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Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P)

Topic Areas
Scientific Rating
Child Welfare Relevance
Disruptive Behavior Treatment (Child & Adolescent)
1  — Well-Supported by Research Evidence
Medium
Parent Training Programs that Address Behavior Problems in Children and Adolescents
1  — Well-Supported by Research Evidence
Medium

About This Program

Target Population: For parents and caregivers of children and adolescents from birth to 12 years old with moderate to severe behavioral and/or emotional difficulties or for parents that are motivated to gain a more in-depth understanding of positive parenting

For parents/caregivers of children ages: 0 – 12

Program Overview

Level 4 Triple P is one of the five levels of the Triple P - Positive Parenting Program® System which is also highlighted on the CEBC. Level 4 Triple P helps parents learn strategies that promote social competence and self-regulation in children as well as decrease problem behavior. Parents are encouraged to develop a parenting plan that makes use of a variety of Level 4 Triple P strategies and tools. Parents are then asked to practice their parenting plan with their children. During the course of the program, parents are encouraged to keep track of their children's behavior, as well as their own behavior, and to reflect on what is working with their parenting plan and what is not working so well. They then work with their practitioner to fine tune their plan. Level 4 Triple P practitioners are trained to work with parents' strengths and to provide a supportive, nonjudgmental environment where a parent can continually improve their parenting skills. Level 4 Triple P is offered in several different formats (e.g., individual, group, self-directed, and online). The CEBC evaluated the standard version of Level 4 Triple P as described above and not any other variations (including early teen versions or those for children with developmental delays).

Program Goals

The goals of Triple P - Positive Parenting Program® - Level 4 are:

  • Increase competence in promoting healthy development and managing common child behavior problems and developmental issues
  • Reduce use of coercive and punitive methods of disciplining children
  • Increase use of positive parenting strategies in managing their children's behavior
  • Increase confidence in raising their children
  • Decrease behavior problems in their children (for families experiencing difficult child behaviors)
  • Improve partners' communication about parenting issues
  • Reduce stress associated with raising children

Logic Model

View the Logic Model for Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P).

Essential Components

The essential components of Triple P - Positive Parenting Program® - Level 4 include:

  • Uses developmentally appropriate interventions with a variety of media:
    • Provides a program designed for infants, toddlers, preschoolers and elementary school-aged children, as well as a distinct program for early teens and another for parents of children with disability
    • Delivered with a variety of resources (such as parent workbooks, parent DVD collections, practitioner presentations, a self-directed workbook, and an online application) used in session and later in assigned homework to impart information and to provide a parent with practice exercises when at home
  • Uses an explicit self-regulatory framework:
    • Includes principles of:
      • Self-sufficiency
      • Self-efficacy
      • Self-management
      • Problem-solving
    • Parents taught how to monitor their own and their child's behavior, and asked to set specific and observable goals for change
    • Self-management and self-sufficiency enhanced by having the practitioner prompt the parent to review his or her application of new parenting strategies, reflecting on what they did well in the process (their strengths), and then setting specific goals for any difficulties or challenges they experienced
    • Parent assisted in applying the principles they have learned to solve problems in a self-sufficient manner that leads to more independence
    • Practitioners encouraged to use multiple, relevant examples with families and to create a flexible teaching environment
  • Uses the principles of minimal sufficiency to ensure cost effectiveness:
    • Allows tailoring of intervention intensity to meet individual family needs which helps cost effectiveness
    • Assesses the level of risk the family faces via intake interview, questionnaires, monitoring, and observation of parent-child interaction by practitioner
    • Tailors the level of intensity based on the level of risk and difficulty the family faces (i.e., the higher the risk, the higher the intensity)
    • Administers assessments after completion of Level 4 Triple P to determine if a family needs Level 5 Triple P or other further support
  • Incorporates identifiable program elements to promote generalization and transfer of learning:
    • Uses multiple examples as part of its flexible training philosophy
    • Teaches generalization and maintenance across time, situations, and children
    • Teaches parents strategies for managing high-risk situations (e.g., going shopping) to ensure generalization across contexts
  • Offers and evaluates flexible delivery modalities such as:
    • Individual delivery
    • Group delivery with 8–12 parents
    • Self-directed program delivery, including an online version
    • May be offered in a variety of settings (e.g., home, clinic, school, family resource center)

Program Delivery

Parent/Caregiver Services

Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) directly provides services to parents/caregivers and addresses the following:

  • Parents with children with moderate to severe behavior problems (e.g., multiple behavior problems, aggressive behavior, oppositional defiant disorder, conduct disorder, learning difficulties), significant difficulty managing these behaviors, lack of positive parenting skills including how to manage the following: stress, mild-moderate depression symptoms, anxiety, anger, parenting partner conflict, and negative attributional thinking
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: In Level 4 Triple P, the parent(s) and/or caregivers are the main participants; other family members may be asked to join if it fits into the family's parenting plan. The intention is to empower parents or caregivers to raise children and to become increasingly self-reliant. Children can be involved in the initial phases of intervention for assessment via interview and/or observation. Children are also involved for parent-child interaction observation later in the program.

