development, evaluation, and multinational dissemination of the triple p-positive parenting program

CP08CH14-Sanders ARI 1 March 2012 8:50

Development, Evaluation, andMultinational Disseminationof the Triple P-PositiveParenting ProgramMatthew R. SandersParenting and Family Support Center, School of Psychology, The University ofQueensland, St. Lucia QLD 4072, Australia; email: [email protected]

Annu. Rev. Clin. Psychol. 2012. 8:345–79

First published online as a Review in Advance onDecember 6, 2011

The Annual Review of Clinical Psychology is onlineat clinpsy.annualreviews.org

This article’s doi:10.1146/annurev-clinpsy-032511-143104

Copyright c© 2012 by Annual Reviews.All rights reserved

1548-5943/12/0427-0345$20.00

Keywords

public health, parenting, child health, child behavior, dissemination,evidence-based practice, Triple P-Positive Parenting Program

Abstract

The quality of parenting children receive has a major influence on theirdevelopment, well-being, and life opportunities. Of all the potentiallymodifiable influences that can be targeted through preventive inter-ventions, none are more important than the quality of parenting chil-dren experience. Prevention interventions targeting parenting shouldbe widely used to promote positive developmental outcomes for chil-dren and adolescents. This review argues that the development of com-prehensive evidence-based strategies to improve the quality of parent-ing is best viewed as a major public health challenge. Using the TripleP-Positive Parenting Program as an exemplar, the initial development,gradual transformation into a public health model, and then global dis-semination of the approach is described. The assumptions underpin-ning the public health approach to parenting support are discussed,along with key criteria that need to be met for the approach to work.Factors that facilitate and impede the global implementation and dis-semination of evidence-based parenting programs are considered alongwith implications for future research, policy, and practice.

345

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Contents

INTRODUCTION. . . . . . . . . . . . . . 347Why Parenting Programs

Are So Important . . . . . . . . . . . 347The Triple P-Positive

Parenting Program . . . . . . . . . 348Principles of Positive

Parenting . . . . . . . . . . . . . . . . . . 352Triple P Evidence Base . . . . . . . . 355

BUILDING A PUBLICHEALTH APPROACH TOPARENTING SUPPORT . . . . 355In Search of a Name . . . . . . . . . . . 357Self-Regulation and the

Adoption of a PublicHealth Framework . . . . . . . . . 357

Increasing the Reachof Parenting Programs. . . . . . 358

PUTTING IT ALLTOGETHER: THESIMULTANEOUSIMPLEMENTATION OFALL LEVELS OF THETRIPLE P SYSTEM. . . . . . . . . . 360

ESSENTIAL CRITERIA FORMAKING A PUBLICHEALTH APPROACH TOPARENTING WORK . . . . . . . . 361Having Parenting Programs

Available that Work . . . . . . . . 361Having Evidence of

Cost-Effectiveness . . . . . . . . . . 362Ensuring Cultural Relevance

and Acceptability . . . . . . . . . . . 362Reducing Stigma Associated

with Participation inParenting Programs . . . . . . . . 362

Engaging Consumers in theDevelopment ofEvidence-BasedPrograms . . . . . . . . . . . . . . . . . . 363

Establishing AchievableParticipation Targets . . . . . . . 363

Having an Evaluation Plan andTracking Population-LevelIndicators . . . . . . . . . . . . . . . . . . 363

CREATING A GLOBAL ANDSUSTAINABLE SYSTEMOF DISSEMINATION . . . . . . . 364Capacity to Go to Scale . . . . . . . . 364Developing a System of

Professional Training. . . . . . . 364Practitioner Accreditation . . . . . 365Flexible Tailoring and

Responsive ProgramDelivery . . . . . . . . . . . . . . . . . . . 366

Ensuring Competent TrainersAre Used . . . . . . . . . . . . . . . . . . 366

Tailoring Training Methodsto Target Groups . . . . . . . . . . 366

Maintaining TrainingQuality . . . . . . . . . . . . . . . . . . . . 366

Technical and ConsultationSupport . . . . . . . . . . . . . . . . . . . . 366

Encouraging Reflective PracticeThrough Supervision . . . . . . . 367

KEY CHALLENGES INWORKFORCEDEVELOPMENT . . . . . . . . . . . 367Quality of Organizational

Leadership . . . . . . . . . . . . . . . . . 367Ensuring Adequate

Infrastructure Support . . . . . . 368Taking a Long-Term View

of WorkforceDevelopment . . . . . . . . . . . . . . 368

GLOBAL DISSEMINATIONOF TRIPLE P . . . . . . . . . . . . . . . . 368Build a Local Evidence Base . . . 368Connect International

Researchers . . . . . . . . . . . . . . . . 369Tune in to Local Issues . . . . . . . . 369

IMPLICATIONS FOR POLICYAND PRACTICE . . . . . . . . . . . . 369Public Policy Advocacy

for Parenting Programs . . . . . 369Research, Policy,

and Practice . . . . . . . . . . . . . . . . 370

346 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


FUTURE DIRECTIONS. . . . . . . . 370Parenting Across the

Lifespan . . . . . . . . . . . . . . . . . . . 370Broadening Parenting Programs

to Address Children’s HealthProblems . . . . . . . . . . . . . . . . . . 370

CONCLUSION . . . . . . . . . . . . . . . . . 371

INTRODUCTION

There is a growing international consensusamong developmental, family and clinicalpsychologists, public health researchers, policyadvocates for evidence-based practices, andprevention scientists that safe, nurturing, andpositive parent-child interactions lay the foun-dations for healthy child development (Collinset al. 2000, Coren et al. 2002, Dretzke et al.2009, Embry 2004, Gutman & Feinstein 2010,Kirp 2011, Stack et al. 2010). How childrenare raised in the early years and beyond affectsmany different aspects of their lives includingbrain development, language, social skills, emo-tional regulation, mental and physical health,health risk behavior and their capacity to copewith a spectrum of major life events (Beaver &Belsky 2011, Belsky & de Haan 2011). Theselife events and transitions include parental sep-aration and divorce (e.g., Hetherington et al.1989, Stallman & Sanders 2007), loss (e.g.,Bradley 2007), chronic illness (e.g., Gustafssonet al. 2002), recovery following natural disasters(e.g., Jones et al. 2009) and parental mentalillness (e.g., McFarland & Sanders 2003).

Adverse family experiences such as inter-rupted maternal care, living with one biologicalparent, exposure to criticism and harsh, puni-tive disciplinary practices, family dysfunctionand lower marital adjustment, parental distress,and parental psychopathology are all associatedwith an increased risk of psychopathologyamong children and adolescents (Baker et al.2005, Chadwick et al. 2008, Emerson 2003,Hastings et al. 2006, Hastings & Lloyd 2007,Koskentausta et al. 2007, Wallander et al.2006). Conversely, exposure to competent

parenting (defined here as warm, responsive,consistent parenting that provides bound-aries and contingent limits for children ina low-conflict family environment) affordschildren many developmental and life advan-tages including secure attachment, acceleratedlanguage development, greater readiness forschool, higher academic achievement, reducedrisk of antisocial behavior and substanceabuse problems, an increased likelihood ofinvolvement in higher education, improvedphysical health, and greater capacity for laterintimate relationships (Guajardo et al. 2009,Gutman & Feinstein 2010, Moffitt et al. 2011,Stack et al. 2010). Clearly, how parents raisetheir children is an important determinant ofthe well-being of children, and there is nomore important potentially modifiable targetof preventive intervention.

Why Parenting ProgramsAre So Important

The case for strengthening efforts to improvethe quality of parenting children receive is com-pelling. Four decades of experimental clini-cal research have demonstrated that structuredparenting programs based on social learningmodels are among the most efficacious and cost-effective interventions available to promote themental health and well-being of children, par-ticularly children at risk of child maltreatmentand developing social and emotional problems(Collins et al. 2000, Foster et al. 2008, Mercy &Saul 2009, Mihalopoulos et al. 2011, Nat. Res.Counc. Inst. Med. 2009, Serketich & Dumas1996, Taylor & Biglan 1998).

Positive parenting programs based on sociallearning and cognitive-behavioral principlesare the most effective in reducing problembehaviors in children and adolescents (Dretzkeet al. 2009, Kazdin & Blase 2011, Serketich& Dumas 1996). These interventions typicallyprovide active skills training or coaching toparents involving video or live modeling ofskills, practice of skills, feedback followingdirect observation of parent-child interaction,and between-session homework assignments

www.annualreviews.org • The Triple P-Positive Parenting Program 347

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Triple P: a multilevelsystem of parentingsupport known as theTriple P-PositiveParenting Program

in how to apply positive parenting (e.g.,descriptive praise, incidental teaching, simplereward charts, clear instructions) and contin-gency management principles (e.g., logicalconsequences, nonexclusionary timeout, andexclusionary timeout) to daily interactionswith their children. Different delivery for-mats have been successfully trialed includingindividual programs, small group programs,large group seminar programs, self-directedprograms, telephone-assisted programs, andmore recently, online parenting programs (seeDretzke et al. 2009, Nowak & Heinrichs 2008,Sanders 2008, Sanders et al. 2011a).

Numerous meta-analyses of parenting in-terventions attest to the benefits that parentsand children derive (particularly children withconduct problems) when parents learn positiveparenting skills (Brestan & Eyberg 1998; Corenet al. 2002; de Graaf et al. 2008a,b; Nowak &Heinrichs 2008). These benefits include chil-dren having fewer behavioral and emotionalproblems and more positive interactions withtheir parents and siblings, improved parentalpractices, improved mental health, and lessparental conflict.

There is growing evidence that parentingprograms are also useful in the prevention ormanagement of a range of other child prob-lems. These include challenging behavior inchildren with developmental disabilities (Plant& Sanders 2007; Sanders & Mazzucchelli 2011;Whittingham et al. 2006, 2009, 2011), persis-tent feeding problems (Adamson et al. 2011,Sanders et al. 1997, Turner et al. 1994), re-current pain syndromes (Sanders et al. 1994,1996), anxiety disorders (Rapee et al. 2010), andthose who are overweight and obese (West et al.2010). Positive intervention effects on child andparent outcome measures have been reportedacross diverse cultures (e.g., Matsumoto et al.2010, Morawska et al. 2010, Turner et al. 2007),family types (e.g., Stallman & Sanders 2007),age groups (e.g., Boyle et al. 2010, Ralph et al.2003), and delivery settings (e.g., Morawskaet al. 2011, Sanders et al. 2011a). In most stud-ies, positive intervention effects are maintainedover time (e.g., Sanders et al. 2007a).

The cumulative evidence clearly supportsthe efficacy and robustness of social learning–based parenting interventions, and there is astrong case for such programs to be made morewidely available. However, the limited reachof most evidence-based parent programs en-sures that these programs make little impacton prevalence rates of social and emotionalproblems of children and child maltreatmentat a population level. The limited impact ofavailable parenting interventions on children’sproblems at a population level underpinned thedevelopment of the Triple P-Positive Parent-ing Program as a public health intervention(Sanders 1999, 2008, 2010; Sanders & Murphy-Brennan 2010a).

The Triple P-PositiveParenting Program

The Triple P-Positive Parenting Program(hereafter referred to as Triple P) has its originsin social learning theory and the principles ofbehavior, cognitive, and affective change articu-lated in the 1960s and 1970s. The public healthmodel of parenting support used in Triple Ptook 30 years to develop and involved the col-lective efforts of a number of staff and postgrad-uate students at the University of Queensland(see Sanders et al. 2002).

The aim of Triple P is to prevent severe be-havioral, emotional, and developmental prob-lems in children and adolescents by enhancingthe knowledge, skills, and confidence of par-ents. To achieve this goal, Triple P incorporatesfive levels of intervention on a tiered continuumof increasing strength for parents of childrenfrom birth to age 16. The suite of multilevelprograms comprising the Triple P system aredesigned to create a family-friendly environ-ment that better supports parents in the taskof raising their children, with a range of pro-grams tailored to the differing needs of parents.Triple P is best thought of as a blended, mul-tilevel intervention comprising both universaland targeted interventions within a comprehen-sive system of parenting support.

348 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Figure 1The Triple P model of graded reach and intensity of parenting and family support services.

The rationale for this multilevel strategy isthat there are differing levels of dysfunction andbehavioral disturbance in children and adoles-cents, and parents have different needs and pref-erences regarding the type, intensity, and modeof assistance they may require. The multilevelstrategy utilizes the principle of the “minimallysufficient” effective intervention as a guidingprinciple to serve the needs of parents. As pre-sented in Figure 1, the system enables prac-titioners to determine the scope of the inter-vention and is designed to maximize efficiency,contain costs, avoid waste and overservicing,and ensure the program has wide reach in thecommunity.

The Triple P system has a range of evidence-based tailored variants and flexible delivery op-tions that target different groups of high riskor vulnerable parents (e.g., parents of childrenwith a disability; abusive, depressed, or mari-tally discordant parents). The multidisciplinarynature of the program involves the utilization ofthe existing professional workforce in the task of

promoting competent parenting. Table 1 sum-marizes the key features of the Triple P multi-level model.

Universal Triple P (Level 1). The Universalfacet of the Triple P intervention involves theimplementation of media and informationalstrategies pertaining to positive parenting.These strategies are intended to destigmatizeparenting and family support, to make effectiveparenting strategies readily accessible to allparents, and to facilitate help-seeking andself-regulation by parents who need higher-intensity intervention. Universal Triple Pincludes the use of radio, local newspapers,newsletters at schools, mass mailings to familyhouseholds, presence at community events,and Web site information.

