Parenting in the early years

Matthew R Sanders, Ph.DParenting and Family Support Centre

The University of QueenslandBrisbane, Australia

The central importance of parenting in children’s lives

Starting a family

• Most young people envisage a future with children and 90% of married couples experience it (Cowan & Cowan, 1995)

• Transition to first time parenthood is considered a critical time of disequilibrium for individuals, couples and families

• Is a normative, socially supported

• The transition to parenthood can result in increased conflict

• Half of all new parents report a decline in relationship satisfaction (35% reporting small or moderate decline, 12% showing severe decline)

• Decline related to decrease in disposable income, personal free time, frequency and enjoyment of sex, quality time shared with just the spouse

• Couple communication becomes more negative (fatigue and limited distraction free time)

• Gender roles become more traditional• Both partners can experience role strain

Why early parenting is important

Many reasons

The importance of parenting in the early yearsHart & Risley (1995)

• Discover how everyday family experience influences the development of language, social and intellectual competence

• To assess how much parent-child interaction in infancy and toddlerhood predict subsequent school accomplishments

Study

• Children from professional, working class and welfare homes

• Monthly 1 hour observations in homes for 2.5 years, from age 10 months onwards

• Reassessed at age 3 and age 9-10 years

Language Experience

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Professional Working-class Welfare

Encouragements

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Predictors of Children’s Accomplishments at 9-10

• Children’s language accomplishments at age 3 (rate of vocabulary growth, vocabulary use and IQ)

• Early family experience (feedback tone, symbolic emphasis, and guidance style) were better predictors than child’s early accomplishments

• Family SES explain 30% of variance, parenting variables explained 61% of variance

What Would be Needed to Create Equal Opportunities for Children

• To provide the average child with a welfare background with weekly language experience similar to that experienced by children from a working class background, would require 41 hrs per week of out of home experience as rich in words as that addressed to children in professional homes

• They would need 26 hours of substituted experience with affirmation to catch up with the average child from a working class background

The majority of parents do not

participate in any form of parent education

A different approach is needed

Triple P System

• Population-wide system of coordinated, multi-level programs from before birth to adolescence

• Evidence-based approach, well researched• Tiered continuum-interventions of increasing

intensity• Parenting support readily accessible—multiple

access points• Building continuity of principles and strategies

across intensity levels and practitioners

Levels of Intervention

Universal Triple PUniversal Triple PLevel OneLevel One

Primary Care Triple PLevel three

Selected Triple PLevel Two

Standard Triple PLevel four

Enhanced Triple PLevel five

Key assumptions

• Parenthood preparation is about promoting flexibility, adaptation and capacity to change

• Prenatal to adolescence• Principle of sufficiency• Multidisciplinary

Principles of Effective Parent Consultation

• Empowerment model• Addresses known risk factors• Developmentally timed to optimize

impact• Based on explicit testable theoretical

framework• Culturally appropriate• Cost-effective

Self regulation framework

Parental Self regulation

1Self

sufficiency2

Self efficacy

3Self

management

4Personal agency

5Problemsolving

Principles of positive parenting

• Ensuring a safe, engaging environment

• Creating a positive learning environment

• Using assertive discipline

• Having realistic expectations

• Taking care of yourself as a parent

Breadth of reach

Individual Group Self-directed

Media and Communication strategyLevel 1-Universal

Brief parenting adviceLevel 2-Selected

Narrow focus parent skills trainingLevel 3-Primary Care

Broad focus parent skills trainingLevel 4-Standard

Intensive family interventionLevel 5-EnhancedIn

crea

sing

Int

ensi

ty

Hig

hLo

w

Program variants

Core Triple PProgram

Teen Triple P

PathwaysTriple P

Stepping StonesTriple P

IndigenousTriple P Lifestyle

Triple PWorkplace

Triple P

Family Transitions

Triple P

Triple P for teachers

Research and practice link

11 controlled single case trials

29 RCT Efficacy trials

9 Effectiveness trials

6 Dissemination trials

Sanders, 1980Sanders & Glynn, 1981Sanders & Dadds, 1982

Sanders & Christensen, 1985Dadds, Schwartz & Sanders, 1987Sanders, Markie-Dadds, Bor & Tully, 2000McFarland & Sanders, 2000Hoath & Sanders, 2003

Markie-Dadds & Sanders(in press)Zubrick, et al, 2005Sultana et al, 2002Dean & Myors, 2003

Turner & Sanders, 2003Sanders, et al in press

Sample studies

Changing nature of research questions

• What type or level of intervention is effective in preventing or managing what problems, under which circumstances•Using which delivery modalities (individual, group, telephone assisted, self directed)•In what delivery contexts (primary care, school, work)•At what point in a child’s development

• How do these intervention effects come about and do they last?

Ensuring adequate population reach

Establishing intervention targets

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49.5

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82.5

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0102030405060708090

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Desired reduction in population prevalence (%)

Nec

essa

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opul

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ach

(%)

How can reach be improved?

