Written evidence submitted by Triple P UK (EYI0093)

1. This is a submission by Triple P UK to the Science and Technology Committee of the House of Commons Inquiry into Evidence Based Early Years Interventions.

2. Triple P UK is a social enterprise providing training, resources and implementation support to organisations seeking to create healthier communities by improving children’s and parents’ mental health, reduce child abuse and neglect and improve children’s social mobility.

3. The Triple P  ̶  Positive Parenting Program is designed to improve the health and wellbeing of communities by supporting the development of more resilient and nurturing families. It is one of the most extensively researched systems of parenting interventions in the world. It is one of the few programmes to have demonstrated success in addressing ACEs at a community level.

4. Clinically evaluated e-mental health solutions can help take proven population-health interventions that address ACEs to scale cost-effectively.

Question 1: The evidence-base (including overseas experiences) for the link between adverse childhood experiences and long-term negative outcomes, and any gaps in that evidence base, as well as data on which specific adverse childhood experiences produce greatest adverse impact.

5. Adverse Childhood Experiences surveys have emerged as an important population-level indicator of need across the community since a ground-breaking study in the US by Felitti et al (1998) [i].

6. Felitti’s highly cited research demonstrated the link between 10 categories of abuse and neglect and household dysfunction and adult onset of chronic disease, mental illness, violence and being a victim of violence, among many other consequences.

7. Rather than any one indicator having the most impact, an ACE score is calculated as a sum or accumulation of a number of indicators experienced at any time during childhood with a score of 1-10 possible. Felitti et al. found a strong graded relationship between:

• The breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.
• That most people (64%) have an ACE score of one; 12% of the population has an ACE score of 4 and that having an ACE score of 4 markedly increases the risk of chronic disease.
• An ACE score of 4 nearly doubles the risk of heart disease and cancer, it increases the likelihood of becoming an alcoholic by 700 percent, and the risk of attempted suicide by 1200 percent.
• Four or more ACEs meant a child had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, more than 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity.

8. The Felitti study has generated more than 70 scientific articles. A comprehensive review of studies of the ACE survey is listed here.

9. The value and ethics of using ACEs scales as a screening tool to identify vulnerable individuals is currently open to debate. Researchers such as Director of the US Crimes against Children Research Center, Professor David Finkelhor, suggest screening for ACEs risks creates an unethical “Field of Dreams’’ scenario where need is identified in individuals while there is little support in the community available[ii]. Leitch (2017) argues that trauma-informed care is important, but it is an approach that depathologises certain behaviours rather than an intervention[iii] and that the deficits model of ACEs in researching and advocating interventions for particular ACEs can have unintended negative consequences for individuals by focusing solely on risk factors and excluding potential protective factors.

10. The types of screening tools to be used to identify indicators of ACEs are also debated. Finkelhor suggests still much more work needs to be done to develop and refine possible ACE-informed screening instrumentsii before they are used routinely in practice in medical settings, for example.

11. Research into ACEs does suggest that individuals are most likely to thrive in an environment where toxic social and biological influences are minimised, where the development of resilient and prosocial behaviour is enhanced and where opportunities and influences on problem behaviour are lessened[iv].

12. Rather than prioritising one particular ACE indicator over another, and one single section of the community for support over the majority, researchers such as Finkelhor and Oral et al (2016) point out that ACE scales are valuable in demonstrating the need for a community-wide preventative and treatment approach to reduce prevalence rates in children across the populationii v; in other words a public health approach.

Question 2: The quality of the existing evidence-base for specific early-years interventions that aim to address adverse childhood experiences and minimise their effects in later life.

13. Predicting later calls for a public health response to ACEs, Felitti et al (1998) suggest that prevention of adverse childhood experiences, “will ultimately require societal changes that improve the quality of family and household environments during childhood’’i. The authors argue against relying on tertiary support at adulthood.

