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New Directions in Child Abuse and Neglect Research (2014)

Chapter: 6 Interventions and Service Delivery Systems

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Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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6


Interventions and Service
Delivery Systems

Since the 1993 National Research Council (NRC) report was issued (NRC, 1993), significant advances have occurred in the development and dissemination of model programs for treating and preventing various forms of child abuse and neglect (Daro and Benedetti, 2014). 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. Many communities also have access to primary and secondary prevention services designed to reduce the risk for child abuse or neglect for families experiencing difficulties. Among this growing array of service options, an increasing number of interventions have strong evidence of efficacy with at least a portion of their target populations. Many others are aggressively building their evidence base and now operate with increased awareness of the need for and the value of robust evaluative data.

The current evidence base also suggests that the availability of these services is uneven across communities and populations, leaving many of the most vulnerable children and families without adequate services. Even when identified, children who are victims of child abuse or neglect may not receive the therapeutic services needed to address their serious developmental and behavioral problems. Families at significant risk of child abuse or neglect as a result of mental health issues, domestic violence, or substance abuse are among those least likely to be adequately served by the current array of preventive and family support services. And when services are offered, their quality and potential impacts vary greatly (Paxson and Haskins, 2009). On balance, however, much progress has been made in the ability

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

to successfully identify, engage, and assist a growing proportion of children and families that have experienced or are at risk for child abuse and neglect.

The purpose of this chapter is to describe those program models and intervention strategies with the strongest evidence of success, identify approaches that have been found lacking, and highlight the importance of building an integrated system of care to enhance the capacity to successfully prevent child abuse and neglect and treat victims. In developing this conceptual framework, the committee intentionally considered the collective challenges facing all relevant interventions instead of segmenting the discussion into the traditional silos of treatment and prevention services. Also highlighted are the common challenges faced with all interventions in attempting to enhance their assessment, implementation, replication, and sustainability.

The child abuse and neglect interventions reviewed here are aimed in part at improving the capacity of parents and caretakers to cease certain harmful behaviors or to adopt behaviors commonly accepted as contributing to healthy child development. The behaviors targeted include those that are illegal and wrong, as well as those for which evidence demonstrates a link to negative or positive impacts on a child’s development or safety. 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. This chapter focuses on why it is important to develop, implement, assess, and sustain an array of strong interventions that address the consequences of child abuse and neglect (treatment) and offer promising pathways to improve parental capacity to support optimal child development by reducing risks and strengthening protective factors (prevention). The committee recognizes the wider range of interventions that address myriad issues associated with an elevated risk for child abuse and neglect, such as substance abuse treatment programs, domestic violence interventions, depression treatments, income support programs, child care, and community violence prevention programs. The discussion here, however, is limited to strategies whose core objectives include reducing child abuse and neglect, improving parental capacity, and ameliorating the consequences of child abuse and neglect.

The first two sections of the chapter identify an array of service strategies and program models that have demonstrated success in achieving their targeted outcomes, as well as those efforts that have failed to fulfill

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

expectations. Because of variations in legal authority, target population, and scope across the various elements of the child abuse and neglect service continuum, this evidence is presented in two broad groupings: treatment programs designed to reduce reincidence and ameliorate the consequences of child abuse or neglect, and prevention efforts designed to enhance parental capacity, improve child outcomes, and reduce a child’s risk for experiencing abuse or neglect. The third section of the chapter examines a set of issues that have limited the replication and efficacy of interventions designed to address child abuse and neglect. Although the issues addressed are not exhaustive, they illustrate the challenges facing both public child welfare systems and the direct services provided to children and families. 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. The fourth section examines important aspects of building an integrated system of care, including organization culture and interagency networks. The final section presents conclusions.

Any intervention or reform strategy, regardless of its target population or primary outcomes, appears to benefit from a set of “core ingredients” (Barth et al., 2012). Although identifying the exact nature of these ingredients is a work in progress, they generally include building on a strong theoretical foundation that links intended outcomes to a clearly articulated theory of change, offering the program at a sufficient dosage and duration to make it possible to achieve the intended outcomes, staffing the program with individuals who have the knowledge and competencies to work with participants to achieve the desired outcomes, and operating within a system of quality assurance to ensure that the program is delivered properly and the desired outcomes are achieved (Chorpita et al., 2005; Duncan et al., 2010; Wulczyn et al., 2010). As noted in the following sections, these characteristics, among others, help distinguish successful efforts from those with less promise.

TREATMENT PROGRAMS

The greatest change in the development of treatment programs to address child abuse and neglect has been an emphasis on evidence-based practices rather than new theories that might suggest radically different treatment areas. Two primary advances have occurred. The first is the development of therapies that specifically target the impact of trauma or

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

abuse on children. These approaches deal mainly with posttraumatic stress, depression, and anxiety—the primary emotional impacts of abuse. There is a robust literature on interventions addressing these outcomes, but it is not exclusive to child abuse. This research base acknowledges the importance of screening for trauma (including abuse) and validating its occurrence, but encompasses strategies that operate within the traditional framework of mental health interventions. Treatment clinically targets the outcomes or the mental health condition, not the event or cause per se. This focus is consistent with the evidence showing that not all children exposed to child abuse, various forms of trauma, or even terrible lives in general develop mental health disorders. The emphasis also is on modular approaches that address multiple clinical outcomes rather than a single presenting problem.

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. It has long been known that parenting approaches, parental behaviors, and their interaction with child behaviors are primary determinants of behavioral problems in children. In child abuse and neglect situations, behavioral problems are both a consequence of abuse or neglect and a potential risk factor for triggering physical abuse. It is not only physical or sexual abuse that may produce behavioral problems in children; the inconsistent or coercive parenting that often characterizes neglect is also implicated (Gardner, 1989; Patterson et al., 1990; Stormshak et al., 2000). Neglecting parents may be inattentive, unresponsive, or inconsistent. Therefore, effective parenting interventions are the first-line treatments both for dealing with behavior problems in child victims and for reducing the risk for subsequent child abuse and neglect.