Recommended Intensity:

The program comes with a variety of delivery options: 1) Three group versions which have five 2-hour group sessions and three 20-minute individual telephone consultations for each family offered over eight consecutive weeks; 2) Two online versions, one with eight self-paced online modules for caregivers of children up to 12 years old and one with six modules for caregivers of teens; 3) A self-directed workbook which is self-paced; or 4) Three individual or standard versions which have 10 1-hour sessions that occur weekly.

Recommended Duration:

Program interventions typically take place over 2-3 months. If accommodations are needed (e.g., low literacy clients), the duration may be longer.

Delivery Settings

This program is typically conducted in a(n):

  • Adoptive Home
  • Birth Family Home
  • Foster / Kinship Care
  • Hospital
  • Outpatient Clinic
  • Community-based Agency / Organization / Provider
  • Group or Residential Care
  • School Setting (Including: Day Care, Day Treatment Programs, etc.)
  • Virtual (Online, Telephone, Video, Zoom, etc.)

Homework

Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) includes a homework component:

Homework is an integral part of Level 4 Triple P and is agreed upon in session and reviewed in the following visit as part of the parent learning to self-regulate. Homework could include monitoring of parent behavior, implementation of positive parenting strategies (e.g., behavior charts) and discipline routines, practice sessions with child, viewing videos, reading parent workbooks, problem-solving exercises, and planned discussion with parenting partner.

Languages

Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) has materials available in languages other than English:

Arabic, Chinese, Danish, Dutch, Flemish, French, German, Japanese, Portuguese, Romanian, several other languages, Spanish, Swedish, Vietnamese

Papiamentu, Urdu

Resources Needed to Run Program

The typical resources for implementing the program are:

For individual families, practitioners will need the accompanying parent resources for a given intervention and a space to talk with the parent that is comfortable for the parent (e.g. appropriate level of privacy, etc.). These practitioners will also need equipment to show families DVD clips (e.g., laptop with a DVD, portable DVD player, TV with DVD, etc.). For group interventions, practitioners will need A/V equipment to deliver a PowerPoint as well as show DVD clips to parents. Practitioners will also need a white board or flip chart. Level 4 interventions require a single practitioner/consultant to provide the direct service. However, it is highly recommended that agencies staff their Level 4 Triple P program in order to sustain it.

Manuals and Training

Prerequisite/Minimum Provider Qualifications

Level 4 Triple P provider training courses are usually offered to practitioners with a post-high school degree in health, education, child care, or social services. In exceptional circumstances this requirement is relaxed when the prospective practitioners are actively involved in "hands-on" roles dealing with the targeted parents, children and teenagers. These particular practitioners have developed, through their workplace experience, some knowledge of child/adolescent development and/or have experience working with families.

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Sanders, M. R., Markie-Dadds, C. & Turner, K. M. T. (2013). Practitioner's manual for Standard Triple P (2nd ed.). Triple P International Pty Ltd.

Turner, K. M. T., Markie-Dadds, C. & Sanders, M. R. (2010). Facilitator's manual for Group Triple P (3rd ed.). Triple P International Pty Ltd.

The manual is provided with other training materials at the Triple P Provider Training Course.

Training Information

There is training available for this program.

Training Contact:
Training Type/Location:

Most commonly training is provided onsite with an agency or organization hosting the training. However, Triple P America also hosts and provides trainings in an Open Enrollment format several times a year for agencies and organizations that do not have a large enough group for an agency-based training. Open Enrollment trainings are conducted in major cities around the U.S., depending on regional demand, and are posted on the Triple P America website.

Number of days/hours:

Training for Level 4 Triple P standard version is three days for training, one full-day for preaccreditation 4-6 weeks following training, plus 1/2 day accreditation (per trainee) 6-8 weeks posttraining. Training for Level 4 Triple P group version is also a 3-day training course followed by a one-day preaccreditation day 4-6 weeks posttraining, and a 1/2 day accreditation (per trainee) conducted 6-8 weeks after training. Training cohorts are comprised of 20 trainees with one Level 4 Triple P trainer for both the training and preaccreditation days. These cohorts are divided into smaller groups during the final accreditation procedures. The actual training hours for each training day are 9:00 am - 4:30 pm, including two 20-minute breaks and a 45-minute lunch break, most often catered onsite by the hosting agency. The self-directed and online versions of Level 4 Triple P do not have training courses. It is recommended, however, that agencies that provide these versions have trained providers available to answer parents' questions.

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) as listed below:

Support using the Triple P Implementation Framework includes several tools designed to support agencies in the successful adoption of Triple P. Examples of these documents include:

  • Implementation Workbook
  • Implementation Preparation Form
  • Organizational Readiness Checklist
  • Quality Assurance Considerations
  • Evaluation Checklist
  • Sustainability Considerations
  • Shared Learning Networks

Triple P Implementation Tools are provided with support from an Implementation Consultant for agencies adopting Triple P. Please email contact.us@triplep.net for more information related to the Triple P Implementation Framework.

