Original Article

An Evaluation of the Efficacy of a Triple P-Positive Parenting Program Podcast Series Alina Morawska, PhD, Helen Tometzki, BPsychSci, Matthew R. Sanders, PhD ABSTRACT: Objective: Parenting programs based on cognitive-behavioral and social learning principles are effective in changing child behavior problems and parenting styles. However, such programs typically have limited population reach. The current study aimed to evaluate the efficacy of a brief radio series that provided parenting advice based on the Triple P-Positive Parenting Program. Method: One hundred thirty-nine parents of children aged 2 to 10 years who had concerns about their child’s behavioral and/or emotional adjustment were recruited, randomly assigned to either an intervention or waitlist control group, and completed online self-report measures. Parents in the intervention group were given access to seven Triple P podcasts online over a period of 2 weeks. Results: Parents in the intervention group improved significantly more than parents in the control group, from pre- to postintervention, on measures of child behavioral problems and parenting style, self-efficacy, and confidence. These short-term intervention effects were maintained at the 6-month follow-up. Conclusion: These results suggest that brief radio and online parenting programs can be effective and have the potential to reach a large proportion of parents experiencing child behavior problems. Limitations, clinical significance, and future research suggestions are discussed. (J Dev Behav Pediatr 35:128–137, 2014) Index terms: parenting, mass media, child behavior, online intervention.

P

arenting programs based on cognitive-behavioral and social learning principles are the most empirically supported intervention for preventing and treating child behavior problems.1,2 These programs have demonstrated significant reductions in early-onset child behavior problems,3,4 with effects typically being maintained over time.5,6 Parenting programs have also been effective in improving a number of parental outcomes, including reducing dysfunctional parenting styles, increasing parental self-efficacy, and decreasing parental stress.7,8 Although both intensive and brief parent training interventions are effective, their potential to reduce population prevalence rates of disruptive behavior problems is hindered by high dropout rates in some studies9 and low participation in evidence-based parenting inter-

From the Parenting and Family Support Centre, School of Psychology, The University of Queensland, Brisbane, Queensland, Australia. Received May 2013; accepted October 2013. Disclosure: Dr. Alina Morawska is an author on several resources within the Triple P-Positive Parenting Program (“Triple P”). Professor Sanders in the founder and lead author of Triple P. Triple P is owned by the University of Queensland (UQ). UQ, through its technology transfer company Uniquest PTY LTD, has licensed Triple P International to disseminate the program worldwide. Royalties stemming from this dissemination work are paid to Uniquest then distributed between the University, Faculty, School, Parenting and Family Support Centre and contributory authors in accordance with UQ’s intellectual property policy. Professor Sanders has no share ownership in Triple P International. The authors declare no additional conflict of interest. Address for reprints: Alina Morawska, PhD, Parenting and Family Support Centre, School of Psychology, University of Queensland, Brisbane 4072, Australia; e-mail: [email protected] Copyright Ó 2014 Lippincott Williams & Wilkins

128 | www.jdbp.org

ventions.10 Furthermore, barriers preventing parents from attending face-to-face programs include employment commitments, lack of transport, childcare or financial difficulties, inconvenient locations, a fear of stigma or judgment by others,11 and a substantial demand on parents’ time. Low participation limits the impact of parenting interventions in the wider community; therefore, more accessible, less invasive, and less timeconsuming parenting interventions are needed.1 To make a substantive impact on the prevalence of child behavioral and emotional problems, integrated prevention and intervention approaches, embedded in a public health framework, are required. These prevention and intervention efforts should harness the opportunities provided by technology, nontraditional service delivery, and self-help interventions.12 The media are increasingly used as an approach to parenting intervention that can potentially address a number of barriers to participation and can reach a wider audience. However, research into the effectiveness of media-based approaches in changing child or parent behavior is relatively limited. Sanders et al13 found that parents who watched a 12-episode television series based on the Triple P-Positive Parenting Program reported significant improvements in child behavior and perceived parenting competence, compared with those who did not watch the show. The positive effects were maintained at the 6-month follow-up. More recently, a television series depicting families attending Triple P was evaluated. The results suggest that parents who watched the program significantly improved on measures of child behavior, parenting style, and parental well-being at postintervention Journal of Developmental & Behavioral Pediatrics

