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An appraisal of a parenting intervention

An appraisal of a parenting intervention

reducing behavioural and emotional problems in children.

To draw a conclusion from the critical appraisal and make recommendations.

Research question

Investigate the effectiveness of the Triple P Positive Parenting Programme in reducing behavioural and emotional problems in children.

Background

There has been increasing concern among various communities about the high rates of mental health problems in children and young adults (Sanders et al. 2008). The most common problems among children are emotional and behavioural problems, with a prevalence of 15% and 14% in boys and girls of 4 – 12 years of age, respectively, (Sawyer 2000). Dretzke and his colleagues have reported that there is a significant relationship between conduct problems in childhood and adulthood outcomes such as criminal behaviour, drug abuse, child abuse, and many other psychiatric disorders and also a range of difficulties like low self esteem and poor relationships with peers (Dretzke et al. 2009).

It is important that the parenting style does have an impact on the outcomes of the child. The three different parenting styles, described by Baumrind (1991), namely authoritative, permissive, and authoritarian have varied levels of warmth and control. Clear evidence shows that there is an association between the authoritarian and the permissive styles and poor child outcomes (Baumrind 1989, 1991a,b; Bronte-Tinkew et al. 2006; Castrucci and Gerlach 2006; Simons and Conger 2007). The evidence highlighted that the permissive parenting style is significantly associated with negative outcomes such as, school misbehaviour, aggression, and alcohol and drug use (Patock-Peckam and Morgan- Lopez 2006). Similarly, inconsistent discipline and harsh corporal punishment have been strongly associated with high levels of childhood behaviour problems (Blader 2006).

In the light of these findings, parenting interventions are recognised as the most powerful and cost effective interventions for the treatment of children with conduct problems (Sanders, Bor and Morawska 2007). The purpose of these interventions is to increase positive interactions and decrease coercive and inconsistent parenting practice with children (Sanders et al. 2007). Improvements have been recognised in both parental perceptions and parenting skills, added to improvements in the social skills of the children and school adjustment, and a reduction in emotional and behavioural problems (Barlow and Stewart- Brown 2000).

The Triple P-Positive Parenting Programme is a comprehensive multilevel system developed by Sanders and his colleagues at the University of Queensland in Brisbane, Australia. The purpose of this programme is to reduce the severe emotional, behavioural, and developmental problems in children, preadolescent, and young adults by improving the quality of parenting advice available to parents, and enhancing parents’ knowledge, and skills: self-monitoring, setting goals through self determination, self evaluation of their performance and attitude, and the ability to choose different strategies. Moreover, the programme helps parents to be independent in solving problems by increasing their confidence. The program encourages positive, non-punitive techniques for child management to parents, which is considered a substitute to coercive parenting practice. This program also concentrates on changing parental attitudes from negative to positive disciplines and supports parents to identify alternative explanations for child behaviours (Sanders 1999).

The programme contains five levels of intervention, which gradually increase in strength for parents for children from birth to 12 years. Each level provides parents with the necessary knowledge and skills to deliver the information.

Level 1 is a universal parenting strategy and provides parents with valuable information through the media and promotional campaigns. The purpose is to increase community awareness, to help families respond by participating in parenting programmes, and to create a clear, comfortable atmosphere by outlining solutions to the most common behavioural problems in children. Level 2, is a short primary healthcare intervention lasting one or two sessions. The aim of this level is to provide early developmental guidance for parents, who have children with mild behavioural difficulties.

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Level 3, a four-session intervention, focuses on parental skills training and it targets children with mild to moderate difficulties. Level 4, is a more intense of eight to ten session training program for individual or groups of parents whose children have more severe behavioural difficulties in and level 5 is an enhanced course for families with difficulties such as marital conflict, high levels of stress, and depression (Sanders 1999).

