Programs that Work
Triple P Positive Parenting Program
Healthy and Safe Children
Children not experiencing physical, psychological or emotional abuse
Age of Child
Early Childhood (0-8)
Middle Childhood (9-12)
Type of Setting
Community-Based Service Provider
Type of Service
Type of Outcome Addressed
Child Abuse and Neglect
Evidence Level (What does this mean?)
The Triple P Positive Parenting Program is a multilevel system of family intervention that aims to prevent severe emotional and behavioral disturbances in children by promoting positive and nurturing relationships between parent and child. According to the Triple P developers, apart from improving parenting skills, "the program aims to increase parents' sense of competence in their parenting abilities, improve couples' communication about parenting, and reduce parenting stress. The acquisition of specific parenting competencies results in improved family communication and reduced conflict that in turn reduces the risk that children will develop a variety of behavioral and emotional problems" (Sanders, Turner, et al., 2002).
The program has five intervention levels of increasing intensity:
- Level 1: The first level consists of a universal media information campaign that targets all parents in a community and involves social marketing and health promotion.
- Level 2: The second level involves primary care providers offering advice and discussion to parents on children's developmental and behavioral issues.
- Level 3: Also a brief health care intervention conducted in primary care, Level 3 targets children with mild to moderate behavior difficulties and includes active skills training for parents. Moderate behavior difficulties include such problems as tantrums, whining, and fighting with siblings.
- Level 4: The fourth and penultimate level is an intensive 10-session individual or 8-session group parent training program for children with more severe behavioral difficulties, such as oppositional defiant disorder, conduct disorder, and learning difficulties.
- Level 5: The fifth level, "Enhanced Triple P," is offered to families that complete a level four Triple P intervention and who either request or are identified as eligible for further services. This level includes behavioral interventions for parents, home-based skills training, and training in other coping skills. This additional four-session intervention is available to families who are identified as at-risk for child maltreatment. These are generally families with co-occurring child behavioral issues, such as conduct disorder or learning disabilities, and parental problems such as stress and/or depression (Sanders, Turner, et al., 2002).
The Triple P Positive Parenting Program is suitable for parents of all children and adolescents. The evaluation cited in this program summary applies to Triple P when provided to parents of children 8 years old and younger.
Prinz, Sanders, et al. (2009) conducted the first population-based trial of the entire Triple P system, randomly assigning entire communities to the Triple P intervention to assess the effects of Triple P on substantiated cases of child abuse and neglect, among other outcomes. The study was conducted on families with children below 8 years of age, and it was the first trial of Triple P to have taken place in the United States. The authors randomly assigned 18 counties in a southeastern state, with population sizes between 50,000 and 175,000 and ranging from rural to semi-urban, to treatment or control conditions.
The authors examined the following population-level outcomes, all three of which were derived from independent data-collection systems deposited within a state-run statistical division:
- substantiated cases of child maltreatment, recorded by Child Protective Services staff
- child out-of-home placements, recorded through the foster care system
- child hospitalizations and emergency room visits due to injuries related to child maltreatment, recorded by hospital staff in compliance with mandatory reporting requirements.
Key Evaluation Findings
Prinz, Sanders, et al. (2009) examined the difference in the pre-post change across communities and found statistically significant effects of Triple P on the change of all three of the measured population-level outcomes from pre- to posttest. Specifically:
- Substantiated rates of child maltreatment grew in the control counties during the implementation period, from 11.12 cases per 1,000 children to 15.06 cases per 1,000. In the treatment communities, substantiated cases of child abuse and neglect did not change significantly over the course of the intervention.
- Out-of-home placements in the treatment counties fell from 4.27 to 3.75 per 1,000 children, compared with an increase in the control counties from 3.10 to 4.46 per thousand.
- Rates of child hospitalizations and emergency room visits resulting from child maltreatment fell from 1.73 to 1.41 cases per 1,000 in the treatment communities, compared with an increase in the control communities from 1.41 to 1.69 per 1,000.
Community-based service providers, public health and social service agencies, and government agencies.
