pathways triple p-positive parenting program: effects on parent-child relationships and child...

14
Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems TAMERA L.WIGGINS, D.PSYCH. n KATE SOFRONOFF, PH.D. n MATTHEW R. SANDERS, PH.D. n This study examined the effects of Pathways Triple P (PTP), an early intervention program designed to promote positive parent-child relationships. Sixty parents met the inclusion criteria of borderline to clinically significant relationship disturbance and child emotional and behavioral problems. They were randomly allocated into PTP or a wait-list (WL) control group. PTP was delivered in a group format for 9 weeks and consisted of parent skills training and cognitive behavior therapy targeting negative attributions for child behavior. Significant intervention effects were found for im- proving parent-child relationships and reducing behavior problems with gains main- tained at 3-month follow-up. Limitations of the study and implications for future research are discussed. Keywords: Attachment; Parent Training; Parent-Child Relationships Fam Proc 48:517–530, 2009 M ental health problems in children are a major public health concern (Costello, Foley, & Angold, 2006). In Australia, prevalence estimates indicate that 14% of children have clinically significant emotional or behavioral disorders (Sawyer et al., 2001). Although many factors are implicated in the development of psychopathology, the quality of the parent-child relationship has been repeatedly emphasized as having an important role to play (Belsky, 1984; Sroufe, 1997). This emphasis forms the pri- mary theme of longitudinal studies, research on mediating effects and socialization theories. Such studies have shown that indicators of parent-child relationship quality (e.g., attachment security and disrupted parental discipline) predict child emotional and behavioral problems (Greenberg, Lengua, Coie, & Pinderhughes, 1999; Patterson, Forgatch, Yoerger, & Stoolmiller, 1998). Research on mediating effects has found substantial evidence that parent-child relationship variables mediate the relationship Family Process, Vol. 48, No. 4, 2009 r FPI, Inc. 517 PROCESS Correspondence concerning this article should be addressed to Kate Sofronoff, School of Psy- chology, The University of Queensland, Brisbane, Australia. E-mail: [email protected] n The University of Queensland, Qld, Australia

Upload: tamera-l-wiggins

Post on 20-Jul-2016

216 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

Pathways Triple P-Positive Parenting Program:Effects on Parent-Child Relationships and ChildBehavior Problems

TAMERAL.WIGGINS,D.PSYCH. n

KATESOFRONOFF,PH.D. n

MATTHEWR.SANDERS,PH.D. n

This study examined the effects of Pathways Triple P (PTP), an early interventionprogram designed to promote positive parent-child relationships. Sixty parents met theinclusion criteria of borderline to clinically significant relationship disturbance andchild emotional and behavioral problems. They were randomly allocated into PTP or await-list (WL) control group. PTP was delivered in a group format for 9 weeks andconsisted of parent skills training and cognitive behavior therapy targeting negativeattributions for child behavior. Significant intervention effects were found for im-proving parent-child relationships and reducing behavior problems with gains main-tained at 3-month follow-up. Limitations of the study and implications for futureresearch are discussed.

Keywords: Attachment; Parent Training; Parent-Child Relationships

Fam Proc 48:517–530, 2009

Mental health problems in children are a major public health concern (Costello,Foley, & Angold, 2006). In Australia, prevalence estimates indicate that 14% of

children have clinically significant emotional or behavioral disorders (Sawyer et al.,2001). Although many factors are implicated in the development of psychopathology,the quality of the parent-child relationship has been repeatedly emphasized as havingan important role to play (Belsky, 1984; Sroufe, 1997). This emphasis forms the pri-mary theme of longitudinal studies, research on mediating effects and socializationtheories. Such studies have shown that indicators of parent-child relationship quality(e.g., attachment security and disrupted parental discipline) predict child emotionaland behavioral problems (Greenberg, Lengua, Coie, & Pinderhughes, 1999; Patterson,Forgatch, Yoerger, & Stoolmiller, 1998). Research on mediating effects has foundsubstantial evidence that parent-child relationship variables mediate the relationship

Family Process, Vol. 48, No. 4, 2009 r FPI, Inc.

517

PROCESS

Correspondence concerning this article should be addressed to Kate Sofronoff, School of Psy-chology, The University of Queensland, Brisbane, Australia. E-mail: [email protected]

nThe University of Queensland, Qld, Australia

Page 2: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

between stressors (e.g., poverty and marital conflict) and child and adolescent psy-chopathology (Grant et al., 2006).

Socialization theories have maintained that the family has a disproportionate in-fluence on socialization with childhood being a period in which stable personalityattributes are developed (Maccoby, 1992). Attachment theory proposes that parentsprovide a secure base from which a child can explore their environment and thenreturn for emotional and/or physical support (Bowlby, 1988). Optimal developmentaloutcomes are thought to be associated with parenting practices that promote auton-omy and when parents are sensitive, responsive, and available to the child when re-quired (Bowlby, 1988).

Several parent skills training interventions have led to reduced child behaviorproblems and dysfunctional discipline practices and a greater sense of parentalcompetence (Sanders, Markie-Dadds, Tully, & Bor, 2000; Sanders et al., 2004). Thecurrent study aimed to extend this research by evaluating whether an enhancedversion of the Triple P Positive Parenting Program, Pathways Triple P (PTP)(Sanders & Pidgeon, 2005), improved the quality of parent-child relationships andreduced child emotional and behavioral problems when parents have specificallyidentified concerns about the relationship with their child.