The main purpose of this assignment is to investigate the effectiveness of this parenting intervention program in enhancing the relationship between parents and their children and reducing the emotional, behavioural, developmental problems in children. This evidence base would be helpful for the health visitor as a guide and to increase the awareness about this intervention among families.

Method and results

Since the question is what is the available evidence to show the positive impact of the Triple P Positive Parenting Program on child and family wellbeing and a reduction in behavioural and emotional problems in children?

PICO (Population: children and their parents; Intervention: Triple P- positive parenting programme; Comparator: other parenting programmes; Outcome: reduce the emotional, behavioural, conduct problems in children, improve quality of life, and improve wellbeing of children and parents).

Since the focus is to find out the effectiveness of the Triple P- positive Parenting Program on child behaviour problems, I focused on the evidence available in the electronic research engine (Medline, PubMed, The Cochrane Library, and PsycInfo). The main focus was on existing reviews, in particular systematic reviews and good quality reviews or studies.

Key words

The research terms were Triple P or Positive Parenting Program, and parenting program, and children/child, and children with behavioural problems, emotional problems or conduct problems.

The research strategy was limited to the papers written in English and published in the last ten years from 2000 to 2010 and to systematic review or meta-analysis. The Cochrane database had no meta-analysis or reviews on the Triple P positive parenting program that fulfilled the search criteria. Medline (OVIDSP) had 38 articles containing the term “Triple P- positive parenting program”, Pubmed had 31 articles, and PsycInfo research generated 23 hits.

Study Type

The authors

Level of Triple P

Meta- Analysis

(Nowak and Heinrichs 2008)

Triple P Positive Parenting Program system.

Meta-Analysis

(de Graaf et al. 2008)

Level 4.

Meta- Analysis and systematic Review

(Thomas and Zimmer-Gembeck 2007)

Comparing Triple P-positive parenting program with Parent-child Interaction Therapy (PCIT).

Systematically searching for evidence

Many papers and review articles have examined the intervention from different level of Triple P the Positive Parenting Program. Three meta- analyses have been chosen for the critical appraisal which have fulfilled the criteria and met the research terms. As it is shown above in the table.

1st study

Thomas, R. & M. J. Zimmer-Gembeck (2007) Behavioral outcomes of Parent-Child Interaction Therapy and Triple P-Positive Parenting Program: a review and meta-analysis. Journal of Abnormal Child Psychology, 35, 475-95.

2nd study

de Graaf, I., P. Speetjens, F. Smit, M. de Wolff & L. Tavecchio (2008) Effectiveness of the Triple P Positive Parenting Program on behavioral problems in children: a meta-analysis. Behavior Modification, 32, 714-35.

3rd study

Nowak, C. & N. Heinrichs (2008) A comprehensive meta-analysis of Triple P-Positive Parenting Program using hierarchical linear modeling: effectiveness and moderating variables. Clinical Child & Family Psychology Review, 11, 114-44.

PROPOSED METHOD OF CRITICAL APPRAISAL

Critical Appraisal

To critically examine the evidence provided by these papers, which are a systematic review, critical appraisal checklist provided by the critical appraisal programme, from the Public Health Resource Unit, Institute of Health Science, Oxford was used (accessed from http://www.phru.nhs.uk). The 10 questions are adapted from Oxman AD, Cook DJ, Guyatt GH, Users’ guide to medical literature. VI. How to use an overview. JAMA 1994; 272 (17): 1367-1371.

Study

(Thomas and Zimmer-Gembeck 2007)

Objective

1- To provide a comprehensive assessment of the evidence condition of using Triple P and PCIT in both Australia and the USA

2- To determine the effectiveness of delivery of both interventions: Triple P and PCIT.

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3- To identify all RCTs and single group follow up studies for both interventions between 1980 and 2004.

4- To find out the capacity for each type of intervention in improving behaviours in both parents and children.

Did the review ask a clearly- focused question?

Yes. Population: caregivers and children between 3 to 12 years old.

