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ORIGINAL PAPER Effectiveness of Group Positive Parenting Program (Triple P) in Changing Child Behavior, Parenting Style, and Parental Adjustment: An Intervention Study in Japan Takeo Fujiwara Noriko Kato Matthew R. Sanders Published online: 9 February 2011 Ó Springer Science+Business Media, LLC 2011 Abstract The purpose of this study is to investigate the effectiveness of a group-based family intervention program known as the Group Positive Parenting Program (Triple P), with families in Japan. Reductions in children’s behavioral problems, changes in dysfunctional parenting practices, and affects on parenting adjustment were examined. Par- ticipants of both the intervention and control groups (N = 91 and N = 24, respectively) were recruited from mothers visiting health clinics in Kawasaki City, Kanaga- wa. Intervention and control groups were assessed in terms of child behavior (Strength and Difficulty Questionnaire, SDQ), parenting style (Parenting Scale, PS), and parenting adjustment (Depression-Anxiety-Stress Scale, DASS; and Parenting Experience Survey, PES), both pre- and postin- tervention. A repeated measures multivariate analysis of variance was used to determine the intervention’s effects. The SDQ score for the conduct problems subscale indi- cated a significant intervention effect. In addition, the postintervention scores for all subscales of the PS, the DASS depression subscale and total scores, as well as ratings for perceived difficulty of parenting in the PES, were significantly reduced in the intervention group alone. The PES also revealed that confidence in parenting significantly increased only in the intervention group. Group Triple P is effective in decreasing child conduct problems, dysfunctional parenting practices, depression, anxiety, stress, and the perceived level of parenting diffi- culty, as well as in improving parenting confidence, among Japanese families. Keywords Child abuse Á Parenting Á Intervention Á Behavior problem Á Adjustment Introduction Addressing and remedying child abuse and neglect, also known as child maltreatment, is a high-priority public health issue in Japan. Even after the enactment of the Child Abuse Protection Law in Japan, the number of cases reported to the Child Guidance Center—which is similar to the Child Protection Service in the UK or US—has increased dramatically to total 40,639 cases in 2007— around 40-fold increase since 1990 (1,101 cases) and a 1.7- fold increase since 2001 (23,274 cases) (Children’s Rain- bow Center 2009). It is unknown whether this growth is due to a real increase in the number of children being maltreated or simply because of an increase in the number of cases being reported. In any case, other statistics reveal that a significant number of Japanese mothers are dis- tressed about their parenting skills. One study, for example, found that 65% of mothers in Japan do not have confidence in their parenting abilities, 33% of mothers find parenting difficult, and 18% of mothers believe that they maltreat their children (Nihon Shouni Hoken Kyokai (The Japanese Society of Child Health) 2001). The types of abusive behaviors exhibited by parents vary, including emotional abuse (80%), physical abuse (49%), excessive discipline T. Fujiwara (&) Department of Social Medicine, National Research Institute for Child Health and Development, Setagaya-ku, Tokyo 157-8535, Japan e-mail: [email protected] N. Kato Department of Health Promotion, National Institute of Public Health, Wako-shi, Saitama, Japan M. R. Sanders School of Psychology, University of Queensland, Brisbane, QLD, Australia 123 J Child Fam Stud (2011) 20:804–813 DOI 10.1007/s10826-011-9448-1

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ORIGINAL PAPER

Effectiveness of Group Positive Parenting Program (Triple P)in Changing Child Behavior, Parenting Style, and ParentalAdjustment: An Intervention Study in Japan

Takeo Fujiwara • Noriko Kato • Matthew R. Sanders

Published online: 9 February 2011

� Springer Science+Business Media, LLC 2011

Abstract The purpose of this study is to investigate the

effectiveness of a group-based family intervention program

known as the Group Positive Parenting Program (Triple P),

with families in Japan. Reductions in children’s behavioral

problems, changes in dysfunctional parenting practices,

and affects on parenting adjustment were examined. Par-

ticipants of both the intervention and control groups

(N = 91 and N = 24, respectively) were recruited from

mothers visiting health clinics in Kawasaki City, Kanaga-

wa. Intervention and control groups were assessed in terms

of child behavior (Strength and Difficulty Questionnaire,

SDQ), parenting style (Parenting Scale, PS), and parenting

adjustment (Depression-Anxiety-Stress Scale, DASS; and

Parenting Experience Survey, PES), both pre- and postin-

tervention. A repeated measures multivariate analysis of

variance was used to determine the intervention’s effects.

The SDQ score for the conduct problems subscale indi-

cated a significant intervention effect. In addition, the

postintervention scores for all subscales of the PS, the

DASS depression subscale and total scores, as well as

ratings for perceived difficulty of parenting in the PES,

were significantly reduced in the intervention group alone.

