Guest Editorial

The translation of an evidence-based parenting program into regular clinical services

Matthew R Sanders
Parenting and Family Support Centre, University of Queensland, Brisbane QLD

PP: 123 - 126

Keywords

prevention, parent training, family intervention, effectiveness, dissemination

Article Text

It is now widely accepted that dysfunctional parenting practices and family conflict are generic risk factors related to a wide variety of behavioural and emotional problems in children and adolescents. Indeed of all the potentially modifiable risk and protective factors that can affect children's development, improving parenting skills and confidence holds the greatest potential in improving children's health status and well being, and in reducing the risk of developing serious mental health problems. Evidence to support the importance of good parenting in the aetiology, maintenance, treatment and prevention of childhood problems is substantial. This evidence comes from diverse fields and areas of inquiry including animal research, behavioural genetics, developmental studies using both cross sectional and longitudinal designs, and intervention research where parenting variables are manipulated in both treatment and prevention trials (see Sanders, 1999).

There is substantial evidence from randomized controlled trials that behavioural family interventions based on social learning principles are effective in the prevention and treatment of a range of childhood behavioural and emotional problems. Research evaluating the clinical utility of these interventions fall into these categories - efficacy trials, effectiveness trials and dissemination trials.

Efficacy trials evaluate the effects of an intervention when delivered under fairly controlled conditions using carefully selected and trained personnel. Typically, these evaluations are conducted with carefully defined populations, that may or may not have co-occurring additional problems and assess child and parent outcomes, using reliable and validated assessment tools. Typically such trials involve a multi-modal, multi-informant approach to evaluation and include independent observation of parent-child interaction, clinical diagnostic interviews, and completion of parent-and or teacher-report measures. Such trials are expensive, often conducted within University-based specialist clinical research units or centres and have stringent inclusion and exclusion criteria, tight experimental controls, favour randomised group comparison methodologies, and use sophisticated measurement of outcomes.

Effectiveness trials test the robustness of interventions through evaluating their impact when delivered through regular services. The interventions are typically delivered by clinical staff employed by those services, using client populations where comorbidity is the rule rather than the exception. This services-based research tests the robustness of the intervention and the main criterion for success is change in client behaviour or functioning. These effectiveness trials provide a test of an intervention's applicability, feasibility and generalisability in the community settings.

Dissemination trials test the effectiveness of various strategies and procedures that seek to transfer knowledge regarding evidence-based parenting interventions on to other professionals and service providers. In a dissemination trial the test of how well the dissemination intervention works concerns a change in practitioner or agency behaviour rather than client behaviour or outcomes per se, although both may be examined concurrently. Dissemination refers to the process of spreading knowledge of an innovation and promoting its adoption. This involves a process of communication between those who know about an innovation (researchers and program developers) and those who do not (service providers in various clinical or community settings) which is often referred to as diffusion. Adoption refers to the acceptance and implementation of an innovation by the dissemination targets, which may be individual practitioners, organisations and/or policy makers. To be considered successful, adoption must occur while maintaining intervention fidelity, integrity or adherence. That is, the critical features of the intervention are implemented consistently across adopters, with minimal drift from the original validated procedures. Successful dissemination does not rest with the initial adoption of an innovation. Maintenance refers to the sustained implementation of an innovation and its incorporation into usual practice.

An intervention can be classified according to the level of evidential support available as well-established, probably efficacious or experimental. To be considered well-established, an intervention must be:

1. highly specified (usually through intervention manuals) so that procedures can be understood and replicated by others
2. validated in studies with clearly defined samples
3. documented to be effective in either
   1. at least two group design studies demonstrating statistically significant superiority to a placebo condition, or superiority or equivalence to an established intervention, or
   2. a large series of single-case design studies employing good experimental design and demonstrating superiority as stated above; and
4. demonstrated to be effective in studies by at least two independent investigators.

