This document discusses adopting a public health approach to improving parenting practices in order to reduce behavior problems in children. It notes that while evidence-based parenting programs have been shown to be effective, few parents participate in them due to limited availability and engagement challenges. A public health approach aims to strengthen parenting skills across whole populations using a variety of minimally intensive formats to maximize reach, including self-administered materials, brief consultations, and online/TV programs. This broader reach can achieve greater impacts on children's outcomes than traditional intensive formats alone. The Triple P Positive Parenting Program is presented as a model that incorporates different levels of support.

1. A Public Health Approach to Improving Parenting Practices: An Overview of Principles and Practices for Meeting Diverse Family NeedsCarol W. Metzler, Oregon Research Institutecarolm@ori.orgORI Research To Practice Conference, December 2010

2. The need for effective parenting interventionsThe importance of supporting parents in raising healthy and successful childrenPrevalence of children’s behavior disorders: 18%Dysfunctional parenting practices & family relationships Poor prognosis for long- term trajectory, including health outcomes as adults

3. Parenting affects many important developmental outcomesParental influence is pervasiveLanguage, communicationSustained attention and problem solvingSocial skills and peer relationshipsPhysical health and well beingBrain injury and adverse effects of exposure to violenceEmotion regulationSchool achievement Reduced social, emotional, behavioral, and health problems

4. Problem behaviors develop over timeBy age 6: aggressive behavior, difficulty managing strong feelings, weak academic skillsElementary school years: academic difficulties, poor bonding to school, rejection by peersBy early adolescence: drift toward other troubled peers, experimentation with problem behaviorsThe earlier these problems begin, the more chronic and serious they become throughout adolescence

5. Problem behaviors are COSTLY

6. How can we reduce these problems and raise successful children and youth?

7. Promote positive parenting usingevidence-based prevention and treatment practices

8. Positive parenting involves…A safe, engaging environment

9. A positive learning environment

10. Warm, nurturing interactions

11. Assertive discipline – clear, fair, consistent, proactive

12. Realistic expectations

13. Parents’ self-careWhy evidence-based practices?Our best bet is on programs that have shown positive benefits in experimental evaluations Supported by data, not just based on theory Rigorously tested and shown to be more effective than “usual care” or an alternative practiceCan be reproduced in other settingsIncreases our confidence in the results

14. The need for effective parenting interventionsEvidence-based parenting programs make a differenceMore skillful parentsHealthier family relationshipsDecreased behavior problems in children and youthImproved social skills and academic outcomesImproved health outcomes as adults

15. Evidence-based models of family interventions for childhood problemsParent education and trainingExamples:PMTO, Triple P, Incredible Years, Strengthening Families 10-14Skills focused, strengths basedWarm, positive parent-child interactions and relationshipEncourage and reinforce desirable behaviorMonitor children’s activitiesSet clear limits on problem behaviors, and consistently enforce them with fair, non-harsh consequencesEffective problem-solvingGeneralize skills to new situations

16. Evidence-based models of family interventions for childhood problemsHome visitingExamples:Nurse-Family Partnership, Healthy Families New York Skills focused, strengths basedWarm, positive parent-child interactions and relationshipParenting educationInformation on child developmentSocial supportLink family with community resources

17. Evidence-based models of family interventions for childhood problemsFamily therapyExamples:Functional Family Therapy, Multisystemic Therapy Skills focused, strengths basedPromote warm, positive family interactions and relationshipsPromote a relational understanding of problem behaviorImprove parenting skillsImprove family communication, problem solvingGeneralize skills to new situationsDiscourage contact with deviant peersLink family with community resources

18. The challenge of reaching parents with effective parenting interventionsMost parents struggle from time to time with difficult child behaviorsDespite effectiveness, few parents participate in evidence-based parenting programs (Sanders et al., 2007)Limited availability outside of major metropolitan areas (Connell et al., 1998)Poor participation – substantial challenges in recruiting and retaining parents (Spoth & Redmond, 2000)

19. Limited reach of evidence-based parenting programsLimited availability + poor participation = limited reachThus, most parents who could benefit from parenting assistance never receive it

20. The goal of a public health approach to improving parentingAchieve positive changes in parenting practices across a whole populationReduce the prevalence of socioemotional and behavioral problems in children

21. A public health approach to improving parentingTo 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 childrenA public health approach requires us to think about how we can get effective parenting supports to the maximum number of people.

