Parenting matters. So important to support parents in raising healthy children. The quality of the parenting that children receive really matters and it affects every aspect of their development.There is a reasonably high prevalence of children’s behavior disorders; it currently stands at about 18% of children.When children have difficulties with behavior problems when they are young, coupled with poor family relationships and dysfunctional parenting practices, the children are much more likely to grow up continuing to have problems with the law, substance use, and poor functioning and poor health as an adolescent and adult.
Thanks to Matt Sanders of University of Queensland for this slide.
We know that parenting programs that have undergone rigorous evaluation and are evidence-based can make a substantial difference in families’ lives.
More intensive, in situ
So, there are a number of evidence-based parenting interventions, and that’s great.Most parents struggle from time to time with difficult child behaviors and could use some help…Challenges re: recruitment and retention: Scheduling conflicts, logistical difficulties, fatigue, insufficient motivation to get out, not wanting to join a group.
So we need to think about this in a whole new way.The goal of a public health approach to improving parenting is to achieve positive changes in parenting practices across a whole population, thereby reducing the prevalence of socioemotional and behavioral problems in children. (Prevalence means the percentage of a population with a particular problem or characteristic.)A public health framework gets us thinking bigger.
Focus today on two aspects of the RE-AIM formula that undergird the public health approach: Reach and efficacy.
Understand the principles of maximizing program reach through a using a variety of appealing delivery formats and agents, and increasingefficiency of delivery…and maximizing efficacy through adapting to different levels of families’ needs and promoting parental self-regulation.Public health perspective requires us to look for efficient ways to meet a diverse range of needs among a diverse range families through a variety of delivery formats.
Can organize these formats into varying levels of intensity to meet varying levels of need.Not everyone needs a 12-session parenting group or a full course of meetings with a therapist. Some parents can benefit from a lighter dose – a brief consultation, a workshop, a self-administered course, an online program, etc.
158 ethnically diverse parents of 3-6 year olds, half with clinical levels of behavior problems, and half within normal range.In this sample, the most common approaches that our field offers are least preferred by parents. Hmmm.Pattern is also consistent for mothers vs. fathers, and Caucasians vs. minorities. Consistent preference for self-administered approaches across subgroups.
Not JUST about individual families one at a time, but ALSO about affecting the entire community
20 countries, 18 languages, 4 continents: N. America, Australia, Europe, AsiaDifferent levels of intensity for different levels of need.
17 core parenting strategies presented
Natural touchpoints for parents
Standard – core program – is designed for dealing with children’s conduct problems
Preliminary results of pilot studyECBI intensityN (Internet) = 24; N (Waitlist) = 32; intervention effect sig. p<.001, d=1.49
The Triple P Parenting Media Study is testing the efficacy of a 10-episode video media series on parenting Content is derived from the Triple P Positive Parenting ProgramResearch sites: Eugene and Portland, OregonSample: 300 parents having difficulty handling their 3-6 year old children’s behavior problems and not otherwise receiving parenting support servicesPreliminary analyses on the first 209 participants also suggest that the Triple P Media Series actually helped parents. Significant Tx vs. WL at T2; ES = .53SignificantTx vs. WL at T3; ES = .62Scale range: 36 – 252 Clinical cutoff: 132Effects for both mothers and fathers on dysfunctional parenting practices and parenting knowledge
Underscore the importance of meeting the needs of diverse families – --different income levels--different racial/ethnic groups--different degrees of family risk and difficultiesDennis Embry will help us think outside the box about how we can use a variety of resources and approaches to meet family needs.And Mark Eddy/Laura Rains will discuss methods for matching intensity of treatment to different levels of need.Betsy Davis will discuss issues related to meeting the needs of culturally diverse families.
A few words about appeal and engagement from our Parenting Media study. Our goal was to create a program that is more entertaining than your standard instructional video, and more instructional than reality TV, such as Nanny 911 or Supernanny.Hosted format. We use footage of real families in real situations; compelling, dramatic, emotionally evocative and engaging footage; vox pops (that is, person on the street interviews); a parent group with Matt Sanders; and what we call “hero” families who we follow through an episode to see their struggles and successes.Families from the US, Australia, and United Kingdom. American host/narrator. Diversity of families, faces, and accents.
