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Enhancing parental capabilities
Matthew R Sanders, Ph.D.
Parenting and Family Support Centre
The University of Queensland
HFCC, Sydney, February 2014
At a glance
Why parenting is so important
Challenges facing the
field
Enhancing impact
What’s next
Parenting influences every phase of a
child’s development
• School attainment
• Peer relationships
• Obesity/health
• Antisocial behavior/drug use
• Sexuality/HIV
• Preparedness
• Social skills
• Early literacy
• School readiness
• Secure attachment
• Emergent language
• Emotion regulation
Early years
Preschool
transition to school
Middle childhood
Adolescence
Improving parenting is a common pathway
to achieving diverse child outcomes
Child benefits
of positive parenting
Improved child well being
Reduced child maltreatment
Reduced child social, emotional
behavioral problems Reduced risk for
later problems (academic failure, substance abuse,
delinquency)
Greater success at school, work,
and in relationships
Many different children benefit
Child
problems
Conduct
problems (ODD, CD, ADHD)
Chronic health
problems (Obesity, feeding
problems, asthma,
eczema, diabetes)
Internalizing
problems (Anxiety,
depression,
trauma)
School
problems (Peer relations,
classroom
behaviour)
Children with
developmental
disabilities (ASD,II, traumatic
brain injury, CP)
…and many important adult outcomes
Adult benefits
of positive parenting
Improved self efficacy
Improved relationships
and social support
Reduced family conflict
Reduced personal distress
Greater success at work
Three more P’s
Benefits to children,
parents and communities
Powerful
Pervasive
Persistent
Increasing policy level recognition of
the importance of parenting programs
Child
benefits
Parent/s
benefits
“Child and
Family”
friendly
environment
Positive
support for
children’s
development
Community
benefits
Self regulation is important to enhancing
parental capability
Parental
Self regulation
Self-management
Self-efficacy Personal agency
Self-sufficiency
Minimally
Sufficient
Intervention
Re
du
ced n
eed f
or
support
Parental self regulation
in action
• Has a clear sense of purpose
• Knows what behaviours, skills
and values to promote as a
parent
• Has realistic expectations
• Self-monitors automatically,
rather than consciously or
deliberately
• When personal standards/values
are violated she brings her
current behaviour under personal
control
• Tunes into her own actions and
searches for explanations
• Uses her knowledge to develop
options and plans
• Carries out plan and revises plan
as needed
• Expects that she can bring about
good outcomes
• Is reflective, capable of identifying
strengths and weaknesses, without
being unhelpfully self critical
• Reflections increase her self
efficacy
• Mostly enjoys the process
Self regulatory capability is
influenced by context and be learned
Parental
capacity
• Substance abuse
• Serious mental health problems
• Family violence
• Lack of social support
• Poverty (unemployment)
• Lack of parental knowledge
• Lack of preparation
• Adverse life events (disasters)
• Teamwork partner support
• Extended family support
• Social support
• Access to parenting programs
• High quality child care and
schools
• Primary heath care services
Weaken
Strengthen
Why parenting is so important
Challenges facing the
field
Enhancing impact
What’s next
Are we there yet?
Tension between the relative merits of
universal and targeted interventions
Targeted
interventions
for vulnerable
families
Universal
interventions
for all
families
A blended approach needed
Level 5
Level 4
Level 3
Level 2
Level 1
Intensive family Intervention………................
Broad focused parenting skills training………...
Narrow focus parenting skills training………….
Brief parenting advice……………………………
Media and communication strategy…………….
