New Directions in Child Abuse and Neglect Research (2014) / Chapter Skim
Currently Skimming:
6 Interventions and Service Delivery Systems
6 Interventions and Service Delivery Systems
Pages 245-296
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From page 245... ...
. In addition to the public child protection and child welfare systems found in all communities, a variety of treatment programs targeting victims and perpetrators of child abuse and neglect are offered through various mental health and social service agencies.
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Parental capacity and behaviors can be altered either directly by providing services to individual caretakers to improve their knowledge and skills, or indirectly by creating a context in which doing the "right thing" is easier, such as by reducing stress and increasing support within the immediate family and local community. The child welfare system, as described in Chapter 5, provides a necessary public policy and service response but is insufficient to address the immediate and long-term consequences of child abuse and neglect or give families the support they need to prevent these outcomes.
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Improving outcomes for a greater proportion of victims and those at risk of child abuse and neglect will require new research on such issues as cultural relevance, replication fidelity, cost-effectiveness, service delivery reform, and service integration. In addition to offering guidance on how to structure and target specific interventions, such research can guide reforms in public child welfare and other public service delivery systems to improve overall service quality and create an institutional infrastructure capable of sustaining such reforms.
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The second main advance in treatment interventions is in approaches to problematic parenting and behavior problems in children. Child abuse and neglect represent extreme forms of problematic parenting, and parenting interventions are the most common service recommendation in child welfare.
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It is the basis for two interventions that have been used in child welfare populations. The first, Multi-dimensional Treatment Foster Care (Chamberlain et al., 2008)
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-- also is increasingly being used in child welfare cases. A number of these parenting interventions have been shown to improve child welfare outcomes in addition to improving behavior problems in abused and neglected children.
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TF-CBT has been tested extensively with children involved with the child welfare system, including those in foster care placement. It has also been widely disseminated in a variety of public mental health settings through the National Child Traumatic Stress Network.
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. In addition, anxiety management training and CBT have been identified as possibly efficacious for African American youth.
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These advances include the extensive testing of TF-CBT models that have been shown to be effective. Finding: The application of well-established parent management train ing programs with proven success to children and families involved in the child welfare system has been highly successful with regard to improved outcomes across behavioral problems caused by child abuse and neglect, as well as a reduced need for further involvement in the child welfare system across metrics such as reabuse and rereferral.
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. Equally important, however, were the growing number of national home visiting programs being developed and successfully implemented by public agencies and community-based service organizations.
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Beyond the broad implementation of home visiting programs, those seeking to prevent child abuse and neglect continue to design, implement, and assess a range of initiatives. These initiatives include, among others, parent education services; crisis intervention programs that provide telephone numbers for families facing an immediate crisis or seeking parenting advice, as well as crisis nurseries; education for children and adolescents on assault prevention, antibullying behaviors, and nonviolence; efforts to assess new parental concerns and service needs; public education to raise awareness and alter parental behaviors; and initiatives designed to change how health care professionals and others working directly with children recognize and respond to potential child abuse and neglect.
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These and similar gains were most concentrated among families with the fewest material and emotional resources at the time they enrolled in the program. As noted earlier, confidence in home visiting as an effective way to address child abuse and neglect, as well as other poor child developmental and
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While home visiting programs continue to build an evidence base around a wide range of outcomes, preventing child abuse and neglect as measured by a reduction in initial or subsequent abuse and neglect reports remains an area in which consistent findings are lacking. Also, as promising models are taken to scale, sustaining their impacts is proving problematic.
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While unique challenges are faced by parents and families dealing with difficult circumstances, such as substance abuse, mental illness, poverty, domestic violence, or divorce, and those parenting a child with behavioral or developmental difficulties, these parents would not all be expected to engage in abusive or neglectful behavior in the absence of parenting education services. An assessment of parenting education models by the California E vidence-Based Clearinghouse for Child Welfare identified several social learning-based educational efforts with robust results supported by repeated randomized controlled trials, including two that are often cited as demonstrating strong potential to reduce the risk for child abuse and neglect.
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From page 259... ...
counties over a 2-year period, demonstrating a decrease in child abuse and neglect. Additionally, multiple randomized controlled trials of the model in various cultural contexts have found it to have positive impacts on parent-reported child behavior problems, reducing dysfunctional parenting and improving parental competence (Bor et al., 2002; Leung et al., 2003; Martin and Sanders, 2003)
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A randomized controlled trial of a whole-school intervention provided universally to students by teachers found that the program moderated the developmental trend of increasing peer-reported victimization, self-reported aggression, and aggressive bystanding compared with schools randomly assigned to the control group. The program also moderated a decline in empathy and an increase in the percentage of children victimized compared with the other intervention conditions (Fonagy et al., 2009)
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. One of the most thoroughly examined public education and awareness campaigns addressing child abuse has been the effort to prevent shaken baby syndrome, now termed abusive head trauma.
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The extent to which these programs can result in sustained population-level change in parenting behaviors remains unclear. Professional Practice Reforms In addition to the provision of direct services to new parents, increased consideration is being given to how best to use existing service delivery systems that regularly interact with families to address the potential for abuse and neglect.
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. Eighteen private practice primary care clinics participated in a cluster randomized controlled trial.
