The Role of Parenting Programmes in the Prevention of Child Maltreatment

The Role of Parenting Programmes in the Prevention ofChild Maltreatmentap_12 199..209

Matthew Sanders1 and Aileen Pidgeon2

1School of Psychology, University of Queensland, St Lucia, Brisbane, and 2School of Social Sciences, Bond University, Gold Coast, Queensland, Australia

Child maltreatment is a major worldwide concern and continuing high rates of abuse demand action. This article examines the role of parentingprogrammes as a strategy to prevent child maltreatment in the population as a whole and also as a targeted intervention for parents who haveabused, or are at risk of abusing, their children. We argue that a blend of universal and targeted interventions is needed to reduce the prevalenceof child maltreatment. Parenting interventions that concurrently target positive parenting and effective child management skills, dysfunctionalparental attributions, and increasing parents’ capacity to regulate their emotions are particularly useful. A variant of the Triple P—PositiveParenting Program, known as Pathways Triple P, is discussed to illustrate the value of this approach. Contextual factors that need to be addressedin working with child protection cases are also discussed. The role of training and supervision is discussed in the context of disseminatingevidence-based parenting programmes, and future directions for research are presented.

Key words: child abuse; parenting; prevention; Triple P.

Theoretical, Clinical, and Empirical Basis ofthe Pathways Triple P (PTP) for Parents atRisk of Harming Their Children

The maltreatment of children by their parents or caregivers is amajor public health and social welfare issue (World HealthOrganization (WHO), 2009). Parents (including natural, step,and de facto) account for over 70% of all persons believed tobe responsible for perpetrating the majority of substantiatedcases of child maltreatment (Australian Institute of Health andWelfare (AIHW), 2005). Child maltreatment can be broadlydefined as ‘a failure to protect the child from harm and a failureto provide the positive aspects of a parent-child relationship thatcan foster development’ (Wekerle & Wolfe, 1996, p. 492). Thenumber of official reports of child maltreatment in mostWestern countries continues to rise each year (AIHW, 2008; USDepartment of Health and Human Services, 2008). In Australia,all key indicators of child abuse have increased annually for thepast 7 years, including child abuse notifications, substantiatedabuse cases, children on care and protection orders, and thenumber of children in out-of-home care (AIHW, 2008). Forexample, the number of child protection notifications almost

tripled from 107,134 in 1999–2000 to 309,517 in 2006–2007,with 58,563 cases of child maltreatment being substantiated in2006–2007. Rates of children aged 0–16 years who were thesubject of a child protection substantiation in 2006–2007 rangedfrom 2.4 per 1,000 in Western Australia to 9.3 per 1,000 in theNorthern Territory (AIHW, 2008).

The purpose of this article is to define child maltreatment andto briefly explore its nature and significance. This article willalso explore the potential role of parenting programmes inreducing the prevalence of child maltreatment and introducea cognitive–behavioural parenting intervention, known as Path-ways Triple P (PTP), as an example to illustrate the complexitiesof working with parents at risk of harming their children.

Significance of Child Maltreatment

Child maltreatment substantially contributes to child mortalityand morbidity and has long-lasting effects on mental health,drug and alcohol misuse, risky sexual behaviour, obesity, andcriminal behaviour that persist into adulthood (Hussey, Chang,& Kotch, 2006; Widom, White, Czaja, & Marmorstein, 2007).The evidence indicates that maltreated children are more likelyto suffer antisocial outcomes including externalising behaviours,oppositional behaviour, conduct disorders, and delinquency(Kotch et al., 2008; Lansford, Berlin, Bates, & Pettit, 2007;Maas, Herrenkohl, & Sousa, 2008; Sternberg, Lamb, Guterman,& Abbott, 2006), as well as internalising problems such asanxiety, depression, withdrawal, and post-traumatic stress dis-order (Cerezo & Frias, 1994; Haugaard, Reppucci, & Feerick,

Correspondence: Matthew Sanders, School of Psychology, Universityof Queensland, St Lucia, Brisbane, QLD 4072, Australia. Fax: +61 7 33656724; email: [email protected]

Accepted for publication 20 September 2010

doi:10.1111/j.1742-9544.2010.00012.x

What is already known on this topic

1 Problem of child maltreatment.2 Averse child outcomes.

What this article adds

1 Importance of parenting intervention.2 Prevention of child maltreatment.

Australian Psychologist 46 (2011) 199–209© 2011 The Australian Psychological Society

