IACAPAP Textbook of Child and Adolescent Mental Health

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INTRODUCTIONPARENTING PROGRAMSDivna Haslam, Anilena Mejia, Matthew R. Sanders &Petrus J. de Vries

Divna Haslam PhD
Parenting and Family
Support Centre, University of
Queensland, Australia

Anilena Mejia PhD
Parenting and Family
Support Centre, Universityof Queensland, Australia &Institute for Scientific Research
and Technology (INDICASAT),
PanamaMatthew R Sanders PhD
Parenting and Family
Support Centre, University of
Queensland, Australia

The Card Players. Basile de Loose (1809-1885)

Conflict of interest: Dr Sanders
and Dr Haslam are authors ofvarious Triple P resources. The
Triple P – Positive Parenting
Program is owned by the
University of Queensland(UQ). UQ through its maintechnology transfer company,
UniQuest Pty Ltd, has licensed

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2016. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Haslam D, Mejia A, Sanders MR & de Vries PJ. Parenting programs. In Rey JM (ed), IACAPAP e-Textbook ofChild and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions
2016.

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IACAPAP Textbook of Child and Adolescent Mental HealthT

he importance of growing up in a nurturing and supportive family
environment cannot be underestimated. Raising children in a warm,
loving environment sets them on a positive developmental trajectory forlater life success (Biglan et al, 2012). Conversely, children raised in homes withinconsistent and harsh parenting or with high levels of conflict can be adversely
impacted.
Parenting programs have been developed to support parents and equipthem with effective disciplinary skills to manage current parenting challenges,
with the hope of protecting children from later life adversity. In this chapter you
will learn about parenting programs, their theoretical foundations, for what kindof problems they are recommended, how to evaluate their impact, and the main
issues you might face when delivering parenting interventions, particularly in low
and middle income countries and other low resource settings.

THEORETICAL BACKGROUND OF PARENTINGPROGRAMS

Triple P International Pty Ltd
to publish and disseminate theprogram worldwide. Royalties
stemming from published Triple
P resources are distributed
to the Faculty of Health andBehavioral Sciences at UQ,Parenting and Family Support
Centre, School of Psychology
at UQ, and contributory
authors. No author has any
share or ownership in Triple P
International Pty Ltd. Dr Mejia
is an honorary researcher at
UQ but receives no royalty from
Triple P dissemination

Petrus J de Vries MBChB,
MRCPsych
Division of Child & Adolescent
Psychiatry, University of CapeTown, South Africa
Conflict of interest: none
disclosed

Before the 1960s, problematic child behaviors were typically addressedusing therapeutic methods directed at the child or adolescent (e.g., individual
psychoanalysis/psychotherapy or child institutionalization). The late 1960s weremarked by a shift in the field of child psychology and psychiatry. Around thistime, interventions started to focus on changing parents’ behaviors and making
them active participants in therapeutic interventions. This shift was due to a
growing understanding of how parents can influence children’s behavior. Theories
on behavioral modification (Skinner, 1965), social cognitive models (Bandura, 1977)
and those having to do with coercive family interactions (Patterson, 1982) shaped
the development of what became known as parenting programs. Table A.12.1
presents a brief synthesis of each of these theories and their contribution to thedevelopment of parenting programs.
Parenting programs have proliferated since the 1960s with different
programs focusing on developing different types of skills in parents (e.g., behavior
management, self-efficacy, and/or knowledge). There are now several meta-analyses
on the effectiveness of these interventions and comparing those with different
theoretical orientations (e.g., Lundahl et al, 2006). However, the programs mostwidely used are those based on behavioral and social cognitive models (i.e., thetheories described in Table A.12.1). Typically these programs are manualized andhave manuals, training materials and accreditation systems. They are commonly
known as “behavioral family interventions” or “parenting training programs”.
Examples include The Incredible Years (Webster-Stratton & Reid, 2015), The
Triple P—Positive Parenting Program (Sanders, 2012), and Parent Management
Training—The Oregon Model (Forgatch, 1994).

TYPES OF PROBLEMS THAT CAN BE TARGETEDWITH PARENTING PROGRAMSParenting programs are recommended for the prevention and treatment of
externalizing (e.g., oppositional, aggressive, or impulsive behaviors, such as noncompliance, disobedience, fighting, aggression and answering back) (Furlong et al,

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Table A.12.1

Theoretical foundations of parenting programs

BEHAVIORAL
THEORIES(Skinner, 1953)

SOCIALCOGNITIVE
MODELS(Bandura, 1977)

Main contribution:

Main contribution:

Main contribution:

There arecontingencies
involved in theparent-childinteraction.

Parental cognitions,such as attributions,
expectancies andbeliefs, determine
parents’ behavior.

There are coercive
interactions in families.

••

Parents influencechildren’s behavior
through positive
reinforcement orconsequences, suchas attention andpraiseChildren’s difficult
behavior canbe inadvertently
reinforced byparents’ attention
to it, while positive
behavior can beeliminated byparents’ inattention

•

•

•

Parental cognitions
will influenceparental confidence,
their decisionmaking and their
behavioral intentions
Parents needto understandthe interactional
explanations they
have for their child’s
behaviour and theirown
Interventions should
target self-efficacy

COERCION THEORY(Patterson, 1982)

•

•

•

The aversive behaviorof each person infamily interactions
is terminated by theaversive behavior of
the other person, but
the long-term effectis an increase in thelikelihood that theaversive behavior will
occur again
If a child whines when
asked to do something
and the parent stops
demanding, thewhining will stop.
However, both thewhining and thedemand (aversive
behavior) are more
likely to occur again
Parents need to betaught strategies
for positive childmanagement asalternative to coercive
parenting practices

Click on the image to preview
the Incredible Years parenting
program (20:01)

Click on the image to viewfamilies completing group Triple
P (4 video clips by Brighton &Hove City Council). It showssome of the techniques that
Triple P teaches, and the effectit has on children’s behavior.

