Enhancing parental capabilities - Helping Families …helpingfamilieschange.org/wp-content/uploads/2014/03/...Parenting influences every phase of a child’s development • School

Enhancing parental capabilities

Matthew R Sanders, Ph.D.

Parenting and Family Support Centre

The University of Queensland

HFCC, Sydney, February 2014

At a glance

Why parenting is so important

Challenges facing the

field

Enhancing impact

What’s next

Parenting influences every phase of a

child’s development

• School attainment

• Peer relationships

• Obesity/health

• Antisocial behavior/drug use

• Sexuality/HIV

• Preparedness

• Social skills

• Early literacy

• School readiness

• Secure attachment

• Emergent language

• Emotion regulation

Early years

Preschool

transition to school

Middle childhood

Adolescence

Improving parenting is a common pathway

to achieving diverse child outcomes

Child benefits

of positive parenting

Improved child well being

Reduced child maltreatment

Reduced child social, emotional

behavioral problems Reduced risk for

later problems (academic failure, substance abuse,

delinquency)

Greater success at school, work,

and in relationships

Many different children benefit

Child

problems

Conduct

problems (ODD, CD, ADHD)

Chronic health

problems (Obesity, feeding

problems, asthma,

eczema, diabetes)

Internalizing

problems (Anxiety,

depression,

trauma)

School

problems (Peer relations,

classroom

behaviour)

Children with

developmental

disabilities (ASD,II, traumatic

brain injury, CP)

…and many important adult outcomes

Adult benefits

of positive parenting

Improved self efficacy

Improved relationships

and social support

Reduced family conflict

Reduced personal distress

Greater success at work

Three more P’s

Benefits to children,

parents and communities

Powerful

Pervasive

Persistent

Increasing policy level recognition of

the importance of parenting programs

Child

benefits

Parent/s

benefits

“Child and

Family”

friendly

environment

Positive

support for

children’s

development

Community

benefits

Self regulation is important to enhancing

parental capability

Parental

Self regulation

Self-management

Self-efficacy Personal agency

Self-sufficiency

Minimally

Sufficient

Intervention

Re

du

ced n

eed f

or

support

Parental self regulation

in action

• Has a clear sense of purpose

• Knows what behaviours, skills

and values to promote as a

parent

• Has realistic expectations

• Self-monitors automatically,

rather than consciously or

deliberately

• When personal standards/values

are violated she brings her

current behaviour under personal

control

• Tunes into her own actions and

searches for explanations

• Uses her knowledge to develop

options and plans

• Carries out plan and revises plan

as needed

• Expects that she can bring about

good outcomes

• Is reflective, capable of identifying

strengths and weaknesses, without

being unhelpfully self critical

• Reflections increase her self

efficacy

• Mostly enjoys the process

Self regulatory capability is

influenced by context and be learned

Parental

capacity

• Substance abuse

• Serious mental health problems

• Family violence

• Lack of social support

• Poverty (unemployment)

• Lack of parental knowledge

• Lack of preparation

• Adverse life events (disasters)

• Teamwork partner support

• Extended family support

• Social support

• Access to parenting programs

• High quality child care and

schools

• Primary heath care services

Weaken

Strengthen

Why parenting is so important

Challenges facing the

field

Enhancing impact

What’s next

Are we there yet?

Tension between the relative merits of

universal and targeted interventions

Targeted

interventions

for vulnerable

families

Universal

interventions

for all

families

A blended approach needed

Level 5

Level 4

Level 3

Level 2

Level 1

Intensive family Intervention………................

Broad focused parenting skills training………...

Narrow focus parenting skills training………….

Brief parenting advice……………………………

Media and communication strategy…………….

Breadth of reach

Inte

nsity

of in

terv

entio

n

Addressing

ongoing

challenges

Achieving wider

reach

Improving our

interventions

Improving

implementation quality

Better

outcomes

for children

and parents

Achieving

wider reach

Wider adoption

of a population

approach

Normalise

parenthood

preparation

Winning “hearts

and minds”

More

families

participate

at lower

cost

Why do we need a population approach? Children in the clinically elevated range on the SDQ

(N=1500)

