Journal of Intellectual and Developmental Disability
ISSN: 1366-8250 (Print) 1469-9532 (Online) Journal homepage: http://www.tandfonline.com/loi/cjid20
Stepping Stones Triple P: the theoretical basis
and development of an evidence‐based positive
parenting program for families with a child who
has a disability
Matthew R Sanders, Trevor G Mazzucchelli & Lisa J Studman
To cite this article: Matthew R Sanders, Trevor G Mazzucchelli & Lisa J Studman (2004)
Stepping Stones Triple P: the theoretical basis and development of an evidence‐based positive
parenting program for families with a child who has a disability, Journal of Intellectual and
Developmental Disability, 29:3, 265-283
To link to this article: http://dx.doi.org/10.1080/13668250412331285127
Published online: 10 Jul 2009.
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Date: 23 March 2016, At: 22:10
Journal of Intellectual & Developmental Disability,
Vol. 29, No. 3, pp. 265–283, September 2004
Stepping Stones Triple P: the theoretical basis
and development of an evidence-based positive
parenting program for families with a child who
has a disability
MATTHEW R SANDERS1
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University of Queensland, Australia2
TREVOR G MAZZUCCHELLI, LISA J STUDMAN
and Disability Services Commission, Western Australia2
Stepping Stones Triple P is the first in a series of programs based on the Triple
P – Positive Parenting Program that has been specifically designed for families
who have a child with a disability. This paper presents the rationale, theoretical
foundations, historical development and distinguishing features of the program.
The multi-level intervention adopts a self-regulation framework in consulting
with parents that involves the promotion of parental self-sufficiency, selfefficacy, self-management skills, personal agency and problem-solving skills.
This paper describes the key program design features, intervention techniques,
model of clinical consultation, its clinical applicability, and empirical base. The
10-session individually administered version of the program, known as Standard
Stepping Stones Triple P is described and the important role of training,
supervision and agency support in disseminating the program is discussed.
Stepping Stones Triple P (SSTP) forms part of the Triple P – Positive Parenting Program
which is a system of parenting and family interventions for parents of children who have
or are at risk of developing behavioural or emotional problems (Sanders, 1999). SSTP is
the first in a series of parenting programs that has been specifically designed for families
who have a child with a disability.
1
Address for correspondence: Matthew R. Sanders, PhD, Professor of Clinical Psychology, School of
Psychology, University of Queensland, St Lucia 4072, Queensland, Australia. E-mail: [email protected]
2
The University of Queensland and the Disability Services Commission in Western Australia are the joint
copyright holders of Stepping Stones Triple P.
ISSN 1366-8250 print/ISSN 1469-9532 online/04/030265-19
# 2004 Australasian Society for the Study of Intellectual Disability Inc.
DOI: 10.1080/13668250412331285127
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Sanders, Mazzucchelli & Studman
The Triple P system of intervention has evolved over a 25-year period from a series of
controlled outcome studies that demonstrate the efficacy and effectiveness of the parent
training methods used in the program (see Sanders, 1996, 1999; Sanders, Markie-Dadds,
Tully, & Bor, 2000). The parent training methods employed in Triple P have been shown
to be effective in reducing children’s disruptive behaviour in a variety of populations,
including children from maritally discordant homes (Dadds, Schwartz, & Sanders, 1987),
children of depressed parents (Sanders & McFarland, 2000), children in step-families
(Nicholson & Sanders, 1999), children with persistent feeding difficulties (Turner,
Sanders, & Wall, 1994), children with behaviour problems in rural and remote areas
(Connell, Sanders, & Markie-Dadds, 1997), children with ADHD (Bor, Sanders, &
Markie-Dadds, 2002; Hoath & Sanders, 2003), and children at risk for child abuse and
neglect (Sanders, Pidgeon, Gravestock, Connors, Brown, & Young, 2004).
SSTP incorporates core Triple P parent consultation strategies and introduces
additional parenting and behaviour change strategies drawn from the disability
literature. It is a family intervention program for families of pre-adolescent children
with disabilities who currently have or are at risk of developing behaviour problems.
The overall aim of SSTP is to help parents develop effective management strategies for
dealing with a variety of childhood behaviour problems and developmental issues. The
approach has been demonstrated to be effective for children with intellectual and
physical disabilities who have disruptive behaviour problems (Harrold, Lutzker,
Campbell, & Touchette, 1992; Roberts, Mazzucchelli, Studman, & Sanders, 2002;
Sanders & Plant, 1989; Sanders, Plant, & McHale, 2002). The present paper provides a
rationale for the development of the program, and describes the program’s conceptual
basis, core intervention procedures and empirical foundations.
Rationale for the development of Stepping Stones Triple P
The rationale for the development of SSTP relates to both the prevalence of serious
behaviour difficulties in children with a disability and the consequent stress on
caregivers. Problem behaviours such as aggression, tantrums, and self-injury are more
prevalent in children with an intellectual disability than in children without a disability.