Formal Support for Implementation

There is formal support available for implementation of Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) as listed below:

Triple P America employs Implementation Consultants who provide support through a mix of on-site, teleconferencing, webinar, and email support. Triple P Implementation Consultants support organizations in the implementation planning process and sharing of Triple P implementation tools for agencies/jurisdictions adopting Triple P. This support is available throughout an initiative; often more intensive at first and tapering off as sites/jurisdictions develop effective plans for maintenance. Triple P America provides consultation, resources and tools related to evaluation and fidelity monitoring but does not provide direct oversight or collect data from implementing sites. Implementation Consultants use the tools from the Triple P Implementation Framework to foster local ownership of the intended outcomes and processes for evaluation. Sites are supported in fostering effective leadership and following best practices for workforce development, service delivery, and quality improvement cycles. While Implementation Consultants focus on support for administrators and managers of initiatives, Triple P Trainers are an available resource to sites seeking additional consultation and support for practitioners through developed workshops, tailored support days, and/or consultation calls at an additional cost.

Fidelity Measures

There are fidelity measures for Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) as listed below:

Triple P has three quality assurance/fidelity checks built into its implementation framework:

  • Accreditation of Practitioners – Completed within the context of a Triple P Provider Training Course, this establishes baseline competence of all practitioners and certifies them as being able to implement the program as intended. The accreditation process has two steps: obtaining a passing score on a written exam and displaying competence in parent consultation skills as scored by an accredited Triple P trainer through direct observation or DVD submission. Procedures are in place to help and "recycle" practitioners to master the intervention when they do not pass accreditation.
  • Session Checklists – Each intervention has a session checklist which assists practitioners in implementing the service as intended. These checklists are integrated into the training protocol and are found in all Triple P manuals. Organizations have the flexibility to utilize these instruments as self-assessments or in more formal quality assurance procedures.
  • Peer Support Networks - A crucial element in implementation sites involves the adoption of a self-regulatory framework and the use of the Peer Assisted Support and Supervision (PASS) model of quality assurance. During PASS sessions, practitioners present cases, obtain feedback from other qualified practitioners, and continue to supplement their skills with continuing education. Practitioners learn the PASS model at training, and the PASS manual and checklist are available to trained practitioners through the Triple P Provider Network.

Other quality assurance and fidelity checks available and Triple P America implementation consultants will work with local agencies to craft a plan that is consistent with local oversight agency procedures. Please email contact.us@triplep.net for further information on measures of fidelity.

Implementation Guides or Manuals

There are implementation guides or manuals for Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) as listed below:

Triple P has two levels of implementation tools available. There are a range of documents available to agency leadership and managers that provide guidance on organizational and systems level factors. Implementation Consultants provide support to organizations to develop their own handbook of implementing Triple P, using the tools and processes in the Implementation Framework to provide a context specific guide for those responsible for coordinating the implementation of Triple P at that organization or region. For the direct service provider, each level of Triple P includes a Practitioner Manual with step-by-step guidelines for successful delivery of Triple P.

Tools associated with the Triple P Implementation Framework are provided in conjunction with support from a Triple P Implementation Consultant for agencies or jurisdictions interested in adopting Triple P. The Triple P Practitioner Manuals are provided as part of the Triple P Provider Training Courses. Please email contact.us@triplep.net from more information related to the Triple P Implementation Framework. The relevant Triple P Practitioner Manual is provided to practitioners when they attend a Triple P Provider Training Course.

Implementation Cost

There have been studies of the costs of implementing Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) which are listed below:

Research on How to Implement the Program

Research has been conducted on how to implement Triple P - Positive Parenting Program - Level 4® (Level 4 Triple P) as listed below:

  • Aldridge, W. A., II, Murray, D. W., Prinz, R. J., & Veazey, C. A. (2016). Final report and recommendations: The Triple P implementation evaluation, Cabarrus and Mecklenburg counties, NC. Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill. https://fpg.unc.edu/publications/final-report-and-recommendations-triple-p-implementation-evaluation-cabarrus-and
  • Asgary-Eden, V., & Lee, C. M. (2012). Implementing an evidence-based parenting program in community agencies: What helps and what gets in the way? Administration and Policy in Mental Health and Mental Health Services Research, 39(6), 478–488. https://doi.org/10.1007/s10488-011-0371-y
  • Breitkreuz, R., McConnell, D., Savage, A., & Hamilton, A. (2011). Integrating triple P into existing family support services: A case study on program implementation. Prevention Science, 12(4), 411–422. https://doi.org/10.1007/s11121-011-0233-6
  • Fawley-King, K., Trask, E., Calderon, N. E., Aarons, G. A., & Garland, A. F. (2014). Implementation of an evidence-based parenting programme with a Latina population: feasibility and preliminary outcomes. Journal of Children's Services, 9, 295–306. https://doi.org/10.1108/JCS-04-2014-0024
  • Fives, A., Pursell, L., Heary, C., Nic Gabhainn, S., & Canavan, J. (2014). Parenting support for every parent: A population-level evaluation of Triple P in Longford Westmeath. Final report. Athlone, Ireland: Longford Westmeath Parenting Partnership. https://www.researchgate.net/publication/283903988_Parenting_support_for_every_parent_A_population-level_evaluation_of_Triple_P_in_Longford_Westmeath_Final_Report
  • Mazzucchelli, T. G. & Sanders, M. R. (2010). Facilitating practitioner flexibility within evidence-based practice: Lessons from a system of parenting support. Clinical Psychology: Science and Practice, 17(3), 238–252. https://doi.org/10.1111/j.1468-2850.2010.01215.x
  • McPherson, K. E., Sanders, M. R., Schroeter, B., Troy, V., & Wiseman, K. (2016). Acceptability and feasibility of Peer Assisted Supervision and Support for intervention practitioners: A Q-methodology evaluation. Journal of Child and Family Studies, 25(3), 720–732. https://link.springer.com/article/10.1007%2Fs10826-015-0281-9
  • McWilliam, J., Brown, J., Sanders, M. R., & Jones, L. (2016). The Triple P implementation framework: The role of purveyors in the implementation and sustainability of evidence-based programs. Prevention Science, 17, 636–645. https://doi.org/10.1007/s11121-016-0661-4
  • Morawska, A., Sanders, M., Goadby, E., Headly, C., Hodge, L., McAuliffe, C., Page, S., & Anderson, E. (2011). Is the Triple P-Positive Parenting Program acceptable to parents from culturally diverse backgrounds? Journal of Child and Family Studies, 20, 614–622. https://doi.org/10.1007/s10826-010-9436-x
  • Romney, S., Israel, N., & Zlatevski, D. (2014). Exploration-stage implementation variation: Its effect on the cost-effectiveness of an evidence-based parenting program. Zeitschrift für Psychologie, 22, 37–48. https://doi.org/10.1027/2151-2604/a000164
  • Sanders, M. R., Prinz, R. J., & Shapiro, C. J. (2009). Predicting utilization of evidence-based parenting interventions with organizational, service-provider and client variables. Administration and Policy in Mental Health and Mental Health Services Research, 36(2), 133–143. https://doi.org/10.1007/s10488-009-0205-3
  • Seng, A. C., Prinz, R. J., & Sanders, M. R. (2006). The role of training variables in effective dissemination of evidence-based parenting interventions. The International Journal of Mental Health Promotion, 8, 20–28. https://www.tandfonline.com/doi/abs/10.1080/14623730.2006.9721748
  • Shapiro, C. J., Prinz, R. J., & Sanders, M. R. (2012). Facilitators and barriers to implementation of an evidence-based parenting intervention to prevent child maltreatment the Triple P-Positive Parenting Program. Child Maltreatment, 17(1), 86–95. https://doi.org/10.1177/1077559511424774
  • Shapiro, C. J., Prinz, R. J., & Sanders, M. R. (2015). Sustaining use of an evidence-based parenting intervention: Practitioner perspectives. Journal of Child and Family Studies, 24, 1615–1624. https://doi.org/10.1007/s10826-014-9965-9
  • Van Mourik, K., Crone, M. R., & Reis, R. (2018). Relevance of the intervention module "Coping with stress and unhelpful emotions" for parents living in multi-ethnic deprived neighborhoods. Children and Youth Services Review, 88, 426–433. https://doi.org/10.1016/j.childyouth.2018.03.036

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Several meta-analyses, see citations following, have been conducted on Level 4 Triple P, however, these articles are not used for rating and therefore are not summarized:

    • de Graff, I., Speetjens, P., Smit, F., de Wolff, M., & Tavecchio, L. (2008). Effectiveness of the Triple P Positive Parenting Program on parenting: A meta-analysis. Family Relations, 57(5), 553–566. https://journals.sagepub.com/doi/10.1177/0145445508317134
    • de Graff, I., Speetjens, P., Smit, F., de Wolff, M., & Tavecchio, L. (2008). Effectiveness of the Triple P Positive Parenting Program on behavioral problems in children: A meta-analysis. Behavior Modification, 32(5), 714–735. https://doi.org/10.1177/0145445508317134
    • Sanders, M. R., Kirby, J. N., Tellegen, C. L., & Day, J. J. (2014). The Triple P-Positive Parenting Program: A systematic review and meta-analysis of a multi-level system of parenting support. Clinical Psychology Review, 34(4), 337–357. https://doi.org/10.1016/j.cpr.2014.04.003

    When more than 10 research articles have been published in peer-reviewed journals, the CEBC reviews all of the articles as part of the rating process and identifies the most relevant articles to the topic area(s) in which the program is being reviewed, with a focus on randomized controlled trials (RCTs) and controlled studies that have an impact on the rating. The 10 articles chosen for Level 4 Triple P are summarized below:

    Sanders, M. R., Markie-Dadds, C., Tully, L. A., & Bor, W. (2000). Triple P-Positive Parenting Program: A comparison of enhanced, standard, and self-directed behavioral family intervention for parents of children with early onset conduct problems. Journal of Consulting and Clinical Psychology, 68(4), 624–640. https://doi.org/10.1037/0022-006X.68.4.624

    Type of Study: Randomized controlled trial
    Number of Participants: 305

    Population:

    • Age — 3 years
    • Race/Ethnicity — Caucasian
    • Gender — Not specified
    • Status — Participants were families with preschool age children with behavioral conduct problems who were recruited through a community outreach campaign.