and the 6-month follow-up.14 These effects were strengthened when parents received an additional self-help workbook and web support.15 Furthermore, parents with more severe problems and who were of higher sociodemographic risk at preintervention were more likely to watch the entire series.14 Parents seem to benefit from mass media interventions, such that televised educational programs and self-directed parenting programs can lead to long-term improvements in parenting style and child behavior. Television is one method of reaching a mass audience, but increasingly various forms of online media access are becoming more common and widely accepted by parents across socioeconomic groups.16 Recently, online parenting programs have also been shown to be effective.17–19 Thus, although there is emerging evidence for the use of mass media and online parenting programs, many gaps remain including evidence for other media formats (e.g., radio), low intensity, and brief online options, which do not necessarily entail parents following a specific structured program. In particular, there is very limited information on mass media approaches, which can be used within a public health, universal framework to enhance positive parenting at a population level. This study examined the efficacy of a series of podcasts from a radio broadcast on 612 ABC Brisbane Mornings with presenter Madonna King and Triple P founder, Professor Matthew Sanders. The series was embedded in a regular morning radio program that covered a range of current affairs and topics. The podcasts were radio excerpts focused on how parents can apply principles of positive parenting in managing children’s oppositional and disruptive behaviors. The current study evaluated the efficacy of a short series of these brief radio podcasts, in a randomized-controlled trial. The study was conducted entirely online, providing a novel example of intervention design and delivery, aiming to reduce both time demands on parents and stigma associated with seeking help. It was hypothesized that, compared with parents in the waitlist control (WLC) group, parents in the Triple P podcast intervention group, at postintervention, would report: (1) significant improvements in parental perceptions of their child’s behavioral and emotional adjustment; (2) a significant reduction in the use of dysfunctional parenting styles, including laxness, overreactivity, and verbosity, and; (3) a significant improvement on parental self-efficacy and confidence in managing child emotional and behavioral problems.

METHOD Participants Participants were 139 parents (92.8% mothers and 6.5% fathers) with a mean age of 36.99 years (SD 5 5.70 years), who had difficulties with, or concerns about, their child’s behavioral and/or emotional adjustment. The children were aged 2 to 10 years, with a mean age of 6.06 years (SD 5 2.13 years), and the sample consisted Vol. 35, No. 2, February/March 2014

of 53 girls (38.1%) and 86 boys (61.9%). The majority of parents were biological or adoptive (97.1%) and married or cohabitating (82%), and most children lived in an original family (72.6%). Fifty-five parents (39.6%) had sought professional help in the past for their child’s social, emotional, or behavioral problems, of whom 26 (18.7%) sought help from psychologists. Twenty-seven parents (19.4%) had participated in a parenting program in the past, and 111 parents (79.9%) said that they had heard of Triple P before participating in the current study. Table 1 displays the means, standard deviations, percentages, x2 statistics, and p values of the demographic variables for the intervention and waitlist control (WLC) groups. The groups did not significantly differ on any of the demographic variables.

Recruitment Principals of schools around Australia were asked via e-mail to advertise the study in their school newsletters; 165 parents read the study information sheet and gave their informed consent to participate. Parents were randomly assigned to either the intervention or WLC group (N 5 84 and N 5 81, respectively) and then completed a brief eligibility questionnaire. Reasons for exclusion from the study included the child not meeting the age criteria and parents having no concerns about the child’s emotional or behavioral adjustment. If parents reported that their child had an intellectual or developmental disability, they were also ineligible for this study. Sixteen parents failed the eligibility check and an additional 9 declined to participate at this stage. Parents who passed the eligibility check were sent e-mails informing them what group they were in, what they were to expect from the progression of the study, and their personal link to complete the first questionnaire. A total of 139 parents (N 5 73 intervention and N 5 66 WLC) completed the preintervention questionnaire.

Measures A questionnaire was administered to parents to gather sociodemographic information about the child and family, including the parent and child’s age and sex, marital status, and family composition. The Eyberg Child Behavior Inventory (ECBI20) is a 36-item measure of parental perceptions of disruptive behavior in children between the ages of 2 and 16 years. It consists of a measure of the frequency of disruptive behaviors (Intensity) rated on a 7-point scale, ranging from never (1) to always (7), and a measure of the number of behaviors that are a problem for parents (Problem), using a yes-no format. The current study found good internal consistency for both subscales: Intensity (a 5 .90) and Problem (a 5 .87). The clinical cutoff is based on an Intensity subscale score of $131 and a Problem score of $15. The Child Adjustment and Parent Efficacy Scale (CAPES21) was used to measure child behavioral and emotional adjustment and parental confidence. It © 2014 Lippincott Williams & Wilkins

129

Table 1. Demographic Characteristics of Participants at Preintervention Intervention Variable

Control

M

SD

M

SD

t

p

36.49

5.77

37.55

5.61

1.09

.277

Child’s age (yr)