A comprehensive study on the Isle of Wight found the prevalence of mild to severe
behaviour problems in children with intellectual disability to be 50% (Rutter, Tizard, &
Whitmore, 1970). In an Australian study, Einfeld and Tonge (1996) found that 40.7% of
those with an intellectual disability and aged between 4 and 18 years could be classified
as having a severe emotional and behaviour disorder or as being psychiatrically
disordered. The Western Australian Child Health Survey reported that 18% of all
children surveyed had emotional or behaviour problems (Zubrick et al., 1995). Overall,
these results indicate that children who are diagnosed with an intellectual disability are
2–3 times more vulnerable to demonstrating a variety of behaviour problems.
The duality of developmental and behavioural problems creates difficulties on a
number of levels. For the individual child, behaviour problems are distressing, can
interfere with the child’s ability to learn new social and educational skills, can lead to
exclusion from community settings, such as school or day-care, and in some cases may
threaten physical health (Rojahn & Tasse, 1996; Tonge, 1999).
The parents and siblings of children with both disability and disruptive behaviour
problems report experiencing substantial levels of stress (Cuijpers, 1999). Families often
require more respite services in order to cope (Sloper, Knussen, Turner, & Cunningham,
Stepping Stones Triple P
267
1991). Indeed, Quine and Pahl (1985) found that the most important factor predicting
the ‘‘felt need’’ of parents for assistance with their intellectually disabled child was the
presence of behaviour problems in the child.
The presence of behaviour problems has also been identified as having a strong
influence on parents’ decisions to find an out-of-home placement (Bromley & Blacher,
1991). At a community level, problem behaviours in people with developmental
disabilities result in the use of more resources from multiple agencies, and more intense
and costly interventions, such as institutionalisation (Burchard, Burchard, Sewell, &
VanDenBerg, 1993; Scheerenberger, 1981). Hudson, Jauernig, Wilken, and Radler (1995)
estimated total yearly costs (additional to the routine cost of service provision and
independent of the client’s disability or skill level) incurred by a small sample of
Australian adults with challenging behaviour in 1992 to range from $2,284 to $132,697,
averaging $40,510.
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Role of family factors
Child and caregiver exchanges reflect influences from the broader social context within
which these interactions are embedded. Interactional processes may reflect biological
processes such as birth complications and genes or other contextual factors such as
maternal or family stress. The impact of such variables on child development is mediated
by the interactional exchanges between the child and their caregivers (Capaldi,
DeGarmo, Patterson, & Forgatch, 2002; Patterson, 2002).
Developmental outcomes can be influenced by the quality of a child’s family
environment and family adjustment. Family characteristics that influence children’s
development include: parents’ levels of depression; level of education; inter-generational
parenting experiences and cultural expectations; social support; quality of marital
relationships; financial resources; child temperament; quality of parent-child transactions; family-orchestrated child experience; and provision of health and safety
(Guralnick, 1997; Nihira, Meyers, & Mink, 1980).
Parents of children with disabilities tend to experience many additional demands and
high levels of stress that may then influence child-parent interactions. This is especially
the case when a child has severe or multiple disabilities (Llewellyn, Dunn, Fante,
Turnbull, & Grace, 1999). Further, parental stress-related depression has been shown to
be related to child adjustment and correlated with poor disciplinary practices. Poor
discipline provides a direct mediational link with developmental outcomes (Conger,
Patterson, & Ge, 1995).
The development of techniques to observe and analyse the moment-to-moment
interactional patterns amongst family factors has produced replicable relationships
between these factors and antisocial child behaviour. When parents use coercive means
as the primary mode for managing their children, aggressive behaviour develops (Eddy,
Leve, & Fagot, 2001). Both positive and negative reinforcement are involved in the
strengthening of the interrelationships between the aggressive behaviour of one person
and the submissive behaviour of the recipient (Patterson & Reid, 1984).
Once a stable pattern of interaction between parents and child is established, it can be
altered by a number of factors, such as transient emotional states like fatigue, fear, anger
or stress. For example, parents are more likely to react to child misbehaviour irritably on
stressful days. When stress is chronic or prolonged this type of interaction may be
maintained by reinforcement of parents’ behaviour (immediate child compliance) and
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268
Sanders, Mazzucchelli & Studman
may lead to more consistent punitive parenting methods. Parents’ cognitions about what
a particular child behaviour means can also affect a given interactional sequence
(Patterson & Reid, 1984).
As families of children with disabilities experience higher levels of stress than other
parents, the resulting irritable transactions are more likely to escalate and be maintained
through interlocking patterns of reinforcement even after environmental stress or
emotional trauma has passed. Such sustained patterns can lead to delinquency or child
abuse. Using home observations, interviews and questionnaires with several hundred
families, Patterson and Reid (1984) established that observed irritable reactions by
mothers covaried with child-rearing patterns that covaried, in turn, with measures of
antisocial child behaviour.
A systems-contextual approach is a useful model for the health care of children with
disabilities. It is the pattern of escalating coercive regulatory interaction between child
and parent that requires treatment (Patterson, 1991). Parent training to address conduct
problems has been shown to produce replicable positive outcomes in well-controlled
studies using objective measures (Forgatch & Patterson, 1998). Strengthening parents’
resources to cope with the demands of raising a child with a disability promotes positive
caregiver interaction, decreases the display of interfering interactional styles and
enhances positive parental perceptions of child functioning (Dunst, Trivette, & Deal,
1988).
