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Intervention Summary

Triple P--Positive Parenting Program

The Triple P--Positive Parenting Program is a multilevel system or suite of parenting and family support strategies for families with children from birth to age 12, with extensions to families with teenagers ages 13 to 16. Developed for use with families from many cultural groups, Triple P is designed to prevent social, emotional, behavioral, and developmental problems in children by enhancing their parents' knowledge, skills, and confidence. The program, which also can be used for early intervention and treatment, is founded on social learning theory and draws on cognitive, developmental, and public health theories. Triple P has five intervention levels of increasing intensity to meet each family's specific needs. Each level includes and builds upon strategies used at previous levels:

  • Level 1 (Universal Triple P) is a media-based information strategy designed to increase community awareness of parenting resources, encourage parents to participate in programs, and communicate solutions to common behavioral and developmental concerns.
  • Level 2 (Selected Triple P) provides specific advice on how to solve common child developmental issues (e.g., toilet training) and minor child behavior problems (e.g., bedtime problems). Included are parenting tip sheets and videotapes that demonstrate specific parenting strategies. Level 2 is delivered mainly through one or two brief face-to-face 20-minute consultations.
  • Level 3 (Primary Care Triple P) targets children with mild to moderate behavior difficulties (e.g., tantrums, fighting with siblings) and includes active skills training that combines advice with rehearsal and self-evaluation to teach parents how to manage these behaviors. Level 3 is delivered through brief and flexible consultation, typically in the form of four 20-minute sessions.
  • Level 4 (Standard Triple P and Group Triple P), an intensive strategy for parents of children with more severe behavior difficulties (e.g., aggressive or oppositional behavior), is designed to teach positive parenting skills and their application to a range of target behaviors, settings, and children. Level 4 is delivered in 10 individual or 8 group sessions totaling about 10 hours.
  • Level 5 (Enhanced Triple P) is an enhanced behavioral family strategy for families in which parenting difficulties are complicated by other sources of family distress (e.g., relationship conflict, parental depression or high levels of stress). Program modules include practice sessions to enhance parenting skills, mood management strategies, stress coping skills, and partner support skills. Enhanced Triple P extends Standard Triple P by adding three to five sessions tailored to the needs of the family.

Variations of some Triple P levels are available for parents of young children with developmental disabilities (Stepping Stones Triple P) and for parents who have abused (Pathways Triple P).

Descriptive Information

Areas of Interest Mental health promotion
Outcomes
1: Negative and disruptive child behaviors
2: Negative parenting practices as a risk factor for later child behavior problems
3: Positive parenting practices as a protective factor for later child behavior problems
Outcome Categories Social functioning
Ages 0-5 (Early childhood)
6-12 (Childhood)
26-55 (Adult)
Genders Male
Female
Races/Ethnicities Non-U.S. population
Settings Outpatient
Other community settings
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History Development of Triple P began in Australia, with research findings on the program first published. Since then, the intervention has been examined in a series of controlled outcome studies with results published in more than 90 articles. More than 40,000 service providers around the world have received professional training in Triple P. The program has been implemented in Australia, Belgium, Canada, England, Germany, Hong Kong, Iran, Japan, the Netherlands, New Zealand, Romania, Singapore, Switzerland, and the United States.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: No
Evaluated in comparative effectiveness research studies: Yes
Adaptations Adaptations of Triple P have been developed for use in various countries, including Belgium, Germany, Hong Kong, Iran, the Netherlands, Singapore, and Switzerland. All Triple P parenting resource materials for the birth to age 12 programming are available in English and Spanish. Triple P materials have been translated into several other languages, such as Chinese, Farsi, German, and Japanese.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Universal
Selective
Indicated

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Outcomes

Outcome 1: Negative and disruptive child behaviors
Description of Measures Negative and disruptive child behaviors were measured by systematic, direct observation using the Family Observation Schedule and by parental reports using the Eyberg Child Behavior Inventory, the Parent Daily Report, the Strength and Difficulty Scale, and the Child Attention Problems Rating Scale.
Key Findings In one study in Australia, families with a 3-year-old received Enhanced Triple P (ETP; level 5), Standard Triple P (STP; level 4), or a self-directed version of Triple P (SDTP; level 4) or were randomly assigned to a wait-list control group. After the intervention:

  • Children of families who received ETP showed significantly less observed negative behavior than children of families who received SDTP (p < .05) or children of control group families (p < .05). Children of families who received STP also showed significantly less observed negative behavior than children of families who received SDTP (p < .05).
  • Mothers of families who received ETP reported less negative child behavior than mothers of families who received SDTP (p < .05) or mothers of control group families (p < .001). Similarly, mothers of families who received STP reported fewer child behavior problems than mothers of families who received SDTP (p < .05) or mothers of control group families (p < .001). Mothers of families who received SDTP also reported fewer child behavior problems than mothers of control group families (p < .05).
  • Fathers of families who received either ETP or STP reported less negative child behavior than fathers of control group families (p < .01) and fewer child behavior problems than fathers of families who received SDTP (p < .05).
  • On two measures of clinically significant change in observed child disruptive behavior (i.e., a score above 1.96 on the Reliable Change Index and a 30% reduction):

    • Children of families who received ETP were more likely than children of families who received SDTP (p < .05) or children of control group families (p < .001) to demonstrate clinically significant reductions in disruptive behavior.
    • Children of families who received STP were more likely than children of control group families to demonstrate clinically significant reductions in disruptive behavior (p < .01).
    • Children of families who received any version of Triple P were more likely than children of control group families to move from the clinical to the normal range of functioning on disruptive behavior (p < .01 or less, depending upon the version of Triple P received).
In a study conducted in Hong Kong, Chinese families with a child 3-7 years old received Triple P or were randomly assigned to a wait-list control group. After the intervention:

  • Parents of families who received Triple P reported fewer child behavior problems (p < .001) and lower problem intensity (p < .001) than parents of control group families. Parents of families who received Triple P also reported fewer conduct problems (p = .002), peer problems (p = .03), and emotional symptoms (p = .03) and less hyperactivity (p = .03) than parents of control group families (p < .005).
  • Within families who received Triple P, parents of male children reported lower postintervention scores on hyperactivity and conduct problems than parents of female children (p < .05 for both variables).
In a study conducted in Australia, families with a preschooler received Enhanced Group Triple P or were randomly assigned to a no-intervention control group. At posttest:

  • Parents of families who received Triple P reported greater improvements in child behaviors (p < .05) compared with parents of families in the control group. This finding was still statistically significant 12 and 24 months following the intervention.
  • In an analysis of the clinical significance of outcomes, 77% of families who received Triple P underwent clinically reliable change in child problem behavior, compared with only 18% of control group families.
In another Australian study, families with a child 5-9 years old who had attention-deficit/hyperactivity disorder (ADHD) received Enhanced Triple P (level 5) or were randomly assigned to a wait-list control group. Although both groups improved from baseline to posttest, parents of families who received Triple P reported lower levels of disruptive child behavior (p < .05) than parents of control group families.

In a fourth Australian study, low-income families with a child 2-6 years old received Primary Care Triple P (level 3) or were randomly assigned to a wait-list control group. After the intervention:

  • Parents of families who received Triple P reported significantly fewer targeted problem behaviors than parents of control group families (p < .001).
  • Mothers of families who received Triple P reported child behavior problems occurring in fewer settings than parents of control group families (p = .014).
  • In an analysis of clinically significant outcomes, compared with control group families, a greater proportion of families who received Triple P reached reliable change in a positive direction on parental reports of the number of settings in which problem behavior occurs (p = .011).
Studies Measuring Outcome Study 1, Study 2, Study 3, Study 4, Study 5
Study Designs Experimental, Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 2: Negative parenting practices as a risk factor for later child behavior problems
Description of Measures Negative parenting practices (e.g., negative, coercive, or inadequate parenting, parental stress) were measured by systematic, direct observation using the Family Observation Schedule and by self-report using the Parenting Scale, the Parenting Sense of Competence Scale, and the Depression-Anxiety-Stress Scale.
Key Findings In one study in Australia, families with a 3-year-old received Enhanced Triple P (ETP; level 5), Standard Triple P (STP; level 4), or a self-directed version of Triple P (SDTP; level 4) or were randomly assigned to a wait-list control group. After the intervention:

  • Mothers and fathers of families who received ETP or STP reported less frequent use of dysfunctional discipline strategies than mothers and fathers of control group families (p < .001 to p < .05).
  • Mothers and fathers of families who received ETP reported less use of dysfunctional discipline than mothers and fathers of families who received SDTP (p < .001 to p < .05).
  • Mothers of families who received STP reported less use of dysfunctional discipline than mothers of families who received SDTP (p < .001).
  • Mothers of families who received STP or ETP reported greater parenting competence than mothers of families who received SDTP (p < .05) or mothers of control group families (p < .001). Mothers of families who received SDTP reported greater parenting competence than mothers of control group families (p < .001).
In a study conducted in Hong Kong, Chinese families with a child 3-7 years old received Triple P or were randomly assigned to a wait-list control group. After the intervention:

  • Compared with control group parents, parents of families who received Triple P had lower scores on the use of dysfunctional parenting behavior (p < .001), including lower subscale scores on laxness (p < .001), overreactivity (p = .002), and verbosity (p < .001).
  • Compared with control group parents, parents of families who received Triple P had lower scores on perceived parental problems (p < .001) and higher scores on perceived parent sense of competence (p < .001), including higher subscale scores on parental efficacy (p < .001) and satisfaction (p = .007).
In a study conducted in Australia, families with a preschooler received Enhanced Group Triple P or were randomly assigned to a no-intervention control group. At posttest:

  • Parents of families who received Triple P had larger reductions in the overall reported use of dysfunctional parenting (p < .05), including subscale scores for laxness (p < .05), overreactivity (p < .05), and verbosity (p < .05), than parents of control group families. This finding was still statistically significant at 12 and 24 months following the intervention.
  • Parents of families who received Triple P had larger reductions in reported caregiver depression (p < .05), anxiety (p < .05), and stress (p < .05) than parents of control group families. This finding was still statistically significant at 12 and 24 months following the intervention.
  • Parents of families who received Triple P had larger reductions in reported conflict between partners over child rearing than parents of control group families (p < .05). This finding was not robust at 12 months but was statistically significant at 24 months following the intervention.
In another Australian study, families with a child 5-9 years old who had ADHD received Enhanced Triple P (level 5) or were randomly assigned to a wait-list control group. At posttest, parents of families who received Triple P had significant reductions in their reported use of verbosity compared with parents of control group families.

In a fourth Australian study, low-income families with a child 2-6 years old received Primary Care Triple P (level 3) or were randomly assigned to a wait-list control group. After the intervention:

  • Mothers of families who received Triple P reported less use of dysfunctional parenting strategies than mothers of control group families (p = .001).
  • In an analysis of clinically significant outcomes, compared with control group families, a greater proportion of families who received Triple P reached reliable change in a positive direction on parental reports of verbosity (p = .006).
Studies Measuring Outcome Study 1, Study 2, Study 3, Study 4, Study 5
Study Designs Experimental, Quasi-experimental
Quality of Research Rating 2.9 (0.0-4.0 scale)
Outcome 3: Positive parenting practices as a protective factor for later child behavior problems
Description of Measures Positive parenting practices were measured by self-report using the Parenting Scale and the Parenting Sense of Competence Scale.
Key Findings In one study in Australia, families with a 3-year-old received Enhanced Triple P (ETP; level 5), Standard Triple P (STP; level 4), or a self-directed version of Triple P (SDTP; level 4) or were randomly assigned to a wait-list control group. After the intervention:

  • Mothers of families who received STP or ETP reported greater parenting competence than mothers of families who received SDTP (p < .05) or mothers of control group families (p < .001).
  • Mothers of families who received SDTP also reported greater parenting competence than mothers of control group families (p < .001).
In a study conducted in Hong Kong, Chinese families with a child 3-7 years old received Triple P or were randomly assigned to a wait-list control group. After the intervention, compared with parents of control group families, parents of families who received Triple P had lower scores on perceived parental problems (p < .001) and higher scores on perceived parent sense of competence (p < .001), including higher subscale scores on parental efficacy (p < .001) and satisfaction (p = .007).