Selected Triple P (Level 2). The SelectedTriple P program has utility for many parentsand is intended to normalize parenting inter-ventions. There are two delivery formats for


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Table 1 The Triple P-Positive Parenting Program system of parenting and family supporta

Level ofintervention Intensity Program variant Target population Modes of delivery

Interventionmethods used

Level 1

Media andcommunica-tion strategyon positiveparenting

Very lowintensity

Stay Positive All parents andmembers of thecommunityinterested ininformation aboutparenting topromote children’sdevelopment andprevent or managecommon social,behavioral, andemotional problems

Web site to promoteengagement. May alsoinclude televisionprogramming, publicadvertising, radio spots,newspaper and magazineeditorials

Coordinated mediaand promotionalcampaign to raiseawareness of parentissues, destigmatizeand encourageparticipation inparentingprograms. Involveselectronic andprint media

Level 2

Briefparentinginterven-tions

Lowintensity

Selected Triple PSelected TeenTriple P

SelectedStepping StonesTriple P

Parents interested ingeneral parentinginformation andadvice or withspecific concernsabout their child’sdevelopment orbehavior

Series of 90-minutestand-alone large groupparenting seminars or one ortwo brief individualface-to-face or telephoneconsultations (up to20 minutes)

Parentinginformationpromoting healthydevelopment oradvice for a specificdevelopmentalissue or minorbehavior problem(e.g., bedtimedifficulty)

Level 3

Narrow focusparentingprograms

Low tomoderateintensity

Primary CareTriple P

Primary CareTeen Triple P

Primary CareStepping StonesTriple P

Parents with specificconcerns as abovewho require briefconsultations andactive skills training

Brief program (about80 minutes) over three tofour individual face-to-face ortelephone sessions

Combination ofadvice, rehearsal,and self-evaluationto teach parents tomanage discretechild problems

Triple PDiscussionGroups

Series of two-hour stand-alonegroup sessions dealing withcommon topics (e.g.,disobedience, hassle-freeshopping)

Brief topic-specificparent discussiongroups

Level 4

Broad focusparentingprograms

Moderateto highintensity

Standard Triple PGroup Triple PSelf-DirectedTriple P

Standard TeenTriple P

Group TeenTriple P

Self-Directed TeenTriple P

Online Triple PBaby Triple P

Parents wantingintensive training inpositive parentingskills

Intensive program (about 10hours) with delivery optionsincluding 10 60-minuteindividual sessions;

or five two-hour group sessionswith three brief telephone orhome visit sessions;

or 10 self-directed workbookmodules (with or withouttelephone sessions);

or eight interactive onlinemodules

Broad focus sessionson improvingparent-childinteraction and theapplication ofparenting skills to abroad range oftarget behaviors.Includesgeneralizationenhancementstrategies

(Continued )

350 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Table 1 (Continued )

Level ofintervention Intensity Program variant Target population Modes of delivery

Interventionmethods used

Standard SteppingStones Triple PGroup SteppingStones Triple PSelf-DirectedStepping StonesTriple P

Parents of childrenwith disabilities whohave, or who are atrisk of developing,behavioral oremotional problems

Targeted programinvolving 10 60- to90-minute individualsessions or two-hourgroup sessions

Parallel program with afocus on parentingchildren withdisabilities

Level 5

Intensivefamilyinterventions

Highintensity

Enhanced Triple P Parents of childrenwith behaviorproblems andconcurrent familydysfunction such asparental depressionor stress, or conflictbetween partners

Adjunct individuallytailored program with upto eight individual60-minute sessions (mayinclude home visits)

Modules includepractice sessions toenhance parenting,mood managementand stress-copingskills, and partnersupport skills

Pathways Triple P Parents at risk ofmaltreating theirchildren. Targetsanger managementproblems and otherfactors associatedwith abuse

Adjunct program withthree 60-minuteindividual sessions ortwo-hour group sessions

Modules includeattribution retrainingand angermanagement

Lifestyle Triple P Parents of overweightor obese children.Targets healthyeating and increasingactivity levels as wellas general childbehavior

Intensive 14-session groupprogram (includingtelephone consultations)

Program focuses onnutrition, healthylifestyle, and generalparenting strategies

Family TransitionsTriple P

Parents goingthrough separationor divorce

Intensive 12-session groupprogram (includingtelephone consultations)

Program focuses oncoping skills, conflictmanagement, generalparenting strategies,and developing ahealthy coparentingrelationship

aOnly program variants that have been trialed and are available for dissemination are included.

Selected Triple P: (a) brief and flexible consul-tation with individual parents and (b) parentingseminars with large groups of parents. The briefand flexible consultation format involves one totwo consultation contacts (20 minutes each) andis designed for parents with relatively minor andfairly discrete problem behaviors that do notrequire more intensive levels of intervention.However, this is also a useful and nonthreat-

ening strategy to help parents begin to addresstheir own parenting behaviors but in the con-text of their asking for information or assistanceabout their child’s behavior. The interventioncan be provided in the context of childcare,daycare, and preschool settings, and in othersettings where parents may have routine contactwith service providers and other professionalswho regularly assist families. Selected Triple P


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


can be viewed as a form of anticipatory develop-ment guidance. The parenting seminar formatof Selected Triple P, called the Triple P Sem-inar Series, involves three 90-minute sessionsdesigned for delivery to large groups of parents.The seminar series includes specific seminarson the following topics: The Power of PositiveParenting; Raising Confident, CompetentChildren; and Raising Resilient Children. Thethree seminars are independent of each otherso that parents can attend any or all of themand still benefit. Seminars are used to promoteawareness of Triple P and as brief and infor-mative sessions for any parent. Each seminarincludes a presentation, a question-and-answerperiod, and distribution of a parenting tipsheet, and practitioners are available at the endof the session to deal with individual inquiriesand requests for further assistance.

Primary Care Triple P (Level 3). PrimaryCare Triple P, like Selected Triple P, is ap-propriate for the management of discrete childproblem behaviors that are not complicated byother major behavior management difficultiesor significant family dysfunction. The key dif-ference is that provision of advice and informa-tion alone is supported by active skills trainingfor those parents who require it to implementthe recommended parenting strategies. Thisprogram level is especially appropriate for par-ents of infants, toddlers, and preschoolers withrespect to common child behavior problemsand parenting challenges. Level Three involvesa series of four brief (20-minute) consultationsthat incorporate active skills training and theselective use of parenting tip sheets cover-ing common developmental and behavioralproblems of preadolescent children. This briefand flexible consultation modality also buildsin generalization enhancement strategies forteaching parents how to apply knowledge andskills gained to nontargeted behaviors andother children in the family. Primary CareTriple P can be administered in either individ-ual or group settings, and there are also tailoredvariants for parents of children and adolescents

with a disability (Primary Care SteppingStones, Primary Care Teen Steeping Stones).

Standard Triple P (Level 4). The Level 4program benefits children and adolescents whohave detectable problems but who may or maynot yet meet diagnostic criteria for a behavioraldisorder, and parents who are struggling withparenting challenges. Parents learn a variety ofchild management skills, in either a group orindividual setting, and how to apply these skillsboth at home and in the community. Level 4combines the provision of information with ac-tive skills training and support, as well as teach-ing parents to apply skills to a broad range oftarget behaviors with the target child and sib-lings. There are also variants of Level 4 Triple Pfor first-time parents undertaking the transitionto parenthood (Baby Triple P) and parents of achild with a developmental disability (SteppingStones Triple P).

Enhanced Triple P (Level 5). EnhancedTriple P is an optional augmentation ofStandard (Level 4) Triple P for families withadditional risk factors that might need to beaddressed through the intervention. Many fam-ilies can receive sufficient benefit from StandardTriple P without extending programming withEnhanced Triple P. Enhanced Triple Pincludes optional intervention modules onpartner communication, mood managementand stress coping skills for parents, and addi-tional practice sessions addressing parent–childissues. There are several variants of Level 5Triple P including Family Transitions Triple P(for parents undergoing separation or divorce),Lifestyle Triple P (for parents of overweightor obese children), and Pathways Triple P (forparents at risk of child abuse).

Principles of Positive Parenting

Triple P seeks to help parents increase theirconfidence, skills, and knowledge about raisingchildren; to be more positive in their dailyinteractions with children; to be less coercive,

352 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


depressed, stressed, or anxious; to have lessconflict with partners over parenting issues;and to have lower levels of stress and conflictin managing work and family responsibilities(Sanders 2008). The program targets childrenat five different developmental periods: infant,toddler, preschooler, primary schooler, andteenager. Within each developmental periodthe reach of the intervention can vary from be-ing very broad (targeting an entire population)or quite narrow (targeting only high-risk chil-dren). Triple P seeks to target modifiable familyrisk and protective factors causally implicatedin the onset, exacerbation, or maintenance ofadverse child development outcomes.

To achieve this, five core principles of pos-itive parenting form the basis of the program.These were selected from the developmentalliterature to directly address specific risk andprotective factors known to predict positive de-velopmental and mental health outcomes inchildren. Table 2 shows how these princi-ples are operationalized into a range of specificparenting skills.

Safe and engaging environment. Childrenof all ages need a safe, supervised, and thereforeprotective environment that provides opportu-nities for them to explore, experiment, and play.This principle is essential to promote healthydevelopment and to prevent accidents and in-juries in the home (Peterson & Saldana 1996,Risley et al. 1976).

Positive learning environment. Althoughthis principle involves educating parents in theirrole as their child’s first teacher, the programspecifically teaches parents to respond posi-tively and constructively to child-initiated in-teractions (e.g., requests for help, information,advice, and attention) through incidental teach-ing and other techniques that assist children tolearn to solve problems for themselves.

Assertive discipline. Triple P teaches par-ents specific child management and behaviorchange strategies that are alternatives to

Self-regulation:a process wherebyparents are taughtskills of personalchange to modify theirown behavior andbecome independentproblem solvers

coercive and ineffective discipline practices(such as shouting, threatening, or using phys-ical punishment). These strategies includeselecting ground rules for specific situations;discussing rules with children; giving clear,calm, age-appropriate instructions and re-quests; presenting logical consequences; usingquiet time (nonexclusionary timeout) andtimeout; and using planned ignoring.

Realistic expectations. This principle in-volves exploring with parents their expecta-tions, assumptions, and beliefs about the causesof children’s behavior and choosing goals thatare developmentally appropriate for the childand realistic for the parent. Parents who areat risk of abusing their child are more likelyto have unrealistic expectations of children’scapabilities (Azar & Rohrbeck 1986).

Parental self-care. Parenting is influenced bya range of factors that affect a parent’s self-esteem and sense of well-being. All levels ofTriple P specifically address this issue by en-couraging parents to view parenting as part ofa larger context of personal self-care, resource-fulness, and well-being and by teaching practi-cal parenting skills that both parents are able toimplement.

Application of Triple P’s principles teachesparents to encourage their child’s social andlanguage skills, emotional self-regulation,independence, and problem-solving ability.It is hypothesized that attainment of theseskills promotes family harmony, reducesparent–child conflict, fosters successful peerrelationships, and prepares children to besuccessful at school. To achieve these childoutcomes, parents are taught a variety ofchild management skills, including monitor-ing problem child behavior; providing briefcontingent attention for appropriate behavior;arranging engaging activities in high-risk par-enting situations; using directed discussion andplanned ignoring for minor problem behavior;giving clear, calm instructions; and backing up


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Tab

le2

Cor

epa

rent

ing

skill

sin

trod

uced

inT

ripl

eP

-Pos

itiv

eP

aren

ting

Pro

gram

Par

ent-

child

rela

tion

ship

enha

ncem

ent

skill

s

Enc

oura

ging

desi

rabl

ebe

havi

or

Tea

chin

gne

wsk

ills

and

beha

vior

sM

anag

ing

mis

beha

vior

Ant

icip

atin

gan

dpl

anni

ngSe

lf-re

gula

tion

skill

sM

ood

and

copi

ngsk

ills

Par

tner

supp

ort

skill

sP

artn

ersu

ppor

tski

llsG

ivin

gde

scri

ptiv

epr

aise

Sett

ing

ago

odex

ampl

eE

stab

lishi

nggr

ound

rule

sP

lann

ing

and

adva

nced

prep

arat

ion

Mon

itori

ngch

ildre

n’s

beha

vior

Cat

chin

gun

help

ful

thou

ghts

Impr

ovin

gpe

rson

alco

mm

unic

atio

nha

bits

Tal

king

with

child

ren

Giv

ing

nonv

erba

lat

tent

ion

Usi

ngin

cide

ntal

teac

hing

Usi

ngdi

rect

eddi

scus

sion

Dis

cuss

ing

grou

ndru

les

for

spec

ific

situ

atio

ns

Mon

itori

ngow

nbe

havi

orR

elax

atio

nan

dst

ress

man

agem

ent

Giv

ing

and

rece

ivin

gco

nstr

uctiv

efe

edba

ck

Show

ing

affe

ctio

nP

rovi

ding

enga

ging

activ

ities

Usi

ngas

k,sa

y,do

Usi

ngpl

anne

dig

nori

ngSe

lect

ing

enga

ging

activ

ities

Sett

ing

deve

lopm

enta

llyap

prop

riat

ego

als

Dev

elop

ing

pers

onal

copi

ngst

atem

ents

Hav

ing

casu

alco

nver

satio

ns

Usi

ngbe

havi

orch

arts

Giv

ing

clea

r,ca

lmin

stru

ctio

ns

Pro

vidi

ngin

cent

ives

Sett

ing

prac

tice

task

sC

halle

ngin

gun

help

ful

thou

ghts

Supp

ortin

gea

chot

her

whe

npr

oble

mbe

havi

oroc

curs

Usi

nglo

gica

lco

nseq

uenc

esP

rovi

ding

cons

eque

nces

Self-

eval

uatio

nof

stre

ngth

san

dw

eakn

esse

s

Dev

elop

ing

copi

ngpl

ans

for

high

-ris

ksi

tuat

ions

Pro

blem

solv

ing

Usi

ngqu

iett

ime

Hol

ding

follo

w-u

pdi

scus

sion

s

Sett

ing

pers

onal

goal

sfo

rch

ange

Impr

ovin

gre

latio

nshi

pha

ppin

ess

Usi

ngtim

eout

354 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


instructions with logical consequences, quiettime (nonexclusionary timeout), and timeout.

Parents learn to apply these skills both athome and in the community. Specific strate-gies such as planned activities training are usedto promote the generalization and maintenanceof parenting skills across siblings and settingsand over time. Triple P interventions com-bine the provision of quality parenting infor-mation with active skills training and support.At each level of intervention, active skills train-ing methods are used to promote skill acqui-sition. For example, in Universal Triple P,media strategies are used that involve the realis-tic depiction of possible solutions to commonlyencountered parenting situations (e.g., bedtimeproblems). These potential solutions can beillustrated through various mediums, includ-ing television programs, community serviceannouncements, “talkback” radio, newspapercolumns, and advertising. The messages are op-timistic and promote the idea that even the mostdifficult parenting problems are solvable and/orpreventable. In more intensive levels of inter-vention (e.g., Levels 3, 4, and 5), information issupplemented by the use of active skills train-ing methods that include modeling, rehearsal,feedback, and between-session practice tasks.

Triple P Evidence Base

We elected to use a narrative account of howthe system evolved to describe the accumulatedevidence evaluating Triple P rather than at-tempt another meta-analysis or systematic re-view. Such meta-analyses and reviews have beenconducted by others on several occasions, andreaders are referred to these papers to directlyreview this evidence (de Graaf et al. 2008a,b;Nowak & Heinrichs 2008; Thomas & Zimmer-Gembeck 2007). However, it is important tonote that no review has included all availablestudies because evidence continues to be pro-duced, and some trials were published beforethe program was named. Additionally, analysesof the evidence typically exclude single-subjectexperiments using observational methods, tendto blend treatment and prevention studies, and

have focused primarily on children with con-duct problems rather than on the full range ofproblems studied. Notwithstanding these lim-itations, all meta-analyses have concluded thatTriple P has a positive effect on children’s be-havior and adjustment, with evidence beingstrongest in the toddler, preschool, and elemen-tary school age groups. Effect sizes describedacross these analyses have ranged from small tolarge positive effects for Triple P, with a largerange. Such variability in effect sizes is not sur-prising in light of the fact that Triple P is asystem of parenting intervention that containsmultiple levels of varying intensity that includeboth prevention and treatment interventions.

