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Promising Program Seal

Triple P System

Blueprints Program Rating: Promising

A public health approach to reach all parents in a community to enhance parental competence and prevent or alter dysfunctional parenting practices, thereby reducing family risk factors both for child maltreatment and for children's behavioral and emotional problems.

  • Matthew Sanders, Ph.D.
  • Director
  • The University of Queensland
  • School of Psychology
  • Parenting and Family Support Center
  • Brisbane, QLD 4072
  • AUSTRALIA
  • +61 (7) 3365 7290
  • info@triplep.net
  • matts@psy.uq.edu.au
  • http://www.pfsc.uq.edu.au">www.pfsc.uq.edu.au
  • Child Maltreatment
  • Mental Health - Other

    Program Type

    • Parent Training

    Program Setting

    • Community (e.g., religious, recreation)
    • Home
    • Hospital/Medical Center
    • Mental Health/Treatment Center
    • School

    Continuum of Intervention

    • Universal Prevention (Entire Population)
    • Selective Prevention (Elevated Risk)

    A public health approach to reach all parents in a community to enhance parental competence and prevent or alter dysfunctional parenting practices, thereby reducing family risk factors both for child maltreatment and for children's behavioral and emotional problems.

      Population Demographics

      Uses a public health approach to reach all parents in a community. Specifically, parents with a child in the birth to 12 year age range are targeted by the core programs of Triple P. In the population trial, the referent target were parents with children below age 8.

      Age

      • Infant (0-2)
      • Early Childhood (3-4) - Preschool
      • Late Childhood (5-11) - K/Elementary
      • Adult

      Gender

      • Male and Female

      Race/Ethnicity

      • All Race/Ethnicity
      • Family
      Risk Factors
      • Family: Family conflict/violence*, Parent stress*, Poor family management, Psychological aggression/discipline*, Violent discipline*
      Protective Factors
      • Individual: Coping Skills
      • Family: Attachment to parents, Non-violent discipline*, Parent social support

      *Risk/Protective Factor was significantly impacted by the program.

      See also: Triple P System Logic Model (PDF)

      The Triple P Positive Parenting Program is designed as a comprehensive population-level system of parenting and family support for famlies having at least one child in the birth to 12-year-old range. The multilevel system includes five intervention levels of increasing intensity and narrowing population reach. The system is designed to enhance parental competence and prevent or alter dysfunctional parenting practices, thereby reducing an important set of family risk factors, both for child maltreatment and for children's behavioral and emotional problems. In the Triple P system, a media and communication strategy is utilized extensively in a sophisticated and strategic manner to normalize and acknowledge the difficulties of parenting experiences, to break down parental sense of social isolation regarding parenting, to de-stigmatize getting help, to impart parenting information directly to parents, and to alter the community context for parenting.

      In a population level version of Triple P, the existing workforce crossing several disciplines and settings (such as family and social support services, preschool/child-care settings, elementary schools, and other community entities with direct contact with families) is trained to deliver the Triple P system of interventions. They in turn deliver Triple P to parents in 1-10 or more sessions tailored to the severity of the family's dysfunction and/or child's behavioral problems.

      The Triple P Positive Parenting Program is a multi-level preventive intervention system designed for families having at least one child in the birth to 12-year-old range (the core programs). All programming levels of Triple P have carefully developed intervention manuals, systematic training regimens for providers/practitioners, and coordinated resource materials for parents (videos, workbooks and tip sheets). The 5 core principles of positive parenting that are invoked throughout the multi-level Triple P system to promote social competence and emotion self-regulation in children are: (1) ensuring a safe, engaging environment, (2) promoting a positive learning environment, (3) using assertive discipline, (4) maintaining reasonable expectations, and (5) taking care of oneself as a parent. The emphasis is on parents learning how to apply these skills to different behavioral, emotional and developmental issues in children, ranging from common child-rearing challenges to more intense challenges. The five positive parenting principles translate into 35 specific strategies and parenting skills that fit into several major categories: parent-child relationship enhancement, encouraging desirable behavior, teaching new skills and behaviors, managing misbehaviors, preventing problems in high-risk situations, self-regulation skills, parental mood management and coping skills, and partner support and communication skills. Triple P provides developmentally tailored menu options that facilitate parental goal setting and self-regulation. Parents learn how to apply those techniques and strategies that are relevant to their child, the parent's goals and the family situation.

      Universal Triple P (Level 1): The Universal facet of the Triple P intervention involves the implementation of media and informational strategies pertaining to positive parenting. These strategies are intended to destigmatize parenting and family support, make effective parenting strategies readily accessible to all parents, and facilitate help-seeking and self-regulation by parents who need higher intensity intervention. Universal Triple P includes use of radio, local newspapers, newsletters at schools, mass mailings to family households, presence at community events, and website information. Use of local newspapers takes three forms: positive parenting articles written by Sanders (program creator) on specific topics of interest to parents; local press releases on human interest stories that link with Triple P activities; and stories generated by reporters with whom the publicity team has developed working relationships.