5.90

2.27

6.26

1.98

.93

.353

No. children

2.26

.85

2.03

.84

21.60

.112

%

x

p

.23

.631

.09

.770

2.30

.681

.25

.969

5.79

.215

.01

.938

Parent’s age (yr)

n

%

n

2

Parent’s gender Male

4

5.6

5

7.6

Female

68

93.2

61

92.4

Male

46

63.0

40

60.6

Female

27

37.0

26

39.4

Mother

68

93.2

60

90.9

Father

4

5.5

3

4.5

Stepmother

1

1.4

1

1.5

Stepfather

0

0.0

1

1.5

Other

0

0.0

1

1.5

Original family

54

74.0

47

71.2

Step family

8

11.0

7

10.6

Sole parent

9

12.3

10

15.2

Other

2

2.7

2

3.0

Married

49

67.1

50

75.8

Cohabiting

11

15.1

4

6.1

Divorced/separated

9

12.3

10

15.2

Widow/widower

0

0.0

1

1.5

Single

4

5.5

1

1.5

14

19.2

13

19.7

Child’s gender

Relationship to child

Family type

Marital status

Participated in previous parenting program Had heard about Triple P

57

78.1

54

81.8

.30

.583

Had sought professional help

23

31.5

32

48.5

3.93

.047

Ns vary because of missing data.

consists of 30 items rated on a 4-point scale, ranging from “not true of my child at all” (0) to “true of my child very much” or “most of the time” (3). The Total Intensity Scale is a measure of the intensity of the child behavioral and emotional problems. The Behavior subscale consists of 26 items that assess behavior concerns and competencies, and the Emotional subscale consists of 4 items that assess emotional adjustment. Higher scores on the Total Scale and each subscale indicate higher levels of problems. The Confidence Scale consists of 20 items rated on a 10-point scale, ranging from “certain I cannot do it” (1) to “certain I can do it” (10), measuring parents’ level of confidence in managing child emotional and behavioral problems. Higher scores indicate a greater level of confidence in managing problem behaviors. The current study found good levels of internal consistency for the Total Scale and 130 Triple P Podcast Trial

Behavioral and Emotional subscales (a 5 .81, .81, and .63, respectively) and for the Confidence Scale (a 5 .93). The Parenting Scale (PS22) is a 30-item questionnaire measuring 3 dysfunctional discipline styles: laxness (permissive discipline), overreactivity (authoritarian discipline and displays of anger), and verbosity (overly long reprimands or reliance on talking). Each item has a more effective and a less effective anchor, and parents indicate on a 7-point scale the point that best represents their behavior. In this study, there was good internal consistency for the Total score (a 5 .84) and the subscales of Laxness and Overreactivity (a 5 .85 and .84, respectively) but low for Verbosity (a 5 .40). The clinical range for parents is based on a Total score of higher than 3.14 and subscale cutoffs higher than 3.14, 3.04, and 4.04, respectively. Journal of Developmental & Behavioral Pediatrics

The Parenting Task Checklist (PTC23) is a 28-item tool used to assess parenting self-efficacy. For each item, parents are asked to indicate on a scale of 0 (certain I cannot do it) to 100 (certain I can do it) how confident they feel in managing each child behavior. The PTC consists of 2 subscales, Behavioral and Setting SelfEfficacy. The current study found good internal consistency for the Total score and both subscales (a 5 .96, .96, and .90, respectively). The Client Satisfaction Questionnaire24 is a 13-item measure of satisfaction with the service the participants received. Parents rated the quality of the service, the extent to which the program met theirs and their child’s needs, and how much the program helped the parents develop skills and improve their child’s behavior. Items were rated on a 7-point Likert scale, with scores ranging from 13 to 91 and higher scores indicating greater program satisfaction.

Design and Procedure The study was a randomized 2 (group: intervention vs control) 3 3 (time: pre- vs postintervention vs. follow-up) design. Ethical clearance was granted by the University of Queensland in accordance with the standards required by the National Health and Medical Research Council of Australia. Consent was given electronically, parents were randomly assigned to group using computer-generated random assignment, and online eligibility checks were performed. As allocation to group was automatically assigned before participants were tested for eligibility, the number of participants for each group was not equal. Parents completed the preintervention assessment after passing the eligibility check. In line with human ethics research, all parents were given access to the intervention. Parents in the intervention group were given access to the intervention immediately and parents in the WLC group waited 4 weeks before receiving the intervention. All parents completed the second assessment 4 weeks after their first assessment. Parents in the intervention group completed a follow-up assessment 6 months later.