These preliminary analyses suggest that the challenges of parenting are universal, across racial/ethnic, income, and educational groups– what is important is that we develop programs that are responsive to people’s felt need for help. The Triple P Media Series was most attractive and useful to those who needed it the most.
Triple P Metzler 12-3-2010
A Public Health Approach to Improving Parenting Practices: An Overview of Principles and Practices for Meeting Diverse Family Needs<br />Carol W. Metzler, Oregon Research Institute<br />email@example.com<br />ORI Research To Practice Conference, December 2010<br />
The need for effective parenting interventions<br />The importance of supporting parents in raising healthy and successful children<br />Prevalence of children’s behavior disorders: 18%<br />Dysfunctional parenting practices <br /> & family relationships <br />Poor prognosis for long- <br /> term trajectory, including <br /> health outcomes as adults<br />
Parenting affects many important developmental outcomes<br />Parental influence is pervasive<br />Language, communication<br />Sustained attention and problem solving<br />Social skills and peer relationships<br />Physical health and well being<br />Brain injury and adverse effects of exposure to violence<br />Emotion regulation<br />School achievement <br />Reduced social, emotional, behavioral, and health problems<br />
Problem behaviors develop over time<br />By age 6: aggressive behavior, difficulty managing strong feelings, weak academic skills<br />Elementary school years: academic difficulties, poor bonding to school, rejection by peers<br />By early adolescence: drift toward other troubled peers, experimentation with problem behaviors<br />The earlier these problems begin, the more chronic and serious they become throughout adolescence<br />
Parents’ self-care</li></li></ul><li>Why evidence-based practices?<br />Our best bet is on programs that have shown positive benefits in experimental evaluations <br />Supported by data, not just based on theory <br />Rigorously tested and shown to be more effective than “usual care” or an alternative practice<br />Can be reproduced in other settings<br />Increases our confidence in the results<br />
The need for effective parenting interventions<br />Evidence-based parenting programs make a difference<br />More skillful parents<br />Healthier family relationships<br />Decreased behavior problems in children and youth<br />Improved social skills and academic outcomes<br />Improved health outcomes as adults<br />
Evidence-based models of family interventions for childhood problems<br />Parent education and training<br />Examples:<br />PMTO, Triple P, Incredible Years, Strengthening Families 10-14<br />Skills focused, strengths based<br />Warm, positive parent-child interactions and relationship<br />Encourage and reinforce desirable behavior<br />Monitor children’s activities<br />Set clear limits on problem behaviors, and consistently enforce them with fair, non-harsh consequences<br />Effective problem-solving<br />Generalize skills to new situations<br />
Evidence-based models of family interventions for childhood problems<br />Home visiting<br />Examples:<br />Nurse-Family Partnership, Healthy Families New York <br />Skills focused, strengths based<br />Warm, positive parent-child interactions and relationship<br />Parenting education<br />Information on child development<br />Social support<br />Link family with community resources<br />
Evidence-based models of family interventions for childhood problems<br />Family therapy<br />Examples:<br />Functional Family Therapy, Multisystemic Therapy <br />Skills focused, strengths based<br />Promote warm, positive family interactions and relationships<br />Promote a relational understanding of problem behavior<br />Improve parenting skills<br />Improve family communication, problem solving<br />Generalize skills to new situations<br />Discourage contact with deviant peers<br />Link family with community resources<br />
The challenge of reaching parents with effective parenting interventions<br />Most parents struggle from time to time with difficult child behaviors<br />Despite effectiveness, few parents participate in evidence-based parenting programs (Sanders et al., 2007)<br />Limited availability outside of major metropolitan areas (Connell et al., 1998)<br />Poor participation – substantial challenges in recruiting and retaining parents (Spoth & Redmond, 2000)<br />
Limited reach of evidence-based parenting programs<br />Limited availability + poor participation = limited reach<br />Thus, most parents who could benefit from parenting assistance never receive it<br />