The empirical literature is unanimous that behavioral problems are addressed most effectively through interventions that target parents as the primary change agents. In many cases, especially those involving younger children, the interventions are fully parent mediated (Carlson et al., 1989); the children need not be the recipients of individual treatment. This targeting of parents is particularly apt in the context of child abuse and neglect as compared with the typical nonabusive scenario in which children have behavioral problems. Wolfe and others (Graziano and Diament, 1992; Wolf et al., 1987; Wolfe et al., 1988) demonstrated early on that a behavioral parent training program was effective with abusive parents. However, the idea of applying this well-established approach to child abuse and neglect situations did not fully take hold until Urquiza and McNeil (1996) published a paper in Child Maltreatment advancing the application of parent-child interaction therapy (PCIT) in these cases (Urquiza and McNeil, 1996) (PCIT is further discussed below). The emphasis on promoting positive

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

parent-child relationships to address behavioral problems in abused or neglected children resonated with the child abuse and neglect community because behavioral problems in these cases are the result of abusive or neglectful parenting. In other words, applying a proven parent-mediated intervention would simultaneously address the child’s behavior problems and the deficits in the parent-child relationship. Ideally, enhancing the parent-child relationship promotes more secure attachment and stronger bonding, which in turn not only improves child behavior but also lowers the risk for future abuse or neglect.

The focus on parenting interventions is not new; they have always been a primary service for child abuse and neglect cases. What changed was the recognition that parenting practices and child behavior problems are inextricably interrelated and are best addressed through a single parenting-focused intervention, as opposed to sending parents to parent education classes and children to individual therapy when abuse or neglect results in behavior problems. Moreover, the parenting interventions typically offered were didactic classes or peer support, neither of which involve learning and using new skills in difficult parenting interactions. While parenting classes are still common, it is increasingly appreciated that they are unlikely to produce behavior change in abusive or neglectful parents.

Evidence for Effectiveness

The standard, well-established parent management training or behavioral parent training programs have now been applied extensively to child abuse and neglect situations, and in some cases subjected to specific clinical trials. Findings on parent management training suggest robust effects across cultural groups (Lau, 2006; Martinez and Eddy, 2005). PCIT is effective with abusive or neglectful parents (Timmer et al., 2005), as well as with foster parents (Timmer et al., 2006), when children have behavioral problems. For example, the Incredible Years (Herman et al., 2011; Webster-Stratton et al., 2011a,b) has been tested extensively with low-income Head Start families, many of which are at high risk for abuse or neglect or have been involved in the child welfare system.

The Parent Management Training Oregon (PMTO) model is one of the earliest and most well-established interventions for behavior problems. 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), is a treatment foster care model for severely behaviorally disturbed children that teaches foster parents to deliver the PMTO model with the active consultation and support of a consultant. Under the model, youth can be transitioned to regular foster care or their family home in less than 6 months. The second intervention is Keeping Foster and Kin Parents

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

Supported and Trained, a less intensive version of the model for foster parents and kinship caretakers that has been found to be effective in reducing behavior problems and promoting placement stability (Chamberlain et al., 2008). As discussed later in this chapter, another well-established parent management training program—the Positive Parenting Program, commonly known as Triple P (Sanders et al., 2002)—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. PCIT with a motivational enhancement component significantly reduces referrals to the child welfare system compared with services as usual (Chaffin, 2004; Chaffin et al., 2004). In fact, PCIT by itself outperforms PCIT combined with other services (Chaffin, 2004). Alternatives for Families-Cognitive-Behavioral Therapy (AF-CBT) entails parent-child cognitive-behavioral therapy for physically abusive families. It incorporates standard parent management training; coping skills for children and parents; and a process for parents to make amends for the abuse, which reduces behavior problems and violence in both children and parents. Parent-Child CBT (PC-CBT), a similar approach for abusing families in which the intervention is delivered in child and parent groups, also has been shown to improve behavior problems and reduce future aggression (Runyon et al., 2009). And Triple P delivered as a population-based intervention has been shown to offset increases in child abuse referrals and placement rates (Prinz et al., 2009).

Infant mental health interventions have been developed for the very youngest victims of abuse and neglect. These programs are fully parent mediated and focus on enhancing parents’ sensitivity and responsiveness to their children, as well as basic protective parenting. Parents learn to recognize child cues, especially for distress, and to respond in ways that are consistently comforting. Several programs have been tested in clinical trials involving abusive or neglectful situations and been found to be effective in improving parent sensitivity and child adjustment (Bernard et al., 2012; Spieker et al., 2012).

SafeCare is a parenting-focused intervention for neglect situations involving young children. It is a brief structured home-based program, delivered by trained professionals or paraprofessionals, consisting of three components: safety proofing the home, teaching parents how to monitor and manage child health, and coaching in parenting. The parenting coaching component is not intended for cases in which the children have significant behavioral problems, but teaches basic positive parenting skills. In a recent statewide randomized trial taking the intervention to scale, families receiving SafeCare in addition to the usual array of home-based services had significantly lower rates of rereferral to child protective ser-

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

vices (Chaffin et al., 2012a). Implemented in a trial with American Indian families, SafeCare not only was effective but also was highly acceptable to these families (Chaffin et al., 2012b).

Not infrequently, children show more than one internalizing impact of abuse and neglect, including posttraumatic stress, anxiety, and depression. The literature is robust for the effectiveness of Trauma-Focused CBT (TF-CBT) (Mannarino et al., 2012), a structured intervention for children and caregivers that directly targets the impact of traumatic experiences, including physical and sexual abuse. It reduces not only posttraumatic stress, but also depression and moderate behavior problems when present. The intervention consists of standard CBT elements such as psychoeducation, relaxation and emotion regulation skills, and positive parenting. The trauma-specific CBT component is the trauma narrative, which entails gradual exposure to trauma memories and cognitive processing to correct maladaptive trauma-related beliefs. 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. CBT is well established for children with depression or anxiety (Walkup et al., 2008), although research has not specifically addressed whether the proven interventions are equally effective with abused and neglected children.