No information at this time
- The Triple P program implemented by Prinz, Sanders, et al. (2009) was a population-based program that implemented all five levels of Triple P intervention, based on family need, in each county, utilizing the existing workforce. Counties were randomly selected for the study based on their population size and location, not for their "readiness" to adopt Triple P.
- The intensity of the Triple P intervention varies. The intervention ranges from, at Level 1, a media campaign related to positive parenting and the provision of brief information resources, such as tip sheets and videos, to, at Levels 4 and 5, more-intensive parent training programs that target broader family issues, such as relationship conflict and parental depression, anger, and stress.
- The Triple P intervention can be ongoing; however, in the case of the evaluation presented above, it was conducted over the course of two years.
- Service providers involved in delivering the intervention included family support services, social services, preschool and child care settings, elementary schools, nongovernmental organizations, health centers, private-sector practitioners, and other community entities that were engaged, trained, and supported in the implementation of Triple P. This involved engaging 649 service providers across nine treatment counties.
All five levels of Triple P have intervention manuals, systematic training regimens for providers/ practitioners, and coordinated resource materials for parents (videos, workbooks, and tip sheets).
The cost of the infrastructure necessary to implement all levels of Triple P is estimated at less than $12 per child for a community of 100,000 families with children ages 0-8 (Foster, Prinz, et al., 2008). This includes the costs of training service providers and the universal education and media component.
Issues to Consider
The trial conducted by Prinz, Sanders, et al. (2009) offers the first direct empirical evidence of Triple P's effectiveness at preventing and reducing child abuse and neglect. While there is substantial evidence of Triple P's effectiveness from more than 50 well-designed trials, prior to the trial conducted by Prinz, Sanders, et al. (2009) none of the evaluations measured the program's impact on child abuse and neglect, none were conducted in the United States, and many did not evaluate the program as a whole, but rather one or two of its constituent parts (Connell, Sanders, et al., 1997; Sanders, Markie-Dadds, et al., 2000; Bor, Sanders, et al., 2002; Hoath and Sanders, 2002; Leung, Sanders, et al., 2003; Markie-Dadds and Sanders, 2006; Morawska and Sanders, 2006; Roberts, Mazzucchelli, et al., 2006; Turner and Sanders, 2006; Plant and Sanders, 2007; Sanders, Bor, et al., 2007; Bodenmann, Cina, et al., 2008; Hahlweg, Heinrichs, et al., 2008; Sanders, Prior, et al., 2009; Whittingham, Sofronoff, et al., 2009).
The Triple P program received a "promising" rating because the study design included only nine counties that were randomized to treatment or control groups. Furthermore, prior to the intervention, the five-year average of each of the measures of child abuse and neglect were used to ensure the comparability of counties that did and did not receive the Triple P intervention to one another. Based on these five-year averages, it was determined that the intervention and control counties were statistically the same. It appears, however, that the counties may have been significantly different on these measures in the one year prior to the intervention. The authors attempt to account for this difference by examining the difference in the change in the scores; that is, they examine the difference between pretest and posttest scores for the counties that did not receive the treatment, and compare that with the difference between pretest and posttest scores for the counties that did receive the treatment.
Nine counties in a southeastern state of the United States
Triple P America
PO Box 12755
Columbia, SC 29211
Triple P has developed a wide range of resources and curricular materials for organizations and practitioners. Those can be found at the Triple P website: http://www.triplep-america.com/pages/resources/description.html
Bodenmann, G., A. Cina, et al., "The Efficacy of the Triple P-Positive Parenting Program in Improving Parenting and Child Behavior: A Comparison with Two Other Treatment Conditions,"
Behavior Research and Therapy,
Vol. 46, No. 4, 2008, pp. 411-427.
Bor, W., M. R. Sanders, et al., "The Effects of the Triple P-Positive Parenting Program on Preschool Children with Co-Occurring Disruptive Behavior and Attentional/Hyperactive Difficulties," Journal of Abnormal Child Psychology, Vol. 30, No. 6, 2002, pp. 571-587.
Connell, S., M. R. Sanders, et al., "Self-Directed Behavioral Family Intervention for Parents of Oppositional Children in Rural and Remote Areas," Behavior Modification, Vol. 21, No. 4, 1997, pp. 379-408.
