Comparation of enhanced Standard, and Self-directed Triple P.pdf

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Maintenance of Treatment Gains: A Comparison of Enhanced,

Standard, and Self-directed Triple P-Positive Parenting Program

Matthew R. Sanders & William Bor & Alina Morawska

Received: 4 August 2006 /Accepted: 18 May 2007 / Published online: 3 July 2007# Springer Science + Business Media, LLC 2007

Abstract This report describes the 3 year outcomes of three

different variants of the Triple P-Positive Parenting Program,

a behavioural family intervention. Families were randomly

assigned to one of three intervention conditions or to a

waitlist condition. At 1 year follow-up there were similar

improvements on observational and self-report measures of

preschooler disruptive behaviour for Enhanced, Standard and

Self Directed variants of Triple P. At 3 year follow-up

(completed by 139 families), each condition showed a

similar level of maintenance of intervention effects. Approx-

imately 2/3 of preschoolers who were clinically elevated on

measures of disruptive behaviour at pre-intervention moved

from the clinical to the non-clinical range. Across conditions,

there was a comparable preventive effect for each interven-

tion for these high risk children. The implications of the

findings for the development of brief, cost effective

parenting interventions within a public health framework

are discussed.

Keywords Behavioural family intervention . Prevention .

Conduct problems . Parenting

Parenting interventions are widely recognised as one of

the most effective interventions for children with conduct

problems. Parenting interventions, derived from sociallearning, functional analysis, and cognitive – behavioural

principles, are considered the interventions of choice for

conduct problems i n young chi ldren (K ot ler and

McMahon 2004; Prinz and Jones 2003; Taylor and Biglan

1998) and have also proven efficacious in prevention

studies (Webster-Stratton 1998). Positive effects have been

replicated many times across different studies, investiga-tors, and countries, and with a diverse range of client

populations (Sanders 1999). Parents are typically taught to

increase positive interactions with children and to reduce

coercive and inconsistent parenting practices.

Studies of parenting interventions show improvements in

parental perceptions and parenting skills, improvements in

children’s social skills and school adjustment, and reduc-

tions in behaviour and attention problems (Barlow and

Stewart-Brown 2000; Taylor and Biglan 1998). Parenting

interventions are often associated with large effect sizes

(Serketich and Dumas 1996), and the effects often

generalize to a variety of home and community settings

(McNeil et al. 1991; Sanders and Dadds 1982), are

maintained over time (Long et al. 1994), and are associated

with high levels of consumer satisfaction (McMahon 1999;

Sanders et al. 2000a; Webster-Stratton 1989). Parent

training has also been shown to generalise to other family

members, including the behaviour of untreated siblings of

referred children and to the psychological functioning of

the parent (Brestan et al. 1997; Eyberg and Robinson

1982). Evidence is mounting that a variety of delivery

modalities can produce positive outcomes for children

(Sanders 1999), including individually administered face-

to-face programs (e.g., Forehand and McMahon 1981),

group programs (Sanders et al. 2000a; Webster-Stratton

1990), telephone-assisted programs (Connell et al. 1997),

and self-directed programs (Gordon 2000). In addition, a

number of parent training interventions in regular service-

delivery contexts have demonstrated meaningful effects for

children with conduct problems (Dishion et al. 2002; Scott

et al. 2001). Finally, research has also demonstrated the

effects of abbreviated versions of parenting interventions

(Nixon et al. 2004). Although favourable intervention

J Abnorm Child Psychol (2007) 35:983 – 998

DOI 10.1007/s10802-007-9148-x

M. R. Sanders (*) : W. Bor : A. Morawska

The University of Queensland,

Brisbane QLD 4072, Australia

e-mail: [email protected]



effects have been repeatedly demonstrated for standard

parent management training these effects may be moderated

by the type of samples used (treatment vs prevention

samples), the severity of the child’s problem, the presence

of co occurring additional problems such as ADHD,

socioeconomic stressors, and parents mental health status.

Although parenting interventions are generally accepted

as being important for both the prevention and treatment of conduct problems in children, two divergent types of studies

can be identified in the literature. The first is represented by

studies that increase the intensity, duration, complexity and

cost of interventions by concurrently targeting multiple risk

factors. The second is represented by studies that decrease

the intensity, duration, complexity and cost of interventions

to achieve better population reach. The case for the multi-

risk factor reduction approach to prevention stems from

epidemiological studies showing that disruptive behaviour

disorders are complex, multi-determined problems that result

from an interaction of genetic vulnerability, parenting and

family factors, adverse peer influences, school failure, poverty and wider neighbourhood or community influences

(Rutter et al. 1998). The multi-risk factor reduction strategy

is also supported by studies that have identified the

mediators, moderators and predictors of outcomes. For

example, Beauchaine et al. (2005) pooled the data of six

parent training randomized trials concluding that parent

characteristics such as maternal depression moderated

treatment outcomes. Although a number of risk factors

predict the development of conduct problems in longitudinal

studies, there is insufficient experimental evidence showing

that the systematic targeting of multiple risk factors is

essential to prevent conduct problems. Experimental evi-

dence to support the “more is better ” argument is inconclu-

sive. In a recent meta-analysis of parent training Lundahl et

al. (2006) found no evidence for the notion that including

treatment components in addition to basic behavioural parent

training results in improvements in outcome.

The second trend has been the evolution of a population

health approach to parenting interventions (Sanders 1999).

This involves applying population health concepts and

strategies to develop evidence-based parenting interven-

tions that may be effective in preventing conduct problems

at a population level. This approach involves searching for

brief, cost efficient strategies with wider population reach

than traditional intensive individual or group parenting

programs, as the vast majority of children at risk of

developing conduct problems do not access psychological

interventions. Brief parenting interventions delivered by

primary care providers such as public health nurses and

family doctors have been shown to be effective (Turner and

Sanders 2006; Zubrick et al. 2005).

The Triple P-Positive Parenting Program developed by

Sanders (1999) is an example of a population-based,

multilevel approach to parenting intervention. The Triple

P system has five different levels of support for parents in

raising children and it involves a number of different

delivery modalities including individual, group, telephone

assisted and self directed programs. This public health

perspective involves identifying the minimally sufficient

conditions that need to change in order to alter children’s

risk developmental trajectories for developing seriousconduct problems. The two perspectives, namely develop-

ing high strength interventions and developing low inten-

sity interventions to handle complex problems, are not

mutually exclusive and in the Triple P system operate on a

continuum of interventions of increasing intensity and

narrowing population reach.

Little research is available examining the effects of

different levels of intervention support for high risk socially

disadvantaged parents. One approach has been to offer

parents adjunctive interventions over and above standard

parenting skills training (e.g. partner support training, coping

skills training, attribution retraining, problem solving skillstraining and anger management). The evidence that adjunc-

tive interventions improve the clinical outcomes for young

children at risk of disruptive behaviour or established

conduct problems is mixed. In part the inconclusive picture

may reflect diverse studies with childhood populations of

different ages, symptom levels and different adjunctive

interventions. For example, Kazdin and Whitley (2003)

tested the effects of providing a parent problem solving

(PPS) component in addition to standard evidence based

treatment for conduct problems. The children’s ages ranged

from 6 – 12 years and many of the participants fulfilled

diagnostic criteria for conduct disorder. The study found that

those who received PPS experienced better therapeutic

change and had reduced barriers to participation in treatment.

Webster-Stratton (1994) randomly assigned children between

3 and 8 years, diagnosed with a disruptive disorder to an

enhanced or basic program. Although marital communica-

tion, problem solving and self-control skills training,

included in the enhanced program, produced significant

improvements in the parents’ coping, there where no

differences in child behaviour outcomes. Other studies have

shown that parenting training interventions can reduce risk

factors such as maternal depression as well as child

behaviour problems (Sanders and McFarland 2000).

Few studies have examined the effects of varying the

level of intensity of a parenting intervention in the

prevention of conduct problems with children who are

identified as being at high risk for conduct problems. In

particular, it is unclear whether parenting interventions that

incorporate adjunctive interventions designed to mitigate

other family risk factors add to the efficacy and durability

of effects of standard parenting skills training. Adjunctive

interventions designed to reduce marital conflict, depres-

984 J Abnorm Child Psychol (2007) 35:983 – 998



sion, stress, anger management problems or attribution

biases have the potential to augment parenting skills

training. There is some empirical support for adjunctive

interventions, but there are also conflicting findings.