Speltz (1990) has argued that parent skills training interventions that are basedsolely on operant techniques may not show generalized effects across settings or long-term benefits for child development because they do not take account of the possibilitythat the child’s behavior may reflect an attempt to gain physical or psychologicalproximity to an unavailable or insensitive caregiver. While the use of contingencymanagement approaches may impact on behavior in the short-term, it is argued thatthe emotional bond between parent and child is unaddressed and is likely to have anincreasing impact on a child as s/he develops.

The Triple P-Positive Parenting Program incorporates strategies for managingmisbehavior using reinforcement and contingency principles while also addressing theemotional bond between parent and child. Triple P is focused on promoting positiverelationships between parents and their children and equipping parents with positiveand effective behavior management strategies by enhancing their knowledge, skills,and confidence (Sanders, Markie-Dadds, & Turner, 2001). Triple P addresses anumber of factors likely to impact on the quality of the parent-child relationship andchild development such as the bond between parent and child, discipline practices, andchildren’s competence in important developmental domains. The effects of Triple P onthe quality of the parent-child relationship, specifically parent-child attachment, haveyet to be examined.

PTP was developed for parents at risk of child maltreatment addressing key riskfactors through attribution retraining and anger management (Sanders & Pidgeon,2005). It was considered an appropriate intervention for the current research that istargeting problematic attributions of child behavior and strategies for parents inmanaging their own emotions. Parents who have difficulty regulating emotions maybe at risk of emotionally or physically harming children (Sanders & Pidgeon, 2005)and may also be less emotionally available to children leading to poor relationshipsand possible attachment difficulties.

It was hypothesized that parents who received PTP would report significantlygreater reductions in child externalizing and internalizing behavior problems andimprovements in parent-child relationship quality as indicated by the domains of

FAMILY PROCESS518 /

www.FamilyProcess.org

Page 3: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

parent-child attachment, parent involvement, parenting confidence, relational frus-tration, parenting style, and parent attributions for child behavior than those in thewait-list (WL) control group with gains maintained at 3-month follow-up.

METHOD

Participants

Power analysis indicated that for a large effect it was necessary to recruit 26 par-ticipants per group (Cohen, 1988). Participants were 60 parents of a child aged be-tween 4 and 10 years. Parents self referred following a Brisbane community outreachabout the project that included a newspaper advertisement, flyers, university medianotices, and notices in school newsletters. The outreach targeted parents concernedabout a problematic relationship with their child and child emotional or behavioralproblems. A semistandardized telephone interview was used to collect demographicinformation and determine whether families met the study inclusion criteria: a childaged 4–10 years, parent report of borderline to clinically significant parent-child re-lationship disturbance as assessed by the Parenting Relationship Questionnaire(Kamphaus & Reynolds, 2006) with a T-score o41 on the attachment; involvement orparenting confidence scales or 459 on the relational frustration scale and parentreport of borderline to abnormal child emotional or behavioral problems on at leastone of the difficult behavior subscales of the Strengths and Difficulties Questionnaire(Goodman & Scott, 1999). Once 60 eligible participants were identified, recruitmentwas ceased.

Measures

The Family Background Questionnaire (Sanders et al., 2001) was used during thescreening interview to gather relevant demographic information.

Parenting Relationship Questionnaire (Kamphaus & Reynolds, 2006)

Elicits the parent’s perspective on the nature of the relationship. The attachment,involvement, parenting confidence, and relational frustration scales were the focus ofthe current study. Attachment is defined as ‘‘ . . . the affective, cognitive and behav-ioral relationship between a parent and child that results in feelings of closeness,empathy, and understanding on the part of the parent for the child’’ (Kamphaus &Reynolds, 2006, p. 3).

A T score of 41–59 is within the average range (approximately 2/3 of the populationwill score within this range on each of the scales). Scores 31–40 are significantly belowaverage and 60–69 are significantly above average. Scores 10–30 are within the lowerextreme while 70þ is classified as the upper extreme. The internal consistency reli-ability of the subscales analyzed using the current study data were adequate rangingfrom a¼ .75 to .96.

Parenting Scale (Arnold,O’Leary,Wolff, & Acker,1993)

Measures three dysfunctional discipline stylesFlaxness (permissive discipline),overreactivity (authoritarian discipline), and verbosity (overly long reprimands orreliance on talking). The internal consistency reliability of the subscales analyzedusing the current study data were adequate for laxness (a¼ .89) and overreactivity

WIGGINS, SOFRONOFF, & SANDERS / 519

Fam. Proc., Vol. 48, December, 2009

Page 4: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

(a¼ .82) but low for verbosity (a¼ .56), indicating that verbosity may not be a reliableconstruct.

Parent’s Attributions for Child’s Behavior Measure (Pidgeon & Sanders, 2004)

Assesses parents’ negative attribution style for children’s problem behavior yield-ing three stylesFstable, blame and intentional, and internal. These styles reflect thetendency to attribute negative causes to children’s behavior. Higher ratings indicatemore negative attributions about the causes of child behavior. The internal consis-tency reliability of the subscales assessed for the current sample were high rangingfrom a¼ .89 to .94.

