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Contemporary Triple P

Karen M. T. Turner, PhDDeputy Director (Programs and Innovation)Parenting and Family Support CentreThe University of Queensland

Jenna McWilliam, MOrgPsychHead of Organisational Development

Triple P International Pty Ltd

Disclosure statement

• The Triple P - Positive Parenting Program is owned by The University of Queensland which licenses Triple P International Pty Ltd to disseminate the program worldwide

• Royalties are distributed to the Faculty of Health and Behavioural Sciences, School of Psychology and contributory authors

• Associate Professor Turner is a foundational co-author of Triple P resources

• Jenna McWilliam is an employee of Triple P International Pty Ltd

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Why Triple P?

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Our vision

All parents have knowledge, skills and confidence to raise their children a safe, loving, low conflict world

Positive parenting becomes socially 

normative

Adverse Childhood Experiences are 

minimised

Population‐based approaches to 

parenting support become a policy 

priority

Who benefits?

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Good parenting is the clean water of mentalhealth and wellbeing

What a great place to raise children might look like?

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A great place to raise a family

• Values, supports and celebrates the importance of parenting

• Recognises that the wellbeing of children and families is a shared community responsibility

• Respects a parent’s role in determining the values, skills and behaviours they want to promote in their children and the parenting practices they use to get there

• Promotes the social and cultural connectedness of families

• Supports family self-regulation and autonomy in raising children

• Makes high quality, culturally informed, evidence-based parenting support programs accessible for all families

• Ensures that parents are empowered and skilled to participate in planning and decision making that impacts on children and families

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Children’s relationships really matter

• Poorer self‐regulation• Risk of SEB problems• Risk of antisocial behavior, substance abuse, school dropout

Poor life course 

outcomes

Dysfunctional relationships cause 

toxic stress

Positive, nurturing relationships lay the 

foundations (Biglan, 2015)

• Secure bonding• Better self‐regulation• Fewer SEB problems• Academic success

Good life course 

outcomes

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A person with 4 or more is…

Adverse childhood experiences (ACEs)

Life course outcomes• 12.2 times as likely to attempt suicide

• 10.3 times as likely to use injection drugs

• 7.4 times as likely to be an alcoholic

• 2.4 times as likely to have a stroke

• 2.2 times as likely to have ischemic heart disease

• 1.9 times as likely to have cancer

• 1.6 times as likely to have diabetes

Types of ACEsAbuse• Physical• Emotional • Sexual

Neglect• Physical• Emotional

Household dysfunction• Mental Illness• Incarcerated relative• Mother treated violently• Substance abuse• Divorce

Broadening our conceptions of competent parenting

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Core principles of positive parenting

Safe and engaging 

environment

Positive learning 

environment

Consistent assertive discipline

Reasonable expectations

Taking care of oneself

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Gender/age of parent

Education /literacy

Employment status

Poverty

Parental mental health

Connectedness to community

Discrimination

Type of Neighbourhood

Prior help seeking

Family of origin experiences

Culturally normative parenting practices

Immigration status

Government policies and

priorities

AcculturationEnablers and barriers

Social influence

Program itself

Parental concern about child behavior

MotivationParticipation

Social infrastructure

Parenting services

Refugee status

Laws

Level of violence

Ecological context matters

Cognitions or affect

Broadening our conceptions of competent parenting

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Other aspects of parenting

Supporting children’s 

relationships with peers

Balancing work and family 

responsibilities

Effective communication with teachers Healthy 

relationships with extended 

family

Being part of the community

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Why Triple P as a system?

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Make positive parenting a public health priority

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A blueprint for a achieving population level change

1. Clear documentation of need

2. An explicit theoretical framework

3. Build a strong evidence base 

4. Involve consumers to shape program

5. Use cost‐effective interventions

6. Use diverse access points

7. Use intensive programs sparingly

8. Strengthen social structures to support  parenting

9. Employ sustainable system of dissemination

10. Population level outcome data relevant to policy

Adopting a population approach has implications

• Started to focus on different outcomes

• Developed a “system” that blends targeted and universal interventions

• Proportionate Universalism

• Focused on a multidisciplinary, multi-agency workforce

• Needed to be comprehensive (covering multiple stages of development and complexity of problems)

• Needed to be inclusive of all families

• Needed to be culturally informed and relevant

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Not a ‘one-size fits all’ approach

Level 5

Level 4

Level 3

Level 2

Level 1

Intensive family intervention………................

Broad focused parenting skills training………...

Narrow focus parenting skills training………….

Brief parenting advice……………………………

Media and communication strategy…………….

Breadth of reachIntensity of intervention

What does the Triple P System look like now?

