Matthew R Sanders, Ph.D Parenting and Family Support Centre The University of Queensland Australia

1. A Public Health Perspective inthe Delivery of Evidence-Based Parenting InterventionParenting Intervention:Benefits and Challenges Matthew R Sanders, Ph.D Parenting and Family Support Centre The University of Queensland Australia December, 2009

2. At a glance • Why parenting support and education is vital to child well-being • Why a public health approach is necessary • Re-AIM formula applied to parenting intervention • How prevention and less intensive programs can make a difference • Cost-benefits to this approach

3. The need to make effective parenting programs widely available is now firmly established

4. Support for a public health approach gaining momentum “…. a substantial body of well designed, controlled-trial research shows that a small number of parenting programs can produce significant and durable positive changes by increasing positive family relationships, reducing child behavior problems and reducing future rates of child maltreatment”…. “Scientific support is sufficient to warrant the implementation of these evidence based parenting practices in demonstration projects at community health centers “ Source: APA (2009). Effective strategies to support positive parenting in community health centers: Report of the Working Group of Child Maltreatment Prevention. Washington, DC: Author.

5. Policy level advocacy for evidence based parenting programs Groups Examples of policy statements • Institute of Medicine revised report on Preventing Mental, Emotional and behavioural disorders among young people (IOM, 2009) • Council of Europe Positive Parenting in Contemporary Europe (2007)-declaration calling on 46 member states to implement positive parenting programs • UN’s report on Family skills training programmes and drug abuse prevention (2009) • UK Government establishes National Academy for Parenting Practititoners (2007)

6. Far too many children continue to develop preventable social, emotional, behavioral and health problems

7. Behavioral and emotional problems are common Percentage of children with emotional or behavioral problems in the clinical range 20% clinical 80% nonclinical Source: World Health Organization (2003). Caring for children and adolescents with mental disorders. Geneva: World Health Organization, 2003)

8. These problems are very costly • The annual cost in the US in 2007 was estimated to be $247 billion Source:IOM (2009) Preventing Mental, Emotional, and Behavioral Disorders Among Young People: Progress and Possibilities

9. The quality of parenting children receive really matters and affects every aspect of their development

10. Significant improvements in the health and well being of children at a population level cannot be achieved without strengthening the skills, knowledge and confidence of parents in the task of raising their children

11. How can we achieve a population level effect Glasgow et al (2001) Create leverage using the RE-AIM formula Slide courtesy Dr Dennis Embry, Paxis Institute (2006)

12. Achieving population level Impact • Reach X Efficacy X Adoption X Implementation X Maintenance=Population level impact Slide courtesy Dr Dennis Embry, Paxis Institute (2006)

13. What has been done to improve population reach? Reach

14. Develop interventions that have a better “ecological fit” to the concerns of parents

15. Listen to professionals and parents * Under development

16. Test different delivery formats * Under development

17. Delivery contexts Use many service delivery settings and providers

18. What can be done to improve efficacy? Efficacy

19. We have come a long way

20. From small beginnings

21. Building an evidence base takes time The evidence 92 studies 13 Single case experiments 4 Meta analyses 46 Efficacy trials 2 Population trials 27 Effectiveness trials 25 further trials in progress as at November, 2009

22. Triple P Intervention Studies No. Of studies Year Triple P International began Year

23. Some important milestones

24. Become much more consumer focused

25. Adopt a self regulation framework

26. Collaborate with parents in waysthat empower them

27. Our goal has been to develop and test interventions that have a better “ecological fit” to the concerns and preferences of parents as consumers

28. Test different delivery formats

29. “Light touch” interventions for common problems to reach many parents

30. Triple P Media Interventions

31. Adopting a consumer perspective helps to…

32. Example: Using consumer input on program content and cultural acceptability • 158 ethnically diverse parents of 3-6 year children viewed “Making Shopping Fun” episode • Their engagement in the episode (interesting, entertaining and usefulness) and its watchability (would watch it on TV) • 92% found it somewhat, quite or very engaging • 70% said they would probably or definitely watch it on TV • Parents of children with greater problem behavior reported greater likelihood that they would watch it • SES and ethnicity did not predict outcomes Source: Metzler, et al (in prep). Triple P Media Series.

