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 Needs Carol W. Metzler, Oregon Research Institute carolm@ori.org ORI Research To Practice Conference, December 2010
2. The need for effective parenting interventions The importance of supporting parents in raising healthy and successful children Prevalence 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 outcomes Parental influence is pervasive Language, communication Sustained attention and problem solving Social skills and peer relationships Physical health and well being Brain injury and adverse effects of exposure to violence Emotion regulation School achievement Reduced social, emotional, behavioral, and health problems
4. Problem behaviors develop over time By age 6: aggressive behavior, difficulty managing strong feelings, weak academic skills Elementary school years: academic difficulties, poor bonding to school, rejection by peers By early adolescence: drift toward other troubled peers, experimentation with problem behaviors The earlier these problems begin, the more chronic and serious they become throughout adolescence
14. The need for effective parenting interventions Evidence-based parenting programs make a difference More skillful parents Healthier family relationships Decreased behavior problems in children and youth Improved social skills and academic outcomes Improved health outcomes as adults
15. Evidence-based models of family interventions for childhood problems Parent education and training Examples: PMTO, Triple P, Incredible Years, Strengthening Families 10-14 Skills focused, strengths based Warm, positive parent-child interactions and relationship Encourage and reinforce desirable behavior Monitor children’s activities Set clear limits on problem behaviors, and consistently enforce them with fair, non-harsh consequences Effective problem-solving Generalize skills to new situations
16. Evidence-based models of family interventions for childhood problems Home visiting Examples: Nurse-Family Partnership, Healthy Families New York Skills focused, strengths based Warm, positive parent-child interactions and relationship Parenting education Information on child development Social support Link family with community resources
17. Evidence-based models of family interventions for childhood problems Family therapy Examples: Functional Family Therapy, Multisystemic Therapy Skills focused, strengths based Promote warm, positive family interactions and relationships Promote a relational understanding of problem behavior Improve parenting skills Improve family communication, problem solving Generalize skills to new situations Discourage contact with deviant peers Link family with community resources
18. The challenge of reaching parents with effective parenting interventions Most parents struggle from time to time with difficult child behaviors Despite 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 programs Limited availability + poor participation = limited reach Thus, most parents who could benefit from parenting assistance never receive it
20. The goal of a public health approach to improving parenting Achieve positive changes in parenting practices across a whole population Reduce the prevalence of socioemotional and behavioral problems in children
21. A public health approach to improving parenting 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 A 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 impact Population-level impact = Reach x Efficacy x Adoption x Implementation x Maintenance Slide courtesy Dr Dennis Embry, Paxis Institute (2006)
24. Public health approach to improving parenting requires… Maximizing program reach Variety of delivery formats Efficient delivery Provide minimally sufficient supports, but not excessive dosage Improving program efficacy Meet the needs of diverse families Meet diverse levels of families’ needs Empower parents to take charge of the supports of they receive
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26. Meeting diverse levels of need Intensive Home visiting Face-to-face office visits Parenting groups Medium intensity Brief consultation on a specific problem Workshops/seminars Light-touch Self-administered workbooks, written materials Online programs Videos, TV broadcasts
27. How parents would prefer to receive information about effective parenting The highest preference ratings were for TV programs, online programs, written materials Lowest ratings were for home visits, therapists, and parenting groups – the most common evidence-based approaches
28. The efficacy of alternative formats and delivery mechanisms Home visits, office visits, and parenting groups are the most common evidence-based formats 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 One-time workshop on specific topic Self-administered workbook Structured online program TV series on parenting
29. A public health perspective In a public health framework, lighter-touch interventions are part of a larger system of supports may be sufficient level of dosage for some families complement more intensive supports extend the reach of parenting programs to those who might not otherwise be reached are consistent with the principles of minimal sufficiency and self-regulation Even modest effects of lighter-touch interventions could translate into substantial benefits when multiplied across many parents reached
