6

Preventing Child Maltreatment

Key Points Raised by Individual Speakers

•  Universal prevention efforts, especially when focused on new parents, provide evidence of altering parental behaviors and improving outcomes. These positive impacts from early intervention programs are inconsistent across models and populations.

•  Home visits targeted at mothers with depression can reduce child maltreatment and the transmissions of those behaviors across generations.

•  Brief, focused interventions can substantially reduce child maltreatment recurrence rates compared with more typical and higher dose parenting programs.

•  A variety of child maltreatment evidence-based prevention models are now available for dissemination, implementation, and evaluation in community settings.

Because child maltreatment has many causes, different types of efforts are made to prevent it. Speakers at the workshop session on prevention discussed primary interventions for all families, secondary interventions for targeted families (e.g., those that experience mental health disorders or substance use problems), and tertiary interventions to prevent recurrence of child maltreatment and chronic neglect. In all three of these areas, many programs are becoming more focused and targeted on specific behaviors. This trend holds out promise that interventions could be briefer, more structured, and more responsive to outcomes, said several speakers.



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6 Preventing Child Maltreatment Key Points Raised by Individual Speakers  Universal prevention efforts, especially when focused on new par- ents, provide evidence of altering parental behaviors and improving outcomes. These positive impacts from early intervention programs are inconsistent across models and populations.  Home visits targeted at mothers with depression can reduce child mal- treatment and the transmissions of those behaviors across generations.  Brief, focused interventions can substantially reduce child maltreat- ment recurrence rates compared with more typical and higher dose parenting programs.  A variety of child maltreatment evidence-based prevention models are now available for dissemination, implementation, and evaluation in community settings. Because child maltreatment has many causes, different types of ef- forts are made to prevent it. Speakers at the workshop session on preven- tion discussed primary interventions for all families, secondary interventions for targeted families (e.g., those that experience mental health disorders or substance use problems), and tertiary interventions to prevent recurrence of child maltreatment and chronic neglect. In all three of these areas, many programs are becoming more focused and targeted on specific behaviors. This trend holds out promise that interventions could be briefer, more structured, and more responsive to outcomes, said several speakers. 55

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56 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE UNIVERSAL PREVENTIVE INTERVENTIONS Universal prevention programs that target entire populations have evolved in recent decades, said Deborah Daro, Chapin Hall Senior Re- search Fellow at the University of Chicago. Beginning in the 1960s, re- searchers moved from simply trying to raise awareness to developing a large number of programs. As their understanding evolved, the focus of programs narrowed to early developmental stages, with a growing em- phasis on home-based interventions to maximize impact when children are young. In the past few years, universal prevention programs have emphasized infrastructure and community development, the strengthen- ing of existing programs, and a shift toward evidence-based models. Shaken Baby Syndrome1 A good example of recent trends in intervention efforts is the variety of programs developed to prevent shaken baby syndrome, said Daro. Public awareness and community engagement have been cornerstones of efforts in this area. In addition, recent efforts have concentrated aware- ness programs on very specific behaviors. Daro listed several well-known programs, including the Central Massachusetts Shaken Baby Syndrome Campaign, a web-based commu- nity engagement program, and a hospital-based initiative at Pennsylvania State University’s Hershey Medical Center. One common pathway used by these programs is universal education for new parents on coping skills and parenting practices, often including print or video media. In addition, the programs encourage parents to share what they have learned with oth- ers who care for their infants, thus expanding the reach of the curriculum. Daro particularly emphasized the role of parents as spokespersons for these programs. Two-way communication between parents and broader networks, she said, is a major factor in the education of parents and can play a huge role in disseminating positive parenting skills and approaches. It also is important to educate professionals and first re- sponders, who see families when children are very young. In this way, public and professional education work in concert to improve outcomes. 1 In 2009, the American Academy of Pediatrics issued a policy statement recommend- ing that the term abusive head trauma be used instead of shaken baby syndrome to reflect that an injury to the head and brain may be caused by a variety of mechanisms, including shaking and blunt impact (Christian et al., 2009).

