Review article
Stepping Stones Triple P-Positive Parenting Program for children with disability: A systematic review and meta-analysis

https://doi.org/10.1016/j.ridd.2013.01.022Get rights and content

Abstract

This systematic review and meta-analysis evaluated the treatment effects of a behavioral family intervention, Stepping Stones Triple P (SSTP) for parents of children with disabilities. SSTP is a system of five intervention levels of increasing intensity and narrowing population reach. Twelve studies, including a total of 659 families, met eligibility criteria. Studies needed to have evaluated SSTP, be written in English or German, contribute original data, and have sufficient data for analyses. No restrictions were placed on study design. A series of meta-analyses were performed for seven different outcome categories. Analyses were conducted on the combination of all four levels of SSTP for which evidence exists (Levels 2–5), and were also conducted separately for each level of SSTP. Significant moderate effect sizes were found for all levels of SSTP for reducing child problems, the primary outcome of interest. On secondary outcomes, significant overall effect sizes were found for parenting styles, parenting satisfaction and efficacy, parental adjustment, parental relationship, and observed child behaviors. No significant treatment effects were found for observed parenting behaviors. Moderator analyses showed no significant differences in effect sizes across the levels of SSTP intervention, with the exception of child observations. Risk of bias within and across studies was assessed. Analyses suggested that publication bias and selective reporting bias were not likely to have heavily influenced the findings. The overall evidence base supported the effectiveness of SSTP as an intervention for improving child and parent outcomes in families of children with disabilities. Limitations and future research directions are discussed.

Highlights

► Reviewed twelve studies evaluating a parenting program for children with disability. ► Significant moderate effect sizes for reducing reported and observed child problems. ► Significant effect sizes on improving parenting styles, satisfaction/efficacy. ► Significant effect sizes on improving parental adjustment and parental relationship. ► Stepping Stones Triple P is an effective behavioral family intervention.

Introduction

Children with developmental disabilities have been consistently shown to be at increased risk of developing behavioral and emotional problems compared to typically developing children (e.g., Baker, Blacher, Crnic, & Edelbrock, 2002). It has been estimated that children with developmental disabilities are two to three times more likely to show significant behavior problems (Einfeld & Tonge, 1996). Epidemiological surveys indicate that approximately 40–50% of children with intellectual disabilities are prone to develop significant mental health issues (Dekker et al., 2002, Tonge and Einfeld, 2000). When left untreated, problem behaviors in children with disabilities tend to become more severe during childhood and adolescence and often continue into adulthood (Einfeld et al., 2006).

An effective means of targeting child behavioral and emotional problems is through parenting interventions (Dretzke et al., 2005, Olympia et al., 2005). Behavioral family interventions are based on social learning principles and have been shown to be effective across a range of child populations, including children with developmental disabilities (Roberts, Mazzucchelli, Taylor, & Reid, 2003). Hence parenting interventions have become a significant area within the literature on children with developmental disabilities (Matson, Mahan, & LoVullo, 2009). While the primary aim of behavioral family interventions is to reduce level of child behavioral and emotional problems, such interventions also target and have been shown to reduce parenting stress (Singer, Ethridge, & Aldana, 2007). Parenting stress is of particular concern for parents of children with developmental disabilities who consistently report higher levels of stress than parents of typically developing children (Baker et al., 2002, Baker et al., 2003, Baxter et al., 2000). Parenting interventions have also been demonstrated to improve a range of parent and family outcomes including parenting styles, parent satisfaction and confidence in performing the parenting role, and relationships between parents in two-parent households (Barlow et al., 2002, Nowak and Heinrichs, 2008).

One parenting intervention designed specifically for parents of children with disability is the Stepping Stones Triple P-Positive Parenting Program (SSTP; Sanders, Mazzucchelli, & Studman, 2004). SSTP is a parallel version of the Triple P-Positive Parenting Program (Sanders, 2012) for typically developing children that has been shown to be efficacious and effective across four meta-analyses (de Graff et al., 2008a, de Graff et al., 2008b, Nowak and Heinrichs, 2008, Thomas and Zimmer-Gembeck, 2007).