33. How do parents want to receive information about effective parenting?Source: Metzler et al (in prep) Programs with strongest evidence

34. Develop “light touch” interventions for common problems to reach many parents

35. Parent discussion groups Group Primary Care Triple P Preschoolers Toddlers Infants Elementary school age Teenagers

36. Test different delivery formats

37. Primary Care Group Triple P Parent Discussion Groups

38. Hassle Free Shopping with children 2 hour group session Content Process Trained Triple P facilitator Use of DVD footage on common shopping problems Group activity to identify common parent traps (causes/attributions) Watch and discuss “Making Shopping fun” DVD Discussion/planning • Activity 1: Shopping hassles • Activity 2: Parent traps • Activity 3: How to prevent shopping problems • Activity 3: How to manage shopping problems • Activity 4: Getting started

39. Effects on Child BehaviourJoachim, Sanders & Turner (2009).Hassle-free shopping with children- Evaluation of a brief Triple P parent discussion group . Journal of Child Psychiatry and Development. • Fewer shopping specific problems (d=1.6) • Lower levels of dysfunctional parenting (d=.72) • Increased task specific self efficacy (d=1.31) • High consumer satisfaction (M = 34.3; SD = 5.80) d=.75

40. Primary Care Group Triple P Parent Discussion Groups

41. Study 2: Effects on Child Behaviour • Fewer conduct problems (d=1.14) • Lower levels of dysfunctional parenting (d=.71) • Increased task specific self efficacy (d=1.01) • 6 month follow ups underway

42. Improve engagement strategies

43. Who participates in Triple P when it is offered universally? • Child had behavioural or emotional problem (47.8%) • SDQ Conduct Score-borderline or clinical (2 times more likely to participate) • Mothers (86.8%) • Highly stressed in previous 2 weeks (52.9) • Parent of a boy (59.5%) Sanders, et al (2007). Every family: A public health approach to positive parenting. The University of Queensland

44. Engagement • More disadvantaged parents less likely to know about, participate or complete parenting programs • Participating parents benefit regardless of background (Leung et al., 2006; McTaggart & Sanders, 2007) • Underrepresented groups • Fathers • Minority parents • Indigenous parents

45. Ecological Context Parental mental health Discrimination Enablers & barriers Parental concern about child’s behavior Acculturation Neighborhood Familyfriendly policies Motivational variables Program variables Prior help seeking Poverty Engagement Family of origin experience Employment status Social influence Variables Cognitive/ Affective variables Immigration status Gender /age of parent Culturallynormative parenting practices Education /literacy Connectedness

46. Enablers & barriers Parental concern about child’s behavior Perceived vulnerability Severity of child problem Level of parental distress or anxiety Program variables Message Providers-ethnicity, experience, skills Cost/ Accessibility Program format Acceptability of parenting advice Motivational variables Perceived need Anticipated benefits/costs Incentives Competing demands Engagement Social influence Variables In home support Extended family support, Community and neighborhood support Cognitive/ Affective variables Expectancies of benefit Parental self efficacy Access to models Parental attributions

47. Experimental manipulation No testimonial • Motivational variables • Expectancies of benefit • Parental self efficacy • Attributions • Access to models vs Parent testimonial Experimental conditions Engagement vs Expert testimonial

48. Seek direct consumer input to ensure programs are culturally acceptable Connecting Communities Project Brisbane South Divisions of General Practice Parenting and Family Support Centre The University of Queensland Funded by FACSIA, Commonwealth Government of Australia

49. Acceptability of Triple P parenting strategies

50. Design interventions to directly target high need, underserved populations