Interventions: Triple P Positive Parenting Program intervention, compared to PCIT (Parent – Child Interaction Therapy intervention).

The outcomes: child and parents’ behaviours.

Study design

A systematic Review and meta- analyses.

Identify relevant studies

24 studies:

11 RCTs studies of Triple P- positive parenting program

13 studies of PCIT -Parent – Child Interaction Therapy (9 RCTs, 2 single cohort studies, and 2 nonrandomised trails).

The quality of the included study

There was a scoring system.

More than one assessor.

Combining the results

Yes.

Presenting the results

The results were grouped according to the presence of significant differences (pre treatment and post treatment effect) in statistics between treatment group and comparison group:

Child / parent behaviour change during treatment: single group treatment effects.

Child behaviour / parenting: treatment versus comparison groups.

How precise were the results?

P value and confidence interval were reported.

Can the results be applied to the local population?

Can’t tell, because the sample size in studies is relatively small.

Where all important outcomes considered?

Yes.

Should policy or practice change as a result of the evidence contained in this review?

Yes.

Study

(de Graaf et al. 2008)

Objective

To examine the effectiveness of Triple P Level 4 interventions for the purpose of management of behavioural problems in children.

Did the review ask a clearly- focused question?

Yes.

Population: children of 2 to 11 years old with their parents.

Intervention: Triple P Level 4.

Outcome: managing behavioural problems in children.

Study design

Meta- analysis.

Identify relevant studies

15 studies: 14 Randomised Controlled Trails, and one non-random study.

9 studies clinical range and 6 nonclinical ranges.

The quality of the included study

There was a scoring system.

More than one assessor.

Combining the results

Yes.

Presenting the results

The results are expressed as:

–          Investigating the effects of Triple P Level 4 on the Eyberg Child Behaviour Inventory (ECBI).

o   post-measurements’ effect,

o   long-term effects after 6 and 12 months.

–          Triple P across modalities.

o   Effects directly after the intervention,

o   Long-term effects after 6 and 12 months

How precise were the results?

P value and confidence interval were reported.

Can the results be applied to the local population?

Can’t tell due to the small number of participants in the study.

Where all important outcomes considered?

Yes.

Should policy or practice change as a result of the evidence contained in this review?

Maybe.

Study

(Nowak and Heinrichs 2008)

Objective

To examine the impact of the moderator variables on the effectiveness of Triple P-positive parenting program.

To highlight the important factors to be considered in future implementation and planning as a preventative approach.

Did the review ask a clearly- focused question?

Yes.

Population: children and parents.

Intervention: Triple P-positive parenting program.

Outcome: parenting skills, the well being of parent and child, child problem behaviour, parents’ relationship quality, and child self-report.

Study design

Meta-Analysis.

Identify relevant studies

55 studies: study design 29 RCT, 11 quasi- experimental studies, and 15 uncontrolled studies.

The quality of the included study

There was a scoring system.

More than one assessor.

Combining the results

Yes.

Presenting the results

How they are expressed?

How large the size of the result is and how meaningful it is?

The results are expressed in:

Effect size.

Model fit (random effect), homogeneity test.

Moderating variables (source of assessment, level of Triple P, delivery format of Triple P, study design, quality of the study, the year and country publication, child’s age and the proportion of the boys, the child behaviour problems, length of follow up, and attrition post).

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How precise were the results?

P value and confidence interval were reported.

Can the results be applied to the local population?

Yes.

Where all important outcomes considered?

Yes.

Should policy or practice change as a result of the evidence contained in this review?

Yes.

Critical Appraisal of (Thomas and Zimmer-Gembeck 2007)

The Review had a clearly focused question. The population was: children aged between 3 to 12 years old and their caregivers; the intervention: Triple P Positive Parenting Program intervention, compared with PCIT (Parent – Child Interaction Therapy intervention), and the outcomes of interest were children’s behaviours and parents’ behaviours.