2012), and internalizing problems (e.g., depression, anxiety) in children (Kendall
et al., 2008). Research suggests that both sub-clinical and clinical levels of problems
decrease when these interventions are properly implemented (Dretzke et al, 2009).
Many clinical presentations, such as oppositional defiant disorder and conductdisorder, can be treated with focused parenting interventions (Kazdin, 1997).
Parenting programs can also be very useful as adjunctive treatment forchildren with attention deficit hyperactivity disorder (ADHD), mood disorders,or neurodevelopmental and learning disorders (Petrenko, 2013; Skotarczak &Lee, 2015). In these cases, they typically focus on managing behavioral problems
associated with the primary condition. For example, a child with ADHD may
benefit from a combined therapeutic approach comprising medication for the child(if required) and a parenting program. Similarly, a child with a diagnosis of an
autism spectrum disorder may benefit from a combination of individually applied
behavioral therapy and social skills training, while their parents may benefit from

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IACAPAP Textbook of Child and Adolescent Mental Healthparenting training (Tellegen & Sanders, 2013). The parenting component would
focus on teaching parents skills to manage behavioral problems (e.g., difficultywith change in routines) that occur in the context of the primary disorder.
In addition to the prevention and treatment of childhood disorders, many
parenting programs are also used to prevent the development of more serious
problems in adolescence and early adulthood. Some problems that might beprevented include teenage delinquency, truancy, antisocial behavior in adolescence,
early sexual activity, risky sexual behavior, substance misuse, and adult criminality(Haggerty et al, 2013). For example, some parenting programs have been usedas part of broader population interventions to reduce risky sexual activity andthe prevalence of HIV-AIDS (Prado et al, 2007). Note that in this example theintervention is not intending to change the primary outcome (e.g., HIV-AIDS),
but rather used to halt negative developmental trajectories that might result inbecoming infected later on.

TYPES OF PARENTING PROGRAMSParenting programs are interventions that aim to improve child and family
outcomes by equipping parents with effective parenting skills. They differ fromparent education training or psychoeducation—which focus on increasing parent
knowledge about developmental stages or certain conditions—in that parenting
programs include active skills training. They are designed to increase competence
and confidence in parents, allowing them to raise children in a loving, consistent,
predictable, and non-harmful environment. Research suggests that improvementsin parenting style are associated with reductions in child socio-emotional andbehavioral problems (Sanders & Woolley, 2005). Effective programs aim to reduce
known risk factors for poor child and family outcomes such as harsh disciplinary
practices, and strengthen protective factors (i.e., factors that predict positive family
outcomes). See Table A.12.2 for the typical goals of most programs.
According to their primary focus, they can be broadly divided into
prevention, treatment, and blended programs:•

Prevention programs are designed to avoid the development of serious
behavior or emotional problems in children through the acquisition ofparenting skills before problems develop or at the first sign of problems.

Table A.12.2

Common goals of parenting programs

PRIMARY INTERVENTION GOALS•••

Improve parent-child relationships
Reduce negative, coercive or violent discipline practices
Teach parents effective, non-violent parenting practices

SECONDARY INTERVENTION GOALS•••Reduce parental stress, depression, and anxiety
Increase parental confidence and competence
Reduce violence towards children

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IACAPAP Textbook of Child and Adolescent Mental Health••

Typically, these are lower intensity interventions, thus easier andcheaper to implement. They work in a way similar to regular toothbrushing to prevent cavities. When parents are taught effective, safe,
non-violent discipline strategies, children are less likely to develop
emotional and behavioral problems (Forgatch & DeGarmo, 1999).
Treatment programs seek to reduce problem behaviors after they
have developed. To continue with the dental hygiene analogy, theseare similar to going to the dentist to get a cavity filled. Like withprevention programs, they are most effective when implemented as
early as possible (before the cavity becomes large or the tooth is lost),
but they can also be effective even when problems are longstanding or
severe. They are often more intensive in terms of time and cost thanprevention programs given that they cover more content and provide
additional support to families. These programs are best suited tofamilies with higher levels of need or with many risk factors (Kazdin &Whitley, 2003).
Blended approaches are broader than focused prevention and treatment
programs; they can be conceptualized as suites of interventions. Blended
programs often have a range of variants that can be deployed as needed.
For example The Incredible Years has a school-based variant aimed atpreventing problems in the classroom, as well as intensive parenting
interventions for implementation at home. Triple P is also a blended
program with five levels of intervention, ranging from media strategies
targeting whole populations to intensive individual services for families
with complex comorbidities (Prinz et al, 2009).

Most research on the topic has targeted treatment-focused programs forchildren with behavioral or emotional problems at the clinical level or those athigh risk for the development of such problems. Allowing for between-country
variance, only 10% to 15% of children have problems at this level (Jaffee et al,2005). Without early intervention, subclinical levels of problems may escalate into
clinical presentations that are harder to treat. For this reason, prevention programsand blended approaches can be beneficial in reducing the number of cases at awhole population level.

KEY COMPONENTS
Research indicates that programs that include a number of key active
ingredients are most likely to work. For a review of key components of parenting
interventions see the meta-analysis by Kaminski and colleagues (2008).
Components can be broadly classified in those that:•••

Teach parents to respond consistently (e.g., praising their child)
Teach parents strategies to manage difficult behavior (e.g., use of timeout), and
Use active parent participation during training (e.g., role play forparents to practice skills).

A summary of key ingredients that seem to contribute to the effectiveness ofthese programs is listed in the Box.

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KEY COMPONENTS OF
EFFECTIVE PROGRAMS

The program:•
Provides strategies
for increasing
positive parent-childinteractions•
Focuses on parental
consistency•
Allows parents topractice new skills
with their own child•
Teaches theappropriate use ofconsequences, suchas time-out (i.e., thetemporary withdrawalof parental attention
in response to
problem behavior)•
Teaches problem
solving to parents•
Increases parental
sensitivity andnurturing•
Models (or shows)
positive behavior•
Providesopportunities forparents to practicestrategies in thesession via role play•
Teaches emotional
communication skills

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IACAPAP Textbook of Child and Adolescent Mental Health

Most researchers agree
that corporal punishment
is associated with adverse
outcomes, particularly behaviour
problems, later in life.