The PES also revealed that confidence in parenting

significantly increased only in the intervention group.

Group Triple P is effective in decreasing child conduct

problems, dysfunctional parenting practices, depression,

anxiety, stress, and the perceived level of parenting diffi-

culty, as well as in improving parenting confidence, among

Japanese families.

Keywords Child abuse � Parenting � Intervention �Behavior problem � Adjustment

Introduction

Addressing and remedying child abuse and neglect, also

known as child maltreatment, is a high-priority public

health issue in Japan. Even after the enactment of the Child

Abuse Protection Law in Japan, the number of cases

reported to the Child Guidance Center—which is similar to

the Child Protection Service in the UK or US—has

increased dramatically to total 40,639 cases in 2007—

around 40-fold increase since 1990 (1,101 cases) and a 1.7-

fold increase since 2001 (23,274 cases) (Children’s Rain-

bow Center 2009). It is unknown whether this growth is

due to a real increase in the number of children being

maltreated or simply because of an increase in the number

of cases being reported. In any case, other statistics reveal

that a significant number of Japanese mothers are dis-

tressed about their parenting skills. One study, for example,

found that 65% of mothers in Japan do not have confidence

in their parenting abilities, 33% of mothers find parenting

difficult, and 18% of mothers believe that they maltreat

their children (Nihon Shouni Hoken Kyokai (The Japanese

Society of Child Health) 2001). The types of abusive

behaviors exhibited by parents vary, including emotional

abuse (80%), physical abuse (49%), excessive discipline

T. Fujiwara (&)

Department of Social Medicine, National Research Institute

for Child Health and Development, Setagaya-ku,

Tokyo 157-8535, Japan

e-mail: [email protected]

N. Kato

Department of Health Promotion, National Institute

of Public Health, Wako-shi, Saitama, Japan

M. R. Sanders

School of Psychology, University of Queensland,

Brisbane, QLD, Australia

123

J Child Fam Stud (2011) 20:804–813

DOI 10.1007/s10826-011-9448-1

(17%), and neglect (0.4%) (Nihon Shouni Hoken Kyokai

(The Japanese Society of Child Health) 2001).

To address this situation, it is necessary to adopt pre-

vention strategies comprising those that are population-

based and those that focus on high-risk families (Fujiwara

2007). However, since the prevention of child maltreat-

ment is an urgent issue, strategies that target high-risk

parents are considered the most efficient means of helping

distressed mothers or mothers with difficult children in the

short term.

The children at highest risk of being maltreated include

those from low-income families (Brown et al. 1998;

Cappelleri et al. 1993; Kotch et al. 1999; Wu et al. 2004),

those with mothers who have a mental illness (Brown et al.

1998; Chaffin et al. 1996; Dinwiddie and Bucholz 1993;

Kotch et al. 1999; Windham et al. 2004), those with one or

more siblings (Fujiwara et al. 2008; Kotch et al. 1999; Wu

et al. 2004), and those with developmental delays

(Famularo et al. 1992; Sidebotham and Heron 2003;

Zelenko et al. 2000). Previous studies have reported the

effectiveness of intervention as a strategy for preventing

child maltreatment in high-risk situations (Eckenrode et al.

2000; Olds et al. 1997; Roberts et al. 1996).

A review of 21 studies involving home-visitation

programs for parents at risk for child maltreatment found,

on average, a 40% reduction in child maltreatment out-

comes among program participants, compared to the

control group (Hahn et al. 2003). This intervention was

considered effective, since it provided parents with

information on child health and development, enabled

them to build problem-solving skills, and gave them

greater access to social services and other resources, all

of which enabled the parents to reduce misbehavior in

their children (Yoshikawa 1995). There is also evidence

supporting the effectiveness of both intensive, short-term

therapy geared toward family preservation, and parenting

education that targets high-risk families (MacLeod and

Nelson 2000).

The Triple P (Positive Parenting Program) is a form of

behavioral family intervention based on social-learning

principles; it was designed as a comprehensive, multilevel,

and prevention-oriented system to support parenting

(Sanders 1999). Triple P showed a large effect size in

reducing child maltreatment in a large population-based

randomized controlled study in the US (Prinz et al. 2009).

Triple P comprises five levels of intervention, with group-

based interventions (Group Triple P) included in level 4;

this intervention is conducted for groups consisting of

10–12 parents, all of whom are imparted new knowledge

and active skills. The intervention is an approach that tar-

gets parents of children who have detectable problems but

do not exhibit sufficient symptoms to be diagnosed with a

behavioral disorder (Sanders 1999).

