Pathways Triple P and the Child Welfare System: A Promising Fit

Abstract

Parents referred to the child welfare system following maltreatment allegations are often ill-prepared to constructively address child disruptive behaviors, despite the high prevalence of these behaviors among this population. Evidence-based parent-mediated interventions are effective in improving parenting skills; however, they are rarely offered within the child welfare system. The purpose of this pilot project was to evaluate the fit and acceptability of one parent-mediated training program (Pathways Triple P) to case managers and parents within this system of care. We implemented Pathways Triple P and subsequently interviewed referring case managers and parents who had participated in the program. Case managers felt the program would work well within the existing child welfare system and would help them to better serve parents. They felt the program had potential to improve parenting skills and prevent future maltreatment. Parents appreciated the program’s use of diverse methods, and the variety of parenting techniques taught. In keeping with case manager expectations, participants reported that their enhanced parenting skills and new ability to use non-physical discipline resulted in a better home life. We conclude that Pathways Triple P fits well within the child welfare system and is acceptable to both case managers and parents within this system.

1. Introduction

Children in the child welfare system are at a higher risk for serious psychopathology, including disruptive behavior problems and the development of conduct disorder, than are children in the general population (Gewirtz & August, 2008). In fact, one study showed that 39% of children in the child welfare system suffered from attention deficit and hyperactivity disorder, conduct disorder, and/or oppositional defiant disorder (Garland, Hough, McCabe, Yeh, Wood, & Aarons, 2001). Furthermore, a national probability study of children of parents under investigation for child maltreatment determined that 43% of the children had borderline or clinical levels of externalizing behaviors (U.S. Department of Human Services, Administration for Children and Families, 2005). These behavioral issues – while often a consequence of the maltreatment which led to entry into the child welfare system – also present a challenge to parents’ coping skills. That is, some parents lack the knowledge, skills and competence necessary to address difficult child behaviors. This parenting deficiency increases the risk for the use of harmful parenting practices, which may then exacerbate child behavior problems (Bender, et al., 2007; Coie & Dodge, 1998; Dodge, Bates & Pettit, 1990; Mersky & Reynolds, 2007). For parents referred to the child welfare system due to maltreatment allegations, parent-mediated interventions may reduce disruptive child behavior problems by improving parenting capacity and strengthening parent-child relationships.

The need for effective parent-mediated interventions within the child welfare system is great, with an estimated 30% of the 2,000,000 parents entering the child welfare system each year receiving parent training (Barth, 2008; Barth, et al., 2005). Unfortunately, most parent training programs provided within the child welfare system have not been subject to rigorous evaluations and thus cannot be considered evidence-based (Barth, 2008). In addition, many fail to emphasize the reduction of child behavior problems, thus leaving parents unprepared to respond assertively to difficult behaviors. In order to ensure the success of parent-mediated interventions within the child welfare system it is critical that they are efficacious (Drake, et al., 2001), fit well within the child welfare system (Barth, 2008), and are acceptable to parents referred to child protective services (Cooper, Hill, & Powe, 2002). Thus, the purpose of this pilot project was to conduct a preliminary assessment of the acceptability and fit of an evidence-based parent-mediated intervention, Pathways Positive Parenting Program (Triple P; Sanders, 1999), when delivered within one child welfare system in a midsized Midwestern city.

1.1. Factors Associated with Intervention Dissemination

A growing number of empirically supported parent-mediated interventions are available (e.g., Herschell, Calzada, Eyberg, & McNeil, 2002; Sanders, Markie-Dadds, & Turner, 2003; Webster-Stratton, 1994) and the use of evidence-based practices (EBPs) has become the “gold standard.” There is a growing expectation that all usual standard services provided in systems of care such as the child welfare system be evidence-based (Drake, et al., 2001). Given this expectation, it is important to address issues inherent to integrating EBPs into this system of care. A number of theorists have discussed the challenges inherent in dissemination of effective interventions, such as parent-mediated interventions, to initial or additional real-world practice contexts like the child welfare system. Schoenwald and Hoagwood (2001) noted the importance of considering characteristics of service systems, organizations/agencies, practitioners, clients, interventions, and delivery of services when determining the transportability of interventions. Additionally, a good fit between the service delivery system, intervention, and client is necessary (Berwick, 2003). Salient characteristics of each are discussed next.

