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Level 5 Pathways Triple P

Evidence rating
3
Cost rating
1
Review: January 2019

Level 5 Pathways Triple P is a parenting programme. It is a targeted-indicated programme for parents who have difficulty regulating their emotions and as a result are considered at risk of physically or emotionally harming their children (aged 16 or younger). It is delivered in a variety of settings including the home of the family, a clinic or a community centre. It aims to improve children’s mental health and wellbeing, prevent maltreatment, and prevent crime, violence and antisocial behaviour.

The programme can either be completed in a group, or on an individual basis, and is delivered over the course of five sessions of 1–2 hours duration. In these sessions, parents learn how to develop appropriate expectations of their child’s behaviour, manage their own behaviour, and manage unwanted child behaviour. 

EIF Programme Assessment

Evidence rating
3

Level 5 Pathways Triple P has evidence of a short-term positive impact on child outcomes from at least one rigorous evaluation.

What does the evidence rating mean?

Level 3 indicates evidence of efficacy. This means the programme can be described as evidence-based: it has evidence from at least one rigorously conducted RCT or QED demonstrating a statistically significant positive impact on at least one child outcome.

This programme does not receive a rating of 4 as it has not yet replicated its results in another rigorously conducted study, where at least one study indicates long-term impacts, and at least one uses measures independent of study participants. 

What does the plus mean?

The plus rating indicates that this programme has evidence from at least one level 3 study, along with evidence from other studies rated 2 or better.

Cost rating
1

A rating of 1 indicates that a programme has a low cost to set up and deliver, compared with other interventions reviewed by EIF. This is equivalent to an estimated unit cost of less than £100.

Child outcomes

According to the best available evidence for this programme's impact, it can achieve the following positive outcomes for children:

Supporting children's mental health and wellbeing

based on
6.08-point improvement on the Pediatric Health-related Quality of Life Inventory (child self-report)
Improvement index: +16
This means we would expect the average participant in the comparison group who did not receive the intervention (ie, someone for whom 50% of their peers have better outcomes and 50% have worse outcomes), to improve to the point where they would have better outcomes than 66% and worse outcomes than 34% of their peers, if they had received the intervention.
Immediately after the intervention
based on

Preventing child maltreatment

based on

Preventing crime, violence and antisocial behaviour

based on

This programme also has evidence of supporting positive outcomes for couples, parents or families that may be relevant to a commissioning decision. Please see About the evidence for more detail.

Level 5 Pathways Triple P

Key programme characteristics

Who is it for?

The best available evidence for this programme relates to the following age-groups:

  • Toddlers
  • Preschool
  • Primary school
  • Preadolescents

How is it delivered?

The best available evidence for this programme relates to implementation through these delivery models:

  • Individual
  • Group

Where is it delivered?

The best available evidence for this programme relates to its implementation in these settings:

  • Home

The programme may also be delivered in these settings:

  • Community centre
  • In-patient health setting
  • Out-patient health setting

How is it targeted?

The best available evidence for this programme relates to its implementation as:

  • Targeted indicated

The programme can be delivered in both a group setting and on an individual basis. In the intervention’s most robust study (Lanier et al., and Kohl et al.,) it was tested with individuals in their home. The other two studies (Wiggins et al., 2009; Sanders et al., 2004) tested it in a group setting.

Where has it been implemented?

Australia, Canada, France, Germany, Netherlands, New Zealand, Singapore, United States

UK provision

This programme has been implemented in the UK.

UK evaluation

This programme’s best evidence does not include evaluation conducted in the UK.

Spotlight sets

EIF does not currently include this programme within any Spotlight set.

Level 5 Pathways Triple P

About the programme

What happens during delivery?