While there is ample research-based evidence indicating

the effectiveness of Group Triple P in reducing disruptive

behavior among Western children (Turner et al. 2007,

1997; Zubrick et al. 2005), limited research has been

conducted on its effectiveness with regards to children

raised in an East Asian culture. Of the studies conducted

with East Asian subjects, Leung et al. (2003) investigated

the effectiveness of Group Triple P on families living in

Hong Kong and found that it reduced parental reports of

conduct problems in children, suggesting the acceptability

of Group Triple P in East Asian cultures. In addition,

Matsumoto et al. (2007) report the effectiveness of Group

Triple P for Japanese families living in Australia, and

acceptability in Japanese society (Matsumoto et al. 2010).

It remains to be seen, whether such success with regard to

Group Triple P can be replicated for Japanese families

living in Japan in general and for those recruited through

the routine child health service delivery in particular.

Group Triple P is thought to be quite robust across

different cultures, despite cultural differences therein.

Group Triple P emphasizes self-regulation—that is, parents

form their own goals, which are informed by their culture

rather than by the mere adoption of Western ideas about

raising children. Therefore, it is likely that Japanese indi-

viduals in Japan will incorporate the ideas inherent in

Group Triple P and adjust it in ‘‘Japanese’’ ways, to

improve their parenting practice and adjustment; this, in

turn, will reduce behavioral problems in their children.

The purpose of this study was to investigate the effec-

tiveness of Group Triple P in reducing behavioral problems

in children, changing dysfunctional parenting practices,

and influencing parenting adjustment among families in

Japan.

Methods

Participants

Participants in this intervention study were recruited from

mothers visiting health clinics for mandatory health

checkups for their 3-year-old children. Recruitments were

carried out in 2007–2008 in three areas in Kawasaki City,

Kanagawa Prefecture, which is a suburban residential area

near Tokyo. Flyers were also distributed to find mothers

who felt that their child had behavior problems or who

found parenting to be difficult. In addition, public health

nurses who observed behavioral problems in children were

asked to recommend to those children’s mothers that they

participate in the study. In several cases, the sibling of a

child undergoing the health checkup exhibited behavior

problems; the mothers of such children were also eligible

for participation. Control-group participants were recruited

J Child Fam Stud (2011) 20:804–813 805

123

along with those of the intervention group, during the same

health checkups; thus, for the current study, participants

could not be randomized, and a service-based evaluation

using a quasi-experimental design was considered optimal.

In total, 91 mothers participated in the intervention group,

while 24 mothers participated in the control group.

Intervention

In general, Group Triple P comprises eight sessions over an

eight-week period, and it is ideally conducted in groups of

10–12 parents. Since it is extremely difficult to persuade

Japanese fathers to participate in such programs, we focused

only on mothers. Group Triple P uses an active skills-

training process to help mothers acquire new knowledge and

skills. The eight sessions are as follows: one group session

geared toward providing an overview of the program and

establishing rapport within the group (2 h each), three group

sessions in which parent training is conducted (2 h each),

three follow-up consultations by telephone (15–30 min

each), and a final group session. The integrated telephone

consultations provide additional support to mothers while

they practice what they have learned in the group session, all

while following self-regulation theory.

The parent-training component involves discussions of

17 core child-management strategies designed to help

parents promote their children’s competence and develop-

ment (e.g., praise for good behavior, creating engaging

activities, and imparting incidental teaching) and to man-

age misbehavior (e.g., by setting rules, providing clear

instructions, communicating the consequences of an action,

and enforcing quiet time). In addition, participants are

introduced to a ‘‘planned activities routine’’ to generalize

what they have learned and help them strengthen their

parenting skills. Active training methods such as modeling,

rehearsal, practice, feedback, and goal-setting are used

throughout the duration of the program, to teach specific

parenting skills. In the final group session, participants

share the knowledge and insights they acquired during the

program, set future goals, and create plans to achieve those

goals; the session also provides an opportunity for partic-

ipants to celebrate the completion of the program.

Measures

Child Behavior

The Strengths and Difficulties Questionnaire (SDQ). The

SDQ is a 25-item measure of parents’ perceptions of pro-

social and difficult behaviors in their child, and it is

designed to assess the frequency of positive and negative

behaviors in children (Goodman 1997). It consists of five

subscales (i.e., emotional symptoms, conduct problems,

hyperactivity, peer problems, and prosocial behavior), and

the score for each subscale is computed by summing the

scores for the five items therein. The difficult behavior

score in the SDQ is calculated as the sum of the scores

obtained for the emotional symptoms, conduct problems,

hyperactivity, and peer problems subscales. The SDQ in

Japanese has been validated as having adequate internal

reliability (emotional symptoms, 0.61; conduct problems,

0.51; hyperactivity, 0.75; peer problems, 0.52; and proso-

cial behavior, 0.69) (Matsuishi et al. 2008). The difficult

behavior score has also been found to have adequate

internal reliability (r = 0.76) and good test–retest reli-

ability (r = 0.85) (Smedje et al. 1999).

