matthew r sanders, ph.d parenting and family support centre the university of queensland australia
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A Public Health Perspective in the Delivery of Evidence-Based Parenting Intervention Parenting Intervention: Benefits and Challenges. Matthew R Sanders, Ph.D Parenting and Family Support Centre The University of Queensland Australia December, 2009. At a glance. - PowerPoint PPT PresentationTRANSCRIPT
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A Public Health Perspective inthe Delivery of Evidence-Based
Parenting Intervention
Parenting Intervention:Benefits and Challenges
Matthew R Sanders, Ph.D
Parenting and Family Support Centre
The University of Queensland
Australia
December, 2009
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At a glance
• Why parenting support and education is vital to child well-being
• Why a public health approach is necessary• Re-AIM formula applied to parenting
intervention• How prevention and less intensive programs
can make a difference• Cost-benefits to this approach
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The need to make effective parenting programs widely
available is now firmly established
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Support for a public health approach gaining momentum
“…. a substantial body of well designed, controlled-trial research shows that a small number of parenting programs can produce significant and durable positive changes by increasing positive family relationships, reducing child behavior problems and reducing future rates of child maltreatment”….
“Scientific support is sufficient to warrant the implementation of these evidence based parenting practices in demonstration projects at community health centers “
Source: APA (2009). Effective strategies to support positive parenting in community health centers: Report of the Working Group of Child Maltreatment Prevention. Washington, DC: Author.
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Policy level advocacy for evidence based parenting programs
Groups Examples of policy statements• Institute of Medicine revised report on
Preventing Mental, Emotional and behavioural disorders among young people (IOM, 2009)
• Council of Europe Positive Parenting in Contemporary Europe (2007)-declaration calling on 46 member states to implement positive parenting programs
• UN’s report on Family skills training programmes and drug abuse prevention (2009)
• UK Government establishes National Academy for Parenting Practititoners (2007)
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Far too many children continue to develop preventable social,
emotional, behavioral and health problems
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Behavioral and emotional problems are common
Percentage of children with emotional or behavioral problems in the clinical range
20% clinical
80% nonclinicalSource: World Health Organization (2003). Caring for children and adolescents with mental disorders. Geneva: World Health Organization, 2003)
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These problems are very costly
• The annual cost in the US in 2007 was estimated to be $247 billion
Source: IOM (2009) Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities
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The quality of parenting children
receive really matters and affects every
aspect of their development
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Significant improvements in the health and well being of children at a population level cannot be achieved without strengthening
the skills, knowledge and confidence of parents in the task of raising their children
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How can we achieve a population level effect
Glasgow et al (2001)
Create leverage using the RE-AIM formula
Slide courtesy Dr Dennis Embry, Paxis Institute (2006)
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Reach X Efficacy X Adoption X Implementation X Maintenance=Population level impact
Slide courtesy Dr Dennis Embry, Paxis Institute (2006)
Achieving population level Impact
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Reach
What has been done to improve
population reach?
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Develop interventions that
have a better “ecological fit” to the concerns of
parents
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Listen to professionals and parents
Triple Pvariants
Pathways
Children with asthma*
Stepping Stones
Resilience*
Gifted & TalentedBaby*
Lifestyle
Workplace
Media series
Indigenous
* Under development
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Test different delivery formats
Delivery formats
Individual
Web *
Self directed
TVseries
Over the phone
Small Group
Large group
* Under development
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Delivery contexts
Hospital inpatient
Religious organizations
Child care
Workplace
Preschools/Schools
Mental health services
GP practices
Home
visiting
Community
centres
Use many service delivery settings and
providers
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Efficacy
What can be done to improve
efficacy?
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We have come a long way
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From small beginnings
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The evidence92 studies
13Single case experiments
46Efficacy
trials
27Effectiveness
trials
2Population
trials
4Meta
analyses
Building an evidence base takes time
as at November, 2009
25 further trials in
progress
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Triple P Intervention Studies
1980
1981
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1984
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1989
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1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
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2002
2003
2004
2005
2006
2007
2008
0
20
40
60
80
100
120
Cumulative No. of Triple P Intervention Studies
Cumulative No. Intervention Stud-ies
Year we gave Triple P a
Name
No
. O
f s
tud
ies
Year
Year Triple P International
began
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Some important milestones
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Become much more consumer
focused
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Adopt a self regulation framework
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Collaborate with parents in waysthat empower them
Ultimate goal is parental
independence and autonomy
Parent decides on goals,
strategies and values
Parent has plan, monitors ,
evaluates outcome and
revises accordingly
Provide parent with support
and advice to “minimally sufficient”
degree needed
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Our goal has been to develop and test
interventions that have a better “ecological fit” to
the concerns and preferences of parents as
consumers
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Test different delivery formats
Delivery formats
Individual
Web *
Self directed
TVseries
Over the phone
Intensive Small Group
“Light touch” large group
“Light touch” small group
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“Light touch” interventions for common problems to
reach many parents
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Triple P Media Interventions
Television programsFamilies
DMDM 1&2
8 sessionTriple P on
line
Weekly Triple P Radio
broadcastsand podcasts
10 episodeTriple P
Parenting Media series
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Adopting a consumer perspective helps to…
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Example: Using consumer input on program content and cultural acceptability
• 158 ethnically diverse parents of 3-6 year children viewed “Making Shopping Fun” episode
• Their engagement in the episode (interesting, entertaining and usefulness) and its watchability (would watch it on TV)– 92% found it somewhat, quite or very engaging– 70% said they would probably or definitely watch it on
TV• Parents of children with greater problem behavior
reported greater likelihood that they would watch it• SES and ethnicity did not predict outcomes
Source: Metzler, et al (in prep). Triple P Media Series.