How is it delivered?
  • Pathways Triple P is an adjunctive intervention for parents undertaking a Level 4 Triple P programme (e.g. Group Triple P or Standard Triple P). 
  • The programme is delivered by a single practitioner over five sessions, and can either be delivered to groups of approximately eight parents where each session lasts 120 minutes, or on an individual basis where each session lasts 60–90 minutes. 
What happens during the intervention?
  • At the beginning of the programme, practitioners assess the needs of the family.
  • The intervention is comprised of three core modules taught over five sessions, which provide parents with an opportunity to learn new attributional styles and anger management techniques that will support them with improving and maintaining their positive parenting skills.
  • The first two sessions primarily help parents to develop realistic expectations of their children, as well as notice when they may be misattributing child behaviour.
  • The next two sessions involve teaching parents anger and mood management strategies.
  • The last session focuses on how parents can maintain changes, problem-solve for the future, and create future goals. 

What are the implementation requirements?

Who can deliver it?
  • Pathways Triple P is delivered by one practitioner who has experience in providing regular interventions; typically, a school counsellor, nurse, psychologist, social worker or allied health professional.
  • Practitioners are recommended to have a minimum QCF-4/5 qualifications. In addition, it is expected that practitioners will have experience of working with parents at high risk of physically maltreating their children. 
What are the training requirements?
  • Practitioners delivering Pathways Triple P must attend two days of training and a half-day accreditation session.
  • Practitioners must have completed one of the following Triple P courses as a prerequisite to attending Pathways: Group, Standard, Group Teen or Standard Teen. 
How are the practitioners supervised?
  • It is recommended that practitioners undergo peer supervision four times a year. The supervision is delivered in two-hour sessions by one practitioner with a minimum QCF-7/8 level qualifications and previous Triple P experience.
  • Triple P has also developed their own Peer-Assisted Supervision and Support Model (PASS), whereby practitioners can both provide and receive structured feedback from each other while they deliver the programme. PASS sessions are conducted in small groups of 6–8 practitioners and run for 1–2 hours every month.
  • Triple P UK can also provide additional clinical support for practitioners, as either a one-day workshop or a small-group phone consultation with a Triple P trainer. 
What are the systems for maintaining fidelity?

Programme fidelity is maintained through the following processes:

  • Training manual
  • Other printed material
  • Other online material
  • Video or DVD training
  • Face-to-face training
  • Fidelity monitoring
  • Quality assurance checklist
  • Practitioner accreditation
  • Intervention fidelity checklists, completed by practitioners after each session
  • Supervision and practitioner support standards using the Peer Support Network. 
Is there a licensing requirement?

There is no licence required to run this programme.

How does it work? (Theory of Change)

How does it work?
  • Pathways Triple P is based on evidence linking child maltreatment to parents’ unrealistic expectations and/or attributions of children’s behaviour and intentions.
  • During the programme, parents learn how to develop appropriate expectations of their child’s behaviour. They also learn effective strategies for managing their own behaviours, including negative moods and feelings, as well as their child’s unwanted behaviour.
  • In the short term, parents’ competence and confidence in their parenting will improve, and they will no longer feel the need to use harsh or inappropriate discipline to manage their child.
  • In the long term, both child behaviour and parenting practices will improve. 
Intended outcomes

Supporting children's mental health and wellbeing
Preventing child maltreatment
Preventing crime, violence and antisocial behaviour

Level 5 Pathways Triple P

About the evidence

Level 5 Pathways Triple P’s most rigorous evidence comes from an RCT which was conducted in the USA.

This study identified statistically significant positive impact on a number of child and parent outcomes.

This programme has evidence from at least one rigorously conducted RCT along with evidence from an additional comparison group study. Consequently, the programme receives a 3+ rating overall.

Study 1

Citation: Lanier et al., 2018
Design: RCT
Country: United States
Sample: 144 families, with children between 3 and 12 years old (mean = 7.3 years)
Timing: Post-test
Child outcomes: Improved quality of life
Other outcomes: None that meet the level 3 criteria.
Study rating: 3

Lanier, P., Dunnigan, A., & Kohl, P. L. (2018). Impact of Pathways Triple P on Pediatric Health-Related Quality of Life in Maltreated Children. Journal of Developmental and Behavioral Pediatrics: JDBP.