Child and Family Posttraumatic Stress Intervention (Berkowitz, 2011), a brief trauma-focused intervention, has been shown to be effective in preventing chronic posttraumatic stress disorder when delivered shortly after a trauma. It consists of assessing trauma impact with feedback to families, providing psychoeducation and normalizing about traumatic stress, and teaching coping skills. Although not yet specifically tested in child abuse or neglect cases, this intervention has been shown to be effective in domestic violence cases and is potentially applicable as an early intervention in cases of child abuse and neglect.

There are also well-established interventions for anxiety and depression in children. CBT is the first-line treatment and may be combined with medication in some cases (Walkup et al., 2008). Children are given information about anxiety or depression; are taught relaxation and coping skills; undergo cognitive restructuring designed to change maladaptive and unhelpful thoughts; and in the case of depression, are taught exposure to unrealistic fears and behavioral activation. Parents may or may not be actively involved in this therapy. The literature has not established that these models work specifically with abused and neglected children, but there is no reason to believe that they would not.

TF-CBT and many parent management training programs have been found to be equally effective for minority youth and their families among

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

the samples included in clinical trials. For example, equivalent outcomes for TF-CBT have been observed for African Americans (Scheeringa et al., 2010). A school-based group version of TF-CBT (Cognitive-Behavioral Intervention for Trauma in Schools [CBITS]) was initially tested and found effective in the highly diverse Los Angeles school district, where a majority of children are immigrants (Jaycox et al., 2002). Culturally adapted versions of CBITS for Latinos and American Indians have been developed (Chaffin et al., 2012b; Workgroup on Adapting Latino Services, 2008). Another trauma-focused intervention (Resilient Peer Treatment) has been identified as probably efficacious for abused African American youth. Several interventions for anxiety have shown some efficacy with ethnic minority youth (Huey and Polo, 2008). Group cognitive-behavioral therapy (GCBT) has been identified as possibly efficacious for African American and Latino youth (see Huey and Polo, 2008). In addition, anxiety management training and CBT have been identified as possibly efficacious for African American youth. For conduct problems, a variety of approaches show some degree of efficacy; specific approaches tend to differ for African American and Hispanic/Latino youth. Consistent efficacy has been found for Multisystemic Therapy (MST) and Coping Power with African American youth, and for Brief Strategic Family Therapy (BSFT) with Latino youth. In addition, MST has been effective with Native Hawaiian youth (Rowland et al., 2005), and in a small randomized controlled trial, The Incredible Years was found to be effective for maladjusted Chinese American youth (Lau et al., 2011). While these interventions have not been tested specifically with abused and neglected youth, there is no reason to believe they would not be effective with this population.

In 2013 a comparative effectiveness review of parenting interventions, trauma-focused treatments, and enhanced foster care approaches that address child abuse and neglect was conducted under the auspices of the Agency for Healthcare Research and Quality (Goldman Fraser et al., 2013). While the authors note the support for a number of promising treatment strategies, the review found that methodological gaps in the evidence limit the ability to compare results across studies adequately.

The Bottom Line

There are two big success stories in interventions for children affected by abuse and neglect. The first is TF-CBT. Tested extensively, it has been found effective for children and families from diverse backgrounds and circumstances and has been adapted specifically for foster children and children in residential care (Mannarino et al., 2012). TF-CBT has been widely disseminated throughout the United States, and there are well-established training models for the program.

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

The second big success story is the application of well-established parent management training programs to child welfare populations. Many of these programs have been found not only to improve behavior problems caused by child abuse and neglect but also to impact child welfare outcomes such as reabuse and rereferral.

The most pressing remaining questions relate to how these interventions can be taken to scale in the mental health and service settings where abused and neglected children receive their care. These questions about implementation and sustainability are not specific to interventions in child abuse and neglect. Questions specific to child welfare relate more to service planning and to how many of what types of interventions should be readily available or ordered for families in the child welfare system. The current approach is to order a single, limited intervention for each problem, which often results in a long list of services that families must complete as part of their child welfare case plan (Society for Prevention Research, 2004). As demonstrated by Chaffin and colleagues (2004), a single evidence-based intervention may actually be more effective for both child and system outcomes than multiple services designed to address the many different problems families may have.

Finding: Significant advances have been achieved in the development of therapies that specifically target the impact of trauma or abuse on children. 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 training 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.

Finding: More research is needed to explore how better to deploy effective treatment intervention programs in the mental health and service settings where abused and neglected children receive care. Questions to be addressed relate to the types and breadth of services to provide for children and families, as well as how to sustain the impact of effective programs over the long term.

PREVENTION STRATEGIES

Over the past 50 years, child abuse and neglect prevention strategies evolved to draw on what was known about the scope of the problem at the

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

time and beliefs about how best to prevent its initial occurrence. Responding to the diverse causes of child abuse and neglect suggested by ecological theory, prevention strategists emphasized the development of a continuum of separate but integrated interventions designed to provide the array of therapeutic and support services necessary to shore up failing or vulnerable families. Within this framework, each component was equally important to achieving positive outcomes regardless of its target population; its targeted outcomes; and, in some cases, evidence of its effects.

At the time of the 1993 NRC report, the concept of prevention had begun to shift from a horizontal to a more vertical structure in which particular emphasis was placed on initiating a strong relationship between parent and child at the moment a woman became pregnant or at the time a child was born (Daro, 2009; Daro and Cohn-Donnelly, 2002). The message changed from providing a plethora of prevention services to placing highest priority on building a network of services that would strengthen the supports available to new parents and link these services in a more intentional and effective manner than had previously been the case.

Support for new parents has taken many forms over the past 20 years, with leadership in these programs generally being shared by state health and human service administrators and community-based program advocates. A comprehensive review conducted in 1993 identified 37 major parent support initiatives operating in 25 states; 9 states (Delaware, Florida, Hawaii, Kentucky, Minnesota, Missouri, Rhode Island, Vermont, and West Virginia) offered statewide parent education and support programs, generally through their department of maternal and child health (Bryant, 1993). Key components of these state efforts included parent education, child health and developmental assessments, and health and social service referrals.