      Selected Triple P (Level 2): The Selected Triple P program has utility for many parents and is intended to normalize parenting interventions. There are two delivery formats for Selected Triple P: brief and flexible consultation with individual parents; and parenting seminars with large groups of parents. The brief and flexible consultation format involves one to two consultation contacts (20 minutes each) and is designed for parents whose children have relatively minor and fairly discrete problem behaviors that do not require more intensive levels of intervention. The intervention can be provided in the context of well childcare, daycare and preschool settings, and in other settings where parents may have routine contact with service providers and other professionals who regularly assist families. Selected Triple P can be viewed as a form of anticipatory development guidance. The parenting seminar format of Selected Triple P involves three 90-minute sessions designed for delivery to large groups of parents. The seminar series includes specific seminars on the following topics: The Power of Positive Parenting; Raising Confident, Competent Children; Raising Resilient Children. The three seminars are independent of each other so that parents can attend any or all of them and still benefit. Seminars are used to promote awareness of Triple P and as brief and informative sessions for any parent. Each seminar includes a presentation, a question and answer period, distribution of a parenting tip sheet, and availability of practitioners at the end of the session to deal with individual inquiries and requests for further assistance.

      Primary Care Triple P (Level 3): The Primary Care Triple P program, like Selected Triple P, is appropriate for the management of discrete child problem behaviors that are not complicated by other major behavior management difficulties or significant family dysfunction. The key difference is that provision of advice and information is supported by active skills training for those parents who require it to implement the recommended parenting strategies. This program level is especially appropriate for parents of infants, toddlers and preschoolers with respect to common child behavior problems and parenting challenges. Level Three involves a series of four brief (20 minute) consultations that incorporate active skills training and the selective use of parenting tip sheets covering common developmental and behavioral problems of pre-adolescent children. This brief and flexible consultation modality also builds in generalization enhancement strategies for teaching parents how to apply knowledge and skills gained to non-targeted behaviors and other children in the family.

      Standard and Group Triple P (Level 4): The Level 4 program benefits indicated populations of children who have detectable problems but who may or may not yet meet diagnostic criteria for a behavioral disorder, and parents who are struggling with parenting challenges. Parents learn a variety of child management skills and how to apply these skills both at home and in the community. Level 4 combines the provision of information with active skills training and support, as well as teaching parents to apply skills to a broad range of target behaviors in both home and community settings with the target child and siblings.

      Enhanced Triple P (Level 5): Enhanced Triple P is an optional augmentation of Standard (Level 4) Triple P for families with additional risk factors that might need to be addressed through the intervention. It includes optional intervention modules on partner communication, mood management and stress coping skills for parents, and additional practice sessions addressing parent-child issues.

      The Triple P system has a standard training and quality-promotion protocol that is used worldwide. Professional training courses delivered by professional trainers involves attendance in a multi-day training program (2 or 3 days, depending on course level), intensive self-review of intervention materials, competency practice and feedback at a day-long session, and completion of accreditation requirements. The training process includes didactic instruction, modeling by the trainer, video examples of discrete skills, small-group exercises for active skills practice, and group discussions of key issues.

      Population System Approach: In a population level system trial, the existing workforce are trained to deliver the Triple P system of interventions. Service providers may include family support services (social workers and therapists affiliated with county health centers, mental health centers, and schools), social services (family services, social workers), preschool and child-care settings (directors, teachers), elementary schools (parent educators, guidance counselors, kindergarten teachers), early childhood workers, child abuse prevention, private sector practitioners, health centers (primary healthcare providers), and other community entities having direct contact with parents and families. In the population trial that was evaluated, 649 service providers participated in Triple P professional training in 9 counties. Sixty-four percent of county providers were trained in only Levels 2/3, and 36% were trained in Level 4 or above. About a third of the latter group also received training in Levels 2/3. The mean per-county number of Triple P trained individuals was 38.8 providers per 50,000 population. Based upon interviews with trained service providers, it is estimated that between 8,883 and 13,560 families participated in some level of Triple P across the 9 counties.

      Although Triple P uses social learning principles, the trial described here is based on the following conceptual framework:

      1. Official child maltreatment measures grossly underestimate the magnitude of the problem. There are many parents in the population who might be engaging in abuse-prone parenting practices, which means a broad strategy is needed for preventive interventions.
      2. A preventive approach is needed that reduces the population pool of families who might contribute to substantiated and potential cases of child maltreatment.
      3. Triple P offers a population-based approach to strengthening parenting. In addition to evidence supporting the effectiveness for various facets of Triple P in improving parenting and reducing children's problems, it has been found that concurrent implementation of multiple levels of Triple P in a population application can reduce coercive parenting.
      4. It is new territory to determine whether a population approach to parenting intervention such as Triple P can have preventive impact on population-level indicators of child maltreatment.