Available at
https://journals.lww.com/jrnldbp/Citation/2018/12000/Impact_of_Pathways_Triple_P_on_Pediatric.4.aspx

Study design and sample

The first study is a rigorously conducted RCT.  

This study involved random assignment of parent–child dyads to a treatment group (n = 75) or a control group (n = 69).

This study was conducted in the USA, with a sample of children between the ages of 3 and 12 (mean = 7.3 years). Parents had a mean age of 32.6 (SD = 7.82). The sample was predominantly African American (67%), and most of the children in the sample received free or reduced-price lunches (94%). Parents reported a mean income of $2,023.61 for the last month (range = $420 to $9,416).

Measures

Quality of life was measured using the Pediatric Health-Related Quality of Life Inventory (child and parent report). 

Findings

This study identified a statistically significant positive impact on a child outcome.

This includes improved quality of life (Pediatric Health-Related Quality of Life Inventory). 

More Less about study 1

Study 2

Citation: Sanders et al., 2004
Design: RCT
Country: Australia
Sample: 98 families, with children between 2 and 7 years old (mean age = 4.4 years)
Timing: Post-test; 6-month follow-up
Child outcomes: Reduced parental potential for child abuse
Other outcomes: Reduced parental blame and intentional attribution of child’s misbehaviour (at post-test and 6-month follow-up)
Improved parental unrealistic expectations of child behaviour (at post-test)
Study rating: 2+

Sanders, M.R., Pidgeon, A.M., Gravestock, F., Connors, M.D., Brown, S., & Young, R.W. (2004). Does Parental Attributional Retraining and Anger Management Enhance the Effects of the Triple P – Positive Parenting Program with Parents at Risk of Child Maltreatment? Behavior Therapy, 35: 513–535.

Available at
https://www.sciencedirect.com/science/article/abs/pii/S0005789404800303

Study design and sample

The second study is an RCT.

This study involved random assignment of 98 parents to the Pathways Triple P intervention group (n = 50), or to the Group Triple P control group (n = 48).

This study was conducted in Australia with parents who had a child aged 2–7 years. An equal proportion of male and female children were tested. Most participants were mothers, married, with at least two children, a mean age of 34 years, and no significant financial difficulties. In addition, approximately half of the sample had completed secondary school. A small percentage were currently using illicit drugs, abusing alcohol, and in contact with statutory authority for suspected abuse and/or neglect.

Measures

  • Child disruptive or problematic behaviour was measured using the Revised Family Observation Schedule (expert observation of behaviour), the Eyberg Child Behaviour Inventory (parent report), and the Parent Daily Report Checklist (parent report).
  • Parental potential risk for child abuse was measured using the Child Abuse Potential Inventory (parent report).
  • Parental attribution of children’s misbehaviour was assessed using the Parent’s Attributions for Child’s Behaviour Measure (parent report).
  • Parental experience and expression of anger was assessed using the State-Trait Anger Expression Inventory (parent report).
  • Parental anger in response to child-related situations was measured using the Parental Anger Inventory (parent report).
  • Parents’ unrealistic expectations of children’s behaviour was measured using the Parent Opinion Questionnaire (parent report).
  • Parental discipline practices (including laxness, over reactivity, and verbosity) were measured using the Parenting Scale (parent report).
  • Parental feelings of competence were assessed using the Parent Sense of Competence (parent report).
  • Parents’ ability to cooperate and work together in family management was assessed using the Parent Problem Checklist (parent report).
  • Parental difficulty in managing their child’s behaviour in a range of situations was assessed using the Home and Community Problem Checklist (parent report).
  • Parental adjustment (including symptoms of depression, anxiety, and stress) was assessed using the Depression Anxiety and Stress Scale (parent report).

Findings

This study identified statistically significant positive impact on a number of child and parent outcomes, at post-test, including:

  • parental potential for child abuse (Child Abuse Potential Inventory).
  • parental blame and intentional attribution of child’s misbehaviour (Parent’s Attributions for Child’s Behaviour Measure).
  • parents’ unrealistic expectations of child behaviour (Parent Opinion Questionnaire).