EVALUATING EFFECTIVENESS
In the previous section key elements or active ingredients of parenting
programs were discussed. However, it is important to keep in mind that many
programs are promoted or implemented without evidence that they work. Thosewith evidence of efficacy gathered through a body of empirical research (usually
including randomized controlled trials) are known as evidence-based programs.
Clinicians have the ethical responsibility to ensure that interventions offered tofamilies have some evidence of effectiveness—a core principle of evidence-based
practice. However, it is also necessary to maximize resources, particularly whenworking in low-income settings. It can be tempting to make programs up (i.e.,develop them from scratch), with the risk that they might be ineffective and awaste of resources.

Click on the image to view
the United Nations Office on
Drugs and Crime (UNODC) listof evidence-based parenting
interventions

A number of programs have been found to be effective after rigorous
evaluation (Haggerty et al, 2013). These include The Incredible Years (WebsterStratton & Reid, 2015); Parent-Child Interaction Therapy (Brinkmeyer & Eyberg,
2003); Triple P—Positive Parenting Program (Sanders, 2012); Nurse Family
Partnership (Olds et al, 2003); and Strengthening Families Program (Kumpfer etal, 1996). More information about these can be found in Table A.12.3. Manyinternational bodies, such as the United Nations Office on Drugs and Crime(UNODC, 2009), have lists of evidence-based parenting interventions.

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Table A.12.3 Summary of selected evidence-based parenting programs*
NAME**

Strengthening
Families

Parent-ChildInteraction
Therapy

TARGETOUTCOMES

Involves 14 two-hour group sessions
focusing on parenting skills, children’s social
skills, and family life skills•
It can be implemented for preschoolers, elementary school children,
early teens (10-14), high school teens(12-16), and as group classes (7-17)•
There is a home DVD with ten
30-minute lessons•

Typically used for the treatment of
oppositional defiant disorder or conductdisorder. Has two stages of intervention:•
Child-directed interaction and•Parent-directed interaction
Average of 14 sessions (10-20) of one to twohours per week.

•

Parents of children aged •2-7 with behavioral
problems••

Improved parent-childrelationshipEffective parenting skills
Effective discipline

There is a treatment version and aprevention version
The program is split into differing ages:
babies, toddlers, pre-schoolers, andschool age children
Each program has a different methodof delivery•

Families with children
aged 0-12 years

Reduction in childconduct problems andhyperactive behavior
Improved parenting
skillsReduced negative
parenting strategies
Increased childcompliance and positive
affect••The Incredible
Years

TARGET
AUDIENCE

SUMMARY•••

Children with high riskfor drug abuse, crimeand other delinquent
behavior
Different versions of the
program contain agegroup specific activities
SFP 10-14 is aimed at
low-risk families

•
•
•

•
•
•
•

•
•

Nurse Family
Partnership•••

Triple P—
Positive
Parenting
Program••

Delivered by registered nurses to low•income first-time mothers
One-to-one home visits from pregnancy •until the child is two years old
The nurse visits every one or two
weeks, depending on the schedule
decided by the parent and nurse
Nurses use professional knowledge,
judgement and skill while applying
guidelines

Low-income first-time
mothers
The program is mosteffective with parents
and children who are at
high-risk

A parenting and family support system
aimed at prevention and treatment of
behavioral and emotional problems inchildren and teenagers
The intensity varies from light to highly
targeted interventions depending on
the needs of each family
Delivery may include personal
consultation, group or online courses,
self-help interventions or public
seminars

Can target any age from •birth to sixteen years.
Specialist program•
also target parents ofchildren with a disability,
health or weight•
concerns, parents going
through divorce andIndigenous families

•
•

•
•
•

Reduced substanceabuse and delinquency
Improved family
relationships
Reduced risk factors forproblem behaviors inhigh risk children

Improved pregnancy
outcomes
Improved health anddevelopment of the child
Positive life course inparents

Reduced behavioral andemotional problems
Improved parental
wellbeing and parenting
skillsReduction in negative
parenting strategies*All these programs require payment of a licensing fee for training and materials.
**Click on the name of the program to access the website.

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It is beyond the scope of this chapter to review the key concepts ofevidence-based practice. However, guidelines on how to judge effectiveness ofinterventions can be found in Chapter A.6 of the IACAPAP Textbook. Listed
in the Box 3 are some questions that can assist you in judging if the program
you are considering is likely to be effective. More information about how toassess evidence of effectiveness can also be found in a summary by the World
Health Organization (2013) available here.
QUESTIONS WORTH ASKING WHEN CHOOSING A PARENTING PROGRAM

•
•
•
•

•
•
•
•
•

Is the program grounded in a strong theoretical framework?
Does the program target known risk and protective factors?
Does the program include most of the key components associated with effective
parenting?
Has the program been evaluated scientifically and shown to improve the target
outcomes using:•
Randomized controlled methodology•
Strong quasi-experimental trials•
Designs in real world delivery settings•
Population trials (if the target audience is a whole population)?
Can the program focus in the population you are seeking to treat?
Are gains maintained after the conclusion of the program?
Have positive findings been replicated independently of the original research team?
Has the program been evaluated in contexts similar to the one where you will be
implementing the program?
Are appropriate resources, training and implementation support available?

Click on the image to accessthe WHO report “Preventing
Violence: Evaluating Outcomesof Parenting Programmes”

PRACTICAL ISSUES IN THE DELIVERY OF
PARENTING PROGRAMS
While parenting programs can be very useful, there are other aspects toconsider, such as whether a parenting program is the treatment of choice, as well
as delivery issues. These include:••Child protection and safeguarding of children. It is possible thateither during assessment or delivery of a parenting program, concerns
about child safety may be raised. Safeguarding and protecting children
has to be of paramount importance. Where child protection becomes aconcern, this has to be dealt with as a priority. Facilitators will need to
discuss concerns with their supervisor and, if appropriate, with parents,and swiftly take the necessary action.
Parental mental health problems. There is much evidence thatparental mental illness (e.g., depression) can adversely affect theirability to parent (Oyserman et al, 2000). However, when it is clear thata parent has a serious mental illness, such as a psychotic disorder, severe
depression or anxiety, it may not be appropriate to offer a parenting
program until the mental illness has been assessed and stabilized.
Supporting parents to find appropriate treatment should therefore be
the priority in these cases. On the other hand, if a parent has a lowlevel mood or anxiety disturbance they may still be able to participate
in the program while also seeking additional assistance. Clinicians
should monitor parents’ mood and reactions throughout the course