      • Social Learning

      The population trial randomized geographical units to condition, matching on demographic and child-abuse variables, and evaluated the impact of implementing Triple P with the existing workforce on population indicators related to child maltreatment. This trial targeted rates and aggregate dimensions for entire geographic areas to study broad impact. The U.S. Triple P System Population Trial consisted of the stratified random assignment of 18 medium-sized counties in a southeastern state to dissemination and control conditions, controlling for county population size, county poverty rate, and county child abuse rate. Evaluation was done after the 2-year period of intervention dissemination.

      After 2 years of intervention, randomly surveyed households in the Triple P System counties showed significantly higher proportion of awareness regarding Triple P than did those in Control counties. The comparison of Triple P System and Control conditions revealed differential and positive effects on the Triple P System counties for rates of substantiated child maltreatment, child out-of-home placements, and hospitalizations or emergency-room visits for child maltreatment injuries.

      In an Australian non-random and non-equivalent comparison design, the implementation of the Triple P System (TPS) was associated with significantly greater reductions in emotional problems and psychosocial distress in both children and their parents than in the care as usual (CAU) condition. The intervention effects were for overall psychosocial problems and emotional difficulties, but not for conduct problems, hyperactivity and peer relationship difficulties. Reductions in coercive parenting were found in both the TPS and CAU conditions, but there was a 14% greater reduction in the TPS communities than in the CAU communities.

      U.S. Population Study:

      • Positive effects in the Triple P System counties for rates of substantiated child maltreatment, child out-of-home placements, and hospitalizations or emergency-room visits for child maltreatment injuries, compared to Control counties.

      Australia Population Study:

      • Triple P System was associated with significantly greater reductions in emotional problems and psychosocial distress in both children and their parents than in the care as usual condition.
      • No intervention effects were found for conduct problems, hyperactivity and peer relationship difficulties.

      Significant Program Effects on Risk and Protective Factors:

      • Greater reduction in coercive parenting was found in TPS vs. CAU conditions (Australian Study).

      This study is generalizable to similar counties in the United States.

      U.S. Population Trial

      • Chance for reporter bias in the three major outcome variables.
      • Outcome measures tend to underestimate instances of child maltreatment.
      • Unclear whether effects will be sustained over time.
      • Possibility for spillover into Control counties based on Triple P provider movement or in what counties families receive treatment.
      • The assignment of counties was set up at one level, with blocking, but didn't analyze at that level.

      Australian Trial

      • Non-equivalent comparison group, with pretest differences favoring controls.
      • No effects on conduct problems.

      • Blueprints: Promising
      • Coalition for Evidence-Based Policy: Near Top Tier
      • Crime Solutions: Effective
      • OJJDP Model Programs: Effective

      Nicole Young
      First 5
      Santa Cruz, CA
      Email: nicole@opti-solutions.com
      Phone: (831) 594-1498
      Website: first5scc.org/families-are-strong/triple-p

      Barbara Sheppard
      Cabarrus Health Alliance
      Cabarrus County, NC
      Email: Barbara.Sheppard@cabarrushealth.org
      Phone: (704) 920-1367
      Website: www.cabarrushealth.org/153/Triple-P-Positive-Parenting_Program

      Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J. & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The U.S. Triple P System population trial. Prevention Science, 10, 1-12.

      Sanders, M. R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S. & Bidwell, K. (2008). Every family: A population approach to reducing behavioral and emotional problems in children making the transition to school. The Journal of Primary Prevention, 29, 197-222.

      Triple P America
      E-mail: contact.us@triplep.net
      Phone: (803) 451-2278
      Web: www.triplep.net/glo-en/home/

      Study 1

      Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J. & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The U.S. Triple P System population trial. Prevention Science, 10, 1-12.

      Prinz et al., 2009

      Evaluation Methodology

      Design: The U.S. TPSPT (Triple P System Population Trial) consists of the stratified random assignment of 18 medium-sized counties (population between 50,000 and 175,000) in a southeastern state to dissemination and control conditions, controlling for county population size, county poverty rate, and county child abuse rate. Population size was the main factor in selecting counties to arrive at units that were reasonably comparable by eliminating very small counties that would not have sufficient population to implement the preventive interventions and detect effects, and by eliminating very large counties that would individually account for too much of the overall variance.

      The population indicators chosen for this trial met several criteria: (1) standardized across counties and delivered to a central repository; (2) measure of child maltreatment or its immediate consequence; (3) associated with significant human and financial costs; and (4) recorded by personnel not involved in the dissemination of the preventive intervention in the population trial. Substantiated child maltreatment was chosen over reports because the former is associated with real and potentially costly sequelae beyond the initiation of an evaluation or investigation. The three population indicators chosen for the study had the added benefit of being derived from three separate systems (i.e., Child Protective Services, Foster Care System and hospitals), which allowed for relatively independent corroboration and documentation of possible preventive effects.