Parenting Style

Parenting Scale (PS). The PS is a 30-item questionnaire

that measures dysfunctional discipline styles in parents

(Arnold et al. 1993); it yields a total score based on three

factors: (1) laxness (permissive discipline), (2) over-reac-

tivity (authoritarian discipline, displays of anger and irri-

tability), and (3) verbosity (overly long reprimands or

reliance on talking to impart discipline). The scale shows

adequate internal consistency with respect to the total

(a = 0.84), laxness (a = 0.83), and over-reactivity

(a = 0.82), but only modest internal consistency with

respect to verbosity (a = 0.63). It also has good test–retest

reliability (r = 0.84, 0.83, 0.82, and 0.79, respectively).

Parenting Adjustment

Depression-Anxiety-Stress Scales (DASS). The DASS is a

42-item questionnaire designed to assess symptoms of

depression, anxiety, and stress in adults (Lovibond and

Lovibond 1995). All three of the DASS subscales have

been demonstrated to have high reliability (depression,

a = 0.91; anxiety, a = 0.84; and stress, a = 0.90).

Parenting Experience Survey (PES). In the PES, parents

are asked to rate the following: (1) the perceived level of

difficult behavior in their child; (2) their subjective per-

ceptions of their parenting role (e.g., how rewarding,

demanding, and stressful they find parenting to be); (3)

their confidence level and level of support they receive as a

parent; (4) for two-parent families, the extent of agreement

between partners over child discipline and the level of

support they receive from their partner in their role as

parent; and (5) their degree of happiness with the rela-

tionship with their partner (Turner et al. 1999).

Procedures

The intervention group was asked to complete the afore-

mentioned questionnaires during the first and last sessions of

806 J Child Fam Stud (2011) 20:804–813

123

the Group Triple P. For the control group, the questionnaires

were mailed to the participants at the time of recruitment;

they completed the questionnaires at home and returned the

responses by mail. After 8 weeks, the participants were

again sent the same questionnaires, to be returned by mail.

Statistical Analysis

As the current study did not employ randomization to

choose the participants who would undergo intervention,

the intervention and control groups were compared in

terms of their demographic characteristics (Table 1). A

repeated measures multivariate analysis of variance (MA-

NOVA), adjusted for the covariates that differed signifi-

cantly between the groups, was used to analyze the two

groups’ responses to the aforementioned questionnaires.

Pairwise t-test comparisons between the pre- and postin-

tervention responses were also performed. Statistical

analyses were performed with the aid of Stata 10 SE

software (StataCorp, College Station, TX, USA).

Ethics

Informed consent was obtained from each participant,

under the condition that any information obtained from the

study would not be used for other purposes or shared with a

third party. Each participant was assigned an anonymous

identification number, and the data associated with the

participants were linked to their respective identification

numbers. The Institutional Review Board at the National

Institute of Public Health approved the protocols of this

study (NIPH-IBRA #06013).

Results

Characteristics of the Recruited Sample

Table 1 shows the demographic characteristics of the

intervention and control groups. The areas from which the

participants were recruited differed among the groups: 60%

of the intervention group was from area C, while 50% of

the control group was from area B. The gender distribu-

tions of the children also differed: boys were predominant

among the intervention group (67%), while girls consti-

tuted the majority (56%) in the control group. Age varied

widely among the children in the intervention group—from

one to 8 years—while most of the children in the control

group were 2 or 3 years old. However, there was no sta-

tistically significant difference between the average age of

the children in the two groups; it was 3.10 (SD = 1.35) and

2.92 (SD = 0.58) years for the intervention and control

groups, respectively. The mothers’ age distribution was

large in the intervention group (24–45 years), but the

average age was not different between the groups (inter-

vention group, 36.1 years [SD = 3.84]; control group,

34.8 years [SD = 5.01]). Other variables were similar, or

at least not statistically different, between the two groups.

Intervention Effects

Table 2 presents the means and standard deviations of each

dependent measure before and after the intervention, along

with the F statistics and significance values yielded by

repeated measures MANOVA, all of which show the effect

of the intervention. As described above, there were dif-

ferences between the two groups in terms of residential

area and the gender of the children; therefore, these vari-

ables were included in the repeated measures MANOVA.