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1997; McHolm, MacMillan, & Jamieson, 2003; Widom, 1999;Widom, Dumont, & Czaja, 2007). Children and youth whoreceive high levels of negative parenting practices (i.e., physicalpunishment and yelling) are more likely to be involved inaggressive behaviours (Canadian Centre for Justice Statistics,2002), and children who experience physical abuse may exhibitlow self-esteem, deficits in social competency, difficulty formingrelationships with peers (Bolger, Patterson, & Kupersmidt,1998; Fergusson, Boden, & Horwood, 2008), self-harmingbehaviours (Yates, Carlson, & Egeland, 2008), and suicidal ide-ation (Afifi et al., 2008; Evans, Hawton, & Rodham, 2005).Other sequelae among victims of maltreatment include cogni-tive delays and learning difficulties and long-term deficits ineducational achievement (Boden, Horwood, & Fergusson, 2007;Haugaard et al., 1997; Lansford et al., 2007), substance abuse(Widom, White, Czaja, & Marmorstein, 2007), and an increasedrisk of personality and eating disorders (Johnson, Cohen,Kasen, & Brook, 2002; Johnson et al., 2001). In the long term,studies of maltreatment have shown that the experience ofabuse has important effects on adult functioning in the areas ofphysical and mental health, use of substances, interpersonalrelationships, criminality, and parenting (Lansford et al., 2007;Mullen, Martin, Anderson, Romans, & Herbison, 1996). In sum,the burden of mental ill health resulting from child maltreat-ment is substantial (Hussey et al., 2006).

The WHO (2006) report on prevention of child maltreatmenthighlighted the need for this issue to achieve the prominenceand investment in prevention and epidemiological monitoringthat is given to other serious public health concerns with life-long consequences affecting children—such as HIV/AIDS,smoking, and obesity. The report recommended expansion ofthe scientific evidence base for the magnitude, effects, and pre-ventability of child maltreatment. The high prevalence rates andthe salient social impact of physical abuse on children, adults,families, and the larger society demonstrate the importance ofpreventing child maltreatment. In addition, the high burdenand serious long-term consequences of child maltreatmentwarrant increased investment in preventive and therapeuticstrategies from early childhood. Preventing a complex problemsuch as child abuse is challenging for both researchers andclinicians.

A more recent WHO report on violence prevention (WHO,2009) identified parenting programmes as being essential tofoster safe, stable, and nurturing relationships with parents andother caregivers. Early parenting interventions such as Nurse–Family Partnership (Olds et al., 1997) targeting high-risk youngfirst-time mothers and the Triple P—Positive Parenting Program(Sanders, 2008), which adopts a whole of population approachto promoting competent parenting, were identified as promisingapproaches to prevent child maltreatment. However, this blend-ing of indicated and universal parenting interventions needsto address what is known about the determinants of childmaltreatment.

Determinants of Child Maltreatment

Although no specific variable has been identified as necessaryand sufficient for the development of physically abusive behav-iour in parents (Berger, 2005; Kolko & Swenson, 2002; Svedin,

Wadsby, & Sydsjo, 2005), the development of an ecologicalmodel of parenting has provided a useful framework to helpunderstand the multi-factorial nature of child maltreatment(Belsky, 1980; Sidebotham, 2001). The ecological model con-ceptualises child maltreatment as multiply determined by theinterrelationship among ontogenetic (individual), microsystem(family), exosystem (community), and macrosystem (culture)levels, and that these determinants modify each other (Belsky,1980; Sidebotham, 2001).

Discussion as to the role of exosystem and macrosystem vari-ables contributing to child maltreatment continues to be pre-vention focused (Belsky, 1980; Sidebotham, Heron, & Golding,2002). In this framework, the definitions of child maltreatmentfocus on what is inappropriate not only at the individual level(i.e., discrete abuse events) but also at the dyadic level namelycoercive, hostile parent–child interactions (Dong et al., 2004;Wekerle & Wolfe, 1998). Adopting this view of child maltreat-ment as part of an ongoing problem in the parent–child rela-tionship involves targeting the factors that contribute tonegative parent–child relationships while promoting positiverelationship factors (Wekerle & Wolfe, 1998). Specifically, theseinclude increasing parents’ confidence and competence to dealwith children’s misbehaviour by targeting parents’ maladaptivecognitions and patterns of behaviours that may be precursors toand serve to maintain the abusive acts (Sanders & Cann, 2002;Snyder & Patterson, 1995).

Models that focus on the ontogenetic and microsystemvariables as the basis for coercive or abusive parent–childinteractions provide a useful framework (Azar & Weinzierl,2005; Pidgeon & Sanders, 2009; Wolfe, 1999). These modelsinclude the attributional–behavioural, cognitive–behavioural,and family systems models—all of which are variations ofcognitive–social learning models. The application of thesemodels emphasising reciprocal influences between parents andchildren is important in evaluating how parents respond tochildren’s behaviour and the processes through which parents’responses are generated.