1.1.1. Service delivery system

The child welfare system is charged with ensuring child safety, permanency and well-being and is well-positioned to serve as a gateway to evidence-based interventions aimed at improving parenting capacities and reducing high-risk child and adolescent behaviors. Thus there is a critical need for cost-effective, brief evidence-based interventions to be readily accessible to parents who have been referred to child protective services for the abuse or neglect of their children. At the agency and practitioner levels, it is important that agency leadership actively support new interventions and provide sufficient agency resources, including ensuring provision of training and support for front-line staff, adequate staff time, and reasonable workloads (Glasgow & Emmons, 2007; Proctor, Knudsen, Fedoravicius, Hovmand, Rosen, & Perron, 2007).

1.1.2. Intervention

Important intervention characteristics include a minimal intensity required for effectiveness (Glasgow & Emmons, 2007). It is also important that interventions be manualized, with guidelines provided as to which elements can be modified to best suit client needs. Proctor, et al. (2007) noted that agency directors valued interventions which were applicable to real-world client populations and problems. Chapman, Zechel, Carter, and Abbott (2004) agreed, emphasizing the importance of the intervention’s relevance to clients as well as its effectiveness. Other important intervention characteristics fall under the heading of service delivery characteristics. These include characteristics necessary for client access to services: availability, accessibility, accommodation, affordability, and acceptability (Penchansky & Thomas, 1981). The first four characteristics have been noted as potential barriers to client access (Cooper, Hill, & Powe, 2002). For instance, are interventions available when clients need them, at convenient days and times? Are interventions held at locations accessible to clients, and is transportation provided? Are they affordable to clients or is the cost covered by insurance? Are buildings wheelchair-accessible, and are interventions delivered in languages other than English when necessary? Is on-site child care available and affordable? (Kazdin, Holland, Crowley, & Breton, 1997).

1.1.3. Client

Client characteristics that are important to a good fit with an intervention include a perceived need for the intervention and the ability to complete intervention elements (Cooper, et al., 2002). Kazdin and colleagues (1997) noted that obstacles to completing an intervention include the logistical barriers described in section 1.1.2, stressful life circumstances, schedule conflicts, and critical life events such as illnesses, new jobs and relocation to a new neighborhood. Clients also actively evaluate the acceptability of the intervention and its relevance to their life circumstances. In Kazdin’s study, clients who experienced fewer of these barriers attended more treatment sessions than did clients who experienced more barriers; moreover, when controlling for client characteristics and critical life events, the mere perception of barriers to participation was predictive of client drop-out (Kazdin, et al., 1997).

Prior to implementing a parent-mediated intervention into the child welfare system, it is therefore important to evaluate its fit and acceptability with the target population in the target system of care. We examined these factors for one EBP (Pathways Triple P) when implemented with parents with open child welfare cases following a maltreatment report.

1.2.Triple P

Triple P is a continuum of programs which provide parent management training techniques at five different levels of intensity, using different service delivery modalities across multiple levels of the intervention (Sanders, Markie-Dadds, & Turner, 2003). Level 4 Triple P is an eight-week parent-mediated intervention that aims to improve positive parent-child interactions and parenting behaviors in order to reduce child behavior problems. It has been shown to be effective in improving parenting capacity and child mental health outcomes when provided to parents of children with early onset conduct disorder, parents at risk of child maltreatment, depressed mothers, and parents experiencing marital conflict (Sanders, et al., 2003; Sanders, Markie-Dadds, Tully & Bor, 2000; Sanders & McFarland, 2000). Level 5 (Pathways) Triple P, which includes the Level 4 curriculum as well as three add-on modules, has promising evidence demonstrating that it can improve parenting skills and attitudes, increase parenting-efficacy, and reduce child behavior problems (Sanders, Pidgeon, Gravestock, Conners, Brown, & Young, 2004). Designed to alter negative parent beliefs and reduce parental anger and stress, the add-on modules were developed for parents who were at risk for child maltreatment, suggesting that it is an ideal candidate for parents in the child welfare system. Yet Triple P, as well as other parent-mediated interventions, is understudied with parents in the child welfare system. Given that parents within this system of care often mirror the populations for whom Triple P and Pathways Triple P have been effective, Triple P may be especially appropriate for use with parents who have been referred to child protective services.