In an earlier study we (Sanders et al. 2000a) compared

three variants of Triple P and a wait-list condition in a

sample of 305 families with a 3-year old child. The three

interventions from most to least intrusive were an EnhancedBehavioural Family Intervention (EBFI; Enhanced Triple P);

standard behavioural family intervention (SBFI; Standard

Triple P); and a completely self directed behavioural family

intervention (SDBFI; Self Help Triple P). The short-term

effects of the intervention showed that by 1-year post

intervention all three interventions were associated with

similar levels of improvement on child and parent outcome

measures. However, it is quite plausible that a 1-year follow-

up period is insufficient to adequately assess the potential

differential maintenance effects of the three intervention

conditions.

The present study therefore reports on the longer termoutcomes. It was hypothesized that there would be a tiered

effect with the most intensive behavioural family interven-

tion (EBFI) being associated with best outcomes compared

to a standard behavioural family (SBFI) intervention which

would in turn would be more effective than the self directed

behavioural family intervention (SDBFI). These differential

effects were predicted to be evident on direct observation,

parent and teacher reports and independent diagnostic

measures. It was also hypothesized that the EBFI approach

would be more successful in preventing the development of

externalizing behaviour problems in children who were at

risk of disorder but who were below the threshold of

severity to warrant a formal diagnosis at pre-intervention.

Finally we predicted similar tiered condition differences on

measures of parent reported negativity, dysfunctional

parenting, parenting distress and conflict over parenting.

Materials and Methods

Participants

Participants were 305 families with a 3-year-old child.

Participants responded to a community outreach campaign

that included newspaper stories as well as posters and flyers

displayed in childcare centres, kindergartens, preschools

and community health centres. The campaign targeted three

low-income areas of Brisbane, which had a high proportion

of families with young children, high levels of juvenile

crime, and high rates of unemployment (Australian Bureau

of Statistics 1990, 1991, 1992).

A standardized telephone interview was used to ensure

families met the following criteria: (a) child aged between

36 and 48 months; (b) mothers reported they were

concerned about their child’s behaviour; (c) the child

showed no evidence of developmental disorder or signifi-

cant health impairment; (d) the child was not currently

having regular contact with another professional or agency

or taking medication for behavioural problems; and (e) the

parents were not currently receiving therapy for psycho-

logical problems, were not intellectually disabled andreported they were able to read the newspaper without

assistance. Subsequently mothers completed and returned

three questionnaires (see below) that assessed child behav-

iour, marital conflict, and depression. For inclusion in the

study, mothers had to rate their child’s behaviour as being

in the elevated range on the Eyberg Child Behaviour

Inventory (ECBI Intensity score > 127 or Problem score >

11; Eyberg and Ross 1978), a measure which has been

shown to powerfully discriminate and predict diagnosed

disruptive disorders in the preschool period (Rich and

Eyberg 2001). They were also required to have at least one

of the following family adversity factors: (a) maternaldepression as measured by a score of 20 or more on the

Beck Depression Inventory (Beck et al. 1979); (b)

relationship conflict as measured by a score of 5 or more

on the Parent Problem Checklist (Dadds and Powell 1991);

(c) single parent household; (d) low gross family income

(less than AUD$345 per week) or low occupational prestige

as indicted by a rating of 5.0 or higher for the major income

earner on the Power, Privilege and Prestige Scale (Daniel

1983). In the recruited sample, 52% of the families had two

of the family risk factors listed above, 36% had three

factors and 12% met all of the family risk factors. This

represents a predominately high risk sample of families, as

population assessment of risk factors in Brisbane indicates

medium risk of one to two factors affects less than 40% and

high risk of three or more risk factors represents less than

20% of the population. In our sample the distribution of

risk was 52 and 48%, respectively (Dwyer, Nicholson &

Battistutta 2003). Chi square analyses indicated no signif-

icant difference across conditions for the four family risk

criteria detailed above, indicating that the groups were well

matched prior to intervention.

Overall, 940 families responded to the outreach campaign.

Of these, 216 families met the initial telephone screening

criteria but did not return the screening questionnaires. Of the

remaining 724 families who returned screening question-

naires, 343 families were excluded for the following reasons:

(a) child not aged 3 years (37%); (b) child’s behaviour not

elevated (17%); (c) no family risk criteria evident (19%);

(d) family already receiving assistance (17%); (e) child had a

developmental disorder or significant health impairment

(9%); or (f) parents reported significant literacy problems

(1%). The remaining 381 families met all inclusion criteria but

76 families declined to participate.

J Abnorm Child Psychol (2007) 35:983 – 998 985



Demographic characteristics of the sample are summa-

rized in Tables 1 and 2. Parents were Caucasian, predom-

inantly lower socioeconomic class, with a predominance of

male children (68%). Seventy percent of families included

the biological father of the target child, 4% were step-

fathers, and in 26% of families no father figure was present.

Mothers were generally the biological parent of the target

child (97%) with the remaining 3% of mothers being either stepmothers, adoptive/foster mothers or absent. On average,

mothers were 31 years of age and fathers 34 years. Over a

third of mothers had not completed high school (40.9% in

EBFI; 30.6% in SBFI; 31.1% in SDBFI), and there were no

differences between groups on this variable χ2(1, 138)=

0.508, ns. There were no significant differences among the

four groups on sociodemographic characteristics prior to

intervention.

Interviews with parents indicated that 40% of families

were experiencing financial difficulties; about 7% of

mothers and 9% of fathers had a history of drug use; 55%

of mothers and 37% of fathers had a family history of psychiatric illness; 20% of mothers and 30% of fathers had

a family history of criminal activity; 8% of mothers and 4%

of fathers reported witnessing at least one violent interac-

tion (i.e., hit partner with hand or object) between their

parents in their family of origin and 20% of mothers and

13% of fathers reported that during their childhood, they

had been physically abused by their parents (i.e., required

medical treatment as a result of being disciplined). Using

the Child Abuse Potential Inventory (CAPI: Milner 1986),

56% of mothers and 29% of fathers had elevated scores on

the Abuse scale indicating that these parents were at high-

risk of physically abusing their own child and may have

already done so. Overall, 25 risk factors implicated in the

development of children’s conduct problems were exam-

ined in this study using standardised questionnaires and

interviews. Approximately 60% of the sample reported the

presence of 5 or more of the 25 risk factors for conduct

problems (see Table 2) confirming that a sample of children

at high-risk of developing conduct problems had been

recruited.

Measures

Family Background Interview

Mothers and fathers (where applicable) completed a

standardized interview about their level of education, any

current financial difficulty, and characteristics of their

family and family of origin. Information was sought on present and prior use of drugs and alcohol, criminal history,

history of psychiatric illness, and violence in family of

origin directed to a parent or themselves. Each of the above

issues was addressed during a semi-structured interview

that required forced choice responses (i.e., Yes or No and

frequency ratings).

Diagnostic Interview

Diagnostic Interview Schedule for Children – Parent version

is a structured interview designed to assess DSM-IV

psychiatric disorders and symptoms in chil dren andadolescents aged 6 to 17 years (Shaffer et al. 2000). The

interview was used to assess the presence of attentional/

hyperactivity and conduct problems in children. Mothers

were asked to indicate the presence or absence of each of

18 symptoms listed in the DSM-IV (American Psychiatric

Association 1994) diagnostic criteria for ADHD. Children

were diagnosed with attentional/hyperactivity problems if

mothers reported that six or more symptoms of inattention

and six or more symptoms of hyperactivity – impulsivity had

persisted for at least 6 months.

Observation of Mother and Child Behaviour

Mother and child behaviour were assessed using a 30-min

video-recorded home observation. The observation was

divided into three 10 min tasks recorded consecutively

without interruption: (a) parent and child worked through a

children’s activity book (e.g., mazes, colouring-in, puzzles);

(b) parent and child remained in the same room but

completed separate activities; and (c) parent directed ten

Table 1 Selected demographic characteristics (3-year follow-up data)

EBFI (n=48) SBFI (n=50) SDBFI (n=41) Statistic

M (SD) M (SD) M (SD) F

Child’s age (months) 84.94 (5.66) 83.72 (5.25) 82.63 (5.06) 2.07

Years together as a couple 9.09 (6.35) 5.77 (4.79) 8.03 (6.24) 2.30

Number of children in family 2.27 (1.22) 2.22 (1.02) 2.17 (0.77) < 1

F for main effect of intervention condition

EBFI Enhanced Behavioural Family Intervention; SBFI Standard Behavioural Family Intervention; SDBFI Self-directed Behavioural Family

Intervention




standardized instructions (presented on a palm card) to their

child (e.g., come and sit here please; please put the toy back

in the box). These settings were chosen to replicate a

number of experiences that occur regularly in family life. If

fathers and siblings were present, mothers included them in

the interaction but directed the ten instructions to the target

child. To minimize reactivity effects, observers did not interact with participants and positioned themselves in a

minimally obtrusive location.