Parenting and Child Maltreatment

The interaction between the emotional, behavioural, and cog-nitive adjustment of parents—especially parents’ maladaptivecognitions, anger, and coercive parenting practices—provides aframework for understanding the development of abusiveparenting practices (Milner & Chilamkurti, 1991; Pidgeon &Sanders, 2009). Physically and emotionally abusive parenting isin part a result of parents’ escalated anger and aggressiveresponse to children’s behaviour (Knutson & Bower, 1994;Pidgeon & Sanders, 2009). A large percentage of reportedabusive incidents are the result of parent’s attempts to disciplineor control the behaviour of their child (Straus & Gelles, 1990).The existing literature emphasises parents’ inability to manageanger as a significant contributing factor in their use of harshdiscipline (Action & During, 1992; Mammen, Kolko & Pilkonis,2002; Nomellini & Katz, 1983) and incidents of child abuse(Ammerman, 1990; Petersen, Gable, Doyle, & Ewigman, 1997).When parents react primarily in anger to children’s behaviour,they are at greater risk of abusive behaviour (Rodriguez &Green, 1997).

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Maltreating parents have been shown to differ from non-maltreating parents in their inability to cope with anger-provoking situations (Rodriguez & Green, 1997). Kadushin andMartin’s (1981) study of abusive parents suggests that abusiveparents are more likely to perceive their child’s behaviour asprovocative and respond with anger. Consequently, anger is acommon factor underlying the act of parents physically abusingchildren (Kolko, 1996; Mammen et al., 2002). Researchers con-cerned with child maltreatment have shown that parents whoare at risk of maltreating their children often reveal maladaptivecausal reasoning processes in their explanations for children’sproblem behaviours (Dopke, Lundahl, Dunsterville, & Lovejoy,2003; Milner, 2003; Pidgeon & Sanders, 2009). Often, the causalattributions at-risk parents offer to explain their children’s dif-ficult behaviours seem to reflect not only the child’s behaviourbut also the characteristics of the parent or the family circum-stances (Dadds, Mullins, McAllister, & Atkinson, 2003; Joiner &Wagner, 1996). Researchers have consistently observed thatparents’ dysfunctional attributions indirectly contribute to childmaltreatment by increasing parent–child interactions character-ised by intense parental anger where parents tend to overreactand use more severe discipline strategies such as threats, yelling,hitting, grabbing, and pushing (Dix, Ruble, & Zambarano, 1989;Nix et al., 1999).

There has been a major advance in the last decade in theknowledge of parenting cognitions and their relationship toparental affect and behaviour (Azar & Weinzierl, 2005; Dix,Reinhold, & Zambarano, 1990; Kolko & Swenson, 2002;Sanders et al., 2004). Research has been primarily concernedwith how parents’ cognitive disturbances increase the potentialfor anger and aggression in parenting (Bugental et al., 2002;Pidgeon & Sanders, 2009). These cognitive disturbances includemaladaptive schema and unrealistic expectations regarding chil-dren and parent–child interactions, negative attributional bias ininterpreting child behaviour, and negative parenting behaviour(Grusec & Mammone, 1995; Miller & Azar, 1996; Pidgeon &Sanders, 2009; Sanders et al., 2004). Research has found attri-butional differences between maltreating parents, parents at riskof maltreating children, and not at-risk parents (Chavira, Lopez,Blacher, & Shapiro, 2000; Dadds et al., 2003; Pidgeon &Sanders, 2009; Slep & O’Leary, 1998). Existing evidence indi-cates that maltreating parents tend to hold a suit of distortedbeliefs and unrealistic expectations regarding their children’sbehaviour and their own interactions with their children (Black,Heyman & Slep, 2001). Pidgeon and Sanders (2009) noted thatparents at risk of maltreating their children were more prone toattributing the cause of children’s misbehaviour to internal andstable child characteristics, and they were also more likely toattribute intent and blame to the child for the misbehaviour.These negative attributions have been associated with overre-active and coercive parenting (Bugental, 2000), angry feelingsin parents (Slep & O’Leary, 1998), and the use of harsh pun-ishment (Azar, 1997).

Pidgeon and Sanders (2009) examined the differences in thelevel of negative attributions, depression, anxiety and stress,dysfunctional parenting practices, and perceived child behav-iour problems of clinically angry, at-risk of child maltreatment(CA) parents, and non-angry, not at-risk of child maltreatment(NA) parents. Participants were 82 families with a child aged

2–7 years. The results showed significant differences betweenthe CA and NA mothers’ anger-intensifying attributional stylefor both negative and ambiguous negative child behaviour andanger-justifying attributions for negative parenting behaviour.The CA mothers, relative to NA mothers, also reported beingmore depressed, stressed and anxious, and using more dysfunc-tional parenting practices with their children. In addition, theCA participants identified significantly more problem behav-iours and intensity of problem behaviours in their children thandid NA participants. The results from this study lend support tothe notion of targeting parents’ anger-intensifying and anger-justifying attributions in order to enhance outcomes in parent-ing interventions and subsequently reduce the risk of childmaltreatment.