Intervention Podcasts were recorded from an existing ABC public radio program broadcast throughout 2008 to 2010, which discussed issues involving positive parenting skills that aimed to improve child behavior in the home. Seven episodes ranging from 9 to 14 minutes were selected; these were titled “Positive Reinforcement,” “Rewards and Gifts for Children,” “Managing Disobedience,” “Dealing with Aggression,” “Sharing,” “Mealtime Difficulties,” and “Social Responsibility and Empathy.” The core parenting information included in the podcasts was based on evidence-based parenting principles and strategies that have been extensively evaluated in face-to-face interventions.25 The format of these podcasts was conversational, in which the presenter asked questions of the parenting expert relevant to the topics discussed. As Vol. 35, No. 2, February/March 2014

part of this study, parents could listen to the podcasts online or download them, and they were made available after completion of the preintervention assessment in 3 phases over 2 weeks (2 were available immediately, the next 3 after 5 days, and the final 2 an additional 5 days later). Parents were emailed when a new set of podcasts was available. Parents were given an additional 2 weeks to implement the strategies and listen to the 7 podcasts, and podcasts remained available throughout the study.

Statistical Analysis Short-term intervention effects were analyzed by 2 repeated-measures multivariate analysis of variance (MANOVAs). The dependent variables for child behavior were measures of intensity and number of problems (ECBI) and emotional and behavioral adjustment (CAPES). Dependent variables for parenting were measures of dysfunctional parenting styles of laxness, overreactivity, and verbosity (PS), parenting self-efficacy (PTC), and parents’ confidence in managing child emotional and behavioral problems (CAPES Confidence). The level of significance for the univariate analyses was established by using a family-wise modified Bonferroni correction in which a p value of .05 is divided by the number of measures in each analysis. The 6-month follow-up analyses also used repeated-measures MANOVAs. Treatment outcome was measured via the typical method of including only completers of treatment, thus excluding those who drop out of the trial before the postintervention or follow-up assessment phases. Intentto-treat analyses were also performed, in which participants who did not complete the postintervention and follow-up assessments were included in the analysis using the last-observation-carried-forward approach, as a more conservative method of evaluating the efficacy of the treatment. Reliable change indices and clinically significant change analyses were performed to determine whether the effects of the intervention were reliable and clinically meaningful.26

RESULTS Preliminary x2 analyses revealed no differences between groups on demographic variables or preintervention-dependent variables. However, significantly more parents in the control group had previously sought help for child behavioral and/or emotional problems. There were minimal missing data, and missing values were replaced with the item mean.

Attrition Of the 139 participants who completed the preintervention questionnaire, 100 parents (71.9%) completed the postintervention questionnaire. Attrition proportions were significantly different between groups, such that a greater amount of parents in the intervention group did not complete postintervention assessment (N 5 23, N 5 5 elected to withdraw from the study, 38.4%) © 2014 Lippincott Williams & Wilkins

131

Figure 1.

Consort flow diagram.

than the waitlist control (WLC) group (N 5 11, 16.7%). Thirty-five (47.9%) parents in the intervention group completed the 6-month follow-up. Figure 1 shows the consort diagram of the attrition rates for the study. Participants who dropped out of the study were compared with participants who completed the study, at both postintervention and follow-up. No differences were 132 Triple P Podcast Trial

found between participants on demographic variables or preintervention-dependent measures.

Short-Term Intervention Effects Child Behavior There was a significant multivariate effect for time, F4,95 5 14.26, p , .001, and time by group interaction, Journal of Developmental & Behavioral Pediatrics

F4,95 5 6.28, p , .001, for child behavior, using Wilk’s criterion. However, no significant multivariate effects were found for group, F4,95 5 2.36, p 5 .059. Pre- and postintervention means and standard deviations, univariate time by group interaction effects, significance levels, and effect sizes are displayed in Table 2. Parents in the intervention group reported a significantly greater decrease in the frequency and number of child behavior problems from pre- to postintervention than parents in the WLC group. The Child Adjustment and Parent Efficacy Scale (CAPES) Emotional and Behavioral time by group interactions were not significant. Significant univariate time, F1,98 5 8.54, p 5 .004, and group, F1,98 5 4.78, p 5 .031, effects were found for the CAPES Emotional subscale, suggesting that parents in the intervention group reported significantly greater child emotional adjustment when averaged over time, compared with parents in the WLC group. A significant univariate effect for time was found for CAPES Behavioral, F1,98 5 15.77, p , .001, suggesting that both groups improved over time.

pared with parents in the WLC group. The Parenting Task Checklist (PTC) setting time by group interaction was not significant.