Observation sessions were coded in 10-s time intervals,

using the Revised Family Observation Schedule (FOS-RIII;

Sanders et al. 1996). Two composite scores were computed.

Negative parent behaviour comprised the percentage of

intervals the parent displayed any negative behaviour

during the 30-min observation as coded by negative

physical contact, aversive question or instruction, aversive

attention, or interruption. Negative child behaviour com-

prised the percentage of intervals during which the child

displayed any category of negative behaviour namely non-

compliance, complaint, aversive demand, physical negative

or oppositional behaviour. The FOS has demonstrated reli-

ability and discriminant validity, and is sensitive to the ef-

fects of behavioural interventions (Sanders and Christensen

1985). For this study, negative parent behaviour was sig-

nificantly correlated with negative child behaviour (r =0.51,

p <0.0001).

Four trained observers coded the interactions. Each rater

coded a selection of interactions from each of the three

assessment phases (i.e., pre-, post- and follow-up). All

coders were blind to the intervention conditions of

participants, stage of assessment, interactions used for

reliability checks, and the specific hypotheses being tested.

To maintain reliability, coders completed 36 h of training

using pre-coded tapes, coded practice interactions in

fortnightly supervision meetings, and computed Kappa

statistics each week. Inter-rater agreement was assessed by

having one fifth of the observations randomly selected and

coded by a second rater. A satisfactory level of inter-rater

agreement (Kappa) was achieved with 0.73 for parent

behaviour and 0.74 for child behaviour.

Parent-report Measures

Beck Depression Inventory (BDI: Beck et al. 1979) The

BDI, administered to mothers only, was used as a screening

measure and completed prior to randomization. The BDI is a

21-item questionnaire that assesses symptoms of depression

in adults. It has been extensively used and shown to havegood internal consistency (α=0.81 for non-psychiatric

samples), moderate to high test – retest reliability (ranging

from r =0.60 to r =0.90 for non-psychiatric populations), as

well as satisfactory discriminant validity between psychiatric

and non-psychiatric populations (Beck et al. 1988).

Child Abuse Potential Inventory (CAPI; Milner 1986). The

CAPI completed only at pre-intervention, was used to assess

parents’ potential for physical child abuse. The abuse scale

classifies parents as abusing, non-abusing or nurturing

parents. The measure includes three validity scales: lie,random response and inconsistency scales to assess common

types of response distortion. Response distortion indexes

were computed if one or more of the validity scales were

elevated. Subsequently, data were excluded from the

analyses if a response distortion index was elevated.

According to Milner (1986), the abuse scale has high

internal consistency (r =0.92 to r =0.98), moderate test – retest

reliability (r =0.91 at 1 day to r =0.75 at 3 months), shows

high correlations between abuse potential scores and

confirmed physical abuse, and is able to discriminate

between control parents and parents who have physically

abused their children.The following parent-report measures were completed at

pre- and post-intervention and at 1- and 3-year follow-up.

Eyberg Child Behaviour Inventory (ECBI; S. M. Eyberg

and Pincus 1999). The ECBI is a 36-item, multidimensional

measure of parental perceptions of disruptive behaviour in

children aged 2 to 16 years. It incorporates a measure of

frequency of disruptive behaviours (Intensity score) rated on

7-point scales, and a measure of the number of disruptive

Table 2 Selected risk factors (3-year follow-up data)

EBFI (%) SBFI (%) SDBFI (%) p

Single parent a 20.80 32.00 22.00 0.379

Male child b 67.50 66.20 69.30 0.919

Mother using illicit drugsa 4.20 2.00 7.30 0.462

Father using illicit drugsa 6.10 7.40 4.00 0.871


Interventiona Respective n for Single parent, Mother using illicit drugs and Father using illicit drugs: EBFI ( n=48); SBFI (n=50); SDBFI (n=41). b Respective n for Male child: EBFI (n=77); SBFI (n=77); SDBFI (n=76).




behaviours that are a problem for parents (Problem score).

The ECBI has high internal consistency for both the

Intensity (r =0.95) and Problem (r =0.94) scores, good test –

retest reliability (r =0.86), and reliably discriminates between

problem and non-problem children (Robinson et al. 1980).

Using the present sample, a moderate level of inter-rater

agreement was obtained between mothers and fathers (r =

0.49, p<0.000).

Parent Daily Report (PDR; Chamberlin and Reid 1987).

The PDR is a checklist with 33 problem child behaviours

and one item referring to the use of physical punishment by

parents. Parents recorded which behaviours occurred each

day on an occurrence or non-occurrence basis over a 7-day

period. A Total Behaviour score (the sum of all occurrences

of problem behaviours for the week) and daily mean score

were computed. Using the present sample, the PDR has high

internal consistency for both mothers and fathers responses

with alpha coefficients of 0.86 and 0.83, respectively. The 6-day test – retest reliability was high for both parents (α=0.82

and 0.77), with moderate inter-rater agreement (r =0.59, p<

0.0001).

Parenting Scale (PS; Arnold et al. 1993). This 30-item

questionnaire measures dysfunctional discipline styles in

parents. It yields a Total score based on three factors:

Laxness (permissive discipline); Overreactivity (authoritarian

discipline, displays of anger, meanness and irritability); and

Verbosity (overly long reprimands or reliance on talking).

According to Arnold et al. (1993), the Total score has

adequate internal consistency (α=0.84), good test – retest

reliability (r =0.84), and reliably discriminates between

parents of clinic and non-clinic children.

Parenting Sense of Competency Scale (PSOC; Gibaud-

Wallston and Wandersman 1978). A 16-item version of this

questionnaire was used to assess parents’ views of their

competence as parents on two dimensions: (a) satisfaction

with their parenting role; and (b) feelings of efficacy as a

parent. The total score shows a satisfactory (α=0.79) level

of internal consistency (Johnston and Mash 1989).

Parent Problem Checklist (PPC; Dadds and Powell 1991).

The PPC is a 16-item questionnaire that measures conflict

between partners over child-rearing. Six items explore the

extent to which parents disagree over rules and discipline

for child misbehaviour, six items rate the occurrence of

open conflict over child-rearing issues, and a further four

items focus on the extent to which parents undermine each

other ’s relationship with their children. The PPC has a

moderately high internal consistency (α=0.70) and high

test – retest reliability (r =0.90; Dadds and Powell 1991).

Using the present sample, there was a significant correla-

tion between mothers and fathers’ responses (r =0.36, p<

0.0001).

Abbreviated Dyadic Adjustment Scale (ADAS; Sharpleyand Rogers 1984). The ADAS is an abbreviated, 7-item

version of the 32-item Spanier Dyadic Adjustment Scale

(Spanier 1976). It is a measure of the quality of dyadic

relationship adjustment, that reliably distinguishes between

distressed and non-distressed couples on relationship satis-

faction drawing upon aspects of communication, intimacy,

cohesion and disagreement. The measure is moderately

reliable (α=0.76), has an item total correlation of 0.57

(Sharpley and Rogers 1984), and moderate inter-rater

agreement was achieved with the present sample (r =0.56,

p<0.0001).

Depression Anxiety Stress Scales (DASS; Lovibond and

Lovibond 1995b). The DASS is a 42-item questionnaire

that assesses symptoms of depression, anxiety and stress in

adults. The scale has high reliability for the Depression (α=

0.91), Anxiety (α=0.81) and Stress (α=0.89) scales, and

good discriminant and concurrent validity (Lovibond and

Lovibond 1995a, b).

