Medical Professional Publications

Triple P – Positive Parenting Program: An evidence-based program for parents of children with challenging behaviors

(From the Spring 2012 issue of Everything Matters: In Patient Care)

Michelle Byrum RN, MSN, CPNP, Certified Pediatric Nurse Practitioner, Developmental and Behavioral Pediatrics

“I have tried everything, and nothing seems to work.” This is a frequently heard statement from parents of children with difficult behaviors. The majority of parents strive very hard to raise children who are compliant, respectful, and successful. Unfortunately, some children display behaviors which are contrary to these goals, resulting in parents who become overwhelmed and stressed. In these situations, it is sometimes prudent for the parent to participate in a parent training program, which helps parents learn how to encourage positive behaviors and effectively manage difficult behaviors. Dr. Rebecca Baum, Director of the Behavioral Medicine and Consultation Clinic explains, “When a child’s behavior becomes challenging, parents may find themselves spending most of their time paying attention to negative behavior. While the parent is working really hard to improve the child’s behavior, this type of attention may actually makes things worse. Parents often need help understanding reasons why children misbehave, figuring out ways to encourage desirable behavior, and successfully addressing misbehavior when it occurs.”

There are a number of parenting programs that exist for the purpose of helping parents manage challenging behaviors. At Nationwide Children’s, we offer Incredible Years, Parent Child Interaction Therapy (PCIT), Active Parenting, and Triple P. While all of these programs are effective and evidence-based, the purpose of this article is to elaborate on the Triple P program.

The Triple P – Positive Parenting Program – is an evidence-based, multi-level intervention for reducing behavioral, emotional, and developmental problems in children. The goal of Triple P is to equip parents and families with the knowledge and the skills necessary to manage challenging behaviors. The program draws on principles of social learning, cognitive-behavioral therapy, and developmental theory, integrating each into a cohesive and comprehensive parenting intervention. Triple P was developed by professor Matt Sanders, PhD, from the Parenting and Family Support Centre in the School of Psychology at the University of Queensland. Since its development, the Triple P program has been adopted by several government agencies around the world as their standard for parenting intervention.

Triple P aims to provide parents with just the right amount of intervention, while maintaining efficiency and cost-effectiveness. It accomplishes this goal through its use of levels of intervention that are each of increasing intensity. The different levels of Triple P also allow the provider to tailor the intervention to best meet the needs of the family.

Level 1 is a population dissemination model, which uses print and electronic media to increase awareness of parenting resources and the need for a structured approach to parenting. An example of a Level 1 approach might be the placement of signs on public transportation which recommend that parents spend five to 10 minutes per day of uninterrupted play time with their child. Also on this sign would be a phone number to contact for further parenting assistance.

Level 2 is an intervention that targets specific, mild behavioral difficulties. This may be in the form of a brief parenting seminar led by a professionally trained behavioral specialist. Another Level 2 intervention would be the provision of handouts pertaining to specific behavior problems. Triple P has developed tip sheets that can be provided to families in clinic, and target problems such as tantrums, hitting, bedtime issues, and lying.

Level 3 is a model designed for primary care. It is a brief, four-visit intervention targeting a specific mild to moderate behavior problem. This model is designed for the clinician to meet with the parents over a course of four weeks, and uses a combination of tip sheets, videos, and active skills training to enable the parent to more effectively manage the behavior.

Level 4 is an intervention designed for more difficult or severe behavior problems. Level 4 can be delivered in an individual or group format. It generally lasts eight to 10 weeks and covers many types of behavior, rather than one specific problem. Behaviors may include aggression, meltdowns, running away in public and self injury. Level 4 is available for typically developing children, as well as children with intellectual and developmental disabilities. The group format is a common model in parenting interventions for difficult behaviors. David Michalec, PhD at the Child Development Center (CDC) at Nationwide Children's, says, “We find that the group model is especially important because of the support it offers to parents. Parents realize that they are not alone. Our participants see that other families of children with disabilities have the same challenges and the same joys. Parents are also great resources of local information and tell each other about local support groups, social events, and recreational activities geared for their child.”

Level 5 is for parents who are also experiencing relationship conflict, depression, or extremely high levels of stress. This intervention would be in an individual consultation format and is in addition to the completion of a Level 4 intervention.

Nationwide Children’s is pleased to offer the Triple P parenting intervention in a number of different models and settings. The Behavioral Medicine and Consultation Clinic (BMCC) offers Triple P Level 3. This parenting program targets families of children already seen in BMCC, who are in need of an intervention of moderate intensity. Over the course of four visits, the clinician works with the parents to assess, monitor, and change a specific problem behavior.

The Center for Autism Spectrum Disorders (CASD) also offers Triple P Stepping Stones, targeting parents of children with an Autism Spectrum Disorder who also have disruptive behaviors. Like the Stepping Stones group at CDC, it is a group program where parents meet together to discuss behavior problems and solutions. The CDC offers Triple P Stepping Stones, which is a Level 4 intervention that is specifically developed for parents of children with intellectual and developmental disabilities. The CDC offering of Stepping Stones is an eight week group program with six group sessions and one individual session. Usually there are between eight and 15 parents, and the sessions are delivered without the child in attendance. “Triple P Group Stepping Stones is important because many children with a developmental disability also have coexisting behavioral challenges. These behavioral challenges can negatively impact many spheres of functioning including family life, sibling relationships, school performance, and public behavior. Unfortunately, significant behavioral problems can interfere with treatment from therapists and teachers. The Triple P Group Stepping Stones program is uniquely tailored to meet the needs of these families. It is important to note that this program works! Research has shown many positive results for families and children. The Child Development Center is also collecting data to measure effectiveness for our groups,” reports Michalec.

The Triple P – Positive Parenting Program is extremely helpful for families who need additional guidance in the promotion of positive parent-child interactions and in managing difficult behaviors. Triple P’s model is unique in that it provides the opportunity to deliver an intervention to many groups of people, from an entire population group to a single mother and her child. For the parents, the experience builds confidence in their ability to effectively reduce negative behaviors, while improving relationships.

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