Impact and acceptability of Group Triple P for - Parenting and Family ...

The effectiveness and
acceptability of
Group Triple P Positive
Parenting Programme
delivered to aboriginal
parents in Canada.
C.Houlding 1 , F.Schmidt 1 , S.Stern 2 , J.Jamieson 1 , & D.Borg 3
1. Lakehead Universty
2. University of Toronto
3. Dilico Anishinabek Family Care

Acknowledgements
• Leadership, staff and clients of Dilico
Anishinabek Family Care.
• The First Nations communities in which the
research took place
• Agencies within the system of local children's
services.

Introduction
• Aboriginal communities in Canada are at increased
risk of a broad range of poor outcomes, , including
high rates of unemployment, incarceration, low
educational attainment and adverse health outcomes.
• Of all off-reserve aboriginal children, 40 per cent live
in poverty, including substandard housing,
overcrowding, mould.
• Close to 100 First Nations communities must boil
their water
• Almost half of aboriginal children under 15 years old
living in urban areas live with a single parent (Campaign 2000)

Context
• These vulnerabilities developed in the context of cultural
destruction associated with colonisation, including residential
schools (Kirmayer, et al., 2000)
• Residential schools; 19 th century - aggressive assimilation,
forced separation from parents and communities, active
discouragement of culture.
• Physical, emotional, sexual abuse, high+ mortality.

Aboriginal Children
• Aboriginal children in Canada are at increased
risk of a broad array of significant emotional
and behavioural difficulties including suicide,
substance abuse, fetal alcohol syndrome (Kirmayer,
Brass, & Tait, 2000).

Parenting Programmes
• Parent training has been commonly used to
address some of the mechanisms leading to
emotional and behavioural problems in
children.
• Parenting programmes based on behavioural
social learning models help improve parenting
and child competencies and decrease
children’s s problematic behaviours (Dretzke, Davenport,
Frew, Barlow, Stewart-Brown, Bayliuss, Taylor, Sandercock, & Hyde, 2009).

Triple P Parenting Programme
• Improve outcomes for children and parents (deGraaf, Speetjens,
Smit, deWolff, & Tavecchio, 2008a;b),
• Evidence for good outcomes in other cultures
including Japanese-Australian and Chinese (Leung, Sanders,
Leung, Mark, & Lau, 2003; Matsumoto, Sofronoff, & Sanders, 2007), , ).
• Also evidence for good outcomes in indigenous
families living in Australia (Turner, et al., 2007).

Triple P Positive Parenting
Programme
The programme is designed to encourage;
• Caring relationships.
• Appropriate expectations
• Appropriate activities
• Appropriate behaviour management strategies.
• Self regulation in parents (Turner, Markie-Dadds, & Sanders, 2002).

Parenting programmes don’t
always translate
• Members of ethnic minorities may be less
likely to attend and/or be retained in
mainstream parenting programs (Biglan & Metzler, 1999)
(Biglan & Metzler, 1999).
• This may be due to cultural differences in
perceptions of the value or relevance of
parenting groups.

Need to Develop Specific?
• Kazdin (1993): attempting to develop and
evaluate interventions for every culture is
unrealistically time consuming and costly.
• Culture-specific interventions do not appear to
yield superior outcomes to generic programs
Kazdin (1993) .
• Treatment as usual = no better than wait list
(Weisz, Jensen-Dobson, & Hawley, 2006)

Adapting ESTs
• Use ‘guiding principles’ to shape culturally
sensitive adaptations of existing models of
intervention.
• Range of adaptations : small changes to
existing programs (e.g. ethnically similar
actors in support materials) to large
(interventions developed specifically for a
particular cultural group) (Kazdin, 2000).

Indigenous Australian Triple P
• Developed with extensive consultation (Turner, Richards, &
Sanders, 2007).
• Similar content to regular Triple P.
• Changes to resources, images and materials
(simplified text; use of actors and scenarios)

In this context...
Dilico Anishinabek Family Care...
• Thunder Bay and 13 First Nations
communities
• Mid 2000s parenting identified as a priority.
• Leadership attended a children’s s mental health
conference.
• Consulted with Band Councils
• Decided to adopt Triple P.

Process of Research
• Dilico Anishinabek approached Lakehead
University to collaborate in a formal
evaluation of use of Triple P.
• Permission from Band Councils.

