Towards a public health approach to parenting

Matthew R. Sanders and Alina Morawska on the importance of parenting, and properly assessing interventions.
AS Sutton and colleagues described in the previous article, there are various parenting, school and community, and personal factors at play in determining a child’s risk of developing serious conduct problems. The temptation is therefore to conclude that when it comes to interventions, ‘more is better than less’; but we think that this has not been convincingly demonstrated.

AS Sutton and colleagues described in the previous article, there are various parenting, school and community, and personal factors at play in determining a child’s risk of developing serious conduct problems. The temptation is therefore to conclude that when it comes to interventions, ‘more is better than less’; but we think that this has not been convincingly demonstrated.
Some large-scale multi-risk-factor- reduction approaches that include parenting, school and child-specific interventions with older school-aged children have shown promise but are complex to administer, costly to implement and have yet to show strong long-term outcomes. But in young children (toddler and preschool-aged children) there is strong evidence that social-learning-based parenting programmes are effective with a wide range of families from quite diverse socio-economic and ethnic backgrounds. We choose to focus on such programmes.  

Parenting is the key

There are two keys to diverting children from the pathway towards externalising problems and crime: parenting and early intervention. Even factors that don’t immediately appear to be related to parenting in fact are: for example, the impact of financial difficulties and high-crime neighbourhoods on the child is mediated primarily through the effect on the family and the parent–child relationship (Conger et al., 1992). And early intervention is vital because it has been shown to be more effective (e.g. Tremblay et al., 1995), easier (e.g. Kazdin, 1987), and more cost-effective in both the short and long terms (Schweinhart & Weikart, 1992). Indeed, the public cost from childhood for individuals with persistent, poorly controlled antisocial behaviour is
up to 19 times higher than for control children, involving many agencies (Scott
et al., 2001).
Quality of parenting is the strongest potentially modifiable risk factor contributing to early-onset conduct problems. Evidence from behaviour genetics research and epidemiological, correlational, and experimental studies shows that parenting practices have a major influence on many different domains of children’s development (Collins et al., 2000). Specifically, the lack of a warm, positive relationship with parents, insecure attachment and inadequate supervision of and involvement with children are strongly associated with children’s increased risk for behavioural and emotional problems (e.g. Frick et al., 1992; Patterson et al., 1992; Shaw et al., 1996).
Children who experience a pattern of harsh discipline in which limits are intermittently enforced learn to achieve desired ends through coercive means (Patterson et al., 1989, 1992). This coercive pattern contributes to the development of problem behaviour, and the child fails to learn self-control and positive social skills. These young children are at significant risk for subsequent difficulties with school adaptation and relationships with peers and teachers, further compounding their risk for eventual problems such as substance use, antisocial behaviour, and participation in delinquent activities (e.g. Loeber & Farrington, 1998). On the other hand, when a parent interacts with a young
child in ways that involve many warm, responsive, reinforcing, and stimulating exchanges, clear, calm instructions and non-harsh, consistent discipline, a
positive and caring relationship between parent and child is more likely to be established, as well as socially skilled repertoires in the child (Ainsworth, 1979; Rutter, 1979).

What works?

Parenting interventions, derived from social-learning, and cognitive-behavioural principles, are considered the interventions of choice for conduct problems in young children (Prinz & Jones, 2003). Parent management training (PMT) programmes have also proven efficacious in prevention studies (e.g. Sanders et al., 2000). In these programmes, parents are typically taught to increase positive interactions with children and to reduce coercive and inconsistent parenting practices.
Studies evaluating PMT interventions often show large effect sizes (Serketich & Dumas, 1996) and have been replicated many times across different studies, investigators and countries (Sanders, 1999). The effects often generalise to a variety of home and community settings (McNeil et al., 1991; Sanders & Dadds, 1982), with two-biological-parent families, step-parents, and single parents. The results are maintained over time (Long et al., 1994), and are associated with high levels of consumer satisfaction (McMahon, 1999).
Studies on PMT show improvements in parental perceptions and parenting skills, improvements in children’s social skills and school adjustment, and reductions in behaviour and attention problems (Barlow & Stewart-Brown, 2000). What’s more, evidence is mounting that a variety of delivery modalities can produce positive outcomes for children (Sanders, 1999), including individually administered face-to-face, group, telephone-assisted, and self-directed programmes. In addition, a number of effectiveness trials of PMT interventions have demonstrated meaningful effects for children who already have conduct problems (e.g. Dishion et al., 2002; Scott et al., 2001; Taylor et al., 1998).
The benefits of PMT interventions are not restricted to children; several studies have shown beneficial effects in other aspects of family functioning, including reduced maternal depression and stress, increases in parental satisfaction and efficacy, and reduced couple conflict over parenting issues (Sanders et al., 2000; Sanders & McFarland, 2000; Schuhmann et al., 1998; Webster-Stratton, 1990).