This pilot study fits into a larger research agenda that seeks to: (1) examine the translatability of Triple P and Pathways Triple P to a child welfare service delivery setting, (2) prevent child maltreatment and conduct disorder, and (3) promote safe, stable and nurturing parent-child relationships among the vulnerable child welfare population. The specific aims of this study were to:

1. ensure our ability to implement Pathways Triple P within the child welfare system and to collect preliminary data to inform a larger randomized control trial,

2. explore acceptability of the intervention to parents and referring case managers

3. explore the fit between Pathways Triple P and parents in the child welfare system, and between Pathways Triple P and case managers.

2. Methods

The project paired researchers with key child welfare partners in both public and private agencies. Agency leadership collaborated in study design and decision-making through a series of planning meetings and advisory board meetings that were held throughout the research process.

We conducted a pilot study of Pathways Triple P with parents who had been referred to the child welfare system because of maltreatment allegations and were case managed by either the public or private child welfare agencies in a midsized Midwestern city. The state in which it is located utilizes a partnership between public and private agencies to serve children and families in the child welfare system. Cases are assigned to either the public agency or one of several performance-based contract agencies for case management and/or service provision (Lee & Samples, 2008). All study procedures were approved by the Washington University institutional review board and the Missouri Department of Social Services Children’s Division.

2.1. Procedure

Project staff attended two staff meetings of agency supervisors and some case managers in both public and private agencies to speak about the pilot project. Information about the Pathways Triple P program was presented and questions were answered at each of these meetings. Some case managers were also identified by agency leadership and contacted individually by project staff and informed about the pilot project. Most case managers, however, learned about the program from their supervisors. Written materials about the intervention were also provided to supervisors and case managers. Case managers were asked by the Principal Investigator to examine their caseloads for parents meeting the program eligibility requirements (or were instructed to do so by their supervisor). Recruitment for the program occurred between September and November, 2008.

Parents were eligible for participation in the pilot project if they had an open case with either a public or private child welfare agency in one metropolitan area, spoke and read English, and had at least one child 6–10 years old who did not have a serious medical condition or pervasive developmental disorder. They also needed to be available to attend group sessions one evening per week. Case mangers of parents meeting these criteria told them about the program and asked their permission for project staff to contact them for program recruitment. If parents agreed, case managers provided parent demographic and contact information on a short recruitment form, which was given to project staff.

Project staff then called the parents, screened them for eligibility, and informed them further about Pathways Triple P, the research study and their rights as a research participant. Parents who agreed to participate were assigned to the experimental or comparison conditions via batch-randomization. [Because the purpose of this paper is to describe the fit and acceptability of Pathways Triple P, we do not report data from the comparison condition.] Project staff scheduled a pre-intervention home visit with parents and mailed them a packet containing information about the program, a pretest survey, and further information about Pathways Triple P. At the home visit, project staff first answered questions about Pathways Triple P and the research study, then reviewed the informed consent form and obtained signatures, and finally accepted the parent’s completed surveys. All participants were given a $20 stipend for the pre-intervention home visit; participants in the experimental condition also received $10 stipends for participation in the program at each weekly session, with bonuses if they participated in all elements of the program. Total compensation for all elements of the eleven-week program was $160 for experimental condition participants.

Participants in the experimental condition were provided the Pathways Triple P program, which was delivered by a trained and accredited Pathways Triple P practitioner. The eleven-week program consisted of weekly activities:

1. Sessions 1 – 4: evening groups held at a central location;

2. Sessions 5 – 7: phone calls from the facilitator to individualize content covered in the group sessions to the unique family circumstances;

3. Session 8: evening group (sessions 1–8 covered material in Level 4 Triple P);

4. Sessions 9–11: home visits from the facilitator (these sessions covered material in the Level 5 add-on modules).

Participants were given workbooks to keep and were asked to complete weekly homework activities. In order to facilitate access to the intervention, free taxi rides and child care were provided for the group sessions. Project staff also made reminder calls prior to each group session and home visit. Inclement winter weather caused the cancellation of some of the facilitator home visits. With participant agreement, the material from those visits was covered via extending the length of the next home visit.

