The Triple P System
What are the levels of intervention in the Triple P system?
Level 1: Universal Triple P
This level of intervention involves using health promotion and social marketing strategies to make available to parents information about how they can promote their child’s development and deal with commonly encountered behaviour issues, many of which are best viewed as part of normal development. Information may be accessed through a community-wide media strategy that includes the use of television, print and other electronic media to increase community awareness, acceptance and support for the importance of parenting. The aim of this level of intervention is to facilitate parents' access to information about how to deal with common child-rearing issues.
In the past, the Triple P media strategy has included the production of a 13-episode television series on parenting and family survival skills (aired in New Zealand), a regular newspaper column on parenting, radio interviews, participation in nationally televised current affairs programs dealing with parenting issues, community service announcements on both television and radio (conveying brief messages about positive parenting), and a telephone information line.
The media has the potential to reach far greater segments of the population at any one time than other forms of community outreach and can be used to increase the visibility of parenting messages. Media campaigns can be developed for national, state or local community access. The media strategy can support other levels of intervention to send optimistic yet realistic messages to the community about the importance of parenting; depict realistic solutions to commonly encountered problems; and suggest where families can go for further help. This strategy serves to normalise and destigmatize parenting difficulties and prompt parents to seek help, information or advice on children’s behaviour if they need it.
Level 2: Selected Triple P (Seminar)
Selected Triple P (Individual Support)
Selected Teen Triple P
The media-based parenting information campaign can be supported by providing information to parents through primary care services and other community agencies in regular contact with families of young children. Primary care services refer to those services and programs that have wide reach in the community and are therefore readily accessible to parents. These services are well positioned to provide preventively oriented parenting programs because parents use them frequently, see them as credible sources of information about children, and do not associate them with the stigma often attached to seeking specialist mental health services.
The Selected (Individual Support) Triple P parenting information strategy involves primary care professionals in regular contact with families having periodic discussions with parents about developmental and behavioural issues, and providing parents with information about how to cope with specific child-rearing issues. Parenting tip sheets and videos can be used as part of anticipatory developmental guidance provided by the practitioner. Each tip sheet suggests effective ways of preventing or solving a common child management or developmental problem and typically includes information about the problem, why the problem may develop, how to prevent the problem, how to manage or solve the problem, and where to go for further help if required. Agencies display available resource material to prompt parents to request information from their practitioner. Information is provided within a brief consultation format (one or two 10-minute sessions) that clarifies the presenting problem, explains the materials and tailors the information to the family’s needs. Families are invited to return for further help if they have any difficulties.
Level 2 interventions may also include the Triple P Seminar Series. These are designed for delivery to large groups of parents and include three 90 minute sessions. The seminar series includes specific seminars on the following topics The Power of Positive Parenting; Raising Confident, Competent Children; Raising Resilient Children. Seminars are used to promote awareness of Triple P and as informative brief information sessions for any parent. The sessions include a presentation, and a question and answer session. Other program resources including tipsheets can be displayed in the room and practitioners can be on hand to deal with individual inquiries and requests for further assistance.
The Teen Triple P Seminar Series is also available and addresses specific issues such as: Raising Responsible Teenagers; Raising Competent Teenagers; and Getting Teenagers Connected.
Level 3: Primary Care Triple P
Primary Care Teen Triple P
Primary Care interventions incorporate brief behavioural counselling as an early detection and brief intervention approach to managing identified problems. This level of intervention involves four 15-30 minute consultations with parents. Practical advice on managing a specific problem behaviour is provided, assisted by the use of parenting tip sheets and video resources. Primary Care interventions may also incorporate active skills training procedures such as behavioural rehearsal. This involves modelling and then coaching parents in the implementation of specific parenting strategies or routines using rehearsal, constructive feedback and goal setting.
Session 1 involves obtaining the history and nature of the presenting problem, setting goals for change; and baseline monitoring to track the occurrence of problem behaviour. Session 2 involves discussing the results of the baseline monitoring, sharing conclusions about the nature of the problem (i.e. the diagnostic formulation) and its possible causes; and negotiating a parenting plan (using a tip sheet or designing a planned activities/planning ahead routine). This session also involves identifying and countering any obstacles to implementation of the new routine by developing a personal coping plan with each parent. The parents then implement the program. Session 3 involves monitoring the family’s progress and discussing any implementation problems, it may also involve introduction of additional parenting strategies and more intensive active skills training exercises. The aim is to refine the parents’ implementation of the routine as required and provide encouragement for their efforts. Session 4 involves a progress review, trouble shooting for any difficulties the parents may be experiencing, positive feedback and encouragement, and termination of contact.
Level 4: Standard Triple P
Group Triple P
Group Teen Triple P
Self-Directed Triple P
As in Level 3, this level of intervention combines the provision of information with active skills training and support. It also teaches parents to apply parenting skills to a broad range of target behaviours in both home and community settings with the target child and siblings. There are several different delivery formats available at this level of intervention.