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10

Development of the Triple P System

Standard

Enhanced

GroupSelf‐

Directed

Discuss’nGroups

Primary Care

Seminars

Media Series

Level 5

Level 4

Level 3

Level 2

Level 1

Standard Teen

Group Teen

Self‐Directed Teen

Teen Discuss’nGroups

Primary Care Teen

Teen Seminars

Teen

OnlineIndigenous Online

Pathways

Standard Stepping Stones

Group Stepping Stones

Self‐Directed 

SS

Primary Care SS

LifestyleFamily 

TransitionsResilience

Stay Positive

What’s the evidence?

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Questions about effectiveness are complex

What intervention… delivered by whom…in what context… via which delivery modality is effective with what kind of parent, child or youth problems… at what age… in what family, 

cultural and community  context?...and how does the intervention effect

come about?Adapted from Gordon Paul (1969). Behavior therapy appraisal and status. McGraw‐Hill

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1137 authors

499 conceptual papers

353 institutions

274 evaluation studies, including 137 RCTs

30 countries

773 total papers

Building an evidence base takes time

First population trial published

International dissemination begins

Growth of international projects

Program development begins

Program gets a name

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Types of evidence

• Single-case experiments(Sanders & Glynn, 1981)

• RCTs(Sanders et al., 2000)

• Quasi-experimental studies(Zubrick et al,1995; Doyle et al, 2016)

• Place-based RCTs(Prinz et al, 2009, 2016)

• Evaluations in LMIC(Mejia et al, 2014)

• Meta analyses(Nowak & Heinrichs, 2008; Sanders et al., 2014)

• Service-based evaluations(Santa Cruz, 2016)

• Consumer preference studies(Metzler et al., 2013)

• Training, implementation and supervision studies(Hodge et al., 2016)

• Evaluations in diverse cultures(Sumargi et al., 2015)

• Qualitative studies(Frank et al., 2015)

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What about long-term effects?

• Sanders et al. (2014) meta-analysis: 70 studies with follow up (2–36 months)

• Hahlweg et al. (2015) conducted 10 year follow up (90% retention) of universally offered Group Triple P

- Significant reductions of child behavioural and emotional problems at 10 year follow up for internalising problems, externalising problems, parenting practices

• Smith (2015) conducted 15 year follow up of linked administrative data in WA

- Higher levels of literacy and numeracy, school attendance (grade 11), fewer emergency room visits

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Competency-based training across diverse cultures

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Training delivered in 27 countries

From small beginnings…

• 7,170 professional training courses run worldwide

• 108,056 training places

• 76,496 unique practitioners

• Reaching millions of children

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What’s new?

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Working towards population level change

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Intensive early intervention with vulnerable families

• €100 toys annually and book packs

• Facilitated access to enhanced preschool

• Public health workshops

• Facilitated access to local services

• Access to social events

High treatment = PLUS

• Baby massage (year 1)

• Triple P (PC, Discussion Groups, Group - years 2-3)

• Mentoring (until 4 or 5 years)

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Effects on cognitive functioning

British Ability Scales (Elliot et al, 1997)

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Areas of development Impacts during the program Impacts at school entry

Cognitive developmentCognitive improvements from 18 months 

onward

10 Point IQ gap between children in the 

high and low treatment groups

Language developmentHigh treatment children were better at 

combining words at 24 months

25% of high treatment children had above 

average verbal ability compared to 8% of 

low treatment children

Approaches to learningHigh treatment children showed better 

approaches to learning from 36 months

High treatment children were better able 

to control their attention than low 

treatment children

Social and emotional development

2% of high treatment children were at risk 

of behavioural problems compared to 

17% of low treatment children at 48 

months

25% of high treatment children not on 

track in their social competence 

compared to 43% of low treatment 

children

Physical wellbeing and motor

development

24% of high treatment children were 

overweight compared to 41% of low 

treatment children at 48 months

High treatment children had better gross 

and fine motor skills

Working with technology

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• Mentor introduces and summarises modules

• Video clips of families in action• Interactive exercises• Individual goal setting, feedback and weekly 

check in• Downloadable worksheets • Personalised and printable parent workbook 

(email or Word file; full text and bullet point versions)

• Downloadable podcasts• Review and reminder strategies (text 

messages, emails)• Self‐regulatory focus with decreasing 

support

Triple P Online:

Providing support where parents are looking for it

Does adding phone support improve outcomes?