The goal of a public health approach to improving parenting<br />Achieve positive changes in parenting practices across a whole population<br />Reduce the prevalence of socioemotional and behavioral problems in children<br />
A public health approach to improving parenting<br />To significantly improve the health and well being of children at a population level, we must strengthen parents’ skills, knowledge, and confidence in the task of raising their children<br />A public health approach requires us to think about how we can get effective parenting supports to the maximum number of people. <br />
How can we achieve a population level effect?<br />Create leverage using the RE-AIM formula (Glasgow et al, 2001)<br />Slide courtesy Dr Dennis Embry, Paxis Institute (2006)<br />
Achieving population-level impact<br />Population-level impact =<br />Reach x Efficacy<br />x Adoption x Implementation x Maintenance <br />Slide courtesy Dr Dennis Embry, Paxis Institute (2006)<br />
Public health approach to improving parenting requires…<br />Maximizing program reach<br />Variety of delivery formats<br />Efficient delivery<br />Provide minimally sufficient supports, but not excessive dosage <br />Improving program efficacy<br />Meet the needs of diverse families<br />Meet diverse levels of families’ needs<br />Empower parents to take charge of the supports of they receive<br />
Formats for reaching parents<br />Home visiting<br />Face-to-face office visits<br />Parenting groups<br /><ul><li>Brief consultation on a specific problem</li></ul>Workshops/seminars<br />Self-administered workbooks, written materials<br />Videos<br />Online programs<br />TV broadcasts<br />
Meeting diverse levels of need<br />Intensive<br />Home visiting<br />Face-to-face office visits<br />Parenting groups<br />Medium intensity<br />Brief consultation on a specific problem<br />Workshops/seminars<br />Light-touch<br />Self-administered workbooks, written materials<br />Online programs<br />Videos, TV broadcasts<br />
How parents would prefer to receive information about effective parenting<br />The highest preference ratings were for TV programs, online programs, written materials<br />Lowest ratings were for home visits, therapists, and parenting groups – the most common evidence-based approaches<br />
The efficacy of alternative formats and delivery mechanisms<br />Home visits, office visits, and parenting groups are the most common evidence-based formats<br />But self-administered and other no-clinician formats have shown substantial and sustained effects on parenting and child behavior outcomes, even for at-risk families<br />One-time workshop on specific topic<br />Self-administered workbook<br />Structured online program<br />TV series on parenting<br />
A public health perspective<br />In a public health framework, lighter-touch interventions<br />are part of a larger system of supports<br />may be sufficient level of dosage for some families<br />complement more intensive supports<br />extend the reach of parenting programs to those who might not otherwise be reached<br />are consistent with the principles of minimal sufficiency and self-regulation<br />Even modest effects of lighter-touch interventions could translate into substantial benefits when multiplied across many parents reached<br />
Principle of minimal sufficiency<br />The principle of minimal sufficiency calls on us to provide interventions that are <br />sufficient to meet the need<br />but not more than is needed<br />This makes efficient use of resources<br />Parents’ time<br />Professionals’ time<br />Provider agency resources<br />Public or private funding<br />
Principle of parent self-regulation<br />Parental <br />Self regulation<br />Reduced need for support<br />Minimally <br />Sufficient <br />Intervention<br />
Triple P - Positive Parenting Program: A sophisticated public health approach to helping parents<br />Five-level system <br />Level 1 – Universal: Media<br />Level 2 – Selected: 1-2 targeted sessions<br />Level 3 – Primary care: 4 targeted sessions<br />Level 4 – Standard: 8-10 session parenting group or face-to-face<br />Level 5 – Enhanced: Intensive intervention for highest-risk families<br />Developed by Matt Sanders at the Univ of Queensland in Australia<br />20 countries, 18 languages, 4 continents<br />
Program topics <br />Encouraging behavior you like<br />Teaching new skills and behaviors<br />Managing misbehavior<br />Dealing with disobedience<br />Handling fighting and aggression<br />Planning for and dealing with high-risk situations<br />Establishing good bedtime routines<br />Shopping successfully with children<br />Raising confident and competent children<br />Parental self-care<br />Parenting Media Project<br />