Reliability and Clinical Significance of Change The reliable change index26 was calculated for Eyberg Child Behavior Inventory (ECBI) Intensity, ECBI Problem, and Parenting Scale (PS) subscale scores from preto postintervention to determine whether statistically reliable change had occurred. Table 3 shows the number and percentage of participants in each group who reliably improved or worsened on each scale. Parents in the intervention group reliably improved more than parents in the WLC group on measures of ECBI Intensity, PS Laxness, and PS Verbosity. The percentage of parents who scored in the clinical range for child behavior and parenting style at pre- and postintervention are also displayed in Table 3. These results indicate that parents in the intervention group reported significantly more movement from the clinical to nonclinical range than parents in the WLC group on measures of ECBI Intensity and PS Laxness and Verbosity.

Parenting Style and Self-Efficacy A significant multivariate effect for time, F6,93 5 6.31, p , .001, and time by group interaction, F6,93 5 5.18, p , .001, was found for parenting and parenting efficacy, using Wilk’s criterion. However, no significant multivariate effects were found for group, F6,93 5 .58, p 5 .745. Pre- and postintervention mean values and standard deviations, univariate time by group interaction effects, significance levels, and effect sizes are presented in Table 2. Parents in the intervention condition reported a significant reduction in their use of dysfunctional parenting styles and improvements in parental self-efficacy (for child behavior) and confidence in managing child behavior problems from pre- to postintervention, com-

Long-Term Intervention Effects Two repeated-measures multivariate analysis of variance (MANOVAs) were used to assess the long-term intervention effects for child behavior and parenting style and self-efficacy and were followed up with univariate ANOVAs. Only the intervention group was analyzed, and preintervention to 6-month follow-up effects were compared. A significant multivariate time effect was found for both child behavior, F4,31 5 10.15, p , .001, and parenting style and self-efficacy, F6,29 5 10.85, p , .001, with significant univariate effects found for all subscales of child behavior and parenting style and self-efficacy,

Table 2. Short-Term Intervention Effects for Child Behavior and Parenting Intervention (n 5 45) Preintervention Measure

Control (n 5 55)

Postintervention

Preintervention

Postintervention

Mean

SD

Mean

SD

Mean

SD

Mean

SD

ANOVA F1,99

ECBI Intensity

138.53

25.90

118.94

27.11

132.34

30.98

128.87

30.75

24.04

,.001 .56

ECBI Problem

p

d

Child behavior 17.42

5.90

13.11

7.81

16.96

6.28

15.05

6.79

5.24

.024 .39

CAPES Emotional

3.65

1.42

3.22

1.26

4.12

1.42

3.83

1.40

.34

.563 .10

CAPES Behavioral

30.92

5.02

28.88

5.18

30.09

6.15

28.91

6.05

1.13

.291 .15

PS Laxness

2.74

1.00

2.34

.86

2.45

.75

2.48

.86

10.97

.001 .49

PS Overreactivity

3.38

.93

2.98

.77

3.27

1.05

3.26

.99

11.55

.001 .39

PS Verbosity

4.00

.85

3.39

.88

3.74

.74

3.83

.87

19.47

,.001 .88

PTC Behavior

68.51

18.14

81.88

16.55

71.95

20.65

74.14

19.22

11.87

.001 .57

PTC Setting

84.71

11.64

88.15

14.65

86.45

12.57

87.61

11.12

1.08

.300 .19

142.80

25.24

159.34

23.37

144.82

31.44

150.46

31.40

5.60

.020 .38

Parenting

CAPES Confidence

ANOVA, (time 3 group interaction); ECBI, Eyberg Child Behavior Inventory; CAPES, Child Adjustment and Parent Efficacy Scale; PS, Parenting Scale; PTC, Parenting Tasks Checklist.

Vol. 35, No. 2, February/March 2014

© 2014 Lippincott Williams & Wilkins

133

Table 3. Reliable Change Indices and Clinical Change

Group

Reliably Improved, % (n/n)

ECBI Intensity

Intervention

24.4 (11/45)

ECBI Problem

Intervention Control

20.0 (11/55)

PS Laxness

Intervention

28.9 (13/45)

Measure

Control

p

15.11 ,.001

0

0 33.3 (15/45)

Control

11.1 (5/45)

Control

26.6 (12/45)

Control

57.8 (26/45)

35.6 (16/45)

0

47.3 (26/55)

49.1 (27/55)

.308

2.2 (1/45)

77.8 (35/45)

42.2 (19/45)

3.6 (2/55)

67.3 (37/55)

49.1 (27/55)

12.43

.002

4.4 (2/45)

40.0 (18/45)

17.8 (8/45)

3.79

.052

7.3 (4/55)

16.4 (9/55)

18.2 (10/55)

0

62.2 (28/45)

55.6 (25/45)

0

58.2 (32/55)

61.8 (34/55)

2.2 (1/45)

44.4 (20/45)

22.2 (10/45)

3.6 (2/55)

29.1 (16/55)

41.8 (23/55)

1.8 (1/55)

Intervention

Clinical Range Clinical Range Preintervention, Postintervention, % (n/n) % (n/n)

2.35

3.6 (2/55)

PS Intervention Overreactivity PS Verbosity

x2

Reliably Worse, % (n/n)

13.54

.001

1.8 (1/55)

x2

p

8.89 .012 2.74 .254 10.18 .006 4.53 .104

10.45 .005

ECBI, Eyberg Child Behavior Inventory; PS, Parenting Scale.

as shown in Table 4. These results indicate that the intervention effects were maintained at the 6-month follow-up.