Breadth of reach
Inte
nsity
of in
terv
entio
n
Addressing
ongoing
challenges
Achieving wider
reach
Improving our
interventions
Improving
implementation quality
Better
outcomes
for children
and parents
Achieving
wider reach
Wider adoption
of a population
approach
Normalise
parenthood
preparation
Winning “hearts
and minds”
More
families
participate
at lower
cost
Why do we need a population approach? Children in the clinically elevated range on the SDQ
(N=1500)
M = 8.2
N
Scores
Clinical range
N = 119
What if we moved the population mean down
.5SD
M = 8.2
N
Scores
Clinical range M = 5.5
N = 99
Percentage Reduction
M = 8.2
M = 5.45
N
Scores
Clinical range
N = 99
17% reduction
20 Fewer Cases
A potential saving of
$5,255,980
What if we moved the population mean down
1SD
M = 8.2 Clinical range
M = 5.5
M = 2.7
Scores
N
N = 79
Percentage Reduction
M = 8.2 Clinical range
M = 5.45
M = 2.7
Scores
N
N = 79
34% reduction
40 Fewer Cases
A potential saving of
$10,511,960
Evidence supporting population level effects is increasing
Journal of Clinical Epidemiology (in
press)
Population-based approaches can
work and are very cost effective
• Lower rates of child out-
of-home (foster care)
placements (d=1.22)
• Lower rates of hospital-
emergency room
maltreatment injuries
(d=1.14)
• Substantiate cases of
child maltreatment
(d=1.09)
• Benefit to Cost Ratio
(return on one dollar
investment) $8.74
Costs and benefits of prevention programs Source: WSIPP (January 2014, Inventory of Evidence-Based, Research-Based, and Promising Practices
For Prevention and Intervention Services for Children and Juveniles
in the Child Welfare, Juvenile Justice and mental Health Systems
Prevention Program Manualized Classification Cost beneficial
Circle of Security Yes Promising N/A
Healthy Families America Yes Research based No (18%)
Kaleidoscope Play and
Learn
Yes Promising N/A
Nurse-Family Partnership Yes Evidence-Based Yes (76%)
Other Home visiting
programs
Varies Research Based No (26%)
Parent-Child Home Program Yes Promising No (26%)
Parent Mentoring Program Yes Promising N/A
Parents and Children
Together
Yes Promising N/A
Parents as Teachers Yes Research Based No (36%)
Promoting first relationships Yes Promising N/A
Safe Babies, Safe Moms Yes Promising -
Triple P System Yes Evidence based YES (100%)
Achieving
wider reach
Wider adoption of
population
approach
Enhance
individual
capacity
Winning “Hearts
and Minds”
More
families
participate
at lower
cost
How individuals deliver Triple P matters
0
200
400
600
800
1000
1200
1400
Year 1 Year 2 Year 3 Year 4 Year 5
Model 1: 6 grps Model 2; 4sems, 3 grps. 40 OL Model 3: 6sems, 2grps, 5DiscGrps, 40OL's
# of
families
served
N=1300 790 contact hours-30
cases averted. 4.3
times more families
N=850 860 contact hours. 20
cases averted. 2.8 times
more families
N=300 1200 contact hours.
7 significant cases
averted
Costs and benefits for an organisational
rollout targeting (5-10 year olds)
Model of delivery
using 10
practitioners
# of families
served over 5
years
Average intervention
costs per child
Cost savings
@ $186,366 lifetime
savings per case
averted
Model 1 3000 $221 $13,013,05
Model 2 8500 $68 $36,870,183
Model 3
13000
$43
$56,389,692
Sustained
use of
program
Lower
cost per
family
$$
No use or
little use
Higher
cost per
family
$$$$$$
Low
enablers
and high
barriers
High
enablers
and low
barriers
Organisational
climate matters Organisational context
R
etu
rn o
n
Inve
stm
en
t
High
Low
Increasing
population
reach
Wider adoption of
population
approach
Enhance
individual
capacity
Winning hearts
and minds of
parents
More
families
participate
at lower
cost
Improving reach means enhanced end user
input throughout
75.6
69.7
48.2
51.6
49.5
48.2
35.8
29.5
13.3
8.1
8.9
45.7
38.4
49.2
48.4
37.7
45.5
24.5
17.1
24.5
13.2
15.7
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Individually tailored programs
Home visits
Web-based program
Group program
Parent seminar
Television program
Self-directed
Self-directed with phone
Newspaper article
Religious organisation access
Radio segment
Parents of Typically Developing Children N=540
Parents of Chidren with Disabilities N=564
Use communication strategy to promote
engagement and build social momentum
Slide no.34
Using technology to increase
population reach
Increasing
awareness
A navigation
route
Working
through
modules
Celebrating
success
Engaging
parents
Ongoing
challenges
Achieving better reach
Improving quality of
interventions
Improving
implementation
Better
outcomes
for both
children and
parents
Improving
quality of
intervention
Helping parents of
children who a bullied
Combining parenting
interventions with other
interventions
Better
outcomes
for both
children and
parents
Depression
Lower
self-esteem
Anxiety
Loss of
friendships
Suicide
Behaviour
problems
Health
problems School
absenteeism
Increased risk of severe mental health
problems, school dropout, involvement
in criminal justice system
Bullying has serious consequences
Facilitative parenting skills taught in
Resilience Triple P
Be available and responsive to your child.