Child Behavior Checklist (Achenbach & Rescorla, 2000, 2001)

Measures parent perceptions of child emotional and behavioral problems. The twobroadband scales of internalizing and externalizing problems were the focus of thecurrent study. The internal consistency reliability of the scales analyzed using thecurrent study sample were adequate ranging from a¼ .77 to .92.

Strengths and Difficulties Questionnaire (Goodman & Scott,1999)

Screens for child emotional and behavioral problems measuring parent perceptionsof the extent of prosocial and difficult behaviors. Five scales are derived from themeasure: emotional symptoms, conduct problems, inattention/hyperactivity, peerproblems, and prosocial behaviors. Scores have been found to discriminate betweenlow- and high-risk samples (Goodman & Scott, 1999).

Procedure

Following the screening interview, eligible families were randomly allocated intointervention or WL groups. Randomization was achieved by the principal investigatordrawing participant identification numbers at random and allocating alternatively tothe treatment and WL groups. Assessment packages were mailed and parents asked tocomplete the questionnaires and return in the reply-paid envelope before the start ofthe intervention. Participants completed the questionnaires again after the inter-vention and before the WL group beginning the intervention. Parents in the inter-vention group completed the 3-month follow-up assessment by mail. The flow ofparticipants through the stages of the study is depicted in Figure 1. There was noblinding to group assignment.

Enhanced Cognitive Behavioral Family Intervention

The intervention consisted of a 9-week group program (see Appendix A) withweekly 2-hour sessions (Sanders & Pidgeon, 2005). At the beginning of the program,parents were asked to set relational goals for change in their child’s and their ownbehavior. The first four parent skills sessions addressed 17 core parent strategies. Tenof these are skills for promoting child development through developing positive re-lationships with children, encouraging desirable behavior, and teaching new skills andbehaviors. Seven of the strategies are for managing misbehavior. Strategies for im-proving parent-child relationships include spending quality time with children, talk-ing with children, and showing affection (Sanders et al., 2001). The individual skills

FAMILY PROCESS520 /

www.FamilyProcess.org

Page 5: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

are presented to parents in the context of discussing the importance of children havinga warm, predictable, and secure environment for their development and that somechild emotional and behavioral problems develop when this is not available to chil-dren. In order to encourage generalization and maintenance of skills, the parent skillssessions are completed with planned activities routines. These draw together theparenting skills learnt throughout the program and prepare parents for high-risksituations in a variety of settings.

Assessed for eligibility(n=64)

EA-Enrollment

EA-Randomization

Excluded(n=4)

Not meeting inclusion criteria(n=4)

Allocated to wait-list control(n=30)

Completed post-interventionassessment

(n=22)Did not complete post-intervention

assessment, declined(n=8)

Allocated to intervention(n=30)

Received allocated intervention(n=27)

Did not receive allocated intervention(n=3)

Lost to follow-up,did not complete in allocated time

(n=2)

EA-Analyzed(n=30)

Excluded from analysis(n=0)

N/A

EA-Analyzed(n=30)

Excluded from analysis(n=0)

Allocation

Follow-up

Analysis

FIGURE 1. The flow of participants through the study.

WIGGINS, SOFRONOFF, & SANDERS / 521

Fam. Proc., Vol. 48, December, 2009

Page 6: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

The four PTP sessions support parents in identifying beliefs and intergenerationalinfluences that often lead to negative interactions with children (Sanders & Pidgeon,2005). Exercises assist parents to understand the impact of their beliefs and behavioron their child’s feelings and the quality of the parent-child relationship. Cognitivebehavioral therapy targets the identification and understanding of negative emotionsand the possible impact of these on parenting. The intervention emphasizes the self-regulatory framework by encouraging parents to modify their own behavior and be-come independent problem solvers (Sanders et al., 2001). It is expected that theemotional bond between parent and child improves through reducing coercive inter-actions and increasing parents’ ability to regulate their own emotions, show affection,and spend quality time with their child.

Treatment Integrity

Six therapists were trained, accredited, and supervised in the delivery of PTP (oneregistered psychologist and five conditionally registered psychologists all undertakingpostgraduate training in psychology). Groups were allocated two therapists and 10participants. Therapists followed the manualized protocol and completed detailedsession checklists of the protocol content. Clinical supervision was provided weekly for1 hour by senior registered psychologists.

Analyses of possible therapist effects using repeated measures MANOVAs for thekey outcome variables of parent-child relationship quality and child behavior prob-lems found no significant differences between the three therapy groups. The majorityof parents (81.4%) completed seven or more sessions of the 9-week program.

RESULTS

Statistical Analyses

Completers (intervention, n¼ 27, and control, n¼ 22) and intent-to-treat analyseswere conducted to assess intervention effects using a series of repeated measuresMANOVAs conducted separately for each of the conceptually related dependentvariables: child behavior; parent-child relationships; dysfunctional parenting style;and parent attributions of child behavior. For the intent-to-treat analyses, preinter-vention scores for noncompleting participants were inserted at postintervention(Kendall, Butcher, & Holmbeck, 1999). Significance was specified at po.05. Whensignificant interactions were found between experimental group and time for theomnibus MANOVAs, univariate analyses were examined to identify which of the de-pendent variables showed significant effects. The interaction between group and timewas the focus of the current study as this reflects differential effects over time betweenthe intervention and control groups.