The SSTP system uses a public health approach to parenting in order to promote widespread dissemination of programs and provide the minimally sufficient level of intervention required to meet the needs of each individual family (Mazzucchelli & Sanders, 2011). The SSTP programs vary according to the level of intensity of the intervention, and the mode and context of delivery. There are five levels of intervention: Level 1 is a media and communications strategy; Level 2 is a brief selective intervention, such as one or two large-group seminars; Level 3 is narrow-focus training where brief, tailored interventions are delivered individually to parents; Level 4 includes broad-focus training of 10 sessions delivered through individual, group, or self-directed formats; and Level 5 includes intensive additional modules for families experiencing extra problems (e.g., parental stress or partner conflict). Research studies have provided evidence for the efficacy of a number of versions of SSTP. At least one study has investigated a version of SSTP from each of Levels 2–5 (e.g., Hampel et al., 2010, Plant and Sanders, 2007, Roberts et al., 2006, Sofronoff et al., 2011, Roux et al., 2013, Tellegen and Sanders, 2013).

The objective of this paper was to provide the first systematic review of the current state of research evidence for SSTP, using meta-analytic procedures to synthesize data where appropriate. Studies to be included in this review involved parents of children with disabilities and no restrictions were placed on study design, e.g., randomized controlled trial (RCT), uncontrolled study. The first aim was to evaluate the success of SSTP in effecting change in child problems, such as behavioral or emotional problems. The second aim was to evaluate the impact of SSTP on parenting styles, parenting satisfaction and efficacy, parental adjustment, parental relationships, and observations of child behavior and parenting behavior. The third aim of the review was to conduct moderator analyses to compare treatment effects across the different levels of SSTP interventions. It was hypothesized, based on previous Triple P meta-analyses (de Graff et al., 2008a, de Graff et al., 2008b, Nowak and Heinrichs, 2008, Thomas and Zimmer-Gembeck, 2007) and positive results in individual SSTP evaluation studies (e.g., Plant and Sanders, 2007, Roberts et al., 2006, Sofronoff et al., 2011, Roux et al., 2013, Tellegen and Sanders, 2013, Whittingham et al., 2009), that significant effect sizes would be found for most of the outcome variables. Additionally, it was expected that any differences found across SSTP levels would be such that larger effect sizes would be associated with higher levels of SSTP intervention.

Section snippets

Eligibility criteria

To be included in the review, studies needed to meet the following inclusion criteria:

  • (a)

    The study reported outcomes from an evaluation of an intervention recognized by the authors of the paper as a form of Stepping Stones Triple P. Note that no limitations were set regarding trial design for including studies.

  • (b)

    The study was available in English or German.

  • (c)

    The study reported means, standard deviations and sample sizes either within the publication or upon author contact.

  • (d)

    The study contributed

Description of studies

The searches yielded a total of 1451 papers and the final set of unique studies after excluding duplicates was 983. After screening papers for relevance according to title and abstract, 342 papers remained that were related to Triple P. After assessing these articles for eligibility, 12 studies were included in the meta-analysis. Papers were excluded if they were not on Stepping Stones Triple P (n = 307), not an evaluation study (n = 19), and did not contain original data (n = 5). See Fig. 1 for

Discussion

This paper forms the first review evaluating the evidence base for SSTP, a behavioral family intervention designed specifically for parents of children with disability. A systematic review using meta-analytic techniques was conducted to evaluate the research across seven different outcome categories. Child problems were the primary outcome of interest and the secondary outcomes were parenting style, parenting satisfaction and efficacy, parental adjustment, parental relationship, child

Conclusion

This systematic review and meta-analysis supported the effectiveness of SSTP interventions for parents of children with disabilities. Moderate effects were found on child behavior across all levels of intervention. Significant effects were found for improving parenting styles, parenting satisfaction and efficacy, parental adjustment, parental relationship, and child observations. No significant effects were found on parent observation data. The review lacked statistical power to find

Disclosure statement

Professor Sanders in the founder and lead author of the Triple P-Positive Parenting Program (“Triple P”). Triple P is owned by the University of Queensland (UQ). UQ, through its technology transfer company Uniquest PTY LTD, has licensed Triple P International to disseminate the program worldwide. Royalties stemming from this dissemination work are paid to Uniquest then distributed between the University, Faculty, School, Parenting and Family Support Centre and contributory authors in accordance

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