*Talk often. *Do fun things together. *Be
available when your child needs you. *Look out
for warning signs that something might be
wrong.
Support your child’s friendships.
*Get to know other parents. * Arrange play-
dates. * Participate in events at the school.
Help your child to be independent.
* Take into account what other children are
allowed to do. * Teach your child to do things for
themselves. * Help your child make their own
decisions appropriate to their age and maturity.
Teach your child to play well.
* Help your child set goals for play. * Reward and
encourage good play skills. * Help your child to
review how they go.
Coach your child to deal with difficult situations.
Help your child to: * interpret situations; * make a plan
to handle a problem; * practise a response.
Help your children resolve conflicts.
* Avoid taking sides. * Provide coaching before it gets
out of hand. * Encourage children to listen to each
other and to think of a solution that is fair for everyone.
Work with your child’s teacher and school.
* Do not to blame school staff. * Let staff know exactly
what happened and how it affected your child. *
Request help.
* Calmly follow up until sorted. * Thank staff for their
efforts.
Managing parents emotions
(sample video from RTP)
Effects of Resilience Triple P
Outcome Effect size
Bullying of Child:
Overt bullying (teacher) d=.57
Child reports d=.44
Parent reports reduced bullying d=.52
Child Internalizing
Preschool Feelings (Depression)
Index (parent) d=.51
Child reports feeling better d=.63
Parent report of child coping d=.74
Child Social Skills
Observational assessment of child skills d =.72
Improved sibling relationship d=.30
Child Depression (Parent report)
N=111
0
1
2
3
4
5
6
RTP AC
0 months 3 months 9 months
Healy, K.L. & Sanders, M.R. (2014). Randomized controlled trial of a family intervention for
children bullied by peers. Manuscript under review
Improving
quality of
all
intervention
Helping parents of
children who a bullied
Testing additional
intervention components
Better
outcomes
for both
children and
parents
Children with conduct problems have
difficulties with emotions
• Identifying emotions in themselves
(Cook, Greenberg & Kushe, 1994).
• Reading emotional cues in others
(e.g. facial expressions and voice
tone),
• Ability to talk about their emotional
experiences (Strand & Nowicki,
2000).
• Poorer understand of the causes of
their own emotions
Does adding an emotion component to
Triple P enhance child outcomes?
• Parent-child interactions are
an important context for
learning about emotions
• Emotion-focused variant of
Group Triple P involved
– discussion of recent upsetting
events
– discussion of feelings
– coaching child about dealing
with emotions in future
Does emotion coaching improve
Triple P outcomes?
Findings
EETP produced greater changes in – use of emotional labels (d= .78, medium)
– discussion of causes (d= .74, medium)
– emotion coaching (d= 1.08, large)
X GTP had greater changes in child
conduct problems (d=1.09, large)
X Extra focus on emotions did NOT improve
child or parent outcomes
X Both interventions produced
improvements in dysfunctional parenting
practices (PS), parenting self efficacy
(PTC), parental distress (DASS) and
parents were similarly satisfied with both
(CSQ)
150.9
143.7
115.6
129
122.8 127.6
40
60
80
100
120
140
160
Group Triple P Emotion Enhanced TripleP
Pre Post FU
d=1.09 (large effect)
Source: Salmon, Dittman, Sanders, Rebecca Burson, & Hammington (in press). Does Adding an Emotion Component Enhance the
Effects of the Triple P-Positive Parenting Program? Journal of Family Psychology.