The extent of clinically significant change was analyzed for completers using twomethods: the Reliable Change Index (Jacobson & Truax, 1991) and normative com-parisons (Barkley, Edwards, Laneri, Fletcher, & Metevia, 2001).

A series of paired t-tests using results from the time periods of postintervention and3-month follow-up were conducted to assess the maintenance of intervention effects.A conservative approach was used, inserting preintervention scores at follow-up fortwo participants lost to follow-up.

FAMILY PROCESS522 /

www.FamilyProcess.org

Page 7: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

Preliminary Analyses

Participant characteristics are reported in Table 1. Independent samples t-testsfound no significant differences between the intervention and control groups fortarget child’s age, t(58)¼ � .79, p¼ .436; mother’s age, t(58)¼ � 1.58, p¼ .119; fa-ther’s age, t(43)¼ � .24, p¼ .815; and family size, t(58)¼ .12, p¼ .908. Fisher’s exacttest found no significant differences between the experimental groups for gender ofparticipants (majority female), mother and father’s level of education (high proportionof university educated parents), mother and father’s employment status (majorityemployed), marital status (majority married or de facto), and engagement in otherservices for child difficulties (majority not receiving another service). There were no

TABLE 1

Initial Participant Demographic Characteristics for Each Experimental Group

Variable

Intervention (n¼30) Control (n¼30)

M SD M SD

Child’s age (years) 6.4 2.0 6.0 2.3Mother’s age (years) 38.3 6.4 35.9 5.7Family size 3.9 1.0 3.9 1.2Father’s age (years) 40.2 (n¼ 25) 6.4 39.8 (n¼20) 4.6

n % n %

Male 23 76.7 23 76.7Participant parent female 29 96.7 27 90Mother’s educationoYear 12 4 13.3 4 13.3Year 12 4 13.3 4 13.3Trade/apprenticeship/TAFE 7 23.3 7 23.3Tertiary 15 50 15 50Father’s educationoYear 12 3 10 2 6.7Year 12 4 13.3 3 10Trade/apprenticeship/TAFE 4 13.3 4 13.3Tertiary 14 46.7 11 36.7Mother’s employmentHome duties 14 46.7 8 26.7Part-time 13 43.3 14 46.7Full-time 3 10.0 8 26.7Father’s employmentUnemployed 0 0 0 0Part-time 0 0 2 6.7Full-time 25 83.3 18 60No significant financial difficulties 26 86.7 23 76.7Other child services 5 16.7 3 10Marital statusMarried 21 70 17 56.7De facto 4 13.3 3 10Divorced 2 6.7 2 6.7Separated 1 3.3 3 10.0Never married 2 6.7 5 16.7

WIGGINS, SOFRONOFF, & SANDERS / 523

Fam. Proc., Vol. 48, December, 2009

Page 8: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

significant differences between the groups for gender of the target child (majoritymale, p¼ 1.0) or for financial difficulties, w2(1)¼ 1.0, p¼ .317 (majority reporting theyhad no significant financial problems).

No significant differences were found between the groups on any dependent mea-sures (Table 2) preintervention.

Attrition

Sixty preintervention assessment packages were mailed to participants. A total of49 parents (intervention, n¼ 27 and waitlist, n¼ 22) completed the postinterventionassessments (82% of the initial sample). At 3-month follow-up, 2 parents from theintervention group did not complete the assessment.

At postintervention there were no significant differences in dropout rates betweenthe intervention (three parents or 10%) and control (eight parents or 26.7%) groups,w2(1)¼ 2.78, p¼ .095.

TABLE 2

Dependent Measures at Pre- and Postintervention for Each Experimental Group and at 3-Month

Follow-Up for the Intervention Group

Measure

and group

Preintervention Postintervention

Intervention

M (SD)

Control

M (SD)

Intervention

M (SD)

Control

M (SD)

Effect

Size

Partial

g2

3-month

follow-up

Intervention

M (SD)

PRQ

Attachment 35.2 (11.5) 39.5 (11.1) 43.9 (9.8) 41.7 (11.8) .126 n 43.6 (9.6)

Involvement 39.5 (11.7) 42.1 (10.9) 45.5 (10.5) 42.9 (10.0) .126 n 46.0 (11.1)

Parenting

Confidence

36.0 (8.1) 35.2 (10.4) 45.1 (7.2) 37.2 (9.1) .220 n 45.7 (8.7)

Relational

frustration

74.7 (9.8) 73.2 (14.8) 64.9 (10.4) 68.8 (11.3) .058 63.7 (9.9)

CBCL

Internalizing

Problems

59.1 (9.5) 59.8 (10.2) 53.3 (9.5) 58.0 (12.4) .084 n 53.4 (10.8)

Externalizing

Problems

64.8 (9.6) 65.5 (10.0) 57.7 (9.7) 63.4 (10.4) .128 n 56.2 (14.0)