Child Behavior

The repeated measures MANOVA revealed a significant

intervention effect on the SDQ conduct problems subscale

(F (2, 108) = 6.11, p = 0.003), with only the intervention

group showing a reduction, of 1.01 points (t = -5.89,

p \ 0.001). The intervention group demonstrated a 2.10-

point reduction in terms of the SDQ difficult behavior score

(t = -5.75, p \ 0.001). The mean score on the SDQ

prosocial subscale increased by 0.58 points in the inter-

vention group (t = 2.97, p = 0.004). The significant effect

of area was noted only with respect to the SDQ conduct

problems subscale (F (4, 216), p = 0.015).

Parenting Style

The repeated measures MANOVA indicated a strong sig-

nificant intervention effect on all the subscales of the PS.

Only the mothers in the intervention group reported a

significant reduction in the use of dysfunctional parenting

strategies: after the intervention, the group’s total score

decreased by 0.71 points (t = -12.3, p \ 0.001); in the

score for the laxness subscale, by 0.52 points (t = -6.58,

p \ 0.001); in the score for the over-reactive subscale, by

0.96 points (t = -9.10, p \ 0.001); and in the score for the

verbosity subscale, by 0.84 points (t = -8.38, p \ 0.001).

In addition, the mean scores for the laxness, over-reactiv-

ity, and verbosity subscales were each within the clinical

range (Matsuishi et al. 2008) before the intervention, but

outside the clinical range after intervention. There were no

significant gender and area effects on the PS scores.

Parenting Adjustment

According to repeated measures MANOVA, the postin-

tervention mean score for the DASS depression subscale

J Child Fam Stud (2011) 20:804–813 807

123

Table 1 Demographic characteristics of the intervention and control groups (N = 115)

Intervention (N = 91) Control (N = 24) Chi-square or t p value

N (%) or Mean (SD) N (%) or Mean (SD)

Area A 10 (11.0) 7 (29.2) 12.6 0.002

B 26 (28.6) 12 (50.0)

C 55 (60.4) 5 (20.8)

Gender Female 30 (33.0) 13 (56.5) 4.34 0.037

Male 61 (67.0) 10 (43.5)

Missing 0 1

Age (years) 1 3 (3.3) 0 (0) 13.7 0.018

2 31 (34.1) 4 (16.7)

3 35 (38.5) 19 (79.2)

4 8 (8.8) 0 (0)

5 7 (7.7) 1 (4.2)

6? 7 (7.7) 0 (0)

Average 3.10 (1.35) 2.92 (0.58) 0.64 0.521

Number of children 1 49 (53.9) 6 (25.0) 10.3 0.016

2 35 (38.5) 17 (70.8)

3 6 (6.6) 0 (0)

4 1 (1.1) 1 (4.2)

Average 1.55 (0.67) 1.83 (0.64) 1.86 0.065

For children with siblings,

order of child among siblings

Eldest 31 (73.8) 8 (44.4) 7.16 0.028

Youngest 9 (21.4) 10 (55.6)

Middle 2 (4.8) 0 (0)

Mother’s age B19 0 (0) 0 (0) 12.6 0.027

20–24 1 (1.2) 0 (0)

25–29 2 (2.4) 3 (13.6)

30–34 21 (25.0) 9 (40.9)

35–39 48 (57.1) 5 (22.7)

40–44 10 (11.9) 5 (22.7)

45? 2 (2.4) 0 (0)

Missing 7 2

Average 36.1 (3.84) 34.8 (5.01) 1.35 0.181

Father’s age B24 0 (0) 0 (0) 6.50 0.165

25–29 1 (1.2) 2 (9.1)

30–34 22 (25.9) 4 (18.2)

35–39 40 (47.1) 10 (45.5)

40–44 16 (18.8) 6 (27.3)

45? 6 (7.1) 0 (0)

Missing 6 2

Average 37.3 (4.29) 37.5 (4.73) 0.19 0.854

Mother’s education level \High school 1 (1.1) 0 (0) 9.58 0.088

High school 12 (13.3) 5 (22.7)

Professional school 11 (12.2) 7 (31.8)

Some college 22 (24.4) 6 (27.3)

College 41 (45.6) 4 (18.2)

Graduate school 3 (3.3) 0 (0)

Missing 1 2

808 J Child Fam Stud (2011) 20:804–813

123

was significantly reduced in the intervention group

(p = 0.023), compared to the control group. Overall, the

repeated measures MANOVA revealed a significant inter-

vention effect on the DASS total score of the intervention

group, which decreased by 8.66 points (t = -5.03,

p \ 0.001). There were no significant gender and area

effects on the DASS scale.

The repeated measures MANOVA for the PES

revealed a significant intervention effect on the mothers’

perception of difficult behavior in their children: the mean

rating by those in the intervention group decreased by

0.65 points after the intervention (t = -5.13, p \ 0.001).