30. Principle of minimal sufficiency The principle of minimal sufficiency calls on us to provide interventions that are sufficient to meet the need but not more than is needed This makes efficient use of resources Parents’ time Professionals’ time Provider agency resources Public or private funding
31. Principle of parent self-regulation Parental Self regulation Reduced need for support Minimally Sufficient Intervention
32. Triple P - Positive Parenting Program: A sophisticated public health approach to helping parents Five-level system Level 1 – Universal: Media Level 2 – Selected: 1-2 targeted sessions Level 3 – Primary care: 4 targeted sessions Level 4 – Standard: 8-10 session parenting group or face-to-face Level 5 – Enhanced: Intensive intervention for highest-risk families Developed by Matt Sanders at the Univ of Queensland in Australia 20 countries, 18 languages, 4 continents
33. Program topics Encouraging behavior you like Teaching new skills and behaviors Managing misbehavior Dealing with disobedience Handling fighting and aggression Planning for and dealing with high-risk situations Establishing good bedtime routines Shopping successfully with children Raising confident and competent children Parental self-care Parenting Media Project
38. Triple P evidence base The evidence 142 studies at 43 research institutions Single case experiments Meta analyses Efficacy trials Population trials Effectiveness trials 25 further trials in progress as of September 2010
39. Effects of population trial of Triple P system on child maltreatment Fewer out-of-home placements Fewer substantiated child maltreatment cases Fewer 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 problems Less dysfunctional parenting Less anger Less conflict over parenting High consumer satisfaction Effect sizes up to d=1.6 Child behavior problems - intensity
41. Effects of Triple P Online Child behavior problems - intensity Lower levels of child conduct problems Less dysfunctional parenting Greater parenting confidence Less parental anger High consumer satisfaction Effect sizes up to d=1.49
42. Effects of Triple P Media Series Lower levels of child conduct problems More child prosocial behaviors Less dysfunctional parenting Greater parenting knowledge Effect sizes up to d=.75 Parenting Media Project
43. The importance of appeal and engagement to achieving outcomes If we can’t engage parents, they won’t benefit Acknowledging parents as consumers with preferences Formats that fit ecologically into their lives Messages that engage and resonate Strategies that address their needs
44. Improving reach, appeal, and effectiveness for diverse populations Still much to learn about how to maximize the reach, appeal, and effectiveness of family interventions for different… Income groups Racial/ethnic groups Degrees of family risk and difficulties 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.
45. Broad reach, broad appeal Goal of the Triple P Parenting Media Series was to create a “media product” that has broad reach and broad appeal Engaging, entertaining, watchable Realistic Appealing to a diverse audience Mothers and fathers Income levels Ethnic and racial groups Different levels of challenge with children So that everybody can see themselves in it Parenting Media Project
46. Preliminary results – appeal High rates of watching the Triple P Parenting Media Series High satisfaction ratings: interesting, entertaining, useful, familiar situations, relevant to daily life Broad appeal across racial/ethnic, income, and educational groups, and other family characteristics Non-working moms and those most challenged by children’s behavior problems are finding it most useful Those with lower education and lower self-efficacy have been more likely to watch all episodes on schedule Parenting Media Project
47. In conclusion… A public health approach focuses on population-level impact reaching as many families as possible variety of formats varying levels of intensity minimally sufficient dosage empowering parents to take charge of the help they receive With a public health approach, we can reach a large number and broad range of parents engage them in the message encourage them to try out new skills have a substantial impact on important outcomes Parenting Media Project
48. Implications and challenges For researchers and program developers: to develop and test programs in a variety of formats and different levels of intensity, with broad reach, broad appeal, AND good efficacy For practitioners: To incorporate a public health perspective into practice adapting to diverse needs utilizing a variety of formats, delivery mechanisms, and levels of intensity to meet family needs Parenting Media Project
49. Thank youTriple P information at www.triplep.net Parenting Media Project
Notas do Editor
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.