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57 PREVENTING CHILD MALTREATMENT Some randomized trials have shown an increase in parental aware- ness and the use of alternative strategies. In an upstate New York study, treatment communities had a 53 percent reduction in head trauma from substantiated abuse, comparing pre- and postintervention rates over a 6- year historical control period followed by 5.5 intervention years (Dias et al., 2005). No decrease was recorded in Pennsylvania—where this treat- ment was not provided—during this time period. Anecdotal evidence, Daro said, also points to greater awareness among parents and to an in- creased comfort level discussing parenting techniques and skills. The behaviors documented by such evidence “sit at the core of good public health initiatives,” said Daro. “Why do we stop smoking? Why do we use seatbelts? It is because individuals are willing to tell other individu- als to change their behavior. . . . Person-to-person change is a way to generate normative change in a much quicker way than if you rely solely on a formal intervention.” Shaken babies make up a small percentage of the overall child abuse problem, Daro continued, but focusing on the behavior has merit given its fatal consequences in many cases and the high costs associated with head trauma. In addition, it is a problem for which there are clear and demonstrated ways to lessen its frequency. Ecological Theory and Community Prevention Ecological theory provides a useful structure for child abuse work, Daro said. “Child maltreatment has lots of causes,” she explained, “and we need lots of ways to address it.” But social service systems tend to be narrowly targeted, which is not very hospitable to ecological theory. Much work happens independently without regard for other areas, and success is measured on an individual level rather than a population level. “The idea of doing community prevention,” Daro continued, “is in part driven by trying to be more explicitly in tune with ecological theory.” Community programs existed since the turn of the last century, serv- ing as a critical intervention during the Progressive Era. More recently, investments in place-based strategies surfaced again in the 1960s as part of the War on Poverty. Today’s community programs to address child maltreatment target high-risk communities and incorporate various inter- ventions, and each program has very different levels of research and evaluation. Some look at the effects of the entire initiative, while others focus only on one or two components. Common pathways used by these community programs fall into sev- eral categories. Expanding services and providing more resources is a

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58 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE constant goal, whether through better use of existing resources or adding elements to a program. Many programs also work to change the relation- ship between provider and participant, Daro said, which is known as “practice reform.” This strategy sets clear standards for interaction and describes common messages and specific behaviors for anyone working with families. For example, she noted that Triple P (Positive Parenting Program) has a specific training program where they train every provider in the community in order to put out a common definition about the rela- tionship of parent and child.2 Some programs also use agency reform initiatives that are working to change institutional culture. This strategy may focus on creating a sys- temic response to child abuse, bringing agencies together to act in concert. Finally, some programs focus on normative change. “They want people to be different,” Daro observed. “They want to change the values around mutual reciprocity or appropriate caregiving, and they go to the families themselves.” This style of broad-scale outreach, she said, at- tempts to change the way parents view their responsibilities, both inde- pendently and collectively. Some research on community initiatives has found measurable re- ductions in child abuse reports, substantiated cases, hospital emergency room use, and out-of-home placements at the population level, though other initiatives have not demonstrated measurable population-level change. “It is not uniform, but there is certainly some evidence that under certain circumstances the strategy can work.” Research also shows changes in parent self-reporting that suggest fewer adverse parenting practices and other normative changes. The tar- get communities have seen better engagement and more mobilization of community resources. “People are doing more. They can generate greater interest. They get more people involved,” Daro said. Continuing Challenges Implementing these programs and generating positive outcomes con- tinues to face steep challenges. Generating new social networks can be difficult, Daro pointed out, as opposed to enriching ones that already ex- ist. Some families are very isolated when they enter the program and have a difficult time building connections. Another issue is considering which neighborhoods can support community-level initiatives. Less stressed communities, Daro said, gen- 2 Additional discussion of the Triple P model can be found in Appendix D.