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How do parents want to receive information about effective parenting?
Source: Metzler et al (in prep)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Percent indicating "quite" or "very interested" in receiving parenting information in each of nine formats
clinical nonclinical
Programs with
strongest evidence
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Develop “light touch” interventions for common problems to reach many
parents
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Parent discussion groups Group Primary Care Triple P
• Preschoolers•Toddlers•Infants
•Elementary school age•Teenagers
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Test different delivery formats
Delivery formats
Individual
Web *
Self directed
TVseries
Over the phone
Intensive Small Group
“Light touch” large group
“Light touch” small group
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Primary Care Group Triple P Parent Discussion Groups
Hassle Free
Shopping
Fighting and
aggression
Disobedience Bedtime
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Hassle Free Shopping with children 2 hour group session
Content• Activity 1: Shopping
hassles
• Activity 2: Parent traps
• Activity 3: How to prevent shopping problems
• Activity 3: How to manage shopping problems
• Activity 4: Getting started
Process• Trained Triple P facilitator• Use of DVD footage on
common shopping problems
• Group activity to identify common parent traps (causes/attributions)
• Watch and discuss “Making Shopping fun” DVD
• Discussion/planning
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Effects on Child BehaviourJoachim, Sanders & Turner (2009).Hassle-free shopping with children- Evaluation of a brief Triple P parent discussion group . Journal of Child Psychiatry and Development.
d=.75
• Fewer shopping specific problems (d=1.6)
• Lower levels of dysfunctional parenting (d=.72)
• Increased task specific self efficacy (d=1.31)
• High consumer satisfaction (M = 34.3; SD = 5.80)
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Primary Care Group Triple P Parent Discussion Groups
Hassle Free
Shopping
Fighting and
aggression
Disobedience Bedtime
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Study 2: Effects on Child Behaviour
• Fewer conduct problems (d=1.14)
• Lower levels of dysfunctional parenting (d=.71)
• Increased task specific self efficacy (d=1.01)
• 6 month follow ups underway
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Improve engagement
strategies
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Who participates in Triple P when it is offered universally?
• Child had behavioural or emotional problem (47.8%)
• SDQ Conduct Score-borderline or clinical (2 times more likely to participate)
• Mothers (86.8%)• Highly stressed in previous 2 weeks (52.9)• Parent of a boy (59.5%)
Sanders, et al (2007). Every family: A public health approach to positive parenting. The University of Queensland
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Engagement
• More disadvantaged parents less likely to know about, participate or complete parenting programs
• Participating parents benefit regardless of background (Leung et al., 2006; McTaggart & Sanders, 2007)
• Underrepresented groups– Fathers– Minority parents– Indigenous parents
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Gender /age of parent
Education /literacy
Employment status
Poverty
Parental mental health
Connectedness
Discrimination
Neighborhood
Prior help
seeking
Family of origin
experience
Culturally
normative parenting practices
Immigration status
Family
friendly policies
Acculturation
Ecological Context
Enablers & barriers
Cognitive/Affective variables
Social influenceVariables
Program variables
Parental concern about child’s
behavior
Motivational variables Engagement
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Enablers & barriers
Cognitive/Affective variablesExpectancies of benefit
Parental self efficacyAccess to models
Parental attributions
Social influenceVariables
In home supportExtended family support,
Community and neighborhood support
Program variablesMessage
Providers-ethnicity, experience, skillsCost/ AccessibilityProgram format
Acceptability of parenting advice
Parental concern about child’s behavior
Perceived vulnerabilitySeverity of child problem
Level of parental distress or anxiety
Motivational variables
Perceived needAnticipated benefits/costs
IncentivesCompeting demands
Engagement
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Experimental manipulation
Motivational variables
• Expectancies of
benefit
• Parental self
efficacy
• Attributions
• Access to models
Engagement
No testimonial
Parent testimonial
Expert testimonial
Exp
erim
enta
l co
nd
itio
ns
vs
vs
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Seek direct consumer input to ensure programs are culturally
acceptable
Connecting Communities ProjectBrisbane South Divisions of General Practice
Parenting and Family Support CentreThe University of Queensland
Funded byFACSIA, Commonwealth Government of
Australia
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Acceptability of Triple P parenting strategies
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Design interventions to
directly target high need, underserved
populations
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Positive Parenting after separation
or divorce
Investigators:
Dr Helen Stallman
Prof Matt Sanders
Funded by Australian Research Council In collaboration with Relationships Australia (Qld)
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Relationship breakdown
• Relationship breakdown is a major life stressor for parents, children, and their extended families
• Although declining 40% of all marriages end in divorce1
• Half of all divorces involve parents• Divorce impacts on 44, 000 Australian
children each year.
