Welcome to parent college

The woman was young and thin, with shiny long hair and a European accent. Sitting in a parenting class at the San Francisco Child Abuse Prevention Center last fall, she described what she had done to her son recently.

The scene would be familiar to many parents: She picked up her 6-year-old after school. The boy wanted to keep playing, so he started crying and yelling and pretending to hit her. She took him home and began preparing a snack. He went to the bathroom and, afterward, demanded his mom pull up his pants for him. She told him to do it himself. He refused and wandered about the house, trousers around his ankles.

“I reminded him about two times,” she recalled to her parenting classmates. “‘Please pull up your pants.’”

Instead, he grabbed a full gallon of milk from the fridge and clumsily toted it to the kitchen table.

What did he think he was doing? She snapped. She yelled, and he startled. He dropped the milk on the floor, where it exploded and seeped into the thick carpet. “Sorry! sorry! sorry!” the boy cried, in the way kids do when they’re searching for a real-life undo button.

She fought the urge to yell again. Controlling her temper had been one of her goals in the class. The milk took two hours to clean, yes. But she realized the mess was both their faults.

“He’s scared of me,” she told the group.

Molly Jardiniano, the class instructor, reassured the woman. “I like how you caught yourself, you realized the emotions going on there,” she said. Later in the class, she explained how the boy was just misbehaving for attention. “For him it's like, ‘I can make a connection. She's constantly going to talk to me because my pants are down.’”

The class included parents who had been suspected of child abuse as well as those who were simply at the ends of their ropes. This particular mother had come voluntarily for help dealing with anger.

Cracking open a workbook, Jardiniano explained how parents could avoid similar meltdowns. “If you want the behavior that makes you happy, you've got to praise it. I want you to track your praising. P-R-A-I-S-E. Praise your child.”

Praising is a core tenet of Triple P, the Positive Parenting Program, which is the curriculum behind the parenting class at the San Francisco center. Triple P is a prominent player in a little-explored corner of the healthcare realm: Programs that aim to teach parents how to be parents.

For most of human history, parents have relied on tradition and ancestral wisdom for parenting help. A major shift came in 1946, when a pediatrician named Benjamin Spock published The Common Sense Book of Baby and Child Care, a bestseller that urged a permissive, individualistic approach to child-rearing. Before long, many experts turned to better parenting as a way to soothe domestic conflict and even cure social ills. Classes like Triple P have proliferated in recent decades, and now, more than a dozen programs strive to curb child abuse through good parenting.

Many of these programs target frustrated or isolated parents who haven’t laid a finger on their kids. But others are geared toward parents who are already suspected of abuse, as well as those who are “at risk” of abusing. Social workers would rather keep kids with their parents if it’s reasonably safe to do so. If a mildly abusive parent can be reformed, his child is less likely to enter foster care.

The driving philosophy is that parenting is not necessarily intuitive. You have to pass a test to drive a car or represent someone before a judge, but not to do something as important as raising a child. “Parenting doesn't come naturally to everyone,” Jardiniano told me in an interview. “And parents feel shame … if it doesn't.”

States’ social-welfare agencies can choose from several different parenting programs. SafeCare, a program developed by John Lutzker, a public health professor at Georgia State University, sends visitors to help parents in their homes. In Child-Parent Psychotherapy, a clinician with a master’s degree or higher might help parents instill rituals. (Therapists might suggest moms smooth out their mornings by setting a bowl of cereal on the table the night before, for example.) Other programs help parents play with their kids. When I visited one such initiative in the Bay Area, Family Connections, some 20 toddlers sat playing and making crafts at squat tables with their parents alongside them.

Triple P’s advantage is scale: Facilitators preach its gospel of firm, yet calm, parenting across 25 countries. It’s designed so it can be delivered to entire cities at once. It’s for kids of all ages, not just toddlers, and its practitioners don’t need to be social workers or nurses—with training, even clergy or police officers can administer parts of the curriculum.

Most of these programs are supported by studies showing they reduce child maltreatment rates by at least some amount. They are “evidence-based,” to use a favorite term of the social-intervention crowd. In Triple P’s case, the most compelling support came in the form of a large experiment performed some 10 years ago across South Carolina, which appeared to show that the program greatly improved the child-rearing techniques of the parents who were exposed to it.

Since then, thousands of parents have been helped by Triple P. But recently, critics have called some of the evidence behind Triple P into question, and some have recommended that cities using the program abandon it. Some critics cite flaws in the studies that measured the supposed positive effects of Triple P. Their concerns raise an important question: Can good parenting be taught to wayward parents in the same way that calculus is to undergrads?