    Location/Institution: Australia

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to evaluate the effectiveness of three types of Triple P [now called Level 4 Triple P] in treating behavioral conduct problems in a sample of families with preschool age children. Families were randomly assigned to enhanced BFI (EBFI), standard BFI (SBFI), self-directed BFI (SDBFI), or wait list (WL). Standard BFI employed the same materials as the self-directed program but added active skills training and support from a trained practitioner. Measures utilized include the Parent Daily Report (PDR), the Eyberg Child Behavior Inventory (ECBI), the Family Observation Schedule (FOS-R-III), and the Parenting Sense of Competence Scale. Results indicate that the two practitioner-assisted interventions were associated with lower levels of parent-reported disruptive child behavior, lower levels of dysfunctional parenting, and parents reported a heightened sense of competence. Children in the EBFI condition showed more reliable improvement, although by the end of the 1-year follow-up all Triple P conditions had achieved similar levels of improvement in disruptive behavior. The practitioner-assisted programs were associated with greater improvement in parent-reported disruptive behavior. Limitations include findings cannot be generalized to parents whose children are at high risk for the development of conduct problems or who are recruited through other means; reliance on self-reported measures; and 1-year outcomes were compared to pretest levels only, not to waitlist controls.

    Length of controlled postintervention follow-up: 1 year.

    Bor, W., Sanders, M. R., & Markie-Dadds, C. (2002). The effects of the Triple P-Positive Parenting Program on preschool children with co-occurring disruptive behavior and attentional/hyperactive difficulties. Journal of Abnormal Child Psychology, 30(6), 571–587. https://doi.org/10.1023/A:1020807613155

    Type of Study: Randomized controlled trial
    Number of Participants: 87

    Population:

    • Age — 3 years
    • Race/Ethnicity — Caucasian
    • Gender — Not specified
    • Status — Participants were families with preschool age children with behavioral conduct problems.

    Location/Institution: Australia

    Summary: (To include basic study design, measures, results, and notable limitations)
    The study used a subset of the same sample as Sanders et al. (2000). The purpose of the study was to compare two variants of a behavioral family intervention (BFI) program known as Triple P [now called Level 4 Triple P], using 87 preschoolers with co-occurring disruptive behavior and attentional/hyperactive difficulties. enhanced BFI (EBFI), standard BFI (SBFI), or a waitlist (WL) control group. Measures utilized include the Revised Family Observation Schedule (FOS-RIII), the Beck Depression Inventory (BDI), the Child Abuse Potential Inventory (CAP), the Eyberg Child Behavior Inventory (ECBI), the Parent Daily Report (PDR), the Parenting Sense of Competency Scale, and the Parent Problem Checklist. Results indicate that participation in both Triple P conditions were associated with lower levels of parent-reported child behavior problems, lower levels of dysfunctional parenting, and greater parental sense of competence than the wait-list conditions. EBFI was also associated with less observed negative child behavior. These effects were maintained at the 1-year follow-up. Limitations include reliance on self-reported measures and findings cannot be generalized to parents whose children are at high risk for the development of conduct problems or who are recruited through other means.

    Length of controlled postintervention follow-up: 1 year.

    Markie-Dadds, C., & Sanders, M. R. (2006). Self-directed Triple P (Positive Parenting Program) for mothers with children at-risk of developing conduct problems. Behavioural and Cognitive Psychotherapy, 34(3), 259–275. https://doi.org/10.1017/S1352465806002797

    Type of Study: Randomized controlled trial
    Number of Participants: 63 families

    Population:

    • Age — Children: 2–5 years; Parents: 32–35 years
    • Race/Ethnicity — Predominately Caucasian
    • Gender — Children: 40 Male and 23 Female; Parents: Not specified
    • Status — Participants were parents with children with disruptive behaviors recruited through a community outreach campaign.