Other independent analyses prepared byseveral policy advising groups have concludedthat the evidence has justified Triple P’sinclusion on many evidence-based lists forwell-established or promising interventions.These have included the National Institute ofClinical Excellence guidelines for the treat-ment of conduct disorder (NICE 2006), theWorld Health Organization’s recommendedprograms for global violence reduction (WHO2009), the United Nations’ Task force on fam-ily based treatment for prevention of substanceabuse (UNODC 2009), Blueprints for Vio-lence Prevention (http://www.colorado.edu/cspv/blueprints), the California ClearingHouse for Evidence-Based Social Work(http://www.cebc4cw.org), and the NationalAcademy for Parenting Research (http://www.parentingresearch.org.uk). There arealso independent replications of various TripleP interventions across several countries and cul-tures (e.g., Gallart & Matthey 2005, Hartung &Hahlweg 2011, Heinrichs & Jensen-Doss 2011,Moharreri et al. 2008).

BUILDING A PUBLIC HEALTHAPPROACH TO PARENTINGSUPPORT

The starting point for Triple P was as a home-delivered program targeting parents of disrup-tive preschool children (Sanders & Glynn 1981)as part of this author’s PhD in psychology at


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.

http://www.colorado.edu/cspv/blueprints

http://www.colorado.edu/cspv/blueprints

http://www.cebc4cw.org

http://www.parentingresearch.org.uk

http://www.parentingresearch.org.uk


the University of Queensland. The first evalua-tion study was conducted between February andOctober in 1978. A series of single-subject ex-periments using interrupted time series designsestablished the efficacy of the program on inde-pendently observed measures of child disrup-tive behavior and parenting. Early evaluationsused multiple-baseline across-subjects designswithin the applied behavior analytic tradition(Baer et al. 1968). The foundational work, withmentoring advice from Professors Ted Glynnand Todd Risley, focused on a relatively un-derstudied issue; namely, the extent to whichparents, when trained to manage their chil-dren’s behavior in one setting (home), wouldgeneralize their skills to other relevant settings,such as shopping trips (Sanders & James 1983).The work of early parent-training researchers,such as Patterson (1982) and Koegel et al.(1978), and programs using the Hanff Modelof parent training including the IncredibleYears (Webster-Stratton 1989), Parent-ChildInteraction Therapy (Fernandez & Eyberg2009), and Helping the Non-Compliant Child(Forehand & McMahon 1981), had shown thatparents of children with conduct problemscould be trained via active skills training to usepositive parenting skills to change their chil-dren’s disruptive behavior. However, it was un-clear whether the coaching methods employedwere successful in teaching parents to gener-alize their parenting skills across different set-tings, siblings, behaviors, and times (Sanders &James 1983, Stokes & Baer 1977).

Sanders & Glynn (1981) showed that teach-ing parents self-management and preemptiveparenting skills in addition to positive parentingand contingency management skills increasedthe extent to which parents generalized changesin their parenting across different childcare set-tings. Sanders & Dadds (1982) tested the effectsof building into a parenting program a pro-cedure known as Planned Activities Training(PAT). PAT focused on anticipatory or pre-emptive parenting strategies rather than con-tingency management. Sanders & Christensen(1985) subsequently showed that the parenttraining methods used produced positive effects

across a range of different home settings (e.g.,bedtime, mealtime).

Once the training methods for workingwith individual parents with disruptive childrenwere developed, a series of studies examined theapplication of positive parenting methods withother clinical problems. During this period(1983–1990) the basic parenting interventionwas tested with parents of children with adevelopmental disability who had high ratesof challenging behavior. For example, Sanders& Plant (1989), using a multiple-baselineacross-subjects design, demonstrated that theparenting intervention produced a sustaineddecrease in observed disruptive behavior inboth a training setting, with therapist present,and in a generalization setting, where thetherapist was absent. These early positiveeffects with parents of children with a disabilitywere subsequently replicated and extended inrandomized controlled trials (RCTs) in the pasttwo decades (Plant & Sanders 2007, Robertset al. 2006). Other applications included test-ing the effects with young children with habitdisorders such as thumb sucking (Christensen& Sanders 1987), bedtime problems (Sanderset al. 1984), and mealtime problems (Daddset al. 1984), and with children with feedingdisorders (Turner et al. 1994), recurrent ab-dominal pain (Sanders et al. 1990), and ADHD(Bor et al. 2002, Hoath & Sanders 2002).

In the mid 1980s, Dadds et al. (1987a,b)tested the effects with maritally discordantcouples, examining whether combining abrief four-session partner support interven-tion (Partner Support Training) would enhancethe effects of parent training. The findingsshowed that parents who were maritally discor-dant maintained improvements in their child’sobserved disruptive behavior and parenting,whereas couples receiving only individual par-ent training relapsed at six months follow-up.The partner support intervention made no dif-ference to parents without marital problems.

Other studies subsequently explored theeffects of providing adjunctive interventions inaddition to parenting skills training, includingthe effects of increasing social support for

356 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


single parents (Dadds & McHugh 1992),partner support training for stepparents(Nicholson & Sanders 1999), and cognitivecoping skills training for clinically depressedmothers (Sanders & McFarland 2000).

In Search of a Name

Between 1978 and 1993, the parenting inter-ventions and methods forming the basis ofTriple P did not have an official name and werevariously referred to in scientific publicationsas behavioral parent training, behavioral familyintervention, cognitive-behavioral family inter-vention, and occasionally parent managementtraining. None of these descriptors were “par-ent friendly.” In 1993, when a name was neededfor a large-scale project targeting the parentsof 300 disruptive three-year-olds, the programbecame known as the Positive Parenting ofPreschoolers Program. In 1994, to encompassa wider age range of children, “preschoolers”was removed, and the program simply becameknown locally as the Triple P-Positive Parent-ing Program. Triple P was first used in a scien-tific publication by Sanders & Markie-Dadds(1996), and in 2002 we began referring to theintervention model as the Triple P System toreflect the multilevel nature of the program andthe increasing recognition of Triple P as a pub-lic health approach to parenting support (seeSanders et al. 2002).

Self-Regulation and the Adoptionof a Public Health Framework

The realization that most parents who expe-rience significant problems with their childrenreceive no assistance, combined with the recog-nition that many more parents needed to com-plete parenting programs in order to make anysignificant impact on the social and emotionalproblems of children, prompted the developersof Triple P to adopt a public health approach toparenting support. Traditional clinical modelsof parent training primarily focus on the treat-ment of children and their parents with alreadywell-established problems, leaving untreated

Public healthapproach toparenting support:an approach toparenting support thatemphasizes the need totarget parents at awhole-of-populationlevel in order toachieve meaningfulchange inpopulation-levelindices of parent andchild outcomes

the majority of children who develop social,emotional, or behavioral problems and the ma-jority of parents who have concerns about ev-eryday parenting issues. Various epidemiolog-ical surveys show that most parents concernedabout their children’s behavior or adjustmentdo not receive professional assistance for theseproblems, and when they do, they typicallyconsult family doctors or teachers, who rarelyhave specialized training in parent consultation(see Dittman et al. 2011, Sanders et al. 2008b).A public health approach to increasing par-enting support offers an alternative frameworkto the traditional clinical treatment modelof parent training. This approach ensuresthat large numbers of parents who mightbenefit actually do participate to producemeaningful change at a whole-of-populationlevel rather than individual improvement at anindividual-case level (Prinz & Sanders 2007).

Within a public health framework, an ap-proach to supporting parents is needed thatprotects and promotes parents’ fundamentalrights to make decisions about how they raisetheir children rather than an approach that isjudgmental, critical, or prescriptive. When par-ents are offered information and strategies thathave been shown to work, they can make moreinformed choices about how to tackle their con-cerns about parenting. The principle of self-regulation has been a central construct in thedesign of the Triple P system from the begin-ning (Sanders & Glynn 1981). Self-regulationis a process whereby individuals are taught skillsto change their own behavior and become in-dependent problem solvers in a broader socialenvironment that supports parenting and fam-ily relationships (Karoly 1993, Sanders 2008,Sanders & Mazzucchelli 2011). The approachto self-regulation used in Triple P is de-rived from social-cognitive theory. Accordingto Bandura (1986, 1999), the development ofself-regulation is related to personal, environ-mental, and behavioral factors; these factors op-erate separately but are interdependent.

The rationale for focusing on self-regulationin parenting is compelling. First, the capacityfor self-regulation is associated with various


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


positive life outcomes such as academic achieve-ment, income, savings behavior, physical andmental health, better interpersonal relation-ships, and happiness (e.g., Aspinwall 1998,Duckworth & Seligman 2005, Fredrickson &Joiner 2002, Mischel et al. 1988, Moffitt et al.2011, Shoda et al. 1990, Tangney et al. 2004,Tsukayama et al. 2010). Second, deficits inself-regulation are found in many personal andsocial problems and psychological disordersincluding aggression, anxiety, criminal behav-ior, depression, and impulse control problemssuch as binge eating and alcohol abuse (e.g.,Avakame 1998, Baumeister et al. 1994, Moffittet al. 2011, Tangney et al. 2004, Tremblay et al.1995). Third, self-regulation is an importantmechanism in the success of many psycho-logical interventions including acceptance andcommitment therapy (Hayes et al. 1999), be-havioral activation therapy (Martell et al. 2001,2010), dialectical behavior therapy (Linehan1993), problem-solving therapy (Nezu 1986),self-control therapy (Rehm 1977), and in somepositive psychology interventions (Kashdan &Rottenberg 2010, Mazzucchelli et al. 2010).Finally, deficits in self-regulation in earlychildhood predict adult health, economic, andsocial behavior (Moffitt et al. 2011).

Increasing the Reachof Parenting Programs

Group variants. To increase the reach ofthe intervention, a group variant known asGroup Triple P was developed (Turner et al.1998). Originally designed as a “light-touch,”low-intensity intervention for use as part of alarge-scale universal prevention initiative, theeight-session program consisted of four two-hour group sessions and four brief telephoneconsultations. The initial demonstration ofthe effects of Group Triple P using a quasi-experimental design was the largest evaluationof a universal parenting intervention at thetime, involving some 1,600 parents in thetrial (see Zubrick et al. 1995). The studytargeted parents drawn from two low-incomecatchment areas in Perth, Western Australia.

The 804 parents participating in Group TripleP reported significantly fewer conduct prob-lems, less dysfunctional parenting, and lowerlevels of parental distress and marital conflictthan parents in services-as-usual comparisoncommunities at post intervention and at oneand two years follow-up (Zubrick et al. 2005).

The beneficial effects of Group Triple Pfor children and parents have been replicatedin several RCTs and service-based evaluationsinitially in Australia (e.g., Gallart & Matthey2005) and then overseas. These include RCTsshowing reduced problem behaviors andimproved parenting with Australian Aboriginalparents (Turner et al. 2007), parents in HongKong (Leung et al. 2003), Germany (Cinaet al. 2006), Switzerland (Bodenmann et al.2008), Japan (Matsumoto et al. 2007), and Iran(Tehrani-Doost et al. 2009), and in a rangeof nonexperimental service-based evaluations(Cann et al. 2003, Crisante 2003, Lindsayet al. 2010). The core group program has alsobeen successfully used with adaptations withparents at risk of child maltreatment (Sanderset al. 2004, Wiggins et al. 2009), parentsexperiencing separation and divorce (Stallman& Sanders 2007), parents of gifted and talentedchildren (Morawska & Sanders 2009), parentsof children with feeding problems (Adamsonet al. 2011), parents of children with ADHD(Bor et al. 2002, Hoath & Sanders 2002),parents of teenagers (Ralph & Sanders 2003),parents of multiples (Brown et al. 2011),parents of overweight and obese children(West et al. 2010), and highly stressed workingparents (Sanders et al. 2011b).

Self-help and telephone-assisted variants.To further improve access for parents, aself-help version of the 10-session individualprogram was developed (Connell et al. 1997).A series of RCTs showed that this 10-sessionself-help parenting program could be success-fully delivered to parents in rural areas usinga self-help workbook alone or in combinationwith a brief (10- to 30-minute) weekly tele-phone consultation (Connell et al. 1997). Theefficacy of this self-help plus telephone-assisted

358 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


intervention was subsequently replicated andextended and shown to be effective whendelivered by regular telephone counselingservice for parents (Morawska & Sanders2006a,b), with parents of disruptive preschool-ers (Markie-Dadds & Sanders 2006a,b), andwith parents of teenagers (Morawska et al.2005, Stallman & Ralph 2007).

Using the mass media. A public healthapproach to parenting support requires aneffective media and communication strategy toengage parents (Sanders & Prinz 2008). Massmedia campaigns have been used to increaseawareness to induce behavioral changes inprevention studies focusing on cancer, cigarettesmoking, vaccinations, exercise, and cardio-vascular risk (Borland et al. 1990, Flay 1987,McDivitt et al. 1997, Owen et al. 2006, Salonenet al. 1981).

In 1995, we began examining the effectsof using different types of media interven-tions, particularly television programming,as a means to promote positive parentingon a larger scale. This work included theuse of radio programs, newspaper columns,promotional and advertising materials, and theInternet. For example, Sanders et al. (2000)investigated the feasibility of using a televisionseries on parenting to promote positive familyoutcomes. The Families series, originally airedat prime time on commercial television in NewZealand in 1995, was a 30-minute, 12-episode“infotainment”-style program. The programused an entertaining format to provide practicalinformation and advice to parents on a varietyof common behavioral and developmentalproblems in children as well as on otherparenting issues. An RCT evaluation of theprogram (see Sanders et al. 2000) showed thatmothers watching the series reported signifi-cant reductions in the number of child behaviorproblems posttreatment in comparison withthe control group, and there was a significantdecrease in the number of children who scoredin the clinical range on a measure of disruptivebehavior. Mothers in the media condition alsoreported an increased sense of competence and

satisfaction in their parenting abilities relativeto mothers in the control group.

Sanders et al. (2008a) and Calam et al. (2008)evaluated a six-episode observational documen-tary television series, Driving Mum and DadMad, on ITV, the United Kingdom’s largestcommercial network. This series depicted theexperiences and emotional journey of five fam-ilies with children with severe conduct prob-lems as they participated in Group Triple P(an eight-session group program). The seriesattracted an average of 5.1 million viewers and25% market share of the viewing audience inthe United Kingdom, demonstrating the audi-ence potential of a parenting series that is basedon the actual experiences of real families under-going the Triple P group intervention. All fiveparticipating on-air families made significantgains on all key indices of outcome. The evalua-tion showed that parents who watched the seriesreported improved self-efficacy and reducedconduct problems, parental distress, coerciveparenting, and marital conflict over parenting.

Low-intensity seminar series. Our searchto distill the core elements of interventionscontinued with the development and trialingof a large-group seminar series and additionalsmall-group, stand-alone, topic-specific dis-cussion groups for parents. A three-sessionseminar series on positive parenting wasdeveloped as a transition-to-school program(Sanders et al. 2008a) and was designed tobe a cost-efficient universal program. Severalevaluation studies showed positive interventioneffects for the series, and it has been usedextensively in large-scale rollouts of Triple P asa public health intervention (e.g., Sanders et al.2008a, 2009). A variant has also been developedand trialed for parents with a developmentaldisability (Sofronoff et al. 2011).