The way you’re raised affects your personality, your work, and your health for the rest of your life. Abusive childhoods are linked to an array of health issues, from depression to stroke to a shortened lifespan. Even a relatively mundane form of poor parenting, emotional neglect, has been shown to compromise a person’s ability to experience enthusiasm or pleasure—potentially for life. At the very worst end of the spectrum, child abuse and neglect kill about 1,500 kids each year.

Abused children arrive at school with broken bones, head injuries, bruises, and cigarette marks. Whether spanking counts depends on the state, but even some of the most conservative states have decreed that if a beating causes injury, it’s abuse. In one telephone survey of parents with at least one child under age eight, 10 percent self-reported that they spanked their kids with an object frequently or very frequently.

All this crappy parenting is costly. Research from the Perryman Group, a financial analysis firm, has found that each case of child maltreatment eventually costs society $1.8 million over the victim’s life-span because she is far more likely to need rehab, have a teen pregnancy, and drop out of high school.

When parents are repeatedly and severely hurting their children, or sexually abusing them, child-protection workers whisk them out of their parents’ custody. But mild or unproven abuse cases are harder for agencies to handle, and they rarely result in a child’s removal. The front-page reports of kids made to run or drink water or sleep outside until they die, are, thankfully, quite rare. More often, experts say, abuse happens when discipline escalates.

Foster care isn’t a perfect solution, either. “Most children who are abused go through the foster care system, which is horrible,” said Robert Block, past president of the American Academy of Pediatrics. “It doesn't allow them time to establish new connections because they don't stay in foster homes for very long.”

Increasingly, child-welfare agencies are placing parents involved in poorly substantiated abuse and neglect cases through a process known as “alternative response.” Rather than have abuse or neglect charges filed against them in court, these parents can jump through a series of hoops to prove they can parent. Often, one of these hoops is a parenting class. According to ​a CDC study, 65 percent of parents who go through a program like this do better than controls.

Triple P is one of the most widespread and most-studied of these interventions. It began as a home-visiting program that was developed in 1982 at the University of Queensland, Australia, by the psychologist Matthew Sanders and his colleagues. With an eye toward broad dissemination and cost savings, they soon added phone consultations, class-like sessions, and mass media campaigns. “You know how vast Australia is,” Sanders told the New York Times in 2013. “Our question was how do we ensure that all families, regardless of where they lived, could access good quality evidence-based parenting interventions.”

Agencies that use Triple P can deploy it at five different levels of intensity. In its most basic form, it consists of mass-media messages about good parenting. In the middle levels, parents take a series of seminars on good parenting, and at the highest, the seminars are combined with one-on-one consultations with trainers.

“I think highly of it,” said Anthony Biglan, a senior scientist at the Oregon Research Institute who has studied such interventions. He said he likes that it’s designed to reach everyone. “You don't have to wear a hair shirt to get help.”

According to Triple P, parents should praise good behavior, even on an otherwise terrible-behavior day. Small annoyances, like making faces or repeating a word, should simply be ignored. The last resort is time-out. Parents should be precise in what they say. The program’s parent workbook advises, “Children may not follow instructions that do not clearly tell them what to do — Denise! or Don’t be silly.” Reading Triple P’s materials, you’d be forgiven for thinking kids are like tiny labradors, eager to please and easily trained.

Not every parent swallows this advice easily, Jardiniano said. Most people parent however they were raised, even if they now take a dim view of their own upbringings. (Block, an outspoken opponent of spanking, says parents often tell him, “‘Well I was spanked, and look at me,’” he says. “And I want to say, ‘Yeah, look at you.’”)

Even parents who vow not to repeat their own parents’ mistakes will likely succumb, when stressed and sleep-deprived, to whatever feels instinctive. And there’s a yawning gap between insufficient praising and criminal child abuse. Because of that, the parenting-class instructors have a tricky job: To show parents that, no matter what they’re doing, there’s probably room for improvement.

In January, I visited a Level 4 Triple P class at the Children’s Advocacy Center in Plano, Texas. It was a clean, friendly-looking place hung with inspirational posters. One proclaimed, “I am not afraid of storms, for I have learned how to sail my ship.”

In a suburb with a population of more than a quarter-million, there were three parents in attendance. One of them was Marcus Palmer, a 35-year-old dad with tattooed arms who slumped into a chair, rubbed his face, and yawned.

