Triple P Master class Empowering parents, self-regulation, flexible delivery and cultural diversity Matthew R Sanders, PhD University of Queensland February, 2012, HFCC Glasgow At a glance Use Self Regulation Framework Parental Self regulation Minimally Sufficient Intervention Tools for personal change Tools for personal change Practices that promote parental self-regulation Conveying respect in an emotionally supportive context Building an optimistic outlook Building a Collaborative Relationship Letting go of control through “guided participation” model Challenging beliefs about clients needs to be rescued Challenging self defeating behaviour Establishing expectancies that promote self regulation Avoiding encouraging dependency Techniques that promote parental self regulation Using prompts for self appraisal (“How did that go”?) Apply principles of the “minimally sufficient” intervention (decreasing praise/external reinforcers) Using Specific techniques Praise unprompted use of specific self regulatory skills Use signaled fading of support Asking parents to share their rationales for decisions Reinforce generalization of parenting skills across settings, tasks, siblings At a glance Responsive programme delivery Flexibility vs fidelity Content variations Low risk Slide no.9 Process variations High risk Low risk High risk Process Variations Low Risk More sessions High Risk Advice to use or not to use specific strategies Session length Session location No agenda or session structuring School contact No review of homework Switch to briefer version Repeated abandoning of agenda Individual prep before group Always proving answers More emphasis on practice and DVD Giving feedback without Content Variations Low Risk Modify examples to make more relevant High Risk Withholding information about certain strategies Modify steps from a tipsheet in a Suggest parent stray from parenting plan principles underlying the recommended parenting strategy Changing focus of session to partner support Combining a selection of Triple P strategies with programs Tailoring is enhanced when we strengthen the voice of consumer But families differ in many different ways… Reducing dropout by matching Triple P to clients needs • • • • • Triple P works best when delivered with fidelity As a multilevel system Avoids inflexible, non responsive delivery Responding to parents needs by tailoring of process and content Implementation Triple P well is skilful work And what about… Tailoring to needs of parents Grandparents Foster parents Using epidemiology and qualitative methods to tailor program to needs Working parents Parents of children with CP Parents of multiples Parents of children with ASD Tailoring content or process (as needed) Testing efficacy of adapted version Consumer input Æ ResearchÆ Program modification Grandparent Triple P (Kirby & Sanders, in prep) Consumer Input through focus groups Research Arguments over parenting “There are arguments around discipline, about how we as grandparents treat the grandkids I suppose versus how the parents do it.” Concerns over grandparent role taking “I just get the feeling that sometimes my son is starting to take me a little bit more for granted. And that becomes overwhelming and frustrating.” Parents dislike unsolicited parenting advice from own parents (Thomas, 1990) Grandparents report finding the role exhausting and demanding (Fitzpatrick & Reeve, 2003) Program Modification Inclusion of module centered on effective communication skills and problem solving Session 4: How to build a positive parenting team (e.g., dealing with emotional distress, page 88) Inclusion of strategies to manage emotional distress Session 5: Grandparent survival skills (e.g., Exercise 6 ways to look after yourself, page 108) Tailoring Process Knowledge gained from consumers Research evidence Tailored variant ready for empirical testing Sample applications being trialed Name Who for Target age Group Delivery format Fear-Less Triple P Parents of children with an anxiety disorder Primary school age children 6 session Group Resilience Triple P Parents of children who are bullied Parents of 4-12 year 8 session Group olds parent (4) and parent plus child (4) Fuss Free Feeding Parents of children Triple P with feeding difficulties Parents of toddlers and preschool children 8 session group Baby Triple P First time parents New borns 8 session Group Triple P online Parents of children with early onset conduct problems Parents of 3-8 year olds 8 session Individual Disaster Recovery Triple P Parents of children exposed to natural disasters Universal 1 session Large group seminar Grand Parent Triple P Grandparents 2-12 years 8 session Group Aspects of the program designed to ensure responsivity and tailoring • Parents determine the specific goals for their child and family • Triple P offers a menu of parenting options and facilitates the parent making informed choices • Multi-modal methods of presenting and delivering content • Protocols for managing process issues What predicts movement along the engagement trajectory Precontemplative Contemplative Start Ready for action Movement along program completion trajectory Finish Modifying enablers and barriers to participation Using program features to enhance outcome Modifiable Program variables Use relevant examples Use providers who are similar to parents Ensure program is low or no cost Use preferred delivery format Ensure advice is culturally acceptable