Triple P for parents of children with a dis-ability. In comparison to parents of typicallydeveloping children, parents of children witha developmental disability experience consid-erably more stress in raising their children,and their children are more likely to develop


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


mental health problems. Beginning in 1996 incollaboration with the Disabilities ServicesCommission in Western Australia, we com-menced the development of a parallel systemof parenting support known as Stepping StonesTriple P, modeled on the core multilevel sys-tem of Triple P, for parents of children with adisability (Roberts et al. 2006). A series of stud-ies has evaluated each of the Stepping Stonesprogram variants, including an intensive 10-session individual program, an eight-sessiongroup program, a self-help program, a brief pri-mary care variant, and a two-session seminarseries on positive parenting (Plant & Sanders2007, Roberts et al. 2006).

Topic-specific parent discussion groups.The final stage in the development of a groupformat involved the development of topic- andage-specific discussion groups for up to 20 par-ents at a time. Two RCTs have shown mediumto large effect sizes on child outcome for discus-sion groups on disobedience, hassle-free shop-ping, bedtime, and fighting and aggression.Sustained intervention effects were obtained inboth trials ( Joachim et al. 2010, Morawska et al.2011).

Online parenting interventions. The de-velopment of a suite of online programs forparents is the most recent aspect of programdevelopment. Access to high-speed Internetconnections has increased remarkably over thepast five years, and this has fostered a prolif-eration of Web sites providing information onparenting. An Internet search using the term“positive parenting” yielded millions of hits.However, most Web sites on parenting, includ-ing government-sponsored sites, have neverbeen evaluated to determine whether using theWeb improves parenting skills. The challengefacing parenting researchers is to harness theutility of the online world—including socialmedia—and transform it into an effective,evidence-based platform of parenting support.

Online Triple P offers parents a parent-controlled learning environment that isconsistent with consumer preference (see

Metzler et al. 2011), improves the convenienceand reach of the intervention, and reducesthe cost of delivery to parents. The onlineparenting program included eight educationalmodules with interactive exercises and briefvideos and was recently tested in a sample of127 parents (Sanders et al. 2011a). Comparedto a waitlist control group, Online Triple Pwas effective and was associated with largeeffect sizes on key variables (child behavior,dysfunctional parenting, parenting confidence,and parental anger) that were similar to thosefor in-person group delivery. Love et al. (2011)recently argued that Online Triple P couldbe further enhanced by combining it with amoderated social network for parents at riskof child maltreatment. The effects of such anintervention are currently under investigation.

PUTTING IT ALL TOGETHER:THE SIMULTANEOUSIMPLEMENTATION OFALL LEVELS OF THE TRIPLEP SYSTEM

The approach to building a system of interven-tion involved developing and testing in isola-tion the different levels and variants of the pro-gram rather than integrating multiple levels atthe outset. Such an approach is consistent withCollins and colleagues’ (2009) recently advo-cated model of building the components of anintervention prior to implementing a complexmulticomponent system of intervention. TheTriple P system now has a full spectrum of inte-grated, theoretically consistent, preventive andtreatment interventions ranging from very lighttouch to intensive programs for more complexand difficult-to-treat behavioral and emotionalproblems. The goal was to ensure that eachcomponent of the intervention system workedand had an evidence base to justify inclusion in apublic health model, with supporting evidencefor every component. A demonstration that thesimultaneous implementation of the multilevelsystem could produce population-level benefitswas required.

360 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Implementation of Triple P as a systeminvolved targeting defined geographical catch-ment areas and tracking the population-levelimpact on indices of child well-being, mal-treatment, and parenting. The simultaneousimplementation of multiple levels allowed forsynergies to develop and helped to create mo-mentum for a parenting program in a commu-nity. To date, two large-scale population-levelevaluations of the Triple P system have beenpublished that have shown the feasibility andcost-effectiveness of this approach; severalother evaluations are in progress in the UnitedKingdom, Canada, Sweden, Ireland, Australia,New Zealand, and Belgium.

Sanders et al. (2008b,c) described the imple-mentation and evaluation of the Every Familyproject. Every Family targeted parents of all4- to 7-year-old children in 20 geographicalcatchment areas in Australia. All parents in 10geographic catchment areas could participatein various levels (depending on need andinterest) of the multilevel Triple P suite ofinterventions. Interventions consisted of amedia and communication strategy, parentingseminars, parenting groups, and individuallyadministered programs. These parents werethen compared to a sample of parents fromthe other 10 geographical catchment areas.The evaluation of population-level outcomeswas through a household survey of parentsusing a structured computer-assisted telephoneinterview. Following a two-year interventionperiod, parents in the Triple P communitiesreported a greater reduction in behavioraland emotional problems in children and incoercive parenting and parental depression andstress, greater program awareness, and higherlevels of exposure to Triple P than parentsin comparison communities. These findingsshowed for the first time that population-levelchange in parenting practices and child mentalhealth outcomes could be achieved through apublic health model targeting parenting.

Prinz et al. (2009) took the approach topopulation-level implementation one step fur-ther using a cluster randomized design. Eigh-teen counties in the state of South Carolina

Population-levelchange: theassociated changes inparenting practice andchild behavior andemotion resultingfrom the adoption andimplementation of apublic health approachto parenting support

were randomly assigned to either the Triple Psystem or to care-as-usual control. Followingintervention, the Triple P counties observedlower rates of founded cases of child maltreat-ment, hospitalizations and injuries due to mal-treatment, and out-of-home placements due tomaltreatment. This was the first time a publichealth parenting intervention had shown posi-tive population-level effects on child maltreat-ment in a randomized design with county as theunit of random assignment.

ESSENTIAL CRITERIAFOR MAKING A PUBLICHEALTH APPROACH TOPARENTING WORK

Much has been learned about how to imple-ment a public health approach to increasingparenting support in communities. Detailedimplementation guidelines have been devel-oped and are being used in a number of repli-cation studies around the world. These rolloutscontinue to refine our understanding of howbest to implement large-scale psychological in-terventions. Several criteria need to be met forthe approach to work.

Having Parenting ProgramsAvailable that Work

Parents prefer parenting programs that aresupported by evidence that they actually work(e.g., Sanders et al. 2011c). However, parentsvary greatly in the level and type of supportthey require or are prepared to participatein. Some parents are seeking basic advice ondealing with common parenting problems andissues (e.g., establishing bedtime routines),and yet others have more serious problemsthat require more intensive intervention overa longer period. This variation in need wasbehind the development of a range of Triple Pdelivery formats, variants, and levels of inten-sity. To ensure that the diverse needs of parentsare addressed, a population-level parentingstrategy requires different evidence-basedinterventions to be available.


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Stay Positive: amedia communicationstrategy aimed atengaging parents inpositive parentingstrategies in anonstigmatized way

Having Evidence of Cost-Effectiveness

A public health approach to parenting sup-port can be a very cost-effective approach toprevention. Foster et al. (2008) estimated thatthe infrastructure costs associated with theimplementation of the Triple P system in theUnited States was $12 per participant, a costthat could be recovered in a single year by aslittle as a 10% reduction in the rate of abuse andneglect. Aos et al. (2011) conducted a carefuleconomic analysis of the costs and benefitsof implementing the Triple P system usingindices of improvement on rates of child mal-treatment (out-of-home placements and ratesof abuse and neglect). Their findings showedthat for an estimated total intervention cost of$137 per family if only 10% of parents receivedTriple P, there would be a positive benefit of$1,237 per participant, with a benefit-to-costratio of $9.22. The benefit-to-cost ratio iseven higher when higher rates of participationare modeled. Other economic analyses ofimplementation of Triple P as a system havesimilarly shown the intervention to be highlycost-effective in the prevention of antisocialbehavior (e.g., Mihalopoulos et al. 2007, 2011).

Ensuring Cultural Relevanceand Acceptability

Public health interventions need to be accept-able to ethnically and socioeconomically di-verse parents. RCTs, focus groups, and surveymethods have been used to establish the accept-ability and effectiveness of parenting strategiesused in Triple P (e.g., praise, positive attention,quiet time, and timeout) with a diverse range ofparents, including parents from Australia, theUnited States, New Zealand, Japan, Singapore,Hong Kong, Iran, Scotland, England, Ireland,Sweden, Belgium, the Netherlands, Germany,Turkey, Switzerland, South Africa, and Panama(e.g., Bodenmann et al. 2008, Matsumoto et al.2010, Morawska et al. 2010). In this culturalacceptability work, it is important to accessparents directly rather than to rely exclusivelyon the views of professionals serving minority

populations, who can seek to be “cultural gate-keepers,” holding views on cultural accept-ability that differ from those of the parents(Morawska et al. 2011).

Apart from its cross-cultural robustness,Triple P has been shown to be effective withparents from all socioeconomic groups, includ-ing socioeconomically disadvantaged parents.McTaggart & Sanders (2007) showed that fam-ily income and education levels of parents didnot moderate intervention effects of GroupTriple P when delivered as a transition-to-school program. However, specific efforts arerequired to engage some lower-income minor-ity parents, and fathers in general, because theyare less likely to participate than are other par-ents, even though the interventions can be justas effective when they do participate (Leunget al. 2003, Turner et al. 2007).

Reducing Stigma Associated withParticipation in Parenting Programs

When development-enhancing and life-course-altering parenting programs arerestricted to a small minority of vulnerableparents with established serious problems (acommon approach used in targeting parentinginterventions), such programs can be viewedas something for struggling or “failed” parentswith difficult children or for parents involved inthe child protection, justice, or mental healthsystems. As an unfortunate result, parentingprograms become associated with stigma.Hence, an effective engagement strategy isneeded to ensure that all parents can participatein the interventions in a nonstigmatized way.To normalize parental engagement, a mediaand communication strategy is needed that isdesigned to complement and to be theoreti-cally consistent with other types of parentingsupport. An example of such an approachis the Stay Positive communication strategy(see http://www.triplep-staypositive.net),which has been used in a number of large-scale population rollouts of Triple P. Activemedia outreach strategies include radio an-nouncements, newspaper columns, editorials,

362 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.

http://www.triplep-staypositive.net


television features, and promotion of programsthrough the Internet. This approach aims toincrease receptivity toward participating inTriple P and other family/child interventions,normalize the process of seeking help for chil-dren with behavioral and emotional problems,and increase the visibility and reach of variousinterventions.

Engaging Consumersin the Development ofEvidence-Based Programs

The content of parenting programs and theprocesses of delivery benefit greatly from con-sumer input (Sanders & Kirby 2011). Parentshave increasingly been used to provide insightsat various stages of the development, imple-mentation, and evaluation of Triple P. For ex-ample, Metzler et al. (2011) showed parents aprototypical episode of a television series basedon Triple P that is being used in a clinical trialto ensure the footage was considered cultur-ally acceptable and engaging to a mixed-racesample of U.S. parents (including Caucasian,Spanish-speaking, and African American par-ents). Parents overwhelmingly confirmed thatthe multicultural footage was acceptable tothem.

Kirby & Sanders (2011) used focus groupswith grandparents to identify parenting sit-uations that grandparents found challenging(e.g., communicating about grandchild disci-pline with their own adult children). On thebasis of work with these groups, Group TripleP has been modified to include a greater fo-cus on conflict management and teamwork withbirth parents, and a new variant of Triple P,Grandparent Triple P, is currently under de-velopment. We have also used consumer pref-erence surveys to solicit parents’ and practi-tioners’ views on the cultural appropriatenessand relevance of parenting procedures, materi-als (written and DVD), program features, anddelivery methods (Morawska et al. 2010). Ineach of these studies, parents have viewed theprogram as highly culturally appropriate anduseful.

Establishing AchievableParticipation Targets

Careful attention needs to be given to ensuringthat participation targets are set at the outsetso that the necessary numbers of practitionersare trained who have the capacity, interest, andorganizational support to implement the pro-gram with fidelity. The resources required toimplement the program vary as a function of thecosts of delivering the intervention (number ofsessions required), the type of provider who de-livers the program (e.g., nurses, psychologists,social workers, teachers, family support work-ers, doctors), and how active practitioners areafter initial training. A limited number of veryactive practitioners who see hundreds of fami-lies a year would achieve far greater populationreach than a large number of practitioners whouse the intervention infrequently (Shapiro et al.2011). Limiting training access to practitionerswho are prepared to negotiate specific deliverytargets helps to ensure greater program reach.Moderate program use by many providers indiverse delivery settings enables the spread ofthe program to a more diverse population ofparents.

Having an Evaluation Plan andTracking Population-Level Indicators

Reliably assessing the prevalence and incidencerates of child problems and parenting practicestargeted by an intervention is a major chal-lenge for all prevention interventions. Severaldifferent approaches have been used to assesspopulation-level effects of Triple P. Theseinclude accessing aggregate archival data at acounty or local government level to track ratesover time of child abuse and neglect cases,hospitalizations and emergency room visits dueto maltreatment, and out-of-home placements(Prinz & Sanders 2007). Household telephonesurveys using random digit dialing have alsobeen used (Sanders et al. 2007b). Population-level indices can also be complemented byservice-based data concerning outcomesachieved by participating parents using


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


TPI: Triple PInternational

Dissemination:the process of takingevidence-basedparentinginterventions from theresearch laboratoryand delivering them toparents in thecommunity

standardized parent- or child-report instru-ments. Data linkage at the individual-caselevel across different administrative systems inhealth, education, and welfare sectors is partic-ularly valuable and can enable a broader rangeof outcomes to be assessed at an individual-case level over time. There is a need for a rangeof brief, reliable, valid, and change-sensitivemeasures of parenting for use in public healthinterventions. Such measures need to be lowcost; easy to use, score, and interpret; have lowliteracy demands; easy to translate into differ-ent languages; and have consistent responseformats across different areas assessed.

CREATING A GLOBAL ANDSUSTAINABLE SYSTEM OFDISSEMINATION

Several world bodies have recognized that pos-itive parenting programs are essential to in-crease safe, stable, and nurturing relationshipsbetween children and their parents/carers ifglobal violence is to be reduced. These groupsinclude the World Health Organization’sViolence Prevention Alliance (http://www.who.int/violenceprevention). The emergingfield of implementation science is devotedto studying the implementation process asso-ciated with the successful translation of re-search findings into practice. Various modelsof sustainable program implementation haveemerged and are being evaluated (Aarons et al.2011; Fixsen et al. 2005; Sanders & Murphy-Brennan 2010a,b). Unfortunately, most of thediscussion about implementation has focusedon high-income countries (mostly English-speaking countries), where the majority of ef-ficacy trials have been conducted. However,there is a great need to introduce culturallyappropriate and effective parenting support tolow- and middle-income countries in Sub-Saharan Africa, Central and South America,Central and Southeast Asia, the Middle East,and Eastern Europe, where high rates of childmaltreatment, family violence, and substanceabuse are common (UNODC 2009, WHO2009). In order to achieve such levels of

implementation, parenting interventions mustpossess several important characteristics.