M = 8.2

N

Scores

Clinical range

N = 119

What if we moved the population mean down

.5SD

M = 8.2

N

Scores

Clinical range M = 5.5

N = 99

Percentage Reduction

M = 8.2

M = 5.45

N

Scores

Clinical range

N = 99

17% reduction

20 Fewer Cases

A potential saving of

$5,255,980

What if we moved the population mean down

1SD

M = 8.2 Clinical range

M = 5.5

M = 2.7

Scores

N

N = 79

Percentage Reduction

M = 8.2 Clinical range

M = 5.45

M = 2.7

Scores

N

N = 79

34% reduction

40 Fewer Cases

A potential saving of

$10,511,960

Evidence supporting population level effects is increasing

Journal of Clinical Epidemiology (in

press)

Population-based approaches can

work and are very cost effective

• Lower rates of child out-

of-home (foster care)

placements (d=1.22)

• Lower rates of hospital-

emergency room

maltreatment injuries

(d=1.14)

• Substantiate cases of

child maltreatment

(d=1.09)

• Benefit to Cost Ratio

(return on one dollar

investment) $8.74

Costs and benefits of prevention programs Source: WSIPP (January 2014, Inventory of Evidence-Based, Research-Based, and Promising Practices

For Prevention and Intervention Services for Children and Juveniles

in the Child Welfare, Juvenile Justice and mental Health Systems

Prevention Program Manualized Classification Cost beneficial

Circle of Security Yes Promising N/A

Healthy Families America Yes Research based No (18%)

Kaleidoscope Play and

Learn

Yes Promising N/A

Nurse-Family Partnership Yes Evidence-Based Yes (76%)

Other Home visiting

programs

Varies Research Based No (26%)

Parent-Child Home Program Yes Promising No (26%)

Parent Mentoring Program Yes Promising N/A

Parents and Children

Together

Yes Promising N/A

Parents as Teachers Yes Research Based No (36%)

Promoting first relationships Yes Promising N/A

Safe Babies, Safe Moms Yes Promising -

Triple P System Yes Evidence based YES (100%)

Achieving

wider reach

Wider adoption of

population

approach

Enhance

individual

capacity

Winning “Hearts

and Minds”

More

families

participate

at lower

cost

How individuals deliver Triple P matters

0

200

400

600

800

1000

1200

1400

Year 1 Year 2 Year 3 Year 4 Year 5

Model 1: 6 grps Model 2; 4sems, 3 grps. 40 OL Model 3: 6sems, 2grps, 5DiscGrps, 40OL's

# of

families

served

N=1300 790 contact hours-30

cases averted. 4.3

times more families

N=850 860 contact hours. 20

cases averted. 2.8 times

more families

N=300 1200 contact hours.

7 significant cases

averted

Costs and benefits for an organisational

rollout targeting (5-10 year olds)

Model of delivery

using 10

practitioners

# of families

served over 5

years

Average intervention

costs per child

Cost savings

@ $186,366 lifetime

savings per case

averted

Model 1 3000 $221 $13,013,05

Model 2 8500 $68 $36,870,183

Model 3

13000

$43

$56,389,692

Sustained

use of

program

Lower

cost per

family

$$

No use or

little use

Higher

cost per

family

$$$$$$

Low

enablers

and high

barriers

High

enablers

and low

barriers

Organisational

climate matters Organisational context

R

etu

rn o

n

Inve

stm

en

t

High

Low

Increasing

population

reach

Wider adoption of

population

approach

Enhance

individual

capacity

Winning hearts

and minds of

parents

More

families

participate

at lower

cost

Improving reach means enhanced end user

input throughout

75.6

69.7

48.2

51.6

49.5

48.2

35.8

29.5

13.3

8.1

8.9

45.7

38.4

49.2

48.4

37.7

45.5

24.5

17.1

24.5

13.2

15.7

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0

Individually tailored programs

Home visits

Web-based program

Group program

Parent seminar

Television program

Self-directed

Self-directed with phone

Newspaper article

Religious organisation access

Radio segment

Parents of Typically Developing Children N=540

Parents of Chidren with Disabilities N=564

Use communication strategy to promote

engagement and build social momentum

Slide no.34

Using technology to increase

population reach

Increasing

awareness

A navigation

route

Working

through

modules

Celebrating

success

Engaging

parents

Ongoing

challenges

Achieving better reach

Improving quality of

interventions

Improving

implementation

Better

outcomes

for both

children and

parents

Improving

quality of

intervention

Helping parents of

children who a bullied

Combining parenting

interventions with other

interventions

Better

outcomes

for both

children and

parents

Depression

Lower

self-esteem

Anxiety

Loss of

friendships

Suicide

Behaviour

problems

Health

problems School

absenteeism

Increased risk of severe mental health

problems, school dropout, involvement

in criminal justice system

Bullying has serious consequences

Facilitative parenting skills taught in

Resilience Triple P

Be available and responsive to your child.