This particular session was devoted to what some instructors say is parents’ favorite subject: managing misbehavior.

The instructor, Fran Hollingsworth, told the parents to establish some ground rules.

“We respect our elders,” Palmer volunteered. “In my house, it's yes sir and yes ma'am. We don’t say ‘no.’” His biggest headache, he says, is when his 7-year-old refuses to eat dinner.

Hollingsworth asked him what he would do if his daughter rejected a plate of spaghetti.

“Before this class or now?” Palmer said, laughing. Then, more earnestly: “We need to eat all our food so we can take a bath and go to bed.”

Hollingsworth nodded approvingly.

According to Triple P, when kids break a rule, parents should calmly ask them to go back and do things the right way. Hollingsworth played an official Triple P video in which a young boy runs through the kitchen. The Australian actress playing his mother said, “What’s our rule? We walk through the house. Now go back and show me.” The kid complied, wordlessly and with a smile. “Thank you for showing me how we walk through the house,” his mother said.

Then come the nuclear options: “Quiet time,” in which the child is made to sit quietly to the side of the room, and the more severe “time-out,” in which he does the same thing, but in a different room. These are billed by Triple P as “good alternatives to yelling at and smacking your child.”

Hollingsworth asked the parents where they would do a time-out in their homes. Palmer said the kitchen table.

Through a Spanish interpreter, one woman said she wasn’t sure where she’d hold the time-outs. She has a small apartment and three kids, and there aren’t enough rooms to separate them all.

In the instructional video, a boy slammed two blocks together while the actress playing his mother was on the phone. Afterward, she told him, “you're going to stay in quiet time for three minutes.” The mother grabbed the boy by the arm. The boy immediately hopped up and sat down in a chair without complaint.

“Ignore protests!” the video encouraged, as the boy sat motionlessly and without kicking any objects or people around him.

Later, Palmer confided that he thought the sequence was a bit of a stretch. “In a perfect world, that's great,” he said. “But kids I know will say, ‘whatever, mom!’”

The next day, I met up with Palmer at the auto shop where he works. He was in the middle of a messy legal battle with his exes for the right to visit his kids. He said he had taken a second job serving chicken at Wingstop to help pay the court fees and child support. He hoped that completing a parenting class will prove to the judge that he’s a good dad.

His exes lived in different states, and he had seen his 7-year-old daughter only once since 2012, for a 10-day stretch. “Ridiculously hard,” he called the predicament. Palmer and others in the Triple P class had to make “behavior charts” for their kids—posters to fill with stickers for good behavior. Palmer made one and showed it to his daughter when they Skyped. She wasn’t as excited as if she had seen it in person, he said.

He was skeptical of some of the Triple P adages. About kids for whom time out doesn’t work, he said, “if it was 10 years ago, I'd say, they get the belt.” These days, “People are too quick to call CPS. Kids nowadays get away with way too much.”

Still, Palmer said Triple P provides a “good foundation,” and his kids don’t usually require discipline beyond a stern look or losing a privilege. His own parents were violent and absent, and he always wanted to do better. “I wanted to be there and not be physical,” he said.

About a month after we met, Palmer’s ex-girlfriend, who was living in Florida, became homeless. Palmer offered to let her and the couple’s 7-year-old, Madyson, move in with him and his new wife in Texas. By phone, Palmer said he’s been deploying some of the Triple P lessons, like stating things in a positive way— “talk respectfully to adults,” instead of “don’t talk back.”

It’s been only about two weeks, but he says the strategies are working better than expected.

“Are the other adults in the house also using the Triple P tactics?” I asked.

Not yet, he said. “Adults have to be trained, too.”

Of all the parenting interventions out there, many state and local agencies pick Triple P because volumes of studies have proven its success.

In 2003, Sanders, the Australian psychologist who invented Triple P and Ron Prinz, a psychology professor and director of the Parenting and Family Research Center at the University of South Carolina, had a team of professors randomly assign 18 counties in South Carolina to two groups. In one, hundreds of practitioners within the counties were trained to deliver at least the basic level of Triple P to parents. The other counties offered whatever parent services they always had. After two and a half years, the counties with Triple P averaged 33 percent fewer confirmed child abuse cases, 16 percent fewer out-of-home placements for children, and 13 percent fewer hospital-treated child maltreatment injuries than the controls. Further analyses by an independent economist suggested the cost of the Triple P system would be recouped within a single year.