In a study conducted in Australia, families with a child 5-9 years old who had ADHD received Enhanced Triple P (level 5) or were randomly assigned to a wait-list control group. At posttest, compared with parents of control group families, parents of families who received Triple P reported higher levels of confidence in successfully dealing with their child's disruptive behaviors in a variety of settings.

In another Australian study, low-income families with a child 2-6 years old received Primary Care Triple P (level 3) or were randomly assigned to a wait-list control group. After the intervention:

  • Mothers of families who received Triple P reported significantly greater satisfaction with parenting (p = .005) and significantly lower anxiety and stress (p = .005) than mothers of control group families.
  • In an analysis of clinically significant outcomes, compared with control group families, a greater proportion of families who received Triple P reached reliable change in a positive direction on parental reports of parenting satisfaction (p = .005).
Studies Measuring Outcome Study 1, Study 2, Study 4, Study 5
Study Designs Experimental
Quality of Research Rating 3.0 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 0-5 (Early childhood)
26-55 (Adult) 		68% Male
32% Female 		100% Non-U.S. population
Study 2 0-5 (Early childhood)
6-12 (Childhood)
26-55 (Adult) 		58% Male
42% Female 		100% Non-U.S. population
Study 3 0-5 (Early childhood)
26-55 (Adult) 		57% Male
43% Female 		100% Non-U.S. population
Study 4 6-12 (Childhood)
26-55 (Adult) 		80% Male
20% Female 		100% Non-U.S. population
Study 5 0-5 (Early childhood)
26-55 (Adult) 		53% Male
47% Female 		100% Non-U.S. population

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Negative and disruptive child behaviors 3.2 3.1 3.2 2.8 2.5 2.9 2.9
2: Negative parenting practices as a risk factor for later child behavior problems 3.2 3.2 3.1 2.9 2.5 2.6 2.9
3: Positive parenting practices as a protective factor for later child behavior problems 3.2 3.2 3.2 2.8 2.6 2.9 3.0

Study Strengths

The psychometric properties of the outcome measures are adequate, the intervention implementation was enhanced by a series of procedures to ensure program fidelity, and the analyses used were appropriate.

Study Weaknesses

Some studies showed improvement in both intervention and comparison groups at the postintervention assessment, which may indicate the influence of confounding variables. The statistical power of some analyses in two of the studies may have been low due to small sample sizes and large standard deviations.
Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
3.8 4.0 3.8 3.8

Dissemination Strengths

The practitioner's manual is easy to navigate and provides detailed instructions on all aspects of program implementation. Formal training on each of the five program levels is available to organizations implementing this program. Extensive training and implementation support is accessible to implementers through the Triple P Practitioner Network. An array of standardized assessment instruments is provided to implementers to measure the progress of families participating in the program. Session fidelity summaries are completed by implementers to support quality assurance.

Dissemination Weaknesses

Some of the written materials for parents are quite dense and assume parents have reading comprehension skills at the 6th-grade level or above. Materials include limited discussion on how to adapt the curriculum so it is culturally appropriate for participating families. No protocol for routine supervision of quality assurance measures was provided.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
Parent workbooks $20-$32 per participant Yes
Positive parenting booklets $6.50 per participant Yes
Parenting tip sheets $8-$11 for a set of 10 Yes
2- to 3-day, on-site training and half-day follow-up training (includes session fidelity checklists and pre-and posttest assessment measures) $21,415-$26,195 per site for up to 20 practitioners, depending on level of training Yes
Telephone consultation $200 per hour No
Clinical support $3,035 per day No
Pre- and postaccreditation quality assurance support $3,035 per day No