PACBM

Blame and

intentional

37.2 (8.3) 36.1 (8.1) 29.4 (11.7) 37.0 (7.1) .294 n 30.1 (11.4)

Stable 14.3 (5.5) 16.8 (7.0) 11.8 (4.7) 15.9 (6.5) .028 12.2 (4.6)

Internal 17.4 (7.5) 18.1 (7.1) 13.7 (6.9) 17.7 (7.1) .051 14.5 (7.3)

PS

Laxness 2.9 (0.9) 2.9 (1.0) 2.3 (0.7) 3.0 (1.2) .210 n 2.2 (0.8)

Overreactivity 3.9 (1.0) 3.6 (0.8) 2.8 (0.8) 3.5 (0.9) .213 n 2.8 (1.0)

Verbosity 3.9 (0.7) 3.9 (1.0) 3.0 (0.8) 4.1 (1.1) .311 n 3.0 (1.0)

Note. CBCL¼ child behavior checklist, PACBM¼parent’s attributions for child’s behaviormeasure; PRQ¼Parenting Relationship Questionnaired; PS¼parenting scale.

nStatistically significant effects.

FAMILY PROCESS524 /

www.FamilyProcess.org

Page 9: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

Short-Term Intervention Effects

Parent-child relationship quality

The repeated measures MANOVA revealed a significant effect for the Group-Time interaction [completers: Pillai’s Trace¼ .233, F(4, 44)¼ 3.343, p¼ .018, partialZ2¼ .233; intent-to-treat: Pillai’s Trace¼ .242, F(4, 55)¼ 4.389, p¼ .004, partialZ2¼ .242] on parent-child relationship quality. Examination of the univariate ana-lyses demonstrated significant Group � Time interactions for parenting confidence[completers: F(1, 47)¼ 12.139, p¼ .001, partial Z2¼ .205; intent-to-treat:F(1, 58)¼ 16.375, po.001, partial Z2¼ .220]; attachment [completers: F(1, 47)¼ 5.687,p¼ .021, partial Z2¼ .108; intent-to-treat: F(1, 58)¼ 8.379, p¼ .005, partial Z2¼ .126],and involvement [completers: F(1, 47)¼ 6.216, p¼ .016, partial Z2¼ .117; intent-to-treat: F(1, 58)¼ 8.333, p¼ .005, partial Z2¼ .126]. There was no significant interactioneffect for relational frustration [completers: F(1, 47)¼ 1.846, p¼ .181, partialZ2¼ .038; intent-to-treat: F(1, 58)¼ 3.591, p¼ .063, partial Z2¼ .058]. Examination ofthe means found a significantly greater increase for the intervention than for thecontrol group on parenting confidence, attachment, and involvement.

Parenting style

The repeated measures MANOVA revealed a significant Group � Time interaction[completers: Pillai’s Trace¼ .388, F(3, 45)¼ 9.526, po.001, partial Z2¼ .388; intent-to-treat: Pillai’s Trace¼ .352, F(3, 56)¼ 10.151, po.001, partial Z2¼ .352]. Examina-tion of the univariate analyses demonstrated significant Group � Time interactionsfor laxness [completers: F(1, 47)¼ 14.228, po.001, partial Z2¼ .232; intent-to-treat:F(1, 58)¼ 15.406, po.001, partial Z2¼ .210], verbosity [completers: F(1, 47)¼ 24.411,po.001, partial Z2¼ .342; intent-to-treat: F(1, 58)¼ 26.206, po.001, partial Z2¼ .311],and overreactivity [completers: F(1, 47)¼ 13.083, p¼ .001, partial Z2¼ .218; intent-to-treat: F(1, 58)¼ 15.739, po.001, partial Z2¼ .213]. Examination of the means showeda significantly greater reduction in the use of dysfunctional parenting practices for theintervention group than for the control group.

Parent attributions

The repeated measures MANOVA revealed a significant Group � Time interaction[completers: Pillai’s Trace¼ .339, F(3, 45)¼ 7.697, po.001, partial Z2¼ .339; intent-to-treat: Pillai’s Trace¼ .306, F(3, 56)¼ 8.246, po.001, partial Z2¼ .306]. Examina-tion of the univariate effects demonstrated a significant Group � Time interaction forthe negative blame and intentional attribution style [completers: F(1, 47)¼ 22.207,po.001, partial Z2¼ .321; intent-to-treat: F(1, 58)¼ 24.137, po.001, partial Z2¼ .294]but not for the stable [completers: F(1, 47)¼ 1.032, p¼ .315, partial Z2¼ .021; intent-to-treat: F(1, 58)¼ 1.650, p¼ .204, partial Z2¼ .028] or internal [completers:F(1, 47)¼ 2.428, p¼ .126, partial Z2¼ .049; intent-to-treat: F(1, 58)¼ 3.130, p¼ .082,partial Z2¼ .051] attribution styles. Examination of the means showed that there wasa significantly greater reduction of blame and intentional attributions for the inter-vention group than for the control group.