After experimental condition participants had completed the program, project staff once again met with all participants in their homes. The post-intervention home visits included turning in completed posttest surveys and a short semi-structured interview.

After completion of the program, caseworkers who had submitted referrals to project staff were invited to participate in a semi-structured group interview about their experience with recruitment for Pathways Triple P and their views on its utility with their clients. At the group interview, case managers provided informed consent and completed demographics forms before the start of the interview. All interviews (participant and case manager) were conducted by interviewers trained in qualitative methods and were recorded and transcribed verbatim, with names of participants masked.

2.2. Measures

Participants were asked to complete a paper-and-pencil survey. The survey included questions about demographics of the parent participant and his/her child and standardized questionnaires of child behavior and parenting practices, but the latter will not be detailed as they are beyond the scope of the current report. Case managers also completed paper-and-pencil demographics and workplace status questions (e.g., job title).

Interview guides for the case manager and participant interviews were created with the assistance of a qualitative research expert. Both interview guides included open-ended questions and probes to elicit further information or clarify responses if necessary. All questions were designed to elicit respondent comments about the helpfulness and fit of Pathways Triple P with the child welfare system (case manager interviews) and with parents (participant and case manager interviews). Case manager interview question topics included (a) their experiences with assisting with recruitment for the pilot project, (b) the acceptability and integration of Pathways Triple P into the child welfare system, (c) aspects of the program that should remain the same or be modified for future implementations, and (d) their opinion of potential program impact when implemented on a larger scale. Program participant interview question topics included: (a) overall impressions of Pathways Triple P, (b) aspects of the program which the participants found helpful and unhelpful, (c) aspects of the program that should remain the same or be modified for future implementations, (d) preferences for balance between group/phone/home visits aspects of the program, (e) logistical aspects of the project, such as transportation and child care, that were helpful or unhelpful to them.

2.3. Participants

Case managers referred 20 parents for the pilot project; 13 parents were eligible to participate, nine of which consented and completed pre-intervention surveys (six in the experimental condition and three in the comparison condition). See Figure 1 for a detailed disposition of participants throughout recruitment and program participation. One experimental condition participant dropped out between intake and the start of the program due to schedule conflicts with a new job. See Table 1 for program participant demographics. The mean age of experimental condition participants was 34 (range 24–43); five were female and one was male; three were Caucasian, two were African-American, and one was American Indian; all had at least completed high school; none were currently married; four were unemployed and had a family income of <$10,000/year, whereas the other two were employed and had higher family incomes. The mean age of participants’ children was 8. To protect privacy of participants, female pronouns will be used for the remainder of this paper.

Figure 1.

Participation of parents at all stages of pilot project

Table 1.

Demographics of Pathways Triple P participants

Age
Mean (years)	33.6
SD	7.3
Gender
Female	83%
Male	17%
Race/ethnicity
American Indian	17%
African American	33%
Caucasian	50%
Hispanic/Latino	--
Education
High School	33%
Some college	50%
Graduate degree	17%
Marital Status
Single	50%
Divorced/separated	50%
Married	--
Employment
Employed	33%
Unemployed	67%
Receiving TANF benefits
Yes	50%
No	50%
Household income
<$10,000	67%
$10,000–19,999	17%
$20,000–29,999	17%
Age of participant’s child
Mean (years)	7.8
SD	1.5

One case manager and one supervisor participated in the group interview. Both respondents were college-educated, Caucasian females who worked full-time for the local child protective services agency. A third was available at the scheduled time but declined to participate, citing her perceived inability to contribute anything meaningful.

