilities. There is effective in alleviating both parents’ depression
increasing evidence that family conflict and children’s conduct problems to a greater
contributes to work stress, low motivation, degree than standard individual parent training
accidents at work, and low productivity. Conflict alone. This finding points to the potential for
with children before and immediately after work parenting interventions to contribute to the
is a source of considerable stress for many treatment of adult psychopathology.
parents. We have recently developed and
evaluated Triple P as a worksite intervention Principle 8: Develop appropriate evidence
where the effects of the intervention are assessed based interventions for culturally and
at both the family and worksite level. Sanders linguistically diverse groups
and Martin (2003) found that working parents
who had completed Workplace Triple P reported In a multicultural society any universal parenting
significantly higher levels of self efficacy in intervention needs to be responsive to the
completing work assignments and lower parenting needs of culturally and linguistically
occupational stress compared to a waitlist diverse groups. We have recently developed and
control group. Ultimately programs tailored to trialled a version of Group Triple P developed
the needs of working parents and delivered at specifically for Indigenous Australian parents. In
work may put flesh on 'family friendly' a randomised controlled trial Turner and Sanders
(in prep) found that after participating in

13
Sanders

Indigenous Triple P parents reported a powerful and underutilised resource.


significantly lower levels of behavioural and Empirically supported parenting and family
emotional problems in their children, increased intervention strategies arguably should be the
parental self efficacy and lower levels of parental centrepiece of public health efforts to prevent
distress. These positive findings and similar family and relationship distress and child mental
results with other ethnic groups indicate that health problems. While it is undoubtedly true
core principles of positive parenting are that healthy families lead to healthy, well
applicable in many different cultural contexts adjusted children, in order to achieve this ideal,
when the programs are made culturally relevant. family practitioners need to break away from a
traditional delivery paradigm and adopt a far
Principle 9: Develop effective systems of more contextual perspective in understanding
dissemination and quality assurance and ameliorating parenting and other family
difficulties in the community. Parenting
Many evidence based programs (e.g. parent interventions are amongst the most powerful and
management training) have little impact on cost-effective tools available to promote better
children’s health and well being because they are mental health. As a community we must invest
not properly disseminated. The design of further in promoting the well being of our
effective systems of dissemination to avoid the children through supporting evidence based
problem of programs becoming reified and static parenting interventions.
needs to be configured to accommodate an
evolving evidence base, that requires meaningful
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