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IACAPAP Textbook of Child and Adolescent Mental Health••of the program and take appropriate action. For example, if a parent
appears to be getting upset or teary in a group session, the practitioner
should speak to the parent privately outside the group to determine if
additional support is necessary.
Privacy and confidentiality. It is important to conduct sessions in aroom where discussions are private and where confidentiality can be
maintained. When parenting programs are delivered in a group format,
it is useful to explicitly state privacy expectations at the start of thegroup. This will allow parents to share their thoughts and experiences
and facilitate group discussion. It is important to make clear that
personal information discussed in a session should not be shared withothers outside the session. Parents should also be informed that privacy
and confidentiality will be upheld unless there is concern about risk totheir children’s safety, to themselves or to others. This is part of the dutyof care of all child health professionals.
Parenting programs and specific child problems. While the generalprinciples of parenting programs are helpful for all children, there are
specialized programs where highly specific targets are included. For
instance, in some programs for autism spectrum disorder, parents
might be provided with specific training in turn-taking, stepping into
the “attentional spotlight” of the child, how to arrange the environment
to encourage communication and so on. For a review of “naturalistic
developmental behavioral interventions”, many of which use parents asactive treatment partners and include parent coaching, click here.
In these programs there is often an emphasis on learning to understandthe function of a particular behavior. For instance, a child with autism
spectrum disorder may use a particular behavior not to get attention,
but rather to avoid attention. A time-out strategy would therefore not

A Triple P program session in Kenya

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IACAPAP Textbook of Child and Adolescent Mental Health••be appropriate in that instance. There is also a specialized approach tofunctional analysis of behavior in children with intellectual disability
and specific genetic disorders, such as fragile X, Prader-Willi, Angelmanor Cornelia de Lange syndromes, for instance. In many of these genetic
disorders, specific behaviors may be associated with sensory sensitivities,
pain, cognitive inflexibility, avoidance behaviors, or exaggerated needfor behavioral reinforcement with eye contact. These are specialized
scenarios for which specific modules or parenting approaches are
required. For example, the Stepping Stones Triple P program has been
evaluated with parents of children with a range of specific neurodevelopmental disorders (Tellegen & Sanders, 2013).
Poverty and low socio-economic status. It is crucial to note that,particularly in low- and middle-income countries, parents may arrive
at a parenting program with an empty stomach. Just as children can’t
learn if they are hungry, parents can’t make use of training if they are
hungry or thirsty. A drink and a biscuit can go a long way to help
parents concentrate. Likewise, ensuring that parents have access toprinted materials, baby sitting or transport will be helpful. For example,
provide notepads, pens and copies of monitoring forms parents need
to use at home rather than expecting them to make their own copies.
Stigma and shame. Many come to the program having received
the overt or covert message that they are not good enough parents
or that they need to be “trained”. It is important that group leadersand facilitators keep in mind that parents may feel stigmatized andashamed. It is important to acknowledge such feelings, and to use
parents’ knowledge and experiences to assist in the program, rather
than for facilitators to assume a position of exclusive expertise. The
facilitator should explicitly acknowledge the expertise of the parents
and empower them to achieve their own family goals. Many people
would say that parenting is the most difficult job any parent will everdo!

Matters relevant to low and middle-income countries
This section discusses how to ensure parenting interventions are relevant tospecific cultures, the adaptations that can be made to fit the context of low income
countries, and how to enhance their value-for-money.
Most parenting interventions have been developed, evaluated andimplemented in western, English-speaking, high-income countries. However,meta-analytic reviews have indicated that evidence-based parenting programs
implemented in other countries are at least as effective as in the country where they
had originated (Gardner et al, 2015); only minimal adaptations being required.
There are, however, a number of low-risk cultural and contextual adaptations that
can help increase engagement and improve cultural appropriateness.
Cultural relevance
Parenting interventions have been tested in different countries and cultures(See Table A.12.4 for examples). Some of them have also been adapted following
rigorous and systematic procedures to improve the fit for the target population.
An example can be found in Baumann et al (2014) for the adaptation of the

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Click on the image to view aclip that illustrates the life andresilience of women in the highrisk Panamanian neighborhoodof San Joaquin

TESTING A
PARENTINGPROGRAM IN A
LOW-RESOURCESETTING
In 2012, the governmentof Panama funded a
research project to
explore the cultural
relevance and efficacy of
Triple P in low-resource
communities in Panama.
The research team
explored the acceptabilityof the program to parents
and practitioners inthose communities, andconducted a trial to test if
the program was effective
in reducing behavioral
problems in children aged
3 to 12. The program
was considered culturally
acceptable and theparents who participatedin the intervention wereless stressed and lesshostile towards theirchildren who, in turn,were better able to follow
instructions.
Few studies of parenting
programs have been
conducted in low income
countries. See Mejia et al(2012) for a review.

10IACAPAP Textbook of Child and Adolescent Mental Health

CASE EXAMPLE
BEING A PARENTING PRACTITIONER IN EL SALVADOR

Josefa is a social worker at a community center in one of the most violent neighborhoods in
San Salvador.
Most fathers in this neighborhood are in prison, and mothers are under considerable stresstrying to raise their children without support. There is one child, Gabriel, who is 8 years
old and has severe behavioral problems. He does not follow instructions and is aggressive
towards his mother and peers. He is at high risk of gang involvement and antisocial behavior
later in life. Josefa undertook some training on a parenting program some time ago.
However, she faces several barriers for delivering the program in this context:•
Gabriel’s mother cannot read or write, so she can’t complete assessments, read theworkbook or follow the videos (which are only available in English with subtitles)•
Gabriel and his mother come from a rural town and recently moved to the city. Josefa
is not sure if the strategies from this parenting program will be appropriate to theirtraditions and values•
Like Gabriel, there are many children in the neighborhood with severe difficulties.
Josefa does not have capacity to see all parents. She will ask one of the mothers in
the community to assist her in delivering the intervention•
Josefa was trained more than 10 years ago and does not have anybody to supervise
her cases
Table A.12.4 Examples of evidence-based parenting programs implemented around the world*
PARENTING PROGRAM