The authors acknowledge that the number of interview participants was small. This is potentially problematic because one goal of qualitative research is to recruit enough participants to thoroughly cover the topic area (reach saturation). However, in a study of the number of participants necessary to reach data saturation, Guest, Bunce, and Johnson (2006) found that 94% of findings were uncovered in the first six interviews. This is similar to Kuzel’s (1992) recommendation that five – eight participants are sufficient when interviewing participants about an experience they have in common. Given these guidelines, it is reasonable to expect that the available parent interview data represent near-saturation on the topic.

2.4. Analysis

Our analysis of the interview data was conducted via a multistage, iterative process. We first read the transcripts to obtain an overall impression of program participant and case manager comments. Interview transcripts were imported into Nvivo 8, a qualitative analysis software program. Our analysis of the data was then conducted in two stages, using a combination of deductive and inductive approaches. Because our interest was in discerning the fit between Pathways Triple P, the child welfare system, and parents within this system of care, in the first stage we conducted an initial deductive coding pass with this framework in mind (Pope, Ziebland, & Mays, 2000). Our codes for this coding pass were the question topics described above; we marked sections of transcripts corresponding to each question. The resulting comments were organized by code and respondent, printed out, and were carefully read in preparation for a second, inductive coding pass. The purpose of this analysis stage was to allow further themes and key topics to emerge from the data. A thorough review of the results of the first coding pass provided an initial list of new codes. Project staff discussed the themes and key topics described by these codes and arrived at a consensus about definitions for codes to be used for the second coding pass. All of the transcripts were then coded again, using a constant comparative analysis technique (Thorne, 2000), in which each transcript, theme, or statement was compared with all others to discern similarities, differences, and relationships between them. In the case of the current data, this technique also included comparing case manager and program participant statements of the relative importance and goodness of fit of various elements of the program.

3. Results

3.1. Fit of Triple P within child welfare system

Case managers mentioned a number of elements which were important to the fit of Pathways Triple P within the child welfare system. These included the recruitment process, the parent’s current status within the child welfare system (i.e., is the child currently residing in the home with the parent or in an out-of-home placement), the timing of the intervention, and the quality of the program itself.

Overall, case managers felt that the recruitment process was suitably simple and fit well within their existing work schedule; that is, the referral form was short, easy to complete, and did not ask for information that the parents could easily later relay to project staff. Recruitment for the program was initially slow. Case managers reported this was partially due to a dearth of parents with children between the ages of 6 and 10 in their caseloads early in the recruitment process. However, they also felt slow recruitment was related to an overall sense that they initially lacked all relevant program information. This was especially true when program information was provided to them by their supervisors and not project staff. One mentioned that there was very little discussion about Pathways Triple P in the office, resulting in few case managers from her office making referrals to the study. They suggested that contacting case managers directly would help them be aware of Pathways Triple P and better understand how it would benefit their clients.

Like I mentioned earlier, someone coming to present [the program] at one of our monthly meetings with all the units would be a good idea. Just so everyone knows what there is to offer. We get handed flyers and brochures all the time on services so it’s easy just to put them on a pile on your desk that you never even look at, so I think having someone talk about the program and what it has to offer would help.

Case managers felt that Pathways Triple P would be a better fit for parents whose children remained in the home than for parents whose children had been removed. The weekly homework requirement would prohibit this being a good fit for those parents whose children were currently in foster care, even if they were court-ordered to attend parent training as a condition of return of their children to the home. In addition, they noted that many of the programs run by the local child welfare system are short-term but intensive, so timing of a referral to Pathways Triple P was important. “A lot of times we find our families, while in the intervention, are very overwhelmed with the number of services; as a worker you don’t want them to be even more overwhelmed than they already are.” Although they thought Pathways Triple P would take too much time for parents participating in such other intensive services, case managers felt that the program would be helpful to their clients as an aftercare option.

It fits pretty well with our interventions… sometimes even if parents go through our whole program we still have some concerns, so we’d want them to participate in something a little bit more long-term or in addition to what they’ve already received (from us).

Another aspect of Pathways Triple P which case managers felt made it a good fit for the child welfare system was its quality: it is effective in teaching new parenting skills, and would probably, in their view, reduce future instances of maltreatment or neglect. They felt that its focus on parents of young children would be especially effective:

We see it’s really early intervention that is helpful. Because once your kid gets to be about 13, if you have had very poor parenting skills up to that point, trying to reel that child back in and [get them to] buy into the fact that you’re the parent when they’re a teenager is really hard.