There was also a significant intervention effect on the

mothers’ rating vis-a-vis the degree to which they find

parenting stressful, with only those in the intervention

group reporting a significant decrease (t = -3.24,

p = 0.002). A significant intervention effect was also

found on the mothers’ rating of how confident they felt in

their parenting role, with only the intervention group

reporting a significant increase (0.6 points; t = 5.57,

p \ 0.001). The repeated measures MANOVA did not

demonstrate a significant intervention effect on the

mothers’ ratings, indicating (1) their perceived level of

support in their parenting role, (2) the extent of agreement

between them and their respective partners regarding

child discipline, as well as the level of support they

receive from their partners in their role as parent, and (3)

their degree of happiness with the relationship with their

respective partners. This was despite the fact that the pre-

and postintervention ratings for these measures were

significantly different in the intervention group, but not in

the control group.

Discussion

To the best of our knowledge, the present study is the first

evaluation of the effectiveness of Group Triple P for

families in Japan, recruited through the routine child health

service delivery. In brief, the overall findings demonstrate

that among families living in suburban areas near Tokyo,

Group Triple P was effective in reducing mothers’ reports

of conduct problems in their children, promoting appro-

priate parenting styles, and reducing maternal distress

arising from parenting.

This study has some limitations. First, it employed a

nonrandomized design that induced selection bias in the

intervention group. For example, the sample characteristics

indicate that mothers with a male child were more likely to

join the intervention group. However, to reflect this bias,

the baseline difference on SDQ was adjusted in the anal-

ysis. In addition, the preintervention parenting style and

parenting adjustment measures were generally similar

between the two groups. It should be noted that previous

studies on Group Triple P employed a randomized design

by randomly assigning participants to either an intervention

group or a waitlist control group (Leung et al. 2003;

Matsumoto et al. 2010; Turner et al. 2007). Further

research should consider using a cross-over randomized

study design, to evaluate the effectiveness of Group Triple

P use in Japan.

Another limitation of this study is in its use of subjective

measurements. While we used validated scales, they were

nonetheless self-reported measures. Future research should

entail a combination of subjective measurements under-

taken by the parents of the children’s behaviors, as well as

Table 1 continued

Intervention (N = 91) Control (N = 24) Chi-square or t p value

N (%) or Mean (SD) N (%) or Mean (SD)

Father’s education level \High school 0 (0) 1 (4.6) 8.07 0.089

High school 11 (12.5) 4 (18.2)

Professional school 10 (11.4) 5 (22.7)

Some college 0 (0) 0 (0)

College 53 (60.2) 11 (50.0)

Graduate school 14 (15.9) 1 (4.6)

Missing 3 2

Annual household income

(in millions of yen)

\3 2 (2.3) 0 (0) 2.98 0.702

3–5 15 (17.4) 6 (30.0)

5–7 27 (31.4) 4 (20.0)

7–10 24 (27.9) 6 (30.0)

10–15 16 (18.6) 4 (20.0)

15? 2 (2.3) 0 (0)

J Child Fam Stud (2011) 20:804–813 809

123

objective measurements undertaken by psychologists or

psychiatrists. In addition, direct observations of child–

parent interactions were not incorporated into the design of

the current study, but should be added to future research

plans.

Nonetheless, the current study does have strong points,

as it employed a service-based evaluation—that is, in this

study, mothers were recruited via the regular child health

service, which is the most feasible way of introducing

parent-training in Japan. Therefore, the effectiveness of

Group Triple P, which was delivered to parents in the most

feasible way, was able to assess parenting-related matters.

In addition, as the provider of child health services can

serve as an initial gateway for consultation on child mal-

treatment, it is possible to deliver consultations in the case

of child maltreatment among participants—and, if needed,

a prompt referral to a Child Guidance Center (similar to

child protection services in the US or UK) can be provided.

The present study clearly showed the effectiveness of

Group Triple P in reducing conduct problems and hyper-

activity as measured with the SDQ. These findings are

consistent with those of Matsumoto et al. (2007), who

report a significant intervention effect on child behavior as

measured with the Eyberg Child Behavior Inventory

(Eyberg and Pincus 1999). Additionally, according to

that study, Cohen’s effect size (Cohen 1988) for the

Table 2 Pre- and post-dependent measures for the intervention and control groups and comparisons obtained with repeated measures MANOVA

Scale Score

range

Intervention group Control group Adjusted pre/post time effect�

Pre Post Pre Post F (df) p-value

Mean (SD) Mean (SD) Mean (SD) Mean (SD)

SDQ

Emotional symptoms 0–10 1.81 (0.21) 1.68 (1.75) 1.42 (1.35) 1.54 (1.32) 0.51 (2, 108) 0.600