This systematic review and meta-analyses included 24 randomised controlled trails (RCTs) for the Triple P program and different types of studies for PCIT – (9 RCTs, 2 single cohort studies, and 2 nonrandomised trails). There was a follow up from reference lists, and experts were contacted andonly published studies were used. Language restrictions were not mentioned. There was more than one assessor.

The authors tried to combine the results by grouping according to the presence of significant differences (pre treatment and post treatment effect) among the treatment group compared to the comparison group; child behaviour and parent behaviour changes during treatment: single group treatment effects, and child behaviour and parenting: treatment versus comparison groups.

Generally, the results demonstrated a positive impact for both interventions, but the influence of these interventions varied according to the length of the intervention, components, and the outcome data source. A reduction was shown in both interventions in parent-reported child behaviour and in parenting problems.

P value and confidence interval were reported to show the differences in all studies. Moreover, the effect sizes were moderate to large for all forms of Triple P except for Media Triple P which was small. While the effect sizes of PCIT were large for the child and parent behaviours outcomes when the assessment was parent- reported, except one model of the PCIT called Abbreviated PCIT.

Moderate effect sizes were found in the Abbreviated PCIT. The results were presented in a precise manner. All important outcomes were considered. I think that policy could be changed to some extent because the results were conclusive regarding effectiveness. however generalizability of the inferences is limited due to following issues.

In many studies the demographic characteristics of study population were obscure. As a consequence, generalization of the inferences could be problematic. There was heterogeneity of studies with regard to the ways of family recruitment, ranging from self-referred families to referrals from clinicians or professional sources.

Thirdly, due to the use of the assessment of ECBI, Eyberg Child Behaviour Inventory, and CBCL the Child Behaviour Checklist, the results were less meaningful for effect sizes for the behaviours of children found in the Triple P’s studies than those found in PCIT’s studies.

Critical appraisal of (de Graaf et al. 2008)

The Meta- analysis had a clearly focused question. The Population: children of 2 to 11 years old with their parents; the intervention: Triple P Level 4, and the outcome: managing behavioural problems in children.

The meta-analysis included 15 studies: 14 Randomised Controlled Trails, and one non-random study. There were 9 clinical range studies and with the remaining studies having a nonclinical range.  Language restrictions were not mentioned. There was more than one assessor.

The authors tried to combine the results by grouping according to the presence of significant differences (The results are expressed by investigating the effects of the Triple P Level 4 on the Eyberg Child Behaviour Inventory (ECBI) of post-measurement effects, and long-term effects after 6 and 12 months. The second level was Triple P across modalities, effects immediately after the intervention, and after 6 and 12 months for long-term effects.

In summary, the results demonstrated that Level 4 of Triple P interventions had a positive impact in reducing disruptive behaviours in children. This progress appeared and was maintained over time; for further improvement and enhancement there should be follow up in the longer term.

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P value and confidence interval were reported to show the differences in all studies; moreover, the overall effect size was statistically significant in 14 studies of children’s behaviour at post measurement, as observed by parents (z=4.49, p<.001). All important outcomes were considered. I think that policy cannot be changed due to the limitations of the study.

Firstly, the number of the sample size of the participants was relatively small in the included studies, which makes it difficult to apply the results of the study to the local population. Secondly, sometimes the long term analysis in some studies is used as in the analysis of the post-intervention. As a consequence, the effect sizes of the longitudinal comparisons must be conducted carefully. Thirdly, it would be better if each of the parents reported separately to see if more differences appear than when the parents reported about the child together. Fourthly, the results could be limited and showed a narrow research domain according to the restrictions of the inclusion criteria.

Critical appraisal of (Nowak and Heinrichs 2008)

The Meta-analysis had a clearly focused question. The Population were children and parents,; the Triple P-positive parenting program was the intervention, and the outcomes were: parenting skills, the well being of parent and child, child problem behaviour, and parents’ relationship quality.