14. Director of the US Crimes against Children Research Center, Professor David Finkelhor (2017), suggests that one of the most important hypotheses prompted by ACE research is that prevention of childhood adversities may have substantial population level health benefitsii. He writes:

“. . . the most useful confirmation of this hypothesis is not through the refinement of better ACE screening tools. Rather it is through the development and evaluation of programs that prevent the occurrence of childhood adversities in the first place and then the experimental demonstration of the population health effects from their dissemination.’’

15. ACE scales are primarily related to family functioning and identify a potential baseline for a population-health approach to reduce prevalence rates. A parenting intervention with a demonstrated ability to reduce child maltreatment indicators and improve mental health issues across the population should therefore be a critical factor in protecting and supporting children’s development.

16. Oral et al (2016) outline that a focus on primary prevention of ACEs, in which the incidence of ACEs is reduced at the population level, will have the greatest individual and societal impact. The authors highlight Triple P as a rare example of a successful population health approach:

“Targeted primary prevention programs at the community and societal levels are rare. Three of 17 studies evaluating universal campaigns measured child abuse as an outcome, and of these, two of the three studies found significant decreases. Triple-P or Positive Parenting Program is an example of a universal program that supports positive parenting at the individual, family, community, and societal levels through targeted education and social campaigns.”[v]

17. The Triple P – Positive Parenting Program is one of two programmes in the world with the strongest evidence to prevent child maltreatment[vi]. It does this by improving family functioning at a population-level with an interlocking system of programmes, from light-touch to more intensive interventions, and clinically tested digital interventions capable of supporting families cost-effectively and at scale.

18. Triple P works with parents to activate their skills of self-regulation by focusing on a strengths-based approach which helps them identify and develop their competencies. Parents in turn are taught to develop such skills in their children.

19. The interlocking nature of the Triple P system means that one level of programme intensity supports the other. A communications strategy breaks down any potential barriers parents have about accessing support, as parents may not have associated family stressors with a solution such as an evidence-based parenting programme. Light-touch programmes deliver improved outcomes for potentially large numbers of children and families[vii] as well as acting as a low-barrier entry point for more vulnerable families to learn more about positive parenting. These families often self-select into more intensive support such as group or enhanced programmes[viii]. Clinically evaluated online programmes are now increasingly preferred by parents and extend programme reach even further for minimal investment.

20. Under the multi-level model, it is the parent, rather than a practitioner, who decides which level of support is appropriate for their needs. Consequently, engagement is led by the consumer, rather than authorities. Brief interventions are often preferred by parents, who then decide if more help is needed. Minimally sufficient programmes are appropriate for a wide range of families and needs[ix].

Question 3: The extent to which local and national government policies for early-years intervention reflect that evidence-base, and the challenges involved in disseminating, accessing and using the latest evidence, as well as the opportunities for intervention suggested by the evidence but not currently being implemented.

21. To break down current silo-ed approaches obstructing a population-health approach to the delivery of evidence-based parenting support in the United Kingdom, parenting needs to be viewed through a public health lens to treat and prevent ACEs in the UK.

22. A number of international policy papers call for the integration of evidence-based parenting programmes such as Triple P into medical practices. American Academy of Pediatrics policy guidelines advocate the use of Triple P to help reduce the toxic health effects of poverty on children and promote childhood resilience to adversity [x]. Evidence-based parenting programmes such as Triple P, by their multi-level, dose-appropriate nature, are also able to integrate prevention and treatment approaches across multiple sectors, such as health, social care, education and criminal justice.

23. Triple P programmes are commonly delivered by a range of professionals working across a range of sectors.  Such cross-sectoral co-operation and delivery of a common evidence-based system of support can contribute towards the creation of caring communities that are ‘‘parent and family friendly’’ places to live and raise children[xi] by integrating service delivery through schools, GPs and services supporting vulnerable families.

24. In the UK, parenting support has traditionally been relegated to local authority early years and early help services. Initial widespread delivery of parenting programmes, particularly through Sure Start centres, has since been dramatically reduced.