• Be inclusive, normalize and destigmatizeparenting programs

• Listen to what parents say they want • Use multiple access points and delivery

contexts• Adopt an ecological model to support

parenting throughout the lifespan

Can we more effectively harness the power of the media to promote

positive family relationships?

Why television?

• Worldwide there are 2.7 billion regular viewers of television (Eurodata, 2005)

• Widely available-99% of households have at least,1 TV set (US average=2.8) (Woodard & Gridina, 2000).

• TV is the major source of news and new information

• Third most preferred information source for parenting advice and rated as one of the most useful (FACS,2004)

Huge potential reach

• Observational documentaries or “coach” television series are the new genre and attract large viewing audiences in the target demographic

• Nanny 911 attracts around 8 - 9.5 million viewers, and around 7 million households, and is sometimes winning its time slot among adults 18-49, 18-34, 25-34, and Women 18-49, 18-34, and 25-54, and is ranked in the top 20 among 12-34 year olds.

• Supernanny averages around 8.5-9.5 million viewers, and around 6.9 million households, and is ranked in top 20 shows among 18-49 year olds.

Reality TV Series on Parenting

• ITV largest commercial network in the UK• Series captures the emotional journey of the families

undertaking Group Triple P • Depicts the triumphs and setbacks as they learn positive

parenting strategies• 5 families (9 parents, 5 target children between 3-7, 6

siblings)• All had severe conduct problems (ODD, CD)

complicated by additional difficulties (profound deafness, ADHD, chronic sleep disturbance, encopresis, physical health problems)

• Poor parenting complicated by other factors including marital conflict, depression, anger management problems, sleep deprivation, and unemployment

“Driving Mum and Dad Mad”

Theoretical framework for series

Sustainedbehaviour change

Initialbehaviour change

Behavioralintentions

Media Strategy•Attract and maintain audience

•Model specific parenting skills

•Attribution retraining•Episode specifictip sheets

•Self help workbook•Weekly reminders•Audio streaming of parenting messages

•Video streaming of Every Parent’s Survival Guide

•Email support

•Cross Media promotion

•Advertising•Trailers

Contemplation/Preparation for action Action Maintenance

Pre-Contemplation

Increasedtask specific self efficacy

IncreasedSocial support

The ITV families

Based on Group Triple P (Sanders,etal, 1999)•Parents attended 4, 2 hour group sessions •3 weeks of telephone consultations (30 minute calls)•Had weekly between session tasks to complete•Final group session

GPE Design

Parents with

2-6 year oldN=500

TV aloneconditionN=250

Enhanced TV condition

N=250

•Watch 6episodes

•Tip sheets on from ITV

•Watch episodes •Self help workbook •Access website•Tip sheets•Audio and video streaming

•Email support

Time 1 Time 312 months

Time 23 months

ITV website for program

Sample media series tip sheets

Clinical Outcomes with participating “on air” families

4.64**2.6 (1.2)4.3 (1.1)Parenting Scale

2.28*4 (4.3)9.1 (4.1)Parent Problem Checklist

2.63*10.9 (14)22 (10.3)Stress

1.29*7.3 (12.9)11.8 (10.9)Depression

4.13**92.7 (6.32)56.6( 25.02)Parenting efficacy

87.5%4.54**101 (26.6)171 (32.2)ECBI Intensity

Move from clinic range

T testsPostMean (SD)

PreMean (SD)

Measure

sig level - * <.05; ** <.005

Effects on child disruptive behavior

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Standard Enhanced

ECB

I Int

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core

s

Pre Intervention Post Intervention

Clinical cutoff

Clinical significance of change

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Standard TV Condition Enhanced TV Condition

Pre Intervention Post Intervention

% clinically elevated

Overall results

Both groups showed significant reductions in:• Child behavior problems (ECBI-Intensity and

Problem scores)• Parental anger (PAI)• Parental task specific self efficacy (PSBC)• Dysfunctional parenting (PS Laxness,

overreactivity, verbosity, Total) • Parental depression-DASS-depression) • Parental stress (DASS-stress)

Summary of findings (to date)

Enhanced condition families reported greater improvements than families in the standard condition on the following:

• Child behaviour difficulties (ECBI Intensity and Problem scores)

• Dysfunctional parenting strategies (PS:laxness, overreactivity and total score)

• Parental anger (PAI-problem score)• Parental disagreements about discipline (PPC-

Intensity and problem scores)

Design interventions that increase population reach

Level 2Triple P Seminar Series

Seminar 1

The Power of Positive Parenting

Seminar 2

Raisingconfident, competent

children Seminar 3

Raising resilient children

90 minute large groupparenting seminarsInvitation to return

Triple PSeminar Series Tipsheets

Seminar participants – Who comesChildren’s behavior

42.4Total difficulties

40.6Peer problems

47.8Hyperactivity

56.5Conduct Problems

40.6Emotional Symptoms

% Clinically elevated

SDQ Subscales

Effects of Triple P Seminars on Child Adjustment

12.33 12.5511.61

9.91 10.17

12.86

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IntroductoryExposure

Full Exposure Waitlist Control

Tot

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Pre-Intervention Post-Intervention