22. How can we achieve a population level effect?Create leverage using the RE-AIM formula (Glasgow et al, 2001)Slide courtesy Dr Dennis Embry, Paxis Institute (2006)

23. Achieving population-level impactPopulation-level impact =Reach x Efficacyx Adoption x Implementation x Maintenance Slide courtesy Dr Dennis Embry, Paxis Institute (2006)

24. Public health approach to improving parenting requires…Maximizing program reachVariety of delivery formatsEfficient deliveryProvide minimally sufficient supports, but not excessive dosage Improving program efficacyMeet the needs of diverse familiesMeet diverse levels of families’ needsEmpower parents to take charge of the supports of they receive

25. Formats for reaching parentsHome visitingFace-to-face office visitsParenting groupsBrief consultation on a specific problemWorkshops/seminarsSelf-administered workbooks, written materialsVideosOnline programsTV broadcasts

26. Meeting diverse levels of needIntensiveHome visitingFace-to-face office visitsParenting groupsMedium intensityBrief consultation on a specific problemWorkshops/seminarsLight-touchSelf-administered workbooks, written materialsOnline programsVideos, TV broadcasts

27. How parents would prefer to receive information about effective parentingThe highest preference ratings were for TV programs, online programs, written materialsLowest ratings were for home visits, therapists, and parenting groups – the most common evidence-based approaches

28. The efficacy of alternative formats and delivery mechanismsHome visits, office visits, and parenting groups are the most common evidence-based formatsBut self-administered and other no-clinician formats have shown substantial and sustained effects on parenting and child behavior outcomes, even for at-risk familiesOne-time workshop on specific topicSelf-administered workbookStructured online programTV series on parenting

29. A public health perspectiveIn a public health framework, lighter-touch interventionsare part of a larger system of supportsmay be sufficient level of dosage for some familiescomplement more intensive supportsextend the reach of parenting programs to those who might not otherwise be reachedare consistent with the principles of minimal sufficiency and self-regulationEven modest effects of lighter-touch interventions could translate into substantial benefits when multiplied across many parents reached

30. Principle of minimal sufficiencyThe principle of minimal sufficiency calls on us to provide interventions that are sufficient to meet the needbut not more than is neededThis makes efficient use of resourcesParents’ timeProfessionals’ timeProvider agency resourcesPublic or private funding

31. Principle of parent self-regulationParental Self regulationReduced need for supportMinimally Sufficient Intervention

32. Triple P - Positive Parenting Program: A sophisticated public health approach to helping parentsFive-level system Level 1 – Universal: MediaLevel 2 – Selected: 1-2 targeted sessionsLevel 3 – Primary care: 4 targeted sessionsLevel 4 – Standard: 8-10 session parenting group or face-to-faceLevel 5 – Enhanced: Intensive intervention for highest-risk familiesDeveloped by Matt Sanders at the Univ of Queensland in Australia20 countries, 18 languages, 4 continents

33. Program topics Encouraging behavior you likeTeaching new skills and behaviorsManaging misbehaviorDealing with disobedienceHandling fighting and aggressionPlanning for and dealing with high-risk situationsEstablishing good bedtime routinesShopping successfully with childrenRaising confident and competent childrenParental self-careParenting Media Project

34. Triple P formats

35. Service delivery settings and providers

36. Triple P variants* Under development

37. Self-regulation framework: Collaborating with and empowering parents

38. Triple P evidence baseThe evidence142 studies at43 research institutionsSingle case experimentsMeta analysesEfficacy trialsPopulation trialsEffectiveness trials25 further trials in progressas of September 2010

39. Effects of population trial of Triple P system on child maltreatmentFewer out-of-home placementsFewer substantiated child maltreatment casesFewer child maltreatment injuries (hospital and emergency room)Effect sizes up to d=1.22

40. 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.Lower level of conduct problemsLess dysfunctional parenting Less angerLess conflict over parentingHigh consumer satisfaction Effect sizes up to d=1.6Child behavior problems - intensity

41. Effects of Triple P Online Child behavior problems - intensityLower levels of child conduct problemsLess dysfunctional parentingGreater parenting confidenceLess parental angerHigh consumer satisfactionEffect sizes up to d=1.49

42. Effects of Triple P Media SeriesLower levels of child conduct problemsMore child prosocial behaviorsLess dysfunctional parenting Greater parenting knowledgeEffect sizes up to d=.75Parenting Media Project

43. The importance of appeal and engagement to achieving outcomesIf we can’t engage parents, they won’t benefitAcknowledging parents as consumers with preferencesFormats that fit ecologically into their livesMessages that engage and resonateStrategies that address their needs

44. Improving reach, appeal, and effectiveness for diverse populationsStill much to learn about how to maximize the reach, appeal, and effectiveness of family interventions for different…Income groupsRacial/ethnic groupsDegrees of family risk and difficultiesImproving 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.

45. Broad reach, broad appealGoal of the Triple P Parenting Media Series was to create a “media product” that has broad reach and broad appealEngaging, entertaining, watchableRealisticAppealing to a diverse audienceMothers and fathersIncome levelsEthnic and racial groupsDifferent levels of challenge with childrenSo that everybody can see themselves in itParenting Media Project