The 'Teen Triple P' Positive Parenting Program : a preliminary evaluation

Foreword | Adolescents who develop severe conduct disorders are at greater risk of becoming involved in juvenile crime, including property crime, interpersonal violence, theft, arson and illegal substance use. Prior research has found that dysfunctional parenting practices often place children at risk of developing conduct problems and are among the strongest predictors of later delinquent behaviour. Various programs have been developed to assist parents in improving their parenting skills. This paper evaluates one such program, the 'Teen Triple P' Positive Parenting Program. Preliminary results suggest positive outcomes for most participating parents. There have been significant reductions in a variety of risk factors, with some evidence of improvements still being maintained after six months. Further extensive evaluations are being undertaken to assess the reliability of these preliminary findings.

Toni Makkai
Acting Director

Dysfunctional parenting practices place children at risk of developing conduct problems (Hawkins, Catalano & Miller 1992) and are among the strongest predictors of later delinquent behaviour (Loeber & Stouthamer-Loeber 1986). Family conflict and dysfunctional parenting practices are also related to a wide variety of adverse developmental and behavioural outcomes in adolescence including drug abuse, poor school achievement and truancy (Sanders 1995). Where children display antisocial behaviour, parents are often poorly equipped to provide consistent affection and discipline (Greenwood et al. 1997).

Serious conduct problems have been shown to be strongly associated with substance use and abuse (Hawkins et al. 1992; Kellam, Brown & Fleming 1983). Studies show that behavioural problems are more likely to begin before drug abuse than vice versa, however an escalation of delinquent or antisocial acts is often accompanied by substance abuse (Prinz & Connell 1997). Indirect evidence suggests that family support reduces the likelihood of adolescent substance abuse and conduct problems (Cauce et al. 1990; Cohen & Wills 1985; Wills, Vaccaro & McNamara 1992).

Interventions aimed at reducing adolescent delinquency have typically been based on a treatment model, however there is limited evidence that such treatment is effective once adolescents have developed severe and pervasive antisocial behaviour patterns. The Pathways to prevention report (National Crime Prevention 1999) defined the need for a developmental approach to crime prevention. Two developmental pathways have been identified that explain the emergence of antisocial/conduct behaviour problems in childhood (Patterson 1982; Patterson, Capaldi & Banks 1991; McMahon & Estes 1997):

• the early-starter model; and
• the late-starter model.

Although the early-starter model becomes entrenched in the preschool years, a significant number of children do not exhibit problem behaviour in early childhood, but become part of a late-starter group, with problems emerging in early adolescence (McMahon & Estes 1997).

The ‘Triple P’ system

The Positive Parenting Program (referred to as 'Triple P') is a unique parenting and family support system developed at the University of Queensland, and initially created to assist parents of children who fit the early-starter model. Triple P uses a tiered system of intervention. On a scale of increasing intervention strength, programs include:

• media- and information-based strategies;
• brief consultation primary care interventions;
• more intensive parent training; and
• enhanced behavioural family interventions.

The multiple tiers of intervention in the program allow it to provide different levels of support depending on parental need. Additionally, there is a range of delivery options, including individual and group sessions, self-directed and telephone-assisted components. Triple P is designed as an intervention for all parents and its use of different media promotes easy access to the program.

Teen Triple P was developed for parents of older children who fit the late-starter model. It addresses issues that might lead to severe adolescent antisocial and delinquent behaviour. Teen Triple P targets parenting risk factors, such as:

• harsh, coercive discipline styles;
• parent-teenager conflict and communication difficulties;
• parental monitoring of teenagers' activities;
• parental depression; and
• marital conflict.

Teen Triple P provides parents with assertive discipline skills to preserve parental authority in a consistent and nurturing manner and to help teens maintain regard for family norms of appropriate behaviour as well as respect for school and wider community expectations.

