We examined the impact of the implementation of The Triple P-Positive Parenting Program in North Carolina (NC) on reducing child maltreatment, a serious public health problem in the US with lasting harmful effects on children. In 2012 and 2013, 34 of 100 counties in NC implemented Triple P. A panel data set with county-level child welfare data and emergency department (ED) discharge data from 2008 to 2015 for 100 counties in NC was constructed. A quasi-experimental design using difference-in-differences analysis estimated the association between the implementation of Triple P and the rate of (1) investigated child maltreatment reports; (2) entry into foster care; and (3) ED visits concerning for child maltreatment. Implementation of Triple P was associated with in a 4% decrease in the county rate of investigated reports of child maltreatment (RR = 0.96, 95% CI [0.93, 0.99]) and a 7% decrease in the county rate of children in foster care (RR = 0.93, 95% CI [0.88, 0.98]). Each of these findings was robust to one but not both sensitivity tests performed. There was no reduction in county-level rates of ED visits with ICD-9-CM codes concerning for child maltreatment. Implementation of Triple P in NC outside of the parameters of scientific study is associated with small reductions in the rates of child maltreatment reports and foster care placements. Additional research is needed to understand whether such small reductions justify the substantial investment communities are making in Triple P.
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International Classification of Diseaes-9-Clinical Modification
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Aldridge, W. (2016). Ensuring active implementation support for North Carolina counties scaling the triple P system of interventions. FPG Child Development Institute.
Asgary-Eden, V., & Lee, C. M. (2011). So now we've picked an evidence-based program, what's next? Perspectives of service providers and administrators. Professional Psychology: Research and Practice, 42(2), 169–175.
Barlow, K. M., Thomson, E., Johnson, D., & Minns, R. A. (2005). Late neurologic and cognitive sequelae of inflicted traumatic brain injury in infancy. Pediatrics, 116(2), e174–e185.
Bärnighausen, T., Oldenburg, C., Tugwell, P., Bommer, C., Ebert, C., Barreto, M., . . . Rockers, P. (2017). Quasi-experimental study designs series—paper 7: Assessing the assumptions. Journal of Clinical Epidemiology, 89, 53–66.
Belsky, J. (1993). Etiology of child maltreatment: A developmental-ecological analysis. Psychological Bulletin, 114(3), 413–434.
Brown, M. J., Thacker, L. R., & Cohen, S. A. (2013). Association between adverse childhood experiences and diagnosis of cancer. PLoS One, 8(6), e65524.
Cameron, A. C., & Trivedi, P. K. (2005). Microeconomics. Cambridge: Cambridge University Press.
Chaffin, M., & Friedrich, B. (2004). Evidence-based treatments in child abuse and neglect. Children and Youth Services Review, 26(11), 1097–1113.
Chaffin, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., Jackson, S., Lensgraf, J., & Bonner, B. L. (2004). Parent-child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72(3), 500–510.
Chapman, D. P., Whitfield, C. L., Felitti, V. J., Dube, S. R., Edwards, V. J., & Anda, R. F. (2004). Adverse childhood experiences and the risk of depressive disorders in adulthood. Journal of Affective Disorders, 82(2), 217–225.
Cook, T. D., Shadish, W. R., & Wong, V. C. (2008). Three conditions under which experiments and observational studies produce comparable causal estimates: New findings from within-study comparisons. Journal of Policy Analysis and Management, 27(4), 724–750.
Coyne, J. C., & Kwakkenbos, L. (2013). Triple P-positive parenting programs: The folly of basing social policy on underpowered flawed studies. BMC Medicine, 11(1), 11.
de Graaf, I., Speetjens, P., Smit, F., de Wolff, M., & Tavecchio, L. (2008). Effectiveness of the triple P positive parenting program on behavioral problems in children: A meta-analysis. Behavior Modification, 32(5), 714–735.
Dong, M., Dube, S. R., Felitti, V. J., Giles, W. H., & Anda, R. F. (2003). Adverse childhood experiences and self-reported liver disease: New insights into the causal pathway. Archives of Internal Medicine, 163(16), 1949–1956.
Dong, M., Giles, W. H., Felitti, V. J., Dube, S. R., Williams, J. E., Chapman, D. P., & Anda, R. F. (2004). Insights into causal pathways for ischemic heart disease: Adverse childhood experiences study. Circulation, 110(13), 1761–1766.
Dube, S. R., Anda, R. F., Felitti, V. J., Chapman, D. P., Williamson, D. F., & Giles, W. H. (2001). Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: Findings from the adverse childhood experiences study. Jama, 286(24), 3089–3096.
Dube, S. R., Felitti, V. J., Dong, M., Giles, W. H., & Anda, R. F. (2003). The impact of adverse childhood experiences on health problems: Evidence from four birth cohorts dating back to 1900. Preventive Medicine, 37(3), 268–277.