Effects of Triple P Seminars on parenting practices

3.12 3.073.29

2.852.6

3.23

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3.5

Introductory Exposure Full Exposure Waitlist Control

To

tal D

ysfu

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aren

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Scor

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S)

Pre-Intervention Post-Intervention

Consumer satisfaction with seminars

85.4 87.6 89.7 90.8 91.286.4

90 87.993.8 96

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help c

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imple

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Per

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Par

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Making interventions widely available through flexible

delivery

Effects of Telephone Consultation on Toddler behaviorMorawska & Sanders (in press)

95100105110115120125

Self Helpalone

Self Help +telephonesupport

WaitlistControl

ECB

I Int

ensi

ty

Pre Post Follow-up

Does increasing the intensity of intervention improve outcomes?

Issue

• Complex cases require attention to additional risk factors

• But how should this be done?– Does addressing parental attributions improve

outcome?– Does strengthening couples relationship improve

child outcomes?– Does teach parents emotional coping skills enhance

outcome?

Child maltreatment: The role of parental attributions

• An attribution is a causal explanation individuals use to explain events that occur to them.

• Parents at risk of child maltreatment are more likely to blame their child for the child’s misbehavior.

• Parents’ misattributions for children’s behavior can lead to poor parent-child attachment and an increased risk of child maltreatment.

• Group Triple P Condition– Four group sessions

• Positive parenting approach• Promoting children’s development• Managing misbehavior• Planning ahead

– Four phone consultations• Pathways Triple P Condition

– Group Triple P plus• Attribution retraining • Anger coping skills

Pathways Triple P

Main findings

Both conditions showed significant improvements over time on all key outcome measures

• Parental anger (PAI and STAXI)

• Disruptive child behavior (ECBI scores)

• Observed disruptive behavior (FOS)

• Dysfunctional discipline (Parenting Scale)

• Dysfunctional parent expectations (POQ) • Child abuse potential (CAPI abuse scale)• Dysfunctional attributions for own behavior• Child blame attributions for own behavior• Dysfunctional attributions for child’s

behavior on dimensions of Blame, Intent and Stability

Pathways Triple P showed greater improvements on measures of:

Couple conflict and dysfunctional parenting

Parenting and Couple Conflict

Children are more difficult and parenting is more stressful when parents report- high levels of conflict over parenting- low marital satisfaction - low levels of partner support

Partner Support Training

Casual conversations

PartnerSupport

Problem solving

discussions

Effects of Group Triple P on Marital Conflict

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10

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50

Group Triple P Group Triple + PartnerSupport TrainingPa

rent

ing

Con

flict

Inte

nsity

Sco

res

Pre Post Follow Up

(Source: Hooper, Sanders & Markie-Dadds, 2003)

Effects of Marital Discord on Treatment Outcome

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MDPT MDPT+PS NMDPT NMDPT+PS

% o

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vior

Pre Post FU

Parent training as a treatment for parental depression

Effects of Group Triple P on mothers depression

Intervention Group

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Depression Stress

% in

Clin

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R

ange

Pre Post FU 1yr

Coping skills training

Education aboutmoods

Relaxation/stress

management

Managing dysfunctional

thoughts

Coping Plans at high risk

times

Reliable Change Index

RELIABLE CHANGE INDEX

CHILD BEHAVIOR

52

54

56

58

60

62

64

Post FU

% R

elia

bly

Impr

oved

BFI CBFI

RELIABLECHANGE INDEX

BDI DEPRESSION SCORES

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Effects of intensity of intervention on child outcomes

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Enhanced TripleP

Standard Triple P Self directedTriple P

WL% o

f int

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f dis

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beha

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Pre Post FU1 yr 3 year FU

Lessons learned

• More intervention is not always better than less at least with parents of younger children

• Pre intervention characteristics of parents can not be relied on to identify who will need adjunctive support

• Working hypothesis: Adjunctive interventions should only be offered after exposure to a moderate intensity parenting intervention

• And only if specific risk factors related to parents capacity to implement parenting skills do not change with a less intensive intervention

Post natal well being program

Post natal well being programBurns & Sanders 2005

• 12 sessions– 6 session of CBT– 3 sessions partner support training– 3 sessions of positive parenting

Diagnostic Outcome

Mothers maladaptive cognitions

Effects on marital communication

Conclusions

• Parenting interventions are amongst the most powerful and cost effective interventions available to assist children

• Good parenting should be at the centre piece of public health efforts to improve developmental outcomes in children

Thank you for your attention

Research evidence

To download summary monograph visit– www.triplep.net/01_about/about.htm

• For more information about Triple P contact www.triplep.net

• Research information on Triple Pwww.pfsc.uq.edu.au