Client Satisfaction The Client Satisfaction Questionnaire was completed at the 6-month follow-up, and results indicate that parents in the intervention group reported moderate satisfaction with the program they had received (M 5 60.22, SD 5 9.83). The majority of parents (76.5%) rated the quality of the service they received as “good” or better, and 58.8% were satisfied with the program. Furthermore, the majority of parents reported that the program helped them deal more effectively with their child’s behavior (67.6%) and with problems that arise in their family (61.8%). Parents were also asked at follow-up how many of the podcasts they listened to and whether they continued to refer back to the podcasts after the study was over. Most (76.5%) parents listened to all of the podcasts; all podcasts were listened to between 1 and 2 times, and 14.7%

referred back to the podcasts after they had completed the postintervention questionnaire.

Intent-to-Treat Analysis An intent-to-treat analysis was performed, using the last-observation-carried-forward method, to determine whether the intervention effects found would remain significant when data of participants who dropped out were included in the analysis. Both postintervention and follow-up effects were calculated. At postintervention, of the 10 dependent measures, 5 remained significant: ECBI Intensity, F1,137 5 12.15, p 5 .001; PS Laxness, F1,137 5 7.91, p 5 .006; PS Verbosity, F1,137 5 7.84, p 5 .006; PS Overreactivity, F1,137 5 14.41, p , .001; and PTC Behavior, F1,137 5 6.86, p 5 .010. Two measures were no longer significant: ECBI Problem, F1,137 5 1.94, p 5 .166, and CAPES Confidence, F1,137 5 2.57, p 5 .111; and 3 remained not significant: CAPES Emotional, F1,137 5 .02, p 5 .886, CAPES Behavioral, F1,137 5 .21, p 5 .646, and PTC Setting, F1,137 5 .56, p 5 .456. These results are not

Table 4. Long-Term Intervention Effects for Child Behavior and Parenting Style and Self-Efficacy Preintervention Measure

Mean

SD

Mean

SD

ANOVA, F1,33

p

ECBI Intensity

137.25

24.14

121.49

26.98

18.09

,.001

ECBI Problem

Domain Child Behavior

Parenting

Follow-Up

17.06

6.18

11.86

7.37

29.37

,.001

CAPES Emotional

3.57

1.40

2.89

1.65

6.29

.048

CAPES Behavioral

31.17

5.12

25.21

8.55

29.86

,.001

PS Laxness

2.84

1.07

2.53

1.05

6.33

.017

PS Overreactivity

3.47

1.02

3.02

1.02

15.28

,.001

PS Verbosity

4.19

.81

3.84

1.08

6.80

.013

PTC Behavior

66.20

20.43

82.82

16.13

46.13

,.001

PTC Setting

82.60

12.65

92.12

7.46

27.45

,.001

142.16

25.37

162.27

32.58

13.30

.001

CAPES Confidence

ANOVA, (time effect); ECBI, Eyberg Child Behavior Inventory; PS, Parenting Scale; PTC, Parenting Tasks Checklist; CAPES, Child Adjustment and Parent Efficacy Scale.

134 Triple P Podcast Trial

Journal of Developmental & Behavioral Pediatrics

surprising considering the high attrition rates. However, intent-to-treat analyses for follow-up data found that all significant effects remained so.