What is Stepping Stones Triple P?
SSTP tailors the strength of family interventions to the individual needs and preferences
of parents. For example, many parents want simple practical advice about how to tackle
a specific developmental issue or problem behaviour, such as disobedience, tantrums,
sleeping or feeding problems. Other parents, with multiple difficulties across both
child and adult domains (e.g., severe child aggression in the context of parental
depression and relationship conflict), require more intensive intervention. Parents
also vary in their degree of knowledge, motivation, prior experience, access to support,
and family stresses (e.g., unemployment, single parent status, low socioeconomic status).
Potentially effective programs vary in complexity, including the strength, intensity
and scope of the intervention, the setting in which it takes place, the target population,
who delivers the intervention and the cost of delivery. The aim is to offer the most
cost-effective program that can be accessed by the largest number of ‘‘at risk’’
families.
The SSTP model has five levels of intervention strength designed to cater for the
differing levels of support families require. Table 1 outlines the levels of intervention,
including a universal parent information strategy which provides all interested parents
with access to useful information about parenting (Level 1). Level 2 involves the
provision of information and advice for a specific parenting concern. Level 3 is the
provision of information and advice with the addition of active skills training. Level 4
involves broad focused parenting skills training and Level 5 is an enhanced behavioural
family intervention program for families where parenting difficulties are complicated by
other sources of family distress.
Table 1
The Triple P model of parenting and family support
1. Universal Triple P
Media-based parenting
information campaign
2. Selected Triple P
Information and advice
for a specific parenting
concern
Target population
Intervention methods
Program resources
All parents interested
in information about
promoting their child’s
development.
A coordinated information .
campaign using print
and electronic media
.
and other health
promotion strategies
to promote awareness
of parenting issues and
normalise participation
.
in parenting programs
such as Triple P. May
include contact with
professional staff
(e.g., telephone
information line).
Parents with a specific
concern about their child’s
behaviour or development.
Provision of specific
advice on how to
solve common child
developmental issues
and minor child
behaviour problems.
May involve face-to-face
or telephone contact
with a practitioner
(about 20 minutes
over two sessions)
or seminars
(60–90 minutes).
.
.
.
.
.
.
.
Possible target behaviours
General parenting issues
Developmental issues
and tasks such as enhancing
communication and play skills
Common every day
behaviour difficulties such
as whining, and problems
with sharing
Level 1 materials
Positive Parenting and
Stepping Stones Triple
P booklets
Triple P Tip Sheet
Series and Stepping Stones
Triple P Tip Sheet Series
Every Parent Video Series
Triple P Video Series
Stepping Stones Triple
P: A survival guide for
families with a child who
has a disability
Five Steps to Positive
Parenting wall chart
Common behaviour difficulties
or developmental transitions,
such as bedtime routine
difficulties and toilet training
.
269
.
Triple P: A
.
Guide to the System
Media and promotional
kit (including promotional
.
poster, flyer, brochure, radio
announcements, newspaper
columns)
Every Parent: A
positive approach to
children’s behaviour
Stepping Stones Triple P
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Level of intervention
270
Table 1. (Continued)
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Target population
3. Primary Care Triple P
Narrow focus parenting Parents with specific
skills training
concerns about their
child’s behaviour or
development who require
consultations or active
skills training.
4. Standard Triple P
Broad focus parenting
skills training
Parents wanting intensive
training in positive parenting
skills. Typically targets
parents of children with
more severe behaviour
problems.
Intervention methods
Program resources
A brief program
(about 80 minutes
over four sessions)
combining advice
with rehearsal and
self-evaluation to
teach parents to
manage a discrete
child problem
behaviour.
May involve
face-to-face or
telephone contact
with a practitioner.
.
.
A broad focus program
(about 10 hours over
8–10 sessions) for parents
requiring intensive training
in positive parenting
skills and generalisation
enhancement strategies.
Application of parenting
skills to a broad range
of target behaviours,
settings and children.
Program variants include
individual, group or
self-directed (with or
without telephone
assistance) options.
.
.
.
.
.
.
.
Possible target behaviours
Level 2 materials
Practitioner’s Manual for
Primary Care Triple P
Consultation flip chart for
Primary Care Triple P
Practitioner’s Manual for
Primary Care SSTP
.
Level 1 to 3 materials
Practitioner’s Manual for
Standard Triple P and Every
Parent’s Family Workbook
Facilitator’s Manual for
Group Triple P and Every
Parent’s Group Workbook
Every Parent’s Self-Help
Workbook
Practitioner’s Manual for
Standard Stepping Stones
Triple P and Stepping
Stones Triple P Family
Workbook
.
.
.
.
.
.
.
.
Discrete child behaviour
problems such as tantrums,
whining, fighting with siblings
Developmental issues such
as independent selfcare skills
Multiple child behaviour
problems
Aggressive behaviour
Oppositional defiant disorder
Conduct disorder
Challenging behaviour
Learning difficulties
Developmental issues such
as sharing, communication
and toilet training
Sanders, Mazzucchelli & Studman
Level of intervention
Level of intervention
5. Enhanced Triple P
Behavioural family
intervention
Target population
Parents of children with
concurrent child behaviour
problems and family
dysfunction.