Using social influence to enhance outcomes Modifiable social influence Variables Engage both parents Provide program in home Engage extended family Involve friends and neighbors Cognitive/affective strategies to enhance outcomes Modifiable Cognitive/ Affective variables Ask parent to identify anticipated benefits of tasks Prompt and reinforce efficacy predictions Use peer models Attribution retraining Enhancing motivation Motivational variables Have parent speak to parents who have already completed Provide incentives for attendance Reduce competing demands Develop troubleshooting plan Characterizing the type of intervention What works? Triple P is NOT a single program What level of intensity? •Universal •Selected •Primary care •Standard •Enhanced •Full system What mode of delivery? •Individual •Group •Over the Phone •Media based •Web based •Self directed What variant? •Core program •Teen •Stepping Stones •Lifestyle •Resilience •Workplace •Fear-less Characterizing the children and families we serve For whom? What child? What parent? •Prematurity •Low birth weight •Developmental disability •Internalising •Externalising •Type and severity of behavior problem •Depressed •Highly stressed •Maritally discordant •Abusive •Substance abusing •Minority parents •Indigenous •Grandparents •Foster What family? • Unhappy couples • Separated/divorced • Incarcerated • Step/blended family • Single parent •Teen parent • Extended family Characterizing Providers and System of Care What delivery system? What provider? •No single discipline delivers Triple P •Government/NGO/ private •Self directed In what setting? •Home •Clinic (inpatient, outpatient, hospital) •School/Preschool •Child care •At work •Over the phone •Web-based What funding context? •Recurrent funding •Policy setting •Mainstreamed •Prevention or Treatment •Workplace support Why parents sometimes resist change Negative emotion •Anger •Contempt •Sadness •Fear History of 10,000 defeats Parents story about the history •Attributions for child’s behavior •Attributions about own behavior Parental resistance •“I won’t” •“I can’t” •Homework Parent LOW SES •Depressed •Anti-social •High stress •Low education •Poverty Practitioner behaviours that support avoidance Broader Ecological Context Parental mental health Discrimination Enablers & barriers Parental concern about child Acculturation Family friendly policies Perceived vulnerability Severity of child problem Level of parental distress or anxiety Motivational variables Program variables Perceived need Anticipated benefits/costs Competing demands Poverty Employment status Neighborhood Engagement Cognitive/ Affective variables Expectancies of benefit Parental self efficacy Access to models Parental attributions Providers-ethnicity, skills Cost/ Accessibility Program format Acceptability of parenting advice Social influence Variables In home support Extended family support, Community and neighborhood support Gender /age of parent Culturally normative parenting practices Connectedness Education /literacy Prior help seeking Family of origin experiences Immigration status Enablers & barriers Parental concern about child’s behavior Perceived vulnerability Severity of child problem Level of parental distress or anxiety Program variables Motivational variables Perceived need Anticipated benefits/costs Incentives Competing demands Engagement Message Providers-ethnicity, experience, skills Cost/ accessibility Program format Acceptability of parenting advice Cognitive/ Affective variables Social influence Variables Expectancies of benefit Parental self efficacy Access to models In home support Extended family support, Community and neighborhood support Parental attributions Usefulness Minority parents and professionals views on cultural appropriateness New variants Parents of children who are bullied Can parenting influence peer relationships? Bullying is highly distressing • Can have serious long term consequences Bullying Anxiety Loss of friendships Behaviour problems Suicide School bullying has severe consequences Health problems Lower self-esteem Depression School absenteeism Increased long-term risk of severe mental health problems, school dropout, involvement in criminal justice system Who gets bullied? Child social behaviour response to aversive peer behaviours Facilitative Parenting warm, responsive and encouraging parents that promotes child’s social competence PREDICTS PROTECTS (Healy & Sanders, under review) MORE Peer Victimisation LESS Peer Victimisation What is Facilitative Parenting? Talks to child about issues Facilitative Parenting Enjoys child’s company Facilitates peer interaction Communicates well with child’s teacher Helps child resolve conflicts Not aggressive to others in defense of child Avoids over protectiveness Encourages appropriate independence Tackling parents attributions Resilience Triple P video clip Parents emotions can get in the way Effects of Resilience Triple P Short-term effects • • Other effects: ÐTotal SDQ (post d=.56 ; FU=d=.93) • Ð Child’s distress(post d=.38; FU d=1.13 ) • Ð Facilitative parenting (Post d=.15; FU d=.65) Slide no.46 Post d=.38; FU d=1.21 Positive Parenting after separation or divorce Relationship breakdown is painful Relationship breakdown • • • • Relationship breakdown is a major life stressor for parents, children, and their extended families Although declining 40% of all marriages end in divorce1 Half of all divorces involve parents Divorce impacts