The primary aim of Teen Triple P is to assist parents to promote positive skills and abilities in their teenage children, which contributes to the prevention of more serious adolescent health-risk behaviour, and delinquent or antisocial behaviour. The program helps to:

• promote the independence and health of families through enhancing parents' knowledge, skills and confidence;
• promote the development of non-violent, protective and nurturing environments for teenagers;
• promote the development, growth, health and social competence of teenagers;
• reduce the incidence of adolescent delinquency, substance abuse, conduct disorder and behavioural problems by diverting teenagers away from risky developmental pathways;
• enhance long-term resourcefulness and self-sufficiency of parents in guiding their children through the teenage years; and
• promote existing school-based support systems and enhance them with additional resources and programs.

This paper describes a preliminary evaluation of a group Teen Triple P program delivered to parents of pre-adolescent children at the transition from primary to secondary school. This transition is considered to be a time of apprehension and anxiety for parents. It is reasoned that they may therefore be more receptive to receiving advice on adolescent and parenting problems at this time. Schools provide a convenient and appropriate community-based contact point where such parenting issues can be discussed.

Group Teen Triple P

Group Teen Triple P is a group-format behavioural family intervention program requiring eight hours participation (typically a two-hour session once a week for four weeks). It employs an active skills training process to help parents acquire new knowledge and skills via observation, discussion, practice and feedback.

Positive parenting skills are demonstrated by videos and by practitioner modelling. These skills are then practised in small groups. Parents receive constructive feedback about their use of skills in an emotionally supportive context.

The first two-hour session addresses developmental issues and considers the likely causes of behaviour problems. The second session introduces strategies for encouraging children's development. The third and fourth sessions introduce strategies parents can use to manage undesirable and 'risky' teen behaviour (such as staying out late, smoking and drinking alcohol).

These group meetings are complemented by homework, parent workbooks and video screenings. The video depicts scenarios commonly confronted by parents of teenagers. The program also includes individual post-group phone consultations of up to 30 minutes duration, once a week for four weeks. There is a total of approximately 10 contact hours per family.

Although delivery of the program in a group setting may mean parents receive less individual attention, there are several benefits of group participation for parents. These include support, friendship and constructive feedback from other parents, as well as opportunities for parents to normalise their parenting experience through peer interaction.

Participants

Potential participants for this study were 771 parents with 12- to 13-year-old children from four schools in two Queensland locations (one northern; one southern). Both were low socioeconomic areas with high juvenile crime rates. In both locations, one school was randomly assigned to receive the initial group program, and the other to receive it one year later. All participation by parents and children was entirely voluntary.

At the start of the school year in 2000, letters were mailed to all parents of newly enrolled year 8 students advising them about the project. The letter explained that parents would be telephoned by researchers at the university and invited to participate in a brief confidential telephone survey aimed at identifying difficulties encountered in relation to parenting a year 8 child. They were also asked to provide written consent for their child to participate in a survey at school that would gather valuable information about teenagers' attitudes and behaviours. Parents were advised that the survey asked questions about risky adolescent behaviour including smoking, alcohol and drug use, sexual activity and antisocial behaviour, and that a copy of the survey was available at each school should they wish to inspect it prior to giving consent. A consent form was included with the letter, and a prepaid addressed envelope was also provided. The letter included a registration form for the group Teen Triple P program. Parents were invited to participate in one of several different group sessions during the coming weeks. Group sessions were offered in the school library at times such as 10am-12 noon, 1-3pm, 4-6pm and 7-9pm.

Participants

Parents were surveyed by means of a computer-assisted telephone interview (CATI) at the University of Queensland. Interviews lasted about 18 minutes and comprised verification that the person was the parent or guardian of the child on the school's enrolment list, and telephone adaptations of two established questionnaires:

• the Strengths and Difficulties Questionnaire (SDQ) which asks parents to describe their children's behaviour; and
• the Family Background Questionnaire (FBQ) which asks parents about their family structure, composition and resources.

At the end of each interview, parents were asked if they had received the consent form for their child to complete the Adolescent Health and Wellbeing Survey. Parents were encouraged to sign and return the form, and a replacement was sent to any parent who had mislaid or not received the form.

