CDC-Funded Triple P System Population Trial

Presented by:

Ron Prinz, University of South Carolina

U.S. Triple P System Population Trial

Principal Investigators: Ron Prinz & Matt Sanders

Funding Agency: Centers for Disease Control and Prevention (CDC)

Project Director: Cheri Shapiro

CDC Collaborating Officials: Dan Whitaker, Kendell Cephas

Key points for this presentation

• Description of the population trial—which is midway towards completion

• Illustration of the range of service providers and agencies involved in Triple P delivery

• Reflections on feasibility, acceptability, benefits for workforce

• Indications of population penetration thus far

Primary aims of the trial

• Reduce risk for child maltreatment• Reduce risk for child behavioral/emotional

problems• Implement all levels of the Triple P system to

promote positive parenting principles and strategies population-wide

• Test population penetration of the system• Assess impact at population level, rather than

with individuals at a clinical level

Background context of trial

• South Carolina context backdrop for the trial:– Significant funding cuts to social services and family

mental health services– Multiple disciplines and agencies serving target

population with little cross-coordination– Services often disconnected, relying on conflicting

approaches, having poor referral pathways– Service providers usually experienced but often

inadequately trained – Little prior exposure to evidence-based parenting

programs

Research design

• 18 counties located in South Carolina:– Each between 50,000 and 175,000– None with prior exposure to Triple P – Random assignment of counties:

(1) Triple P System

(2) Comparison (services as usual)

• Counties were matched on child abuse rates, poverty, and population size

Intervention Counties

Comparison Counties

South Carolina counties

Target population

All families:• with children in the birth to 7-year-old range• residing in the nine Triple P counties (or the nine

comparison counties)

Child maltreatment; Childhood Injuries

• Child maltreatment (birth to 7 years)– 17.5 investigated cases per 1,000 children– 6.5 founded (substantiated) cases per 1,000 children

• Child out-of home placements:3.8 placements per 1,000 children

• Child injuries (hospitalization and ER visits):615 visits per 10,000 children

However, official records grossly underestimate the extent of detrimental parenting practices

Coercive parenting practices

0

10

20

30

40

50

60

70

Threatening and notfollowing through

Shouting or becomingangry

Single spank More than one spank Spanking with object

Parenting practices (likely or very likely)

% o

f Par

ents

.

Coercive parenting practices

0

5

10

15

20

25

30

0 1 2 3 4 5

Number of coercive parenting practices (likely or very likely)

% o

f Pare

nts

.

Strategies to de-compartmentalize

• Avoid narrow linkage to child abuse– With practitioners– With parents

• Promote adoption of key Triple P assumptions• Disseminate all levels of Triple P

Avoid narrow linkage to child abuse

• With practitioners:– NO: “Triple P is being disseminated to prevent child

abuse.”– YES: “Triple P benefits parents and children in many

different circumstances.”

• With parents:– NO: “We are providing this parenting and family

support so that you don’t abuse your child in the future.”

– YES: “Good parenting and family support is for every parent.”

Promote key assumptions of Triple P

• Principle of sufficiency• Parenthood preparation is about promoting

flexibility, adaptation and capacity to change• Promote parental self-regulation, family-driven

goal setting, flexible delivery modalities and program intensities

• Multidisciplinary:– Practitioners from many disciplines who serve families– No discipline “owns” or controls Triple P

• As a result:– Involve many settings and service providers– Create multiple access points for families

Key assumptions continued

Levels of intervention

Universal Triple PUniversal Triple PLevel OneLevel One

Primary Care Triple PLevel three

Selected Triple PLevel Two

Standard Triple PLevel four

Enhanced Triple PLevel five

Universal Triple P

Triple PMedia strategy

De-stigmatize Validate

EmpowerNormalize

Strategies to increase public awareness

• Multiple publicity strategies– Press releases– Reporter-initiated news stories– Positive Parenting articles (Sanders)– Radio public-service announcements (PSAs)– Community events– School newsletters, other mailings– Bumper stickers, memorabilia

• Involve larger numbers of parents in lower program levels (e.g., parenting seminars)

Constructive media coverage

Level 2: Triple P Seminar Series

Seminar 1

The Power of Positive Parenting

Seminar 2

Raisingconfident, competent children

Seminar 3

Raising resilient children

90 minute large groupparenting seminarsInvitation to return

Communications strategy: Cumulative view

0

10

20

30

40

50

60

Q4 2003 Q1 2004 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005 Q3 2005

Time

Num

ber

Sanders Articles Press Releases Run Seminars & Community Events

Training of service providers

Providers of Triple P: Settings

• Mental health centers• Health clinics• County child welfare departments• Elementary schools• Preschools and daycare centers• NGOs and non-profit organizations• Churches and other religious institutions• Private sector