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59 PREVENTING CHILD MALTREATMENT erally can implement programs faster, and programs that are quicker to implement have better outcomes. The community also has an impact on the program operations, which has to factor into the decision-making process. Many programs fail because they do not have an intentional and stra- tegic framework to guide decision making, said Daro. “These are com- plex initiatives. There are a million balls in the air.” Programs with three or four distinct components, she said, inevitably have to let some things go, and someone must make decisions about how to prioritize and allo- cate resources to keep the operation from being too scattered and there- fore ineffective. Community intervention programs also require large investments, Daro pointed out, which means that consideration must be given to how they can remain sustainable and consistent. Creating measurable change takes time, and a program must be built with that constraint in mind. Finally, Daro addressed the importance of timing and focus when de- livering services. “We lack a science of execution,” she said. When par- ents are “absolutely at wit’s end,” they need something to help them through that difficult period. “We don’t know how to get that something to the parent at the point at which they need it, and that is what we are really struggling with.” Future Opportunities to Strengthen Universal Prevention Programs The outcomes of programs could be strengthened through an inten- tional focus on the contexts of intervention programs and individual fam- ilies, Daro said. Additional research also will be necessary on the sustainability of reform and population-level change. Assuming that every family is at risk could provide benefits by providing a universal assessment at a specified point in time, Daro said. The system also could benefit from a greater understanding of the critical elements necessary for high-quality interventions and a sense of how much programs can adapt while retaining those ingredients. In addition, using technology more effectively could have many ben- eficial impacts, such as improving supervision, empowering participants to seek information, and strengthening provider–participant relationships. Finally, public and private programs need to be integrated more closely to maximize support for community programs. “There are simply not enough public dollars to meet the needs of families and children at

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60 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE risk,” Daro concluded. She emphasized that “people need to be empow- ered to act on their own to support parents and protect children.” Discussion In response to a question about the expense of preventive services, Daro pointed out that the cost varies widely. “The real trick is linking families with the level of service they need, not more, not less.” She add- ed that cost can be minimized by looking to the systems that are already in place and adapting them as necessary. Another participant pointed to a lack of economic analysis in childhood abuse and neglect and the need for precise and targeted cost-benefit and comparative effectiveness anal- ysis of welfare programs; several panelists agreed with this point. SECONDARY PREVENTIVE INTERVENTIONS WITH HIGH-RISK POPULATIONS Delivery of services through home visits shows promise for decreas- ing the transmission of child maltreatment across generations, said Frank Putnam, professor of pediatrics and child psychiatry at the Cincinnati Children’s Hospital Medical Center and professor of psychiatry at the University of North Carolina School of Medicine. Home visits are a common intervention in many countries, but they are more limited in the United States and tend to attract high-risk families with inadequate re- sources. At present, Putnam said, about 500,000 families across the country are participating in home visiting programs. The Results from Research In a brief review of research on home visitation, Putnam reported that only one out of five trials found a substantiated reduction of substan- tiated abuse, but four out of five showed a reduction in parent-reported abuse (Astuto and Allen, 2009).3 Putnam pointed out that population studies see a higher frequency of parent-reported abuse (including sexual abuse, physical abuse, and shaken baby syndrome) than substantiated abuse reports, so he thinks it is important not to discount those data. Home visitation programs also have demonstrated influence on parenting 3 Additional discussion about home visiting programs is included in Appendix D, in- cluding a summary of evaluations of the effectiveness of home visiting models for pro- moting child well-being and a discussion of the strength of the available evidence.