These state initiatives, coupled with the continued expansion of several national home visiting models, have increased public policy interest in the pivotal role of early home visiting in this emerging system of early intervention services. The seminal work of Olds and colleagues showing initial and long-term benefits from regular nurse visiting during pregnancy and a child’s first 2 years of life provided the most robust evidence for the effectiveness of this intervention (Olds et al., 2007). 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. Although initially not rigorous in their evaluation methodologies, programs such as Parents as Teachers, Healthy Families America, and the Parent-Child Home Program demonstrated respectable gains in parent-child attachment, access to preventive medical care, parental capacity and functioning, and early identification of developmental delays (Daro, 2011).

The call for a major federal investment in home visiting programs was

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

first voiced by the U.S. Advisory Board on Child Abuse and Neglect (1990), which cited the statewide system operating in Hawaii and the early findings of Olds and colleagues. While the U.S. Advisory Board’s recommendation was well received by child abuse and neglect advocates, substantial federal support for this strategy has only recently been provided. Authorized under the Patient Protection and Affordable Care Act (ACA) of 2010, the Maternal, Infant and Early Childhood Home Visiting Program will provide $1.5 billion to states, territories, and tribal entities to expand the availability of home visiting programs and create a system of support for families with children aged 0-8. As of the end of the 2012 federal fiscal year, the federal government had awarded $340 million in formula grants to 56 states and territories and an additional $182 million in competitive grants to selected states and territories that demonstrated the interest and capacity to expand and/or enhance their home visiting programs. A total of $21 million in funding also has been provided to multiple tribal entities for purposes of establishing home visiting programs targeting the unique needs of the Native American population. In terms of direct research support, the legislation provides funding for an interdisciplinary, multicenter research forum to support scientific collaboration and infrastructure building related to home visiting research.

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. In addition to targeting change at the individual level, prevention efforts focus on altering community context and implementing a variety of strategies to create social service networks and social environments more conducive to positive parenting and healthy child development (Daro and Dodge, 2009). Compared with early home visiting, these efforts, in general, are more diffuse and less governed by national standards or expectations.

Evidence for Effectiveness

Today, prevention research is guided by a set of rigorous standards addressing research design and quality, such as the criteria for efficacy, effectiveness, and dissemination established by the Society for Prevention

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

Research (2004). The adoption of shared evidentiary standards in the field allows for the identification and testing of programs deemed effective and suitable for replication, adoption, or dissemination. Alternatively, these standards facilitate the identification of programs that lack a sound theoretical model or clinical base, show no effect, and should not be implemented further.

This section focuses primarily on those effective prevention interventions for which evidence shows a reduction in child abuse and neglect reports and other child safety outcomes, such as a lack of reported injuries and accidents. Also identified are programs with documented effects on risk and protective factors that are correlated with child abuse and neglect, including parent characteristics, child characteristics, and the parent-child relationship.

Home Visiting

As noted, the provision of home-based interventions at the time a woman becomes pregnant or gives birth is one of the most widely disseminated child abuse and neglect prevention strategies (Daro, 2010). Although findings remain inconsistent across program models, target populations, and outcome domains, the approach continues to demonstrate impacts on the frequency of child abuse and neglect and harsh punishment (Chaffin et al., 2012a; DuMont et al., 2010; Lowell et al., 2011; Olds et al., 2010; Silovsky et al., 2011), parental capacity and positive parenting practices (Connell et al., 2008; Dishion et al., 2008; DuMont et al., 2010; LeCroy and Krysik, 2011; Nievar et al., 2011; Roggman et al., 2009; Zigler et al., 2008), and healthy child development (DuMont et al., 2010; Lowell et al., 2011; Olds et al., 2007; Shaw et al., 2009). Likewise, home visiting programs that engage families with older children (aged 5-11) have demonstrated an ability to reduce depressive symptoms, parental stress, and life stress and enhance parental competence and social support (DePanfilis and Dubowitz, 2005).

Findings of a 15-year follow-up study of families enrolled in the Nurse Family Partnership’s randomized clinical trials support that program’s long-term positive impacts on both parents (Eckenrode et al., 2010) and children (Kitzman et al., 2010; Olds, 2010). In contrast to control families, mothers who received the program were involved in fewer substantiated reports for maltreatment, abuse, and neglect, and children were less likely to report running away or to have had contact with the juvenile justice system. 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

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

behavioral outcomes, contributed to the inclusion of the Maternal, Infant and Early Childhood Home Visitation Program in the ACA. As of this writing, 12 home visiting models that serve young children have met the criteria for identification as an evidence-based model appropriate for this initiative in that one or more rigorous evaluations have documented impacts in one of eight core outcome domains (child health; child development and school readiness; family economic self-sufficiency; linkages and referrals to other services; maternal health; positive parenting practices; reduction in child abuse and neglect; or reduction in juvenile delinquency, family violence, or crime) (Avellar et al., 2012). However, only 3 of the 12 approved models have had a measurable and significant impact in reducing either child abuse or neglect reports or the incidence of harsh parenting.

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. For example, a broad replication of the Nurse Family Partnership in Pennsylvania resulted in no significant differences in visits to hospital emergency departments for serious injuries between families enrolled in the program and a comparison group (Matone et al., 2012). Other studies also have raised concern about the extent to which home visiting services are able to prevent the recurrence of physical abuse or neglect (MacMillan et al., 2005) or alter the developmental consequences of abuse or neglect (Chaffin, 2004; Cicchetti and Toth, 2005).

For the past several years, a number of states and local communities have explored ways of extending support to a greater proportion of newborns and their parents. In contrast to targeted approaches that limit services to parents identified as high risk, these more universal initiatives are built on a public health model aimed at altering the context in which parents raise their children. Specifically, these initiatives offer comprehensive assessments and a limited number of service contacts to all parents or all first-time parents living within a specific geographic area (e.g., neighborhood, city, county) (Daro and Dodge, 2010). Assessments of the impacts of this approach have found that families are receptive to offers of such assistance and are able to access additional services in a more timely and appropriate manner (Dodge et al., 2013; Urban Institute, 2012).