Client Satisfaction Questionnaire (CSQ). Administered at

post-intervention only, the 13 item CSQ addresses the

quality of service provided; how well the program met the parents’ needs, increased the parent ’s skills and decreased

the child’s problem behaviours; and whether the parent

would recommend the program to others. The measure

derived is a composite score of program satisfaction ratings

on 7-point scales (a maximum score of 91 and a minimum

score of 13 are possible). Using the present sample, the scale

has high internal consistency (α=0.96), an item total

correlation of 0.66 and inter-item correlations of 0.30 – 0.87.

Measures of Child Behaviour and Diagnostic Assessment

at 3 Year Follow-up

Sutter – Eyb erg Stude nt Behav iour Inventory (SESBI;

Rayfield et al. 1998). The SESBI is a 38-item measure of

teachers perceptions of disruptive behaviour in children aged

2 – 16 years. It incorporates a measure of disruptive behaviours

(intensity) rated on a 7-point scale and a measure of the

number of disruptive behaviours that are a problem for

teachers. The SESBI has high internal consistency for both the

Intensity (α=0.97) and Problems Scores (α=0.95).




Diagnostic Interview At 1 and 3 year follow-up the parent

of each child underwent a structured diagnostic interview by

a trained research assistant using the Diagnostic Interview

Schedule for Children to measure disruptive behavioural

disorders (DISC; Shaffer et al. 2000).

Design

A randomized group comparison design was used with four

conditions (EBFI, SBFI, SDBFI, and waitlist (WL)) and

four time periods (pre- and post-intervention, 1 and 3-year

follow-up).

Procedure

The research was approved and conducted under National

Health and Medical Council Ethical guidelines. Families

completed a 90-min semi-structured interview, parent-report

measures, and home-observation prior to randomization toone of the four conditions. Subsequently, families allocated

to the SDBFI condition were given the self-directed

materials and instructed on how to use them. Families

allocated to the practitioner-assisted conditions (EBFI and

SBFI) attended 60 to 90 min weekly sessions with a

practitioner on an individual basis in local community health

and neighbourhood centres. After-hours appointments were

available to encourage both parents (where applicable) to

attend. In two-parent families, fathers attended 58% of the

appointments in these conditions. Following completion of

the intervention (approximately 17 and 15 weeks following

the pre-assessment for the EBFI and SBFI conditions,respectively), families were reassessed using the parent-

report and home observation measures. Intervention families

were reassessed 1 and 3-years after program completion.

Families allocated to the WL condition received no treatment

and had no contact with the research team for 15 weeks.

These families completed the post-assessment, participated

in the program of their choice, and took no further part in the

study. At each assessment phase, a substantial number of

fathers participated by completing the questionnaire mea-

sures. At pre, post, 1- and 3-year follow-up, 206 (92%), 156

(91%), 91 (92%), 86 (89%) of fathers from the EBFI, SBFI

and SDBFI conditions respectively, completed and returnedquestionnaire booklets. There was no difference in father

participation rates across conditions either prior to, during or

at the 1 and 3 year follow-up assessments.

Treatment Conditions

Self-directed Behavioural Family Intervention (SDBFI;

Level 4 Self-help Triple P) Families in the SDBFI (see

Connell et al. 1997) condition received a ten session self-

directed program comprising Every Parent (Sanders 1992)

and Every Parent ’ s Workbook (Sanders et al. 1994). This

program involved parents learning 17 core child manage-

ment strategies. Ten of the strategies are designed to

promote children’s competence and development (e.g.,

quality time; praise; behaviour charts) and seven strategies

are designed to help parents manage misbehaviour (e.g.,setting rules; planned ignoring; time-out). In addition,

parents were taught a 6-step planned activities routine to

enhance the generalization and maintenance of parenting

skills (i.e., plan ahead; decide on rules; select engaging

activities; decide on rewards and consequences; and hold a

follow-up discussion with child). Consequently, parents

were taught to apply parenting skills to a broad range of

target behaviours in both home and community settings

with the target child and all relevant siblings. By working

through the exercises in their workbook, parents learn to

set and monitor goals for behaviour change and enhance

their skills in observing their child’s and their own behaviour.

Standard Behavioural Family Intervention (SBFI; Level 4

Standard Triple P) Like parents in the SDBFI condition,

parents in the SBFI were taught the 17 child management

strategies listed above and planned activities training.

Each family also received Every Parent (Sanders 1992)

and a workbook, Every Parent ’ s Fam ily Workb ook

(Markie-Dadds et al. 1999), and active skills training and

support from a trained practitioner (see Sanders and Dadds

1993). Active skills training methods included modelling,

role-plays, feedback and the use of specific homework tasks.

On average, parents attended ten appointments and comple-

ted approximately 10 h of intervention in this condition.

Completers of this intervention were those families that

completed Session 9 (planned activities training). Although

the practitioner did not consult directly with children, parents

were encouraged to bring their child to six of the ten sessions

to facilitate practise of the skills being introduced.

Enhanced Behavioural Family Intervention (EBFI; Level 5

Enhanced Triple P) Parents in the EBFI condition received

the intensive behavioural parent training component as

described above for the SBFI condition. Each family also

received a workbook, Every Parent ’ s Supp lementary

Workbook (Markie-Dadds et al. 1998). On average,

parents attended 12 appointments or about 14 h of therapy

to complete this intervention. The adjunctive interventions

were delivered through a combination of within session

exercises and homework assignments and tailored to the

needs of each family (see Markie-Dadds et al. 1998).

Although all the content of each module was covered with




T a b l e 3

L o n g - t e r m i n t e r v e n t i o n e f f

e c t s

E B F I

S B F I

S D B F I

F t i m e

F i n t

P r e

P o s t

1 - y e a r

3 - y e a r

P r e

P o s t

1 - y e a r

3 - y e

a r

P r e

P o s t

1 - y e a r

3 - y e a r

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

M ( S D )

O b s . N e g . c h i l d b e h a v i o u r . ( % ) a

2 5 . 0 3

( 1 6 . 2 3 )

1 5 . 2 3

( 1 4 . 9 1 )

1 0 . 2 5

( 1 0 . 4 9 )

2 . 6 6 ( 5 . 1 3 )

2 5 . 9 6

( 1 4 . 4 4 )

2 0 . 6 1

( 1 4 . 4 6 )

1 1 . 7 6

( 1 2 . 2 8 )

4 . 5 1 ( 6 . 0 6 )

2 4 . 7 0

( 1 5 . 0 4 )

2 3 . 3 8

( 1 2 . 0 1 )

1 1 . 5 1

( 1 0 . 2 6 )

5 . 2 8 ( 1 0 . 3 7 )

2 . 7 2

1 . 7 2

E C B I

M o t h e r

b

1 5 5 . 5 9

( 2 7 . 7 4 )

1 1 0 . 9 1

( 3 0 . 0 6 )

1 1 6 . 5 9

( 3 0 . 1 1 )

1 0 9 . 4 3

( 3 5 . 2 1 )

1 4 3 . 6 3

( 1 9 . 2 4 )

1 0 7 . 5 0

( 2 3 . 1 3 )

1 1 2 . 0 2

( 2 7 . 1 2 )

1 0 8 . 5 8

( 2 4

. 9 4 )

1 4 5 . 5 0

( 2 2 . 3 8 )

1 1 3 . 6 8

( 2 7 . 0 7 )

1 2 1 . 2 4

( 3 1 . 8 9 )

1 0 3 . 6 2

( 2 6 . 7 3 )

1 . 4 9

1 . 8 9

F a t h e r c

1 3 6 . 8 0

( 3 6 . 3 3 )

1 0 8 . 0 4

( 2 2 . 8 9 )

1 1 5 . 2 0

( 2 6 . 7 2 )

1 1 2 . 4 0

( 2 4 . 9 4 )

1 3 1 . 1 9

( 2 0 . 7 6 )

1 0 8 . 2 7

( 2 7 . 1 2 )

1 0 6 . 1 5

( 2 0 . 6 8 )

1 1 2 . 3 8

( 2 7

. 4 4 )

1 2 3 . 2 0

( 2 8 . 2 2 )

1 0 8 . 8 7

( 2 9 . 0 0 )

1 1 2 . 2 0

( 3 1 . 0 5 )

9 1 . 2 7

( 2 5 . 8 4 )

< 1

3 . 2 9 *

P D R M o t h e r

d

8 . 4 5 ( 3 . 6 2 )

3 . 9 7 ( 2 . 9 0 )

4 . 0 3 ( 2 . 7 1 )

3 . 5 0 ( 2 . 5 5 )