Child emotional and behavioral problems

The repeated measures MANOVA revealed a significant effect for the Group-Time interaction [completers: Pillai’s Trace¼ .123, F(2, 46)¼ 3.226, p¼ .049, partial

WIGGINS, SOFRONOFF, & SANDERS / 525

Fam. Proc., Vol. 48, December, 2009

Page 10: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

Z2¼ .123; intent-to-treat: Pillai’s Trace¼ .135, F(2, 57)¼ 4.461, p¼ .016, partialZ2¼ .135]. Examination of the univariate analyses demonstrated a significantGroup � Time interaction for externalizing behavior problems [completers:F(1, 47)¼ 6.149, p¼ .017, partial Z2¼ .116; intent-to-treat: F(1, 58)¼ 8.503, p¼ .005,partial Z2¼ .128]. The results for internalizing behavior problems were inconsistent[completers: F(1, 47)¼ 3.657, p¼ .062, partial Z2¼ .072; intent-to-treat:F(1, 58)¼ 5.298, p¼ .025, partial Z2¼ .084]. There was a significantly greater reduc-tion of externalizing behavior problems for the intervention group than for the controlgroup. The difference did not reach significance for the completers analysis on in-ternalizing behavior problems.

Clinical Significance

Reliable change

Parent-child attachment showed a significant difference between the groups(Fisher’s exact test, p¼ .013) with 33.3% of the intervention group showing reliableimprovement compared with 4.5% of the control group. There were also significantlymore parents in the intervention (36%) than in the control group (4.8%) showingreliable improvement in parenting confidence (Fisher’s exact test, p¼ .013). Therewas no significant group difference on involvement (Fisher’s exact test, p¼ .362).

A significant difference was found between the intervention (48.1%) and control(4.5%) groups for rates of reliable improvement in overreactive parenting (Fisher’sexact test, p¼ .001).

Significantly more parents in the intervention (55.6%) than in the control (18.2%)group reported a reliable reduction in externalizing behavior problems (Fisher’s exacttest, p¼ .013). The difference did not reach significance for internalizing behaviorproblems (Fisher’s exact test, p¼ .165).

Percentage of each group normalized

Differences between the intervention and control groups for proportion normalizedby postintervention on attachment (Fisher’s exact test, p¼ .267) and involvement(Fisher’s exact test, p¼ .363) did not reach significance.

There were significant differences between the intervention and control groups forproportion normalized by postintervention on parenting confidence, w2(1)¼ 10.443,p¼ .001, and overreactivity, w2(1)¼ 6.470, p¼ .011. For parenting confidence, 60.0% ofthe intervention group within the clinical range preintervention were normalized bypostintervention compared with 6.7% of the control group. For overreactivity, 50.0%of the intervention group within the clinical range at preintervention were normalizedby postintervention compared with 11.8% of the control group.

There was a trend for a higher proportion in the intervention group than in thecontrol group moving from the clinical to normal range on externalizing, w2(1)¼ 3.278,p¼ .070, and internalizing, w2(1)¼ 3.773, p¼ .052, behavior problems, although thesedifferences did not reach significance.

Maintenance Effects

Analyses using paired t-tests were conducted for the intervention group to deter-mine whether treatment gains were maintained from postintervention to 3-monthfollow-up. There were no significant differences for the indicators of parent-child

FAMILY PROCESS526 /

www.FamilyProcess.org

Page 11: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

relationship quality: attachment, t(29)¼ .055, p¼ .956; involvement, t(29)¼ � .561,p¼ .579; parenting confidence, t(29)¼ � .447, p¼ .658; blame and intentional attri-butions, t(29)¼ � .696, p¼ .492; laxness, t(29)¼ .479, p¼ .636; verbosity, t(29)¼ .117,p¼ .908; and overreactivity, t(29)¼ � .077, p¼ .939. Further, no significant differ-ences were found for externalizing, t(29)¼ .826, p¼ .415, or internalizing,t(29)¼ � .040, p¼ .969, behavior problems. These findings indicate that the postin-tervention results were maintained at follow-up.

DISCUSSION

A substantial body of research has identified the parent-child relationship as aprimary influence on child outcomes including risk for emotional and behavioralproblems (Greenberg, 1999). The quality of attachment between parent and child hasbeen proposed to play a key role (Speltz, 1990). The Triple P Positive Parentingprogram has consistently demonstrated significant reduction in child behavior prob-lems but before the current study had not been evaluated in terms of the impact onparent-child attachment or with a population identifying parent-child relationshipdisturbances. The present findings provide support for the efficacy of PTP for im-proving parent-child relationships, including attachment, and reducing child behav-ioral problems.

Parents who received the intervention reported a significantly greater increase inparent-child relationship quality from pre- to postintervention compared with parentsin the control group with benefits maintained at 3-month follow-up. Importantly,parents in the intervention group reported a significantly greater increase in parent-child attachment, parenting confidence, and involvement than those in the controlgroup.

Parents who received the intervention also reported a significantly greater reduc-tion in the use of dysfunctional parenting practices (laxness, verbosity, and overre-activity), blameworthy and intentional attributions for child behavior, and childexternalizing behavior problems from pre- to postintervention than parents in thecontrol group with gains maintained at 3-month follow-up.

Furthermore, a significantly greater proportion of parents in the interventiongroup reliably improved from pre- to postintervention compared with parents in thecontrol group on parent-child attachment, parenting confidence, and overreactiveparenting.