DISCUSSION The current study aimed to address some of the gaps in the current literature on population-level parenting programs by evaluating the efficacy of a brief series of online podcasts based on the Triple P-Positive Parenting Program. All three hypotheses were supported, as parents in the intervention group reported significant reductions in the frequency and number of child behavior problems, greater improvements in parenting styles, parental self-efficacy, and parenting confidence, from pre- to postintervention, compared with parents in the waitlist control (WLC) group. The effects were medium to large and were reliably and clinically significant. All effects were maintained at the 6-month follow-up, suggesting that the primary intervention effects were durable. However, there were limited effects on child emotional adjustment or on setting efficacy. These results indicate that the use of the Internet in delivering the Triple P radio podcasts can be a successful and cost-effective tool for the distribution of brief population-level parenting interventions. The program required no practitioner contact and no financial cost, placed little demand on parents’ time, and gave flexible access to the program. Therefore, the radio podcast program may appeal to parents who have limited spare time, such as parents in full-time work. From a public health perspective, this method of delivery has a huge potential reach. Analysis of the clinical significance of these results revealed that a significant proportion of parents across both groups (48.5%) were in the clinically elevated range on measures of child behavior problems (Eyberg Child Behavior Inventory [ECBI]) and parenting styles (Parenting Scale [PS]) at preintervention. This suggests that there are some aspects of the podcast program that appealed to parents experiencing high levels of child behavior problems and dysfunctional parenting styles. Low-intensity universal parenting programs typically aim to help parents deal with common, less severe child behavior problems25; so, it was unexpected that such large effects were found for parents with children in the clinical range, given the low intensity of the intervention. However, these findings are consistent with previous research, which has found that brief and media-based parenting interventions lead to significant improvements in child behavior and emotional problems, parenting style, and parental self-efficacy and confidence.13–15,27–30 One of the aims of this type of intervention is to reduce the barriers associated with getting help, such as lack of time, lack of access to the intervention, and financial difficulties.11 The online parenting podcasts were less demanding on parents’ time and finances than a program that requires practitioner contact, and its flexibility allowed parents to access the podcasts at a time that suited them. Furthermore, the podcasts were portable, so Vol. 35, No. 2, February/March 2014

that parents could listen to them on any device and in any location, which allowed maximum exposure to the intervention and repetition of the content. There was a moderate level of attrition for the study (27.9%), with significantly fewer parents in the intervention group completing the postintervention assessment than the WLC group. High attrition rates are common in family intervention research with estimates of up to 75% having been reported.31 The higher rates of attrition for parents in the intervention group than typically observed in Triple P face-to-face interventions8 may have been because of an unwillingness to continue to participate once parents had access to the podcasts, the anonymity of an online program reducing participants accountability, lack of time to complete the assessment, dissatisfaction with the program, or the lack of in person support being available. Program satisfaction rates were lower compared with face-to-face intervention3 and more intensive online interventions,17 with only 58.8% of parents reporting being satisfied with the program. This may be a reflection of the fact that parents may have been expecting a different intervention to what they in fact received as part of this project. Future research could investigate what parts of the online podcast program were dissatisfactory, such as program delivery method, technical issues, or podcast content and the effects this has on outcomes. It is important to note that the podcasts were not designed as an intervention but as part of a public health approach to parenting intervention. Given the brevity and low cost of this approach, the potential applications in a public health context would be quite different. Several limitations of the current study need to be considered. Data in relation to the number of podcasts listened to were not recorded during the study. Television Triple P interventions have found that the number of episodes watched was associated with level of improvement, and parents with more severe problems and those of higher sociodemographic risk at preintervention were more likely to watch the entire series.14 Collection of these data in future research would determine if the results were found because of full or partial completion of the intervention, if fewer podcasts would find the same effect, and if repetition of the podcasts is effective. In fact, during the period that the radio show was aired, many other topics and sessions were produced, which were not ordered in any particular sequence. Therefore, future research could determine whether an optimum number of topics are most effective or whether repetition of key themes over time enhances the effects of the program. Furthermore, as this study presented the podcasts in a logical sequence, a question to consider is whether the content of the podcasts relates to outcomes or whether specific topics are more relevant for specific problems. For example, would a miniseries relating to mealtime problems be as effective for parents of children with mealtime difficulties as the generic series we trialed. It would also be © 2014 Lippincott Williams & Wilkins

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important to examine predictors of outcome based on family characteristics. For example, do children with fewer behavior problems respond better to this type of intervention? The current study had a high reliance on self-report data, and independent reports of child and parent behavior were not collected. Future research into the effectiveness of the Triple P podcast series should examine multiinformant assessments and observations of parent-child behavior to triangulate findings. Another limitation is that some demographic information was not collected, such as education level, work status, and ethnicity. Collecting these data could give us a better picture of the type of parents that accessed this type of program delivery and increase the generalizability of the findings. In addition, medical history data were not collected, which could have eliminated potential confounds, such as receiving concurrent professional help or the use of medication for behavioral problems. A final limitation was that the use of only electronic communication and intervention material might have been a barrier to some potential participants. Some participants might have had difficulties listening to or downloading the podcasts, which could have reduced the overall exposure to the Triple P content and satisfaction with the program. To overcome this problem, the program may be administered by way of posting the podcasts on a disk to participants without Internet access. Although this is not as cost-effective as using the Internet, this may increase the number of parents who could access the program and should be considered for future research. In addition, providing contact details of a support person available in cases such as these may reduce the effect of this potential barrier. Nevertheless, given the growing access to and use of Internet-based resources, it is likely that this will become less of a concern for most families. The current study has provided valuable initial evidence supporting the use of radio broadcasts and the Internet in a population-based parenting support program and presented further evidence to suggest that interventions with no practitioner contact can be beneficial even for parents of children with clinical levels of behavior problems. Furthermore, Internet-based Triple P interventions can be accessed by a broad range of parents for very little cost. The implications of these findings suggest that this intervention could be effective on a population-wide level and help parents improve their child’s behavior and parenting styles from their own home. This study has demonstrated that a very brief, Internet-based intervention with no clinician input was effective in reducing child behavior problems in families reporting relatively high levels of problems. Many of these parents had in fact sought prior help for their child’s behavior in the past year, indicating that these were parents with fairly high levels of concern. Clearly, this type of intervention is not likely to be suitable for everyone, nor does it obviate the need for more intensive, face-to-face, individually tailored interventions. However, given increasing calls for a population-based, 136 Triple P Podcast Trial