How Parenting Interventions Can PreventChild Maltreatment

Addressing the deficits in child management skills often foundin abusive parents may be among the most important factors inpreventing child abuse (Black et al., 2001). Parenting deficitsinclude the use of coercive and punitive parenting strategiesthat intensify and perpetuate child behaviour problems, andthereby increase the likelihood of child maltreatment in thefamily. Behavioural family interventions (BFIs), based on sociallearning principles, are increasingly considered an essentialcomponent of child abuse prevention and treatment interven-tions (Chalk & King, 1998; Repucci, Britner, & Woolard, 1997).Within BFIs, parents are typically taught to increase positiveinteractions with their children and to reduce the use of coer-cive and inconsistent parenting practices. These programmesare associated with large effect sizes (Serketich & Dumas, 1996),which often generalise to a variety of home and communitysettings (McNeil, Eyberg, Eisenstadt, & Newcomb, 1991;Sanders & Dadds, 1982), are maintained over time (Long, Fore-hand, Wierson, & Morgan, 1994), and are associated with highconsumer satisfaction (Webster-Stratton, 1989). These pro-grammes also produce improvements on measures of parentaladjustment such as depression, stress, and marital conflict (e.g.,Sanders & McFarland, 2000; Sanders, Markie-Dadds, Tully, &Bor, 2000). A variety of delivery formats have been demon-strated to be effective, including individually administered face-to-face programmes (e.g., Forehand & McMahon, 1981), groupprogrammes (e.g., Webster-Stratton, 1990), telephone-assistedprogrammes (e.g., Connell, Sanders, & Markie-Dadds, 1997),and self-directed programmes (e.g., Markie-Dadds & Sanders,2006). Given that abusive parents often report significantconduct problems in their children, it is important that parent-ing interventions are included in any comprehensive preventiveintervention designed to prevent child maltreatment.

An example of a whole-of-population approach to parentingintervention is the Triple P—Positive Parenting Program devel-oped by Sanders and colleagues at the University of Queensland(Sanders, 2008). Triple P is a multi-level system of parentingintervention. The evidence base supporting the effectivenessand efficacy of Triple P is documented elsewhere (see Sanders,2008), and several independent meta-analyses have concludedthat Triple P is effective at reducing rates of child behaviourproblems and increasing parenting competence across different

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countries and cultures (e.g., de Graaf, Speetjens, Smit, de Wolff,& Tavecchio, 2008; Nowak & Heinrichs, 2008). We now turn toa derivative version of Triple P (PTP), which was designed forparents at risk of harming their children. This is used as anexample to highlight the potential advantages of tailoring aparenting intervention to a high-need under-served parentgroup at risk of child maltreatment.

In addition to PTP, it is important to note that there are a smallnumber of existing child maltreatment prevention and inter-vention programmes that have shown some degree of effec-tiveness in combating child maltreatment. Examples of suchinterventions include the Nurse–Family Partnership (Oldset al., 1997), the Chicago Child Parent Centers (Reynolds,Temple, Robertson, & Mann, 2001), and Parent–Child Interac-tion Therapy (Zisser & Eyberg, 2010). However, these existingchild maltreatment interventions are typically highly targeted,expensive interventions that tend to be intense, independentlyadministered, and single-delivery modality interventions. Thepurpose of the current article is to put forward the case foran intervention that blends targeted and universal elements,and accordingly, the present article will focus on the PTPintervention.

Overview of PTP

PTP is an adaptation of Group Triple P (Sanders, 2008). GroupTriple P is part of a multi-level system of parenting and familysupport intervention using a self-regulation framework (seeSanders, 1999, 2008) that is a strategy for improving parentingefficacy and competence at a population level. The levels ofintervention in the Triple P system vary in intensity on a tieredcontinuum of increasing strength and range from Level 1 Uni-versal Triple P (e.g., media campaign) to Level 5 EnhancedTriple P interventions for families where parenting difficultiesare complicated by other sources of family adversity includingmarital conflict and parental mood disturbance (see Sanders,2008, for a detailed overview of the Triple P system).

Group Triple P consists of four 2-hr parent group trainingsessions. Parents receive a copy of the Every Parent’s Group Work-book (Sanders, Markie-Dadds, & Turner, 2001) containing thekey learning principles of the programme and exercises to becompleted in-session and between sessions. The Group Triple Pprogramme takes 4 weeks to complete, and it involves teachingparents 17 core child management strategies. These strategiesaim to promote positive, caring relationships between parentsand their children. Ten strategies aim to promote children’scompetence and development (e.g., praise, engaging activities,incidental teaching) by increasing parents’ competence and con-fidence not only in encouraging their children’s desirablebehaviour but also in teaching their children new behavioursand skills. Seven strategies aim to help parents develop effectivemanagement skills for dealing with a variety of childhoodbehaviour problems and common developmental issues (e.g.,setting rules, logical consequences, quiet time, time out;Sanders, Montgomery, & Brechman-Toussaint, 2000).