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61 PREVENTING CHILD MALTREATMENT sensitivity and parenting harshness, two important risk factors for mal- treatment. An important factor in understanding research on home visitation is that these programs often have strong site effects, said Putnam. Some sites get very good results, while others do not produce the same kinds of outcomes, which tends to dilute statistical significance (Howard and Brooks-Gunn, 2009). Putnam added that it will be important to research why there are often strong site effects and why the same program seems to produce results in some communities and with some agencies and not with others. In the research sample Putnam and his colleagues have been study- ing of 15,000 families receiving home visits, most of the mothers were single or unmarried, had on average an 11th-grade education, and had young children. Many mothers were estranged from their families and socially isolated, and two-thirds of the mothers in the research sample had a history of maltreatment (Ammerman et al., 2011). Reviews and meta-analysis suggest a two to three times greater risk of maternal depression when mothers have a history of child maltreat- ment. Maternal depression, in turn, is a risk factor for child abuse and neglect. This result is a vicious cycle, Putnam pointed out. “If you were abused, you are more likely to become depressed. And if you become depressed, you are at a higher risk for maltreatment of your offspring.” His study has found that depression and social support strongly affect the relationship between a childhood history of maternal trauma and in- creased parenting stress. In particular, a Beck Depression Inventory of 800 mothers over the course of 9 months had 44 percent scoring in a clinical range split into three groups: one group that scored high and then improved, one that remained chronically depressed, and one that first scored low and then became depressed. In the literature, Putnam said, the rate of maternal depression in home visiting populations is 30 percent, and the majority of those mothers do not get treatment (Ammerman et al., 2011). Dealing with Depression A number of strategies have been put forth for addressing maternal depression in home visitations. Current standard practice involves screening the mother for referral to community services. Another model involves having the home visitors screen the mother and provide a refer- ral to a mental health partner. This technique, Putnam said, was success- ful in Ohio, with two-thirds of mothers who screened positive accepting

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62 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE a referral. Embedding a program within the home visiting model is a third approach. A fourth, which has been used in Louisiana, has the home visitor screen and then provide the counseling directly, supervised by a mental health professional. In-Home Cognitive Behavioral Therapy (IH-CBT) is an intervention Putnam developed with Robert Ammerman (Ammerman et al., 2011). “Because there are so many different home visiting programs,” Putnam said, “we designed this to be as generic and nonprogram-model-specific as possible. In development for 8 years, the program is standardized to 15 sessions plus a booster session, delivered by a social worker with at least a master’s-level education who is supervised by doctoral-level psy- chologists or psychiatrists.” In multiple trials, the researchers saw a positive impact of the em- bedded program for treating depression. In addition, the program in- creased their perceived social support. However, their social networks did not expand significantly, which means they were getting more bene- fit from the same network. The studies showed almost an 80 percent reduction in depression among mothers who completed all 15 sessions, and 60 percent reduction for those who received treatment but did not go through the full program. Two-thirds of those who had no treatment remained depressed (Ammerman et al., 2011). A 3-month follow-up showed continued improvement in the treat- ment population. These trials compare well with randomized controlled trials in clinical settings, as well as with medication trials, Putnam ob- served. Other studies, he added, show that depressed subjects with a his- tory of maltreatment respond poorly to medication but well to cognitive behavioral therapy. Future Opportunities with Home Visiting Systems Home visiting systems provide an opportunity for repeated screening and delivery of services that mothers will accept, Putnam concluded. Mothers learn to trust the home visitors; no-show estimates are lower than for clinic-based services; and the programs can follow families for multiple years. “Delivering those services in the home reduces a lot of barriers. Most of these moms don’t have cars. They don’t have transpor- tation. They have child care problems. They are poor.” Home visitation programs also provide an opportunity to address other risk factors such as maternal PTSD, substance abuse, and domestic violence.