Capacity to Go to Scale

The capacity of an evidence-based program tobe scaled up is crucial in a public health con-text. “Going to scale” means that program de-velopers and disseminators (purveyors) have therelevant knowledge, experience, and resourcesto roll out programs on a large scale and theability to respond to workforce training de-mands. When efforts to disseminate Triple Pbegan in earnest in 1996, we could find no well-established exemplars of how to undertake thetask. To enable the program to go to scale, apurveyor organization, Triple P International(TPI), was established to disseminate the pro-gram worldwide. Since the commencement ofdissemination efforts in 1996, more than 62,000practitioners have been trained across 23 coun-tries to implement Triple P. This would nothave been achieved without a dedicated dissem-ination organization with the necessary fiscalresources and expertise to manage the process.

Developing a Systemof Professional Training

Parents accessing parenting services expectprograms to be delivered competently by pro-fessionals. Evidence-based programs achievethe best results when delivered with fidelity(Beidas & Kendall 2010), and practitionerswith higher levels of competence produce bet-ter child outcomes; in contrast, incompetentlydelivered evidence-based programs may evenbe harmful (Henggeler 2011). Despite this,in many countries the workforce deliveringadvice and guidance to parents is a diversemultidisciplinary group of practitioners thatis often undertrained, poorly supervised,and relatively poorly qualified. This is evenmore pronounced in poorer rural and remotecommunities in high-income countries, and inlow- and middle-income countries.

A training and dissemination system wasdeveloped in 1996 in the Parenting and

364 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.

http://www.who.int/violenceprevention

http://www.who.int/violenceprevention


Family Support Centre at the University ofQueensland. However, our initial attempts todisseminate Triple P in Australia through thismechanism were short-lived. The core businessof research-intensive universities is teachingand research, not disseminating interventionprograms. From a university base we did nothave the infrastructure, financial capacity, orthe necessary business acumen to disseminatethe program on a global scale in a sustainablemanner. Such a task requires collaboratorsand partners outside the field of psychology toprovide expertise in business, marketing, pub-lishing, management of intellectual propertymatters, and international business.

After different options were explored, the re-search and development functions were consol-idated within the university, while the trainingand dissemination functions were completelytransferred to TPI, which became a one-stopshop to handle Triple P resource publications,video production and training, and programconsultation and technical support.

One important aspect of this process wasthat the intellectual property involved in theTriple P system needed to be managed. On theadvice of Uniquest, the University of Queens-land’s technology transfer company, all authorsagreed to assign their intellectual propertyrights to the University of Queensland, whichin turn (through Uniquest) licensed TPI, anindependent company appointed to publishthe program and to disseminate it worldwide.Without such an arrangement, Triple P wouldprobably have remained in the cloisters ofacademia and would have made little impact.

Between 1996 and 1998, a standardizedprofessional training program was developedfor all levels of the Triple P system. This systemof training was built on the successful trainingmethods used in preparing therapists in clinicaltrials and in teaching clinical psychologystudents behavioral family intervention skills.The program adopted an active skills trainingapproach that involved a combination ofdidactic input, video and live demonstration ofcore consultation skills, small-group exercisesto practice skills, problem-solving exercises,

course readings, and competency-based assess-ment. This assessment included a written quizand live or videotaped demonstrations by par-ticipants to show that they had mastered corecompetencies specific to the level of trainingundertaken. Triple P training was designed tobe relatively brief to minimize disruption tostaff schedules and to reduce the need for reliefworkers while staff undertook training. Thetraining experience was structured to providebackground reading, attendance at a one- tofive-day training workshop (based on the levelof intervention), and attendance at a one-dayaccreditation workshop eight to 12 weeksafter initial training. Every training course iscarefully evaluated, and feedback is elicitedon the course content, quality of presentation,opportunities for active participation, andpractitioners’ overall consumer satisfaction.Practitioner feedback is incorporated intorevisions of the training program. A rangeof professionals delivers Triple P interven-tions to parents. To be eligible to undertakeTriple P training, participants must haveprofessional training in psychology, medicine,nursing, social work, counseling, or otherrelated field as well as some prior exposure toprinciples of child development and work withfamilies.

Practitioner Accreditation

To successfully complete a Triple P trainingcourse and become an accredited provider in-volves attendance at a training course and com-pletion of accreditation requirements, includ-ing a short-answer quiz addressing knowledgeof theory, program content, and process is-sues involved in consulting with families. Since1998, accreditation has been incorporated intothe training process, and only practitioners whocomplete accreditation requirements can beconsidered properly trained to deliver the in-tervention. Follow-up studies of participants inTriple P training show that about 85% of prac-titioners who start training become accredited,and of those, about 90% implement Triple P(Seng et al. 2006).


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Flexible Tailoring and ResponsiveProgram Delivery

Many manualized evidence-based programshave been criticized as being rigid and inflex-ible. Mazzucchelli & Sanders (2010) arguedthat delivering a program with fidelity does notmean inflexible delivery and that there are high-and low-risk variations in content and processthat can influence clinical outcomes. The train-ing process encourages practitioners to workcollaboratively with parents and to be respon-sive to client need and situational context whilepreserving the key or essential elements of theprogram. The needs of specific client popula-tions can be met by adapting examples used toillustrate key teaching points and through cus-tomized homework. This type of tailoring pre-serves core concepts and procedures while itmeets the idiosyncratic needs of particular par-ent groups (e.g., parents of twins or triplets orparents of children with special needs).

Ensuring Competent TrainersAre Used

Masters- or doctorate-level professionals(mainly clinical or educational psychologists)are used to train practitioners to implementprofessional training programs. Professionalsinvited to become trainers undergo an inten-sive two-week training program. After initialinduction, trainers are provisionally accreditedand can begin conducting training undersupervision from TPI. To be considered fullytrained, trainers have to complete a skills-basedaccreditation process. Trainers do not workindependently and use standardized materials,which serves to ensure that program integrityis protected. Although many agencies favor atrain-the-trainer model, such an approach canlead to substantial program drift and poorerclient outcomes. Program disseminators canquickly lose control of the training processand, as a result, can find it harder to efficientlyincorporate revisions and changes when on-going research indicates they are required.Maintaining control over the initial training of

providers, although not without its challenges(when the demand for a program occurs indifferent cultural contexts), is achievable andhelps to promote quality standards.

Tailoring Training Methodsto Target Groups

Because Triple P training is delivered to abroad range of service providers, the deliveryof courses must be customized to a certain ex-tent to cater to the special characteristics ofthose undergoing training. This can be accom-plished by ensuring that trainers are familiarwith the local context, including where differ-ent providers work, their role in providing par-enting support, their professional backgrounds,and their level of experience. A good trainerseeks to be flexible enough to cater to the ex-perience and learning styles of the group whileensuring that essential content is properly cov-ered. This tailoring can involve selection ofrelevant (to the audience) case examples andillustrations—drawing upon the knowledge, ex-perience, and expertise of the group—and bybringing to the attention of the group the vari-ant and invariant features of the program.

Maintaining Training Quality

The training organization must carefully man-age and maintain the quality of the training pro-cess itself to minimize program drift at source.To prevent program drift, all trainers usestandardized materials (including participantnotes, training exercises, and training DVDsdemonstrating core consultation skills) andadhere to a quality-assurance process; trainersbecome part of a trainer network, and main-tenance of their accreditation is required. TPImanages all aspects of the training program,including the initial training, post-trainingsupport, and follow-up technical assistance.

Technical and Consultation Support

The Triple P team encourages organizationsand practitioners to access ongoing back-up

366 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


consultative advice posttraining. Triple P staffmembers have ongoing email contact, telecon-ferences, and staff meetings as well as updatedays to address administrative issues (e.g.,data management, performance indicators),logistical issues (e.g., avoidance of accreditationworkshops due to anxiety, referral strategies),and clinical issues (e.g., dealing with specificpopulations, clinical process problems) iden-tified by practitioners. These contacts activelyengage agency staff in troubleshooting.

An online practitioner network has alsobeen established to provide ongoing techni-cal support to practitioners using Triple P(http://www.triplep.org). This network pro-vides practitioners with downloadable clinicaltools and resources (e.g., monitoring forms,public domain questionnaires, and sessionchecklists), updates of new research findings,and practice tips and suggestions. An inter-national practitioner network for accreditedproviders enables Triple P practitioners to keepup to date with the latest developments in theworld of Triple P, including recent researchfindings and new programs being released.

Encouraging Reflective PracticeThrough Supervision

Practitioners who access supervision andworkplace support posttraining are more likelyto implement Triple P. A self-regulatorypeer-assisted approach is the preferred methodof supervision in the dissemination of TripleP (see Sanders & Murphy-Brennan 2010a,Sanders et al. 2002, Turner et al. 2011). Theself-regulation approach to supervision is analternative to more traditional, hierarchicallybased group or individual clinical supervisionwith an experienced, expert supervisor whoprovides mentoring, feedback, and advice.The self-regulation model utilizes the powerand influence of the peer group to promotereciprocal learning outcomes for all partici-pants in supervision groups. Under this model,peers become attuned to assessing the clinicalskills of fellow practitioners and provide amotivational context to enable peer colleagues

to change their own behaviors, cognitions,and emotions so they become proficient indelivering interventions.

KEY CHALLENGES INWORKFORCE DEVELOPMENT

The successful implementation of evidence-based interventions such as Triple P requiresstrong local leadership and the creation of anorganizational climate that embraces evidence-based ways of working with clients (Aaronset al. 2009a; Fixsen et al. 2005, 2009; Turneret al. 2011). Many organizations pay lip serviceto installing evidence-based practices but fail tocreate an organizational climate or workforcedevelopment strategy that sustains effectiveprogram use. Some of the key challenges facedin training workforces to deliver Triple P andhow they have been overcome are discussedbelow.

Quality of Organizational Leadership

The quality of organizational leadership influ-ences innovation within practice settings. Linemanagers seeking to improve service qualitythrough the use of evidence-based practicescan encounter significant resistance from staffmembers, particularly if adoption of the prac-tice has been a top-down process with littleconsultation with staff. When line managersprepare staff adequately to undertake training,trainees typically look forward to the experi-ence, are motivated to learn, and are ready toparticipate. Additionally, the implementationof evidence-based practice within a workforcehas been shown to affect staff emotional ex-haustion and retention: Research indicates thatevidence-based practices that have ongoing fi-delity monitoring are likely to produce higherlevels of staff retention and lower levels of emo-tional exhaustion (Aarons et al. 2009a,b).

The Triple P model of training has soughtto promote better organizational support byproviding manager briefings prior to the com-mencement of staff training. These briefings in-clude an overview of the system of intervention,


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.

http://www.triplep.org


Evidence-basedparenting programs:prevention ortreatmentinterventionssupported by empiricalevidence documentingsignificant change oftargeted parent orchild outcomevariables

its evidence base, and the process of training tobe undertaken by staff; how staff can be sup-ported by managers through the training andaccreditation process; how to set implementa-tion targets; and how to support staff with on-going delivery of the program. It is becomingincreasingly evident that this kind of techni-cal support is important in enabling organiza-tions to become involved in programs such asTriple P. Managers attending these sessions re-port greater clarity in knowledge of programrequirements, are more motivated to adopt theprogram, feel supported by the program dis-seminator (i.e., the training organization) ingetting started, and are in a better position tosupport staff through the training, accredita-tion, and implementation phases.

Ensuring AdequateInfrastructure Support

The adoption of a public health approach to theprovision of parenting services represents a sig-nificant shift in policy for many organizations.Organizations that provide services to parentsand families typically receive funding to delivertreatment services to defined high-need clientgroups as opposed to delivering prevention pro-grams to parents. Involvement in Triple P re-quires a significant reorientation of a workforceto prevention, early intervention, and mentalhealth promotion.

In large-scale rollouts of Triple P, it isparamount to ensure that adequate funding andinfrastructure are in place. For example, experi-ence has shown that government departmentsor organizations may fund the initial trainingof their own staff and other agencies serving apopulation but then expect the local agenciesto allocate funds from their own budgets to payfor implementation (e.g., to purchase necessaryparent resources).

Taking a Long-Term Viewof Workforce Development

One downside of emphasizing brief, cost-effective training processes is that unrealistic

expectations of organizations can be created.For example, an assumption that external train-ing consultants can equip a workforce to delivervastly improved client outcomes through par-ticipation in a brief service training course maybe unrealistic. A more defendable assumptionis that the development of capacity to deliverprograms will take time and that learning tobe a better clinician will continue throughout aprofessional lifetime. It is important to under-take a thorough, detailed planning session inthe adoption or engagement phase, prior to thecommencement of staff training. This will allowfor a smoother process within organizations inthe implementation phase post accreditation.

GLOBAL DISSEMINATIONOF TRIPLE P

There is a great need for evidence-based par-enting programs to be disseminated interna-tionally. The unfortunate reality is that only ahandful of the wealthiest countries account forthe vast majority of published RCTs on par-ent training (e.g., the United States, Australia,Canada, and, to a lesser extent, the UnitedKingdom). The Triple P system has generatedconsiderable international interest and is oneof a small number of evidence-based parentinginterventions to have been successfully dissem-inated across countries and cultures. A numberof key challenges must be addressed to dissem-inate programs internationally.

Build a Local Evidence Base

Every country should aim to develop its ownlocal evidence that the program works. Wehave collaborated with many local research in-stitutions to identify interested and competentresearchers to conduct evaluations of Triple Pto help build a local evidence base. Not only issustainability more likely with local evidence ofimpact, but strategic alliances also can be builtto increase the total pool of researchers acrosscountries contributing to the cumulative inter-national evidence base on parenting programs.Triple P often begins in a new country with a

368 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


small-scale demonstration project to establishthe feasibility and clinical utility of the inter-vention before it is implemented more widely(e.g., Leung et al. 2003). Such an approachensures that the program is meeting local needsand fosters a spirit of openness and criticalevaluation and builds local partnerships thatare needed to sustain an intervention. In manycountries, there are competent researchersbut there is not a pool of well-establishedresearchers with the necessary expertise towrite grants, independently conduct RCTs ofparenting evaluations, and publish outcomesin peer-reviewed journals. An internationalnetwork of Triple P researchers has assistedwith this capacity-building process.

Connect International Researchers

Triple P has benefited greatly from severalimportant collaborations that have fostered in-ternational projects and promoted knowledgeexchange regarding delivery of public healthparenting interventions (e.g., Calam et al.2008, Dittman et al. 2011, Heinrichs et al.2005, Leung et al. 2003, Metzler et al. 2011,Prinz et al. 2009). A coordinated internationalresearch network for interested scientists hasbeen established through the InternationalTriple P Research Network (ITPRN). ITPRNfacilitates communication about researchactivity around the world involving the TripleP system. The network has created a datarepository for outcome studies. The HelpingFamilies Change Conference, an internationalconference for researchers, practitioners, andpolicy makers, takes place in a different countryannually. The conference is centered on TripleP research and practice and connects membersof the ITPRN and the broader community for aseries of focused discussions and presentations.It provides an opportunity for critical appraisalof research conducted on Triple P.