The current intervention showed positive effects for improving important aspectsof the parent-child relationship. The attachment bond between parent and child has asignificant influence on children’s social and emotional development and is consideredan important focus of early intervention programs for child psychopathology(Greenberg, 1999; Speltz, 1990). PTP does not overtly discuss attachment theoryprinciples but it does target a number of key areas for improving parent-child bondssuch as spending quality time with children, showing affection, changing negativeattributions of child behavior, parent emotional regulation skills, and using positiverather than coercive discipline practices. This cognitive-behavioral intervention re-sulted in an improvement in parent-child attachment without specifically discussingattachment theory.

Parenting confidence is important for enhancing parent self sufficiency in parent-ing decisions and problem solving for future challenges long after the program has

WIGGINS, SOFRONOFF, & SANDERS / 527

Fam. Proc., Vol. 48, December, 2009

Page 12: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

been completed (Sanders et al., 2001). Parenting confidence has also been shown tomediate the relationship between maternal mental illness and poor child outcomes(Oyserman, Bybee, Mowbray, & Hart-Johnson, 2005).

The findings of this study replicated earlier studies in that a significant effect forexternalizing problems is consistent with previous research on PTP (Sanders et al.,2004). A reduction in the use of dysfunctional discipline practices in the interventiongroup is also consistent with Sanders et al. (2004).

Overall, the evaluation of PTP demonstrated significant intervention effects forimproving parent-child relationships in terms of parent-child attachment, parentingconfidence, involvement, blame and intentional attributions for child disruptivebehavior, and dysfunctional discipline practices and for reducing externalizing be-havior problems. Despite the significance of intervention effects, there remained aproportion of parents reporting relationship disturbances. Such families may requiremore intensive and individualized support than is available in the group therapyformat.

Speltz (1990) has argued that when there is a focus on operant techniques forreducing behavior problems, interventions are likely to show short-term benefits.Long-term benefits are expected only when the bond between parent and child is alsoaddressed and nurtured. Triple P addresses the bond between parent and child aswell as focusing on child behavior management principles. The current study includeda 3-month follow-up of parents allocated to the intervention group showing thatpostintervention benefits were maintained at follow-up. However, this follow-up pe-riod is limited and longer-term follow-up would further validate intervention effectsfor parent-child relationships.

There are further limitations that require consideration when interpreting theresults of this research. The delivery of the program in a group format and adhering toa standardized protocol, as was required for the current clinical trial, may not providethe individual attention parents may have access to in a clinical rather than researchsetting. Therefore, the study results may underestimate the full potential of inter-vention effects when using PTP in a flexible manner with individualized attention forparent needs.

The study relied on parent perceptions of parent-child relationship quality. Whileparent perceptions are a crucial aspect of the parent-child relationship, an evaluationusing an observational measure of child attachment may provide additional evidencefor determining the efficacy of the program for improving attachment quality. Themajority of parents participating in the program were mothers and highly educated sowe should be cautious in assuming that these results will generalize to other popu-lations.

The current study has contributed to the field of early intervention for childemotional and behavioral disorders. It is widely recognized that it is important toreduce these problems in children and that the parent-child relationship influenceschild development including the development of psychopathology. The study hasshown that the parent-child relationship is amenable to change and that a cognitive-behavioral early intervention program leads to improvements in this relationship andreductions in child behavior problems. Although further research is required to de-termine long-term outcomes and identify those who may not respond to this inter-vention, there is evidence for the benefit of utilizing PTP for parents presenting withconcerns about their relationship with their child.

FAMILY PROCESS528 /

www.FamilyProcess.org

Page 13: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

REFERENCES

Achenbach, T.M., & Rescorla, L.A. (2000). Manual for ASEBA preschool forms and profiles.

Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.Achenbach, T.M., & Rescorla, L.A. (2001). Manual for ASEBA school-age forms and profiles.

Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.Arnold, D.S., O’Leary, S.G., Wolff, L.S., & Acker, M.M. (1993). The parenting scale: A measure

of dysfunctional parenting in discipline situations. Psychological Assessment, 5(2): 137–144.Barkley, R.A., Edwards, G., Laneri, M., Fletcher, K., & Metevia, L. (2001). The efficacy of

problem-solving communication training alone, behavior management training alone, and

their combination for parent-adolescent conflict in teenagers with ADHD and ODD. Journal

of Consulting and Clinical Psychology, 69(6): 926–941.Belsky, J. (1984). The determinants of parenting: A process model. Child Development, 55(1):

83–96.Bowlby, J. (1988). A secure base: Parent-child attachment and healthy human development. New

York: Basic Books Inc.Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ:

Lawrence Earlbaum Associates.Costello, E.J., Foley, D.L., & Angold, A. (2006). 10-year research update review: The

epidemiology of child and adolescent psychiatric disorders: II. Developmental epidemiology.

Journal of the American Academy of Child and Adolescent Psychiatry, 45(1): 8–25.Goodman, R., & Scott, S. (1999). Comparing the Strengths and Difficulties Questionnaire and

the Child Behavior Checklist: Is small beautiful? Journal of Abnormal Child Psychology,

27(1): 17–24.Grant, K.E., Compas, B.E., Thurm, A.E., McMahon, S.D., Gipson, P.Y., Campbell, A.J., et al.