Dube, S. R., Fairweather, D., Pearson, W. S., Felitti, V. J., Anda, R. F., & Croft, J. B. (2009). Cumulative childhood stress and autoimmune diseases in adults. Psychosomatic Medicine, 71(2), 243–250.
Dubowitz, H., & Bennett, S. (2007). Physical abuse and neglect of children. The Lancet, 369(9576), 1891–1899.
Duncan, D. F., Stewart, C. J., Vaughn, J. S, Guest, S., Rose, R. A, Malley, K., & Gwaltney, A. Y. (2018). Management assistance for child welfare, work first, and food & nutrition services in North Carolina (v3.21). University of North Carolina at Chapel Hill Jordan Institute for Families website. URL: http://ssw.unc.edu/ma/. Accessed 2018.
Edwards, V. J., Holden, G. W., Felitti, V. J., & Anda, R. F. (2003). Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the adverse childhood experiences study. American Journal of Psychiatry, 160(8), 1453–1460.
Fang, X., Brown, D. S., Florence, C. S., & Mercy, J. A. (2012). The economic burden of child maltreatment in the United States and implications for prevention. Child Abuse & Neglect, 36(2), 156–165.
Farley, M., & Patsalides, B. M. (2001). Physical symptoms, posttraumatic stress disorder, and healthcare utilization of women with and without childhood physical and sexual abuse. Psychological Reports, 89(3), 595–606.
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., . . . Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258.
Finkelhor, D., Turner, H., Ormrod, R., & Hamby, S. L. (2009). Violence, abuse, and crime exposure in a national sample of children and youth. Pediatrics, 124(5), 1411–1423.
Forgatch, M. S., Patterson, G. R., & DeGarmo, D. S. (2005). Evaluating fidelity: Predictive validity for a measure of competent adherence to the Oregon model of parent management training. Behavior Therapy, 36(1), 3–13.
Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing child abuse and neglect: A technical package for policy, norm, and programmatic activities.
Franey, K. (2001). The cost of child maltreatment: Who pays? We all do: Family Violence & Sexual Assault Institute.
Furlong, M., & McGilloway, S. (2015). Barriers and facilitators to implementing evidence-based parenting programs in disadvantaged settings: A qualitative study. Journal of Child and Family Studies, 24(6), 1809–1818.
Haczku, A., & Panettieri, R. A., Jr. (2010). Social stress and asthma: The role of corticosteroid insensitivity. Journal of Allergy and Clinical Immunology, 125(3), 550–558.
Hussey, J. M., Marshall, J. M., English, D. J., Knight, E. D., Lau, A. S., Dubowitz, H., & Kotch, J. B. (2005). Defining maltreatment according to substantiation: Distinction without a difference? Child Abuse & Neglect, 29(5), 479–492.
Kendall-Tackett, K. (2002). The health effects of childhood abuse: Four pathways by which abuse can influence health. Child Abuse & Neglect, 26(6–7), 715–729.
Kilbourne, A. M., Neumann, M. S., Pincus, H. A., Bauer, M. S., & Stall, R. (2007). Implementing evidence-based interventions in health care: Application of the replicating effective programs framework. Implementation Science, 2(1), 42.
Klevens, J., Barnett, S. B. L., Florence, C., & Moore, D. (2015). Exploring policies for the reduction of child physical abuse and neglect. Child Abuse & Neglect, 40, 1–11.
Lansford, J. E., Dodge, K. A., Pettit, G. S., Bates, J. E., Crozier, J., & Kaplow, J. (2002). A 12-year prospective study of the long-term effects of early child physical maltreatment on psychological, behavioral, and academic problems in adolescence. Archives of Pediatrics & Adolescent Medicine, 156(8), 824–830.
MacMillan, H. L., Wathen, C. N., Barlow, J., Fergusson, D. M., Leventhal, J. M., & Taussig, H. N. (2009). Interventions to prevent child maltreatment and associated impairment. The Lancet, 373(9659), 250–266.
Marryat, L., Thompson, L., & Wilson, P. (2017). No evidence of whole population mental health impact of the triple P parenting programme: Findings from a routine dataset. BMC Pediatrics, 17(1), 40.
Mora, R., & Reggio, I. (2012). Treatment effect identification using alternative parallel assumptions.
National Research Council, & Panel on Research on Child Abuse and Neglect. (1993). Understanding child abuse and neglect. DC: Washington.
Noel, P. E. (2006). The impact of therapeutic case management on participation in adolescent substance abuse treatment. The American Journal of Drug and Alcohol Abuse, 32(3), 311–327.
North Carolina Institute of Medicine. (2018). North Carolina county health profiles. Retrieved from http://nciom.org/map/. Accessed 2018.
Nowak, C., & Heinrichs, N. (2008). A comprehensive meta-analysis of triple P-positive parenting program using hierarchical linear modeling: Effectiveness and moderating variables. Clinical Child and Family Psychology Review, 11(3), 114–144.