The Group Triple P programme teaches parents a plannedactivities routine that aims to enhance the generalisation andmaintenance of parenting skills. Planned activities traininginvolves teaching parents how to anticipate and prepare for

high-risk times where children can be tired or bored (e.g., plan-ning of age-appropriate activities). Parents are taught to applyparenting skills to a broad range of target behaviours in bothhome and community settings with the target child and allrelevant siblings. Parents learn to set and monitor goals forbehaviour change and to enhance their skills in observing theirchild’s and their own behaviour. Active training methods suchas modelling, rehearsal, practice, feedback, and goal setting areused to teach specific parenting skills throughout the pro-gramme within a self-regulatory framework as described bySanders (1999).

PTP specifically targets (1) parents’ anger-intensifying attribu-tional style for their child’s negative behaviour, (2) parents’anger-justifying attributions for their negative parenting behav-iour, and (3) parents’ anger management deficits. PTP consistsof four 2-hr group sessions that specifically address the two riskfactors associated with child maltreatment—dysfunctional attri-butions for parent–child interactions and parents’ dysfunctionalanger and anger-related behaviour. After the group interven-tion, parents participate in four individual telephone consulta-tions (15–30-min duration each). Parents receive a copy of twoworkbooks, Avoiding Parent Traps and Coping With Anger, thatoutline the principles taught in the two modules (focusing onthe risk factors countering parents’ misattributions for parent–child interactions and anger management). These parent work-books have been published together with the existingpractitioner’s workbook (see Pidgeon & Sanders, 2005; Sanders& Pidgeon, 2005a, 2005b, 2005c).

In PTP, parents are taught a variety of skills aimed at chal-lenging and countering their maladaptive attributions forparent–child interactions and changing any negative parentingpractices they are currently using in line with these attributions.The attributional retraining strategies focus on teaching parentshow to counter their misattributions regarding their child’snegative behaviour and their negative parenting behaviourtowards their child. This involves teaching parents how to chal-lenge their misattributions and generate more benign attribu-tions regarding their child’s negative behaviour and generateless anger-justifying attributions for their own negative behav-iour. These sessions teach parents how to counter and alter notonly their anger-intensifying attributional style for their child’sbehaviour but also their anger-justifying attributions for theirnegative parenting behaviour. Parents are invited to participatein group discussion and within-session exercises designed tohelp them identify the reasons why parents can react in nega-tive ways towards children, the impact of negative or harshdiscipline practices on children, and the causes of their ownnegative behaviour towards their child. The exercises are alsodesigned to teach parents how to prevent anger escalation andnegative parenting practices, a process that involves teachingparents to challenge and control their anger-intensifying attri-butions and mistaken explanations for their child’s misbehav-iour. Parents are also introduced to a variety of physical,cognitive, and planning strategies to manage their anger. Theconcept of planning ahead in high-risk situations is alsoaddressed, and parents developed their own coping plans forthese events.

The second module of PTP consists of two anger managementsessions. In these sessions, parents are introduced to the



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emotion of anger and its physical effects, and parents are pro-vided with a variety of techniques and strategies for becomingphysically and mentally relaxed. Parents are also introduced tocognitive therapy as it applies to anger management thatincludes catching unhelpful thoughts, developing alternativecoping statements in anger arousing situations, and challengingthoughts that lead to aggressive responses. Identifying high-risk anger situations and developing coping plans to manageanger in these situations are also covered. PTP concludeswith individual telephone consultations with one of the groupfacilitators.

Evidence for PTP

Sanders et al. (2004) examined whether PTP enhances clinicaloutcomes for either parent or child in families at risk of childmaltreatment compared with Group Triple P. Participants were98 families selected on the basis of having a child aged 2–7 years,where the parent had access to the child on a part-time orfull-time basis (at least 2 days per week), and if they met one ofthe following criteria: (1) the parent had received at least onenotification to the Department of Community Services forpotential abuse or neglect of their children (the notificationneed not have been substantiated) and/or (2) the parentexpressed concerns regarding difficulty in controlling theiranger in relation to their child’s behaviour and scored within anelevated range on three of the four selected subscales of theState–Trait Anger Expression Inventory (Spielberger, 1991). Theoverall exclusion criterion was if the families at the time ofscreening were receiving intensive ongoing family therapy orpsychotherapeutic intervention targeting parenting or childbehaviour, and/or parents had a child with a major medicalcondition, major psychiatric illness, or significant intellectual orphysical impairment. Parents participating in both versions ofthe Triple P BFIs showed significant improvements across a widerange of indices of family functioning, with families receivingthe PTP intervention showing greater improvements on two keyindicators of abuse potential both in the short and long terms(i.e., 6-month follow-up), namely anger-intensifying attribu-tions and child-blame attributions. Mothers receiving the PTPintervention reported significantly lower anger-intensifyingattributional style for both negative and ambiguous negativechild behaviour, and significantly lower child-blame attributionsfor negative parenting behaviour in the short term, and main-tained the intervention gains long term. Participants in bothconditions reported comparably high levels of consumer satis-faction with their respective interventions. However, mothers inthe PTP group reported the attributional retraining session asthe most useful of the 12 sessions in the intervention.