To be considered probably efficacious, an intervention must meet criteria a) and b) above and c) must have its efficacy demonstrated through:

1. two studies showing the treatment is more efficacious than a waitlist control group
2. one good study demonstrating superiority to a drug or psychological placebo, or superiority or equivalence to an established intervention
3. a small series of good single-case design studies; or
4. at least two good studies demonstrating efficacy but flawed by the use of a heterogeneous sample.

Interventions not yet meeting criteria for either of these terms are labelled experimental, although this should not be assumed to mean that the intervention is not efficacious.

The Triple P-Positive Parenting Program developed by Sanders and colleagues at the University of Queensland (see Sanders, 1999) is used as an example to illustrate the translation of an evidence-based system of parenting intervention into services available to parents in the community. Over a 20 year period a large number of randomised controlled efficacy trials have established that behavioural family intervention is effective in reducing conduct and other clinical problems in children (see Sanders, Turner & Markie-Dadds, 2002). Evidence from this work shows that group, individually-administered, telephone-assisted and even completely self-directed programs can be effective in the prevention and treatment of conduct problems in children. Using the APA criteria Triple P would clearly meet the criteria for a well established intervention. However, much less is known about the process of translating such research findings into clinical services. There are many important questions to be addressed. Do the interventions remain effective when delivered through primary care and mental health services? Are there special implementation issues relating to the use of the program with particular communities, ethnic groups or client populations?

Triple P is used as an example to illustrate the complex nature of the dissemination process that is involved in moving from efficacy trials to routine clinical services. This special issue illustrates the challenges involved in successfully implementing evidence-based parenting programs through the experiences of groups in three states in Australia - Queensland, New South Wales and Victoria, all of whom have been involved in the large scale implementation of different levels of the Triple P-Positive Parenting Program. In each case there has been a commitment to ongoing evaluation of the program effectiveness and the papers document the implementation process.

The first paper by Sanders provides an overview of the Triple P system and outlines some key principles regarding the large scale implementation of a population level parenting intervention. This paper argues for the importance of viewing parenting support as a public health issue that needs to be understood within an ecological framework. The paper argues for improving access through better use of the media, primary care, child care centres, schools, and workplaces.

McTaggart and Sanders present the first data of the effects of Triple P, when delivered as part of a transition to school intervention, on teachers' reports of children's behaviour in the classroom. As behaviour problems and learning difficulties at school are major risk factors predicting the development of conduct disorders, it is important to know whether parenting programs can independently affect children's school functioning without concurrent school intervention.

Ralph, Toumbourou, Grigg et al. report on a survey that identifies the major parenting concern of parents of young teenagers in Melbourne and Townsville. The major concerns related to day to day interactions in the home such as fighting with siblings and talking back to parents rather than the more frequently discussed topics such as concerns with drugs, sex or peer influence.

The fourth paper, by Ralph and Sanders, presents pilot data evaluating a brief 8 session group parenting program for parents of teenagers (Group Teen Triple P). Promising short term intervention effects are demonstrated showing how positive parenting skills reduce parent-adolescent conflict, increase parental self efficacy, and reduce parental depression, anxiety and stress.

The next five papers by Dean; Crisante; Cann, Rogers and Worley; Cann, Rogers and Matthews; and Rogers, Cann, Cameron et al., each report on large scale projects where Triple P has been implemented as part of regular service delivery. Outcome data are reported from each group.

An important issue in a multicultural society such as Australia is the extent to which programs such as Triple P are culturally relevant and appropriate to different ethnic communities. Crisante and Ng (2003) present an interesting example of the use of Group Triple P as an intervention for Chinese parents in Western Sydney. The paper includes some useful ideas about how to address culturally specific issues concerning parenting while maintaining the integrity of the program.

The papers presented in this series show that not only can evidence-based programs be successfully implemented across different services and delivery contexts, but that ongoing evaluation can demonstrate that outcomes achieved can be comparable to those achieve in clinical trials. These programs combined with existing research trials show that Triple P is a powerful population level intervention supporting parents to more confidently raise their children. Furthermore these data support the conclusion that the program can be successfully disseminated across a variety of service delivery contexts and remain effective.

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