25. The Centre for Mental Health’s Missed Opportunities report acknowledges the critical importance of parenting interventions in children’s mental health and notes that currently, most interventions for parents are targeted ‘’towards families who have the highest risks or children who are showing early signs of distress’’[xii].  Unfortunately, as the Social Mobility Commission’s Time for Change report points out, for the majority of disadvantaged families in the United Kingdom, parenting support is now at the discretion of local authorities and given limited funds, many authorities are opting for “cheaper programmes with little or no measurable impact’’[xiii] while support for vulnerable families across the country is patchy:

“In many areas, just a dozen or so parents per year were benefiting from programmes known to be effective.’’

26. Time for change warns that without major reform social and economic divisions within Britain’s society are set to widen. The report claims:

“Governments have overly limited their scope of action. They have focussed on improving the education system but shied away from improving parenting.’’

27. The report recommends that government:

“Restore funding for parenting programmes and experiment with online classes to achieve scale without undermining quality – using funding from both health and education budgets and shared objectives across both departments.’’ xxiv

28. A system of support which relies solely on working with families already identified by support agencies, such as child protection systems, will do little to stem community-wide rates of ACEs because of its reliance on non-preventative action after documented child maltreatment has occurred. Research also shows that actual harms to children are much higher than official notification rates demonstrate[xiv]. Targeting individuals also does not support the majority of families not identified by agencies and consequently can be expected to do little, on its own, to reduce community-wide prevalence rates.

29. Mental Health First Aid programmes in schools have been identified as a cost-effective way of identifying potentially vulnerable children for treatment and support. However, as Finkelhor (2017) points out, such an approach to identify the vulnerable verges on the unethical when there is little in the way of community support to direct families or individuals to.

30. Leitch (2017) points out that the potential unintended consequences of using ACEs to identify vulnerable individuals include an unhelpful focus on the negative, rather than building on the strengths of an individual. Screening can also expose individuals to the risk of retraumatisation. A focus on ACEs also might help some practitioners identify the vulnerable, but they frequently may not know what to do nextii.

31. Supporting parents and children to address ACEs requires a systems-wide approach that integrates the health, social care and education sectors, that embraces technology to reach families where they live and work, and which builds on families’ capabilities and competencies with a minimally sufficient model that can effect change at an individual, family and community level by supporting parents and promoting positive parenting skills, promoting healthy child development and intervening early to prevent adverse childhood experiences and long-term negative outcomes.

32. Some local authorities, such as East Sussex and Sheffield, have recognised the value of a population-health approach to evidence-based parenting support, but currently no local authority or clinical commissioning group in the UK has incorporated an online component to take the intervention to scale cost-effectively.

33. Triple P UK advocates that local authorities collaborate across regions to integrate their services, prevent duplication of delivery and take advantage of the online world to dissolve geographical barriers to delivery, creating a sustainable and cost-effective population-health approach to parenting support. This approach can be underwritten by the development of core teams to engage with organisations such as schools and government and non-government organisations working with vulnerable families to co-ordinate service delivery and support pathways.

34. Transforming children and young people’s mental health provision: A Green Paper[xv] suggests 850,000 children and young people have a diagnosable mental health disorder in the UK today and that studies point to the links between mental ill-health and ACEs. Just over half these children have conduct problems. Evidence-based parenting programmes such as Triple P are the only recommended treatment for conduct disorder in children aged 3-11 years under NICE guidance[xvi].  The Green Paper also estimates that currently around 460,000 children and young people are referred to NHS-funded mental health services a year, with 200,000 going on to receive treatment.

35. Given this indication of prevalence and unmet demand, a digital solution such as Triple P Online can provide families and children with immediate access to an intervention which has demonstrated improved outcomes for children’s and parents’ mental health across a number of clinical trials.

36. Online e-mental health interventions give communities the ability to take clinically proven interventions to scale in an extremely cost-effective manner. Using digital marketing tools to target families directly where they live and work, interventions such as Triple P Online offer an immediate service to families as a potential solution to unmet demand for children’s mental health services.