Triple P variants<br />* Under development<br />
Self-regulation framework: Collaborating with and empowering parents <br />
Triple P evidence base<br />The evidence<br />142 studies at<br />43 research institutions<br />Single case experiments<br />Meta <br />analyses<br />Efficacy trials<br />Population trials<br />Effectiveness trials<br />25 further trials in progress<br />as of September 2010<br />
Effects of population trial of Triple P system on child maltreatment<br />Fewer out-of-home placements<br />Fewer substantiated child maltreatment cases<br />Fewer child maltreatment injuries (hospital and emergency room)<br />Effect sizes up to d=1.22<br />
Effects of TP workshop on disobedience Morawska, A., Haslam, D., Milne, D., & Sanders, M.R. (in press). Effects of a Brief Parenting Discussion Group for Parents of Young Noncompliant Children. Journal of Developmental & BehavioralPediatrics.<br />Lower level of conduct problems<br />Less dysfunctional parenting <br />Less anger<br />Less conflict over parenting<br />High consumer satisfaction <br />Effect sizes up to d=1.6<br />Child behavior problems - intensity<br />
Effects of Triple P Online <br />Child behavior problems - intensity<br />Lower levels of child conduct problems<br />Less dysfunctional parenting<br />Greater parenting confidence<br />Less parental anger<br />High consumer satisfaction<br />Effect sizes up to d=1.49<br />
Effects of Triple P Media Series<br />Lower levels of child conduct problems<br />More child prosocial behaviors<br />Less dysfunctional parenting <br />Greater parenting knowledge<br />Effect sizes up to d=.75<br />Parenting Media Project<br />
The importance of appeal and engagement to achieving outcomes<br />If we can’t engage parents, they won’t benefit<br />Acknowledging parents as consumers with preferences<br />Formats that fit ecologically into their lives<br />Messages that engage and resonate<br />Strategies that address their needs<br />
Improving reach, appeal, and effectiveness for diverse populations<br />Still much to learn about how to maximize the reach, appeal, and effectiveness of family interventions for different…<br />Income groups<br />Racial/ethnic groups<br />Degrees of family risk and difficulties<br />Improving the reach, appeal and effectiveness of interventions to diverse populations increases overall public health impact, and helps us meet the needs of individual families before us.<br />
Broad reach, broad appeal<br />Goal of the Triple P Parenting Media Series was to create a “media product” that has broad reach and broad appeal<br />Engaging, entertaining, watchable<br />Realistic<br />Appealing to a diverse audience<br />Mothers and fathers<br />Income levels<br />Ethnic and racial groups<br />Different levels of challenge with children<br />So that everybody can see themselves in it<br />Parenting Media Project<br />
Preliminary results – appeal <br />High rates of watching the Triple P Parenting Media Series<br />High satisfaction ratings: interesting, entertaining, useful, familiar situations, relevant to daily life<br />Broad appeal across racial/ethnic, income, and educational groups, and other family characteristics<br />Non-working moms and those most challenged by children’s behavior problems are finding it most useful<br />Those with lower education and lower self-efficacy have been more likely to watch all episodes on schedule<br />Parenting Media Project<br />
In conclusion…<br />A public health approach focuses on <br />population-level impact<br />reaching as many families as possible<br />variety of formats<br />varying levels of intensity<br />minimally sufficient dosage<br />empowering parents to take charge of the help they receive<br />With a public health approach, we can<br />reach a large number and broad range of parents<br />engage them in the message<br />encourage them to try out new skills<br />have a substantial impact on important outcomes<br />Parenting Media Project<br />
Implications and challenges<br />For researchers and program developers:<br />to develop and test programs in a variety of formats and different levels of intensity, with broad reach, broad appeal, AND good efficacy<br />For practitioners:<br />To incorporate a public health perspective into practice<br />adapting to diverse needs<br />utilizing a variety of formats, delivery mechanisms, and levels of intensity to meet family needs<br />Parenting Media Project<br />
Thank youTriple P information at www.triplep.net<br />Parenting Media Project<br />