Intervention methods
An intensive individually
tailored program
(up to 11 60–90 minute
sessions) for families
with child behaviour
problems and family
dysfunction. Program
modules include practice
sessions to enhance
parenting skills, mood
management
strategies and stress
coping skills, and
partner support skills.
Program resources
.
.
Level 1 to 4 materials
Practitioner’s Manual for
Enhanced Triple P and
Every Parent’s
Supplementary
Workbook
Possible target behaviours
.
Concurrent child behaviour
problems and parent problems
(such as relationship conflict,
depression, adapting to
having a child with a
disability)
Stepping Stones Triple P
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Table 1. (Continued)
271
272
Sanders, Mazzucchelli & Studman
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History and program development
In 1997, Western Australia’s Disability Services Commission in collaboration with the
Parenting and Family Support Centre at The University of Queensland commenced the
development of a behavioural family intervention program with the broad goals of
helping parents of a child with a disability and other family members achieve durable
improvements in the child’s behaviour and lifestyle and in the quality of family life as a
whole.
Many of the ideas and principles incorporated within SSTP evolved as a result of the
experience and feedback provided by parents participating in the research and therapy
programs. The vast disability literature also informed many adaptations, some of which
are listed here: (1) The principles of positive parenting were expanded to reflect some of
the additional challenges faced by parents who have a child with a disability and to
reflect community living and family support movements (e.g., Being part of the
community); (2) Consideration of additional factors that can play a greater role in the
development of behaviour problems in disability (e.g., the accidental reward of ‘‘stopping
disliked activities’’); (3) Additional teaching and behaviour change strategies from the
disability literature (e.g., setting up activity schedules); (4) The development of additional
protocols to deal with issues and behaviours which are more common in children with
disabilities, such as self-injurious behaviour, repetitive behaviours, and pica; (5) Changes
to wording and examples of parenting materials to make them more accessible and
sensitive to parents of children with disabilities.
Theoretical basis
SSTP has the same theoretical and conceptual basis as other parts of the Triple P system
(see Sanders, 1999). It emphasises the importance of the social learning foundations of
many problem behaviours. Social learning models emphasise the bidirectional and
reciprocal nature of parent-child interactions surrounding problem behaviours
(Patterson, 2002). The extensive research literature in the field of child and family
behaviour therapy and applied behaviour analysis (including functional assessments and
consideration of ecological variables and antecedents) has provided parents and
practitioners with many powerful behaviour change strategies. SSTP has explicated these
skills and developed powerful ways of demonstrating and training parents to use them.
Developmental research examining the social ecology of parenting in everyday contexts
emphasises the importance of developing children’s competencies in naturally occurring
parenting situations (e.g., mealtimes, dressing, getting ready to go out) rather than in
artificial training situations. Social information processing models (e.g., Bandura, 1997)
highlight the important role of cognitions (beliefs, attributions, assumptions, expectations) in understanding and modifying parenting behaviour. This research has been used
to provide specific strategies to modify parental cognitions (e.g., guided participation
approach to discussing diagnostic and assessment findings).
Research in the field of developmental psychopathology has identified specific risk and
protective factors linked to adverse developmental outcomes in children that complicate
the task of raising children (e.g., marital conflict, depression). This knowledge has been
used to develop specific modules to address partner support, coping skills and family
caring responsibilities. A unique feature of SSTP is its commitment to a public health
perspective on family intervention. This means seeing preparation for parenthood as a
service that is universally accessible to all parents. Wherever possible, parents of children
Stepping Stones Triple P
273
with disabilities should be able to access parenting advice and support through
mainstream services as well as through specialised services for more serious behaviour
problems.
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Description of program
SSTP provides a system of behavioural family intervention which aims to promote
positive caring relationships between parents and their children and to help parents
develop effective management strategies for dealing with a variety of childhood
behaviour problems and common developmental issues. Triple P principles of parenting
are explored throughout the program and include: ensuring a safe, interesting
environment; creating a positive learning environment; using assertive discipline;
having realistic expectations; and taking care of oneself as a parent (Sanders,
Mazzucchelli, & Studman, 2003). Two additional principles related to parenting a
child with a disability are explored in SSTP. They are family adaptation to having a child
with a disability and being part of the community. There is scope within Triple P to
focus on family stresses that are indicated, such as parental stress, depression, anxiety,
marital conflict and adaptation to having a child with a disability.
SSTP aims to: (1) increase parents’ competence in managing common behaviour
problems and developmental issues found among children with disabilities; (2) reduce
parents’ use of coercive and punitive methods of disciplining children; (3) improve
parents’ personal coping skills and reduce parenting stress; (4) improve parents’
communication about parenting issues and help parents support one another in their
parenting roles; and (5) develop parents’ independent problem-solving skills.