A second series of telephone interviews was conducted 12 months later. The aim was to reinterview all parents in order to ascertain changes that had occurred between time 1 and time 2. However, due to budget limitations it was only possible to interview 280 of the original 602 parents. It is not known whether this smaller sample introduced a bias that would impact on interpretation of the results. However, as the telephone calling method was similar to that used during the first interview series, but simply ceased before the same number of parents was called, there is no reason to suspect any bias.

Student surveys

Following completion of the first telephone interview, further attempts were made to increase the number of completed consent forms returned, and thereby the number of year 8 students allowed to be surveyed. Several notices were sent out by the schools. The Adolescent Health and Wellbeing Survey was then administered during school time to all first-year students at all four participating schools for whom consent had been obtained. Completed questionnaires were obtained from 453 students (59%). When the survey was repeated 12 months later, completed questionnaires were obtained from 360 of these students.

Student surveys

The next phase of the project involved running the group Teen Triple P programs in the two schools that were selected to receive them. All parents with children enrolled in year 8 in these two schools were telephoned personally by staff from the schools and the research team and invited to participate.

In the northern location, of the 169 families who were contacted, 68 parents indicated they were interested in attending a group, 37 attended at least one group session, and 26 completed the program. In three-quarters of cases only one parent from a family attended, with the remaining quarter of cases being both parents, although they did not always attend all sessions together. Of the 37 parents who attended at least one session, only two were fathers attending without the mother. Four couples attended, and the remainder were mothers.

In the southern location, of the 165 families who were contacted, 70 parents indicated they were interested in attending a group, 41 attended at least one group session and 30 completed the program. In three-quarters of cases, only one parent from a family attended with the remainder being both parents, although they did not always attend all sessions together. Of the 41 parents who attended at least one session, only three were fathers attending without the mother. Seven couples attended, and the remainder were mothers. Groups comprised between three and 13 parents.

The group parenting program was offered to all parents as part of a universal intervention and the question arises whether those who attended differed from those who did not attend on the basis of responses to any of the questions asked during the telephone survey. The database is being investigated to try and answer this question as this may assist in engaging more parents in the future. However, anecdotal reports from group facilitators and inspection of parents' pre-test scores suggest that parents who attended reported a wide range of problem behaviour in their year 8 child. Some parents clearly attended because they were already experiencing serious conflict, while others took advantage of the opportunity to learn skills they hoped would prevent or reduce the probability of conflict with their teenager.

Group facilitators were provided with a kit containing the facilitator's manual, a copy of the Teen Triple P group workbook that all participating parents would receive, and a set of overhead transparency slides that are used to present aspects of the group program. In addition, each facilitator was given a copy of the video Every parent's guide to teenagers, which illustrates much of the content of Teen Triple P for parents. After each session, facilitators were required to complete session checklists. These were regularly inspected by the principal investigators to ensure program integrity.

On arrival at the first group session, and immediately prior to beginning the group intervention, parents were asked to complete an assessment booklet. They were advised that they would be requested to complete it again after the completion of the program, about eight weeks later. This assessment was designed to provide data on the following:

• Parent-teenager conflict
  Parents answered questions about recent conflict with their teenager. They were also asked to take additional forms home and have their teenager complete them. The teenager was asked to complete one version of the form about interactions with their father, and another about interactions with their mother (where appropriate). The option was provided for the teenager to mail the completed forms directly to the facilitator, or to seal them separately in an envelope for their parent to return at the following session. Not all teenagers completed the questionnaire.
• Parenting style
  Parents answered questions that indicated how lax or over-reactive they were in responding to problem behaviour by their teenager.
• Parenting beliefs
  Parents answered questions that indicated measures of personal agency, self-efficacy, self-management and self-sufficiency.
• Conflict over parenting
  These questions gauged conflict between parents about child-rearing. They measured parents' ability to cooperate and work together in family management. The questions explored the extent to which parents disagreed over rules and discipline for child misbehaviour, the amount of open conflict over child-rearing issues, and the extent to which parents undermined each other's relationships with their children.
• Parental adjustment
  Parents also completed questions designed to assess their symptoms of depression, anxiety and stress.