Research Design Considerations
• Qualitative research methods have been used
in examination of evidence based parenting
interventions (Stern, Alaggia, Watson, & Morton, 2008)
• Qualitative methods may be more consistent
with cultural values of aboriginal Canadians
than use of standardised instruments (Silverstein & Auerbach,
2009).
• Qualitative research generates rich accounts of
participants’ experience; insight that might be
lost if only quantitative analysis were
considered (Creswell, 2007).

Research Questions
Was participation in Group Triple P helpful?
Were there changes in parenting and child behaviour in aboriginal
parents in Canada following participation in Group Triple P?
Was Group Triple P consistent with the values of aboriginal parents?

METHOD

Participants
• All participants were from one city and two towns in
northwestern Ontario, Canada.

Life in Northern Towns

Parents
Participants..
• Eleven parents, 10 mothers
• Parents of 3-123
yr olds.
• 100% parents self-identified as aboriginal Canadian.
• Not mandated attendance.
• Parent participants had completed Group Triple P parenting
programme.
Facilitators
• Eight group facilitators, working at an aboriginal mental
health agency.
• 50% of facilitators self-identified as aboriginal Canadian.
• Accredited Triple P facilitators.

Procedure
Facilitators;
- Presented research plan
- Managers not told who decided to participate.
Parents;
- Clinicians initially approached.
- Researcher followed up with interested.
- Clinicians not told whether parent ultimately
decided to participate.
- $20 voucher; community meal.

Ethical considerations
• Voluntary
• Anonymous
• Transcription in another city.
• Transcripts reviewed by first and second
authors (i.e. not employed by or members of
the participating organization).
• Cultural – CIHR guidelines (e.g. permission
from Band Councils before starting research;
questionnaires; capacity building).

Interview Questions
Helpfulness
• How was Group Triple P helpful?
• Where there ways in which it was not?
Cultural Appropriateness
• How was the Triple P group consistent with your
values? Or not?
• What strategies did you agree with? Were there
any that you didn't you agree with?

Feedback
• The interviews were recorded, transcribed, and
the data were then analyzed.
• An initial summary was given to facilitator
participants (‘member(
checking’).
• This was made available to parent participants.
• Changes to interpretation of data were made
according to feedback given (Creswell, 2007).

Process in Triple P
• Guided discussion,
• DVDs,
• Workbooks,
• Role plays.
• Based on a ‘self-regulation’.

Intervention in Clinical Practice
• Designed : 8 sessions: 6 group + two follow up
at home (Turner, Markie-Dadds, & Sanders, 2002).
• Two sites: 7 sessions; 5 group + 2 home visits
or phonecalls.
• One site: 3 long sessions on consecutive days,
+ 2 home visits.

Intervention in Clinical Practice
• Some sites used incentives for attendance at
parenting sessions.
• One site: gift bags
• One site: children’s s seasonal clothing for full
attendance. The Band Council of the First Nation
paid for these incentives.

Intervention in Clinical Practice
• The regular DVDs and workbooks were used
for earlier groups.
• Indigenous workbooks and DVDs were used
for later groups (when these resources became
available).
• Some parents were given a choice of the
DVDs they would prefer to use.

Intervention in Clinical Practice
• Parents were not differentiated according to
the resources used within Group Triple P.
• Only the DVDs and workbooks were different.
Other content and process of the program they
received was essentially the same.
• Participants were specifically asked about the
usefulness of the DVDs and workbooks within
interviews.

Intervention integrity
• All facilitators had completed training and
attained competency-based accreditation in
Group Triple P.
• Facilitators received supervision from
managers committed to implementing the
program with fidelity to its design.
• Facilitators had run between two and ten
Group Triple P groups.

Analysis
Phenomenological Descriptive Analysis (Collaizzi, 1978)
- Interview transcribed
- Transcripts read several times
- Coded for key themes/ phrases related to research
questions.
- Meanings
- Themes synthesised.
- Summarised in ‘exhaustive description’.