7 . 5 0 ( 4 . 2 0 )

3 . 8 7 ( 2 . 6 2 )

3 . 8 8 ( 2 . 8 3 )

3 . 0 1 ( 1 . 8 4 )

7 . 4 4 ( 3 . 7 0 )

4 . 9 2 ( 3 . 7 2 )

4 . 5 5 ( 3 . 6 2 )

4 . 1 7 ( 3 . 1 4 )

2 . 9 5 * *

< 1

F a t h e r e

7 . 2 9 ( 4 . 6 1 )

4 . 0 6 ( 3 . 7 5 )

4 . 2 4 ( 4 . 2 7 )

3 . 7 8 ( 3 . 0 6 )

4 . 8 6 ( 3 . 1 5 )

3 . 2 7 ( 2 . 5 2 )

2 . 8 4 ( 1 . 9 9 )

3 . 2 7 ( 2 . 5 1 )

6 . 5 7 ( 4 . 0 9 )

4 . 1 4 ( 3 . 4 8 )

5 . 3 9 ( 4 . 2 9 )

4 . 4 0 ( 3 . 4 4 )

1 . 4 3

< 1

P S M

o t h e r

f

3 . 4 2 ( 0 . 6 1 )

2 . 5 3 ( 0 . 7 3 )

2 . 7 3 ( 0 . 6 9 )

2 . 7 5 ( 0 . 7 6 )

3 . 4 4 ( 0 . 5 8 )

2 . 5 9 ( 0 . 7 0 )

2 . 8 1 ( 0 . 5 9 )

2 . 8 4 ( 0 . 6 6 )

3 . 6 5 ( 0 . 5 5 )

3 . 1 7 ( 0 . 7 0 )

3 . 1 6 ( 0 . 6 5 )

3 . 1 2 ( 0 . 5 1 )

1 . 1 7

1 . 5 3

F a t h e r g

3 . 1 2 ( 0 . 5 5 )

2 . 6 6 ( 0 . 6 4 )

2 . 8 8 ( 0 . 6 0 )

2 . 7 7 ( 0 . 5 5 )

3 . 2 1 ( 0 . 5 1 )

2 . 9 3 ( 0 . 5 9 )

2 . 9 7 ( 0 . 5 3 )

3 . 0 1 ( 0 . 6 1 )

3 . 0 8 ( 0 . 7 1 )

2 . 9 4 ( 0 . 7 8 )

3 . 0 0 ( 0 . 7 5 )

2 . 7 5 ( 0 . 7 8 )

1 . 0 8

1 . 3 2

O b s . N e g . m o t h e r b e h . ( % ) a

0 . 6 1 ( 1 . 4 1 )

0 . 3 9 ( 0 . 7 6 )

0 . 2 3 ( 0 . 4 0 )

0 . 2 5 ( 0 . 8 9 )

1 . 0 5 ( 2 . 8 7 )

0 . 4 9 ( 1 . 0 2 )

0 . 3 8 ( 0 . 6 7 )

0 . 4 5 ( 2 . 3 8 )

0 . 6 4 ( 1 . 0 7 )

0 . 6 0 ( 1 . 1 0 )

0 . 3 6 ( 1 . 0 3 )

0 . 1 0 ( 0 . 3 5 )

< 1

1 . 1 2

P S O C

M o t h e r

h

5 5 . 4 2

( 1 0 . 2 5 )

6 5 . 8 6

( 1 2 . 1 8 )

6 5 . 8 1

( 1 2 . 5 6 )

6 9 . 1 6

( 1 4 . 9 3 )

5 6 . 4 4

( 1 0 . 9 2 )

6 5 . 4 0

( 1 0 . 2 5 )

6 5 . 1 3

( 1 0 . 5 3 )

6 7 . 5

1

( 1 2

. 9 7 )

5 9 . 3 6

( 1 1 . 3 4 )

6 2 . 7 6

( 9 . 9 6 )

6 5 . 7 3

( 1 2 . 7 1 )

6 8 . 8 2

( 9 . 5 2 )

3 . 8 8 *

1 . 0 8

F a t h e r

i

6 2 . 5 6

( 1 0 . 5 4 )

6 6 . 0 0

( 7 . 1 1 )

6 7 . 9 3

( 9 . 6 9 )

7 0 . 7 0

( 1 1 . 2 3 )

6 1 . 7 3

( 8 . 4 2 )

6 4 . 4 6

( 9 . 4 0 )

6 5 . 8 8

( 1 1 . 2 9 )

6 9 . 4

6

( 1 1

. 2 3 )

6 9 . 0 6

( 1 1 . 3 4 )

6 7 . 3 1

( 1 0 . 6 9 )

6 7 . 8 8

( 9 . 4 9 )

7 2 . 6 3

( 1 0 . 2 4 )

1 . 6 5

< 1

A D A S

M o t h e r

j

2 1 . 3 3

( 5 . 9 3 )

2 2 . 6 7

( 5 . 9 0 )

2 3 . 0 7

( 5 . 4 3 )

2 3 . 1 0

( 7 . 2 7 )

2 2 . 0 7

( 4 . 4 5 )

2 3 . 6 3

( 4 . 2 5 )

2 4 . 1 1

( 4 . 3 3 )

2 3 . 9

6

( 5 . 5 8 )

2 1 . 3 8

( 6 . 1 1 )

2 3 . 1 3

( 6 . 2 6 )

2 1 . 4 2

( 8 . 2 5 )

2 2 . 6 3

( 5 . 2 9 )

1 . 1 6

< 1

F a t h e r

k

2 1 . 9 6

( 5 . 7 4 )

2 4 . 0 0

( 5 . 8 5 )

2 2 . 7 2

( 5 . 6 3 )

2 3 . 2 0

( 7 . 6 0 )

2 2 . 9 6

( 4 . 5 0 )

2 2 . 4 8

( 4 . 2 4 )

2 3 . 4 4

( 4 . 4 2 )

2 2 . 5

6

( 5 . 3 1 )

2 3 . 1 3

( 4 . 6 9 )

2 4 . 3 3

( 3 . 6 4 )

2 3 . 4 0

( 4 . 0 8 )

2 4 . 0 0

( 3 . 7 0 )

< 1

< 1

P P C M o t h e r

l

7 . 3 9 ( 3 . 1 8 )

4 . 5 0 ( 3 . 2 0 )

4 . 7 9 ( 3 . 7 7 )

4 . 0 0 ( 3 . 9 8 )

7 . 3 5 ( 3 . 5 0 )

3 . 9 2 ( 2 . 8 6 )

4 . 2 7 ( 3 . 7 0 )

4 . 0 0 ( 3 . 2 4 )

7 . 9 6 ( 2 . 6 9 )

5 . 2 5 ( 3 . 5 3 )

5 . 8 7 ( 4 . 6 9 )

5 . 2 9 ( 3 . 4 7 )

< 1

< 1

F a t h e r m

4 . 8 8 ( 3 . 8 7 )

4 . 3 6 ( 3 . 8 2 )

4 . 6 4 ( 4 . 2 7 )

1 . 6 4 ( 2 . 6 3 )

5 . 0 8 ( 3 . 1 5 )

3 . 8 4 ( 2 . 6 6 )

3 . 7 6 ( 2 . 8 2 )

2 . 8 0 ( 3 . 1 8 )

4 . 9 3 ( 2 . 8 1 )

3 . 9 3 ( 2 . 9 4 )

3 . 2 0 ( 2 . 7 3 )

2 . 4 7 ( 3 . 0 4 )

< 1

1 . 6 8

D A S S

M o t h e r n

2 4 . 5 0

( 1 8 . 6 8 )

1 5 . 3 6

( 1 4 . 8 2 )

1 4 . 3 1

( 1 2 . 9 9 )

1 3 . 6 2

( 1 6 . 8 8 )

2 4 . 0 2

( 1 6 . 5 6 )

1 7 . 4 4

( 1 8 . 0 7 )

1 9 . 6 7

( 1 9 . 5 1 )

1 8 . 0

2

( 1 6

. 2 4 )

2 2 . 7 4

( 1 8 . 6 4 )

1 8 . 2 9

( 1 9 . 5 1 )

1 6 . 0 9

( 1 5 . 5 1 )

1 3 . 0 9

( 1 0 . 8 4 )

< 1

< 1




each family, the amount of time spent on active skills

training varied across families. The findings obtained from

the initial assessment guided practitioners in determining

which areas of the module to practise within sessions.