37. Integrating Triple P Online as the first step of care in a system of early intervention and prevention was recommended by a 2015 report which set out to reform the Australian mental health service delivery system. The Report on the National Review of Mental Health Programmes and Services (2015) acknowledged Triple P as a viable preventative approach for high-risk groups.

“Research on this program concludes that participant parents report being less stressed and depressed, and for their children there are reduced rates of child abuse, reduced foster care placements and decreased hospitalisations from child abuse injuries.”[xvii]

38. Further, the report established that e-mental health offers one of the greatest invest-to-save opportunities for government and the community in mental health. It recommended that: “Plans should include guided access to evidence-based online programmes such as Triple P.’’

39. This delivery system has been effective in Queensland, Australia, where statewide availability of Triple P programmes, including Triple P Online, reached close to 140,000 parents and carers over a period of two years. The rollout reached vulnerable sectors of the community at levels close to or exceeding statewide representation in Queensland. These included low-income families, single-parent families, culturally and linguistically diverse families and Aboriginal and Torres Strait Islander families, many of whom accessed the programme through community seminars or online.

40. The national availability of Triple P Online for vulnerable families in the United Kingdom has also been recommended by a report produced by the Behavioural Insights Team (unofficially known as the “Nudge Unit”), funded by the Joseph Rowntree Foundation. Poverty and Decision Making, How behavioural science can improve opportunity in the UK made the following recommendation:

“The government should provide families in or near poverty with free access to online parenting programmes that are supported by rigorous evaluations (Asmussen, Feinstein, Martin, & Chowdry, 2016; Nieuwboer, Fukkink, & Hermanns, 2013). For example, RCT evidence supports the effectiveness of the Triple P Positive Parenting Program and recent research has shown that an online version provides similar benefits in terms of reductions in child behaviour problems and decreases in parents’ use of ineffective parenting strategies (Day & Sanders). We recommend giving schools, health services and Jobcentres in the UK the ability to refer high risk families to free support of this kind. Additional benefits could be gained by testing behaviourally informed text messages to prompt parents to remain engaged with the programme.”[xviii]

41. Experience in taking the Triple P system to scale in numerous countries shows that support agencies will struggle with screening or a diagnose-treatment approach which stigmatises the people agencies are seeking to support as “failed parents’’. Conversely, data collected as part of the statewide rollout of the Triple P system in Queensland shows that a non-stigmatising population health approach actively encourages potentially vulnerable families to participate, and at higher rates for online interventions.

42. According to Prinz, parenting-focused interventions are not the only factors to consider in a prevention strategy, but are nonetheless critical.

“Another contextual consideration, often overlooked, is the collective modeling and contagion effect of parenting across the entire community, for better or worse. Coercive and problematic parenting practices do not arise in a vacuum, nor do pro-social ones. Interventions to improve parenting are important to child maltreatment prevention but need to be embedded in a broader public health strategy.’’[xix]

Question 4: The support and oversight of research into adverse childhood experiences and relevant interventions, including how research priorities are identified and funded, and the extent to which current interventions are reviewed and contribute to the evidence-base.

43. While a population-health approach to the reduction of rates of adverse childhood experiences is clearly the opportunity in the United Kingdom, a number of structural issues hinder this approach.

44. Some evidence-based lists established as the benchmark of “What Works’’ in the United Kingdom take a restricted view of the evidence. The Early Intervention Foundation’s (EIF) approach is to single out one outstanding piece of research into an intervention to determine eligibility for its evidence-based guidelines.

45. Population-level studies which integrate a systems-wide approach are not included in EIF evaluations nor are service delivery evaluations which evaluate interventions in real-world conditions “in the field’’, such as the national evaluation of Parenting Early Intervention Programme[xx] or the national CANParent trial.

46. Population-level trials of Triple P are included under the category population policy by the Washington State Institute for Public Policy’s cost-benefit analysis.

47. An evaluation of CANParent in which 12 parenting programmes were made universally available suggests universal parenting programmes can be effective in improving parents’ sense of parenting efficacy and mental wellbeing when delivered to the full range of parents in community setting[xxi].  The results point to a population benefit but suggest more research is needed to determine whether benefits can be maintained in the longer term.