How do we judge?

There is increasing evidence that brief self-directed interventions can be effective in reducing early conduct problems (e.g. Morawska & Sanders, in press; Sanders
et al., 2000). The assumption that programmes that address more parenting and family risk factors work better is not supported by several studies. So how do
we judge the relative merits of very different programmes, and the evidence
for them? The box below lists some operational criteria that can be applied
in evaluating the strength of evidence of various parenting programmes in reducing risk of antisocial behaviour.

Assessing evidence on parenting programmes

The following criteria can be used to assess the strength of evidence, by whether a programme clearly meets them, only partially, does not meet them, or there is insufficient information available.
l Strength of supporting evidence (e.g. randomised control trials; independent replication across sites and investigators; no known negative side-effects of intervention; robustness demonstrated through evaluation of derivative programmes with other high-risk populations; follow-up data to demonstrate durability; main outcomes both statistically and clinically meaningful)
l Programme reach (e.g. applied to a range of presenting problems and ages; flexible delivery modalities; multiple levels of parent intervention available of differing intensity depending on specific risk and protective factors) l Theoretical basis (e.g. process uses scientifically derived principles of behaviour, affective and cognitive change; collaborative and empowering model to promote self-sufficiency and self-regulation; range of active skills and training strategies used, such as coaching, feedback and homework assignments; times of delivery of interventions developmentally to maximise impact, such as at the transition to school)
l Promotional strategies (e.g. has materials available to service providers; has a specific component focused on working effectively with the media)
l Cultural appropriateness (e.g. has been shown to be culturally acceptable and effective in diverse cultural contexts)
l Dissemination strategy (e.g. wide availability of parent and practitioner resources; delivered by accredited trainers via properly evaluated training procedures)
l Organisational support (e.g. has a post-training peer support supervision network available to trained providers; practitioner and parent websites available and regularly maintained)
l Evaluation (e.g. programme advocates routine evaluation of child and parent outcomes achieved)
l Cost-effectiveness (e.g. cost information readily available; has had an independent cost-effectiveness analysis conducted)
l Consumer acceptability (e.g. has been shown to have high consumer acceptability)

Using such criteria we can assess the pros and cons of programmes such as
Fast Track – a comprehensive, multicentre, multicomponent programme providing long-term services to children exhibiting aggressive behaviours. The intervention includes classroom management, child directed interventions such as socio-cognitive skills training, parent training, and home visiting. In a prevention trial, over 800 high-risk children were randomly assigned to the Fast Track intervention or to a control group. By the end of the third year of the intervention 37 per cent of the intervention group were considered free of serious conduct problems, compared with 27 per cent of the control group. Teacher ratings of conduct problems provided some evidence that the intervention was preventing conduct problems at school (Conduct Problems Prevention Research Group, 2002). While the effects of Fast Track as a preventive intervention are promising, it is an expensive, resource-intensive intervention, and the cost-effectiveness of the programme will need to be examined once long-term outcome data become available. However, few prevention programmes are able to meet
all the criteria outlined above.
Fast Track, and approaches discussed by Sutton and colleagues in the previous article such as the Nurse-Family Partnership and the Perry Preschool Program, tend to be very resource intensive, but there is evidence that such approaches are also cost-effective in the long term. Nevertheless these approaches tend to target very high-risk children, from highly disadvantaged backgrounds. While children from such backgrounds need assistance and intervention, focusing solely on the very disadvantaged end of the spectrum misses a large proportion of children and families who are also at risk for antisocial and conduct problems.