Triple P providers: Mental health system

• Therapists• Counselors• Home-visiting staff• Case managers, supervisors• Disciplines: social work, psychology, marriage

and family therapy, counseling, nursing, parent educator, psychiatry

Triple P providers: Child welfare system

• TANFF workers• Outreach and home-visiting staff• Case managers, supervisors

Profile of providers

0 5 10 15 20 25 30 35

Counselors, therapists

parent educators

social workers

Child care staff

nurses

other

administrators

educators

Pro

vider

s

Percentage

Profile of Triple P providers

Number of providers trained (through 2005) 568

Mean age of providers 43.5 yrs

% in present position greater than 5 years 42%

Ethnic backgrounds

European Americans

African Americans

Other racial/ethnic

54%

40%

6%Mean # of years in parent consultation work

Greater than 5 years

Greater than 10 years81%

59%

Training impact on providers’ parent consultation skills

1

2

3

4

5

6

7

Adequacy of training Confidence in parentconsultation skills

Overall level of selfefficacy

Pre Training Post Training Follow up

How satisfied were providers?1=very dissatisfied; 7=extremely satisfied

Overall Satisfaction with Training Mean (SD)

Part 1 of Training 6.24 (1.12)

Part 2 of Training (when providers asked to demonstrate competencies)

6.47 (1.14)

0

100

200

300

400

500

600

700

800

Start 2003 Mid 2003 Start 2004 Mid 2004 Start 2005 Mid 2005

Intervention Counties Comparison Counties

Growth in Triple P providers

Population assessment

• Not feasible to assess individual families• Need to rely on available population indicators• Archival data, even with inherent limitations, can

be useful• Telephone surveys of random households

provide population snapshots• Practitioners can provide useful data• Cost effectiveness analysis

Archival data

• Child maltreatment– Rates of investigated CM– Rates of founded (substantiated) CM

• Child injuries (hospitalizations and ER visits)• Child out-of-home placements

Tracking key constructs

• Child maltreatment– Rates of investigated CM– Rates of founded (substantiated) CM

• Child injuries (hospitalizations and ER visits)• Child out-of-home placements• Growth in number of Triple P providers• Awareness of Triple P in the population• Population reach: Parent exposure to Triple P

interventions

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

1999 2000 2001 2002 2003

Year

Intervention Counties

Comparison Counties

Num

ber o

f Pla

cem

ents

per

100

0 C

hild

ren

(0-7

Yea

rs)

Child out-of-home placements

Baseline Years

Telephone surveys of households

• Random telephone survey of households (families with at least on child 6 mos. to 7 yrs. old)

• 1,800 households in intervention counties• 1,800 households in intervention counties• Gauge awareness of Triple P• Other variables:

– Parenting practices– Child behavioral/emotional problems– Parental accessing of services

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

2003 2004 2005

Intervention Counties Comparison Counties

Per

cent

age

of

Res

pond

ents

Parental awareness of Triple P

Population reach of Triple P to date

• Eligible population: 85,000 families with a child birth to 7 years old

• To date: 12,197 families have received direct services via Triple P programming

• 6.8-11.7% receiving Triple P interventions per year (excluding media exposure)

Some lessons learned thus far

• Front-line staff working in different agencies and settings want collaboration and cross-agency communications

• Triple P offered common terms, intervention methods, and system without requiring complex interagency agreements

• Building up a positive contagion effect takes:– Patience– Multiple strategies– Sustaining of community engagement

Conclusions thus far

Population trial has demonstrated:– Feasibility of disseminating the entire Triple P system

at one time– Substantial uptake despite community infrastructure

problems, fractured delivery systems– Growing awareness of Triple P among parents

throughout the population– Potential detectability of population impact through

archival data systems

Conclusions

• Biggest line item of service delivery is personnel:– Dissemination of the Triple P system is not requiring

the addition of service delivery personnel– Using the existing workforce– Training, parenting resource materials, consultation

and support

• The U.S. Triple P System Population Trial is providing a unique opportunity to examine long-term, cumulative impact on the population and on service providers.

Thank you for your attention

Longitudinal tracking of providers

• To assess numbers of families receiving Triple P• Telephone interview 6 months after Triple P training

– 526 providers interviewed to date– Participation rate: 94.3%

• Telephone interview 18 months after Triple P training– 325 providers interviewed to date– Participation rate: 88.3%

0

5

10

15

20

25

1999 2000 2001 2002 2003

Year

Intervention Counties

Comparison Counties

Rates of investigated cases of child maltreatment

Baseline Years

0

1

2

3

4

5

6

7

8

1999 2000 2001 2002 2003

Year

Intervention Counties

Comparison Counties

Num

ber

of Founded

Cas

es P

er 1

,000

Childre

n A

ges

0 - 7

Rates of founded cases of child maltreatment

Baseline Years

0

100

200

300

400

500

600

700

1999 2000 2001 2002 2003

Year

Visi

ts p

er 1

0,00

0 C

hild

ren

(0-7

Yea

rs)

Intervention Counties

Comparison Counties

Child injuries (hospitalizations and ER visits)

Baseline Years