Tune in to Local Issues

Each country has its own unique policies,regulations, practices, and opportunities that

influence service priorities. These differencesneed to be acknowledged and understood. Usu-ally this means listening carefully to how the is-sues of concern are framed and accessing rele-vant policy documents that provide insight intolocal issues. Identifying local opinion leaders isalso critical, as they can become either advo-cates or critics depending on how they are en-gaged with the program.

IMPLICATIONS FOR POLICYAND PRACTICE

Parenting interventions have considerablescope to improve children’s developmental out-comes for any mental health, physical health,or social problem for which potentially modi-fiable parenting and family variables in the on-set, maintenance, exacerbation or relapse of theproblem have been causally implicated.

Public Policy Advocacyfor Parenting Programs

The quality of parenting that children receivecan be affected by the broader social ecologyof parenthood, including economic downturn,war, natural disaster, and the law. Preventionscientists should advocate for child- andfamily-friendly public policies and practicesthat promote the well-being of children andfamilies. Such policies can include supportingbans on the use of corporal punishment inschools and homes, increasing access to high-quality and affordable child care, provision ofuniversal health care, access to quality programsfor early child development, limiting exposureof children to violent television and computergames, and restricting access to unhealthyschool meals. Parenting programs are likely towork best when they occur in a socio-politicalclimate that values children, that recognizesthe importance of the parenting role, and thatis prepared to invest in providing parentingsupport for a better future for children.Achieving this outcome requires a multilevelparenting support strategy that targets allparents.


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Research, Policy, and Practice

In most high-income countries, the quality ofparenting programs offered in a communityrarely features in policy debates. Despite thefact that it is one of the most effective men-tal health interventions available for childrenand adolescents, the funding of parenting ser-vices has often been marginalized. For example,in Australia, parent training interventions wereexcluded from rebatable services provided bypsychologists under Medicare when the Federalgovernment introduced rebates for psycholog-ical services in 2006.

Nevertheless, impressive inroads have beenmade to improve access to evidence-basedparenting programs in several countries, in-cluding Australia, the United Kingdom, theUnited States, New Zealand, Canada, Belgium,Norway, and The Netherlands. Althoughthere are increasing demands that services useevidence-based programs, many parenting pro-grams that lack a credible evidence base con-tinue to receive government funding. At thecore of the problem is that once programs areadopted by agencies, there is rarely a require-ment that clinical outcomes are assessed whenprograms are delivered in everyday practice.Failure by funders to require agencies to re-port on clinical outcomes means that there isa lack of accountability. Until funders of ser-vices demand routine measurement of clinicaloutcomes, evidence-based practice will remainan elusive ideal that is not matched by the nec-essary actions of providers. Service providerscould benchmark their outcomes against effectsizes achieved in clinical trials using the sameintervention. Such data would provide valuablefeedback to providers regardless of whethertheir outcomes match, exceed, or fall short oftrial data.

FUTURE DIRECTIONS

Despite the weight of evidence indicatingthat parenting programs are among the mostefficacious and cost-effective interventionsavailable to promote the mental health andwell-being of children and adolescents, the

majority of families who might benefit donot participate in parenting programs. Theparenting intervention field faces several chal-lenges, which, if addressed, could mean betteroutcomes for millions of children globally.

Parenting Across the Lifespan

Parenting is a task that continues through lifeand presents different challenges continuouslyalong the way. However, parenting programsare typically focused on parents of young chil-dren and rely on the assumption that parent-ing has its greatest impact on infants, toddlers,and preschoolers because of the developmen-tal plasticity of the infant brain in the earlychildhood years. Positive, warm, and supportiveinteractions with family members and critical,conflicted interaction patterns can have positiveor detrimental effects regardless of the child’sor parent’s age.

A lifespan approach to parenting sup-port, however, involves developing evidence-based programs that normalize and destigma-tize parenthood preparation, from the earlyparenting of infants to the parenting ofadult children to the great-grandparenting ofgreat-grandchildren. Programmatic effects areneeded to make culturally appropriate and ef-fective parenting programs available through-out the lifespan of a parent.

Broadening Parenting Programs toAddress Children’s Health Problems

Parents influence many diverse aspects of chil-dren’s lives, including a wide range of social,emotional, and behavioral problems, and par-enting interventions have been developed forsome of these problems. However, many moreremain relatively unexplored. Parenting influ-ences have been demonstrated to be relatedto children’s physical health and well-beingas reflected by inadequate nutrition, seden-tary lifestyles, excessive computer and televi-sion screen exposure, and difficulty coping withchronic health problems such as asthma anddiabetes or life-threatening conditions such as

370 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


cystic fibrosis and cancer. A number of trialsare currently examining the effects of differentvariants of Triple P for specific health issues(e.g., asthma, eczema, and cerebral palsy), butmany areas of parenting and children’s healthand development remain unexplored.

CONCLUSION

Over a 33-year period, Triple P has evolvedinto a whole-of-population parenting supportstrategy. The Triple P system adopted a publichealth approach to the delivery of universalparenting support with the goal of increas-ing parental self-efficacy, knowledge, and

competence in the use of skills that promotepositive development in children and ado-lescents. This change in focus has enabledmillions of children around the world toexperience the benefits of positive parentingand family environments that promote healthydevelopment; as a consequence, fewer childrenhave developed behavioral and emotionalproblems or episodes of maltreatment. TripleP remains a work in progress, and there is muchto learn. When parents are empowered withthe tools for personal change that they requireto parent their children positively, the resultingbenefits for children, adolescents, parents, andthe community at large are immense.

SUMMARY POINTS

1. The quality of parenting that children and adolescents receive has a major influence ontheir development, well-being, and life opportunities.

2. Of all the potentially modifiable influences that can be targeted through preventive inter-ventions, none is more important than the quality of parenting that children experience.

3. Prevention interventions targeting parenting should be widely used to promote the de-velopment of healthy, well-adjusted children and adolescents.

FUTURE ISSUES

1. Parenting across the lifespan: Parenting is a task that continues through life and presentsdifferent challenges continuously along the way. The field of parenting interventionresearch has focused heavily on the parenting of young children. A lifespan approach toparenting support changes this focus and will lead to the development of evidence-basedprograms that normalize and destigmatize parenting interventions and increase supportfor parents.

2. Broadening parenting programs to address children’s health problems: Although par-enting interventions have been developed to address many child social, emotional, andbehavioral problems, numerous problems remain relatively unexplored. Future parentingintervention research should aim to address known gaps in the literature and to furtherexplore the ways in which parenting intervention can address child health issues.

DISCLOSURE STATEMENT

Matthew R. Sanders is the founder and lead author of the Triple P-Positive Parenting Program(“Triple P”). Triple P is owned by the University of Queensland. Dr. Sanders has no ownershipin Triple P International.


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


ACKNOWLEDGMENTS

The author acknowledges colleagues and former students who have contributed to the devel-opment of the Triple P system. These colleagues include Karen Turner, Carol Markie-Dadds,Alan Ralph, Alina Morawska, Trevor Mazzucchelli, Lisa Studman, Felicity West, Aileen Pidgeon,Helen Stallman, and Carmen Spry.

LITERATURE CITED

Aarons GA, Fettes DL, Flores LE, Sommerfield DH. 2009a. Evidence-based practice and staff emotionalexhaustion in children’s services. Behav. Res. Ther. 47:954–60

Aarons GA, Hulbert M, Horwitz SM. 2011. Advancing a conceptual model of evidence-based practice imple-mentation in public service sectors. Adm. Policy Ment. Health 38:4–23

Aarons GA, Sommerfield DH, Hecht DB, Silovsky JF, Chaffin MJ. 2009b. The impact of evidence-basedpractice implementation and fidelity monitoring on staff turnover: evidence for a protective effect.J. Consult. Clin. Psychol. 77:270–80

Adamson M, Morawska A, Sanders MR. 2011. Childhood feeding difficulties: a randomised controlled trialof a group parenting intervention. Manuscript in preparation

Aos S, Lee S, Drake E, Pennuci A, Klima T, et al. 2011. Return on Investment: Evidence-Based Options to ImproveStatewide Outcomes. Olympia: Wash. State Inst. Publ. Policy

Aspinwall LG. 1998. Rethinking the role of positive affect in self-regulation. Motiv. Emot. 22:1–32Avakame EF. 1998. Intergenerational transmission of violence, self-control, and conjugal violence: a compar-

ative analysis of physical violence and psychological aggression. Violence Vict. 13:301–16Azar ST, Rohrbeck CA. 1986. Child abuse and unrealistic expectations: further validation of the Parent

Opinion Questionnaire. J. Consult. Clin. Psychol. 54:867–68Baer DM, Wolf MM, Risley TR. 1968. Some current dimensions of applied behavior analysis. J. Appl. Behav.

Anal. 1:91–97Baker BL, Blacher J, Olsson MB. 2005. Preschool children with and without developmental delay: behaviour

problems, parents’ optimism and well-being. J. Intellect. Disabil. Res. 49:575–90Bandura A, ed. 1986. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ:

Prentice HallBandura A. 1999. Social cognitive theory: an agentic perspective. Asian J. Soc. Psychol. 2:21–41Baumeister RF, Heatherton TF, Tice DM, ed. 1994. Losing Control: How and Why People Fail at Self-Regulation.

San Diego, CA: AcademicBeaver KM, Belsky J. 2011. Gene-environment interaction and the intergenerational transmission of parenting:

testing the differential-susceptibility hypothesis. Psychiatr. Q. In pressBeidas RS, Kendall PC. 2010. Training therapists in evidence-based practice: a critical review of studies from

a systems-contextual perspective. Clin. Psychol. Sci. Pract. 17:1–30Belsky J, de Haan M. 2011. Annual research review: parenting and children’s brain development: the end of

the beginning. J. Child Psychol. Psychiatry 52:409–28Bodenmann G, Cina A, Ledermann T, Sanders MR. 2008. The efficacy of Positive Parenting Program (Triple

P) in improving parenting and child behavior: a comparison with two other treatment conditions. Behav.Res. Ther. 46:411–27

Bor W, Sanders MR, Markie-Dadds C. 2002. The effects of the Triple P-Positive Parenting Programon preschool children with co-occurring disruptive behavior and attentional/hyperactive difficulties.J. Abnorm. Child Psychol. 30:571–87

Borland R, Hill D, Noy S. 1990. Being sunsmart: changes in community awareness and reported behaviourfollowing a primary prevention program for skin cancer control. Behav. Change 7:126–35

Boyle C, Sanders MR, Lutzker JR, Prinz RJ, Shapiro C, et al. 2010. An analysis of training, generalization,and maintenance effects of Primary Care Triple P for parents of preschool-aged children with disruptivebehavior. Child Psychiatry Hum. Dev. 41:114–31

Bradley RH. 2007. Parenting in the breach: how parents help children cope with developmentally challengingcircumstances. Parenting 7:99–148

372 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Brestan EV, Eyberg SM. 1998. Effective psychosocial treatments of conduct-disordered children and adoles-cents: 29 years, 82 studies, and 5,272 kids. J. Clin. Child Psychol. 27:180–89

Brown S, Morawska A, Sanders MR. 2011. Surviving multiples: an evaluation of a group behavioural parentingintervention for parents of twins and triplets. Manuscript in preparation

Calam R, Sanders MR, Miller C, Sadhnani V, Carmont S. 2008. Can technology and the media helpreduce dysfunctional parenting and increase engagement with preventative parenting interventions?Child Maltreat. 13:347–61

Cann W, Rogers H, Matthews J. 2003. Family Intervention Services program evaluation: a brief report oninitial outcomes for families. Aust. J. Adv. Ment. Health 2:208–15

Chadwick O, Kusel Y, Cuddy M. 2008. Factors associated with the risk of behaviour problems in adolescentswith severe intellectual disabilities. J. Intellect. Disabil. Res. 52:864–76

Christensen AP, Sanders MR. 1987. Habit reversal and differential reinforcement of other behaviour in thetreatment of thumbsucking: an analysis of generalization and side-effects. J. Child Psychol. Psychiatry28:281–95

Cina A, Bodenmann G, Hahlweg K, Dirscherl T, Sanders MR. 2006. Triple P (Positive Parenting Program):theoretischer und empirischer Hintergrund und erste Erfahrungen im deutschsprachigen Raum. J. Fam.Res. 1:66–88

Collins LM, Chakraborty B, Murphy SA, Strecher V. 2009. Comparison of a phased experimental approachand a single randomized clinical trial for developing multicomponent behavioral interventions. Clin. Trials6:5–15

Collins WA, Maccoby EE, Steinberg L, Hetherington EM, Bornstein MH. 2000. Contemporary research onparenting: the case for nature and nurture. Am. Psychol. 55:218–32

Connell S, Sanders MR, Markie-Dadds C. 1997. Self-directed behavioral family intervention for parents ofoppositional children in rural and remote areas. Behav. Modif. 21:379–408

Coren E, Barlow J, Stewart-Brown S. 2002. Systematic review of the effectiveness of parenting programmesfor teenage parents. J. Adolesc. 26:79–103

Crisante N. 2003. Training in parent consultation skills for primary care practitioners in early intervention inthe pre-school context. Aust. J. Adv. Ment. Health 2:191–200

Dadds MR, McHugh TA. 1992. Social support and treatment outcome in behavioral family therapy for childconduct problems. J. Consult. Clin. Psychol. 60:252–59

Dadds MR, Sanders MR, Behrens BC, James JE. 1987b. Marital discord and child behavior problems: adescription of family interactions during treatment. J. Clin. Child Psychol. 16:192–203

Dadds MR, Sanders MR, Bor W. 1984. Training children to eat independently: evaluation of mealtimemanagement training for parents. Behav. Psychother. 12:356–66

Dadds MR, Schwartz S, Sanders MR. 1987a. Marital discord and treatment outcome in behavioral treatmentof childhood conduct disorders. J. Consult. Clin. Psychol. 55:396–403

de Graaf I, Speetjens P, Smit F, de Wolff M, Tavecchio L. 2008a. Effectiveness of the Triple P PositiveParenting Program on behavioural problems in children: a meta-analysis. Behav. Modif. 32:714–35

de Graaf I, Speetjens P, Smit F, de Wolff M, Tavecchio L. 2008b. Effectiveness of the Triple P PositiveParenting Program on parenting: a meta-analysis. Fam. Relat. 57:553–66

Dittman CK, Keown LJ, Sanders MR, Rose D, Farruggia SP, et al. 2011. An epidemiological examination ofparenting and family correlates of emotional problems in young children. Am. J. Orthopsychiatry 81:358–68

Dretzke J, Davenport C, Frew E, Barlow J, Stewart-Brown S, et al. 2009. The clinical effectiveness of differentparenting programmes for children with conduct problems: a systematic review of randomised controlledtrials. Child Adolesc. Psychiatry Ment. Health 3:7

Duckworth AL, Seligman MEP. 2005. Self-discipline outdoes IQ in predicting academic performance ofadolescents. Psychol. Sci. 16:939–44

Embry DD. 2004. Community-based prevention using simple, low-cost, evidence-based kernels and behaviorvaccines. J. Community Psychol. 32:575–91

Emerson E. 2003. Prevalence of psychiatric disorders in children and adolescents with and without intellectualdisability. J. Intellect. Disabil. Res. 47:51–58

Fernandez M, Eyberg S. 2009. Predicting treatment and follow-up attrition in parent-child interaction therapy.J. Abnorm. Child Psychol. 37:431–41


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Fixsen DL, Blase KA, Naoom SF, Wallace F. 2009. Core implementation components. Res. Soc. Work Pract.19:531–40

Fixsen DL, Naoom SF, Blase KA, Friedman RM, Wallace F. 2005. Implementation Research: A Synthesis of theLiterature. Tampa: Univ. S. Florida, Louis de la Parte Florida Ment. Health Inst., Nat. Implement. Res.Netw.