      The conditions were: (1) Triple P System, which involved implementation of the core Triple P system with the existing workforce; and (2) Control, which meant services as usual without implementation of Triple P. Prevention of child maltreatment in this design is defined by three population indicators evaluated after a 2-year period of intervention dissemination controlling for the pre-intervention level. The pre-post randomized design builds in a 2-year period deemed to be necessary to train a sufficient number of service providers in the participating counties and to allow a sufficient amount of time for these providers to deliver the preventive interventions to many families. Using the three control variables for stratified random assignment was intended to reduce initial between-condition differences with respect to population size, which could be correlated with services available to families; poverty rate, which might make it more difficult to achieve intervention success; and child abuse rate, which is related to the outcomes of interest.

      TSPST: Specific modifications to the Triple P design for the population trial are as follows:

      • At Level 1, the TPSPT avoided any media outlets (e.g., television) or communication strategies that overlapped with the Control counties.
      • Two different delivery formats for Level 4 Triple P were deployed in the TPSPT: (1) Standard - a 10-session program (up to 90 minutes per session) with individual families that utilizes active skills training methods, as well as home visits or clinic observation sessions (40-60 minutes each); (2) Group - an 8-session group-administered program which employs an active skills training process; the 8 sessions consist of five 2-hour group sessions that provide opportunities for parents to learn through observation, discussion, practice and feedback and three 15-30 minute follow-up telephone sessions providing additional support to parents as they put into practice what they have learned in the group sessions.

      After randomization to condition, recruitment of service providers and organizations took place in the nine Triple P System counties. Service providers were recruited through many settings that provided services to families to participate in Triple P professional training courses. The dissemination staff identified and contacted stakeholders at both the state and local (county) levels in support services for parents of young children, including representatives from a wide range of provider systems such as education, school readiness, childcare, mental health, social services, and health. The staff introduced the Triple P system of interventions to each stakeholder group and organization and then worked with each entity to consider training needs and the ability to deliver parent consultation services. Providers who served families in the Triple P System counties were invited to training courses, and providers in other counties (including the Control counties) were not permitted to participate.

      Sample:
      Counties: All of the 18 counties selected for the TPSPT had population sizes between 50,000 and 175,000 and none of the counties had any prior exposure to Triple P at the start of the population trail. The counties ranged in demographics from rural to semi-urban. In terms of broader context, the agencies and services in these counties had suffered significant funding cuts over several years. The counties appeared to have little or no prior exposure to evidence-based parenting programs of any kind.

      Families: The referent population in the 18 counties was all families with at least one child under 8 years of age (though because this was a population-level trail, no families formally entered the trial). In the Triple P System counties, this is approximately 85,000 families in any given year. The birth to 8 years child group refers to the target age for assessing preventive effects on child maltreatment and was chosen because this is the period of greatest risk for child maltreatment selected by the funder (CDC) for the initiative.

      Service Providers: A key facet of the population-based dissemination of the Triple P system involves the engagement, training, and support of a broad array of service providers from several disciplines and settings including: family support services (social workers and therapists affiliated with county health centers, mental health centers, and schools), social services (family services, social workers), preschool and child-care settings (directors, teachers), elementary schools (parent educators, guidance counselors, kindergarten teachers), non-governmental organizations (e.g., early childhood NGOs, child-abuse prevention NGOs), private sector practitioners, health centers (primary healthcare providers), and other community entities having direct contact with parents and families. For the 2-year intervention period pertinent to this report, 649 service providers participated in Triple P professional training courses. Demographically, 91.7% of the providers were female, 57% European American (not Hispanic), 38.3% African American, 1.3% Hispanic, and 3.4% other ethnic/racial groups, with a mean age of 44.5. Most (81%) of the providers had already been engaged in parent consultation work for at least 5 years prior to Triple P training, and 59% had over 10 years of such experience.

      Measures:
      Public awareness of Triple P - A random telephone survey of households was conducted pre-intervention and again at post-intervention to determine relative growth in public awareness of Triple P in the two sets of counties. The surveys were based on random-dialing sampling of population databases of households where children resided. Response rates for the two administrations of the survey were 42.6% and 49.7%, respectively. Respondents who identified themselves as primary caregivers for at least one child under 8 years of age were asked whether they had heard of each of a number of parenting programs, including Triple P. The number of respondents in the Triple P System counties was 1,794 at pre-intervention and 1,854 at post intervention; 1,836 and 1,826 respectively in Control counties.

      Estimated number of families participating in Triple P - Follow-up telephone interviews with Triple P trained service providers were used to estimate the number of families to whom programming was delivered. Six months after participating in Triple P professional training, providers were contacted and asked about the number of families they served with Triple P (a) in the most recent 4-week period and (b) during the time since participation in Triple P training. The responses to these two interview questions were converted to annualized figures, which provided an upper and lower estimate of the number of families who providers indicated had participated in Triple P programming. These estimates are considered to be rough projections, which on the one hand could be overestimates because there is an assumption of constant rate of programming by any given provider, but on the other hand are likely to be underestimates because the data are extrapolated to a 12-month period even though the intervention period was actually 24 months.