Completers were those families that completed the content

of each of the modules.

Partner support introduced parents to a variety of skills

to enhance their teamwork as parenting partners. It aimed tohelp partners improve their communication, increase

consistency in their use of positive parenting strategies,

and, provide support for each other ’s parenting efforts (e.g.,

not interfering with each other ’s discipline attempts; using

problem solving discussions; strategies for building a caring

relationship as a couple). For single parents, this module

was termed Social Support. Single parents brought a

significant other (e.g., mother or friend) with them to these

consultations. On average, the Partner/Social Support

module was completed in 2 h over two appointments.

Coping skills aimed to assist parents experiencing

personal adjustment difficulties (e.g., depression, anger,anxiety and stress) that interfere with their parenting

ability. Using a cognitive conceptualization, parents were

taught to relax and encouraged to identify and challenge

maladaptive cognitions about their child, themselves, child

management routines or other stressful situations. Parents

were also encouraged to prepare a set of coping self-

statements in preparation for potentially stressful situa-

tions. On average this module was completed in 2 h over

several appointments.

Treatment Integrity

Twelve practitioners (nine female and three male) were

trained and supervised in the delivery of the interventions

(four clinical psychologists; six psychologists completing

postgraduate training in psychology; two psychiatrists).

Prior to completion of the pre-intervention assessment,

practitioners were not aware of intervention groups to

which families had been assigned. Each practitioner was

allocated an equal number of families from the enhanced

and standard conditions. Detailed written protocols that

specified the content of each session, in-session exercises

to complete, and homework tasks were developed for the

standard and enhanced conditions. Practitioners completed

the protocol adherence checklists and videotaped each

intervention session (except home visits). Analysis of

checklists in each condition indicated that 100% of the

practitioners discussed all the content material specified

for that condition with each family and gave out all the

required homework assignments. A random selection of

videotaped sessions was reviewed in weekly supervision

meetings with senior clinical psychologists (i.e. the first

and second authors). F a t h e r o

1 4 . 4 6

( 1 2 . 7 8 )

1 5 . 1 5

( 1 2 . 3 5 )

1 6 . 3 5

( 1 6 . 2 6 )

1 4 . 5 8

( 1 9 . 5 2 )

1 3 . 6 4

( 1 1 . 5 5 )

1 8 . 0 4

( 1 3 . 7 0 )

1 3 . 8 8

( 1 3 . 8 2 )

9 . 7 6 ( 1 4

. 0 3 )

1 3 . 4 0

( 1 1 . 9 9 )

9 . 3 3 ( 7 . 7 3 )

1 0 . 7 3

( 1 0 . 5 5 )

7 . 9 3 ( 8 . 6 2 )

2 . 9 5 * *

1 . 2 6

F t i m e F r a t i o f o r m a i n e f f e c t o f t i m e ; F i n t F r a t i o f o r i n t e r a c t i o n b e t w e e n t i m e

a n d c o n d i t i o n .

E B F I E n h a n c e d B e h a v i o u r a l F a m i l y I n t e r v e n t i o n ; S B F I S t a n d a r d B e h a v

i o u r a l F a m i l y I n t e r v e n t i o n ;

S D B F I S e l f - d i r e c t e d B e h a v i o u r a l F a

m i l y I n t e r v e n t i o n ; E C B I E y b e r g C h i l d B e h a v i o u r I n v e n t o r y ; P D R P a r e n t D a i l y R e p o r t ; P S P a r e n t i n g S c a l e ; P S O C P a r e n t S e n s e o f C o m p e t e n c e S c a l e ; A D A S

A b b r e v i a t e d D y a d i c A d j u s t m e n t S c a l e ; P P C P a r e n t P r o b l e m C h e c k l i s t ; D A S S D e p r e s s i o n A n x i e t y S t r e s s S c a l e ; R e s p e c t i v e n f o r t h e f o l l o w i n g m e a s u r e s a r e :

a O b s . n e g . c h i l d b e h . a n d O b s . n e g . m o t h e r b e h . : E B F I ( n = 3 2 ) ; S B F I ( n = 4 0 ) ;

a n d S D B F I ( n = 3 3 ) .

b E C B I — M o t h e r : E B F I ( n = 4 4 ) ; S B F I ( n = 4 8 ) ; a n d S D B F I ( n = 3 4 ) .

c E C B I — F a t h e r : E B F I ( n = 2 5 ) ; S B F

I ( n = 2 6 ) ; a n d S D B F I ( n = 1 5 ) .

d P D R — M o t h e r : E B F I ( n = 3 5 ) ; S B F

I ( n = 4 6 ) ; a n d S D B F I ( n = 2 7 ) .

e P D R — F a t h e r : E B F I ( n = 2 1 ) ; S B F I

( n = 2 2 ) ; a n d S D B F I ( n = 1 1 ) .

fP

S — M o t h e r : E B F I ( n = 4 3 ) ; S B F I ( n = 4 6 ) ; a n d S D B F I ( n = 3 4 ) .

g P S — F a t h e r : E B F I ( n = 2 5 ) ; S B F I ( n = 2 4 ) ; a n d S D B F I ( n = 1 6 ) .

h P S O C — M o t h e r : E B F I ( n = 4 3 ) ; S B

F I ( n = 4 5 ) ; a n d S D B F I ( n = 3 3 ) .

iP

S O C — F a t h e r : E B F I ( n = 2 7 ) ; S B F

I ( n = 2 6 ) ; a n d S D B F I ( n = 1 6 ) .

jA

D A S — M o t h e r : E B F I ( n = 3 0 ) ; S B

F I ( n = 2 7 ) ; a n d S D B F I ( n = 2 4 ) .

k A D A S — F a t h e r : E B F I ( n = 2 5 ) ; S B F I ( n = 2 5 ) ; a n d S D B F I ( n = 1 5 ) .

lP

P C — M o t h e r : E B F I ( n = 2 8 ) ; S B F I ( n = 2 6 ) ; a n d S D B F I ( n = 2 4 ) .

m P P C — F a t h e r : E B F I ( n = 2 5 ) ; S B F I ( n = 2 5 ) ; a n d S D B F I ( n = 1 5 ) .

n D A S S — M o t h e r : E B F I ( n = 4 2 ) ; S B

F I ( n = 4 5 ) ; a n d S D B F I ( n = 3 4 ) .

o D A S S — F a t h e r : E B F I ( n = 2 6 ) ; S B F I ( n = 2 5 ) ; a n d S D B F I ( n = 1 5 ) .

* = p < . 0 5 ;

* * = p < . 0 6




Results

Preliminary Analyses

There were no significant differences across conditions on

any sociodemographic, observational, parent report or

diagnostic measure at pre-intervention indicating that

randomization produced four similar groups.

Attrition

Three hundred and ten families were recruited to start the

trial. Five did not start (three in EBFI; one in SDBFI; and

one in the waitlist); 51 dropped out at post intervention (18

(22.8%) from EBFI; 13 (16.9%) from SBFI; 14 (18.4%)

from SDBFI; 6 (7.7%) from the waitlist control condition

(254 completed post)). There were no significant differ-

Table 4 Effect sizes for pre-to-post-intervention and pre-to-3-year follow-up outcomes

EBFI SBFI SDBFI

Pre to Post Pre to 3-year Pre to Post Pre to 3-year Pre to Post Pre to 3-year

Obs. neg. child behaviour. (%)a 0.63 1.86 0.37 1.94 0.10 1.50

ECBI

Mother b 1.54 1.46 1.70 1.57 1.28 1.70

Father c 0.95 0.78 0.95 0.77 0.50 1.18

PDR

Mother d 1.37 1.58 1.04 1.39 0.68 0.95

Father e 0.77 0.90 0.56 0.56 0.64 0.57

PS

Mother f 1.32 0.97 1.32 0.97 0.76 1.00

Father g 0.77 0.64 0.51 0.36 0.19 0.44

Obs. Neg. mother beh. (%)a 0.19 0.31 0.26 0.23 0.04 0.68

PSOC

Mother h 0.93 1.07 0.85 0.92 0.32 0.90

Father i 0.38 0.75 0.31 0.78 0.16 0.33

ADAS

Mother j 0.23 0.27 0.36 0.37 0.28 0.22

Father k 0.35 0.18−

0.11 0.08 0.29 0.21PPC

Mother l 0.91 0.94 1.07 0.99 0.86 0.86

Father m 0.14 0.98 0.43 0.72 0.35 0.84

DASS

Mother n 0.54 0.61 0.38 0.37 0.23 0.63

Father o −0.05 −0.01 −0.35 0.30 0.40 0.52


Intervention; ECBI Eyberg Child Behaviour Inventory; PDR Parent Daily Report; PS Parenting Scale; PSOC Parent Sense of Competence Scale;