Flay BR, ed. 1987. Selling the Smokeless Society: 56 Evaluated Mass Media Programs and Campaigns Worldwide.Washington, DC: Am. Publ. Health Assoc.

Forehand R, McMahon RJ. 1981. Helping the Noncompliant Child: A Clinician’s Guide to Parent Training.New York: Guilford

Foster EM, Prinz RJ, Sanders MR, Shapiro CJ. 2008. The costs of a public health infrastructure for deliveringparenting and family support. Child. Youth Serv. Rev. 30:493–501

Fredrickson BL, Joiner T. 2002. Positive emotions trigger upward spirals toward emotional well-being. Psychol.Sci. 13:172–75

Gallart SC, Matthey S. 2005. The effectiveness of Group Triple P and the impact of the four telephonecontacts. Behav. Change 22:71–80

Guajardo NR, Snyder G, Petersen R. 2009. Relationships among parenting practices, parental stress, childbehaviour, and children’s social-cognitive development. Infant Child Dev. 18:37–60

Gustafsson P, Kjellman N-I, Bjorksten B. 2002. Family interaction and a supportive social network as saluto-genic factors in childhood atopic illness. Pediatr. Allergy Immunol. 13:51–57

Gutman LM, Feinstein L. 2010. Parenting behaviours and children’s development from infancy to earlychildhood: changes, continuities and contributions. Early Child Dev. Care 180:535–56

Hartung D, Hahlweg K. 2011. Stress reduction at the work-family interface: Positive Parenting and self-efficacy as mechanisms of change in Workplace Triple P. Behav. Modif. 35:54–77

Hastings RP, Daley D, Burns C, Beck A. 2006. Maternal distress and expressed emotion: cross-sectional andlongitudinal relationships with behavior problems of children with intellectual disabilities. Am. J. Ment.Retard. 111:48–61

Hastings RP, Lloyd T. 2007. Expressed emotions in families with children and adults with intellectual dis-abilities. Ment. Retard. Dev. Disabil. Res. Rev. 13:339–45

Hayes SC, Strosahl KD, Wilson KG, eds. 1999. Acceptance and Commitment Therapy: An Experiential Approachto Behavior Change. New York: Guilford

Heinrichs N, Bertram H, Kuschel A, Hahlweg K. 2005. Parent recruitment and retention in a universal preven-tion program for child behavior and emotional problems: barriers to research and program participation.Prev. Sci. 6:275–86

Heinrichs N, Jensen-Doss A. 2011. The effects of incentives on families’ long-term outcome in a parentingprogram. J. Clin. Child Adolesc. 39:705–12

Henggeler SW. 2011. Efficacy studies to large-scale transport: the development and validation of multisystemictherapy programs. Annu. Rev. Clin. Psychol. 7:351–81

Hetherington EM, Stanley-Hagan M, Anderson ER. 1989. Marital transitions: a child’s perspective. Am.Psychol. 44:303–12

Hoath FE, Sanders MR. 2002. A feasibility study of Enhanced Group Triple P-Positive Parenting Programfor parents of children with attention deficit hyperactivity disorder. Behav. Change 19:191–206

Joachim S, Sanders MR, Turner KMT. 2010. Reducing preschoolers’ disruptive behaviour in public with abrief parent discussion group. Child Psychiatry Hum. Dev. 41:47–60

Jones R, Burns K, Immel C, Moore R, Shwartz-Goel K, et al. 2009. The impact of Hurricane Katrina onchildren and adolescents: conceptual and methodological implications for assessment and intervention.In Lifespan Perspectives on Natural Disasters, ed. K Cherry, pp. 65–94. New York: Springer

Karoly P. 1993. Mechanisms of self-regulation: a systems view. Annu. Rev. Psychol. 44:23–52Kashdan TB, Rottenberg J. 2010. Psychological flexibility as a fundamental aspect of health. Clin. Psychol. Rev.

30:467–68Kazdin AE, Blase SL. 2011. Rebooting psychotherapy research and practice to reduce the burden of mental

illness. Perspect. Psychol. Sci. 6:21–37Kirby JN, Sanders MR. 2011. Using consumer input to tailor evidence-based parenting interventions to the

needs of grandparents. J. Child Fam. Stud. In press

374 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Kirp DL, ed. 2011. Kids First: Five Big Ideas for Transforming Children’s Lives and America’s Future. New York:PublicAffairs

Koegel RL, Glahn TI, Nieminen GS. 1978. Generalization of parent-training results. J. Appl. Behav. Anal.11:95–109

Koskentausta T, Livanainen M, Almqvist F. 2007. Risk factors for psychiatric disturbance in children withintellectual disability. J. Intellect. Disabil. Res. 51:43–53

Leung C, Sanders MR, Leung S, Mak R, Lau J. 2003. An outcome evaluation of the implementation of theTriple P-Positive Parenting Program in Hong Kong. Fam. Process. 42:531–44

Lindsay G, Davies H, Band S, Cullen MA, Cullen S, et al. 2010. Parenting early intervention pathfinder evaluation.Cheshire, UK: Dep. Child. School. Fam., Univ. Warwick

Linehan MM, ed. 1993. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: GuilfordLove SM, Sanders MR, Metzler C, Prinz RJ, Kast EZ. 2011. Enhancing accessibility and engagement in

evidence-based parenting programs to reduce maltreatment: conversations with vulnerable parents.Manuscript in preparation

Markie-Dadds C, Sanders MR. 2006a. A controlled evaluation of an enhanced self-directed behavioural familyintervention for parents of children with conduct problems in rural and remote areas. Behav. Change23:55–72

Markie-Dadds C, Sanders MR. 2006b. Self-directed Triple P (Positive Parenting Program) for mothers withchildren at-risk of developing conduct problems. Behav. Cogn. Psychother. 34:259–75

Martell CR, Addis ME, Jacobson NS, eds. 2001. Depression in Context: Strategies for Guided Action. New York:Norton

Martell CR, Dimidjian S, Herman-Dunn R, eds. 2010. Behavioral Activation for Depression: A Clinician’s Guide.New York: Guilford

Matsumoto Y, Sofronoff K, Sanders M. 2007. The acceptability and effectiveness of the Triple P parentingprogram in a cross-cultural context: results of an efficacy trial. Behav. Change 24:205–18

Matsumoto Y, Sofronoff K, Sanders MR. 2010. Investigation of the effectiveness and social validity of theTriple P Positive Parenting Program in Japanese society. J. Fam. Psychol. 24:87–91

Mazzucchelli TG, Kane RT, Rees CS. 2010. Behavioral activation interventions for well-being: a meta-analysis. J. Posit. Psychol. 5:105–21

Mazzucchelli TG, Sanders MR. 2010. Facilitating practitioner flexibility within evidence-based practice:lessons from a system of parenting support. Clin. Psychol. Sci. Pract. 17:238–52

McDivitt JA, Zimicki S Hornik RC. 1997. Explaining the impact of a communication campaign to changevaccination knowledge and coverage in the Philippines. Health Commun. 9:95–118

McFarland ML, Sanders MR. 2003. The effects of mothers’ depression on the behavioral assessment ofdisruptive child behavior. Child Fam. Behav. Ther. 25:39–63

McTaggart P, Sanders MR. 2007. Mediators and moderators of change in dysfunctional parenting in a school-based universal application of the Triple P-Positive Parenting Program. J. Child. Serv. 2:4–17

Mercy JA, Saul J. 2009. Creating a healthier future through early interventions for children. J. Am. Med. Assoc.301:2262–64

Metzler C, Sanders MR, Rusby J, Crowley R. 2011. Using consumer preference information to increase thereach and impact of media-based parenting interventions in a public health approach to parenting support.Behav. Ther. In press

Mihalopoulos C, Sanders MR, Turner KMT, Murphy-Brennan M, Carter R. 2007. Does the Triple P-PositiveParenting Program provide value for money? Aust. N.Z. J. Psychiatry 41:239–46

Mihalopoulos C, Vos T, Pirkis J, Carter R. 2011. The economic analysis of prevention in mental healthprograms. Annu. Rev. Clin. Psychol. 7:169–201

Mischel W, Shoda Y, Peake PK. 1988. The nature of adolescent competencies predicted by preschool delayof gratification. J. Personal. Soc. Psychol. 54:687–96

Moffitt TE, Arseneault L, Belsky D, Dickson N, Hancox RJ, et al. 2011. A gradient of childhood self-controlpredicts health, wealth, and public safety. Proc. Natl. Acad. Sci. USA 108:2693–98

Moharreri F, Shahrivar Z, Tehrani-doost M, Mahmoudi-Gharaei J. 2008. Efficacy of the Positive ParentingProgram (Triple P) for parents of children with attention deficit/hyperactivity disorder. Iran. J. Psychiatry3:59–63


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Morawska A, Haslam D, Milne D, Sanders MR. 2011. Evaluation of a brief parenting discussion group forparents of young children. J. Dev. Behav. Pediatr. 32:136–45

Morawska A, Sanders MR. 2006a. Self-administered behavioural family intervention for parents of toddlers:part I. Efficacy. J. Consult. Clin. Psychol. 74:10–19

Morawska A, Sanders MR. 2006b. Self-administered behavioural family intervention for parents of toddlers:effectiveness and dissemination. Behav. Res. Ther. 44:1839–48

Morawska A, Sanders MR. 2009. An evaluation of a behavioural parenting intervention for parents of giftedchildren. Behav. Res. Ther. 47:463–70

Morawska A, Sanders MR, Goadby E, Headley C, Hodge L, et al. 2010. Is the Triple P-Positive ParentingProgram acceptable to parents from culturally diverse backgrounds? J. Child Fam. Stud. In press

Morawska A, Sanders MR, O’Brien J, McAulliffe C, Pope S, Anderson E. 2011. Practitioner perceptions ofthe use of the Triple P-Positive Parenting Program with culturally diverse families. Child Adolesc. Ment.Health. Manuscript submitted

Morawska A, Stallman HM, Sanders MR, Ralph A. 2005. Self-directed behavioural family intervention: Dotherapists matter? Child Fam. Behav. Ther. 27:51–72

Nat. Inst. Clin. Excell. Social Care (NICE). 2006. Parent-Training/Education Programmes in the Managementof Children with Conduct Disorders. London: NICE

Nat. Res. Counc. Inst. Med. 2009. Preventing Mental, Emotional, and Behavioral Disorders Among Young People:Progress and Possibilities, ed. ME O’Connell, T Boat, KE Warner, pp. 157–90. Washington, DC: Nat.Acad. Press

Nezu AM. 1986. Efficacy of a social problem-solving therapy approach for unipolar depression. J. Consult.Clin. Psychol. 54:196–202

Nicholson JM, Sanders MR. 1999. Randomized controlled trial of behavioral family intervention for thetreatment of child behavior problems in stepfamilies. J. Divorce Remarriage 30:1–23

Nowak C, Heinrichs N. 2008. A comprehensive meta-analysis of Triple P-Positive Parenting Program usinghierarchical linear modeling: effectiveness and moderating variables. Clin. Child Fam. Psychol. 11:114–44

Owen N, Glanz K, Sallis JF, Kelder S. 2006. Evidence-based approaches to dissemination and diffusion ofphysical activity interventions. Am. J. Prev. Med. 31:35–44

Patterson GR, ed. 1982. Coercive Family Process. Eugene, OR: CastaliaPeterson L, Saldana L. 1996. Accelerating children’s risk for injury: mothers’ decisions regarding common

safety rules. J. Behav. Med. 19:317–31Plant KM, Sanders MR. 2007. Reducing problem behavior during care-giving in families of preschool-aged

children with developmental disabilities. Res. Dev. Disabil. 28:362–85Prinz RJ, Sanders MR. 2007. Adopting a population-level approach to parenting and family support interven-

tions. Clin. Psychol. Rev. 27:739–49Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, Lutzker JR. 2009. Population-based prevention of child

maltreatment: the US Triple P system population trial. Prev. Sci. 10:1–12Ralph A, Sanders MR. 2003. Preliminary evaluation of the Group Teen Triple P program for parents of

teenagers making the transition to high school. Aust. J. Adv. Ment. Health 2:169–78Ralph A, Toumbourou JW, Grigg M, Mulcahy R, Carr-Gregg M, et al. 2003. Early intervention to help

parents manage behavioural and emotional problems in early adolescents: what parents want. Aust. J.Adv. Ment. Health 2:156–68

Rapee RM, Kennedy SJ, Ingram M, Edwards SL, Sweeney L. 2010. Altering the trajectory of anxiety in at-riskyoung children. Am. J. Psychiatry 167:1518–25

Rehm LP. 1977. A self-control model of depression. Behav. Ther. 8:787–804Risley TR, Clark HB, Cataldo MF. 1976. Behavioral technology for the normal middle-class family. In Behavior

Modification and Families, ed. EJ Mash, LA Hamerlynck, LC Handy, pp. 34–60. New York: Brunner/MazelRoberts C, Mazzucchelli T, Studman L, Sanders MR. 2006. Behavioral family intervention for children with

developmental disabilities and behavioral problems. J. Clin. Child Adolesc. Psychol. 35:180–93Salonen JT, Puska P, Kottke TE, Tuomilehto J. 1981. Changes in smoking, serum cholesterol and blood

pressure levels during a community-based cardiovascular disease prevention program—the North KareliaProject. Am. J. Epidemiol. 114:81–94

376 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Sanders MR. 1999. The Triple P-Positive Parenting Program: towards an empirically validated multilevelparenting and family support strategy for the prevention of behavior and emotional problems in children.Clin. Child Fam. Psychol. Rev. 2:71–90

Sanders MR. 2008. The Triple P-Positive Parenting Program as a public health approach to strengtheningparenting. J. Fam. Psychol. 22:506–17

Sanders MR. 2010. Adopting a public health approach to the delivery of evidence-based parenting interven-tions. Can. Psychol. 51:1–23

Sanders MR, Bor B, Dadds MR. 1984. Modifying bedtime disruptions in children using stimulus control andcontingency management techniques. Behav. Psychother. 12:130–41

Sanders MR, Bor W, Morawska A. 2007a. Maintenance of treatment gains: a comparison of enhanced, standard,and self-directed Triple P-Positive Parenting Program. J. Abnorm. Child Psychol. 35:983–98

Sanders MR, Calam R, Durand M, Liversidge T, Carmont S. 2008a. Does self-directed and web-basedsupport for parents enhance the effects of viewing a reality television series based on the Triple P-PositiveParenting Programme? J. Child Psychol. Psychiatry 49:924–32

Sanders MR, Christensen AP. 1985. A comparison of the effects of child management and planned activitiestraining in five parenting environments. J. Abnorm. Child Psychol. 13:101–17

Sanders MR, Cleghorn G, Shepherd RW, Patrick M. 1996. Predictors of clinical improvement in childrenwith recurrent abdominal pain. Behav. Cogn. Psychother. 24:27–38

Sanders MR, Dadds MR. 1982. The effects of planned activities and child management procedures in parenttraining: an analysis of setting generality. Behav. Ther. 13:452–61

Sanders MR, Glynn EL. 1981. Training parents in behavioral self-management: an analysis of generalizationand maintenance effects. J. Appl. Behav. Anal. 14:223–37

Sanders MR, Haslam D, Calam R, Southwell C, Stallman HM. 2011c. Designing effective interventions forworking parents: a web-based survey of parents in the UK workforce. J. Child. Serv. In press

Sanders MR, James JE. 1983. The modification of parent behavior: a review of generalization and maintenance.Behav. Modif. 7:3–27

Sanders MR, Joachim S, Turner KMT. 2011a. A randomised controlled trial evaluation of the effects of TripleP Online for parents of children with conduct problems. Manuscript in preparation

Sanders MR, Kirby JN. 2011. Consumer engagement and the development, evaluation and dissemination ofevidence-based parenting programs. Behav. Ther. In press

Sanders MR, Markie-Dadds C. 1996. Triple P: a multi-level family intervention program for children withdisruptive behaviour disorders. In Early Intervention and Prevention in Mental Health, ed. P Cotton,H Jackson, pp. 59–85. Melbourne: Austral. Psychol. Soc.