Conduct problems 0–10 3.14 (1.75)a 2.13 (1.66)a 2.17 (1.43) 1.96 (1.30) 6.11 (2, 108) 0.003**

Hyperactivity 0–10 4.46 (2.28)a 3.66 (2.21)a 4.38 (2.41) 4.25 (2.29) 0.88 (2, 108) 0.420

Peer problems 0–10 2.78 (1.99) 2.63 (1.75) 2.79 (1.53) 2.71 (1.57) 0.27 (2, 108) 0.762

Difficult behavior 0–40 12.2 (5.34)a 10.1 (4.61)a 10.8 (4.96) 10.5 (4.19) 2.89 (2, 108) 0.060

Prosocial behavior 0–10 5.34 (2.60)a 5.92 (2.51)a 6.17 (2.39) 5.71 (2.65) 2.73 (2, 108) 0.070

PS

Laxness 1–7 3.52 (0.69)a 3.00 (0.62)a 3.57 (0.71) 3.66 (0.62) 10.5 (2, 108) \0.001***

Over-reactivity 1–7 3.89 (1.16)a 2.93 (1.12)a 3.33 (0.26) 3.39 (1.19) 9.58 (2, 108) \0.001***

Verbosity 1–7 4.35 (0.58)a 3.50 (0.93)a 4.21 (0.69) 4.45 (0.54) 9.52 (2, 108) \0.001***

Total 1–7 3.84 (0.50)a 3.13 (0.59)a 3.62 (0.54)b 3.73 (0.54)b 22.2 (2, 108) \0.001***

DASS

Depression 0–14 6.31 (7.50)a 3.02 (5.23)a 4.33 (6.14) 4.38 (6.28) 3.89 (2, 108) 0.023*

Anxiety 0–14 2.90 (4.76)a 1.20 (2.13)a 1.25 (1.80) 1.54 (3.24) 2.58 (2, 108) 0.081

Stress 0–14 10.5 (9.18)a 6.78 (6.53)a 8.17 (7.20) 7.58 (8.63) 2.93 (2, 108) 0.057

Total 0–42 19.7 (20.0)a 11.0 (12.7)a 13.8 (14.4) 13.5 (17.1) 3.91 (2, 108) 0.023*

PES

Parenting is difficult 1–5 3.07 (1.09)a 2.39 (0.80)a 2.50 (0.74) 2.50 (0.83) 5.54 (2, 100) 0.005**

Parenting is rewarding 1–5 3.07 (1.29)a 3.57 (1.14)a 3.13 (1.26) 3.33 (1.27) 0.42 (2, 105) 0.655

Parenting is demanding 1–5 2.99 (1.14) 2.78 (1.14) 2.58 (1.02) 2.58 (0.97) 2.43 (2, 105) 0.093

Parenting is stressful 1–5 3.10 (1.24)a 2.69 (1.05)a 2.42 (1.06) 2.50 (1.14) 4.58 (2, 106) 0.012*

Parenting is fulfilling 1–5 3.07 (1.23)a 3.66 (1.10)a 3.08 (1.32) 3.21 (1.28) 0.87 (2, 105) 0.421

Parenting is depressive 1–5 2.87 (1.32)a 2.33 (1.09)a 2.33 (1.31) 2.04 (1.37) 2.05 (2, 105) 0.134

Confidence in parenting 1–5 2.44 (0.86)a 3.06 (0.89)a 3.00 (0.59) 2.79 (0.93) 7.01 (2, 106) 0.001**

Support for parenting 1–5 2.84 (1.02)a 3.46 (1.10)a 3.08 (1.02) 3.17 (1.13) 2.44 (2, 104) 0.092

Agreement with partner

regarding child discipline

1–5 3.08 (0.97)a 3.37 (0.83)a 3.04 (1.07) 3.25 (0.90) 0.11 (2, 105) 0.894

Support received from partner 1–5 3.28 (1.02)b 3.53 (0.97)b 2.91 (0.90) 3.13 (1.12) 1.45 (2, 105) 0.240

Happiness with partner 0–6 3.49 (1.28)a 3.87 (1.18)a 3.54 (1.22) 3.42 (1.41) 2.18 (2, 106) 0.118

* p \ 0.05, ** p \ 0.01, *** p \ 0.001

Superscripts indicate the means that differ significantly according to pairwise comparisons (a, p \ 0.01; b, p \ 0.05)� Adjusted for children’s gender and their families’ areas of residence

810 J Child Fam Stud (2011) 20:804–813

123

postintervention reduction in the SDQ conduct problems

score in the intervention group was 0.59, which is a

moderate effect size. This effect size was comparable to

that noted with a clinical sample in the case of Group

Triple P interventions (Sanders et al. 2000) and indigenous

groups (Turner et al. 2007) in Australia. Leung et al. (2003)

also report a significant intervention effect on child

behavior as measured by the ECBI and SDQ. In Leung

et al. (2003), not only the SDQ conduct problems and

hyperactivity scores but also the emotional symptoms and

peer problems scores were significantly reduced in the

intervention group, compared to the waitlist control group.