Credibility
Transferability
Is this a credible interpretation
of the data?
Believable from the
perspective of the participant
in the research?
Will this apply or transfer
elsewhere?
Trustworthiness
• Bracketing
• Peer debriefing
• Data saturation
• Formal and informal ’member checking ‘ (asking
participants whether interpretation is consistent with
their experience)
• Description of participants, communities.
Dependability
Assessment of the quality of
the integrated process of data
collection, data analysis,
meaning summaries.
• Process of reviewing, coding, synthesizing
transcripts.
• Two researchers reviewing independently,
synthesised.
Confirmability
How well the findings are
supported by the data
collected?
Degree to which the results
could be confirmed or
corroborated by others.
• Audit trail: including field and reflexive notes (Lincoln
& Guba, 1985), data reduction products and raw
data.

RESULTS

Results: Was it Helpful?
Generally very positive;
The reserve is a small community and we don’t
need a newspaper… the parents will tell you
whether it’s s good or not.. They tell each other and
then it’s s like ‘they told me about this program and
I want to try.’

Results: Was it Helpful?
Seemed to compare well to other programmes;
…Nothing could come close to this parenting
program… it’s s not the answer to everything. Its
not going to fix everything, but it’s s a start and I
really enjoy running it.

Results: Was it Helpful?
Further, these results were noticed by other
agencies including from schools and
childcares;
I get feedback from the daycares or the schools on
‘wow, what’s s happened to him or her?’

Results: Was it Helpful?
Changes in the family’s s overall mental
health and functioning;
I see less stress for the parent, I see the parent becoming hopeful that
they found something that seems to have proven effective. They’re
reporting that the children are more cooperative and ... the family seem
to be happier on a daily basis ... I get reports that they’re absolutely
amazed, they’re applying a technique and following through with that
creates change in such a short time.

Results: Was it helpful?
The program might be considered helpful
because it encouraged a sense of optimism;
I have been [working with parents] for twenty years and
the greatest gift I can give a client is … validation that
they have capacity to do something and that I’m I m there to
support them and that sense of hope for change. And I
think ... the Triple P literature and the videos do that…

Use of Incentives
While incentives were used to encourage
attendance in some groups, the programme
was still perceived as helpful;
They may not be there for parenting. They may
just be there to get their children’s s spring or
summer clothes… but whatever gets them there,
they get the information. Then they’ll run with it…

How Parenting Changed
In promoting responsive relationships…
… so I just kind of learned to drop the dish tray or
leave the laundry basket piled up.. And.. Just sit
and listen to him, what he wants to tell me.

How Parenting Changed
Being more positive;
I think it really did good for me because instead of
me lashing and yelling all the time... it was more
helpful for me to ... actually walk up to him and
just say talk calmly to him without raising my
voice…
I’ve started complimenting [my daughter]…she
just goes shocked ... then she just is kind of shy
because she didn’t t know what to do about it ... I
could see… that she was, like, happy with herself

How Parenting Changed (cont.)
Introducing new strategies for discipline;
…I I did come through circumstances ... you know, like
elders yelling at me ... So, yeah, I thought … ‘okay,
yeah I have to use my calm voice’ … I just have to
keep reminding myself, ‘okay, I have to like stay
calm take a breath.’
... the only way my mum knew how – and she taught
me – is to hit ... after doing wrong. So this is how I
brought up my kids… now there’s s new ways of
disciplining your child so, so I’m I m happy for that … it
seems like the cycle is broken now…

How Parenting Changed (cont.)
Parents mentioned that they were attempting to
improve their consistency across caregivers:
Now we [my ex-husband and I] are
communicating more when it comes to the
behavior and discipline of [our child]... after
taking the Triple P... I went to him... ‘we
need to be on the same page'.

How Parenting Changed (cont.)
Some parents talked about the helpfulness and
impact of a routine, as a strategy that helped to
bring appropriate structure to the child's
activities:
I made... a schedule ... with the charts ... coming home
after school, doing their homework then they get to play
out ... I follow through with it, having a schedule for
them to do ... instead of it being all over. And they’ve
got a certain bed time… because I learned that it’s s better
for the kids to have at least eleven to twelve hours sleep
a night.

How Children Changed
Some participants reported that children’s s competencies
and behaviour improved;
… it really does work. I’m I m really surprised because my kids
were going off the walls once in a while and ... it really
calmed them down and they really started to listen…
... I feel like we’ve grown a lot closer. I feel like she herself is
stronger as a child, too. I feel like Triple P has made me feel
better as a mother and I feel like that it made my daughter
stronger and confident and… more open.