Following completion of the assessment questionnaire, parents completed the eight-session group Teen Triple P program. The aim was to develop new knowledge and skills through observation, discussion, practice and feedback. Parents viewed segments from the video and practised implementing these skills in small groups.

Skills taught included:

• monitoring problem behaviour;
• rewarding desirable behaviour;
• arranging engaging activities;
• using directed discussion for minor problem behaviour;
• making clear, calm requests; and
• backing up instructions with logical consequences.

Parents were also taught how to manage emotional behaviour on the part of their teenager, to set up behaviour contracts to deal with more resistant or established problem behaviours, and to use family meetings to plan how to make necessary changes to family routines. Specific strategies were introduced to help parents deal with risky behaviours and to promote the maintenance of parenting skills across settings and over time. Between sessions, parents were requested to complete homework tasks to consolidate their learning from the group sessions. After the group sessions, they were invited to participate in up to four 15-30 minute follow-up telephone sessions that provided additional support as parents put into practice what they had learned in the group sessions.

Following completion of the eight-week program, parents were requested to complete the assessment questionnaires for a second time. At this time they were also asked to complete a questionnaire measuring consumer satisfaction with parent training programs. This addressed:

• the quality of service provided;
• how well the program met the parent's needs, increased the parent's skills and decreased the child's problem behaviours; and
• whether the parent would recommend the program to others.

Student surveys

The first question the researchers considered was whether parents who participated in the group parenting programs subsequently reported reductions on measures of targeted family risk factors, and improvements on measures of family functioning. Figure 1 shows that, compared with the pre-treatment scores, parents who participated in the group programs did report significant improvements on almost all of the assessment measures. Only the change on personal agency was not statistically significant.

A series of one-way analyses of variance (ANOVA) was conducted to determine whether the predicted reductions met significance (p<.05):

• parent-teenager conflict reduced from a mean of 7.0 to 4.5 post-treatment (F=9.76, df 1,25, p
• parenting styles improved, with reductions on the laxness score from 17.3 to 13.5 (F=15.99, df 1,25, p<.01), and on over-reactivity from 20.5 to 17.1 (F=8.91, df 1,25, p<.01);
• parental beliefs also changed for the better, with parents reporting significant improvements on measures of self-efficacy (F=14.34, df 1,25, p<.01), self-sufficiency (F=6.45, df 1,25, p<.05) and self-management (F=9.05, df 1,25, p<.01), but not on personal agency (F=2.33, df 1,25, p>.05); and
• on the measure of parental conflict over their parenting strategies, parents reported an improvement from 5.3 to 3.1 (F=8.84, df 1,25, p<.01).

Although pre-treatment measures of parental adjustment revealed generally low levels of depression, anxiety and stress, there were nevertheless significant improvements post-treatment:

• for depression, parents improved from a mean score of 4.0 to 2.5 (F=3.35, df 1,25, p<.05);
• for anxiety, scores improved from 1.8 to 1.0 (F=4.87, df 1,25, p<.05); and
• for stress, parents reported a mean score of 6.8 which was significantly reduced to 5.0 post-treatment (F=4.8, df 1,25, p<.01).

Finally, parents' satisfaction with the group program, which was measured once at the end of the program, was generally high, with scores of 5 or above on the 7-point scale (where high scores indicate high levels of satisfaction).

Comparison with parents from control schools

The second question asked was whether there were significant differences between children's problem behaviour depending on whether their school offered group Teen Triple P to parents or not. It had been intended to use the children's responses from the school surveys to answer this question. Unfortunately, not enough parents of children who filled in the survey attended the group parenting program to allow these comparisons to be made. Also, the number of students in all four schools who had consent to complete the survey was less than had been hoped for. However, as many parents completed the telephone surveys on two separate occasions (before the groups commenced, and six months after they were completed), it was possible to compare the reports from parents who participated in the group program with parents from schools that had not offered the program.