Triple P picked up speed on the winds of those results. Few interventions of this scale can claim the support of a randomized, controlled trial—the gold standard in scientific research. In 2011, it was in 14 states, and it’s now in 36. Triple P America estimates the program has been delivered at more than 300 sites.

But Triple P has also come under fire from several researchers who weren’t connected to its founding. Manuel Eisner, a professor of criminology at the University of Cambridge, published a working paper in 2014 describing seven ways that Sanders and Prinz failed to fully report their data. Most significantly, he argued that a closer reading of the data suggest Triple P didn’t necessarily work the way it’s been touted. According to his analysis, the control counties saw an unusually high increase in maltreatment cases, while treatment counties tracked with the statewide trend in child abuse. Eisner is currently trying to replicate the South Carolina study himself.

Eisner claims that Prinz, a consultant to Triple P International, and Sanders, the program’s developer, may have conflicts of interest. Sanders benefits when Triple P expands because royalty payments from sales of Triple P’s materials are partly distributed to the University of Queensland and the authors of Triple P. Eisner says this type of conflict has been associated with biased reporting in past studies. A meta-analysis of 116 Triple-P related studies published in 2014 found that the program improved both parenting practices and children’s behavior—but that, too, was authored by Sanders. A review paper published by Eisner in the journalPLoS One last year found that of four psychosocial interventions, studies of Triple P had the lowest level of conflict-of-interest disclosure.

Sanders and Prinz deny that their roles have affected the studies, noting Triple P has a plan to carefully monitor conflicts of interest. Sanders further believes that developer-involved research is often an important step in establishing a program’s efficacy.

Eisner argues child abuse is too complex of a problem to be addressed with a short, standardized training. “Families with substantial levels of child maltreatment often have histories of unemployment, mental-health problems, criminal records, and substance use,” he said. “Do we really believe that information sheets and short group seminars can address the needs of these parents and fundamentally alter their behavior?”

Meanwhile, in 2013 James Coyne, a behavioral psychologist at the University of Pennsylvania, publicly argued that many of the Triple P studies had fewer than 35 participants—too few for their results to be considered meaningful. (Prinz points out that in a 2014 Triple P meta-analysis, 40 percent of the studies had samples with at least 35 or more families.)

Prinz stood by his findings in a written statement, saying, “Our population study has gone through multiple stages of scientific review by independent scientists who were not predisposed for or against Triple P.”

In an interview, Prinz also said Eisner has a history of submitting complaint letters to journals. “I think he enjoys playing that role,” he told me. “That’s fine. I’m more interested in the science and how we can help families.” (Eisner disputed that characterization, though he has alerted journals about what he feels are flaws in Triple P studies three times.)

Bradley Thomas, the president of Triple P America, told me that Triple P has more than 218 evaluation papers to date, and, “approximately 45 percent of these evaluations have been conducted independently of program authors.”

But the results of those evaluations are mixed. The city of Glasgow, Scotland, provides an example of what could be interpreted as Triple P’s shortcomings. The city launched a Triple P program in 2010 after Scotland’s chief medical officersuggested chaotic home environments might be contributing to chronic illness in the region.

Emails from the time show that Scotland’s social welfare officials in part justified the program because they thought Triple P was a nonprofit. “Triple P is provided on a non-profit making basis with all surpluses going back to [the] University of Queensland to fund further research,” read an internal document from 2010. However, that assumption was wrong—Triple P International is a private, for-profit company.

Glasgow trained hundreds of Triple P practitioners, who administered the program to more than 30,000 families. But when Philip Wilson, a professor of primary care at the University of Aberdeen in Scotland, measured the program’s effects on annual cohorts of 5,000 children in the city, he found it had little effect. Among the families who started Triple P interventions, more than half dropped out, and dropout rates were especially high among the more troubled families. The social and emotional functioning of the entire city’s kids didn’t change, and the child protection register in Glasgow grew during the period. Wilson recommended that Glasgow discontinue the program, but that was only after the local health service had already spent over 4 million pounds (about $5.8 million) on it.

“The people who needed most help were more likely to drop out,” Wilson said. “Our conclusion was that although the system was set up well in Glasgow, actually, it just didn't work. Everyone wants a solution to child maltreatment. We're all desperate and we'll cling at straws.”

The region’s National Health Service rejected Wilson’s conclusions, saying his data was not robust enough. In a statement, Triple P U.K. countered that emotional functioning did improve among kids whose parents actually completed the intervention, and that Wilson’s was not “a study with a proper controlled design.”

