The Triple P Positive Parenting Program
The Positive Parenting Program (Triple P) is a multilevel program to prevent and
offer treatment for severe behavioral, emotional, and developmental problems in
children aged 0 to 16 years through enhancing the knowledge, skills, and confidence
of parents. Triple P incorporates five levels of interventions on a tiered continuum
of increasing intensity. The rationale for this stepped-care strategy is that there are
different levels of dysfunction and behavioral disturbance in children and that parents
may have different needs and desires regarding the type, intensity, and mode of
assistance they require (Sanders, Markie-Dadds, & Turner, 1999). Triple P is designed
as a public health strategy, a population system of interventions that incorporates
different delivery modalities (group, individual, and self-directed).
Levels of Intervention
Level 1 is a form of universal prevention, and it delivers psycho educational information
on parenting skills to interested parents. Level 2 is a brief intervention of one or
two sessions, for parents of children with mild behavioral problems. Level 3 is a foursession
intervention, targets children with mild to moderate behavioral difficulties,
and includes active skills training for parents. Level 4 is an intensive, 8- to 10-session
*b Published as: Graaf, I. de, Speetjens, P., Smit, F., Wolff, M. de, & Tavecchio, L. (2008). Effectiveness of the Triple
P Positive Parenting Program on behavioural problems in children. A meta-analysis. Behaviour Modification, 32,
714 -35.
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parent training program for children with more severe behavioral difficulties or who
are at risk of developing such problems, which can be offered either individually or
in a group of parents. Parents are taught a variety of child management skills. This
intervention is a form of selective or indicated prevention in that the children are at
elevated risk levels of developing behavioral problems. Finally, Level 5 is an enhanced
behavioral family intervention (BFI) program for families in which parenting difficulties
are complicated by other sources of family distress (e.g., marital conflict, parental
depression, or high levels of stress; Sanders et al., 1999).
Standard Triple P, Group Triple P, Self-Directed Triple P
This indicated preventive intervention targets high-risk individuals who are identified
as having detectable problems but who do not yet meet diagnostic criteria for a
behavioral disorder. It should be noted that this level of intervention can target individual
children at risk or an entire population to identify individual children at risk. For
example, a group version of the program may be offered universally in low-income
areas, with the goal of identifying and engaging parents of children with severe
disruptive and aggressive behavior. Parents are taught a variety of child management
skills including providing brief contingent attention following desirable behavior,
how to arrange engaging activities in high-risk situations, and how to use clear,
calm instructions, logical consequences for misbehavior, planned ignoring, quiet time
(nonexclusionary timeout), and timeout. Parents are trained to apply these skills both
at home and in the community. Specific strategies such as planned activities training
are used to promote the generalization and maintenance of parenting skills across
settings and over time (Sanders & Dadds, 1982). As in Level 3, this level of intervention
combines the provision of information with active skills training and support.
However, it teaches parents to apply parenting skills to a broad range of target
behaviors in both home and community settings with the target child and siblings.
Here, it should be noted that there are three delivery formats at Level 4: Standard
Triple P, Group Triple P, and Self-Directed Triple P. Standard Triple P is an individual
10-session program for parents. Group Triple P is an 8-session program conducted
in groups of 10 to 12 parents with four 15- to 30-min follow-up telephone sessions
provided as additional support to the parents. Self-Directed Triple P is a 10-week selfhelp
program for parents and may be augmented by weekly 15- to 30-min telephone
consultations.
Level 4 intervention is indicated if the child has multiple behavior problems in a
variety of settings and there are clear deficits in parenting skills. If the parent wishes
to have individual assistance and can commit to attending a 10-session program,
the Standard Triple P program is appropriate. Group Triple P is appropriate as a
universal (available to all parents) or selective (available to targeted groups of parents)
prevention parenting support strategy; however, it is particularly useful as an early
intervention strategy for parents of children with current behavior problems. SelfDirected
Triple P is ideal for families who live where access to clinical services is poor
(e.g., families in rural or remote areas). It is most likely to be successful with families
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who are motivated to work through the program on their own and where literacy or
language difficulties are not present.
Theoretical Basis of Triple P
Triple P is based on social learning principles (Patterson, Reid, & Dishion, 1982). This
approach to the treatment and prevention of childhood disorders has the strongest
empirical support of any intervention with children, particularly those with conduct
problems (Kazdin, 1987; Sanders, 1996; Sanders & Dadds, 1993; Taylor & Biglan,
1998; Webster Stratton & Hammond, 1997). Furthermore, the Triple-P program is
based on research in child and family behavior therapy, developmental research on
parenting every day (Risley, Clark, & Cataldo, 1976; Sanders 1992, 1996), research
on social information-processing models (e.g., Bandura, 1977, 1995), research from
the field of developmental outcomes in children (e.g., Emery, 1982; Grych & Fincham,
1990; Hart & Risley, 1995; Rutter, 1985), and research on a public health perspective
to family intervention (e.g., Biglan, 1995; Mrazek & Haggerty, 1994; National Institute
of Mental Health, 1998).
Evaluation
The evaluation of Triple P needs to be viewed in the broader context of evaluations
of BFI. There is clear evidence that BFI is beneficial in children with disruptive
behavior disorders (Forehand & Long, 1988; Webster Stratton, 1994). Since 1978,
the intervention methods of Triple P have been subjected to a series of controlled
evaluations (Sanders & Dadds, 1993). Since that time, the intervention methods
used in Triple P have been subjected to a series of controlled evaluations using both
intrasubject replication designs and traditional randomized control group designs.
There is evidence that Triple P is an effective parenting strategy. Several studies
have shown that parenting skills training used in Triple P produces predictable
decreases in child behavior problems, which have typically been maintained over
time. Furthermore, clinically meaningful and statistically reliable outcomes for both
children and their parents have been demonstrated for the standard, self-directed,
telephone-assisted, group, and enhanced interventions. The population varied in the
different studies: parents of children with oppositional behavior, parents of children
with oppositional defiant disorder or conduct disorder, or parents reporting concerns
about disruptive child behavior. Finally, the program has also been successfully used
for several different family types, including two-parent families, single-parent families,
stepfamilies, maternally depressed families, maritally discordant families, and families
with a child with an intellectual disability (Sanders, Markie-Dadds, & Turner, 2003).
In those studies, the following variables were measured: child disruptive behavior,
parent–child interaction, parenting style and confidence, parental adjustment (depression,
anxiety, stress, self-esteem), parenting conflict, and relationship satisfaction.