*Talk often. *Do fun things together. *Be

available when your child needs you. *Look out

for warning signs that something might be

wrong.

Support your child’s friendships.

*Get to know other parents. * Arrange play-

dates. * Participate in events at the school.

Help your child to be independent.

* Take into account what other children are

allowed to do. * Teach your child to do things for

themselves. * Help your child make their own

decisions appropriate to their age and maturity.

Teach your child to play well.

* Help your child set goals for play. * Reward and

encourage good play skills. * Help your child to

review how they go.

Coach your child to deal with difficult situations.

Help your child to: * interpret situations; * make a plan

to handle a problem; * practise a response.

Help your children resolve conflicts.

* Avoid taking sides. * Provide coaching before it gets

out of hand. * Encourage children to listen to each

other and to think of a solution that is fair for everyone.

Work with your child’s teacher and school.

* Do not to blame school staff. * Let staff know exactly

what happened and how it affected your child. *

Request help.

* Calmly follow up until sorted. * Thank staff for their

efforts.

Managing parents emotions

(sample video from RTP)

Effects of Resilience Triple P

Outcome Effect size

Bullying of Child:

Overt bullying (teacher) d=.57

Child reports d=.44

Parent reports reduced bullying d=.52

Child Internalizing

Preschool Feelings (Depression)

Index (parent) d=.51

Child reports feeling better d=.63

Parent report of child coping d=.74

Child Social Skills

Observational assessment of child skills d =.72

Improved sibling relationship d=.30

Child Depression (Parent report)

N=111

0

1

2

3

4

5

6

RTP AC

0 months 3 months 9 months

Healy, K.L. & Sanders, M.R. (2014). Randomized controlled trial of a family intervention for

children bullied by peers. Manuscript under review

Improving

quality of

all

intervention

Helping parents of

children who a bullied

Testing additional

intervention components

Better

outcomes

for both

children and

parents

Children with conduct problems have

difficulties with emotions

• Identifying emotions in themselves

(Cook, Greenberg & Kushe, 1994).

• Reading emotional cues in others

(e.g. facial expressions and voice

tone),

• Ability to talk about their emotional

experiences (Strand & Nowicki,

2000).

• Poorer understand of the causes of

their own emotions

Does adding an emotion component to

Triple P enhance child outcomes?

• Parent-child interactions are

an important context for

learning about emotions

• Emotion-focused variant of

Group Triple P involved

– discussion of recent upsetting

events

– discussion of feelings

– coaching child about dealing

with emotions in future

Does emotion coaching improve

Triple P outcomes?

Findings

EETP produced greater changes in – use of emotional labels (d= .78, medium)

– discussion of causes (d= .74, medium)

– emotion coaching (d= 1.08, large)

X GTP had greater changes in child

conduct problems (d=1.09, large)

X Extra focus on emotions did NOT improve

child or parent outcomes

X Both interventions produced

improvements in dysfunctional parenting

practices (PS), parenting self efficacy

(PTC), parental distress (DASS) and

parents were similarly satisfied with both

(CSQ)

150.9

143.7

115.6

129

122.8 127.6

40

60

80

100

120

140

160

Group Triple P Emotion Enhanced TripleP

Pre Post FU

d=1.09 (large effect)

Source: Salmon, Dittman, Sanders, Rebecca Burson, & Hammington (in press). Does Adding an Emotion Component Enhance the

Effects of the Triple P-Positive Parenting Program? Journal of Family Psychology.