In further support of the efficacy of PTP, Wiggins, Sofronoff,and Sanders (2009) examined the effects of PTP on 60 parentswho met the inclusion criteria of borderline to clinically signifi-cant relationship disturbance and child emotional and behav-ioural problems. Participants were randomly allocated into PTPor a wait-list control group. PTP was delivered in a group formatfor 9 weeks and consisted of parent skills training and cognitivebehaviour therapy targeting negative attributions for childbehaviour. Participants in the PTP condition reported signifi-cantly higher levels of parent–child relationship quality from

pre- to post-intervention compared with participants in thecontrol group, with benefits maintained at 3-month follow-up.Participants in the PTP condition also reported a significantlygreater increase in parent–child attachment and parenting con-fidence and involvement than those in the control group, aswell as a significantly greater reduction in the use of dysfunc-tional parenting practices such as laxness, verbosity, andoverreactivity. Additionally, blameworthy and intentional attri-butions for child behaviour and child externalising behaviourproblems from pre- to post-intervention were maintained at3-month follow-up. In sum, the Wiggins et al. (2009) studyshowed positive effects for improving important aspects of theparent–child relationship, and when combined with the find-ings from Sanders et al. (2004), there is strong support for thenotion that a parenting intervention is a powerful method ofsuccessfully reducing child abuse.

Challenges in Working With Parents at Risk ofHarming Their Children

The delivery of parenting interventions with parents at risk ofmaltreating their children raises some special challenges forprofessionals. Many of these parents can be guarded and suspi-cious of professionals offering parenting support, and profes-sionals need to concurrently address both the content of theprogrammes and the process issues that inevitably arise in deliv-ering the programme. Table 1 summarises these process prob-lems and provides suggestions for dealing with them in thecontext of a parenting intervention. Table 2 outlines some ofthe key principles of effective consultation that have informedthe development of PTP.

Training

All effective interventions addressing child maltreatment requirea system of training that is both cost-effective and sustainable toupskill the workforce. Many potentially useful evidence-basedprogrammes remain inaccessible to professionals and parentsbecause they are not disseminated effectively. The model ofprofessional training developed for Triple P has reached over57,000 practitioners in 22 countries. In designing the trainingprogramme, the following principles were adhered to.

Active skills-based training

To be effective, the programme adopted a skills-based trainingapproach that involved a combination of didactic input, videoand live demonstration of core consultation skills, small groupexercises to practise skills, problem-solving exercises, coursereadings, and competency-based assessment. This assessmentincluded a written quiz and a live or videotaped demonstrationby participants to show that they had mastered core competen-cies specific to the level of training undertaken.

Brevity

If the dissemination of evidence-based programmes weredesigned as a university-based course, employers would be



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reluctant to release staff for training. Consequently, Triple Ptraining was designed to be relatively brief to minimise disrup-tion to staff schedules and to reduce the need for relief workerswhile staff undertook training. The training experience was

structured to provide background reading, attendance at a 5-daytraining course (based on the level of intervention), and atten-dance at a 1-day accreditation workshop 8–12 weeks after initialtraining.

Table 1 Process issues and problems with engagement with maltreating parents

Issue Description Possible solutions

Disruptions to

involvement in

programme

Participants’ lives can be chaotic and unpredictable,

creating obstacles to attending groups and

keeping appointments for home visits

• Allow flexibility in the programme

• Allow participants to switch groups if required

• Be prepared to reschedule home visits a number of times while

maintaining rapport with participant

Barriers to attending

group sessions

Poor planning and organisational skills; transport

problems

• Remind participants frequently about group sessions and home visit

appointments

• Provide transport assistance (e.g., taxis, bus)

Rapport building Participants may be reluctant, resentful, suspicious,

and hostile

• Normalise the process of attending a parenting programme and point out

benefits to participants

• Allow sufficient time for first home visits to build a relationship with

participant in a relaxed atmosphere

Motivational issues There is a high incidence of disruption in

participants’ lives, and attending group sessions is

a significant demand on their time

• Build rapport with participants

• Add small material incentives (e.g., lucky dip)

• Phone participants each week to encourage attendance at next session

• Provide certificates to those who complete the programme (including

home visits and assessment)

Literacy issues Participants may have very poor literacy, particularly

from non-English speaking backgrounds; they find

it difficult to complete questionnaires and written

exercises during sessions

• Give more one-on-one attention (e.g., read out questionnaires question by

question) in group sessions

• Co-facilitators assist in written exercises

Table 2 Principles of effective parent consultation in child maltreatment

Principle Description

Programmes should protect children Parenting programmes should have mechanisms in place for ongoing management of continuing risk to

children while parents are learning skills.

Programmes should empower families Parenting skills programmes aim to enhance families’ ability to solve problems for themselves.

Programmes that promote dependency are destructive. In most instances, families have lesser need for

support over time. Successful parenting programmes build on the existing competencies of family

members.