48. Similarly, an evaluation of a national rollout of parenting programmes across England in 2006 to 2008, the Parenting Early Intervention Programme (PEIP), set out to show that evidence-based parenting programmes can improve parenting skills and the behaviour of children exhibiting, or at risk of developing, antisocial behaviour. Results showed significant improvements for each programme, for parenting laxness, parenting over-reactivity, parent mental well-being, and child conduct problems with improvements largely maintained a year later. All four programmes were effective but there were generally larger effects on both parent and child measures for Triple P.

49. The PEIP evaluation is an extremely important and potentially valuable policy tool but such an industry-level evaluation of actual real-world delivery does not fit under current definitions of “what works’’ which only look at studies often implemented by researchers rather than industry. Industry evaluations are a valuable tool to gauge reproducibility “in the field’’.

Question 5: Mechanisms for bringing together the collection, communication, application and review of evidence to ensure interventions are evidence-based.

50. Rutter et al. (2017) argue that identifying, implementing and evaluating effective responses to major public health challenges requires a different system of evaluation. Rather than a strict linear model grounded in cause and effect, a complex systems model of public health considers poor health and health inequalities as outcomes of a number of interdependent elements within a connected whole.

“Research funding, research activity, and the published evidence base are all heavily skewed towards studies that attempt to identify simple, often short term, individual-level health outcomes, rather than complex, multiple, upstream, population-level actions and outcomes. This skew echoes the prioritisation by policy makers of individual-level interventions over system‑level responses, in the face of broad recognition of the need to do the opposite—so-called lifestyle drift.”

51. The Triple P system, when delivered as a population approach, is a complex system in and of itself which seeks to implement population-level change across complex delivery systems.

52. The science of evaluating population-level change using evidence-based parenting could be regarded as relatively novel, given the skew identified by Rutter et al. towards research and funding of individual-level responses. However, a number of steps can be taken to move the science of public health further towards recognising more complex systems of delivery.

53. Outcome data collected directly from families are important tools in evaluating the impact of parenting programmes. However, community indicators to track community trends and outcomes over time could improve the collection of data to establish population-health outcomes. This system of data collection has the potential to ensure high-quality, shared and accessible information about the health of communities becomes part of business-as-usual in the delivery of programmes to address ACEs.

54. Evaluators of Triple P population-level change trials have developed methods to use external, administrative data to show shifts across time in parenting behaviours which can be attributed to the intervention. Indicators of community well-being can also be derived from data collected by governments and services. The US Triple P System Population Trial used external data collected by child protective services workers, the foster care system and medical personnel in hospitals. The development, refinement and evaluation of standardized community-wide survey tools that show changes in parental beliefs, attributions and behaviours would strengthen this approach.

55. According to Sanders, Burke, Prinz & Morawska (2017):

“To date, few if any population-level indicators have been developed that include parenting (e.g., views on parenting practices; challenges faced) that can be used to routinely track the challenges and priorities of parents over time. Yet access to this information is clearly necessary if we are to measure population-level shifts in child and family outcomes, and the effectiveness of government policy and interventions aimed at shifting family and child well-being for whole communities.’’xxii

56. This call supports recommendations by The World Health Organisation’s Investing in Children European child maltreatment prevention action plan 2015-2020[xxii], which recommends that health risks such as child maltreatment be made more visible by setting up information systems across Member States and that information systems should be used to evaluate preventative programmes to determine whether national targets are being met with standardised tools and methods.

57. As part of suggestions recommending more complex, systems-wide approaches to address ACEs, the US Centers for Disease Control and Prevention advocates [xxiii] that prevention of child abuse and neglect needs to incorporate an extensive public engagement and communication campaign to change social norms in order to support parents and promote positive parenting.  Among other policy recommendations, such as a ban on corporal punishment, it says behavioural parent training programs be used “to lessen harms of abuse and neglect exposure and prevent problem behaviour and later involvement in violence’’.