Source: Australian Bureau of Statistics (2007). Divorces Australia. Canberra, Australia.
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Program Content
12 week program• Divorce – a Family
Transition• Coping with Emotions • Managing Conflict• Balancing work, family,
and play• Positive Parenting
Outcomes
↓ Fewer behavioural and emotional problems
↓Dysfunctional parenting practices
↓Parental Expressed and Trait Anger
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Adoption
What can be done to increase
adoption?
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17 Countries where Triple P has been disseminated
Australia
New Zealand
England
Scotland
Ireland
United States
Canada
Iran
Curacao
Germany
The Netherlands
Belgium
Switzerland
Sweden
Singapore
Japan
Hong Kong
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Understanding the sociopolitical
context better
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Public policy that supports good parenting remains essential to
improve the well being of children and young people
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However policies concerning parenting and family support
rarely win elections
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Seeking linkages to influence policy
• The Council of Australian Governments (COAG) Human Capital Agenda– Communiqué 10 Feb 2006 - Early Childhood Development
• The Council of Australian Governments (COAG) Indigenous Issues– Communiqué 13 April 2007
• Australian Government Attorney General’s Department –– Family Relationship Centres
• Australian Government Department of Family and Community Services and Indigenous Affairs – – Stronger Families and Communities– Raising children network (Australian parenting website)
• Indigenous Parenting and Family Wellbeing• Department of Veterans Affairs –
– Health and Wellbeing initiatives for the Veteran Community• National Mental Health Plan 2008-2011
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A national roll out of Every Family?
• Costs of a national roll out of over 4 years – Equates to approximately $12.00 per child per
year, or $20.45 per family– Substantially less than the cost of a single GP visit
or to immunize a child
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Although costs matters politically
% reduction in prevalence
Potential cost savings
48% $683,000,000
26% $370,000,000
20% $290,000,000
15% $210,000,000
2% $29,000,000
1% $14,000,000
Point at which Intervention pays for itself
Source: Mihalopoulos et al (2007). Is Triple P value for money? Australian and New Zealand Journal of Psychiatry
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Winners are grinners however..
Politicians live in families themselves and are tuned into what their electorates say is important
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and media scrutiny
Some criticism is inevitable
Dealing with it
professionally is NOT
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Implementation
What can be done to increase
implementation?
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Identify what promotes movement along this trajectory
Completes Initial training
Becomesaccredite
d
Starts to use
program
Continues to use
program
Being a high
impact parenting practitione
r
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Strengthen organizational
support for good implementation
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Challenges in upskilling a workforce in evidence based practice
Individual practitioner variables
• Workforce very diverse • Wide range of
experience and expertise
• Inadequate pre-service and in-service training in evidence based approaches
• Low self efficacy
Organizational variables• Non recurrent funding• Many poorly paid for the
type of work they do • Inadequately supervised• High occupational stress
and turnover• Organizational leadership• Delivery of parenting
programs not mainstream
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Self regulation applies to all levels of the Triple P system
Program
developer
TrainerAgenc
yPractition
erParent/
s Child
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Highlight the importance of
customizing delivery while maintaining program fidelity
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Maintenance
What can be done to improve maintenance and
sustainability?
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Allow the system to evolve through
responding to new evidence
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Triple P as a work in progress
• Triple P parent discussion group • Grandparents and Group Triple P• Foster parents and Group Triple P• Parents of children with multiples• Triple P and parents of children with asthma• Baby Triple P (Prem Triple P)• Teen Triple P Seminar series• Primary Care Stepping Stones• Bipolar disorder and Triple P• Triple P and anxious children
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Watch this space
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Our major threats
Complacency and Not using the knowledge
we have
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A final word
The widespread use of positive parenting will be to create a future generation of healthy, happy, resilient children with the life skills they need to contribute to the well being of our communities