At least one randomized study of this approach, conducted in Durham County, North Carolina, found that families with access to an initial nurse home visit at the time their child was born were less likely to use hospital emergency room services; less likely to present with anxiety; and more likely to exhibit positive parenting behaviors, to have strong community connections, and to participate in higher-quality out-of-home care (Dodge et al.,

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

2013). Additional research is required to fully understand the implementation challenges associated with such universal strategies and their ultimate impacts on parental behaviors and child outcomes.

Parenting Education

Improving parents’ capacity to meet the developmental and emotional needs of their children has long been viewed as an effective strategy for preventing child abuse and neglect (Helfer, 1982; Kempe, 1976). Parenting education programs designed to increase knowledge of child development, enhance care, promote positive parent-child interaction and emotional sensitivity, and address child discipline and behavior management are considered a strong theoretical and practical approach to reducing risk and strengthening protective factors (Barth et al., 2005; Johnson et al., 2008). Since parenting education programs can occur in diverse settings, including both home-based and center-based models, and often include additional service components, such as child care services and family support groups, it is difficult to distinguish those impacts that may be attributable to specific parenting education activities (Barth, 2009; Reynolds et al., 2009). Further, the populations utilizing these programs are diverse. 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 Evidence-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 Participants in Webster-Stratton’s The Incredible Years, a multifaceted and developmentally based curriculum for parents, teachers, and children delivered in both primary school and early education settings, demonstrated more positive affective responses and a corresponding decrease in the use of harsh discipline, reduced parental depression, and improved self-confidence and better communication and problem solving within the family (Daro and McCurdy, 2007; Gardner et al., 2010; Reid et al., 2001, 2004; Webster-Stratton et al., 2011b). Significant aspects of the model include group-based training in parenting skills; classroom management training for teachers; and peer support groups for parents, children, and teachers.

Triple P, mentioned earlier, is another well-established and well-researched parent management training program. It consists of a series of integrated or scaled interventions “designed to provide a common set of

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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information and parenting practices to parents who face varying degrees of difficulty or challenges in caring for their children. Based on social learning theory, research on child and family behavior therapy, and developmental research on parenting in everyday contexts, each intervention is designed to reduce child behavior problems by teaching healthy parenting practices and how to recognize negative or destructive practices. Parents are taught self-monitoring, self-determination of goals, self-evaluation of performance, and self-selection of change strategies (Daro and Dodge, 2009, p. 75). A geographically randomized study illustrated the effectiveness of Triple P at a population level (Prinz et al., 2009). Triple P was implemented in 18 randomized medium-sized southeastern U.S. 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).

Most recently, those examining parenting education programs have focused on identifying those elements of the programs that appear to have the most consistent impact on participant outcomes (Barth et al., 2012). A meta-analysis conducted by the Centers for Disease Control and Prevention on training programs for parents of children aged 0-7 identified components of programs that have a positive impact on acquiring parenting skills as demonstrated by increased use of effective discipline and nurturing behaviors (CWIG, 2011). The 77 studies selected for the review all assessed parenting programs that incorporate active learning strategies such as completing homework assignments, modeling, or practicing skills. Among the 14 content and program delivery characteristics examined, the factors most frequently associated with positive outcomes were teaching parents emotional communication skills, helping them acquire positive parent-child interaction skills, and giving them opportunities to demonstrate and practice these skills while observed by a service provider (CWIG, 2011; Kaminski et al., 2008). The study also found small program effects on parent behaviors and skills outcomes with those programs having ancillary services. The researchers hypothesized that these ancillary services were a burden for the parents and program staff, and could impede skills development focused on parent-child interactions.

Universal Antiviolence Education Programs

In contrast to efforts designed to alter the behavior of adults who might commit child abuse or neglect, a category of prevention programs that emerged in the 1980s was designed to alter the behavior of potential victims (CWIG, 2011). Initially, such efforts focused exclusively on provid-

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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ing children information on physical and sexual assault; how to avoid risky situations; and if abused, how to respond. Meta-analyses and evaluations of these programs found they were effective in conveying safety information to children and imparting skills to avoid or lower the risk of assault (Berrick and Barth, 1992; Daro, 1994; MacMillan et al., 1994; Rispens et al., 1997). It remains unclear, however, to what extent these programs can alter adult behavior and responsiveness or change institutional culture in ways that reduce the likelihood of children being victimized and if they are, having their case addressed in an appropriate and transparent manner (Daro, 2010).

More recently, the focus of these universal education programs has expanded to encompass issues of bullying and aggressive behavior, particularly among elementary and middle school students. While the immediate goal of these interventions is to reduce levels of bullying and aggressive behavior among children and youth, accomplishing this goal might potentially contribute to a reduction in these behaviors in adulthood, thereby reducing levels of child abuse. A 2006 Cochrane review of school-based violence prevention programs targeting children identified as being or at risk of being aggressive found that aggressive behavior was significantly reduced in the intervention groups compared with the control groups in 34 trials with data on this outcome, and that positive impacts were maintained in the seven studies reporting 12-month follow-up data (Mytton et al., 2006).

These programs also may impact the response of bystanders to bullying behavior. 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). Likewise, an observational study of playground interactions in schools randomly assigned to a bullying prevention program found declines in bullying and argumentative behavior, increases in agreeable interactions, and a trend toward reduced destructive bystander behaviors (Frey et al., 2005). Children in the intervention group reported enhanced bystander responsibility, greater perceived adult responsiveness, and less acceptance of bullying/aggression (Frey et al., 2005). While not well researched, the observed impacts on children’s response to acts of peer aggression and their increased willingness to speak up and support the victim may have implications for subsequent reductions in various forms of child abuse and neglect. Adolescents and young adults who become increasingly comfortable with the concept of actively resisting aggression toward their peers may be more likely to support normative standards by which such behavior

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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toward children is less tolerated and individuals feel more empowered to seek ways to stop it.