ORIGINALLY
DEVELOPED IN

EVALUATED OR IMPLEMENTED IN
Jamaica (Baker-Henningham et al, 2009)
Netherlands (Posthumus et al, 2012)
Norway & Sweden (Axberg & Broberg, 2012
Forgatch & Degarmo, 2011)
UK

Incredible Years

United States

•
•
•
•
•

Parent Management
Training-Oregon Model

United States••

Iceland (Sigmarsdottir et al, 2013)
Norway (Forgatch & Degarmo, 2011)

Parent-child Interaction
Therapy

United States••

Hong Kong (Leung et al, 2007)
Puerto Rico

United States

•
•
•
•
•
•
•
•
•
•
•
•

CanadaChile
Costa Rica
El Salvador
Netherlands
NorwayPanama (Mejia et al, 2015b)
Peru
Puerto Rico (Matos et al, 2009)
Spain (Orte et al, 2013)
SwedenUK (Seggrott et al., 2014)

Australia

•
•
•
•
•
•
•
•
•

China
CuraçaoGermany
Hong Kong (Leung et al, 2003)
Indonesia (Sumargi et al, 2015)
Japan (Matsumoto et al, 2010)
Netherlands
Panama (Mejia et al., 2015a)
UK

Strengthening Families
Program

Triple P—Positive
Parenting Program*Not an exhaustive list.

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IACAPAP Textbook of Child and Adolescent Mental HealthParent Management Training—Oregon Model in Mexico. If you are intending touse a parenting intervention that has not been tested or adapted for the population
you are working with, it might be beneficial to start by reflecting on the cultural
relevance of the program. If you are familiar with the target group, make sure you
anticipate potential cultural barriers in the implementation of specific strategies.
For example, in some cultures, promoting independent problem solving in young
children might not be accepted by parents. If you are not familiar with thetarget group, you could ask parents how they feel about implementing behavioral
strategies such as time-out or descriptive praise. Does this strategy contradict theircultural values or typical communication practices? If so, how can the strategy be
adapted to fit their culture?
Context-appropriate assessment
Before delivering a parenting intervention, it is recommended to get a senseof the main difficulties your target group is facing. This will allow you to tailor
the intervention to their specific needs. In addition, parents around the world facevery different challenges, thus a one-size-fits-all-approach will not work. Someparents might be facing other complex issues apart from their child’s behavioral
and emotional difficulties, such as child maltreatment or domestic violence. Thesefamilies should be referred to other services, if available; most parenting programs
are not recommended for problems such as severe parental psychopathology,
domestic violence, or child maltreatment.
In relation to child behavioral and emotional difficulties, parents might be
struggling with disobedience, aggression, tantrums or conflict between siblings, forexample. There are standardized questionnaires to help you assess the difficulties
parents might be struggling with. Some of these questionnaires have been translated
into different languages. For example, the Strengths and Difficulties Questionnaire(SDQ) has been translated to most languages and is available free. The SDQ
provides information on both emotional problems, such as anxiety and depression,and behavioral problems, such as tantrums and aggressiveness (Goodman, 1997).
The Eyberg Child Behavior Inventory (ECBI) is also widely-used also but requires
payment of a licensing fee.
Two instruments for parent reports have been developed recently: the Child
Adjustment and Parent Efficacy Scale (CAPES) (Morawska et al, 2014), and the
Parenting and Family Adjustment Scale (PAFAS) (Sanders et al, 2014). The English
version of these instruments can be found in Appendix A.12.2; there are also
versions in Spanish, Portuguese, Turkish and Chinese, all freely available for use.
Please contact the first author to receive a copy of these measures.
It is important to know that literacy levels in many low-income countries
range from 30% to 80%. If parents are illiterate or if it is difficult to collect written
data from them, the program leader can give parents a tally sheet (such as the one
in Appendix A.12.1) so that parents can monitor their children’s behavior for acertain period of time and obtain an estimate of how frequently certain problem
behavior occur. It is best to introduce monitoring before introducing strategies
to obtain an accurate level of baseline behavior. Many programs ask parents tomonitor child behavior between the first and second sessions. The parent can also
complete a monitoring form after the intervention is complete to check problems
have decreased. Alternatively you can ask parents to move stones from one jar to
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IACAPAP Textbook of Child and Adolescent Mental Healthanother each time a problem behavior occurs and then count the stones in each jar
at the conclusion of the week to capture how frequent behavior problems occur.
You can also collect in-depth information through an interview. Make sure togather information on:
•
•
•
•
•

The target problem
Where and when is it most likely to occur (i.e., contextual details about
the problem)
Parent’s explanation of the cause of the problem
Strategies tried in the past without success
Parent’s current goals.

Program fidelity
Most evidence-based parenting programs include a practitioner manual(and often a certified training component). For this reason, they are known as“manualized” programs. Sticking to the manual in relation to the key concepts,
content, and structure is known as program fidelity. Ensuring fidelity is importantbecause programs are most effective when delivered as prescribed and might notwork at all if not delivered with fidelity. However, it is also important to ensure agood fit between the content of the program and parents’ needs. Thus, it is crucial
that practitioners achieve a balance between fidelity and flexibility during delivery(Mazzucchelli & Sanders, 2010). Later in this section we present examples of
low and high risk adaptations that can be made to a program to achieve a balance
between fidelity and flexibility.
Adaptations to content
When one has a clear understanding of the target problem, it is acceptableto make minor adaptations to the content of an existing manual to fit parents’

CASE EXAMPLE
LOW-RISK ADAPTATIONS TO ENGAGE MOTHERS IN KENYA

A practitioner was delivering a parenting program in an informal settlement (slumcommunity) in the outskirts of Nairobi. Some changes made included spending time insmall groups explaining the parenting questionnaires rather than expecting parents to dothem without assistance.
Parents were very shy at the start of the intervention. After noticing this, the practitioner
asked parents how group meetings would typically start in Kenya. Parents reported thatthey would usually start with a praise song and a prayer. As a result, from then on, sessions
started with a praise song and prayer led by one of the parents.
Another change made was to spend extra time discussing the benefits and challenges ofphysical affection---not a common practice among Kenyan parents. Discussions covered thetype of affection parents themselves had received as children and how this influenced theirown parenting. In this way, parents were able to consider the potential benefits of showing
their children affection in a manner that was consistent with cultural expectations. For
example, mothers of boys were able to consider forms of affection other than kissing, which
was not seen as appropriate.
These low-risk adaptations (i.e., they did not change the content of the intervention itself or
undermine the fidelity of the program) allowed mothers to be more open and confident in
discussing their concerns in the group and had a profound impact on the group atmosphereand attendees cooperation.