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63 PREVENTING CHILD MALTREATMENT Discussion In response to a question about education for providers and home visitors, Putnam pointed out that a number of curricula are being devel- oped, particularly in the area of social work. But education on child mal- treatment is not embedded in medicine or in most of psychology. “There are many areas where we need to disseminate this,” he said. Daro expanded on that statement, suggesting that another challenge for workers is learning to strategize with colleagues in different disci- plines. The culture does not necessarily support incoming workers with new skills, she said, and they may get dragged into old ways of doing things regardless of what they learned previously. PREVENTION OF RECURRENCES AND ADVERSE OUTCOMES Tertiary services are generally not voluntary, said Mark Chaffin, pro- fessor of pediatrics at the University of Oklahoma. They focus on fami- lies with recurring instances of maltreatment and emphasize effect size more than reach or penetration. “The consumer of these services, in an economic sense and in many other senses, is actually the system,” Chaffin said. “It is the child welfare system or the courts.” These entities typical- ly select and prescribe these services, but they rarely have done so in a well-informed or assessment-driven manner. Public child welfare systems are highly regulated, Chaffin observed, but they lack a mandate to use proven effective or evidence-based treat- ments. Most services are locally derived and delivered by community- based agencies that may invent their own model without strong guide- lines. An informal search of the Child Family Services Reviews, which evaluate child welfare systems, resulted in no matches for the term “evi- dence based.” “Typically, services in this area have been ideology driven, not evi- dence driven, and that is still the case,” Chaffin said. In the 1980s, the prevailing attitude was that any treatment would be too late and that pre- vention was the only viable option. In the following decade, intervention research focused on sexual abuse and posttraumatic stress (PTS) symp- toms. This resulted in evidence-based services for PTS in children, but left many needs unaddressed because fewer than 20 percent of children in foster care show PTS symptoms. As recently as 2004, a review com- missioned by the Office for Victims of Crime found only a single inter-

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64 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE vention mode—for PTS in child victims—as well supported, and rated no parent-focused or perpetrator models as well supported (Chaffin and Friedrich, 2004). Recent Progress More recently, however, there has been substantial growth in the number of well-supported models that extend well beyond PTS, Chaffin said. In 2012, for example, the California Evidence-Based Clearinghouse for Child Welfare (CEBC), which reviews evidence on interventions for families in child welfare, rated as well supported four parent training models, one foster care stabilization model for children, two foster care stabilization models for adolescents, and four models for children with internalizing anxiety, depression, or PTS. Now it is clear, Chaffin continued, that child maltreatment recidi- vism reduction recurrence rates can be substantially reduced with a brief, focused intervention, compared with more typical and higher dose par- enting programs. One trial showed a reduction from more than 50 per- cent to less than 20 percent measured using an evidence-based treatment. Researchers have replicated these results in settings outside of laborato- ries with cases severe enough to face termination of parental rights. The results also have been extended from physical abuse to neglect and from more acute cases to chronic or deep-end cases. A recent statewide trial also showed significant reductions when adding evidence-based modules to a home-based service system. For every 10 to 15 cases treated, recur- rence dropped by one within the first year, and greater than one in fol- lowing years. “These are meaningful reductions that can be achieved.” The majority of current evidence-based treatments have been bor- rowed from outside child welfare, Chaffin observed. They were devel- oped in other contexts and have been adapted and integrated into service programs for high-risk parents. Many of these evidence-based treatments also require lower doses and fewer sessions compared with previously favored interventions. They take a more behavioral approach, emphasiz- ing adaptive skills, and focus less on verbal exploration of issues. They also tend to be more structured, which Chaffin said gets a mixed reaction from implementation staff. In ideology-based models, providers tended to value comprehensive- ness over depth, trying to fit as many therapies as possible into a pro- gram. Evidence-based treatments look different. They focus on fewer things with greater depth and intensity. Greater quality control is empha-