Furthermore, case managers felt that the program’s inclusion of personalized in-home sessions made it especially likely to be effective in preventing future maltreatment or neglect. “If you’re seeing what’s going on in the home, you’re able to better determine what might not be going correctly for them… and help them understand how to deal with their children.” The other case manager concurred: “a more individualized, specific intervention for each family gives them far more of the tools they need to be able to effectively parent their own children.”

All in all, case managers felt that having access via a simple referral to an effective, individualized parent training program would help them to do their jobs. “Pathways Triple P can benefit… workers in terms of getting resources for that client that will help the family to stay together long-term and not have removal of their children.” The other case manager agreed, saying “the more services we can get the better.”

The evidence for a good fit between Pathways Triple P and the child welfare system would be further substantiated by demonstration that the program was effective in improving parenting skills and lessening risk for future incidents of child maltreatment. Although we did not specifically ask parents about the program’s impact on them, each talked about ways in which the program had influenced their parenting. Although one parent felt that the program had primarily served as confirmation that her parenting skills were good (“I’m not saying I didn’t get anything from the program; I did, I surely did. It was just reinforcement that I’m doing the right thing.”), all others felt that they had made changes to their parenting as a result of Pathways Triple P. The changes started with a new awareness of how they were parenting: “the program mentioned some things about me… that I wasn’t even aware that I was doing until they were brought to my attention.” Participants also reported learning new ways to handle difficult situations with their children. They spoke of learning improved ways to interact with their children, manage children’s requests, handle their own anger, and provide consistent structure and discipline for children. One noted “I have a lot of trouble following through with the discipline, and it gave me some direction on how to go about it without feeling like the bad guy all of the time.” Another participant also spoke of the program’s impact on her discipline style: “It helps you be a better parent. And, you don’t have to just scream… it teaches you how to discipline your child other than hitting them.” She also indicated that the program module on examining the ways you’d been parented was valuable for her, and that as a result she would be less likely to maltreat her children in the future.

You know parenting from your coming up, and how you’ve been disciplined and raised; you don’t have to do your children like that. Most people get whippings and all of that when they’re kids, and they grow up and they take the same thing out on their kids. And, you don’t have to do all of that.

Parents felt that Pathways Triple P helped them to gain parenting skills precisely because it took them through the entire change process from initial awareness to cementing new parenting practices. “It was a process of identifying an issue, showing me how I could change it, and working with me as it changed to make sure that things were changed.” They reported being proud of themselves and the progress that they made, and said that both they and their children were happier with the way things were going at home now.

3.2. Acceptability of Triple P to parents

Parents found the program acceptable and a good fit for their needs. They said they liked the logistical supports, the variety of teaching/learning methods used in the program, and the specific parenting techniques taught.

Specific logistical supports mentioned include the taxi vouchers, child care, reminder calls, and the location and time of the group meetings. All parents used the taxi vouchers to get to and from groups, although several reported one or more problems with waiting for their scheduled ride to arrive. “The taxi voucher helped, because that takes stress off… I was struggling financially as far as paying for gas. Plus, I’m not from [area] so it would have been a struggle for me to find it anyway.” The child care was also seen as helpful and of high quality. “For me, and I’m sure other parents, it’s one less of a stress to worry about what I’m going to do with my children while I’m participating in the program.” Another popular logistical support was the weekly reminder calls; parents said that the calls helped them to prioritize the program in their schedules. The parents had mixed opinions on the time and location of the groups; they generally liked the evening groups but also noted that the ending time meant that their bedtime routines got off to a late start on group nights.

Parents appreciated the variety of structural elements (group, phone calls, home visits) and teaching/learning methods (group discussion, workbook, and video) utilized in the program. The group provided an opportunity for discussion with other parents, which normalized their difficulties and struggles in parenting via seeing others in similar situations. “I thought the group thing was great. I need to be aware that I’m not the only one dealing with these troubled issues. So the group experience is always good for me.” Participants also appreciated the diversity of situations among parents in the group, and said that they were able to get ideas on how to manage their situations from others as well.