Addressing

ongoing

challenges

Enhancing

population reach

Improving our

interventions

Strengthening

implementation

Better

outcomes

for both

children and

parents

Good training is essential

0

1

2

3

4

5

6

7

Australasia US and Canada English speakingEU

Non-Englishspeaking EU

Asia

Process Efficacy: Region Differences

Pre Training Post Training

0

1

2

3

4

5

6

7

Medical Mental Health Education ParaProfessionals

Other

Process Efficacy: Profession Differences

Pre Training Post Training

It is not enough:

The drivers of implementation success

Create strong local partnerships and internal champions

Ensure line management support and

funding

Well trained

and supervised

staff

Establish achieveable

targets

Access available

technical and consultation

support

Make routine evaluation of

outcomes mandatory

Why parenting is so important

Challenges Enhancing

impact

What’s next

How can parenting interventions

tackle problems of global significance

Problems of global

significance

Deep and persistent

disadvantage

Violence towards children

• Australia has one of the

highest rates of

joblessness across

OECD countries.1.3

million jobless families

• Most important cause of

child poverty and a major

contributor to income

inequality

The economic imperative

Health

$61 billion

Defence

$21 billion

Other

$140 billion Education

$28 billion

Social

welfare

$132 billion Source: Australian Commonwealth Budget 2012-13

INCREASING

EXPENDITURE $158 billion by 2016-2017

The consequences of family

joblessness are serious

SCHOOL EXPULSION

3-5 times more likely

BEFORE COURT

2.5 times more likely

CONDUCT PROBLEMS,

DEPRESSION, ADHD OR

SUBSTANCE ABUSE

2 times more likely

The longer the child’s exposure to parental joblessness

the poorer the outcome (Gray & Baxter, 2012)

TESTING SOCIAL INTERVENTIONS Population parenting trial of Triple P system

END-USER ENGAGEMENT Action in 1,000 suburbs

Can parenting programs help disrupt

intergenerational disadvantage?

Problems of global

significance

Deep and persistent

disadvantage

Violence towards children

Children’s exposure to family violence is a

major public health issue

Nearly 53,000 children are murdered each year

150 million (14%) of girls

and 73 million (7%) of boys

under age 18 experience

forced sexual intercourse

and other forms of sexual

violence involving touch,

among boys and girls

Source: UN Secretary General's Study on Violence Against

Children (2013)

Globally violence against children is common Children aged 2-14 experiencing violent discipline in 29 countries

86% 81%

62%

19%

Any violentdiscipline

Psychologicalaggression

Minor physicalpunishment

Severe physicalpunishment

Source: UNICEF, Child Disciplinary Practices at Home: Evidence from Low and Middle Income Countries, New York,

2010

On a global scale problematic

parenting is widespread

• Self-reported incidence of physical abuse

40 times greater than official records (Chang, Runyan, et al, 2005)

• Physical and mental health

consequences of family violence are

serious and long term (Moffitt et al, 2013)

• Violence places a massive burden on

national economies, costing countries

billions of dollars each year in health

care, law enforcement and lost

productivity

Source: Theodore, Chang, Runyan et al. (2005). Epidemiologic features of the physical and sexual

maltreatment of children in the Carolinas. Pediatrics, 115, 331-3337.

Partnership

with

Parenting Organisation Kenya

Children’s Hope Foundation

Raising children in “informal

settlements” Kibera in Kenya

• Calls by WHO Global Violence

Prevention Initiative and UNODC for

development, adaptation,

implementation and evaluation of

EBPs for LMIC

• Two recent meta analyses highlight

the lack of quality research Mejia, A., Calam, R., & Sanders, M.R. (2012). A review

of parenting programs in developing countries:

Opportunities and challenges for preventing emotional

and behavioural difficulties in children. Clinical Child

and Family Psychology Review, 15, 163-175.

Knerr, W., Gardner, F., Cluver, L (2013). Reducing

harsh and abusive parenting and increasing positive

parenting in low- and middle-income countries: a

systematic review. Prevention Science

Mother in Nairobi, Kenya Pilot

Group Triple P

Effects of Group Triple P

N=28

Follow Up Outcomes

Child

CAPES Emotional d = 1.03

CAPES Behaviour d = .76

Parent

CAPES self efficacy d = .71

PS Over-reactivity d = .67

Parental Adjustment

Depression (DASS) d = .49

Anxiety (DASS) d = .57

Stress(DASS) d = .69 0

5

10

15

20

25

30

35

Pre Post Follow Up

CAPES Intensity-Total

New Partnerships in International

Development Projects are needed

Clean water

Positive Parenting

Improved sanitation

A final word

Parenthood

is valued

All parents have

access

Preparation for

parenthood becomes

socially normative

Parenting programs

become a policy

priority and are

funded accordingly

All children can

achieve their

potential in a

safe, loving, low

conflict world

Thank you for your

attention

pfsc.uq.edu.au

triplep.net