Vol. 24, No. 1
February 2019

Triple P: A Multilevel Prevention Intervention Going Statewide in NC

If you have heard of Triple P (Positive Parenting Program), chances are you think of it as one of the better models of parent education available. While this is correct, there's a lot more to this intervention, which explains why North Carolina is making such an effort to spread Triple P across the state.

What is Triple P?
Triple P is a flexible, five-tiered approach that supports positive parenting for the entire community. As the graphic below shows, Levels 1-2 of Triple P are universal--they are designed for all parents and include awareness and education as well as brief parenting advice. Levels 3-5 are for families that need specific help with parenting. Interventions at Levels 3-5 range from online courses, to group parenting classes, to individual family support (Triple P international, n.d.).

Triple P focuses on the same parenting approach and skills across all five levels. Its overarching principles are:

A strength-based, self-regulatory framework
Parents determine the goals
Practitioners use examples relevant to the family
A menu of parenting strategies, and
Practitioners help the parent make informed choices.

The key parenting skills addressed in Triple P are:

Ensuring a safe, interesting environment,
Creating a positive learning environment,
Using assertive discipline,
Having realistic expectations, and
Taking care of yourself as a parent.

In addition, Triple P helps to both prevent and address problem behaviors. Triple P prevents problem behaviors by developing positive relationships, encouraging positive behavior, and teaching new skills and behaviors. Triple P addresses problem behaviors through strategies such as establishing ground rules, directed discussion, planned ignoring, clear and calm instructions, and logical consequences. For more on the Triple P approach, see "My Experiences with Triple P" in the box below.

How is Triple P delivered?
Triple P uses a community's existing resources to deliver all levels of intervention. This means communities have the flexibility to design an approach that supports their specific needs. The goal is to create a Triple P Community Coalition of diverse stakeholders that will assess and design the types of interventions to be implemented.

Triple P's flexibility is also reflected in the agencies and individuals who implement it. Various agencies within a community may provide one or more levels of Triple P. Triple P practitioners, each of whom must receive intensive training and demonstrate fidelity to the model, can also be based in different agencies within the community.

What does the evidence say?
There is strong evidence of the effectiveness of Triple P, both for individuals and communities. A meta analysis of over 100 studies showed benefits to parents and children regardless of the level or type of Triple P intervention. Children showed improvement in social, emotional, and behavioral outcomes and parents showed improvement in parenting practices, parental relationships, and parental confidence (Sanders, et al., 2014). Recent data from North Carolina supports these findings. For example, a preliminary evaluation of online Triple P classes showed an increase in parent confidence to manage the top ten most concerning child behaviors, such as disobedience, tantrums, and aggression (K. O'Connor, personal communication, December 27, 2018).

Triple P has the biggest impact when it is a community-wide, multilevel intervention. Implemented in this way, Triple P has been shown to lead to improved outcomes across agencies. For example, South Carolina counties that implemented Triple P community-wide saw greater reductions in child maltreatment, out-of-home placement, and child maltreatment injuries than counties that did not (Prinz, 2017). This and other evidence shows that when implemented well, Triple P has the ability to impact outcomes throughout the community at multiple levels.

What is North Carolina doing with Triple P?
North Carolina is in the midst of one of the largest Triple P scaling up projects in the country. This work is being supported by the NC Division of Social Services, NC Division of Public Health, Triple P America, Prevent Child Abuse NC, the Impact Center at Frank Porter Graham, and The Duke Endowment. North Carolina's goal is to develop a statewide infrastructure to support the ongoing delivery of Triple P in every county in the state (O'Connor, 2018).

For the purposes of Triple P implementation, North Carolina has been divided into 10 service areas. Each area has a lead implementation agency (LIA) with funding for three full-time positions to support Triple P implementation. Included in the 10 service areas are Wake and Cabarrus, which have a stand-alone, county-level LIA supported with additional funding. For a map of the service areas, click here. For a list of LIAs in each area, click here.

The role of each region's LIA is to support the development of a Triple P Community Coalition that will build local capacity to support agencies to effectively deliver Triple P with fidelity across all levels of intervention. We know from implementation science that without fidelity, interventions not only fail to produce the desired positive outcomes but can actually cause harm. So it is crucial that communities, agencies, and practitioners get the support they need to deliver faithful, sustainable interventions. Part of North Carolina's scaling up efforts includes the Impact Center at Frank Porter Graham's Implementation Capacity for Triple P (ICTP). This website provides tools, evidence, and a simulation lab to support communities in the implementation process. Evidence from pilot counties shows that these supports make a difference in both community and agency capacity to deliver Triple P effectively (Aldridge, et al., 2016).

What is next?
A January 3, 2019 letter from the NC Division of Social Services described the current status of Triple P in North Carolina and specifically addressed what child welfare agencies should be focusing on for the near future. Child welfare leaders are encouraged to reach out to the LIA in their region and participate in local Triple P coalitions. In addition, child welfare staff are asked to consider Triple P online (TPOL) as a possible intervention for families they are working with. This is a free, self-directed, online, Level 4 course for parents of children ages 2 to 12 (see below for website).

Also, county child welfare agencies received a survey to assess how Triple P is being used and to determine whether additional are needed supports for implementing Triple P in child welfare agencies across the state.

This is an exciting time in North Carolina to focus on prevention through the Triple P Parenting System and to create a lasting impact on communities, families, and children.

My Experiences with Triple P

by Krista Kindley-Martin, MSW

Twenty years of my career has been as a child welfare professional in a variety of roles. Eight years of my life has been as a parent--and I have voluntarily completed three different parenting skills courses. The child welfare field secretly challenges me as an individual to ask if I desire to repeat the parenting patterns that shaped me as a child. My answer continues to be "no"!

I am attracted to Triple P (Positive Parenting Program) because I desire to evolve my skills as a positive parent. I participated in the free online version because a parenting group is not available in my community. I was drawn to the connectivity of a parenting group where I could exchange ideas and share encouragement.

Triple P online is a great, effective alternative to an organized, in-person group. The modules are covered through videos, with minimal reading. Within each module, Triple P intentionally guides the caregiver to:

Set goals,
Identify specific parenting challenges or strategies they want to learn,
Become aware of their current parenting behaviors, and
Learn basic child development norms.

Each module provides simple, printable tools to aid the caregiver in transferring the individualized content into home application.

Triple P online is highly interactive and gives homework assignments for practice. The Triple P process makes it easier to change my behavior, which creates the opportunity to become proactive in modifying and managing my child's behavior. The resources in Triple P are an opportunity for child welfare agencies to customize the materials in a group or one-on-one setting with families. Triple P is proven to be effective with children with special abilities. These short modules could be incorporated into home visits or possibly integrated within clinical practice. Triple P provides helpful strategies for me and my evolving child. I'm convinced they could be beneficial for other caregivers as well!.

References for this and other articles in this issue