Public Education and Awareness

A consistent feature of child abuse and neglect prevention programming has been the development of public awareness campaigns. Initially, these efforts focused on raising awareness of the problem and enhancing the public’s understanding of behaviors that constitute abuse and neglect and their impact on child well-being (Daro and Cohn-Donnelly, 2002). In recent years, broadly targeted prevention campaigns have been used to alter specific parental behaviors. For example, the U.S. Public Health Service, in partnership with the American Academy of Pediatrics (AAP) and the Association of SIDS and Infant Mortality Programs, launched its “Back to Sleep” campaign in 1994 to educate parents and caretakers about the importance of placing infants on their back to sleep so as to reduce the rate of sudden infant death syndrome (SIDS). Campaign strategies included media coverage; the availability of a nationwide toll-free information and referral hotline; the production of television, radio, and print ads; and the distribution of informational brochures to new parents. As of 2002, the National Center for Health Statistics reported a 50 percent drop in SIDS deaths and a decrease in stomach sleeping from 70 percent to 15 percent. Although the evidence linking the campaign to changes in these population-level indicators is exploratory, the data are suggestive of how public education might be used to change normative practices (Mitchell et al., 2007).

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. In an evaluation of a 1992 federal campaign to educate the public about the dangers of this practice (“Never Shake a Baby”), one-third of those providing feedback on the campaign indicated that they had no prior knowledge of the potential danger of shaking an infant (Showers, 2001).

Moving beyond basic awareness, Dias and colleagues (2005) developed a universal education program on shaken baby syndrome, which they implemented in an eight-county region in western New York. The program provided information on shaking to parents of all newborns prior to the infants’ discharge from the hospital. During the 6 years before the program, 40 cases of substantiated abusive head injuries were identified in the targeted New York counties—an average of 8.2 cases per year, or 41.5 cases per 100,000 live births. During the 5.5-year period of the intervention, 21 cases of substantiated abusive head injury were identified—3.8 cases per year (a 53 percent reduction), or 22.2 cases per 100,000 live births (a 47 percent reduction). In the Pennsylvania comparison communities, there

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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was no change in the number of such cases observed during the same two time periods (Dias et al., 2005).

Another promising public education and awareness program, The Period of PURPLE Crying, focuses on helping parents understand and cope with the stresses of normal infant crying. The program was tested through four different types of delivery systems: maternity services, pediatric offices, prenatal classes, and nurse home visitor programs. More than 4,200 parents participated in the program. A randomized controlled trial of the program found that it succeeded in enhancing mothers’ knowledge about infant crying. Women who participated in the program were more likely to differentiate “inconsolable crying” from other types of crying that signaled hunger, discomfort, or pain in an infant (Barr et al., 2009).

While these findings are encouraging, others implementing these types of broadly targeted efforts have not achieved comparable results. 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. For example, the medical field has long sought ways to better address healthy child development and child abuse and neglect within clinical settings. Historically, health professionals have faced barriers to using the traditional checkup appointment to carry out this responsibility. Doctors are often uncomfortable discussing sensitive issues, and they frequently lack the training to instigate such conversations and the ability to recognize key warning signs (Benedetti, 2012). Additionally, adequate and comprehensive screening tools have not been made available to all primary care providers (Benedetti, 2012; Dubowitz et al., 2009). The Healthy Steps program, an evidence-based model that places child development specialists within selected pediatric practices, was initially created in 1994 to address this issue. Today, Healthy Steps is available in 17 states and has demonstrated consistent impacts on child health, child development and school readiness, and positive parenting practices (Benedetti, 2012; Caughy et al., 2003; Minkovitz et al., 2003, 2007).

More recently, the Safe Environment for Every Kid (SEEK) program was created to help health professionals address risk factors for child abuse and neglect through a training course, the introduction of a Parent Screening Questionnaire, and the addition of an in-house social worker team to work with families. Two studies were recently conducted to test existing SEEK programs: one to determine outcomes for children and families and

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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one to measure effects on the health professionals participating in the intervention (Benedetti, 2012; Dubowitz et al., 2009). The first was a randomized trial conducted between 2002 and 2005 in resident clinics in Baltimore, Maryland. Families enrolled in the SEEK treatment group showed significantly lower rates of abuse and neglect across all measures compared with controls (Dubowitz et al., 2009). The second study, conducted 2 years later, investigated whether the program changed doctors’ attitudes, behaviors, and competence in addressing child abuse and neglect among their patients (Dubowitz et al., 2011). Eighteen private practice primary care clinics participated in a cluster randomized controlled trial. The pediatricians in the SEEK group showed significant improvement in their abilities to address substance use, intimate partner violence, depression, and stress, and they reported higher levels of comfort and perceived competence in doing so (Dubowitz et al., 2011).

Community Prevention

A focus on the community as an appropriate prevention target is supported by findings of public health surveillance efforts and research on the effects of neighborhood contexts (Coulton et al., 1997; Pinderhughes et al., 2001; Zimmerman and Mercy, 2010). Research using population- and community-level data underscores the pressing need to design, target, and promote preventive service programs in jurisdictions exhibiting the greatest need (Putnam-Hornstein et al., 2011; Wulczyn, 2009). Accordingly, a number of strategies have emerged that focus on ways to better coordinate and integrate services provided through multiple domains and to alter the context in which parents rear their children (Daro and Dodge, 2009). The goal of such efforts is to move from simply assessing the prevention impacts on program participants to achieving population-level change by creating safe and nurturing environments for all children, as well as communities in which parents are supported through both formal services and normative values that foster mutual reciprocity. Although such initiatives are not fully operational in any community, the goal of altering both individuals and the context in which they live potentially provides a potent programmatic and policy response (Daro et al., 2009).