Parents from the schools where the program had not been conducted were matched with parents who had participated. They were matched on socioeconomic status, their child's gender, plus the child's conduct scores as reported during the first interview. Differences were measured based on answers provided during the second parent telephone survey conducted at least six months after completion of the parent groups, and 12 months after the first telephone surveys were conducted.

In response to the question, 'In an overall sense, how difficult has your child's behaviour been in the last 12 months?', parents who had participated in the group program reported significantly less difficult behaviour than the matched comparison group. In response to the question, 'To what extent do you feel confident as a parent?', parents who had participated in the group program reported significantly greater confidence than the matched comparison group. Although there were no significant differences between the two groups on more specific questions about parenting confidence, there was a trend for parents who had participated in a group program to be more confident about managing their teenagers' moods. This was a positive trend, as the Teen Triple P program included a specific strategy aimed at helping parents manage teenagers' emotions in a positive and respectful way.

Program drop out

The program aimed for a retention rate of at least 85 per cent for each of the measures. The retention rate in the student sample was 80 per cent of those for whom active consent had been obtained and who completed the initial survey. The retention rate at the second parent telephone survey was 47 per cent. However, this was primarily a result of insufficient funds being available to complete the second telephone survey to the same level of parent interviewing as was accomplished initially. In retrospect, given the fixed amount of funds available, it may have been preferable to reduce the initial target to around 70-75 per cent of parents in the population. This would have left sufficient funds to conduct the second telephone interview with many more of these same parents. The retention rate for the parenting groups was 75 per cent in both the northern and southern locations. Although this was below the target set, it was still far better than many other group programs have reported.

Conclusions

Preliminary analysis of the Teen Triple P group parenting program showed positive outcomes for most participating parents. There were significant reductions of targeted risk factors, with some evidence of improvements still being maintained at six-month follow-up. The study was generally considered successful in that:

• it provided an empirical validation of an early intervention and prevention strategy that can be implemented in secondary schools; and it provided an empirical validation of an early intervention and prevention strategy that can be implemented in secondary schools; and
• it provided an empirica validation of it provided an empirical validation of resulted in the creation of an empirical database that can now be used to test questions of program effectiveness in preventing or reducing adolescent antisocial behaviour.

The next step is to collect and analyse data from students and parents over time, comparing schools that act as experimental and control groups. The study also needs to be replicated with larger samples over a longer time frame.

Group facilitators reported anecdotal evidence that many parents enjoyed participating in the group program and parents also reported good consumer satisfaction indicating that the program was appropriate for their needs and helped them to achieve their goals. However there is a clear challenge to be more successful with regard to recruitment and engagement. Although this was only a preliminary investigation, it became clear that greater ownership of the program by the participating school is desirable in order to maximise parent engagement, both with the parenting program and with the school more broadly.

Optimising the delivery of the group program by engaging parents at the time their children actually made the transition into high school was thought to be a critical aspect of the intervention. However, it was not possible to accomplish this in the present study because some groups did not commence until term 2 and several more were held over until term 3. More lead-up time to prepare schools at the end of the preceding year would therefore appear necessary to allow groups to commence in term 1.

A greater level of community awareness through features in local newspapers, radio and television appears warranted in order to 'seed the ground' more effectively so that greater parental awareness, interest and participation can be generated. The provision of additional incentives, such as lottery tickets, movie passes and restaurant vouchers for parents who are undecided about the value of attending the parent groups may also be worth trialling.

Staff employed in health, education and welfare agencies are currently undertaking training in Teen Triple P, and a number of additional trials of the program are either underway or in preparation. Currently, the program is being implemented and evaluated over a two-year period as a transition-to-high school intervention in 15 high schools in a relatively disadvantaged corridor in the northern suburbs of Brisbane. Interest in conducting further trials has been expressed in regions as widespread as Western Australia, Singapore, Germany, the United States, Iran and the United Kingdom.

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About the authors

Associate Professor Alan Ralph and Professor Matthew R Sanders are from the Parenting and Family Support Centre, School of Psychology, University of Queensland

This paper is taken from the report of research undertaken with the assistance of a grant from the Criminology Research Council.