Programmes should build on existing

strengths of families

It is assumed that individuals are capable of becoming active problem solvers, even though their previous

attempts to resolve problems may not have been successful.

Programme goals should address known

risk variables

A common goal in most effective programmes is to improve family communication, problem solving,

conflict resolution, and specific parenting skills.

Programmes should be designed to

facilitate access

It is essential that programmes are delivered in ways that increase, rather than restrict, parents’ access to

services. Programmes may take place in many different settings such as clinics, hospitals, homes,

kindergartens, preschools, schools, and worksites.

Programmes should be timed

developmentally to optimise impact

Parenting programmes should be timed to the age and developmental level of the target. Programmes for

particular problems that are delivered at the correct developmental level may have a greater impact

than programmes delivered at another time in the life cycle.

Programmes should emphasise the

importance of the therapeutic

relationship

The therapeutic relationship between the clinician and relevant family members is critical to the

effectiveness of parenting programmes. Clinical skills such as empathy, rapport building, effective

communication, and session structuring are necessary for establishing a good therapeutic relationship.

Programmes should be gender sensitive Parenting skills programmes have the potential to promote more equitable gender relationships within the

family. Interventions should avoid promoting traditional gender stereotypes and power relationships,

and it should aim to promote equality between partners.

Programmes should have an explicit

scientifically validated theoretical basis

Parenting skills programmes should be based on coherent and explicit theoretical principles. The

mechanisms purported to underlie the improvement must also be demonstrated to result in changes

and be responsible for the observed improvements.

Programmes should be culturally

appropriate

Programmes should be tailored in such a way as to respect and not undermine the cultural values,

aspirations, traditions, and needs of different ethnic groups.



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Data responsiveness

An evidence-based programme must continue to evolve on thebasis of evidence. Hence, every Triple P course is carefully evalu-ated and feedback elicited on the training course content,quality of presentation, opportunities for active participation,and practitioners’ overall consumer satisfaction. Practitionerfeedback is incorporated into ongoing revisions of the trainingprogramme.

Viability of the training programme

A training cost structure that is financially viable and affordablefor agencies and individuals is essential. Triple P was originallyconducted by training staff from the Parenting and FamilySupport Centre at the University of Queensland. However, asdemand for training increased, a new entity was established tomanage all aspects of the dissemination of Triple P. This entity,Triple P International, was licensed by the University of Queen-sland to conduct training on its behalf on a self-sustaining basis.Hence, the research and development functions were consoli-dated within the university, and the training and disseminationfunctions became part of Triple P International, an organisationthat handles Triple P publications, video production, and pro-fessional training and dissemination.

Eligibility to participate

The Triple P system of intervention uses a wide range of pro-fessions in the health, education, and social service sectors todeliver the programme. The only requirement is that partici-pants should have professional training in psychology, medi-cine, nursing, social work, counselling, or another related fieldthat has provided prior exposure to principles of child develop-ment. Most training courses involve an interdisciplinary mix,and they bring together participants with quite diverse back-grounds, theoretical orientations to working with families, andvaried clinical experience. The training is cognitive–behaviouralin theoretical orientation. We have found that prior exposure tothis orientation is not essential for participants to successfullyimplement the programme.

Course requirements

To successfully complete a training course to the level of becom-ing an accredited PTP provider involves the following: comple-tion of set readings; attendance at a training course; andcompletion of accreditation requirements, including a shortanswer quiz addressing knowledge of theory, programmecontent, and process issues involved in consulting with families.Only practitioners who complete accreditation requirementscan be considered properly trained to deliver the intervention.

Selection, training, and accreditation of trainers

Courses are typically conducted by clinical or educational psy-chologists with training and experience in the field of BFI.Professionals invited to become trainers undergo an intensive2-week training programme. To maintain intervention integrity,

it is essential that the training process itself is carefully con-trolled to minimise programme drift at source. To prevent pro-gramme drift, all trainers use standardised materials (includingparticipant notes, training exercises, and training videotapesdemonstrating core skills) and adhere to a quality assuranceprocess. Trainers become part of a trainer network and have toadhere to a quality assurance process as part of the maintenanceof their accreditation.

Dissemination

The effective dissemination of Triple P (including PTP) reliesheavily on ensuring that competency-based training of provid-ers is supported by organisational-level advocacy, leadership,and administrative support for practitioners trained to imple-ment the programme. Organisational support assists practitio-ners in sustaining their use of evidence-based practices (Sanders& Murphy-Brennan, 2010). Providing information to policyadvisors and key stakeholders assists organisations in preparingfor the introduction of Triple P (e.g., choosing the right staff totrain) and subsequent implementation of the programme withfamilies (e.g., establishment of implementation targets over adefined time period). Programme drift can occur unless qualitydelivery of the programme is supported by line managers, sothat a workplace culture built around the use of evidence-basedpractices is given more than lip service.