Addressing
ongoing
challenges
Enhancing
population reach
Improving our
interventions
Strengthening
implementation
Better
outcomes
for both
children and
parents
Good training is essential
0
1
2
3
4
5
6
7
Australasia US and Canada English speakingEU
Non-Englishspeaking EU
Asia
Process Efficacy: Region Differences
Pre Training Post Training
0
1
2
3
4
5
6
7
Medical Mental Health Education ParaProfessionals
Other
Process Efficacy: Profession Differences
Pre Training Post Training
It is not enough:
The drivers of implementation success
Create strong local partnerships and internal champions
Ensure line management support and
funding
Well trained
and supervised
staff
Establish achieveable
targets
Access available
technical and consultation
support
Make routine evaluation of
outcomes mandatory
Why parenting is so important
Challenges Enhancing
impact
What’s next
How can parenting interventions
tackle problems of global significance
Problems of global
significance
Deep and persistent
disadvantage
Violence towards children
• Australia has one of the
highest rates of
joblessness across
OECD countries.1.3
million jobless families
• Most important cause of
child poverty and a major
contributor to income
inequality
The economic imperative
Health
$61 billion
Defence
$21 billion
Other
$140 billion Education
$28 billion
Social
welfare
$132 billion Source: Australian Commonwealth Budget 2012-13
INCREASING
EXPENDITURE $158 billion by 2016-2017
The consequences of family
joblessness are serious
SCHOOL EXPULSION
3-5 times more likely
BEFORE COURT
2.5 times more likely
CONDUCT PROBLEMS,
DEPRESSION, ADHD OR
SUBSTANCE ABUSE
2 times more likely
The longer the child’s exposure to parental joblessness
the poorer the outcome (Gray & Baxter, 2012)
TESTING SOCIAL INTERVENTIONS Population parenting trial of Triple P system
END-USER ENGAGEMENT Action in 1,000 suburbs
Can parenting programs help disrupt
intergenerational disadvantage?
Problems of global
significance
Deep and persistent
disadvantage
Violence towards children
Children’s exposure to family violence is a
major public health issue
Nearly 53,000 children are murdered each year
150 million (14%) of girls
and 73 million (7%) of boys
under age 18 experience
forced sexual intercourse
and other forms of sexual
violence involving touch,
among boys and girls
Source: UN Secretary General's Study on Violence Against
Children (2013)
Globally violence against children is common Children aged 2-14 experiencing violent discipline in 29 countries
86% 81%
62%
19%
Any violentdiscipline
Psychologicalaggression
Minor physicalpunishment
Severe physicalpunishment
Source: UNICEF, Child Disciplinary Practices at Home: Evidence from Low and Middle Income Countries, New York,
2010
On a global scale problematic
parenting is widespread
• Self-reported incidence of physical abuse
40 times greater than official records (Chang, Runyan, et al, 2005)
• Physical and mental health
consequences of family violence are
serious and long term (Moffitt et al, 2013)
• Violence places a massive burden on
national economies, costing countries
billions of dollars each year in health
care, law enforcement and lost
productivity
Source: Theodore, Chang, Runyan et al. (2005). Epidemiologic features of the physical and sexual
maltreatment of children in the Carolinas. Pediatrics, 115, 331-3337.
Partnership
with
Parenting Organisation Kenya
Children’s Hope Foundation
Raising children in “informal
settlements” Kibera in Kenya
• Calls by WHO Global Violence
Prevention Initiative and UNODC for
development, adaptation,
implementation and evaluation of
EBPs for LMIC
• Two recent meta analyses highlight
the lack of quality research Mejia, A., Calam, R., & Sanders, M.R. (2012). A review
of parenting programs in developing countries:
Opportunities and challenges for preventing emotional
and behavioural difficulties in children. Clinical Child
and Family Psychology Review, 15, 163-175.
Knerr, W., Gardner, F., Cluver, L (2013). Reducing
harsh and abusive parenting and increasing positive
parenting in low- and middle-income countries: a
systematic review. Prevention Science
Mother in Nairobi, Kenya Pilot
Group Triple P
Effects of Group Triple P
N=28
Follow Up Outcomes
Child
CAPES Emotional d = 1.03
CAPES Behaviour d = .76
Parent
CAPES self efficacy d = .71
PS Over-reactivity d = .67
Parental Adjustment
Depression (DASS) d = .49
Anxiety (DASS) d = .57
Stress(DASS) d = .69 0
5
10
15
20
25
30
35
Pre Post Follow Up
CAPES Intensity-Total
New Partnerships in International
Development Projects are needed
Clean water
Positive Parenting
Improved sanitation
A final word
Parenthood
is valued
All parents have
access
Preparation for
parenthood becomes
socially normative
Parenting programs
become a policy
priority and are
funded accordingly
All children can
achieve their
potential in a
safe, loving, low
conflict world
Thank you for your
attention
pfsc.uq.edu.au
triplep.net
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