    Location/Institution: Queensland, Australia

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to evaluate a self-directed variant of the Positive Parenting Program (Triple P) [now known as Level 4 Triple P] using 63 preschool-age children at-risk of developing conduct problems. Participants were randomly assigned to either self-directed Triple P (SD) or a waitlist group. Measures utilized include the Eyberg Child Behavior Inventory (ECBI), the Parenting Scale (PS), the Parent Daily Report (PDR), Parenting Sense of Competency Scale, (PSOC), the Parent Problem Checklist (PPC), the Depression Anxiety Stress Scales (DASS), and the Client Satisfaction Questionnaire (CSQ). Results indicate that mothers in the SD group reported significantly less child behavior problems, less use of dysfunctional discipline strategies, and greater parenting competence than mothers in the waitlist group. On measures of parental adjustment, there was no significant difference in conditions at postintervention based on mothers’ reports of depression, anxiety, stress, and conflict with partners over parenting issues. Mothers’ reports at follow-up indicated that gains in child behavior and parenting practices achieved at postintervention were maintained. Limitations include small sample size, lack of follow-up of waitlist control condition, reliance on self-reported measures, and lack of generalizability to other ethnic populations.

    Length of controlled postintervention follow-up: 6 months.

    Sanders, M. R., Bor, W., & Morawska, A. (2007). Maintenance of treatment gains: A comparison of Enhanced, Standard, and Self-directed Triple P – Positive Parenting Program. Journal of Abnormal Child Psychology, 35(6), 983–998. https://doi.org/10.1007/s10802-007-9148-x

    Type of Study: Randomized controlled trial
    Number of Participants: 305 families

    Population:

    • Age — 3 years
    • Race/Ethnicity — 100% Caucasian
    • Gender — 68% Male
    • Status — Participants were parents of children displaying behavioral problems.

    Location/Institution: Queensland, Australia

    Summary: (To include basic study design, measures, results, and notable limitations)
    The study used the same sample as Sanders et al. (2000). The purpose of the study was to describe the outcomes of three different variants of the Triple P - Positive Parenting Program [now called Level 4 Triple P]. Families were randomly assigned to Enhanced Triple P (EBFI), Standard Triple P (SBFI), Self-Help Triple P (SDBFI), or wait list (WL). Measures utilized include the Eyberg Child Behavior Inventory (ECBI), the Beck Depression Inventory, the Parent Problem Checklist, the Child Abuse Potential Inventory (CAP), the Diagnostic Interview Schedule for Children–Parent version, a Revised Family Observation Schedule (FOS-RIII), the Parent Daily Report (PDR), Parenting Scale, Parenting Sense of Competency Scale (PSOC), Abbreviated Dyadic Adjustment Scale (ADAS), Depression Anxiety Stress Scales (DASS), Client Satisfaction Questionnaire (CSQ), Sutter–Eyberg Student Behavior Inventory (SESBI), and the Power, Privilege and Prestige Scale. Results indicate that at 1-year follow-up there were similar improvements on observational and self-report measures of preschooler disruptive behavior for Enhanced Triple P, Standard Triple P, and self-directed variants of Triple P. At 3-year follow-up, each condition showed a similar level of maintenance of intervention effects. Approximately 2/3 of preschoolers who were clinically elevated on measures of disruptive behavior at pre-intervention moved from the clinical to the non-clinical range. Limitations include attrition and lack of generalizability to older age groups of children.

    Length of controlled postintervention follow-up: 1 year and 3 years.

    Bodenmann, G., Cina, A., Ledermann, T., & Sanders, M. R. (2008). The efficacy of the Triple P – Positive Parenting Program in improving parenting and child behavior: A comparison with two other treatment conditions. Behaviour Research and Therapy, 46(4), 411–427. https://doi.org/10.1016/j.brat.2008.01.001

    Type of Study: Randomized controlled trial
    Number of Participants: 150

    Population:

    • Age — 2–12 years
    • Race/Ethnicity — Swiss
    • Gender — 50% Male and 50% Female
    • Status — Participants were married couples with children ages 2 to 12 years who were recruited from the media.

    Location/Institution: Switzerland and Australia

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to evaluate the efficacy of group Level 4 Triple P in a sample of married couples with children. Participants were randomly assigned to a group Level 4 Triple P program and were compared with parents of a non-treated control group and parents participating in a marital distress prevention program (Couples Coping Enhancement Training (CCET). Measures utilized include the Parenting Scale (PS), the Parenting Sense of Competence Scale (PSOC), the Parent Problem Checklist (PPC), the Eyberg Child Behavior Inventory (ECBI), and the Dyadic Adjustment Scale (DAS). Results indicate that Level 4 Triple P was effective with Swiss families. Mothers of the Level 4 Triple P group showed significant improvements in parenting, parenting self-esteem, and a decrease in stressors related to parenting. Women trained in Level 4 Triple P also reported significantly lower rates of child’s misbehavior than women of the two other conditions. However, in men only a few significant results were found. Positive effects of the relationship training (CCET) comparison group were somewhat lower than those for the Level 4 Triple P. Limitations include reliance on self-reported measures, no additional independent evaluations were made by clinicians, experts, teachers, or the children themselves.

    Length of controlled postintervention follow-up: 1 year.