Sanders MR, Markie-Dadds C, Rinaldis M, Firman D, Baig N. 2007b. Using household survey data to informpolicy decisions regarding the delivery of evidenced-based parenting interventions. Child Care HealthDev. 33:768–83

Sanders MR, Mazzucchelli T. 2011a. Preventing behavioural and emotional problems in children who have adevelopmental disability: a public health approach. Res. Dev. Disabil. In press

Sanders MR, Mazzucchelli T. 2011b. The promotion of self-regulation through parenting interventions. InPsychology of Self-Regulation, ed. V Barkoukis. Hauppauge, NY: Nova Sci. In press

Sanders MR, McFarland M. 2000. The treatment of depressed mothers with disruptive children: a controlledevaluation of cognitive behavioral family intervention. Behav. Ther. 31:89–112

Sanders MR, Montgomery D, Brechman-Toussaint M. 2000. The mass media and the prevention of childbehavior problems: the evaluation of a television series to promote positive outcomes for parents andtheir children. J. Child Psychol. Psychiatry 41:939–48

Sanders MR, Morrison M, Rebgetz M, Bor W, Dadds M, et al. 1990. Behavioural treatment of childhoodrecurrent abdominal pain. Relationships between pain, children’s psychological characteristics and familyfunctioning. Behav. Change 7:16–24

Sanders MR, Murphy-Brennan M. 2010a. The international dissemination of the Triple P-Positive ParentingProgram. In Evidence-Based Psychotherapies for Children and Adolescents, ed. JR Weisz, AE Kazdin, pp. 519–37. New York: Guilford. 2nd ed.

Sanders MR, Murphy-Brennan M. 2010b. Creating conditions for success beyond the professional trainingenvironment. Clin. Psychol. Sci. Pract. 17:31–35


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Sanders MR, Pidgeon A, Gravestock F, Connors MD, Brown S, et al. 2004. Does parental attributionalretraining and anger management enhance the effects of the Triple P-Positive Parenting Program withparents at risk of child maltreatment? Behav. Ther. 35:513–35

Sanders MR, Plant K. 1989. Programming for generalization to high and low risk parenting situations infamilies with oppositional developmentally disabled preschoolers. Behav. Modif. 13:283–305

Sanders MR, Prinz R. 2008. Using mass media as a population level strategy to strengthen parenting skills.J. Clin. Child Adolesc. Psychol. 37:609–21

Sanders MR, Prior J, Ralph A. 2009. An evaluation of a brief universal seminar series on positive parenting: afeasibility study. J. Child. Serv. 4:4–20

Sanders MR, Ralph A, Sofronoff K, Gardiner P, Thompson R, Bidwell K, Dwyer S, eds. 2008b. Every Family:A Public Health Approach to Promoting Children’s Wellbeing. Brisbane: Univ. Queensland

Sanders MR, Ralph A, Sofronoff K, Gardiner P, Thompson R, et al. 2008c. Every Family: a populationapproach to reducing behavioral and emotional problems in children making the transition to school.J. Prim. Prev. 29:197–222

Sanders MR, Shepherd RW, Cleghorn G, Woolford H. 1994. The treatment of recurrent abdominal painin children: a controlled comparison of cognitive-behavioral family intervention and standard pediatriccare. J. Consult. Clin. Psychol. 62:306–14

Sanders MR, Stallman H, McHale M. 2011b. Workplace Triple P: a controlled evaluation of a parentingintervention for working parents. J. Fam. Psychol. 25:581–90

Sanders MR, Turner KMT, Markie-Dadds C. 2002. The development and dissemination of the Triple P-Positive Parenting Program: a multi-level, evidence-based system of parenting and family support. Prev.Sci. 3:173–98

Sanders MR, Turner KMT, Wall CR, Waugh LM, Tully LA. 1997. Mealtime behavior and parent-childinteraction: a comparison of children with cystic fibrosis, children with feeding problems, and noncliniccontrols. J. Pediatr. Psychol. 22:881–900

Seng AC, Prinz RJ, Sanders MR. 2006. The role of training variables in effective dissemination of evidence-based parenting interventions. Int. J. Ment. Health Promot. 8:19–27

Serketich WJ, Dumas JE. 1996. The effectiveness of behavioural parent training to modify antisocial behaviourin children: a meta-analysis. Behav. Ther. 27:171–86

Shapiro C, Prinz RJ, Sanders MR. 2011. Facilitators and barriers to implementation of an evidence-basedparenting intervention to prevent child maltreatment: the Triple P-Positive Parenting Program. ChildMaltreat. In press

Shoda Y, Mischel W, Peake PK. 1990. Predicting adolescent cognitive and self-regulatory competencies frompreschool delay of gratification: identifying diagnostic conditions. Dev. Psychol. 26:978–86

Sofronoff K, Jahnel D, Sanders MR. 2011. Stepping Stones Triple P seminars for parents of a child with adisability: a randomized controlled trial. Res. Dev. Disabil. In press

Stack DM, Serbin LA, Enns LN, Ruttle PL, Barrieau L. 2010. Parental effects on children’s emotionaldevelopment over time and across generations. Infants Young Child. 23:52–69

Stallman HM, Ralph A. 2007. Reducing risk factors for adolescent behavioural and emotional problems: apilot randomised controlled trial of a self-administered parenting intervention. Aust. J. Adv. Ment. Health2:125–37

Stallman HM, Sanders MR. 2007. “Family Transitions Triple P”: the theoretical basis and development of aprogram for parents going through divorce. J. Divorce Remarriage 47:133–53

Stokes TF, Baer DM. 1977. An implicit technology of generalization. J. Appl. Behav. Anal. 10:349–67Tangney JP, Baumeister RF, Boone AL. 2004. High self-control predicts good adjustment, less pathology,

better grades, and interpersonal success. J. Personal. 72:271–322Taylor TK, Biglan A. 1998. Behavioral family interventions for improving child rearing: a review of the

literature for clinicians and policy makers. Clin. Child Fam. Psychol. 1:41–60Tehrani-Doost M, Shahrivar Z, Gharaie J, Alaghband-Rad J. 2009. Efficacy of positive parenting on improving

children’s behavior problems and parenting styles. Iran. J. Psychiatry Clin. Psychol. 14:371–79Thomas R, Zimmer-Gembeck MJ. 2007. Behavioral outcomes of parent–child interaction therapy and Triple

P-Positive Parenting Program: a review and meta-analysis. J. Abnorm. Child Psychol. 35:475–95

378 Sanders

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.


Tremblay RE, Boulerice B, Arseneault L, Niscale MJ. 1995. Does low self-control during childhood explain theassociation between delinquency and accidents in early adolescence? Crim. Behav. Ment. Health 5:439–51

Tsukayama E, Toomey SL, Faith MS, Duckworth AL. 2010. Self-control as a protective factor against over-weight status in the transition from childhood to adolescence. Arch. Pediatr. Adolesc. Med. 164:631–35

Turner KMT, Markie-Dadds C, Sanders MR. 1998. Facilitator’s Manual for Group Triple P. Brisbane: FamiliesInt. Publ.

Turner KMT, Nicholson J, Sanders MR, ed. 2011. The role of practitioner self-efficacy, training, programand workplace factors on the implementation of an evidence-based parenting intervention in primarycare. J. Prim. Prev. 32:95–112

Turner KMT, Richards M, Sanders MR. 2007. A randomised clinical trial of a group parent education programfor Australian indigenous families. J. Paediatr. Child Health 43:429–37

Turner KMT, Sanders MR, Wall CR. 1994. Behavioural parent training versus dietary education in thetreatment of children with persistent feeding difficulties. Behav. Change 11:242–58

United Nations Office Drugs & Crime (UNODC). 2009. Guide to Implementing Family Skills Training Pro-grammes for Drug Abuse Prevention. New York: United Nations

Wallander JL, Dekker MC, Koot HM. 2006. Risk factors for psychopathology in children with intellectualdisability: a prospective longitudinal population-based study. J. Intellect. Disabil. Res. 50:259–68

Webster-Stratton C. 1989. Systematic comparison of consumer satisfaction of three cost-effective parenttraining programs for conduct problem children. Behav. Ther. 20:103–15

West F, Sanders MR, Cleghorn GJ, Davies PSW. 2010. Randomised clinical trial of a family-based lifestyleintervention for childhood obesity involving parents as the exclusive agents of change. Behav. Res. Ther.48:1170–79

Whittingham K, Sofronoff K, Sheffield J. 2006. Stepping Stones Triple P: a pilot study to evaluateacceptability of the program by parents of a child diagnosed with an autism spectrum disorder. Res.Dev. Disabil. 27:364–80

Whittingham K, Sofronoff K, Sheffield J, Sanders MR. 2009. Stepping Stones Triple P: an RCT of a parentingprogram with parents of a child diagnosed with an autism spectrum disorder. J. Abnorm. Child Psychol.37:469–80

Whittingham K, Wee D, Sanders MR, Boyd R. 2011. Responding to the challenges of parenting a child withcerebral palsy: a focus group. Disabil. Rehabil. 33:1557–67

Wiggins TL, Sofronoff K, Sanders MR. 2009. Pathways Triple P-Positive Parenting Program: effects onparent-child relationships and child behavior problems. Fam. Process. 48:517–30

World Health Organization (WHO). 2009. Preventing Violence Through the Development of Safe, Stable andNurturing Relationships Between Children and Their Parents and Caregivers. Series of Briefings on ViolencePrevention: The Evidence. Geneva: WHO

Zubrick SR, Silburn SR, Garton AF, Dalby R, Carlton J, et al. 1995. Western Australian Child Health Survey:Developing Health and Well Being in the ’90s (Catalogue 4303.5). Perth: Austral. Bur. Statist.

Zubrick SR, Ward KA, Silburn SR, Lawrence D, Williams AA, et al. 2005. Prevention of child behaviorproblems through universal implementation of a group behavioral family intervention. Prev. Sci. 6:287–304


Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.

CP08-FrontMatter ARI 2 March 2012 11:20

Annual Review ofClinical Psychology

Volume 8, 2012 Contents

On the History and Future Study of Personality and Its DisordersTheodore Millon � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

A “SMART” Design for Building Individualized Treatment SequencesH. Lei, I. Nahum-Shani, K. Lynch, D. Oslin, and S.A. Murphy � � � � � � � � � � � � � � � � � � � � � � � � �21

Default Mode Network Activity and Connectivity in PsychopathologySusan Whitfield-Gabrieli and Judith M. Ford � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �49

Current Issues in the Diagnosis of Attention Deficit HyperactivityDisorder, Oppositional Defiant Disorder, and Conduct DisorderPaul J. Frick and Joel T. Nigg � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �77

Psychiatric Diagnosis: Lessons from the DSM-IV Pastand Cautions for the DSM-5 FutureAllen J. Frances and Thomas Widiger � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 109

American Indian and Alaska Native Mental Health:Diverse Perspectives on Enduring DisparitiesJoseph P. Gone and Joseph E. Trimble � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 131

Emotion Regulation and Psychopathology: The Role of GenderSusan Nolen-Hoeksema � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 161

Cognitive Bias Modification Approaches to AnxietyColin MacLeod and Andrew Mathews � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 189

Diagnosis and Assessment of Hoarding DisorderRandy O. Frost, Gail Steketee, and David F. Tolin � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 219

The Behavioral Activation System and ManiaSheri L. Johnson, Michael D. Edge, M. Kathleen Holmes,

and Charles S. Carver � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 243

Prediction and Prevention of Psychosis in Youth at Clinical High RiskJean Addington and Robert Heinssen � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 269

From Dysfunction to Adaptation: An InteractionistModel of DependencyRobert F. Bornstein � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 291

vi

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.

CP08-FrontMatter ARI 2 March 2012 11:20

Personality Disorders in DSM-5Andrew E. Skodol � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 317

Development, Evaluation, and Multinational Disseminationof the Triple P-Positive Parenting ProgramMatthew R. Sanders � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 345

Empirical Classification of Eating DisordersPamela K. Keel, Tiffany A. Brown, Lauren A. Holland, and Lindsay P. Bodell � � � � � � � � 381

Obesity and Public PolicyAshley N. Gearhardt, Marie A. Bragg, Rebecca L. Pearl, Natasha A. Schvey,

Christina A. Roberto, and Kelly D. Brownell � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 405

Cognition in the Vegetative StateMartin M. Monti � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 431

Coping with Chronic Illness in Childhood and AdolescenceBruce E. Compas, Sarah S. Jaser, Madeleine J. Dunn, and Erin M. Rodriguez � � � � � � � 455

Indexes

Cumulative Index of Contributing Authors, Volumes 1–8 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 481

Cumulative Index of Chapter Titles, Volumes 1–8 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 484

Errata

An online log of corrections to Annual Review of Clinical Psychology articles may befound at http://clinpsy.annualreviews.org

Contents vii

Ann

u. R

ev. C

lin. P

sych

ol. 2

012.

8:34

5-37

9. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by S

tate

Uni

vers

ity o

f N

ew Y

ork

- B

ingh

amto

n on

06/

01/1

3. F

or p

erso

nal u

se o

nly.

development, evaluation, and multinational dissemination of the triple p-positive parenting program

Documents