At the 6-month follow-up, parental blame and intentional attribution of child’s misbehaviour remained significantly different from the comparison group.

The conclusions that can be drawn from this study are limited by methodological issues pertaining to a lack of clarity as to whether study attrition undermined the equivalence of the study groups, as well as a lack of clarity in terms of intention-to-treat analysis, hence why a higher rating is not achieved.

More Less about study 2

Study 3

Citation: Wiggins et al., 2009
Design: RCT
Country: Australia
Sample: 60 families, with children between 4 and 10 years old (mean = 6.2)
Timing: Post-test
Child outcomes: Reduced externalising behaviour problems
Reduced internalising behaviour problems
Other outcomes: Improved parenting confidence
Improved attachment
Improved parental involvement
Reduced laxness
Reduced verbosity
Reduced overreactivity
Reduced blame and intentional attributions of child’s disruptive behaviour
Study rating: 2+

Wiggins, T.L., Sofronoff, K., & Sanders, M.R. (2009). Pathways Triple P-Positive Parenting Program: Effects on Parent-Child Relationships and Child Behavior Problems. Family Process, 48: 517–530.

Available at
https://onlinelibrary.wiley.com/doi/full/10.1111/j.1545-5300.2009.01299.x

Study design and sample

The third study is an RCT.

This study involved random assignment of parents to a Pathways Triple P intervention group (n = 30), and a waitlist control (n = 30).

This study was conducted in Australia with a sample of 60 parents, who presented with borderline to clinically significant parent-child relationship disturbance. Parents in the sample also had a child with emotional and/or behavioural problems, aged between 4-10 years (mean age = 6.2 years). This was a motivated sample of parents who self-referred to take part in the study. Most were mothers (93.3%), responding on behalf of their male children (76.7%). In addition, the majority of parents enrolled in the study were married (63.4%), with higher-education (mothers: 50.0%; fathers: 41.7%), in full-time or part-time employment (mothers: 63.4%; fathers: 75.0%), with no significant financial difficulties (81.7%), and not engaging in other services specifically targeting child difficulties (86.7%). 

Measures

  • The Child Behavior Checklist (CBCL) was used to measure parental perception of child emotional and behavioural problems, with a focus on internalising and externalising problems.
  • The Parenting Relationship Questionnaire (PRQ) was used to elicit the parents’ perspective of the parent-child relationship, with attachment, involvement, confidence, and relational frustration scales being the focus of the current study. 
  • The Parenting Scale (PS) was used to measure parental discipline practices, including laxness, over reactivity, and verbosity.
  • The Parent’s Attributions for Child’s Behavior Measure (PACBM) was used to assess parents’ negative attributional styles for the cause of their children’s misbehaviour.

Findings

This study identified statistically significant positive impact on a number of child and parent outcomes, including:

  • child internalising and externalising behavioural problems (Child Behaviour Checklist)
  • parental confidence, attachment, and involvement (Parenting Relationship Questionnaire)
  • parental laxness, verbosity, and overreactivity (Parenting Scale)
  • negative blame and intentional attributions of child’s disruptive behaviour (Parent’s Attributions for Child’s Behaviour Measure).

The conclusions that can be drawn from this study are limited by methodological issues pertaining to a lack of clarity as to whether study attrition undermined the equivalence of the study groups.

More Less about study 3

Other studies

The following studies were identified for this programme but did not count towards the programme's overall evidence rating. A programme receives the same rating as its most robust study or studies.

Lewis, E. M., Feely, M., Seay, K. D., Fedoravicis, N., & Kohl, P. L. (2016). Child welfare involved parents and Pathways Triple P: Perceptions of program acceptability and appropriateness. Journal of Child and Family Studies, 1 – 11.

Whalley, P. (2015) Child neglect and Pathways Triple P: an evaluation of an NSPCC service offered to parents where initial concerns of neglect have been noted. London: NSPCC.

Published February 2019   |   Last updated April 2021