58. By pursuing prevention strategies that affect risk and resilience factors common to different forms of violence, practitioners, communities, and individuals are more likely to prevent several forms of violence simultaneously. The World Health Organisation’s Investing in Children European child maltreatment prevention action plan 2015-2020 recommends interventions that are effective for prevention should form the core of the plan. “These include positive parenting for both male and female caregiver.’’ xxxiii

59. As The World Health Organisation’s child maltreatment action plan states:

“Safe, nurturing relationships with parents and other caregivers, including in institutions, are central to a child’s healthy development. The earlier preventive interventions are made in children’s lives, the greater the benefits to the child. The focus should therefore be on services to promote family health and safe family environments, so as to give every opportunity for positive relationships and improved health and social outcomes.”xxxiii

60. Triple P UK therefore makes the following recommendations:

61. Evidence-based parenting support is established as the first step of care in the treatment and prevention of ACEs as an early intervention measure, supporting families of children from birth to age 16 using a population health approach.

62. A national communications and engagement plan to change social norms around parenting runs concurrently to remove barriers to engagement in parenting programmes, with parents given access to a clinically evaluated behavioural change intervention, such as Triple P Online, as the first step of care to improve children’s access to mental health services.

63. National ring-fenced funding for evidence-based parenting programmes is restored and made available across a range of funding mechanisms, such as health, social mobility, education and social care to remove current funding silos restricting the delivery of evidence-based parenting support.

64. Standardised national tools and methods to track changes in parenting practices, for example, to determine the success and cost-effectiveness of population-health programmes should be developed. External administrative data could also be incorporated.

65. Evidence-based lists should take into consideration meta-analyses and include categories to include population-level trials, such as that included in the Washington State Institute of Public Policy’s cost-benefit analysis under population policy.

66. Local authorities should be encouraged to collaborate to provide a systems-wide approach to the provision of evidence-based parenting, using a digital health intervention such as Triple P Online to go to scale and integrate support for face-to-face delivery around a centralised website. As part of this, core teams can be trained to interface with parents, drive delivery in schools, for example, and engage with other service delivery organisations to integrate delivery across the community to reach vulnerable sections of the population to improve children’s and parents’ mental health, protect children from harm and improve children’s social mobility.

Annex – evidence demonstrating Triple P’s positive impact

67. Triple P is the only system of parenting support which has demonstrated population-level health effects by reducing prevalence rates in the areas of child maltreatment[xxiv] and parents’ and children’s mental health outcomes[xxv] viii.

68. One of the most important studies into the widespread, population-level deployment of Triple P was a trial funded by the United States Centers for Disease Control and Prevention. The Triple P system was made available in nine randomised counties in South Carolina which were compared to nine counties where Triple P was not available, using external administrative data. Practitioners from a broad range of sectors serving families of children from birth to age 12 were trained to deliver the programme. All levels of Triple P, including a communications strategy, were implemented in the nine intervention counties.

69. Following two years of community-wide Triple P implementation, evaluation of maltreatment-related outcomes for all children under age 8 comparing Triple P to control counties showed:

•         13 per cent fewer hospital-treated child maltreatment injuries,

•         21 per cent fewer child out-of-home placements,

•         31 per cent fewer substantiated cases of child maltreatment.

70. All three population indicators showed significant impact which were also all statistically significant despite only 18 units of randomisation (nine intervention counties and nine control counties). Each of the three indicators was derived from an independently recorded data source, which lends further support to the robustness of the findings. The study authors report:

“Substantiated child maltreatment was recorded by child protective services workers, child out-of-home placements were recorded within the foster care system, and child maltreatment injuries were recorded by medical personnel in hospitals x

71. Population-health benefits for Triple P have also been demonstrated in a foundation trial in Brisbane in which the number of children with clinically elevated and borderline behavioural and emotional problems was reduced across the population, while prevalence rates for parents’ reports of depression, stress and coercive parenting fell compared to areas which did not receive the interventionxi.