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And although greater attention is being paid to the development of home visiting interventions, the field embraces a plethora of prevention strategies. Communities and public agencies continue to demand and support broadly targeted primary prevention strategies such as school-based violence-prevention education, public awareness campaigns, and professional practice reforms, as well as a variety of parenting education strategies and support services for families facing particular challenges.
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This is a critical concern because the potential public health benefit of these interventions will be severely limited or unrealized if they are not implemented and sustained effectively in usual-care practice, be it in child welfare, mental health, substance abuse, or primary health care settings (Balas and Boren, 2000)
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, home visiting (Matone et al., 2012) , and various child welfare reforms (Daro and Dodge, 2009)
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. These factors include an appropriate target population, staff skills and training, supervision, caseloads, curriculum, and service dosage and duration, as well as the manner in which services are provided and participants are engaged in the service delivery process.
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. In addition to these interventions targeting mental health and adjustment problems, a child welfare intervention targeting American Indian parents (Chaffin et al., 2012b)
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. One noteworthy effort is the randomized controlled trial of Family Spirit, modeled on Healthy Families America, which found that a family-strengthening home visiting program delivered by paraprofessionals significantly increased mothers' child care knowledge and involvement (Walkup et al., 2009)
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. Child welfare staff were trained to implement a systems of care approach -- an existing evidence-based framework -- to improve practice and service delivery for immigrant Latino children at the system level (Dettlaff and Rycraft, 2010)
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rather than more comprehensive implementation and scale-up strategies. Notable exceptions include studies of system-level implementation in the context of child welfare, such as the use of community development teams to scale up multidimensional treatment foster care in multiple counties (Chamberlain et al., 2012)
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conducted on leaders in child welfare, mental health, and juvenile justice systems implementing multidimensional treatment foster care (Chamberlain et al., 2007) found that published information (journal articles, treatment manuals, Inter
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. To address this need, efforts are under way at the Children's Bureau within the Administration for Children and Families to develop a manual on how to conduct programmatic cost analyses specifically within the child welfare community.
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. Remaining challenges to conducting programmatic cost analysis and economic evaluation in the fields of child abuse and neglect intervention and child welfare include the need for (1)
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Consensus also exists that multicomponent implementation strategies are needed to address the challenges of effective implementation. Finding: Despite the need for information on the economic cost and impact of implementing child and family development or child abuse and neglect prevention programs, few studies have conducted program matic cost analyses or economic evaluations in this area.
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. Organizational culture also can result in improved service engagement, reduced staff turnover, and improved child outcomes, independent of the implementation of evidence-based practices (Glisson et al., 2010)
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. Thus, for example, an examination of child sexual abuse in the Catholic Church implicates a strong organizational culture as a major factor limiting the institution's appropriate response to the problem (Keenan, 2011)
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found that the social networks of county-level child welfare, mental health, and juvenile justice system leaders and staff play a significant role in the implementation of evidence-based practices for abused and neglected youth. System leaders develop and maintain networks of information and advice based on roles, responsibilities, geography, and friendship ties.
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. An extensive literature exists on the nature of interagency collaboration for the delivery of health and human services in general and child welfare services in particular.
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In some instances, the rigor and quality of these innovations may alter the standards of practice throughout an agency, thereby improving the overall service delivery process and enhancing participant outcomes. In other cases, organizations that provide little incentive for staff to adopt new ideas or reduce the dosage or duration of evidencebased models to accommodate an agency's limited resources contribute to poor implementation and reduced impacts.
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Equally important has been the successful application of a number of well-established parent management training programs to children and families involved in the child welfare system. Again, these are programs with well-established theory and large bodies of knowledge.
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The most pressing questions relate to how to take interventions to scale in the public mental health, child welfare, and community-based service settings where children who have experienced child abuse or neglect and families in need of preventive services receive their care. As policy makers place greater emphasis on evidence-based decision making and the implementation of programs that have been proven effective through rigorous evaluation, research will be needed to understand how these highquality interventions can best be replicated, adapted to diverse populations, and incorporated into the overall service delivery system.
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2011. Advancing a conceptual model of evidence-based practice implementation in child welfare.
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2005. Parent-training programs in child welfare services: Planning for a more evidence-based approach to serving biological parents.
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2012b. Is a structured, manualized, evidence-based treatment protocol culturally competent and equivalently effective among American Indian parents in child welfare?
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2010. The role of inter-agency collaboration in facilitating receipt of behavioral health services for youth involved with child welfare and juvenile justice.
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2010. Adapting systems of care for child welfare prac tice with immigrant Latino children and families.
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: Does home visiting prevent child maltreatment? New York: University at Al bany, State University of New York.
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2011. Economic evaluation research in the context of child welfare policy: A structured litera ture review and recommendations.
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2008. Assessing par ent education programs for families involved with child welfare services: Evidence and implications.
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2012. Implementation of AF-CBT by community practitioners serving child welfare and mental health: A randomized trial.
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2011. Bridge over troubled water: Using implementation science to facilitate effective services in child welfare.
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2005. Inter-agency collaboration in child welfare and child mental health systems.
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2011. Prevention of child maltreatment in high-risk rural families: A randomized clinical trial with child welfare outcomes.
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2009. Randomized controlled trial of a paraprofessional-delivered in-home intervention for young reservation-based American Indian mothers.
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Child Welfare 88(4)
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