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IACAPAP Textbook of Child and Adolescent Mental Health

Table A.12.5 Low and high risk adaptations
LOW RISK•HIGH RISK

Language translations done bya certified translator with a back•translation procedure and reviewed by aqualified practitioner

Changing the order of sessions•

Simplifying written materials for parents
with low literacy levels (i.e., using
videos, role-plays or making workbooks
easier to read)•

Changing specific strategies andthe way they are implemented (i.e.,suggesting parents to assist the childto calm down when they are in timeout)•

Modifying examples (e.g., using local
examples or stories)•

Changing the order in which
strategies are introduced to parents•

Including icebreaking activities in groupsessions•

Not structuring sessions with anagenda•Showing video segments more thanonce•

Removing strategies to be taught ina session•

Doing individual exercises as a large
group

•

Adding inconsistent strategies•

Adding additional break in between
sessions•

Removing homework•

Dividing one long session into two
shorter ones•

Providing more sessions when
additional support is required•

Increasing or shortening the length ofsessions or particular exercises•

Slowing down the pace of theintervention•

Including additional spaces fordiscussion

specific needs and cultural expectations. However, it is important that you areclear about which changes are low risk and which may be high risk. Low risk
adaptations include minor changes that make the content locally relevant, such as
modifying examples or including ice-breaking activities, which will not affect thecore ingredients of the intervention. High risk adaptations are those that change
core components of the intervention, such as excluding training in a particularskill (e.g., praise or time-out). See Table A.12.5 for guidelines and examples.
Given that most parenting interventions rely on written materials, it is also
important to consider parents’ literacy level. Trials indicate that parents with low
literacy or intellectual disability can benefit from modified parenting interventions(e.g., Glazemakers & Deboutte, 2013). When working with illiterate parents,
consider using a program that relies on video materials dubbed into the local
language. If you do not have access to videos, consider using role-plays to train
parents on a particular skill and allow additional time for group discussion. You
may also integrate key examples into family stories to make it easier for parents
from storytelling cultures to remember. Where parents are literate but with low

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IACAPAP Textbook of Child and Adolescent Mental Healthlevels of education (i.e., primary school only) writtenmaterials can be adapted to make them briefer andeasier to read.

TRAINING OF FACILITATORS
Most parenting interventions have a wellestablished training to accredit professionals to deliver
them. Only professionals that undergo this training(usually lasting 3 or 4 days) are accredited to deliver
the intervention. This requirement aims to ensure thequality and fidelity of the intervention.
There are parenting interventions freely
available online that do not require facilitators tobe accredited by attending a course. One example isReach Up, an early childhood parenting program. To
be able to deliver the program, potential facilitators
must go through a free online training. Reach Up isquite intensive and is delivered as part of home visits to help parents enhancetheir child’s development. There are several trials showing that Reach Up has beeneffective in Jamaica and there are versions available in English, Spanish, French and
Bangla (Grantham-McGregor & Walker, 2015).

Click on the image to access theReach Up website

While most programs based on social-cognitive and behavioral theories
only allow health professionals to be trained as facilitators, there are several
examples documented in the literature of other parenting interventions that can bedelivered by para-professionals or educated members of the community. There is noevidence that health professionals achieve better outcomes than para-professionals.
Using para-professionals (also referred to as task-sharing—see Chapter J.5 of the
Textbook) might be particularly attractive in low income countries where healthprofessionals are scarce. A decision on the credentials needed for those who will
deliver the intervention should be made based on the:
•
•
•

•

Intervention chosen (e.g., whether the program requires that only
health professionals be trained)
Available resources (e.g., whether there are funds to pay facilitators)
Number of families that need to be reached (e.g., if the aim is to reacha large number of families, using para-professionals or lay facilitators
might be more feasible)
Severity of the target population (e.g., psychologists, psychiatrists andhealth workers might be better equipped to deal with children withsevere problems).

Value for money
Programs that are cost neutral (i.e., the costs of implementation are similar
to the savings made by reducing children’s problems) or cost positive (i.e., thecosts of implementation are lower than the savings made by reducing children’s
problems) should be the first choice. The costs and return on investment of
implementing specific parenting interventions can be found in websites such as
Blueprints. However, these costs have been calculated for a specific set of programs

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15

IACAPAP Textbook of Child and Adolescent Mental Healthin the US. To our knowledge, no cost-effectiveness studies have been conducted in
low income countries. In the absence of such information, the following strategies
can be used to maximize the impact of programs and increasing their value formoney:•••

Some programs can be offered as large seminars in schools andcommunity settings. Providing parenting information to as many
parents as possible in a single session reduces costs and can be a goodstrategy to identify those who need more intensive support
Self-directed learning materials, such as brochures and videos, could
also be used to reach parents with mild difficulties
Some parenting interventions can be delivered by para-professionals

CONCLUSIONSParenting programs are increasingly perceived as a cost-effective meansof preventing and treating emotional and behavioral problems in children.
Their effectiveness is supported by a growing body of empirical research. Whenconsidering using a parenting program:
•

•
•

•
•
•
•

Consider each family’s unique situation through a comprehensive
assessment to determine if a parenting program will be helpful orappropriate
Make sure the parenting program you choose targets known risk factors
It is preferable to offer interventions to parents that are appropriate totheir level of difficulty. In other words, if they have mild difficulties,
you can offer a light-touch intervention of few sessions (i.e. brief
and focused). If they have more severe difficulties, then you can offer
individual support for several sessions.
Make minor or low-risk adaptations to ensure cultural and contextual
fit
Monitor families’ progress throughout the course of the intervention
using clinical judgment and appropriate measurement tools
Provide additional assistance or refer those with other significant
problems (e.g., parental depression, domestic violence) to other services
Access peer support and supervision.