Up to 8 weekly telephone consultations with a Triple P practitioner

• To discuss parenting-related questions/issues

• To promote parent’s self-regulatory skills

• To encourage program adherence

Day & Sanders (2016)

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Primary child outcomes

Pre-FU

WL vs Active* (d = 0.3)

TPOL vs TPOLE** (d = 0.34)

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TPOL TPOLE WLGroup

EC

BI I

nte

nsi

ty s

core

Time

Pre

Post

FU

Phone support aids module completion

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100

Module1

Module2

Module3

Module4

Module5

Module6

Module7

Module8

TPOL with phone support TPOL without phone support

With phone support

Without phone support

Minimum dose

(70.2 % vs 40.8%)

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Implications

TPOL:

• works (7 RCT’s) for children with early onset conduct problems and ADHD

• is very cost-effective

• effects enhanced by professional support for some parents

• can be used in stepped care approach

• engagement process very important

• useful to screen for pre-existing levels of adjustment difficulties (e.g. depression) to decide if support is desirable

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Working in LMICs

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Children’s exposure to violence is a major public health issue

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Children’s exposure to violence is a major public health issue

150 million (14%) of girls and 73 million (7%) of boys under age 18 experience forced sexual intercourse and other forms of sexual violence involving touch

Source: UN Secretary General's Study on Violence Against Children (2013)

The role of parenting programs globally

• WHO Global Violence Prevention Initiative and UNODC calls for development, adaptation, implementation and evaluation of EBPs for LMIC

• Two meta analyses highlight the lack of quality research

- Mejia, A., Calam, R., & Sanders, M.R. (2012). A review of parenting programs in developing countries: Opportunities and challenges for preventing emotional and behavioural difficulties in children. Clinical Child and Family Psychology Review.

- Knerr, W., Gardner, F., Cluver, L (2013). Reducing harsh and abusive parenting and increasing positive parenting in low- and middle-income countries: a systematic review. Prevention Science.

• Programs developed in one country can be successfully used in other

- Gardner, F., Knerr, W., & Montgomery, P. (2015). Transporting evidence-based parenting programs for child problem behaviour (age 3-10) between countries: Systematic review and meta-analysis. Journal of Clinical Child and Adolescent Psychology.

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What’s next?

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We’ve only just begun…

• World population: 7.3 billion

• World population of children aged 0-14: 1.9 billion

• 145 million children are born each year (399,926/day or 278/minute)

• World population from less developed countries: 6 billion

• 28/196 (12.76%) countries have contributed to the published evidence base on Triple P

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Population Reference Bureau. (August, 2015). 2015 World Population Data Sheet. Retrieved from www.prb.org

United Nations, Department of Economic and Social Affairs, Population Division. (2015). World Population Prospects: The 2015 Revision, Key Findings and Advance Tables. Working Paper No. ESA/P/WP.241

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Good parenting and problems of global significance

Parenting support and major environmental problems

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Depletion of fish stock due to damage to coastal reefs

Pollution as a result of burning biomass to meet basic energy 

needs

Working with climate scientists/marine biologists on family‐based cultural change

Working with engineers interested in poverty reduction 

and sustainable energy

Animal welfare Working with veterinary scientists

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A final word

We have learnt a lot about how to build the capacity of parents to raise well adjusted 

children

Activation of community‐wide processes to 

support positive parenting

Population‐based approaches to 

parenting support should become a policy priority

Population level change in parenting is an achievable goal

Triple P International

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Challenges

• Innovations to address to major challenges:

- How to increase the reach of parenting support across a community

- How to implement evidence-based programs effectively

- Digital innovation

The challenge: reaching all families

• How can we increase parenting skills across a community?

• How can we achieve a meaningful, population level change in family resilience and functioning and children’s emotional and behavioural outcomes?

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How are we addressing this challenge?

• Refining the Triple P public health approach

• Communications and engagement strategies

• Supporting community readiness and collaboration

• Supporting flexible delivery of existing programs

• Triple P Online

Example: Queensland Government Triple P initiative

• Universal parenting program led by the Department of Communities, Child Safety and Disability Services

• Aims to give parents practical skills and tools, and help build their confidence

• Aims to reach a large number of families

• Complements reforms in child protection

• Makes a range of Triple P services available to parents free of charge

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Progress so far

• By the end of 2016, we had reached 50,280 parents through:

- 12,752 parents attending seminars

- 23,585 parents attending a range of light touch and more intensive programs

- 13,942 parents accessing Triple P Online

Stay Positive materials

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Billboards and bus stop signs

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Bus wrap

Communication with parents

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The challenge: Effective implementation

“What shall be implemented, how will the task be carried out, and who shall do the work of implementation?”

• What refers to the effective intervention (the EBP)

• How is the process to establish what needs to be done (the set of purposeful implementation activities)

• Who refers to who will do the work to accomplish positive outcomes (implementation teams)

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The Triple P Implementation Framework

The challenge: Digital innovation

• Harnessing the benefits of digital services

• For parents:

- Communications and engagement strategies

- Triple P Online

• For practitioners:

- Online presentation materials

- Automatic Scoring and Reporting Application

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Summary

• Focus on increasing reach to make population level impact across communities

• Invest in strategies to support effective program implementation to increase reach, high quality delivery and sustainability

• Harness the benefits of digital services

Karen Turnerkturner@psy.uq.edu.au

Jenna McWilliamjenna.mcwilliam@triplep.net 

Triple P Internationalwww.triplep.net 

Triple P Blogwww.triplepblog.net  

Triple P Evidence Base www.pfsc.uq.edu.au/evidence