It is unknown why Group Triple P in the current study was

effective only for child conduct problems, and not for

emotional symptoms or peer problems. It might be due to

the ceiling effect: the meanpreintervention score for the

SDQ emotional symptoms subscale was already quite low

in the intervention group (1.81), in comparison to that in

their study (2.79). In addition, it might be difficult to

observe reductions in peer problems within an 8-week

time-span. Additional follow-up studies, especially over

longer periods, are warranted in evaluating the effective-

ness of Group Triple P on child behavior.

The study found that Group Triple P was able to bring

about great improvements in parenting style and parenting

adjustment among Japanese participants. For the interven-

tion group, the effect size for the mean PS total score was

0.79, while those of the mean scores for the laxness, over-

reactivity, and verbosity subscales before and after inter-

vention were 0.84, 1.09, and 1.30, respectively; all of these

are large effect sizes. These results are consistent with those

of Leung et al. (2003) and Matsumoto et al. (2010), sug-

gesting that Group Triple P is suitable for use in East Asian

cultures and effective in affecting change in parenting styles

among East Asian families. In addition, our study indicates

that Group Triple P brought about significant improvements

in parenting adjustment, as measured by the DASS. For the

intervention group, moderate effect sizes were calculated

for the mean DASS depression, anxiety, stress, and total

scores before and after the intervention (0.51, 0.46, 0.46,

and 0.52, respectively). This is a novel finding of our study,

since Matsumoto et al. (2007) did not report a significant

intervention effect on the DASS scores, probably due to its

limited sample size (N = 50). Since our study enrolled 115

participants—a sample size more than twice that of Mat-

sumoto et al. (2007)—we had sufficient statistical power to

show the significant effect of intervention in improving

parenting adjustment.

Regarding PES, Group Triple P was effective in

decreasing the extent to which mothers found parenting to

be difficult and stressful, and in improving their confidence

in their parenting skills. However, although the other

maternal perceptions of parenting—including the degree to

which it was considered rewarding, demanding, fulfilling,

and depressive—changed in the expected direction post-

intervention, no significant intervention effect was

observed. Thus, Group Triple P might be effective in

improving maternal perceptions of the negative aspects of

parenting, such as its difficulty or stressfulness.

On the other hand, the current study did not find Group

Triple P to be effective in bringing about improvements in

areas related to the parent’s partner. This might be due to

our study method: only mothers underwent intervention,

and the fathers were not involved. Group Triple P should

be targeted toward both the mother and father. However,

since we carried out the Group Triple P sessions on

weekdays, participation by working fathers was not pos-

sible. The findings of previous studies have suggested the

association between father involvement and child func-

tioning (Dubowitz et al. 2001; Yogman et al. 1995), which

in turn suggests better outcomes if fathers were involved in

Group Triple P. A recent study reports that paternal

involvement in parenting reduces the risk of injury among

young children in Japan, suggesting that paternal involve-

ment might be associated with providing a safer family

environment (Fujiwara et al. 2010). Future studies should

involve fathers and test the effectiveness of Group Triple P

on scales related to both parents.

In conclusion, the mothers who underwent Group Triple

P intervention reported improved conduct in their children,

a reduction in the use of dysfunctional parenting styles, and

better parenting adjustment, compared to those who did not

undergo intervention. It is necessary and desirable to carry

out further studies that use a randomized design and

include fathers, in order to assess the long-term effects of

intervention and confirm the validity of the current study’s

results. Nonetheless, the current study recommends that

Group Triple P intervention be employed widely as a

strategy for addressing the critical issue of child maltreat-

ment in high-risk situations in Japan.

Acknowledgments This research is supported by Research on

Children and Families, Health and Labor Sciences Research Grants

for the program ‘‘Support Activity on Early Detection of Develop-

mental Disorders Using the Infant–Toddler Health Checkups and Its

Evaluation,’’ funded by the Ministry of Health, Labor, and Welfare

(PI: Noriko Kato). The authors gratefully acknowledge the coopera-

tion of Dr. Hiroko Ishidu and Dr. Mari Mashiko from Kawasaki

City’s local government. We especially appreciate the mothers and

children who participated in this study, without whom the study

would not have been possible.

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