Fit with Parents’ Values
Participants perceived that the strategies and
values on which they were based were
consistent with parents’ values;
With all the families I have worked with, none of
them have said that ‘you know none of this really
fit for me’ or ‘I I don’t t believe in this’. . If anything,
they are like ‘I I do a lot of these’.

Fit with Parents’ Values
There was a sense that the strategies were
experienced as part of parents’ values, not
foreign to them;
… It didn’t t come from our culture, you know my Mum, my
Mum and them before they went to the boarding school. There
was no such thing as ... hitting there was a gentle way of
disciplining, but when they went to the boarding school that’s
where they learnt to hit their kids... so now what they’re
teaching us is the parenting .. to go back to where, … it was
before, the way it’s s supposed to be ...

Fit with Parents’ Learning Styles
And the material was presented in a manner
that parents found compelling;
…The role play in the delivery of the program… is
the style that an aboriginal person would want to
learn, as opposed to a lecture style.
… we are visual learners. We need to see things and
to be taught and get involved.. Practicing.. Helps
them learn and they really enjoyed it.

Indigenous Resources
• Indigenous workbooks were consistently
perceived as an improvement on the regular
workbooks.
• Indigenous DVDs – a more mixed response.

How Could it be Improved?
• A number of participants suggested
incorporating images and scenarios in the
DVDs that are consistent with experience of
aboriginal families;
… It will be nice to see them do [the DVD] on a
reserve.. Because the reserve is like a whole
family… because you have your cousin who lives
next door.. And they help you, so everyone is
involved and not just your household.

How Could it be Improved?
Involve extended families in training;
It would have been good for the grandparent,
even the aunties and uncles.. Because.. my
kids spend a lot of time at their granny’s
house.. or extended family..

Limitations of Triple P
Triple P may be less effective in families with
complex problems;
…So here you are … you go to someone’s s house and it’s
‘okay we’re going to do this on Triple P today’. . Then you
walk in the door and someone’s s got their teeth knocked out
… or there’s s no food in the house because something else
happened. Or there’s s crisis and you want to be moving
forward and Triple P and ‘this is my agenda’. . It’s s not their
agenda. Their agenda is survival. So Triple P would work
best when the family is pretty stable. They want things to
change.

Discussion
• Group Triple P can be beneficial even in the
context of the grave adversity experienced by
aboriginal people in Canada.
• Group Triple P was helpful at introducing new
ideas and refining skills in a compelling
manner.
• Improvements in parenting and child
behaviours were reported.

Discussion: Values
• Consistent with values (c.f. Seven Teachings
of the Anishnabek e.g. shunning; giving honor)
(Dionne, Davis, Sheeber, & Madrigal, 2009).
• Strategies might be more consistent than some
frequently used parenting practices that
emerged as a result of their experiences with
European colonizers.

Discussion: Values
• Way in which strategies taught also consistent
• Many of the participants had experiences with
numbers of other parenting programmes.
• Many considered Triple P better and exceeded
expectations.
• This might be because ‘hands-on’; ‘here and
now’, , rather than focused on feelings/ history/
insight.

Strengths of the Study
• Unique: examination of helpfulness of Group
Triple P with aboriginal parents in Canada.
• Therefore, results provide actual data to inform
decisions about investment in training and
programmes.
• Qualitative design: depth of understanding,
participants’ experiences in their own words.
• Would not have been captured with a quantitative
design.

Limitations of Study
• Retrospective.
• Quasi experimental
• Completers, volunteers.
• Limited number of sites (e.g. health of
communities as moderators of outcomes).
• Heterogeneity in how it was delivered.
• Heterogeneity in resources used.

Implications
• Worth continuing to invest in research
evaluating the program
• Worth investing in enhancing effectiveness
For example, through;
• funding substantial incentives for attendance,
• broadening training to include teens and for
children with special needs, and
• developing strategies to improve the impact for
more complex or dysfunctional families.
• Informative process ‘give us the information’

Future Directions
• Investigate: acculturation,
isolation, problem severity and
complexity, health of host
community as moderators of
outcome.
• Develop aboriginal Canadian
Triple P. Incorporate actors;
scenarios; images; metaphor/
stories relevant to aboriginal
families in Canada.
• Public health model of
intervention (Sanders, 2010).

Thank You!