Another independent study that looked at the effect of Triple P on 73 children aged four to nine in Birmingham, in central England, also found no effects—though that study examined the children’s behavior, rather than that of their parents. In 2013, Flanders, Belgium, ceased funding the program after seeing lackluster results.

Triple P is not the only parenting program that seemed to work well in some places but failed elsewhere. In the U.S., a home-visiting program called Nurse-Family Partnership has been considered “proven” to boost the health of mothers and children alike. But a study in the Lancet found that a similar program in the U.K. called Family-Nurse Partnership did basically nothing. Meanwhile, Healthy Families America, a program in which trained paraprofessionals visit disadvantaged mothers, reduced incidence of physical abuse in New York, but not in Alaska or Hawaii.

It might be that these programs simply don’t travel well. Some of the Scottish Triple P practitioners were skeptical that its brochures—designed for sunny, wide-open Australia—made sense for rainy, cramped Glasgow. As one of the Scottish home-visitors wrote on her blog after the fact, “in an inner-city area of … high rise flats, etc, it really got on my wick that I had to hand families a sheet which told them how they must make sure that their children don’t go near the swimming pool in the garden unattended.”

Some parents I interviewed said they found Triple P helpful. Danielle Keath, who took the course in Texas, said she grew up in a family of yellers. That’s how she would respond, too, when her 3-year-old squished food into the carpet purposefully. But with Triple P, she reduced her yelling by 75 percent, by her own measurements. Keath also used to think it was okay to “swat him on the butt,” but she doesn’t do that anymore. “I’ve learned to coping skills to pull myself away,” she said.

Molly Jardiniano administers pre- and post-tests to her participants, too. At the end of this fall’s course, the parents marked an improvement in both their own parenting practices—as measured by things like over-reacting or giving in under pressure—and in their children’s behavior. And in the scheme of things, the intervention is fairly cheap: Each 12-week class series reaches about 10 parents and costs the San Francisco Child Prevention Center about $5,900. That figure includes Jardiniano’s salary, snacks, childcare for the parents, and bus passes.

So does Triple P work? As Katie Albright, the director of the San Francisco center, mused to me when I visited, “How do you prove a negative?” For any given family, is it possible to know whether Triple P was what stopped them from hitting their kids? Unless welfare agencies make Triple P or a similar program mandatory, parents can refuse the intervention. Even when they attend faithfully, no one really knows whether parents put into practice what they learned.

And perhaps there’s only so much that parenting classes can do. In conversations with prosecutors and social workers around the country, I heard repeatedly that child abuse was closely linked to drug use. And several studies have found that, while most children are abused by someone they live with, the perpetrator is often an unrelated adult, not the parent.

Abusive families’ troubles might run deeper than Triple P can penetrate. In January of 2013, Emma Morrison, a one-month-old in Palm Beach County, Florida, died in the night. Her mother, Lisa Lamoureaux, had been the subject of 11 child-abuse or neglect investigations, and she had been referred to Triple P for further help, according to a Miami Herald report. But Lamoureaux declined the classes, saying she wasn’t interested.

The medical examiner thought Emma had been smothered on accident while in bed with her mother. But neighbors heard “a male's voice yelling during the night and early the next day," the Herald wrote, and a "a child crying constantly throughout the night." Lamoureaux had already taken parenting classes. She also had a history of drug use, a seemingly abusive boyfriend, and so little money social workers suspected she was prostituting herself. (Lamoureaux has not been charged in her death.)

Other children have died when left, in a pinch, with a careless family friend or a violent partner. One Texas prosecutor I spoke with said what would help most with child abuse in his area is better access to affordable child care. In 2014, researchers from the CDC and Clemson College looked at 11 different policies that could potentially reduce the incidence of child abuse and neglect. They found two that actually made a difference: Increasing access to subsidized child care and health care for children.

That would be, of course, less an indictment of Triple P than of a deficit of social services in America, which according to some studies has higher rates of child deaths from maltreatment than almost any European country. Maybe being responsible for a fragile, loud, hungry human is just harder here.

If parents are finding Triple P’s tips useful, it would be foolish to discount it just because it hasn’t singlehandedly solved child abuse. But parents would be better able to cheerfully soldier on through whining and tantrums—as Triple P expects them to—if they had affordable childcare, good housing, and enough money for food. Better still if they no untreated drug problems or ghosts of brutish childhoods haunting them. Triple P and its ilk might be doing wonderful things at the top of parents’ Maslowian pyramids. It’s just that the bases are still full of holes.

[This story was originally published by The Atlantic.]