The Evidence Portal

Parents Under Pressure

About the program

The Parents Under Pressure (PUP) program is an intensive, home-based intervention designed to reduce potential for child-abuse among methadone-maintained parents. It combines methods for improving parental mood and parenting skills.

The PUP program targets multiple domains of family functioning:

  • the psychological functioning of individuals in the family
  • parent–child relationships
  • social contextual factors (i.e. the society the parents live in and how that influences their parental decision making)

The PUP program is multifaceted, with a focus on developing parents’ confidence in their parenting skills through the use of mindfulness-based strategies. This novel feature of the program helps parents manage emotional dysregulation during child-focused play and managing difficult child behavior. This is because poor parenting skills is associated with poor child outcomes and child maltreatment in substance-misusing families (Suchman & Luthar, 2000).

Who does it work for?

The PUP program is aimed at parents who are on methadone maintenance and have children aged between 2 and 8 years old.

The PUP program has been evaluated in Australia (Dawe & Harnett, 2007).

A randomised control trial was conducted with 53 people (20 in the intervention group and 33 in two control groups). On average parents were 30 years old, and children were 4 years old. Most parents were receiving government welfare as their primary source of income.

The program has not been evaluated with Aboriginal Australians.              

What outcomes does it contribute to?

Positive outcomes:

  • Child abuse potential: there are significant reductions in child abuse potential in parents who completed the PUP program, compared to parents who only received standard treatment (Dawe & Harnett, 2007).
  • Parenting stress: there are significant reductions in perceived stress in the parenting role from parents who completed the PUP program, compared to parents who only received standard treatment (Dawe & Harnett, 2007).

No effects:

  • Parent’s substance use: there are no significant effects in a parent’s methadone use (Dawe & Harnett, 2007).

Negative outcomes:

  • No negative effects were found.

How effective is it?

Overall, the Parents Under Pressure program has mixed effects on client outcomes.

How strong is the evidence?

Mixed research evidence (with no adverse effects):

  • At least one high-quality randomised controlled trial (RCT) or quasi-experimental design (QED) study reports statistically significant positive effects for at least one outcome, AND
  • An equal number or more RCT or QED studies of similar size and quality show no observed effects than show statistically significant positive effects, AND
  • No RCT or QED studies show statistically significant adverse effects.

How is it implemented?

The PUP program is conducted on a one-to-one basis, preferably in the family’s home. Sessions generally last 1-2 hours. The program is comprised of 12 modules, although using up to 10 has been shown to be effective (Dawe & Harnett, 2007). A therapist manual provides a theoretical overview, and a parent’s workbook is given to the family and forms the basis of the treatment program.

Modules contain many different exercises that help parents work towards their own parenting goals:

  • Module 1: Starting the PUP Journey – an initial assessment designed to assist parents in understanding the problems they face and how these affect parenting.
  • Module 2: Planning my PUP Journey – feedback on the assessment, shared goals to work towards, and developing ways of monitoring progress towards those goals.
  • Module 3: View of Self as a Parent - aims to strengthen the parent’s view that they are competent in the parenting role.
  • Module 4: Connecting With Your Child to Help Them Feel Loved and Safe – aimed at promoting a positive parent-child relationship.
  • Module 5: Understanding What May Happen When Children are Exposed to Trauma or Loss – focusses on the impact trauma may have on a child
  • Module 6: Health Check Your Child – designed to open up discussions on health, hygiene and nutrition
  • Module 7: How to Manage Emotions when under Pressure: Increasing Mindful Awareness – teach and encourage the use of emotional regulation and self-soothing skills.
  • Module 8: Supporting Your Child to Develop Self-Regulation – aimed at providing strategies to improve child self-regulation.
  • Module 9: Managing Substance Problems – ensures parents are not at risk of developing substance abuse problems, such as drinking too much alcohol.
  • Module 10: Connecting with Family, Community, Culture – connecting with community and receiving support from social networks.
  • Module 11: Life Skills – teaching practical life skills where they don’t currently exist, eg. Budgeting, nutrition, health care, obtaining housing.
  • Module 12: Relationships – addresses issues around communication skills in inter-parental relationships.

How much does it cost?

Not reported

What else should I consider?

The RCT was conducted using an older version of the PUP program that only contained 10 modules. This has been updated in recent years. Please see the PUP website for the most up-to-date information on the program:

Treatment is conducted by clinicians with professional qualifications and experience in treating complex families. Therapists should be trained in the use of the PUP treatment manuals and accompanying parent workbook.

Where does the evidence come from?

One RCT conducted in Australia, with 53 participants (Dawe & Harnett, 2007).

Further resources

The PUP program website:

Dawe, S & Harnett, P (2007), Reducing potential for child abuse among methadone-maintained parents: Results from a randomized controlled trial. Journal of Substance Abuse Treatment, Vol. 32, No. 4, pp.  381-390.

Last updated:

16 Feb 2023

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