72. These findings were replicated in an independent evaluation in Ireland, where the number of children with borderline to clinically elevated social, emotional and behavioural difficulties was reduced by 37.5 per cent, while in the non-treatment counties, the rate increased by 8.6 per centviii.

73. Additionally, before intervention, the evaluators in Ireland found a prevalence rate for childhood social and emotional behavioural problems of 17 per cent of children across all socio-economic groups. It is important to note that less than a third of these children (i.e. 28 per cent) were from lower socio-economic groups, indicating a need across the population, rather than simply those disadvantaged groups more typically perceived as ‘vulnerable’.

74. For parents, significant improvements were found in relation to:

•         Psychological distress,

•         Reporting a good relationship with one’s child,

•         Engaging in positive parenting,

•         Being likely to use appropriate discipline,

•         Being unlikely to use inappropriate discipline for anxious behaviour.

75. Benefits from Triple P are long-lasting. Fifteen-year follow up analysis of data from a trial of Group Triple P with families of three-year-old children in disadvantaged areas of Perth, Western Australia, and compared with external administrative records found better numeracy, literacy and school attendance for the children of parents who participated[xxvi]. Four-year follow up data from the delivery of Group Triple P in German pre-schools showed that changes to parenting behaviour were maintained[xxvii]

76. Triple P has been used in the delivery of services to incarcerated family members. Its online programme has been demonstrated to be effective as part of support for parents with bipolar disorder, and its population-level research trials demonstrating proven child maltreatment and mental outcomes have been reproduced by “real-world evaluations’’ of community-led delivery in the United States and Ireland.

77. For parents with mental health problems, an evaluation showed improvements in parenting quality and large effects for improvements in children’s behaviour[xxviii]. Qualitative analysis found that being in a group with others with mental illness and the focus on child development and parenting with a mental illness were factors in the success of the programme[xxix].

78. A randomised controlled trial which investigated the effects of combining Triple P Online with online psychoeducational information on bipolar disorder found that parents with bipolar disorder reported improved parenting skills and child behaviour[xxx]. 

79. A 2012 trial of Triple P Online with families of children aged 3-9 with conduct problems found the programme led to significantly better outcomes on measures of problem child behaviour, dysfunctional parenting styles, parents’ confidence in their parenting role, and parental anger. At six-month follow-up assessment intervention gains were generally maintained, and in some cases enhanced[xxxi]. The programme has been found effective in six randomised controlled trials, including with families of pre-schoolers with ADHD symptoms.

80. The most extensive meta-analysis conducted into the Triple P system of programmes published in 2014 found that all levels of the Triple P system of programmes produced significant effects for child and parent benefits[xxxii]. A total of 101 studies involving 16,099 families were analysed quantitatively.  Significant short-term effects were found for children's social, emotional and behavioural outcomes, parenting practices, parenting satisfaction and efficacy, parental adjustment, parental relationship and child observational data. Significant effects were found for all outcomes at long-term including parent observational data.

81. The Washington State Institute for Public Policy[xxxiii] estimates the Triple P – Positive Parenting Program system of programmes returns a benefit to cost ratio of $9.17. The Triple P system is classified by WSIPP as a population policy, alongside school-based anti-smoking campaigns.

82. To calculate economic benefit, WSIPP made use of data from the CDC-funded South Carolina trial of the Triple P population system about preventive effects on child maltreatment cases and out of home placements [Prinz et al. 2009] and cost estimation by health economist Michael Foster [Foster et al., 2008][xxxiv].

83. The UK-based Investing in Children estimates the Triple P system generates returns of £5.05 for every pound invested[xxxv]. It suggests the source of these economic benefits to be the areas of:

• Child abuse and neglect,
• Crime,
• Earnings via high school graduation,
• Earnings via reduction in depression,
• Earnings via test scores,
• Health care via reduction in depression,
• Out-of-home placement,
• Special education.

84. An Access Economics report, Positive Family Functioning, found that investment in the Triple P system would lead to an AU$13.83 return for every dollar spent[xxxvi].

December 2017