Although parenting problems occur across the whole spec-trum of socio-economic groups, a public health approach advo-cated by Triple P needs to build in specific engagement strategiesto ensure that those who require assistance the most actuallyreceive it. Disadvantaged parents living in poverty, recent immi-grants, and Indigenous parents need additional efforts to engagethem in parenting programmes (Sanders & Bor, 2007). Otherthreats to effective implementation include difficulty in access-ing necessary programme resources, defunding of a programme,and changes in policy that give lower priority to prevention andearly intervention services for children. Strategies to minimisethese threats include surveying practitioners to identify aids andbarriers to programme implementation and providing ongoingtechnical advice and support to agencies that implement theprogramme.

Cost-effectiveness

Research on the economic value of Triple P has been under-taken to examine the cost-effectiveness of Triple P. In the USA,Foster, Prinz, Sanders and Shapiro (2008) assessed the costs ofestablishing a public health infrastructure to support the imple-mentation of Triple P in nine counties in South Carolina. Theresearchers found that a relatively modest investment resultedin the core infrastructure being created to implement anevidence-based public health intervention. The ultimate costwas calculated to be in the vicinity of $AUD 12 per child.Further, Mihalopoulos, Sanders, Turner, Murphy-Brennan, andCarter (2007) concluded that Triple P is likely to be a worth-while use of limited health funds. The authors found the eco-nomic case for Triple P promising, insomuch as it costs less thanthe amount it saves, until the reduction in prevalence fallsbelow 7% where net costs become positive.



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Summary

Over the past decade, interest in preventing child maltreatmenthas increased substantially both in the scientific and publicdomains. This has resulted not only from its continuing perva-siveness, severity, and increasing prevalence but also from theprofessional community’s highlighting of the significant per-sonal, familial, and social costs associated with child maltreat-ment. As noted in the recent major policy-informing documentson prevention (e.g., National Research Council and Institute ofMedicine, 2009), child maltreatment is a serious public healthproblem. It is also a primary mental health concern as childrenwho are exposed to recurrent conflict or the chronic absence ofemotional and behavioural support in the family are at anincreased risk of serious and long-lasting psychological disorders(Hanks & Stratton, 2002).

Increasingly, Australian governments at state and federallevels are introducing child protection policies and practicesthat support early intervention prevention and family supportapproaches. Despite the growing acknowledgement of childmaltreatment as a societal problem and the general acceptancethat scientific evaluation should be an essential part of all earlyintervention prevention programmes, very few rigorous evalu-ations have been done in Australia or indeed internationally(MacMillan et al., 2009; Tomison & Poole, 2000).

To address the steady increasing prevalence of child maltreat-ment, there is a great need for effective detection and earlyintervention strategies that focus on reducing risk factors andenhancing protective factors associated with child maltreatment.Theory and research indicate that numerous individual andenvironmental factors are associated with child maltreatment(Wolfe, 1999). At the individual level, cognitive factors arethought to mediate verbal and physical aggression directed atchildren (Azar, 1997; Bugental, Blue, & Cruzcosa, 1989; Pidgeon& Sanders, 2009). In addition, there is a strong relationshipbetween parent–child interactional patterns and abusive parent-ing behaviour (Azar & Ferraro, 2000; Patterson, 2002). It is notedthat while parenting interventions appear to be helpful formaltreating parents, they may only address part of a much largerproblem with family interactions (Azar, 1997). The complexnature of child maltreatment and the multiple needs of parentshave led many investigators to argue for more comprehensiveinterventions rather than relying solely on parenting skills train-ing (Ammerman, 1990; Azar, 1997; Lutzker, Huynen, & Bigelow,1998; Petersen et al., 1997). However, there exists a clear differ-entiation between maltreating parents and other parents in termsof cognitive and affective factors (Milner & Dopke, 1997). Thesecritical factors need to be directly addressed by parentinginterventions.

Conclusion

On the basis of current findings, it is proposed that changingparents at risk of child maltreatment anger-justifying and anger-intensifying attributions may enhance the effectiveness of alter-ing their child-rearing practices in the direction of using morereasoning and non-punitive discipline strategies and reduce thetendency to express anger in parent–child interactions. Thisin turn may change the nature of the enduring child-rearing

environment, which could lead to fewer negative consequencesfor the child. Based on these findings, it is recommended thatfuture interventions for parents at risk of child maltreatmentneed to focus on cognitive, affective, and behavioural domains.

This article has put forward the view that programmes suchas PTP may be a useful intervention for parents at risk of mal-treating their children. The findings from Sanders et al. (2004)and Wiggins et al. (2009) highlight the importance that appro-priate interventions for parents at risk of child maltreatmentneed to focus on cognitive, affective, and behavioural domains.Focusing on all three of these domains is likely to enhanceoutcomes for at-risk families by providing parents with thenecessary knowledge and skills to prevent maladaptive attribu-tions for child and parenting behaviour, as well as preventpatterns of behaviour that may be precursors to aversiveparent–child interactions.

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The Role of Parenting Programmes in the Prevention of Child Maltreatment