These outcomes are achieved by creating a supportive learning environment for
parents. In individually tailored sessions, parents can receive practical information about
parenting skills, one-on-one feedback on their implementation of parenting strategies,
and assistance for a range of personal issues.
Parents are taught to consider the function of individual child behaviours and select
strategies accordingly. Addressing the functions of a particular behaviour is important
for children with a disability since escape/avoidance and sensory rewards can inhibit
learning and the acquisition of new skills. Escape or avoidance rewards occur when
misbehaviour leads to the withdrawal of parental demands on the child. Sensory
feedback may serve to maintain self-absorbed or autistic-like behaviours.
The SSTP approach emphasises the importance of teaching children new competencies, such as communication skills. An effective communication system can assist a
child to understand instructions, rules and daily routines and give the child more control
over their environment, thus reducing misbehaviour. Children need ways to express their
needs and desires. Communicating should be a more effective way to have their needs
met than problem behaviour.
Standard Triple P strategies are used in the design of interventions as well as a number
of strategies related more specifically to children with disabilities. Table 2 outlines all
strategies used and examples of applications.
The development of multi-component support plans in the form of planned activities
routines helps parents to generalise parenting skills to novel situations and ‘‘high-risk’’
times when children are likely to be difficult to manage. These plans comprise advance
planning and the use of strategies to prompt and reinforce appropriate behaviour, and
manage misbehaviour. The final step of planned activities routines is a review of how the
274
Sanders, Mazzucchelli & Studman
Table 2
Strategies used in Stepping Stones Triple P interventions
Strategy
Spending quality
time with children
Spending frequent, brief
amounts of time (as little
as 1 or 2 minutes) involved
in child-preferred
activities
Communicating with
your children
Having brief conversations
or interactions with children
about an activity or interest
of the child
Providing physical affection
(e.g., hugging, touching,
cuddling, tickling, patting)
Showing affection
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Description
Using descriptive
praise
Providing encouragement and
approval by describing the
behaviour that is appreciated
Giving attention
Providing positive non-verbal
attention (e.g., smile, wink,
stroke on the cheek, pat
on the back, watching)
Providing tangibles desired
by the child (e.g., a toy, mirror,
torch, article of clothing, food)
with praise and attention
Arranging the child’s physical
and social environment to provide
interesting and engaging activities,
materials, and age-appropriate
toys (e.g., board games, paints,
tapes, books, construction toys)
Arranging a series of pictures or
words representing activities that
children can engage in
Demonstrating desirable behaviour
through parental modelling
Providing other
rewards
Providing engaging
activities
Setting up activity
schedules
Setting a good
example
Using physical
guidance
Providing just enough pressure
to gently move a child’s arms
or legs through the motions
of a task
Applications
Opportunities for parents
to become associated with
rewarding activities and
events, and also for
children to share
experiences and practise
conversational skills
Promoting vocabulary,
conversational and
social skills
Opportunities for children
to become comfortable
with intimacy and
physical affection
Encouraging appropriate
behaviour (e.g., speaking
in a pleasant voice, playing
cooperatively, sharing,
drawing pictures, reading,
compliance)
As above
As above—particularly
for children who do
not respond to praise
and attention
Encouraging independent
play, promoting
appropriate behaviour
when in the community
(e.g., shopping, travelling)
Prompting participation
in the daily routine of
activities
Showing children how
to behave appropriately
(e.g., speak calmly, wash
hands, tidy up, solve
problems)
Teaching self-care skills
(e.g., brushing teeth,
making bed) and other
new skills (e.g., playing
with toys appropriately).
Also, ensuring compliance
with an instruction (e.g.,
‘‘put your hands down’’)
Stepping Stones Triple P
275
Table 2. (Continued)
Strategy
Using incidental
teaching
Using Ask, Say, Do
Teaching backwards
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Using behaviour
charts
Using diversion to
another activity
Establishing ground
rules
Description
Using a series of questions
and prompts to respond to
child-initiated interactions
and promote learning
Using verbal, gestural, and
manual prompts to teach
new skills
Using verbal, gestural, and
manual prompts to teach
new skills beginning with
the last steps of the task
Setting up a chart and
providing social attention
and back-up rewards
contingent on the absence
of a problem behaviour
or the presence
of an appropriate behaviour
Using instructions, questions,
and prompts to divert a child
who may soon misbehave
to another activity
Negotiating in advance a
set of fair, specific and
enforceable rules
Using directed
discussion for
rule breaking
The identification and
rehearsal of the correct
behaviour following
rule breaking
Using planned
ignoring for
minor problem
behaviour
The withdrawal of attention
while the problem behaviour
continues
Giving clear, calm
instructions
Giving a specific instruction to
start a new task, or to stop a
problem behaviour and start
a correct alternative behaviour
Teaching children to
communicate what
they want
Teaching a functionally
equivalent way of
making needs known or met
Applications
Promoting language,
problem solving, cognitive
ability, independent play
Teaching self-care skills
(e.g., brushing teeth,
making bed) and other
new skills (e.g., tidying up)
As above
Encouraging children for
appropriate behaviour
(e.g., playing cooperatively,
asking nicely) and for
the absence of problem
behaviour (e.g., tantrums,
swearing, hitting)
To prevent problem
behaviours (e.g., self-injurious
behaviour, damaging property,
running away)
Clarifying expectations
(e.g., for watching TV,
shopping trips, visiting
relatives, going out in
the car)
Correcting occasional
rule breaking (e.g., leaving
school bag on floor in
kitchen, running through
the house)
Ignoring attention seeking
behaviour (e.g., answering
back, protesting after a
consequence, whining,
pulling faces)
Initiating an activity (e.g.,
getting ready to go out,
coming to the dinner table),
or terminating a problem
behaviour (e.g., fighting over
toys, pulling hair) and saying
what to do instead (e.g., share,
keep your hands to yourself)
Dealing with noncompliance,
temper outbursts, self-injurious
behaviour, pica.