      Population outcome indicators - Three population indicators related to child maltreatment served as the outcome variables for this study and were derived from independent data-collection systems deposited with a state-run statistical division. The first indicator was substantiated child maltreatment recorded by child protective services staff. These data were unduplicated such that no child maltreatment case was counted more than once in a given year. The second was child out-of-home placements recorded through the foster care system. The third was child hospitalizations and emergency room visits due to child maltreatment injuries, which were recorded by medical staff in compliance with mandatory state reporting requirements for hospitals, regardless of whether or when Child Protective Services was involved. All three population indicators were computed as annual rates per 1,000 children in the birth to 8-year-old range.

      Analysis: Prior to conducting the primary pre-post analyses, preliminary analyses of the three population indicators for the 5 years prior to the TPSPT were undertaken retrospectively to determine if the two clusters of counties showed any pre-study trends or differences. Each population indicator was subjected to a County Cluster x Time repeated measures analysis of variance. For each of the indicators, post-intervention rates for the Triple P System and Control conditions were compared, controlling for pre-intervention rate from the year just prior to the initiation of intervention.

      Outcomes

      Pre-intervention demographic characteristics of the counties - The two sets of counties were compared with respect to pre-intervention demographic characteristics. At pre-intervention, the Triple P System counties did not differ significantly from the Control counties with respect to county population, percentage of the population in poverty, and racial composition, and were quite comparable. Pre-intervention levels for the three outcome indicators, calculated as an average of the 5-year period prior to the study for each indicator, also did not differentiate the two sets of counties.

      After 2 years of intervention, randomly surveyed households in the Triple P System counties showed significantly higher proportion of awareness regarding Triple P than did those in Control counties. Consistent with this observation, the Triple P System counties showed significant growth in proportion of Triple P awareness from a mean of 4.8% to a mean of 17.1%, while Control counties did not show significant change from a mean of 4.5% to a mean of 5.5%. Based on follow-up telephone interviews with Triple P service providers, it was estimated that between 8,883 and 13,560 families participated in Triple P within the Triple P System counties. Between 71% and 75% of these families were reported to have received Levels 2/3 Triple P, and the remainder Level 4 Triple P and above.

      Population Outcomes - The unit of randomization - county - was the unit of analysis for the three population outcome indicators: substantiated child maltreatment, child out-of-home placements and hospitalizations or emergency room visits for child maltreatment injuries. The comparison of Triple P System and Control conditions revealed differential and positive effects on the Triple P System counties for rates of substantiated child maltreatment, child out-of-home placements, and hospitalizations or emergency-room visits for child maltreatment injuries.

      Sanders et al. 2008- Australian Trial , Every Family (note that this study was part of a national initiative in Australia known as Beyondblue: The National Depression Initiative)

      Evaluation Methodology

      Design : As trial funders, the Beyondblue organization was interested in determining the "real world" effects of a public health approach to mental health promotion and prevention using evidence-based interventions delivered through regular services. This meant utilizing and upskilling the existing workforce and building upon existing referral networks and delivery mechanisms. A pragmatic evaluation plan was required to track population level auditing or monitoring of parents in a defined catchment area to gauge program effects. The design involved repeated assessment of randomly drawn samples of parents from the catchment areas, rather than attempting to follow individual parents over time. Although this made it harder to detect intervention effects, this design had the advantage of assessing change in a population of parents over time. It was not possible to randomize geographic catchment areas receiving Triple P within the same city to different conditions, as the implementation of a comprehensive media strategy would have meant substantial local across condition leakage. Hence, the evaluation approach involved 10 intervention communities in southern Brisbane that implemented all five levels of the TPS (Triple P System). These communities were compared to 10 non-randomly assigned care as usual (CAU) communities; five in Melbourne, and five in Sydney.

      Household interviews were conducted using a computer-assisted telephone interviewing system (CATI). Trained telephone interviewers and a supervisor were employed to conduct the interviews. A total of 6003 surveys were conducted; 2999 at Time 1 (1499 with parents in the intervention city and 1500 in CAU cities), and 3004 at Time 2 (1504 in the intervention city and 1500 in the CAU cities). Time 1 surveys took place in July 2003; follow-up surveys at Time 2 were conducted in April 2006. Surveys were conducted at pre-intervention and then again at post-intervention two years later. Both times, a randomly drawn sample of parents in the selected catchment areas was asked to participate in the survey and to report on their own and their children's behavior.

      As schools and preschools were the major focal points for the children whose parents were to be surveyed, these settings were used to generate the units of analysis. Schools were ranked on the Index of Relative Socio Economic Disadvantage (IRSED). The IRSED was constructed from 20 variables collected at the 1996 Census of Population and Housing and describes the population of each census Collection District in terms of employment/unemployment, income, education, family structure, housing characteristics, Aboriginality and English language fluency. A school's score is an average of the index weighted by enrollments taking into account the geographical location of the student population. Schools were plotted on a map of the catchment area and placed into clusters on the basis of geographical proximity, similar IRSED scores and number of students. Attention was also given to major geographical boundaries such a major highways, rivers, railway lines and industrial areas. To maximize geographical separation, clusters were arranged so that a buffer region was between them whenever possible. Ten clusters were developed, with the mean number of target children estimated to be an average of 385 in each cluster. To achieve 1500 completed surveys, the minimum number in each cluster was 150. Clusters were then ordered on the basis of school's IRSED scores to represent broad socioeconomic variability.