    Hahlweg, K., Heinrichs, N., Kuschel, A., Bertram, H., & Naumann, S. (2010). Long-term outcome of a randomized controlled universal prevention trial through a positive parenting program: Is it worth the effort? Child & Adolescent Psychiatry & Mental Health, 4, 1–14. https://doi.org/10.1186/1753-2000-4-14

    Type of Study: Randomized controlled trial
    Number of Participants: 280

    Population:

    • Age — 3–6 years
    • Race/Ethnicity — German
    • Gender — Not specified
    • Status — Participants were families and children ages 3 to 6 years who were recruited from German preschools.

    Location/Institution: Germany

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to evaluate group Level 4 Triple P administered universally for the prevention of child behavior problems. Participants were randomly assigned to group Level 4 Triple P or to a control group. Measures utilized include the Kaufman Assessment Battery for Children (K-ABC), the German versions of the Child Behavior Checklist for Ages 1.5-5 (CBCL/1.5-5) and Child Behavior Checklist for Ages 6-18 (CBCL/6-18), the Caregiver Teacher Report Form (C-TRF), Parenting Scale (PS), the Positive Parenting Questionnaire (PPQ), the McMahon and Estes Parent-child interaction task, and the Revised Family Observation Schedule (ROS-R-III). Results indicate that at the 2-year follow-up, both parents in the Level 4 Triple P intervention reported significant reductions in dysfunctional parenting behavior, and mothers also an increase in positive parenting behavior. In addition, mothers reported significant reductions in internalizing and externalizing child behavior. Single-parent mothers in the Level 4 Triple P intervention did not report significant changes in parenting or child problem behavior which is primarily due to inexplicable high positive effects in single parent mothers of the control group. Neither mother-child interactions nor teacher ratings yielded significant results. Limitations include reliance on self-reported measures and sample size was too small to look at incidence rates.

    Length of controlled postintervention follow-up: 2 years.

    Sanders, M. R., Baker, S., & Turner, K. M. T. (2012). A randomized controlled trial evaluating the efficacy of Triple P Online with parents of children with early-onset conduct problems. Behavior Research & Therapy, 50(11), 675–684. https://doi.org/10.1016/j.brat.2012.07.004

    Type of Study: Randomized controlled trial
    Number of Participants: 116

    Population:

    • Age — Children: 2–9 years; Parents: Mean=37 years
    • Race/Ethnicity — 100% Caucasian
    • Gender — 67% Male
    • Status — Participants were children displaying early-onset disruptive behavior difficulties.

    Location/Institution: Queensland, Australia

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to examine the efficacy of Triple P Online (TPOL) [now called, Level 4 Triple P], an eight-module intensive online positive parenting program for parents of children with early-onset disruptive behavior problems, compared with an “internet use as usual” group. Participants were randomly assigned to either the intervention condition or an internet use-as-usual control group. Measures utilized include the Family Background Questionnaire (FBQ), the Eyberg Child Behavior Inventory (ECBI), the Strengths and Difficulties Scale (SDQ), the Parenting Scale (PS), the Parenting Tasks Checklist (PTC), the Depression Anxiety Stress Scales (DASS-21), the Parental Anger Inventory (PAI), the Parent Problem Checklist (PPC), and the Client Satisfaction Questionnaire (CSQ). Results indicate that at post-intervention assessment, parents receiving TPOL had significantly better outcomes on measures of problem child behavior, dysfunctional parenting styles, parents confidence in their parenting role, and parental anger. Limitations include small sample size, underrepresentation of low-income families, and lack of generalizability to other ethnic populations.

    Length of controlled postintervention follow-up: 6 months.

    Heinrichs, N., Kliem, S., & Hahlweg, K. (2014). Four-year follow-up of a randomized controlled trial of Triple P group for parent and child outcomes. Prevention Science, 15(2), 233–245. https://doi.org/10.1007/s11121-012-0358-2

    Type of Study: Randomized controlled trial
    Number of Participants: 280 families

    Population:

    • Age — Children: 3–6 years; Mothers: Mean=35 years; Fathers: Mean=38 years
    • Race/Ethnicity — Not specified
    • Gender — Children: 51% Male; Parents: Not specified
    • Status — Participants were families from 17 preschools/kindergartens.

    Location/Institution: Braunschweig, Germany

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to evaluate the 4-year efficacy of the group-based Triple P [now called Level 4 Triple P] as a prevention program administered universally. Participant preschools were randomly assigned to Triple P or a no parenting intervention control group. Measures utilized include the German version of the Parenting Scale (PS), the Positive Parenting Questionnaire (PPQ), and the German version of the Child Behavior Checklist (CBCL). Results indicate that mothers and fathers from the intervention preschool group reported significant reductions in dysfunctional parenting behavior. Mothers also reported a shallower decline from pre- to post-intervention in positive parenting behavior, which was maintained 4 years later, than mothers in the control group. Fathers from intervention preschools reported a delayed shallower decline in positive parenting during the follow-up than fathers in the control group. In addition, mothers from intervention preschools reported immediate improvement in child behavior problems during the program while mothers from control preschools did not report this immediate change. However, with mothers from intervention preschools reporting more child behavior problems at baseline, the reduction in child behavior problems disappeared by the fourth year. Limitations include reliance on self-report data only and high attrition rate.