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•
•

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Comments?

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IACAPAP Textbook of Child and Adolescent Mental Health

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Parenting programs

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✔

✔

✔

✔

✔

✔

Tuesday

WednesdayThursdayFridaySaturday

Sunday

✔

✔

✔

✔

✔

✔

✔

2

✔

✔

✔

✔

✔

✔

✔

3

✔

✔

✔

✔

✔

✔

✔

4

✔

✔

✔

✔

✔

✔

5

✔

✔

✔

✔

✔

6

✔

✔

✔

✔

7

✔

✔

✔

8

✔

✔

9

✔

10

11

12

13

15

Weekly Total

14

49

5

4

6

10

8

7

9

Total

This type of tally sheet can be used to assess how frequently certain behaviours occur. In this example tally sheet the parent is tracking
how often the child fails to follow instructions. Each time the child says “no” or refuses to do what the parent asked (eg Get dressed)
the parent has placed a tick in the box. In this example we can see that the child failed to follow instructions 9 times on monday, 7times on tuesday and so forth. A weekly total is calculated at the bottom showing that over the whole week the child failed to follow
instructions 49 times in the week. In this example the child said failed to follow instructions 49 times in the week. At the end of theparenting program we would expect to see this number drop dramatically.

✔

1

Refusing to follow clear instructions

MondayBehaviour:

Instructions :Each day the specific behavior occurs on a given day make a mark in the box. At the end of the day counthow many marks have been made. Choose only one behavior at a time to monitor and be clear exactly what the behavior isin advance.

Behavior Tally Sheet

IACAPAP Textbook of Child and Adolescent Mental HealthAppendix A.12.1

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SundaySaturdayFridayThursdayWednesday

Tuesday

Monday

1

2

3

4

5

6

7

8

9

10

11

12

13

15

Total

Weekly Total: _______

14

Each day the specific behaviour occurs on a given day make a mark in the box. At the end of the day count how many marks have beenmade. Choose only one behaviour at a time to monitor.

Behaviour: ___________________________________________

Instructions :Behaviour Tally Sheet

IACAPAP Textbook of Child and Adolescent Mental Health20

IACAPAP Textbook of Child and Adolescent Mental HealthAppendix A.12.2
Child Adjustment and Parent Efficacy Scale (CAPES)*
Please read each statement and select a number 0, 1, 2 or 3 that indicates how true the statement was of yourchild (aged 2-12) over the past four (4) weeks. Then, using the scale provided, write down the number next
to each item that best describes how confident you are that you can successfully deal with your child’s behavior,even if it is a behavior that rarely occurs or does not concern you.
There are no right or wrong answers. Do not spend too much time on any statement.
Example:My child:
Gets upset or angry when they don’t get their own way

0

1

2

3

9

The rating scale is as follows:0.

Not true of my child at all1.

True of my child a little, or some of the time2.

True of my child quite a lot, or a good part of the time3.

True of my child very much, or most of the time

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IACAPAP Textbook of Child and Adolescent Mental HealthChild Adjustment and Parent Efficacy Scale (CAPES)*
How true is thisof your child?
Not at A littleall

My child:

Rate yourconfidence

Quite
a lot

Very
much

2.

Gets upset or angry when they don’t get theirown way
Refuses to do jobs around the house when asked

3.

Worries

0

1

2

3

4.

Loses their temper

0

1

2

3

5.

Misbehaves at mealtimes

0

1

2

3

6.

0

1

2

3

7.

Argues or fights with other children, brothers orsisters
Refuses to eat food made for them

0

1

2

3

8.

Takes too long getting dressed

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

13. Yells, shouts or screams

0

1

2

3

14. Whines or complains (whinges)

0

1

2

3

15. Acts defiant when asked to do something

0

1

2

3

16. Cries more than other children their age

0

1

2

3

17. Rudely answers back to me

0

1

2

3

18. Seems unhappy or sad

0

1

2

3

19. Has trouble organizing tasks and activities

0

1

2

3

20. Can keep busy without constant adult attention

0

1

2

3

21. Cooperates at bedtime

0

1

2

3

22. Can do age appropriate tasks by themselves

0

1

2

3

24. Gets on well with family members

0

1

2

3

25. Is kind and helpful to others

0

1

2

3

0

1

2

3

0

1

2

3

1.

Hurts me or others (e.g., hits, pushes, scratches,
bites)
10. Interrupts when I am speaking to others
9.

11. Seems fearful and scared

0

1

2

3

0

1

2

3

1 = Certain I can’t
do it
10 = Certain I can
do it

12. Has trouble keeping busy without adult attention

23. Follows rules and limits

26. Talks about their views, ideas and needs
appropriately
27. Does what they are told to do by adults*Sanders et al, 2014.

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IACAPAP Textbook of Child and Adolescent Mental Health

Scoring Key for the CAPES
Child Emotional and Behavioral Problems Scale: 27 items (rating scale 0–3). Note that shaded items (inbold) must be reverse scored (i.e., 0=3, 1=2, 2=1, 3=0). To obtain an Emotional Problems Subscale Score, sum
items 3, 11, 18, with a possible range from 0-9. To obtain a Behavioral Problems Subscale Score sum all remaining
items, with a possible range from 0-72. To obtain a Total Intensity Score add the Emotional Problems Subscale andthe Behavioral Problems Subscale Scores together, with a possible range from 0-81. Higher scores indicate greaterlevels of child emotional or behavioral problems.
Parent Efficacy Scale: sum all parent confidence ratings (rating scale 1–10). Note that there are no parent
confidence ratings for shaded items. Possible range for the Total Score is 19–190, with higher scores indicating
greater levels of parent efficacy.