Standard Triple P
This 10-session program incorporates sessions on causes of children’s behaviour problems, strategies for encouraging children’s development and strategies for managing misbehaviour. Active skills training methods used in the sessions include modelling, rehearsal, self-evaluation, and homework tasks. Segments from Every Parent’s Survival Guide [DVD] may be used to demonstrate positive parenting skills. Several generalisation enhancement strategies are incorporated into the program (e.g. training with sufficient exemplars, training loosely) to promote the transfer of parenting skills across settings, siblings and time. Home or clinic practice sessions are also conducted in which parents self-select goals to practise. They are then are observed interacting with their child and implementing parenting skills, and subsequently encouraged to self-evaluate their progress toward meeting their goals. Further sessions cover identifying high-risk situations and developing planned activities routines. Finally, maintenance and relapse issues are discussed. Sessions last about 60 minutes each (with the exception of practice sessions which should last about 40 minutes each).
Group Triple P
Group Teen Triple P
Group Triple P is an 8-session program, ideally conducted in groups of 10-12 parents. It employs an active skills training process to help parents acquire new knowledge and skills. The program consists of four 2-hour group sessions which provide opportunities for parents to learn through observation, discussion, practice and feedback. DVD segments are used to demonstrate positive parenting skills. These skills are then practised in small groups. Parents receive constructive feedback about their use of skills in an emotionally supportive context. Between sessions, parents complete homework tasks to consolidate their learning from the group sessions. Following the group sessions, three 15-30 minute follow-up telephone sessions provide additional support to parents as they put into practice what they have learned in the group sessions. A final group session completes the program. Although delivery of the program in a group setting may mean parents receive less individual attention, there are several benefits of group participation for parents. These benefits include support, friendship and constructive feedback from other parents as well as opportunities for parents to normalise their parenting experience through peer interactions.
Self-Directed Triple P
In this self-directed delivery mode, detailed information is provided in a parenting workbook, Every Parent's Self-Help Workbook which outlines a 10-week self-help program for parents. Each weekly session contains a series of set readings and suggested homework tasks for parents to complete.
Some parents require and seek more support in managing their children than simply having access to information. Hence, the self-help program may be augmented by weekly 15-30 minute telephone consultations. These consultations provide brief, minimal support to parents as a means of keeping them focused and motivated while they work through the program and assists in tailoring the program to the specific needs of the family. Rather than introducing new strategies, these consultations direct parents to those sections of the written materials that may be appropriate to their current situation, as in the Group Triple P telephone sessions.
Level 5: Enhanced Triple P
Following participation in a Level 4 program, families requesting or deemed to be in need of further assistance are invited to participate in this individually tailored program. This level extends the focus of intervention to include home-based skills training, mood management and stress coping skills for parents, and marital communication skills as required. The first session is a review and feedback session in which parents' progress is reviewed, goals are elicited and a treatment plan negotiated. Three enhanced individual therapy modules may then be offered to families individually or in combination: Practice, Coping Skills and Partner Support (refer to comments below). Each module is ideally conducted in a maximum of three sessions lasting up to 90 minutes each (with the exception of practice sessions which should last 40 minutes each). Within each additional module, the components to be covered with each family are determined on the basis of clinical judgement and needs identified by the family (i.e. certain exercises may be omitted if parents have demonstrated competency in the target area). All sessions employ an active skills training process to help parents acquire new knowledge and skills. Parents are actively involved throughout the program with opportunities to learn through observation, discussion, practice and feedback. Between sessions, parents complete homework tasks to consolidate their learning. Following completion of the individually tailored modules, a final session is conducted which aims to promote maintenance of treatment gains by enhancing parents' self-management skills and thus reduce parents’ reliance on the clinician.
Specialist Interventions
Standard Stepping Stones Triple P (Level 4)
Stepping Stones Triple P forms part of the Triple P system of parenting and family intervention. This program includes adaptation for parents of preadolescent children who have a disability. This is a 10 session program that incorporates Triple P parenting training methods and introduces additional strategies drawn from disability research literature. Stepping Stones Triple P aims to help parents develop effective management strategies for dealing with a variety of childhood behaviour problems and developmental issues. The approach has been demonstrated to be effective for children with intellectual and physical disabilities who have disruptive behaviour (Harrold, Lutzker, Campbell & Touchette, 1992; Roberts, Mazzucchelli, Taylor & Reid, 2002 in submission). The “Standard” aspect to the title ‘Standard Stepping Stones Triple P’ refers to the individual consultation format used in this intervention, similar to Level 4 Standard Triple P.
Pathways Triple P (Level 5)
Pathways Triple P is a four session intervention strategy for parents at risk of child maltreatment. This is an adjunctive intervention used in combination with either Group or Standard Triple P. Pathways Triple P aims to help parents build on effective management strategies and address the role that parental explanations for child behaviour and parental anger play in the development of these parenting strategies. Pathways Triple P employs active skills training techniques to help parents acquire new skills in managing their own emotions and behaviours along with those of their children. This intervention has been demonstrated to be effective with parents identified at risk of maltreating their children (Sanders, Pidgeon, Gravestock, Conners, Brown & Young, 2004).