Oates, R. K., Davis, A. A., & Ryan, M. G. (1980). Predictive factors for child abuse. Journal of Paediatrics and Child Health, 16(4), 239–243. https://doi.org/10.1111/j.1440-1754.1980.tb01306.x.
Perrin, E. C., Leslie, L. K., & Boat, T. (2016). Parenting as primary prevention. JAMA pediatrics.
Peterson, C., Florence, C., & Klevens, J. (2018). The economic burden of child maltreatment in the United States, 2015. Child Abuse & Neglect, 86, 178–183.
Prinz, R. J., & Sanders, M. (2006). Testing effects on parenting at a broad scale: The US triple P system population trial.
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The US triple P system population trial. Prevention Science, 10(1), 1–12.
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2016). Addendum to “population-based prevention of child maltreatment: The US triple P system population trial”. Prevention Science, 17(3), 410–416.
Raghavan, R., Brown, D. S., Allaire, B. T., Garfield, L. D., Ross, R. E., & Hedeker, D. (2015). Challenges in using Medicaid claims to ascertain child maltreatment. Child Maltreatment, 20(2), 83–91.
Roberts, M. R., & Whited, T. M. (2012). Endogeneity in empirical corporate finance.
Sanders, M. R., Ralph, A., Sofronoff, K., Gardiner, P., Thompson, R., Dwyer, S., & Bidwell, K. (2008). Every family: A population approach to reducing behavioral and emotional problems in children making the transition to school. The Journal of Primary Prevention, 29(3), 197–222.
Sanders, M. R., Kirby, J. N., Tellegen, C. L., & Day, J. J. (2014). The triple P-positive parenting program: A systematic review and meta-analysis of a multi-level system of parenting support. Clinical Psychology Review, 34(4), 337–357.
Schnitzer, P. G., Slusher, P. L., Kruse, R. L., & Tarleton, M. M. (2011). Identification of ICD codes suggestive of child maltreatment. Child Abuse & Neglect, 35(1), 3–17.
Sedlak, A. J., Mettenburg, J., Basena, M., Petta, I., McPherson, K., Greene, A., & Li, S. (2010). Fourth National Incidence Study of child abuse and neglect (NIS–4): report to congress, executive summary. Washington, DC: US Department of Health and Human Services, Administration for Children and Families..
Shields, A., & Cicchetti, D. (1998). Reactive aggression among maltreated children: The contributions of attention and emotion dysregulation. Journal of Clinical Child Psychology, 27(4), 381–395.
Shonkoff, J. P., Garner, A. S., Siegel, B. S., Dobbins, M. I., Earls, M. F., McGuinn, L., . . . Care, D. (2012a). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.
Shonkoff, J. P., Richter, L., van der Gaag, J., & Bhutta, Z. A. (2012b). An integrated scientific framework for child survival and early childhood development. Pediatrics, 129(2), e460–e472.
Thomas, R., & Zimmer-Gembeck, M. J. (2007). Behavioral outcomes of parent-child interaction therapy and triple P—Positive parenting program: A review and meta-analysis. Journal of Abnormal Child Psychology, 35(3), 475–495.
Thomas, R. E., Baker, P. R., & Lorenzetti, D. (2007). Family-based programmes for preventing smoking by children and adolescents. Cochrane Database of Systematic Reviews, 1.
US Department of Health and Human Services. (2018). Administration for children and families, administration on children, youth and families, children’s bureau. Child Maltreatment 2016. Retrieved from https://www.acf.hhs.gov/cb/resource/child-maltreatment-2018. Accessed 2018.
van Breukelen, G. J. (2013). ANCOVA versus CHANGE from baseline in nonrandomized studies: The difference. Multivariate Behavioral Research, 48(6), 895–922.
Widom, C. S. (1989). Child abuse, neglect, and adult behavior: Research design and findings on criminality, violence, and child abuse. American Journal of Orthopsychiatry, 59(3), 355–367.
Wilson, P., Rush, R., Hussey, S., Puckering, C., Sim, F., Allely, C. S., Doku, P., McConnachie, A., & Gillberg, C. (2012). How evidence-based is an'evidence-based parenting program'? A PRISMA systematic review and meta-analysis of triple P. BMC Medicine, 10(1), 130.
Conflicts of Interest
The project was supported by the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, through Grant Award Number UL1TR001111 and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant KL2TR001109. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The NC DETECT Data Oversight Committees do not take responsibility for the scientific validity or accuracy of methodology, statistical analyses, results, or conclusions presented.
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Schilling, S., Lanier, P., Rose, R.A. et al. A Quasi-Experimental Effectiveness Study of Triple P on Child Maltreatment. J Fam Viol 35, 373–383 (2020). https://doi.org/10.1007/s10896-019-00043-5
- Child maltreatment prevention
- Parenting intervention
- Triple P