(2006). Stressors and child and adolescent psychopathology: Evidence of moderating and

mediating effects. Clinical Psychology Review, 26(3): 257–283.Greenberg, M.T. (1999). Attachment and psychopathology in childhood. In J. Cassidy & P.R.

Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications (pp. 469–

496). New York: Guilford Press.Greenberg, M.T., Lengua, L.J., Coie, J.D., & Pinderhughes, E.E. (1999). Predicting develop-

mental outcomes at school entry using a multiple risk model: Four American communities.

Developmental Psychology, 35(2): 403–417.Jacobson, N.S., & Truax, P. (1991). Clinical significance: A statistical approach to defining

meaningful change in psychotherapy research. Journal of Consulting and Clinical Psy-

chology, 59(1): 12–19.Kamphaus, R.W., & Reynolds, C.R. (2006). Parenting relationship questionnaire manual.

Minneapolis, MN: NCS Pearson Inc.Kendall, P.C., Butcher, J.N., & Holmbeck, G.N. (1999). Handbook of research methods in

clinical psychology (2nd ed.). New York: John Wiley & Sons.Maccoby, E. (1992). The role of parents in the socialization of children: An historical overview.

Developmental Psychology, 28(6): 1006–1017.Oyserman, D., Bybee, D., Mowbray, C., & Hart-Johnson, T. (2005). When mothers have serious

mental health problems: Parenting as a proximal mediator. Journal of Adolescence, 28(4):

443–463.Patterson, G.R., Forgatch, M.S., Yoerger, K.L., & Stoolmiller, M. (1998). Variables that initiate

and maintain an early-onset trajectory for juvenile offending. Development and Psychopa-

thology, 10(3): 531–547.Pidgeon, A., & Sanders, M.R. (2004). Parent’s attributions for Child’s behavior measure. Bris-

bane, Australia: Parenting and Family Support Centre, University of Queensland.Sanders, M.R., Markie-Dadds, C., Tully, L.A., & Bor, W. (2000). The Triple P-Positive Parenting

Program: A comparison of enhanced, standard, and self-directed behavioral family inter-

WIGGINS, SOFRONOFF, & SANDERS / 529

Fam. Proc., Vol. 48, December, 2009

Page 14: Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems

vention for parents of children with early onset conduct problems. Journal of Consulting andClinical Psychology, 68(4): 624–640.

Sanders, M.R., Markie-Dadds, C., & Turner, K.M.T. (2001). Practitioner’s manual for StandardTriple P. Milton, Qld: Families International Publishing Pty. Ltd.

Sanders, M.R., & Pidgeon, A.M. (2005). Practitioner’s manual for Pathways Triple P. Milton,Qld: Triple P International Pty. Ltd.

Sanders, M.R., Pidgeon, A.M., Gravestock, F., Connors, M.D., Brown, S., & Young, R.W. (2004).Does parental attributional retraining and anger management enhance the effects of theTriple P-Positive Parenting Program with parents at risk of child maltreatment? BehaviorTherapy, 35(3): 513–535.

Sawyer, M.G., Arney, F.M., Baghurst, P.A., Clark, J.J., Graetz, B.W., Kosky, R.J., et al. (2001).The mental health of young people in Australia: Key findings from the child and adolescentcomponent of the National Survey of Mental Health and Well-Being. Australian and NewZealand Journal of Psychiatry, 35(6): 806–814.

Speltz, M.L. (1990). The treatment of preschool conduct problems: An integration of behavioraland attachment concepts. In M.T. Greenberg, D. Cicchetti, & M.E. Cummings (Eds.), At-tachment in the preschool years: Theory, research, and intervention (pp. 399–426). Chicago:The University of Chicago Press.

Sroufe, A.L. (1997). Psychopathology as an outcome of development. Development and Psy-chopathology, 9(2): 251–268.

APPENDIX A

Enhanced Cognitive Behavioral Family Intervention: Pathways and Group Triple P

Week Strategies

1 Principles of positive parenting, identifying causes of child behavior, monitoring children’sand own behavior and setting goals for change.

2 Strategies for promoting parent-child relationships, encouraging desirable child behaviorand teaching new skills and behaviors.

3 Strategies for managing misbehavior.4 Planning ahead for high-risk situations to prevent child behavior problems.5 Identifying and understanding parent traps stemming from dysfunctional attributions of

child behavior. Understanding the impact of parent behavior on children.6 Identifying possible reasons for becoming caught in parent traps and learning strategies for

getting out of these traps (e.g., thought switching).7 Understanding and recognizing emotions. Relaxation techniques and pleasurable activities

planning.8 Strategies for coping with unpleasant emotions (e.g., catching unhelpful thoughts,

developing personal coping statements, cognitive challenging and developing coping plansfor high-risk situations).

9 Closure session addressing tips for maintaining family well-being, phasing out of theprogram, strategies for maintaining change, problem solving for potential high-risksituations in the future and setting future goals.

Note. From Practitioner’s Manual for Pathways Triple P (p. 9), by M. R. Sanders and A. M. Pidgeon,2005, Brisbane: Triple P International Pty. Ltd. Copyright 2005 by The University of Queensland.Reprinted with permission.

FAMILY PROCESS530 /

www.FamilyProcess.org