public health approach to prevention and intervention with child behavior problems (e.g., Ref. 32), this type of program, with very low cost and very wide reach, has the potential to make a significant contribution to the suite of evidence-based parenting interventions available to the community. REFERENCES 1. Taylor TK, Biglan A. Behavioral family interventions for improving child-rearing: a review of literature for clinicians and policy makers. Clin Child Fam Psychol Rev. 1998;1:41–60. 2. Lundahl B, Risser HJ, Lovejoy MC. A meta-analysis of parent training: moderators and follow-up effects. Clin Psychol Rev. 2006; 26:86–104. 3. Sanders MR, Markie-Dadds C, Tully LA, et al. The Triple P-Positive Parenting Program: a comparison of enhanced, standard, and selfdirected behavioral family intervention for parents of children with early onset conduct problems. J Consult Clin Psychol. 2000;68:624–640. 4. Brestan EV, Eyberg S. Effective psychosocial treatments of conductdisordered children and adolescents: 29 years, 82 studies, and 5,272 kids. J Clin Child Psychol. 1998;27:180–189. 5. Hood KK, Eyberg SM. Outcomes of parent-child interaction therapy: mothers’ reports of maintenance three to six years after treatment. J Clin Child Adolesc Psychol. 2003;32:419–429. 6. Sanders MR, Bor W, Morawska A. Maintenance of treatment gains: a comparison of enhanced, standard, and self-directed Triple P-Positive Parenting Program. J Abnorm Child Psychol. 2007;35: 983–998. 7. Thomas R, Zimmer-Gembeck M. Behavioral outcomes of parent-child interaction therapy and Triple P-Positive Parenting Program: a review and meta-analysis. J Abnorm Child Psychol. 2007;35:475–495. 8. Nowak C, Heinrichs N. A comprehensive meta-analysis of Triple PPositive Parenting Program using hierarchical linear modeling: Effectiveness and moderating variables. Clin Child Fam Psychol Rev. 2008;11:114–144. 9. Kazdin AE. Parent management training: evidence, outcomes and issues. J Am Acad Child Adolesc Psychiatry. 1997;36:1349–1356. 10. Sanders MR, Markie-Dadds C, Rinaldis M, et al. Using household survey data to inform policy decisions regarding the delivery of evidence-based parenting interventions. Child Care Health Dev. 2007;33:768–783. 11. Morawska A, Sanders MR. A review of engagement and strategies to promote engagement with parenting interventions. J Child Serv. 2006;1:29–40. 12. Kazdin AE, Blase SL. Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspect Psychol Sci. 2011;6:21–37. 13. Sanders MR, Montgomery DT, Brechman-Toussaint ML. The mass media and the prevention of child behavior problems: the evaluation of a television series to promote positive outcome for parents and their children. J Child Psychol Psychiatry. 2000;41:939–948. 14. Calam R, Sanders MR, Miller C, et al. Can technology and the media help reduce dysfunctional parenting and increase engagement with preventative parenting interventions? Child Maltreat. 2008;13: 347–361. 15. Sanders M, Calam R, Durand M, et al. Does self-directed and webbased support for parents enhance the effects of viewing a reality television series based on the Triple P-Positive Parenting Programme? J Child Psychol Psychiatry. 2008;49:924–932. 16. Metzler CW, Sanders MR, Rusby JC, et al. Using consumer preference information to increase the reach and impact of mediabased parenting interventions in a public health approach to parenting support. Behav Ther. 2012;43:257–270. 17. Sanders MR, Baker S, Turner KMT. A randomized controlled trial evaluating the efficacy of Triple P online with parents of children with early-onset conduct problems. Behav Res Ther. 2012;50:675–684.

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