      Ten catchment areas in suburban Melbourne and Sydney were identified to provide the CAU comparison samples. Australian Bureau of Statistics criteria were used to identify suburban catchments with a similar range of sociodemographic diversity in order the match the Queensland clusters as closely as possible. Catchments were constructed to ensure similar numbers of children of the target age resided there. In order to obtain telephone numbers for the CATI, school catchment areas were estimated based on geographical and transportation criteria. A list of telephone numbers was then obtained based on relevant suburban postcodes and census districts, and numbers were dialed at random within these catchment areas. When a household had at least one 4-7 year old child, CATI survey staff asked to interview the primary caregiver who was able to understand basic English. A household was considered unreachable after 15 attempts. Mean interview time was 25 minutes. In the baseline CATI, 39% of eligible calls resulted in a completed interview; this yielded 2,999 participants. In the post-assessment CATI, 35% of eligible calls resulted in a completed interview with a total of 3,004 parents. In the second CATI, 22% of respondents were identified as having been interviewed previously in the baseline survey.

      Triple P was implemented as a whole population approach that blended universal and indicated program elements. A coordinated media and community education campaign involving social marketing and health promotion strategies was used to promote the use of positive parenting practices in the community; increase the receptivity of parents towards participating in Triple P and other family/child interventions; de-stigmatize and normalize the process of seeking help for children with behavioral and emotional problems; increase the visibility and reach of the various interventions; and, counter the often alarmist, sensational or parent-blaming messages in the media. The target communities were provided with information about common behavioral, developmental and mental health problems in children and their families, the value of positive parenting in preventing and reducing these problems, and ways to obtain further information, advice and support. They received access to low-cost, high-quality written resources through a range of venues in the community and access to a telephone support service with Triple P-trained counselors through a statewide telephone counseling service for parents.

      Existing partnerships with local media outlets and new partnerships with community-based media outlets were used to support the media campaign. A cross-promotional media strategy comprising both print and electronic media was employed. Media activities included a positive parenting segment on national and local radio, positive parenting messages for broadcast on radio, and a series of positive parenting community service announcements on a major local television channel.

      Parents could participate in a Triple P Seminar Series conducted in local preschools, schools and community facilities by accredited Triple P providers. Parents were invited to attend up to three 90-minute seminars on topics related to the prevention of emotional and behavioral problems in children. The introductory seminar (The Power of Positive Parenting) was followed by two seminars dealing with common emotional and behavior problems in young children (Raising Confident, Competent Children and Raising Resilient Children). The second and third seminars in the series were designed to build on the foundations of the introductory seminar and show parents how to apply positive parenting principles in practical ways. Tip sheets were provided to parents and included information related to formulating individual solutions to the issues or problems addressed. Topics included promoting self-esteem in children, helping children confront their fears, partner support, coping with stress, helping children do well at school, helping children make friends, dealing with bullying, and dealing with disobedience.

      Parents whose children attended school received six Triple P Newsletters throughout the intervention period. This newsletter included tips and suggestions about positive parenting strategies designed to support their child's education, social competence, coping skills and development of self-esteem. It also provided information on how and where to access other levels of parenting advice and assistance.

      Parents could also enroll in a more intensive program that provided active skills training in a group format. Group Triple P is an eight hour program completed in either four weekly 2 hour sessions or a condensed one day program. It employed an active skills training process to help parents acquire new knowledge and skills across a wide range of child management topics via observation, discussion, practice and feedback. Positive parenting skills were demonstrated with videotapes and modeled by service providers. These skills were then practiced in small groups and parents received constructive feedback in an emotionally supportive context. The program also offered three optional weekly follow-up individual telephone consultations of up to 30 minutes to promote transfer and generalization of learning.

      Schools were invited to participate in a professional development program for teachers based on Workplace Triple P, a variant of Triple P aimed at assisting teachers in dealing with life stressors and difficult situations in the school environment. Participation also provided teachers with an opportunity to become familiar with the Triple P principles and strategies that were introduced to parents attending the school. Such an approach was designed to encourage a collaborative approach between home and schools so that teachers and parents would develop a more consistent approach in managing children. School staff also received briefings about Every Family from project managers and project officers. These 30-minute briefings were designed to provide an overview of the program and a snapshot of what was involved in Workplace Triple P for teachers.