In a recent review of five multicomponent community initiatives, Daro and Dodge (2009) conclude that the implementation of multifaceted interventions that combine direct service reforms with attempts to alter residents’ access to and use of both formal and informal supports are promising but largely unproven. Based on comparisons of administrative data, at least some of the models they reviewed had successfully reduced reported rates of child abuse and injury to young children at the county or community level (Dodge et al., 2004, Prinz et al., 2009), and repeated population-based sur-

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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veys revealed that the models had altered adverse parent-child interactions, reduced parental stress, and improved parental efficacy (Daro et al., 2008). When focusing on community building, several models demonstrated a capacity to mobilize volunteers and engage diverse sectors within the community, such as first responders, the faith community, local businesses, and civic groups, in preventing child abuse (Daro et al., 2008; Melton et al., 2008). At present, however, little information is available on how these attitudes and willingness to support one’s neighbors will translate into a measurable or sustained reduction in child abuse and neglect and enhanced parental support (CDC Essentials for Children, available at http://www.cdc.gov/ViolencePrevention/childmaltreatment/essentials/index.html [accessed March 7, 2014].

Designing and implementing a high-quality multifaceted community prevention initiative is costly. The models examined by Daro and Dodge (2009), each of which focused on only a single county or community within a county, cost approximately $1-$1.5 million annually to implement and evaluate. Moving forward, policy makers need to consider the trade-offs of investing in diffuse strategies designed to alter community context versus expanding the availability of services for known high-risk individuals. For the research community, a potential area of inquiry may lie in examining key mediators of either individual- or population-level outcomes and identifying less costly ways to create these mediators within prevention efforts.

The Bottom Line

Investments in preventing child abuse and neglect increasingly are being directed to evidence-based interventions that target pregnant women, new parents, and young children. Since the 1993 NRC report was issued, the prevention field has become stronger and more rigorous both in how it defines its services and in its commitment to evaluative research. 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.

None of these program approaches are perfect, and they often fail to reach, engage, and retain their full target population successfully. Notable gaps exist in service capacity, particularly in communities at high risk and among populations facing the greatest challenges. And a substantial proportion of those families that do engage in intensive, long-term early intervention programs will exit the services before achieving their targeted

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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program goals. That said, the committee finds the progress in prevention programming to be impressive, but the strategies employed to be underdeveloped and inadequately researched.

Finding: A broad range of evidence-based child abuse and neglect prevention programs increasingly are being supported at the community level to address the needs of different populations. Strategies such as early home visiting, targeting pregnant women and parents with newborns, are well researched and have demonstrated meaningful improvements in mitigating the factors commonly associated with an elevated risk for poor parenting, including abuse and neglect. Promising prevention models also have been identified in other areas, including school-based violence prevention education, public awareness campaigns, parenting education, and professional practice reforms.

Finding: Despite substantial progress in the development of effective prevention models, many of these models require more rigorous evaluation. Research is needed to devise strategies for better reaching, engaging, and retaining target populations, as well as to develop the capacity to deliver services to communities at high risk and among populations facing the greatest challenges.

COMMON ISSUES IN IMPROVING PROGRAM IMPACTS

Developing a pool of high-quality interventions is essential to address the problem of child abuse and neglect. Equally important is understanding how best to replicate, sustain, and integrate these programs into an effective system of care. Unfortunately, in child abuse and neglect as in other areas of health, mental health, and social services, a wide gap exists between available evidence-based interventions and practices and effective methods for their dissemination, implementation, and sustainment. 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). Indeed, the success of efforts to improve services designed to support the well-being of children and families is influenced as much by the process used to implement innovative practices as by the practices selected for implementation (Aarons and Palinkas, 2007; Fixsen et al., 2009; Greenhalgh et al., 2004; Palinkas and Aarons, 2009; Palinkas et al., 2008). It is increasingly recognized that investment in the development of interventions without attention to how they align with service systems, organizations, providers, and consumers results in poor application of evidence-based practices.

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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Indeed, once evidence-based practices are taken to scale, the outcomes and effect sizes documented in their initial clinical trials often are not replicated. One reason for this is that complex interventions frequently are simplified over time in ways that impact key program objectives and strategies (Mildon and Shlonsky, 2011). Poor implementation has been cited as the reason for weakened effects in programs addressing conduct problems (Lee et al., 2008), learning delays (Hagermoser Sanetti and Kratochwill, 2009), crime prevention (Welsh et al., 2010), home visiting (Matone et al., 2012), and various child welfare reforms (Daro and Dodge, 2009). If replicating an evidence-based intervention does not produce a corresponding replication of impact, the intervention cannot be expected to reduce the incidence of the problem it was designed to address. Unless incidence is significantly reduced, the dramatic cost savings purported to follow major investments in high-quality treatment and prevention services may not materialize.

As evidence-based practices move from controlled settings to a real-world context, tension arises between remaining rigidly faithful to the original model and adapting it to local circumstances and needs (Backer, 2001; Bauman et al., 1991). Although adaptation may or may not be a deliberate choice, some form of adaptation is likely to be the rule rather than the exception in community care (Aarons et al., 2012). Ideally, such adaptation does not change the core elements of evidence-based practices, that is, those required elements that fundamentally define the nature of the practices and produce their main effects (Backer, 2001; Bauman et al., 1991; Cardona et al., 2009; Gandelman and Rietmeijer, 2004; Harshbarger et al., 2006; McKleroy et al., 2006; Veniegas et al., 2009).

Understanding when and how to alter a program in ways that enhance rather than diminish its effects represents a major social service challenge. Since the 1993 NRC report was issued, significant research has been conducted on how to define the concept of program fidelity, understand the role of race and culture in determining when and how to adapt evidence-based practices, identify those factors that facilitate or compromise the replication of evidence-based practices with fidelity, and clarify how research can be incorporated into the overall programming planning process. In addition, increased attention is being paid to the costs of interventions relative to their overall impact, resulting in an increased demand for more consistent and comparable methods of quantifying and tracking program expenditures and their long-term impacts on public budgets. This section summarizes this body of research and identifies those areas in need of additional study.

Fidelity as a Strategy for Enhancing Impact

At the most basic level, faithfully replicating programs that have been found effective in rigorous experimental studies is believed to result in a

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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higher likelihood of achieving desired outcomes than replicating programs that lack a strong evidentiary base (Fixsen et al., 2005). Investing in direct service programs with a proven track record offers policy makers a hedge on their investment and provides increased confidence that outcomes also can be replicated. Central to this hypothesis, however, is ensuring that sites replicating a model maintain fidelity to its original design and intent.