on 44, 000 Australian children each year. Source: Australian Bureau of Statistics (2007). Divorces Australia. Canberra, Australia. Program Content & Trial Outcomes 12 week program Five areas • • • • • Divorce – a Family Transition Coping with Emotions Managing Conflict Balancing work, family, and play Positive Parenting Outcomes ↓ Fewer behavioural and emotional problems (ECBI: d=.43) ↓Dysfunctional parenting practices (PS:d=.29) ↓Parental Expressed and Trait Anger (STAXI; d=.22) • ↓Dysfunctional parenting practices (PS:range ) ↓Parental depression (d=.74), anxiety (d=.42), stress(d=.86), acrimony (d=.35), ÇRelationship quality (d=.33) Resilience Triple P Facilitative parent training LESS Peer Victimisation Social and emotional skills for children Australian Research Council funded RCT under way Parenting after natural disaster Queensland Jan 2011 flood resulted in widespread devastation "We now face a reconstruction task of postwar proportions." -- Anna Bligh, Premier of Queensland, Australia, on ravages of floods that affected thousands of homes. Queensland Floods covered vast area • 60% of Queensland flooded – area larger than France and Germany combined • 86 towns and cities across state affected by flooding. • 92 schools, 86 child care centres affected • 20,000 homes flooded • 200,000 stranded • 30 deaths (some still missing) • Costs in excess of $30billion It was a terrifying experience for some children • Their homes were destroyed • They suffered significant loss (family, pets, neighbours, parents jobs) • They were exposed to a media blitz on the flood on TV and radio • Many children were involved in the cleanup Many parents sought information on how to best meet their children’s needs • To understand common psychological reactions of children to the disaster • To restore normality and routine to their daily lives as quickly as possible • To help children cope with anxiety and distress associated with loss, grief and trauma • Children with preexisting emotional problems most at risk Many parents most directly affected were highly distressed themselves Sadness • For losses of every kind Anger • At what has happened • At whoever or whatever caused it • At the injustice, ‘Why me, Why us?’ Helplessness • Feeling overwhelmed and unable to change the situation Fear • Of ‘breaking down’ or ‘losing control’ • Of losing the business, farm, lifestyle Failure • Blaming yourself when events are out of your control Guilt • For being better or worse off than others • For surviving Shame • For being exposed as helpless, ‘emotional’ and needing others • For not reacting as one would wish Isolation • Wanting to be alone • Irritated or cannot bear the demands of being with others Numbness • Feeling empty inside or a loss of all feelings • Feeling detached or withdrawn • Having difficulty concentrating Let Down • A sudden loss of energy and enthusiasm • Other people do not understand how you feel or what you have been through Floods were then immediately followed by massive Category 5 cyclone Cyclone Yasi over Europe Very destructive, fortunately minimal loss of life •Today's News •Video: BP announces loss Flood, cyclone then bush fire Children’s development and the floods Return to normal pathway Developmental capabilities Traumatic event A sudden, traumatic event, in the life of a normally developing child disrupts development Foetal Infant Child Adolescent Stages of development Adult Common social and emotional reactions • Behaving younger than you would expect • Avoidance of activities • Withdrawal • Clinginess and difficulty separating • A sense of danger • Sleep disturbances • Difficulty concentrating • Increased irritability and anger • Sadness • Flashbacks to the event • Upset for no apparent reason • Specific fears (e.g. rain) Disaster Recovery Triple P Cobham, McDermott & Sanders (2011) • • • • • • • • Parenting Seminar Universal 2 hour, large group seminar Information and advice on how parents can help children cope with the disaster experience Identify commonly encountered problems Create positive realistic expectations for recovery Answering children’s questions Review of parent traps Specific parenting strategies Take home tip sheet Peer Assisted Supervision and Support (P.A.S.S) PASS Model of Peer Assisted Support and Supervision • Regular meetings (90-120 minutes) with other practitioners in a supportive small group setting (or pairs) • Can be used in addition to individual supervision provided by workplace • Provides a structured environment for professional development and peer supervision support Goals of PASS Sessions • Assist practitioners learn to implement Triple P effectively • Help practitioners identify strengths and continually refine their skills via – Self-evaluation – Helpful feedback from peers • Increase likelihood of program fidelity and appropriate flexibility to meet parents’ needs Activities PASS session Case review Discussion of implementation issues Professional development activity Three Roles for PASS Sessions • PASS facilitator (rotates with each session) • Practitioner – Shares case, self-evaluates, receives feedback and sets personal goals • Peer mentor/s – Assists self-evaluation, provides positive encouragement and constructive feedback, may assist in role plays NB: Practitioner and mentor roles may rotate within each PASS session Thank you for your attention Further information about Triple P Research:www.pfsc.uq.edu.au Training:www.triplep.net