      Primary care practitioners offered indicated intervention programs requiring participation in 3-4 sessions. Primary Care Triple P is a brief 4-session intervention specifically tailored to the primary care environment. Typically the sessions, each 20-30 minutes long, are delivered over a 4-6 week period. The program employs an active skills training process to help parents acquire new knowledge and skills about a specific child management issue or problem via discussion, practice and feedback. Positive parenting skills are demonstrated on videotape and modeled by practitioners. Information and advice about developing a specific parenting plan are provided to parents by health professionals selecting from a series of 46 tip sheets covering different developmental and behavioral topics. Parents then practice implementing the plan at home between sessions. Practitioners were offered training and accreditation in Primary Care Triple P, as well as support and supervision, as part of this project.

      Existing referral pathways were also reviewed and streamlined to facilitate communication and timely access to the appropriate level of care. Existing staff from the educational and health sector played a crucial role in consulting and liaising with local stakeholders and in promoting collaboration among them, in order to optimize communication and referral pathways and strengthen linkages across the community. Local mental health service and family intervention specialists' providers from Queensland Health serving the catchment areas were offered training in an advanced level Triple P training. This was to ensure they were familiar with Triple P and were in a position to provide consultative backup and receive appropriate referrals of parents and children requiring the most intensive levels of intervention.

      A total of 375 practitioners were trained as part of Every Family, with 73% becoming fully accredited by the training organization, across different levels of Triple P. All participants underwent a standardized training process consisting of 2-5 days training and a further 1-2 days accreditation. The training program employed active skills training procedures, detailed participant notes, practitioner manuals, part workbooks and videotape training material.

      Parents residing in CAU communities could access usual mental health, primary health care, welfare, and school-based services, and participate in any parenting programs available in their community. Although no specific integrated multilevel Triple P intervention was provided by the project team, some existing services may have exposed parents to Triple P if those services had service providers who had been previously trained in the program.

      Sample: Based on the 2001 Australian Bureau of Statistics (ABS) Census data, there were 12,874 children ages 4-7 years in the 10 Brisbane catchment areas. This comprised the total population of children whose parents were eligible to participate in the intervention and provided the pool from which the Brisbane survey sample was drawn. Participants were primary caregivers living in Brisbane, Sydney or Melbourne, with at least one child aged between 4 and 7 years at the Time 1 survey. Almost all caregivers were parents; parents were ineligible to participate if they were less than 18 years of age, did not speak English sufficiently well, had a mental or physical impairment that prevented them from being able to take part in a telephone interview, were staying in the contacted dwelling but did not usually live there, or did not have a child in the desired age range.

      Measures: The measurement plan consisted of a mix of well-validated parent report measures and specific individual questions assessing known risk and protective factors using Likert-type scales. A range of sociodemographic information was collected which included the age and sex of children and parents, respondent's employment status, education level, marital status, annual household income and ethnic background.

      The Strengths and Difficulties Questionnaire (SDQ) was used as the primary outcome variable to assess the nature and extent of children's emotional and behavioral problems as reported by parents. There are 25 items in the SDQ, with each subscale consisting of 5 items. The SDQ provides a total problem score that is generated by summing the scores from all scales except the prosocial scale. The SDQ also yields a score on the emotional subscale, the conduct subscale, the hyperactivity subscale, peer problems subscale and the prosocial subscale. Scores on the SDQ can be classified as normal, borderline and abnormal. Parents were also asked whether they considered their child to have had any emotional or behavioral problems over the past 6 months.

      As parental depression and high levels of parenting stress have been shown to be related to behavioral and emotional problems in children, parental adjustment was assessed. Parents rated how stressed and depressed they had felt over the two-week period prior to the survey on a 5-point Likert scale.

      To assess the presence of parental risk and protective factors, parents were asked about their use of specific parenting strategies for encouraging positive behavior and dealing with misbehavior. Parents were also asked about their use of parenting strategies when their child became anxious or distressed. The parenting strategies for encouraging positive behavior included: praising the child by describing what was pleasing; giving a treat, reward or fun activity; or giving attention such as a hug or wink when the child engaged in positive behavior. Strategies for dealing with misbehavior were divided into two groups. The first set of strategies has been shown to be effective in managing misbehavior and included ignoring the problem behavior, telling the child to stop misbehaving, using a consequence that fits the situation, sending the child to quiet time or time-out, and calling a family meeting to work out a solution. The second set of strategies has been associated with coercive or ineffective discipline and included a single smack with the hand, smacking more than once with hand or with an object other than hand, shouting or becoming angry, and threatening to do something the child would not like but not necessarily following through with it. The strategies for dealing with anxious or distressed behaviors included ignoring the distress by not giving attention; holding, cuddling or using physical contact to settle or calm the child; telling the child to stop being so silly; talking to the child in a soothing way until the fear has passed; allowing the child to avoid the thing he/she is scared of; and encouraging the child to be brave. For each of the parenting strategies, parents were asked to consider how likely they were to use each strategy based on a 4-point Likert scale.