    Length of controlled postintervention follow-up: 4 years.

    Kim, J. H., Schulz, W., Zimmermann, T., & Hahlweg, K. (2018). Parent–child interactions and child outcomes: Evidence from randomized intervention. Labour Economics, 54, 152–171. https://doi.org/10.1016/j.labeco.2018.08.003

    Type of Study: Randomized controlled trial
    Number of Participants: 280

    Population:

    • Age — Children: 2.6–6.0 years (Mean=4.08 years); Mothers: Mean=35.34 years; Fathers: Not specified
    • Race/Ethnicity — Not specified
    • Gender — Children: 49% Female; Parents: Not specified
    • Status — Participants were parents of preschool children.

    Location/Institution: Braunschweig, Germany

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to compare the effectiveness of group Level 4 Triple P behavioral parent training (BPT) to a wait-list control on causal effect of parent-child interactions during preschool years on adolescent children’s behavioral outcomes. Participants were randomized to group Level 4 Triple P or a wait-list control. Measures utilized include the Parenting Scale, the Positive Parenting Questionnaire [PPQ], the Youth Self Report, KINDL-R (a generic instrument for assessing quality of life), the Kauffman Assessment Battery for Children, and the Child Behavior Checklist (CBCL). Results indicate that group Level 4 Triple P reduced externalizing behaviors and improved well-being of children 10 years after the intervention, during a child’s early adolescence. This effect was mediated by changes to parenting during early childhood. Limitations include missing data and lack of generalizability due to sample population consisting from one locality.

    Length of controlled postintervention follow-up: 10 years.

    Smith, G. C., Hayslip, B., Jr., Hancock, G. R., Strieder, F. H., & Montoro-Rodriguez, J. (2018). A randomized clinical trial of interventions for improving well-being in custodial grandfamilies. Journal of Family Psychology, 32(6), 816–827. https://doi.org/10.1037/fam0000457

    Type of Study: Randomized controlled trial
    Number of Participants: 343

    Population:

    • Age — Children: 4–12 years (Mean=7.83 years); Adults: Mean=58.46 years
    • Race/Ethnicity — Children: Not specified; Adults: 44% Caucasian,43% African American, 11% Hispanic/Latino, and 2% Other
    • Gender — Children: 51% Male; Adults: 100% Female
    • Status — Participants were custodial grandmothers.

    Location/Institution: California, Ohio, Maryland, and Texas

    Summary: (To include basic study design, measures, results, and notable limitations)
    The purpose of the study was to compare the effectiveness of behavioral parent training (BPT) [now called Level 4 Triple P], Cognitive–Behavioral Therapy (CBT), and information-only control (IOC) conditions at lowering grandmothers’ psychological distress, improving their parenting practices, and reducing the internalizing and externalizing difficulties of target grandchildren between ages 4 and 12 years. Participants were randomized to BPT, CBT, or IOC. Measures utilized include the 20-item Center for Epidemiological Studies–Depression scale, the 10-item Montgomery-Asberg Depression Rating Scale, the 14-item Hamilton Anxiety Rating Scale, the Parenting Practices Inventory (PPI), the 10-item Positive Affect Index, the Strengths and Difficulties Questionnaire (SDQ), and the Parent Daily Report (PDR). Results indicate that while CBT and BPT interventions were both superior to IOC at both times of measurement on most outcomes, they differed little from each other. Effect sizes were generally in the moderate-to-large range and similar to those found in prior studies of BPT and CBT with traditional birth parents. Limitations include missing data, reliance on self-reported measures, and lack of generalizability due to ethnicity of sample population.

    Length of controlled postintervention follow-up: 6 months.

    Additional References

    Sanders, M. R. (2012). Development, evaluation, and multinational dissemination of the Triple P-Positive Parenting Program. Annual Review of Clinical Psychology, 8, 345–379. https://doi.org/10.1146/annurev-clinpsy-032511-143104

    Sanders, M. R., & Mazzucchelli, T. G. (2018). The power of positive parenting: Transforming the lives of children, parents and communities using the Triple P system. Oxford University Press.

    Sanders, M. R., Turner, K. M. T., & McWilliam, J. (2015). The Triple P – Positive Parenting Program: A community-wide approach to parenting and family support. In M. J. Van Ryzin, K. L. Kumpfer, G. M. Fosco, & M. T. Greenberg (Eds.), Family-based prevention programs for children and adolescents: Theory, research, and large-scale dissemination (pp. 134-159). Psychology Press.

    Contact Information

    Agency/Affiliation: Triple P America
    Website: www.triplep.net
    Email:
    Phone: (803) 451-2278
    Fax: (803) 451-2277

    Date Research Evidence Last Reviewed by CEBC: September 2023

    Date Program Content Last Reviewed by Program Staff: April 2020

    Date Program Originally Loaded onto CEBC: April 2013