Being involved with other parents that had different issues than me just made me aware. Even if I saw things that didn’t directly hit me, I learned through being in the class with other parents and seeing what helped them.

Nonetheless, several parents felt that groups consisting of people with similar status (i.e., fathers) or situations (i.e., parents of children with attention deficit hyperactivity disorder) would offer advantages to group participants.

Although participants valued interaction with other parents in group sessions, they also reported that the facilitator phone calls and home visits were important to them because group time was limited. “I was able to discuss some things during the one-on-one home visit that I wasn’t able to get into in the group because I didn’t want to hold up her schedule.” In other cases the facilitator phone calls and home visits allowed participants to privately discuss their situations with the facilitator.

During the time that we weren’t going to the classes the phone calls helped a lot, because we pinpointed specific areas that I was struggling in, talked about what I was doing to work through them, and discussed the outcome. That was very helpful for me.

The use of videos, discussion, and workbooks made the group sessions very interactive -- a plus to most parents.

A lot of times with these parenting programs you just sit in a class and there are notes, you do the homework and then you pass the class or fail the class. And, you might have some class participation but this actually got everybody involved and everybody had a chance to discuss… and it’s really good. I liked it.

Several also commented that it was helpful for material to be presented in different ways. “Being able to read through the workbook, then watching videos, and discussing it all helped me.” The workbook was valued both for its use during group sessions and to use at home as a reminder of techniques learned in the program. “It helped condense stuff, so you could flip through and quickly get reference.”

Participants mentioned that many of the parenting techniques taught in the class were new to them. All found some techniques helpful (e.g., planned ignoring and the use of behavior charts), although most also mentioned specific techniques that did not work for them. They appreciated having an array of parenting techniques at their disposal, so that they were able to choose what worked best for their situations.

4. Discussion

Findings from this pilot project preliminarily indicate a promising fit between Pathways Triple P and the child welfare system. Specific elements of the fit between the service delivery system, the intervention, and the clients will be discussed in turn.

4.1. Service delivery system

Aspects of the service delivery system which facilitate a good fit with programs include support for the program, adequate resources, and opinions of front-line workers. As Proctor, et al. (2007) noted, it is important that programs enjoy support from child welfare agency leadership and this was clearly evident within the studied child welfare system. Administrators (i.e., regional directors) and supervisors fully supported the implementation of Pathways Triple P. Despite support at this level, some key aspects of the program and the referral process appeared to get “lost in translation” between project staff, supervisors and case managers. This impacted recruitment efforts; however, case managers were clear that slow recruitment was due to front-line workers’ lack of knowledge about the program rather than a lack of support for the specific intervention. Incorporating this feedback, a revised recruitment protocol has been adapted for the next phase in the larger project aimed at testing the translatability of Pathways Triple P to the child welfare system.

Case managers said that the short referral form fit well within their available time and resources for making referrals, an aspect of fit pointed out by Glasgow and Emmons (2007). There was no training necessary since case managers were not providing the intervention themselves; in fact, they were relieved to be able to refer clients to the program for further parenting assistance once they had completed the child welfare system’s in-house intensive programming. A final aspect of fit between Pathways Triple P and the child welfare system is that case managers felt that the program would help them do their jobs better in that it would give them another tool to use to help parents whose children were living in the home to learn better parenting skills and avoid future incidents of child maltreatment or neglect.

4.2. Intervention

A number of characteristics of the intervention facilitate its fit with the child welfare system and with parents within this system of care. These include intensity, manualization, personalization of program content for parents, effectiveness, and logistical assistance to participants. The intervention is eleven weeks long, providing a minimal intensity necessary to promote behavior change (Glasgow & Emmons, 2007). Its length compares favorably with Project KEEP’s 16-week program and Parent-Child Interaction Therapy’s 14-week program (Barth, et al., 2005). Furthermore, the program is manualized, with extensive training required for facilitators (Glasgow & Emmons, 2007). Barth and colleagues noted that parenting programs which include in-home observation of parent-child interactions and customization of content to parents’ needs are more effective than lecture-only parent training interventions. Pathways Triple P includes both customization of content and a mix of group and individual elements, which participants valued. Moreover, parents reported that the program was effective in teaching them new parenting skills, including alternatives to physical methods of disciplining their children.