      Parents were asked to consider how consistent they were in dealing with their child's behavior using a 5-point Likert scale. Parents were also asked how confident they had felt in the last 6 months to undertake their responsibilities as a parent to their 4-7 year old child using a 5-point Likert scale. To assess the availability of practical and emotional support for parents, respondents were asked to rate on a 5-point Likert scale how much they had felt supported in parenting by family, friends or neighbors over the past 6 months. To gauge parental awareness and participation in Triple P, parents were read a list of 5 commonly used parenting programs and asked if they had heard of each of them. To assess potential false positive recognition of parenting programs, one of the program options was fictional. Parental awareness of Triple P was assessed by asking parents whether they had heard or seen anything about Triple P in the past 12 months, and if so, where they had heard about it from a range of options including: friend, relative, neighbor, radio, television, newspaper, school newsletter, etc. If a parent indicated that they had been involved in a Triple P intervention, they were asked how they were involved: attended a brief seminar, had 1-4 brief meetings with a professional, attended group sessions with other parents, had individual sessions of about an hour each, had telephone contact only or some other way.

      Analysis: Logistic regression was used to examine differences between the conditions at Time 1 for each of the key child outcome variables, parent outcome variables, and parenting strategy variables. For each of the variables, change from Time 1 to Time 2 was then assessed by calculating odds ratios and 95% confidence intervals separately for each condition. Tarone's statistics were calculated to test for the equality of odds ratios between the TPS and CAU conditions. This test allowed for statistical comparison of the odds ratios representing change over time when significant change was observed in at least one of the conditions.

      Outcomes

      The TPS and CAU caregivers were similar in terms of the relationship of the participant to the target child, participant age distribution, and child gender, age and school status. Compared to the TPS group, the CAU group was more likely to be older, married, identify with an ethnic group, and have a higher income and education.

      At post-intervention the household survey showed that significantly more parents in the TPS (81.8%) than the CAU (46%) condition were aware of Triple P, and more than three times as many parents in the TPS (7.5%) as in the CAU (2.1%) condition had participated in a Triple P intervention.

      From pre- to post-intervention in the TPS condition, the proportion of children who were clinically elevated on SDQ Emotional Symptoms decreased significantly, whereas in the CAU condition, no significant change was observed. Improvements over time for these children were significantly greater for the TPS condition than the CAU condition. Similarly, children in the TPS condition who were clinically elevated on SDQ Total Difficulties decreased significantly from Time 1 to Time 2, whereas in the CAU condition the proportion did not change significantly. When looking at SDQ Conduct Problems, children in the CAU condition who were clinically elevated decreased significantly from pre- to post-intervention while the proportion for TPS children only approached significance, and odds ratios revealed no significant difference between the conditions. Between Time 1 and Time 2, the proportion of children with Behavioral and Emotional Problems decreased significantly in both the TPS and CAU condition; no significant difference was observed between the conditions in the level of change over time. No significant changes or differences between groups were observed between TPS and CAU in regards to SDQ Hyperactivity or SDQ Prosocial Behavior.

      From Time 1 to Time 2, the proportion of parents in the TPS condition with a "high" score for depression decreased significantly, while in the CAU condition, no change over time was observed. Conversely, from Time 1 to Time 2, the proportion of parents in the TPS condition with a "high" stress score did not change, while in the CAU condition, the proportion increased significantly; thus the increase over time for stress was significantly greater for the CAU condition than the TPS condition. No significant changes were observed from Time 1 to Time 2 in the proportion of parents who were high scorers on confidence, nor on support.

      From Time 1 to Time 2, the proportion of parents in the TPS condition likely to use appropriate parenting strategies for child misbehavior did not change, while in the CAU condition, the proportion increased significantly. When looking at inappropriate parenting strategies for child misbehavior, parents in both conditions likely to use such strategies decreased significantly from Time 1 to Time 2, however the magnitude of pre- to post-intervention change between conditions was significantly greater for the TPS condition than the CAU condition. No change over time or significant differences between TPS and CAU was found for appropriate parenting for fearful/anxious behavior, inappropriate parenting for fearful/anxious behavior, positive parenting or parenting consistency.

      Outcomes: Brief Bullets

      • The Triple P System (TPS) was associated with significantly greater reductions in emotional problems and psychosocial distress in both children and their parents than in the care as usual (CAU) condition.
      • No intervention effects were found for conduct problems, hyperactivity and peer relationship difficulties.
      • A greater reduction in coercive parenting was found in TPS vs. CAU conditions.

      Generalizability
      This study is generalizable to similar populations in Australia.

      Limitations

      • The design is a non-equivalent comparison as there was an inability to randomize communities to conditions.
      • Pretest differences favor controls (they were more educated/affluent).
      • All outcomes were based on household survey data (random digit dialing).
      • Telephone surveys resulted in a 39% response rate, resulting in issues of self-selection bias.
      • There were no effects on conduct problems.
      • Only 2 of 6 scales were significant -- the Total Strengths and Difficulties Scale and one of its subscales.
      • Potential for bias in reporting since only primary caretakers reported on their children's behavior.