276
Sanders, Mazzucchelli & Studman
Table 2. (Continued)
Strategy
Backing up
instructions
with logical
consequences
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Blocking
Description
The provision of a specific
consequence which involves
the removal of an activity or
privilege from the child or the
child from an activity for a
set time
Catching or blocking hands, legs
to prevent the completion of a
behaviour
Using brief
interruption
Having a child sit quietly where a
problem has occurred for a set
time
Using quiet time
for misbehaviour
Removing a child from an activity
in which a problem has occurred
and having them sit on the edge
of the activity for a set time
The removal of a child to an area
away from others for a set time
Using time-out for
serious misbehaviour
Planned activities
Providing engaging activities in
specific high-risk situations
Applications
Dealing with noncompliance,
mild problem behaviours that
do not occur often (e.g., not
taking turns)
Dealing with dangerous
behaviour (e.g., reaching
for an iron, running out
onto the road, attempting to
hit themself) or terminating a
problem behaviour (e.g.,
hitting another person)
Dealing with self-injurious
behaviour, repetitive behaviour,
or struggling during physical
guidance
Dealing with noncompliance,
children repeating a problem
behaviour after a logical
consequence
Dealing with children not
sitting quietly in quiet time,
temper outbursts, serious
misbehaviour (e.g., hurting
others)
To prevent out-of-home
disruptions (e.g., on
shopping trips, visiting,
travelling in a car, bus,
train)
plan went and deciding upon modifications to the plan and goals for next time. At first
parents are encouraged to structure practice-sessions involving easy goals and more
supports for their child. This increases the chances that children will experience the
rewards that come with appropriate behaviour. Over subsequent practice sessions, goals
can gradually be lifted and supports faded. In this way, planned activities routines can
resemble an errorless learning procedure.
For many families, additional family-centred goals may be needed. Family members
who are exhausted from caregiving may need respite care services. Parents experiencing
intrusive negative thoughts or stress-related headaches may benefit from learning
relaxation and coping skills. Some parents may require advocacy skills that can help
them improve their child’s education or gain access to family support services. Parents
whose relationships are strained may benefit from positive communication and other
partner support skills. In each of these examples, family-centred goals and interventions
focus on teaching individual family members new skills, extending resources and social
supports, and strengthening the family system. Additional family-centred goals aim to
Stepping Stones Triple P
277
help parents and other family members become more capable of supporting the child and
contributing to a balanced, meaningful, and fulfilling life at home and in the community.
Distinguishing features
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SSTP is a child and family centred intervention. A number of its features are described
below.
Program sufficiency. This concept refers to the notion that parents differ according
to the strength of intervention they may require to enable them to independently
manage a problem. SSTP aims to provide the minimally sufficient level of support
parents require. For example, many parents want simple practical advice about how
to tackle a specific developmental issue or problem behaviour (e.g., toilet training,
noncompliance, aggression). For many parents, Level 1 or 2 SSTP (which provide
parenting advice, parenting tip sheets and/or video programs demonstrating skills)
may constitute a sufficient intervention. Parents with multiple child behaviour problems across several settings may require a more intensive broad based intervention
(Level 4). Other parents with multiple difficulties across both child and adult domains
(e.g., severe challenging behaviour in the context of parental depression and relationship conflict) may require more intensive intervention. The Level 5 program provides
intervention for additional family risk factors, such as relationship conflict, mood disturbance and high levels of stress. Potentially effective programs vary in complexity,
including strength, intensity and scope of the intervention, the setting in which it
takes place, who delivers the intervention, and the cost of delivery. The aim is to
offer the most cost-effective program that is accessible by the largest number of atrisk families.
Flexible tailoring to address identified risk and protective factors. Within each level of
intervention, considerable tailoring of the program to parents’ particular circumstances is possible to enable specific risk and protective factors to be addressed.
Indeed, even though the intervention is structured, considerable practitioner ingenuity
is required to adapt the program to parents’ unique goals and family circumstances.
Knowledge of parent goals for the child and family, family strengths, available
resources and social supports, sources of stress, and daily routines in the home and
community are all helpful in tailoring the program to the needs of each individual
family.
Varied delivery modalities. Several of the levels of intervention in SSTP can be delivered in a variety of formats, including face-to-face, group, telephone-assisted or selfdirected programs, or a combination of modalities. This flexibility enables parents to
participate in ways that suit their individual circumstances. It also facilitates participation from families in rural and remote areas who typically have less access to professional services.