Reverse score shaded items(i.e. 0=3, 1=2, 2=1, 3=0)

ITEM
Emotional
maladjustment

PARENTALSELF- EFFICACY31118
Behavioural Problems
Subscale
1
2
4
5
6
7
8
9
10
12
13
14
15
16
17
19
20
21
22
23
24
25
26
27

Total Intensity Score

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IACAPAP Textbook of Child and Adolescent Mental HealthParenting and Family Adjustment Scales (PAFAS)*
Please read each statement and select a number 0, 1, 2 or 3 that indicates how true the statement wasof you over the past four (4) weeks. There are no right or wrong answers. Do not spend too muchtime on any statement.
Example:If my child doesn’t do what they’re told to do, I give in and do it myself.

0

1

2

3

The rating scale is as follows:0.

Not true of me at all1.

True of me a little, or some of the time2.

True of me quite a lot, or a good part of the time3.

True of me very much, or most of the time

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IACAPAP Textbook of Child and Adolescent Mental Health

How true is thisof you?

1. If my child doesn’t do what they’re told to do, I give in and doit myself
2. I give my child a treat, reward or fun activity for behaving well
3. I follow through with a consequence (e.g. take away a toy)
when my child misbehaves
4. I threaten something (e.g. to turn off TV) when my childmisbehaves but I don’t follow through5. I shout or get angry with my child when they misbehave
6. I praise my child when they behave well
7. I try to make my child feel bad (e.g. guilt or shame) for
misbehaving to teach them a lesson
8. I give my child attention (e.g. a hug, wink, smile or kiss) when
they behave well
9. I spank (smack) my child when they misbehave
10. I argue with my child about their behavior / attitude
11. I deal with my child’s misbehavior the same way all the time
12. I give my child what they want when they get angry or upset
13. I get annoyed with my child
14. I chat / talk with my child
15. I enjoy giving my child hugs, kisses and cuddles
16. I am proud of my child
17. I enjoy spending time with my child
18. I have a good relationship with my child
19. I feel stressed or worried
20. I feel happy
21. I feel sad or depressed
22. I feel satisfied with my life
23. I cope with the emotional demands of being a parent
24. Our family members help or support each other
25. Our family members get on well with each other
26. Our family members fight or argue
27. Our family members criticize or put each other down
If you are in the relationship, please answer the following 3
questions
28. I work as a team with my partner in parenting
29. I disagree with my partner about parenting
30. I have a good relationship with my partner

Not atall

A little

Quite
a lot

Very
much

0

1

2

3

0

1

2

3

0

1

2

3

0

1

2

3

0
0

1
1

2
2

3
3

0

1

2

3

0

1

2

3

0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0

1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1

2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2

3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3

How true is thisof your child?
Not atall

A little

Quite
a lot

Very
much

0
0
0

1
1
1

2
2
2

3
3
3

*Morawska et al, 2014.

Parenting programs

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IACAPAP Textbook of Child and Adolescent Mental Health

Scoring Key for the PAFAS
All 30 items are rated from 0 to 3. Note that items in bold in the scoring key below must be reverse
scored (i.e. 0=3, 1=2, 2=1, 3=0) before summing the Total Score for each subscale. Please see Table
2 below for further information regarding coding the items. PAFAS consist of two scales Parenting
and Family Adjustment. PAFAS Parenting consists of four subscales and PAFAS Family Adjustment
consists of 3 subscales which can be interpreted using the table below.
SCALE
PAFAS
ParentingParental
consistency
Coerciveparenting
Positive
Encouragement
Parent-childrelationship
PAFAS Family
adjustment
Parentaladjustment
Familyrelationships
Parental
teamwork

Parenting programs

POSSIBLE
RANGE

ITEMS

INTERPRETATION

1,3,4,11,12

Higher scores indicate lower levelof consistency
Higher scores indicate morecoercive parenting
Higher scores indicate lower levelof positive encouragement
Higher scores indicate worse
parent-child relationship

0-15

Higher scores indicate worse
parent adjustment
Higher scores indicate worse
family relationships
Higher scores indicate worse
parental teamwork

0-15

5,7,9,10,13
2,6,8
14,15,16,17,18

19,20,21,22,23
24,25,26,27
28,29,30

A.12

0-15
0-9
0-15

0-12
0-9

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IACAPAP Textbook of Child and Adolescent Mental Health

Item coding
Item
PAFAS Parenting
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

Parenting programs

A.12

Item
PAFAS Family Adjustment
19
20
21
22
23
24
25
26
27
28
29
30

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix A.12.3
SELF-DIRECTED LEARNING EXERCISES AND SELF-ASSESSMENT
MCQ A.12.1 Which of the following isa key component in effective parenting
programs?
A. Time out
B. Telephone follow-up
C. Involving children in theintervention
D. A workbook for parents
E. Parental literacy
MCQ A.12.2 A mother who has a son who
is generally well behaved but occasionallyanswers back may benefit from what typeof parenting program?
A. Treatment-focused
B. Prevention-focused
C. Blended
D. Home visiting
E. Psychoeducation
MCQ A.12.3 Effective parenting programs
are typically based on which of thefollowing?
A. Coercion theory
B. Self-actualization theory
C. Psychoanalytic theory
D. Cultural responsiveness theory
E. Cognitive theory

Parenting programs

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MCQ A.12.4 In a parenting group, a father
is taught about the importance of showing
children physical affection. The father says
he cannot kiss his daughter as it is notculturally appropriate. What should thepractitioner do?
A. Advise to kiss his daughter even if hedoesn’t feel comfortable
B. Validate his concern and tell him not
to show affection if he doesn’t feel
comfortable
C. Prompt the father to think of culturally
appropriate forms of physical affectionthat he would be comfortable in using
D. Ask if the mother could show affection
insteadE. To seek advice from elders
MCQ A.12.5 Which of the following would
be considered a high-risk change when
implementing a parenting program
A. Leaving out the section of the coursethat teaches parents about time out
B. Changing the examples from the onesin the work book to make them more
applicable to local parents
C. Spending extra time on particular
topicsD. Adding extra sessions
E. Shortening some sessions.

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IACAPAP Textbook of Child and Adolescent Mental HealthANSWERS
MCQ A.12.1

Answer: A

MCQ A.12.2

Answer: B

MCQ A.12.3

Answer: A

MCQ A.12.4

Answer: C

MCQ A.12.5

Answer: A

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29