Toward a public health model
To address the difficulties of poor population reach of evidence-based parenting programmes, a public health approach to improving parenting is required. Reducing the prevalence of children’s behaviour problems will require that a large proportion of the population be reached with effective parenting strategies (Biglan, 1995). Thus, a key assumption of a public health or population-based approach is that parenting intervention strategies should be widely accessible in the community. In addition, a public health approach to behaviour change assumes that the mass media play an important role in reaching individuals to affect their knowledge, attitudes and behaviours, in changing public norms, and in affecting institutional policies.
One example of a public health approach to parenting is the Triple P system developed by Sanders and colleagues (Sanders, 1999). The Triple P Positive Parenting Program was designed as a comprehensive population-level system of parenting and family support.
It aims to enhance parental competence, prevent dysfunctional parenting practices, and promote better teamwork between partners, thereby reducing an important set of family risk factors associated with behavioural and emotional problems in children and adolescents. The multilevel system includes five levels of intervention of increasing intensity and narrowing population reach:
l Universal Triple P (Level 1) is a media and communication strategy designed
to target all parents in a population;
l Selected Triple P (Level 2) is a brief one- or two-session intervention;
l Primary care Triple P (Level 3) is a more intensive but brief four-session primary care intervention;
l Standard Triple P (Level 4) is a more intensive eight- to ten-session active skills training programme;
l Enhanced Triple P (Level 5) is the most intensive parenting intervention that targets parenting, partner skills, emotion coping skills, and attribution retraining for the highest-risk families.

Various components of the Triple P system have been subjected to a series
of controlled evaluations, and have consistently shown positive effects
on observed and parent-reported child behaviour problems, parenting practices, and parents’ adjustment. In the Triple P system, the mass media are utilised extensively in a strategic manner to normalise and acknowledge the difficulties of parenting experiences, to break down parents’ sense of social isolation regarding parenting, to destigmatise getting help, to impart parenting information directly to parents, and to alter the community context for parenting (Sanders, 1999).

There are currently two diverging lines of research on how best to prevent conduct problems using differing levels of intensity of intervention. One line focuses on targeting disadvantaged, high risk children, with high-intensity, multicomponent interventions. These interventions typically reach only a small percentage of children who develop conduct problems. The other line of research centres on children with moderate to high levels of risk, and emphasises simplifying the complexity and duration and increasing the population reach of interventions. These two approaches are not mutually exclusive.
It is becoming increasingly evident from the parent training literature that more is not necessarily better than less, when it comes to prevention and intervention with children at risk for behavioural and emotional disorders. While some children and families require intensive interventions, brief targeted methods can be effective even for high-risk children, especially with young children. For moderate-severity problems it may be more efficient to provide a moderate-intensity intervention, and should this prove to be inadequate additional intervention modules could be delivered.
The alternative is to provide all at-risk children with high-intensity interventions, regardless of need and potential response to lower levels of intervention intensity. Such an approach is not cost-effective and is unsustainable for public health systems.
A public health approach needs to focus on efficiency and cost-effectiveness in delivering interventions at a population level. A multilevel intervention approach targeting various problem intensities and levels of risk, provides a model for the reduction of population rates of antisocial behaviour.

- Matthew R. Sanders is Professor of Clinical Psychology at the University of Queensland, Brisbane, Australia. E-mail: [email protected].
- Alina Morawska is at the University of Queensland. Email: [email protected].

Discuss and debate
What are the disadvantages of offering high-intensity interventions?
Is there a trade-off between the intensity of a parenting intervention and the level of population reach achieved?
Can we accurately predict from the pre-intervention characteristics of parents who will respond to different levels of parenting interventions?
How important is the cost-effectiveness of interventions delivered to families?
Have your say on these or other issues this article raises. E-mail ‘Letters’ on [email protected] or contribute to our forum via


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