The analysis included 55 trails, which contained a range of study types, 29 RCTs (randomised controlled trails), 11 quasi-experimental, and 15 uncontrolled studies. Follow up from reference lists was done, and included published studies only in English and German. There was more than one assessor.

The results were analysed by the authors by using hierarchical linear models (HLM) with three levels of data to analyze the effect size. The estimated mean and confidence interval of 95% were provided for measures categories (parenting, the measures of the child problem, the well being of parents, parents’ relationship quality, and child self-report) for conditional and unconditional models of distribution of effect sizes( post, pre-post within group ,and pre- flow up within group effect sizes)., the estimated effect sizes were reported for Triple P intensity, and the delivering formats of Triple P, for the assessment of different sources, and study designs in controlled comparisons. All predictors and the predictors’ coefficients were reported to show the significant differences from zero and the number of samples included studies.

P value and confidence interval were reported to show the differences in the included studies. The effect size was presented in the study so results were precise. It can be applied to the local population in terms of the effectiveness of the interventions. All important outcomes were considered. I think that policy could be changed because the results were conclusive. According to the quality of the study, the score showed that there was not significant differs between randomised controlled trails and non-randomised controlled trails.

Overall, this meta-analysis has shown that Triple P has a positive impact on changes in parenting skills, the behaviour problems in children and the wellbeing of the parents. This effect ranges from small to moderate, being related to intervention intensity. A great impact was found in parent reports, which is considered the most prominent finding of the Triple P system’s impact, as compared to observational measures. Moreover, there was a significant improvement linked to more intensive formats of Triple P and highly distressed families. Several strengths were clearly found in the analysis of the Triple P system, crucially its capacity to make enhancement in parents and children.

Many limitations in this meta- analysis were found. Some moderator variables could not be included in the primary studies, which caused inconsistent reporting (such as socio-economic status (SES) and the age of parents). Furthermore, it must be taken into account that many trials could not provide a control group at follow up time to help compare the intervention with the control group. Moreover, it would be better to develop a wider more evidence base to differentiate between Triple P Level 1 and Level 3 as much as Triple P 4 and Level 5. In addition, this meta-analysis may have missed some studies due to the focus on published trials written in English and German. There were several formats of the Triple P programme such as Stepping Stones Triple P for disabled children, and Indigenous Triple P for Indigenous people in Australia, which focussed on specific family groups and which were not included because of the small sample sizes.

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Conclusion and Recommendations for the implication

The three studies had been demonstrated that Triple P- positive parenting program has a positive impact on the child by reducing their behaviour problems. The Thomas and Zimmer- Gem- beck (2007) reported the effect sizes the range for parenting and child behaviour between 0.38-0.70 and 0.31-0.73, respectively. Moreover, De Graff and colleagues (2008) stated the overall mean effect for post intervention/ follow up range between 0.42- 0.65 for child behaviour problem and for dysfunctional parenting range between 0.54/0.51. Significant improvement was found in the follow up for the child problems behaviour.

Results of the Nowak and Heinrichs (2008) reported that there were no significant differences between the two time points. However, the trend of intervention effects was significant improved between the post-intervention and the follow- up points. Reliable positive effects were demonstrated in the all settings of Triple for child behaviour problems, the behaviour of parenting, and the well being of the parental. In addition, there was a great improvement in the tendency of the relationship quality of parents. In summary, these studies provide evidence base to use such as Triple P- positive parenting program as parenting behaviour interventions to decrease the behavioural problems in children.

Public health program managers are usually looking for making parenting interventions widely accessible as much as possible. Involving the service providers from different disciplines could be the best way of doing this. For instance, in South Carolina there has been training in the delivery of Triple P system trails for many types of professionals such as social workers, nurses, parents’ educators, psychologists, and others (Sanders 2008). Web-based support network should be established for service providers to provide the staff with technical support,



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