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65 PREVENTING CHILD MALTREATMENT sized. “This has been the shift that has been going on and will probably continue.” Future Research and Opportunities Borrowing and adapting from other intervention sources will contin- ue into the future, said Chaffin. “We have a long way to go before we exhaust the possibilities of what we can borrow from other evidence- based treatment literatures,” he said. Many of these interventions are more advanced than in child welfare settings and are resilient enough to be translated across communities, problem areas, populations, and cultures. An important factor to consider is the envelope of effectiveness for different therapies and where their usefulness begins to taper off. Identi- fying the most useful elements within borrowed treatments, and pulling out those crucial ingredients for use in a child maltreatment setting, would increase effectiveness. Adaptation requires the complex task of fitting various strategies to the service system, the context, the policy environment, and the workforce. Evidence-based case management pathways are another area for de- velopment, Chaffin suggested. People providing services need a back- ground in matching those services to clients and families. Today, service plans tend to be scattershot. Parents often cannot realistically complete all the tasks laid out in their service plan. Assessment-driven service models, with fewer targets and greater focus and depth, could be a better fit, with monitoring for outcomes instead of processes. Chaffin also suggested that researchers look beyond immediate out- comes to the developmental, occupational, social, and health conse- quences of interventions for children in the system. Furthermore, new scientific insights into the causes of maltreatment behavior can influence decisions about what interventions to borrow, how to develop new inter- ventions, how to assemble and tailor the elements of interventions, and how to anchor interventions in a clinical science approach rather than an ideological approach. At the end of his presentation, Chaffin noted that neglect is more sta- ble and recurrent than other types of maltreatment, which results in a flood of chronic cases in the child welfare system. In Oklahoma, for ex- ample, more than 40 percent of cases have been seen four or more times in the past, typically for chronic neglect. “We are still married to an epi- sodic and reactive service system. You have to have a report, and that is when you initiate services.” Looking to other chronic diseases, he sug- gested, could inform development of a different methodology for dealing

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66 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE with recurrence. Emerging evidence suggests that evidence-based inter- ventions may have a cumulative service benefit or at least a retained probability of positive response even among highly chronic cases, as is seen in addiction treatment. To explore this possibility, research needs to look at the trajectory of interaction with service systems across a fami- ly’s child-rearing years, changing developmental issues and the match with evidence-based treatments, and the role of monitoring, check-up, and follow-up. For example, who would do such monitoring and how could engagement be sustained, Chaffin asked, especially among highly mobile populations with shifting family compositions? Discussion One participant asked about the ingredients of success, which Chaffin listed as quality control, delivery mechanisms, and program structure. In that regard, he also spoke about implementing structured programs that can be delivered by employees with a bachelor’s-level education. “If you asked me what the number one problem is in public child welfare, I would say it is a workforce problem,” Chaffin said. “Today you have a bachelor’s degree in English literature or recreation or landscaping, and 3 weeks from now you are a child welfare worker with a full caseload. I think it is the exception rather than the rule to find much in the way of course work.” Matching programs with clients could be handled by deci- sional algorithms, Chaffin said. Expertise is necessary for developing the algorithm, but once it exists, someone without a Ph.D. can effectively match elements to a case. Putnam added that the use of continuous quali- ty improvement techniques developed in the business community could have a dramatic effect on child maltreatment programs. In contrast to randomized controlled trials, continuous quality improvement is nimble, cheap, and data-driven. It embraces variation as a way of improving a system and depends on quick feedback to foster continual improvements. John Landsverk, director of the Child and Adolescent Services Re- search Center at Rady Children’s Hospital in San Diego, commented on the lack of data on the cost of prevention services. He noted that child welfare does not have a unit costing system, unlike medical care, in which a certain amount can be attached to each type of visit or proce- dure. This is an important barrier to achieving precision in cost calcula- tions and cost-benefit analyses. He said that a unit cost approach has been developed in Britain and is currently being adapted for use in the United States. Finally, he stated that there are a number of different in- terventions in particular areas that are ripe for comparative effectiveness

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67 PREVENTING CHILD MALTREATMENT research. For example, it may be that one intervention actually delivers a slightly smaller effect than another but costs much less and therefore has a better cost-benefit ratio. Barth brought up the challenge of reengaging families in chronic ne- glect situations without a child abuse report as a mechanism. He said that this could be made more difficult because of the expansion of multiple response programs that do not collect or keep complete information from child abuse reports. Chaffin said such a system would look more like a prevention system than an intervention system. However, he added, “We are still very much at the formative state of beginning to think through understanding how chronic families interact with systems and what they benefit from cumulatively or episodically over time. We are just begin- ning to learn something about chronic neglect cases that would allow us to think about how we would design a different type of system that is less episodic and reactive.”

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