ADAS Abbreviated Dyadic Adjustment Scale; PPC Parent Problem Checklist; DASS Depression Anxiety Stress Scale; Respective n for the

following measures are:a Obs. neg. child beh. and Obs. neg. mother beh.: EBFI (n=32); SBFI (n=40); and SDBFI (n=33). b ECBI — Mother: EBFI (n=44); SBFI (n=48); and SDBFI (n=34).c

ECBI —

Father EBFI (n=25); SBFI (n=26); and SDBFI (n=15).d PDR — Mother: EBFI (n=35); SBFI (n=46); and SDBFI (n=27).e PDR — Father: EBFI (n=21); SBFI (n=22); and SDBFI (n=11).f PS — Mother: EBFI (n=43); SBFI (n=46); and SDBFI (n=34).g PS — Father: EBFI (n=25); SBFI (n=24); and SDBFI (n=16).h PSOC — Mother: EBFI (n=43); SBFI (n=45); and SDBFI (n=33).i PSOC — Father: EBFI (n=27); SBFI (n=26); and SDBFI (n=16). j ADAS — Mother: EBFI (n=30); SBFI (n=27); and SDBFI (n=24).k ADAS — Father: EBFI (n=25); SBFI (n=25); and SDBFI (n=15).l PPC — Mother: EBFI (n=28); SBFI (n=26); and SDBFI (n=24).m PPC — Father: EBFI (n=25); SBFI (n=25); and SDBFI (n=15).n DASS — Mother: EBFI (n=42); SBFI (n=45); and SDBFI (n=34).o DASS — Father: EBFI (n=26); SBFI (n=25); and SDBFI (n=15).




ences in completion or non-completion rates across these

conditions. One hundred and sixty two families completed

the 1-year follow-up (54 in EBFI; 58 in SBFI; 50 in

SDBFI) while 21 dropped out (4 (6.9%) in EBFI; 6 (9.4%)

in SBFI; 11 (18%) in SDBFI). A further 94 dropped out at

3-year follow-up (6 (11.1%) in EBFI; 8 (13.8%) in SBFI; 9

(18%) in SDBFI). In all a total of 139 completed the 3-year

follow-up (48 in EBFI; 50 in SBFI; 41 in SDBFI).As a test of whether there were any differences between

those who completed and those who did not complete 1 and

3 year follow-up in each condition, a series of three way

repeated measures MANOVAs (Condition: EBFI vs SBFI

vs SDBFI × Attrition status: completer vs non completer)

was conducted on all dependent variables. There were no

significant main effects for attrition or the interaction of

attrition and condition suggesting that there was minimal

differential participant attrition across conditions.

Statistical Analyses

The analysis of the longer term intervention effects consisted

of 3 (condition: EBFI vs SBFI vs SDBFI) × 3 (time: post-

intervention vs 1 vs 3 year) repeated measures ANCOVAs and

MANCOVAs, using pre-intervention scores as covariates.

Long Term Intervention Effects

Table 3 shows the means, standard deviations, and univariate

F values for all of the measures at pre- and post-intervention,

and at the 1 and 3 year follow-up, while Table 4 presents the

effect sizes from pre- to post-intervention, and from pre-

intervention to 3-year follow-up. There was a significant

main effect for time on the measure of observed negative

child behaviour, ( F =2.72, p=0.01) but no significant

interaction between condition and time. Table 3 shows there

were lower levels of observed negative child behaviour

across all intervention conditions from post to 1 year and

from 1 to 3 year follow-up, suggesting continued improve-ment across time for all children but no significant differ-

ences between conditions.

Similarly, there were sustained improvements to 3 year

follow-up on mothers’ observed negative behaviour, in the

mothers’ or fathers’ reports of child behaviour, dysfunc-

tional discipline, parenting sense of competence, marital

adjustment, marital conflict, or negative affect, but no

significant condition by time interaction effects.

Teacher Report (3 Year Follow-up)

Table 5 shows the Social competence, SESBI (Intensity) andSESBI (Problem) scores as reported by the child’s teacher at

3 year follow-up. There were no significant condition

differences on any of these measures. All scores were within

the non-clinical range.

Children Meeting Diagnostic Criteria for any Disruptive

Behaviour Disorder

Table 6 reports the results from the DISC interviews

conducted at year 1 and the year 3 follow-up. At 1 and 3

Table 5 Teacher report of conduct problems at school (3-year follow-up data)

EBFI SBFI SDBFI F

M (SD) M (SD) M (SD)

Social Competence Total Scorea 52.19 (22.52) 58.62 (22.06) 58.31 (21.64) < 1

Sutter – Eyberg Intensity Score b 99.00 (44.81) 89.62 (41.53) 89.82 (39.46) < 1

Sutter – Eyberg Problem Scorec 8.09 (9.08) 4.66 (7.19) 6.00 (8.39) 1.72


Interventiona Respective n for Social Competence Scale: EBFI (n=37); SBFI (n=47); and SDBFI (n=35). b Respective n for Sutter – Eyberg Intensity Scale: EBFI (n=37); SBFI (n=45); and SDBFI (n=34).c Respective n for Sutter – Eyberg Problem Scale: EBFI (n=35); SBFI (n=44); and SDBFI (n=33).

Table 6 Percentage of children meeting diagnostic criteria at pre-intervention, 1-year follow-up and 3-year follow-up

EBFI (n=48) SBFI (n=50) SDBFI (n=41) p

Pre (%) 1-year (%) 3-year (%) Pre (%) 1-year (%) 3-year (%) Pre (%) 1-year (%) 3-year (%)

ADHD 52.60 14.30 31.90 63.00 17.00 34.00 50.70 27.10 26.80 0.859

ODD 80.50 36.70 29.80 80.00 37.70 42.00 74.70 39.60 36.60 0.201

CD 31.60 12.20 10.60 31.50 18.90 16.00 37.00 12.50 17.10 0.579

p for Treatment condition effect on 3 year follow-up score after entering prior diagnostic status in binary logistic regression.

EBFI Enhanced Behavioural Family Intervention; SBFI = Standard Behavioural Family Intervention; SDBFI Self-directed Behavioural Family

Intervention




year follow-up there were significantly fewer children

meeting diagnostic criteria in each condition compared to

pre-intervention. Overall, the percentage of children meeting

diagnostic criteria for one or more disorders was 23.4% for

children in EBFI, 32.0% of children in SBFI and 26.8% for

SDBFI. However, there were no significant differences

between conditions in the proportion of children meeting

diagnostic criteria.

Prevention Effects

Table 7 presents the percentage of children who were high

risk at pre-intervention and on the basis of selection criteria

were diagnosis free at 1 and 3 year follow-up. Although

there was a trend for the EBFI group to have a higher overall

percentage of children remaining diagnosis free (88.9%)

compared to SBFI (76.8%) and SDBFI (75.9%), these

differences were not statistically significant for any disorder

or for individual categories of disorder. Table 8 shows the

proportion of children remaining diagnosis free for individ-ual categories of disorder. Once again by 3 year follow-up

80% of all children had not developed any form of

psychopathology.

Prediction of 3-Year Follow-up Child Behaviour

Next we examined whether any pre-intervention character-

istics of parents and children would predict 3 year

outcomes. Four hierarchical multiple regressions were

used in order to examine the relationship between 3-year

follow-up child behaviour outcomes (maternal rating of

ECBI Intensity, observed child negative behaviour, teacher

ratings of SESBI Intensity, and diagnostic status) and pre-

intervention variables. In the regression equations, risk

status (calculated as number of socio-demographic and

family risk variables present), presence of maternaldepression at pre-intervention (measured by the BDI),

maternal abuse potential (CAPI), and level of parental

conflict (maternal PPC Problem score) were entered at

step 1, while mother ’s pre-intervention rating of the

intensity of child behaviour problems (ECBI Intensity)

and child age were entered at step 2.

