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Brief Interven+ons to Popula+on-‐Level Outcomes: The Power of the Mul+level System Symposium B2 HFCC 2015 Our Lineup •  Burcu Akran -‐ School of Health-‐Psychiatric Nursing Department, Uludağ University, Bursa, Turkey •  John Pickering – The University of Queensland, Australia •  Conor Owens – Health Service Execu+ve, Ireland Embrace the rivalry: How sibling conﬂict could beneﬁt the whole community John Pickering & MaXhew Sanders Helping Families Change Conference February 2015 Amsterdam, The Netherlands Declara+on Statement John Pickering is an employee of The University of Queensland (UQ). UQ owns The Triple P-‐Posi+ve Paren+ng Program. The University through its technology transfer company, UniQuest Pty Ltd, has licensed Triple P Interna+onal Pty Ltd to publish and disseminate the program worldwide. Royal+es stemming from published Triple P resources are distributed to the University and contributory authors. John Pickering has no authorial connec+on to Triple P and is not a ﬁnancial recipient of program dissemina+on. MaXhew Sanders is also an employee of UQ and an author of various Triple P resources. Why siblings maXer? -‐ Training ground for aggression (PaXerson, 1986) Linked to conduct problems in pre-‐schoolers (Garcia et al., 2000) -‐ Associated with signiﬁcant behavioural and emo+onal problems in later life (Tuker et al., 2013) -‐ Linked with the development of depression, anxiety, sel-‐harm (Bowes et al., 2014) -‐ Perhaps the most common form of bullying (Skinner and Kowalski, 2013) Siblings have a signiﬁcant impact on key developmental milestones including – (Brody, 1998) -‐  the acquisi+on of interpersonal skills, -‐  cogni+ve development and sensi+vity, -‐  emo+onal development and adjustment, -‐  social understanding, -‐  sharing and social skills, -‐  socio-‐cogni+ve reasoning skills. Sibling Rela+onships are Life Long Why sibling issues maXer to parents? Empirically •  Sibling conﬂict ohen reported as the most prevalent behavioral problem in families (see Brody & Stoneman, 1987) •  Figh+ng with siblings ranked as most “undesirable” behaviour for parents of adolescents (Ralph et al., 2003) •  Most prevalent form of family violence (Straus, Gelles, & Steinmetz, 2003) •  Robust evidence linking paren+ng prac+ces to -‐ –  reduc+ons in conﬂict intensity, opposi+onal behaviour, power tac+cs, and crying; –  increases in reasoning, perspec+ve taking, compliance, and ignoring behaviours (Perlman & Ross, 1997) Sibling Survey Pickering & Sanders (2014) What did parents say? Survey •  N = 409 (mean age = 34.2yrs; 94.1% mothers) –  Mean age eldest sibling = 6.9yrs –  Mean age younger sibling = 4.8yrs •  Sociodemographically skewed •  18.8% of parents par+cipated in a paren+ng program in the past Gepng Along? Overall parent ra+ngs of how well they perceive their children to get along. Percentage of Responses (%) 30% 25% 20% 15% 10% 5% 0% Very Poorly 2 3 Neutral 5 6 Extremely Well Currently in Conﬂict? Percentage of Respondents (%) Percentage of parents of high and low income families currently experiencing sibling conﬂict. 80% 70% 60% Low income 50% 40% 30% 20% 10% 0% Yes No The “ideal” family Behaviour Mean Talking to each other, conversa>ons 4.21 Loyalty or s>cking up for one another 4.09 Kindness 4.05
Protec>veness – looking out for on another 4.00 Helping one another 3.88 -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ Jealousy 2.69 Anger or hos>lity 2.49 Physical Aggression (hiGng, pushing, etc) 2.35 Conﬂicts where the problem never gets worked out 2.13 Threats 2.07 Your Family Frequency of behaviour How problema>c Help desired Anger or hos>lity Physical Aggression Arguments Trying to control each other’s behaviour 3.81 2.55 74.83% 3.77 2.45 74.18% 3.75 2.39 71.52% 3.62 2.33 66.33% Figh>ng over objects 3.34 2.29 62.88% -‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐-‐ -‐-‐-‐-‐-‐-‐ -‐-‐-‐-‐-‐ -‐-‐-‐-‐-‐ Loyalty or s>cking up for one another 3.06 1.41 32.29% Comfor>ng one another 2.95 1.39 30.56% Talking to each other, conversa>ons 2.81 1.41 30.00% Aﬀec>on (hug, kiss, saying “I love you,” etc.) 2.63 1.38 29.31% Teaching (how to play a game, how to read) 2.13 1.33 25.96% Behaviour Causes Parent percep+on of the causes of sibling behaviour problems Problem Mean Low income High income Temperament of the siblings 4.14 4.14 4.15 Siblings not having the skills to problem solve 4.00 3.95 4.03 Siblings not having the skills to nego>ate 3.94 3.88 4.00* Siblings not agreeing with one another 3.70 3.79 3.62 Diﬀeren>al treatment of siblings by parent/s 3.16 3.14 3.17 Disagreement among parents about how to manage conﬂict 3.11 3.11 3.11 Not enough parental involvement in sibling conﬂict 2.86 2.87 2.84 Over interference from parents 2.84 2.84 2.84 Siblings not old enough to act nicely towards one another 2.49 2.52 2.46 Siblings too close in age 2.36 2.40 2.33 Gender diﬀerences among siblings 2.34 2.32 2.37 Strategies Parent acceptability, likelihood of use, and barriers to use of diﬀerent posi+ve paren+ng strategies Acceptability