Wide potential reach. SSTP is designed to be implemented as an entire integrated
system for all families who have a child with a disability. However, the multi-level
nature of the program enables various combinations of the intervention levels and
278
Sanders, Mazzucchelli & Studman
modalities within levels to be used flexibly. This may be done as either universal,
selective or indicated prevention or targeted early intervention strategies depending on
local priorities, staffing and budget constraints.
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Multidisciplinary approach. Many different professional groups provide support and
advice to parents. SSTP was developed as a professional resource that can be used
by a range of helping professionals. These professionals include childcare providers,
community nurses, family doctors, occupational therapists, paediatricians, physiotherapists, psychiatrists, psychologists, social workers, speech pathologists, and teachers. At a community level, rigid professional boundaries are discouraged and
emphasis is placed on providing training and support to a variety of professionals to
become more effective in their parent consultation skills.
Training for generalisation of parenting skills. A key focus of all SSTP interventions
is to train parents to generalise the parenting skills developed throughout the program to new problems, situations and to all relevant siblings. There are five strategies
employed to promote generalisation of skills. (1) A guided participation model of information transfer is used to discuss assessment information with parents and to develop
a shared understanding of the problem and possible contributing factors. This model
involves providing descriptive, factual information and opportunities for parents to
process and react to the practitioner’s inferences and reasoning. The sharing of this
reasoning provides a model for parents to examine causal inferences they make about
their child’s behaviour (Sanders & Lawton, 1993). (2) A self-regulation approach
is used to promote parents’ independence, confidence and future problem solving.
Parents are taught skills to modify their own behaviour. These skills include selecting
goals for their child or themselves, monitoring their child’s or their own behaviour,
considering the function of problem behaviour, choosing and implementing an appropriate method of intervention, and self-monitoring implementation. Parents are
encouraged to identify strengths or limitations in their performance and set future
goals. (3) A sufficient exemplar approach is used to teach parenting skills. This
involves selecting one behaviour problem (e.g., disobedience) to teach parents new
skills. Additional exemplars are then introduced (e.g., hurting others) until the parent
can apply their skills to behaviours for which they have not received specific instruction. (4) Training is conducted ‘‘loosely’’. This involves varying the stimulus context
for training. Diverse examples are used to illustrate the application of parenting skills
to parenting situations. The aim is to help parents apply their skills to varied and
novel situations rather than learning to apply specific management skills in a specific
situation. (5) In Enhanced Triple P, personal coping skills and partner support skills
are incorporated to support the generalisation and maintenance of parenting skills.
Evidence base for Stepping Stones
Several studies have shown that the parent training methods employed in SSTP are
successful in reducing disruptive behaviour in children with disabilities. Sanders and
Plant (1989) delivered a parenting program to parents of pre-school children with
developmental disabilities and behaviour problems. They were interested in whether such
a training program would result in generalised effects to high- and low-risk situations
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Stepping Stones Triple P
279
that were not specifically targeted by the intervention. Five families participated in the
research. Three of the intervention families successfully implemented behaviour
management strategies across multiple target and generalisation settings and experienced
corresponding decreases in child problem behaviour. A control family only demonstrated
reductions in child problem behaviour in the training setting.
Harrold et al. (1992) delivered Contingency Management Training (CMT) and
Planned Activities Training (PAT) to four mothers of pre-school children with significant
developmental delay and disruptive behaviour. Two families received PAT first, followed
by CMT, and two received the interventions in the reverse order. The order of
intervention delivery did not appear to effect efficacy. Both pairs of mother-child dyads
demonstrated improvements in a variety of parenting skills. Children demonstrated more
on-task behaviour, less crying, and less aggressive behaviour. The four mothers who
participated in this study reported high levels of satisfaction with the interventions, with
PAT being slightly preferred over CMT.
Huynen, Lutzker, Bigelow, Touchette, and Campbell (1996) investigated the
effectiveness of PAT alone using a multiple probe design with four mothers. All
mothers gave clearer instructions after the intervention and more than doubled their use
of PAT. In addition, the children demonstrated more compliance and on-task behaviours
following intervention. Observational data registered an increase in the amount of
positive parent-child interaction during community activities. Generalisation of effects
across home and community settings was demonstrated by both mothers and children.
The authors suggested that the generalisation was successful because mothers were
trained in general skills, training was delivered using sufficient examples, and the training
incorporated naturally occurring contingencies for both mothers and children with a
focus on increasing positive affectionate interactions (Lutzker & Steed, 1998).