Foster, E. M., R. J. Prinz, et al., "The Costs of a Public Health Infrastructure for Delivering Parenting and Family Support," Children and Youth Services Review, Vol. 30, No. 5, 2008, pp. 493-501.
Hahlweg, K., N. Heinrichs, et al., "Therapist-Assisted, Self-Administered Bibliotherapy to Enhance Parental Competence: Short- and Long-Term Effects," Behavior Modification, Vol. 32, No. 5, 2008, pp. 659-681.
Hoath, F. E., and M. R. Sanders, "A Feasibility Study of Enhanced Group Triple P-Positive Parenting Program for Parents of Children with Attention-Deficit/Hyperactivity Disorder," Behaviour Change, Vol. 19, No. 4, 2002, pp. 191-206.
Leung, C., M. R. Sanders, et al., "An Outcome Evaluation of the Implementation of the Triple P-Positive Parenting Program in Hong Kong," Family Process, Vol. 42, No. 4, 2003, pp. 531-544.
Markie-Dadds, C., and M. R. Sanders, "Self-Directed Triple P (Positive Parenting Program) for Mothers with Children at-Risk of Developing Conduct Problems," Behavioural and Cognitive Psychotherapy, Vol. 34, No. 3, 2006, pp. 259-275.
Morawska, A., and M. R. Sanders, "Self-Administered Behavioural Family Intervention for Parents of Toddlers: Effectiveness and Dissemination," Behavior and Research Therapy, Vol. 44, No. 12, 2006, pp. 1839-1848.
Plant, K. M., and M. R. Sanders, "Reducing Problem Behavior During Care-Giving in Families of Preschool-Aged Children with Developmental Disabilities," Research in Developmental Disabilities, Vol. 28, No. 4, 2007, pp. 362-385.
Prinz, R. J., M. R. Sanders, et al., "Population-Based Prevention of Child Maltreatment: The U.S. Triple P System Population Trial," Prevention Science, 10, No. 1, 2009, pp. 1-12.
Roberts, C., T. Mazzucchelli, et al., "Behavioral Family Intervention for Children with Developmental Disabilities and Behavioral Problems," Journal of Clinical Child Adolescent Psychology, Vol. 35, No. 2, 2006, pp. 180-193.
Sanders, M. R., "Triple P-Positive Parenting Program: Towards an Empirically Validated Multilevel Parenting and Family Support Strategy for the Prevention of Behavior and Emotional Problems in Children," Clinical Child and Family Psychology Review, Vol. 2, No. 2, 1999, pp. 71-90.
Sanders, M. R., C. Markie-Dadds, et al., "The Triple P-Positive Parenting Program: A Comparison of Enhanced, Standard, and Self-Directed Behavioral Family Intervention for Parents of Children with Early Onset Conduct Problems," Journal of Consulting and Clinical Psychology, Vol. 68, No. 4, 2000, pp. 624-640.
Sanders, M. R., K. M. Turner, et al., "The Development and Dissemination of the Triple P-Positive Parenting Program: A Multilevel, Evidence-Based System of Parenting and Family Support," Prevention Science, Vol. 3, No. 3, 2002, pp. 173-189.
Sanders, M. R., W. Bor, et al., "Maintenance of Treatment Gains: A Comparison Of Enhanced, Standard, and Self-Directed Triple P-Positive Parenting Program," Journal of Abnormal Child Psychology, Vol. 35, No. 6, 2007, pp. 983-998.
Sanders, M., J. Prior, et al., "An Evaluation of a Brief Universal Seminar Series on Positive Parenting: A Feasibility Study," Journal of Children's Services, Vol. 4, No. 1, 2009, pp. 4-20.
Turner, K. M. and M. R. Sanders, "Help When It's Needed First: A Controlled Evaluation of Brief, Preventive Behavioral Family Intervention in a Primary Care Setting," Behavior Therapy, Vol. 37, No. 2, 2006, pp. 131-142.
Whittingham, K., K. Sofronoff, et al., "Stepping Stones Triple P: An RCT of a Parenting Program with Parents of a Child Diagnosed with an Autism Spectrum Disorder," Journal of Abnormal Child Psychology, Vol. 37, No. 4, 2009, pp. 469-480.