Risk status, as well as maternal depression, maternal

abuse potential and conflict over parenting, entered at step

1 did not contribute to the prediction of 3-year follow-up

child behaviour intensity as rated by mothers, F (4,105)=

0.80, ns; child’s observed negative behaviour F (4,89)=1.39,

ns; teacher ’s ratings of the child’s behaviour, F (4,81)=1.16,ns; or diagnostic status, F (4,102)=1.22, ns. The addition of

mother ’s pre-intervention ECBI Intensity score at step 2,

contributed to the prediction of mother ’s 3-year follow-up

ECBI Intensity, F (6,105)=4.12, p<0.01; however, it did not

contribute to the prediction of the child’s observed negative

behaviour F (6,89)=1.04, ns; teacher ’s ratings of the child’s

behaviour, F (6,81)=1.80, ns; or diagnostic status, F (6,102)=

1.06, ns

Discussion

This study examined whether a Triple P intervention that

targeted a range of individual parental adjustment variables

hypothesised to influence the development of conduct

problems would produce better outcomes 3 years after the

intervention for preschoolers at risk of conduct problems than

interventions targeting changes in parenting skills alone.

Sanders et al. (2000a) showed that at 1 year follow-up the

three variants of Triple P produced comparable outcomes on

most measures of child and parent outcome. However, a

Table 7 Prevention of childhood psychiatric disorders: percentage of children with no diagnosis at pre-intervention maintaining diagnosis-free

status at 1-year follow-up and 3-year follow-up

EBFI (n=48) SBFI (n=50) SDBFI (n=41) p

Pre (%) 1-year (%) 3-year(%) Pre (%) 1-year (%) 3-year (%) Pre (%) 1-year (%) 3-year (%)

ADHD 100.00 89.70 84.00 100.00 95.00 78.90 100.00 92.00 74.10 0.620

ODD 100.00 72.70 88.90 100.00 91.70 66.70 100.00 84.60 66.70 0.538

CD 100.00 85.70 93.80 100.00 87.90 84.80 100.00 93.80 87.10 0.629

p for Treatment condition effect on 3 year follow-up score after entering prior diagnostic status in binary logistic regression.


Intervention

Table 8 Prevention of childhood psychiatric disorders: percentage of children with no diagnosis at pre-intervention maintaining diagnosis-

free status at 1-year follow-up and 3-year follow-up (conditions

collapsed)

Pre (n=139) 1-year (n=139) 3-year (n=139)

N (%) N (%) N (%)

ADHD 100.00 91.90 78.90

ODD 100.00 83.30 72.70

CD 100.00 89.00 88.50

Any disorder 100.00 88.06 80




longer period of follow-up would potentially detect any

delayed effects of the more intensive interventions. The

present findings showed a very similar pattern of sustained

improvement at both 1 and 3 year post intervention

irrespective of which variant of Triple P parents received.

All three variants (enhanced, standard and self directed)

showed maintenance of treatment gains and the changes

observed in levels of disruptive behaviour had either maintained or shown further improvement by 3 year

follow-up. There was no evidence of relapse or negative

side effects of intervention on any child or parent measure.

Across all conditions the majority of children (80%) who

were in the clinically elevated range at pre-intervention had

failed to develop any diagnosable disruptive behaviour

disorder. Furthermore those who were below the clinical

threshold prior to intervention remained so 3 years later.

When parents present with child conduct problems and

dysfunctional parenting and have additional family risk

factors such as high levels of partner conflict, or high levels

of depression or stress, it has often been assumed that better maintenance effects will be achieved by targeting these

additional risk factors. The prediction that greater changes in

child disruptive behaviour would occur when an intervention

concurrently targets not only parenting practices, but also

marital communication and parental mood variables was not

confirmed.

The present findings need to be interpreted in the light of

findings from earlier research using the same program

showing additional benefits of adjunctive interventions

such as partner support training (e.g., Dadds et al. 1987),

attributional retraining and anger management (Sanders et al.

2004), and coping skills training (Sanders and McFarland

2000). However, none of these prior studies had long term

follow-up. In contrast there have been three studies using

Triple P that have failed to demonstrate additional benefits

of adjunctive procedures (e.g., Foster et al. 2003; Ireland

et al. 2003; Plant and Sanders 2007). It has also been shown

that the best predictor of parents’ daily stress is the child’s

level of disruptive behaviour (Plant and Sanders 2007) and

parental coerciveness is best predicted by child conduct

problems (Bor and Sanders 2004). Consequently, if dis-

ruptive behaviour decreases as a result of parents imple-

menting positive parenting and effective discipline routines,

there may be little room for adjunctive parenting inter-

ventions used here to add to the outcome.

At first glance the finding that a self-directed interven-

tion was just as effective in the long term as two more

intensive practitioner assisted interventions seem counter-

intuitive. However, this finding is consistent with an

increasing body of evidence showing that self-directed

parenting interventions or interventions involving minimal

assistance can be effective in modifying disruptive behav-

iour in young children (e.g., Morawska and Sanders 2006;

Sanders et al. 2000b). Parents of young children are often

highly motivated to access information about parenting, as

reflected by sales of parenting books being highest with

parents of children aged 0 – 3 years. When parents are

motivationally ready and interested in receiving information

about parenting, providing this information is clear and

understandable, many parents may benefit from simply

accessing the information. Such a finding points to theimportance of the use of mass media, web, and other

modern communication technology in promoting positive

parenting. The toddler period from a neurobiological

perspective is also a good time for parenting interventions

as differences in child rearing have marked effects on

children’s brain development. This developmental plasticity

means that good early parenting may more easily affect

durable changes in language, social skills and emotion.

Other mechanisms may also be at work to suggest that

preschool disruptive behaviour may be particularly sensi-

tive to changes in parenting practices. First, this period is

close to the peak frequency of aggressive and non-compliant behaviours; hence parents may be more receptive

to advice than at later developmental periods (Klimes-

Dougan and Kopp 1999; Tremblay and Nagin 2005).

Second, several longitudinal studies show that disruptive

behaviour in the toddler – preschooler is a unique starting

point for a trajectory of stable childhood, adolescent and

adult anti-social disorders (Fisher et al.1984; Caspi et al.

1995). The third possible mechanism relates to the key role

of parenting practices in maintaining preschool disruptive

behaviour problems and later conduct problems (Campbell

1995; Capaldi et al. 2002; Snyder 1991). Collectively these

findings suggest that intervention in the preschool period

may have particular potency in terms of its impact on

developmental outcomes. All three interventions in the

present study had one common element: providing parents

with clear advice on strategies to modify the parenting

behaviours thus targeting the cent ral risk factor for

continuity of conduct problems.

To be viable as a public health measure, parenting

programs need to be cost-effective (Foster et al. 2003).

Although both therapist contact conditions were relatively

brief, the self-directed program was clearly the most cost

efficient to deliver, requiring no practitioner contact. Little is

known about how much additional time parents must invest

in learning new skills in the three conditions.

The present findings need to be interpreted taking into

account the limitations of the study. First, there was a higher

rate of subject attrition than would have been desirable.

Despite this limitation there was no indication of differential

attrition across conditions. Second, these findings cannot be

generalized to older age groups of children. On the other

hand they cannot be simply dismissed either. Further

research is needed to clarify the effects of brief parenting




interventions with older children with more entrenched

conduct problems.

The main implications of the present findings are that all

three variants of the Triple P system were associated with

favourable long-term outcomes for children in this sample of

high risk 3-year-olds. Using the principle of selecting the

minimally sufficient intervention to produce the desired

outcome points to the potential benefits of making highquality, evidence-based parenting information widely avail-

able to parents. When parents seek and are assessed to

require professional support, the present findings point to the

importance of careful matching of adjunctive interventions to

client characteristics. Instead of offering the same combina-

tion of adjunctive interventions to all high risk families as in

the enhanced condition, it is possible that the adjunctive

interventions, although well received by parents, may not

have been necessary for all parents. There is evidence that

parenting skills training alone can reduce depression and

marital conflict and the pre-treatment characteristics of the

parent on these factors may not be the best indicator of whoneeds to receive an adjunctive intervention. An alternative

approach with high risk children is to offer a standard

moderate intensity intervention and only offer an adjunctive

intervention to non-responders where parental risk factors

are not changed by the parenting intervention.

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