Likelihood of use Percentage repor>ng barriers to use Back up your instruc>on with a logical consequence 4.59 4.53 16.39% Encourage good behaviour in your child 4.56 4.35 19.54% Back up your instruc>on with >me-‐out 4.48 4.22 22.30% Explain the rules to your children 4.27 4.20 28.80% Choose ac>vi>es to teach turn taking 4.29 4.12 26.38% Back up your instruc>on with quiet-‐>me 4.28 3.97 22.30% Have your children play separately if they don’t get along 3.94 3.84 32.79% Get your children to prac>se what they should have done 3.84 3.39 25.41% Lecture your children telling them what they have done wrong 3.20 3.36 33.99% Give your children a smack if they misbehave 2.26 2.16 64.17% Strategy Delivery Parent preferences for diﬀerent evidence-‐based paren+ng delivery methods Strategy Mean A web-‐based program 3.46 A one-‐oﬀ, brief, standalone paren>ng group 3.25 A television program 3.19 A self-‐directed paren>ng program 3.15 An 8-‐week individual face-‐to-‐face program 2.83 A large group parent seminar 2.65 An 8-‐week group based program 2.60 But.... Do Parents Actually MaXer? Exis+ng Interven+ons Focus to date on reducing undesirable behaviors Feinberg et al. (2013) “Siblings Are Special (SIBS)” program 15 session group-‐format aherschool program Enhanced posi+ve sibling rela+onships, appropriate strategies for paren+ng siblings, and child self-‐control, social competence, and academic performance; program also associated with reduced maternal depression and child internalising problems. •  BUT, failed to provide an eﬀect for sibling conﬂict. •  And no engagement of consumers/end-‐users in shaping interven+on • 
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A Triple P Discussion Group for Sibling Conﬂict Pickering & Sanders (2015) An N=1 case study •  Randomised Clinical Trial –  Parents of 2-‐10 year old children –  No more than 4 years age gap between them –  Not seeking alternate help –  Elevated score on measure of sibling conﬂict •  Demographics –  Mother aged 39years –  Two boys ages 4 and 5, with the 4 year old being the target child of the study. –  Married, original family –  Educa+on/Employment: The mother has a higher degree of educa+on (masters, PhD) and works full +me. –  Earns $120,000 -‐ $180, 000 annually. •  Paren+ng Program Experience: has experience •  Arguing: –  A 66.67% decrease in frequency of arguing between +me 1 and +me 3 –  Reported as 33.33% less big of a problem at T2 compared to T1 –  Reported as 4x as big of a problem from T2 to T3 –  Beliefs in ease of changing arguing did not change over +me (stayed stable at easy) –  Amount of help wanted decreased from a lot of help to a liXle help from T1 to T2 –  Amount of help wanted didn’t change from T2 to T3 •  Figh>ng Over Objects (games, toys, clothes…): –  A 75% decrease in frequency from +me 1 to +me 3 –  Reported as 66.67% less big of a problem at T2 compared to T1 –  Reported as 1.5 x as big of a problem at T3 compared to T2 –  Beliefs in ease of changing ﬁgh+ng decreased by 1.5 +mes from easy to neutral from T1 to T2 –  Beliefs in ease of changing ﬁgh+ng increased by 1.5 +mes back to easy from neutral from T2 to T3 –  Amount of help wanted decreased from a lot of help to no help from T1 to T2 and then back to a liXle help at +me three But… •  Jealousy: –  No change in the frequency of jealousy reported over +me –  No change in problem size from T1 to T2, –  From T1 to T2 beliefs in how easy it would be to change jealousy did not change –  From T2 to T3 their beliefs in how easy it would be to change jealousy decreased by 1.5x (from easy to neutral) –  How much help was wanted increased by 2x from T1 to T2 (from no help to a liXle help) –  But decreased again by 50% from T2 to T3 How does all of this ﬁt with the popula+on approach? Parents Prac>>oner Policy makers Agency Children and young people Adop+ng a consumer perspec+ve helps to Tailor program content to needs and aspira+ons of target group Op+mize program delivery Develop stronger consumer advocacy Improve engagement and program reach Model of Program Development Program development and design
Initial feasibility trial
Program refinement
Effectiveness trials
Program refinement
Scaling up of intervention
Dissemination and implementation
Parents and children as consumers
Practitioners and agencies as consumers
Theory building
Embracing the Rivalry Novel ways of engagement Thank you for your aXen+on John Pickering The University of Queensland [email protected] twiXer: @johnpickering What the consumers say •  Arguments, Anger and Aggression main cited problems (and most help desired) •  Child-‐based issues as primary perceived causes •  Posi+ve strategies deemed most acceptable •  Web-‐based or brief-‐group format most preferred Pupng it together •  Siblings are common •  Sibling rela+onships are ideal “training grounds” (for beXer or worse) •  Sibling rela+ons maXer to parents •  Sibling conﬂict is a means of engaging with parents •  S+ll unanswered ques+ons about most eﬀec+ve interven+on – esp. addressing what parents most want help with, and how?