Roberts et al. (2002) reported on a randomised, controlled trial of SSTP involving 48
pre-school children with a disability (e.g., cerebral palsy, Down syndrome, non-specified
developmental delay) and clinically significant rates of problem behaviour. The 44
families involved in the study were also experiencing additional adversity factors such as
relationship conflict and high levels of parental stress and depression. Twenty-seven
children received the SSTP intervention and 21 were allocated to a waitlist control group
where they received their usual early intervention services. Level 4 Standard interventions
(and Level 5 Enhanced interventions, if indicated) were conducted on an individual basis
either within family homes or in a clinic situation as parents preferred. Mothers who
participated in the intervention reported significant decreases in child behaviour
problems, in dysfunctional parenting behaviours (particularly lax and verbose
disciplinary styles), and decreases in parental stress. They also reported an increase in
relationship satisfaction. Control group mothers’ ratings of child behaviour remained
stable from pre- to post-test, with significant decreases in child behaviour problems from
post-test to 6-month follow-up. This indicates that the positive impact of the intervention
was replicated for this group after the waitlist period. Further, independent observations
indicated that intervention families successfully implemented behaviour management
strategies across multiple target and generalisation settings. These settings included
independent play while mother was busy; mealtime and bedtime disruptions; toileting;
and shopping. Significant reductions in oppositional behaviour between pre-test and
post-test that were maintained to 6-month-follow-up were reported for intervention
families. Independent observations showed no significant time effects for the control
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Sanders, Mazzucchelli & Studman
group regarding improvements in parenting practices or child behaviours. Parents also
reported that they found the intervention to be socially valid and highly acceptable.
Sanders et al. (2002) also reported on a randomised controlled trial of SSTP involving
78 families of pre-school children with a disability. This study sought to determine
whether the effects of the standard SSTP program would be enhanced with a targeted
intervention addressing caregiver stress. Children had a variety of disabilities including
cerebral palsy, autistic spectrum disorders, Down syndrome, and other chromosomal
abnormalities. Families were randomly allocated to receive either the standard 10-session
SSTP intervention or the same intervention which was then enhanced by a 6-session
module aimed at reducing stress associated with the caregiving role. The results showed
that the intervention reduced parent reports of difficult child behaviour and that this
change was better maintained for families who received the enhanced module. However,
both interventions were associated with changes in parent sense of effectiveness,
parenting style (laxness and verbosity), and improved parental adjustment.
These trials provide evidence concerning the efficacy of SSTP when delivered as an
individually administered program. Future research is needed to examine whether group
or self-directed formats are effective, whether intervention effects generalise to school
settings, and to identify variables that may function as mediators (e.g., changes in
parental self-efficacy, changes in caregiver burden, depression, social support) or
moderators (e.g., level of disability, age, severity of behaviour problems) of intervention
effects.
Issues in program dissemination: from trials to clinical practice
Although the results from clinical trials have been encouraging, there are several major
issues which must be addressed if behavioural family intervention programs are to be
effectively disseminated. SSTP has been primarily delivered by psychologists. However,
there simply are not the human resources available to deliver the services on the scale
required. Many other professionals are already involved in delivering interventions to
families who have a child with a disability. SSTP is designed for use by a variety of
health, education and welfare professionals who counsel parents.
Specialists delivering enhanced SSTP interventions should have sound knowledge of
child development, disability, family, and psychopathology; have skills in the application
of social learning principles to child behaviour problems; and have experience in the use
of cognitive behavioural techniques in individual and couples programs for adults. The
program employs an active skills training approach for which comprehensive training
and ongoing supervision of practitioners using the program is strongly recommended. To
be an accredited provider, completion of a structured SSTP training program is required.
This training includes detailed instruction in the theoretical and conceptual basis of the
program, techniques of behaviour change, and practical instruction in the management
of therapeutic process issues that arise in working with families.
Managerial commitment to SSTP strongly influences the fidelity of implementation
and the effectiveness of the program. Staff require high-level training and supervision to
develop the necessary background knowledge and skills required to deliver SSTP
effectively. Guidance and specific agency protocols regarding client/family screening;
allocation of cases to specific program levels or interventions; and clinical decision rules
for referral to child mental health staff such as clinical psychologists for more intensive
intervention; need to be established.
Stepping Stones Triple P
281
As the therapeutic context for much SSTP work is likely to be in brief consultations,
high quality self-help materials must form the basis of the program. Ongoing research
will be essential to gauge the effectiveness of SSTP interventions delivered by primary
health care staff in universal, community-wide programs. Further independent
evaluation and replication across sites would be valuable and will provide the essential
strong evidence-base for the ongoing development of resource materials such as
information sheets for parents; primary-care practitioner and parent resources; group
program manuals and workbooks; and further specified modules of indicated
interventions.
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Conclusion
SSTP involves the application of a self-regulation framework to an active skills-based
approach to train parents to change parenting behaviours and practices. It utilises high
quality resources and materials to provide models and examples of how 27 different
parenting skills can be applied to a diverse range of problem behaviours and situations.
The approach aims to build the skills and competencies of both parents and through
them their children to deal with common everyday situations. The program has been
evaluated in two randomised controlled trials that have demonstrated the value of the
approach in reducing behavioural problems in children. Further research examining the
social acceptability of the various parenting strategies used in SSTP is being undertaken,
as is research to examine the effects of the program when delivered on a group basis.
Acknowledgements
The authors thank Lee Shew-Lee for her management of the Perth SSTP project and
Clare Roberts for her management of the evaluation of the Perth SSTP individual trial.
We also thank Healthway Western Australia for part funding of the Perth SSTP
individual trial.
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