The extra-intervention logistical assistance we provided also improved the fit between Pathways Triple P and parents involved with the child welfare system (Cooper, et al., 2002). Parents said that the transportation assistance and on-site child care were important to their participation in the program. Participants liked the weekday evening time and said that the location, although not near their homes, was acceptable since we had provided transportation. Finally, Kazdin, et al. (1997) noted the importance of program delivery in participants’ native language; although all program participants were English-speaking, Triple P has been translated into several languages (e.g., Spanish) and as such is appropriate for non-English-speaking parents as well.

4.3. Client

Elements necessary for a good fit between a program and clients include perceived relevance of the intervention (Cooper, et al., 2002) and acceptability of the intervention to clients (Kazdin, et al., 2002). All participants had been referred to child protective services and thus could be assumed to have an a priori need for a parent training program. Although we did not ask them if they felt the program was relevant to their needs, nearly all participants spontaneously identified ways in which the program helped them change their parenting behavior. They also noted that both they and their children were happy with the improvements to their home life. We believe that this is an indication that Pathways Triple P was relevant to their unique needs.

Both case managers and participants spoke about Pathways Triple P’s acceptability to parents. Case managers said that the program’s nonjudgmental tone would be acceptable for parents who felt that their child’s behavior was the reason they had been referred to child protective services. Participants appreciated the non-prescriptive nature of the program as well, citing that they liked the opportunity to choose from among a variety of parenting techniques those which proved most effective for their situation. This individualization of structured content is an intended characteristic of Triple P (Matsumoto, Sofronoff, & Sanders, 2007). Moreover, they said that using the techniques had helped them to become better parents, another demonstration of the program’s acceptability to them. One concrete measure of their improved parenting skills would be a lack of future incidents of child maltreatment. Although we did not track recidivism for participants in the program, one participant indicated that she’d gained parenting skills that she would utilize instead of hitting her children; this fits with case managers’ belief that the program was likely to reduce future incidents of child maltreatment. Finally, another measure of the program’s acceptability is our low drop-out rate: each parent who attended the first session completed the program. This is far lower than the 20–80% drop-out rate common to parent training programs (Barth, 2008). The one parent who dropped out did so prior to the first session, because of a schedule conflict that arose after consenting to participate. Since Kazdin, et al. (1997) found that participants tend to drop out when they perceive that there are barriers, including acceptability, to their participation in a parent training program, our drop-out rate indicates that parents found the program acceptable and a good fit for their needs.

4.4. Limitations

There are a few limitations to this study. Because it is a pilot project, the number of participants was small by design. As noted in section 2.3, it is possible that data saturation was not reached with the small number of participants. However, given that other researchers have suggested that six interviews are sufficient for over 90% data saturation (Guest, et al, 2006), it is probable that near-saturation was reached for the parent interviews. The number of case managers who participated in the group interview was also low, so it is conceivable that saturation was not reached for these data. Secondly, caution must be used when considering the generalizability of the current results, since all of the participants were involved with a single child welfare system in one Midwest city. Although small, the sample included diverse racial/ethnic identities, ages, and educational experience. It is probable that comparable results would be garnered from similarly diverse samples of participants from other geographic areas. Finally, a third limitation is the lack of follow-up with the participants. Although the program fit well with participants, further studies should be conducted which examine the long-term effects of Pathways Triple P on parents referred to child protective services.

5. Conclusion

Pathways Triple P is an evidence-based parent-mediated intervention that shows promise when used with parents within the child welfare system. Our findings -- based on both parent and case manager reports -- suggest that this program fits nicely with and is acceptable to parents among this vulnerable population. Given these promising results, a large-scale implementation of Pathways Triple P with parents referred to the child welfare system is necessary to document the program’s effectiveness in increasing parenting skills, reducing child behavior problems and preventing maltreatment recidivism.