As replication of evidence-based programs becomes more commonplace, it is increasingly important to design and implement frameworks for defining program fidelity, as well as data management systems that can track the implementation process at the level of specificity needed to ensure consistent replication. Researchers use several theoretical frameworks to define fidelity and address issues of appropriate modification. In summarizing work in this area, Carroll and colleagues (2007) identify five elements of implementation fidelity: (1) adherence to the service model as specified by the developer, (2) service exposure or dosage, (3) the quality or manner in which services are delivered, (4) participants’ response or engagement, and (5) understanding of essential program elements not subject to adaptation or variation.

The rise of implementation science and the need to replicate and scale up evidence-based programs with fidelity across a range of disciplines has led to the development of a number of frameworks identifying an array of factors that should be considered to ensure that replication is faithful to both the structure and intent of the original model (Bagnato et al., 2011; Berkel et al., 2011; Damschroder and Hagedorn, 2011; Dane and Schneider, 1998; Gearing et al., 2011; Hagermoser et al., 2011). 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. Maintaining fidelity is especially important in practice-based research networks and learning collaboratives because it allows networks to gauge outcomes that can be used to make necessary practice and science improvements. Attention to these factors is necessary both in the initial planning process and throughout implementation.

Evidence-Based Treatments and Culturally Diverse Populations

The importance of cultural processes in shaping human functioning is increasingly being recognized. It is therefore critical to understand whether child abuse and neglect interventions are effective with ethnic minority youth who are at risk for or experience child abuse or neglect. A number of scholars have argued that culture matters in the development and testing of prevention and intervention strategies, as well as in the replication and adaptation of evidence-based practices for distinct populations or groups

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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(e.g., Barrera et al., 2011; Bernal et al., 2009; Lau, 2006). According to this perspective, the culturally related processes underlying parenting and sociocultural risks that can lead to or exacerbate abuse and neglect must be considered to ensure the social validity and practical application of an intervention (Lau, 2006).

Another body of literature comprises evaluation of evidence-based interventions with ethnic minority youth and families, focusing on such questions as (1) Are evidence-based interventions effective for ethnic minority youth?, (2) Do minority youth benefit more when interventions are responsive to their cultural context?, and (3) Is there evidence for either culturally specific or culturally adapted youth interventions? (Huey and Polo, 2008, 2010). This literature is still in its infancy. As discussed earlier in this chapter, the extant literature shows that evidence-based interventions delivered to African American and Latino youth can be effective (for additional discussion of this issue, see Huey and Polo, 2008, 2010). These interventions target a range of concerns, including anxiety-related problems, attention-deficit hyperactivity disorder (ADHD), conduct problems, depression, substance use problems, trauma-related problems, and mixed/comorbid problems. Of note, only four interventions have shown effectiveness with ethnic minority youth across multiple trials: CBT, MST, interpersonal therapy (IPT), and brief solution-focused therapy (BSFT). In addition to these interventions targeting mental health and adjustment problems, a child welfare intervention targeting American Indian parents (Chaffin et al., 2012b) has shown effectiveness. Evidence-based interventions appear to work equally well for African American and Latino youth and European American youth, indicating no consistent effects of moderation (Huey and Polo, 2008).

Although most of the interventions investigated in these studies did not explicitly target ethnic minority youth who were abused and neglected, those interventions that did explicitly include this population yielded similar findings regarding effectiveness, moderation, and the impact of cultural adaptation. However, the discussion of cultural elements in reports on evidence-based interventions varies considerably (Huey and Polo, 2008), which may impede understanding of the impact of cultural adaptation; in particular, reporting of the development and evaluation of many culturally adapted interventions is characterized by a relative lack of theory and conceptual framing. Thus, more research is needed to test key assumptions and hypotheses regarding minority youth and the effectiveness of interventions.

A critical gap in this literature is that evidence-based interventions have been tested primarily with African American and Latino youth; with few exceptions, little is known about the effectiveness of evidence-based interventions with Asian American and American Indian youth. For example, there have been few studies on the effectiveness of home visiting models

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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that involve structured, protocol-driven approaches with families in tribal communities (Del Grosso et al., 2012). 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).

To illustrate these issues, interventions targeting American Indian and Alaska Native families and communities need to take account of their history, culture, and tribal diversity (DeBruyn et al., 2001; Weaver, 2003). Thus, addressing child abuse and neglect and trauma among these populations presents unique opportunities to develop culturally sensitive interventions that align with traditional circular and contextual world views and to adapt or enhance evidence-based practices that are based in authentic practitioner-researcher partnerships (Poupart et al., 2009; Spicer et al., 2012). One prominent example, Project Making Medicine, provides training in the clinical treatment of child physical and sexual abuse based on the cultural adaptation of TF-CBT. Entitled Honoring Children, Mending the Circle, the curriculum features an indigenous orientation to well-being and the use of traditional healing practices. Cultural adaptations to family preservation approaches involve using genograms, wraparounds, talking circles, kinship care, healing ceremonies, and traditional adoptions with Native families. This intervention also incorporates tribal elders and extended family in the use of specific cultural approaches, such as storytelling, sweat lodges, feasts, and use of Native languages (Bigfoot and Funderburk, 2011). The effectiveness of these adaptations of clinical tools and interventions merits further research.

In sum, the field of evidence-based interventions for cultural minority populations is still developing. Research is needed on understudied populations, as well as on key assumptions, hypotheses, and implementation issues of culturally adapted evidence-based interventions. Guidelines on when to consider making a cultural adaptation and how specifically to do so would provide important support for the field. Lau (2006) offers an evidence-based approach to making such decisions. Her framework calls for the selective identification of target problems and/or communities for which adaptations are appropriate. More specifically, populations that face unique sociocultural contexts of risk or resilience that differ from those targeted by the original evidence-based intervention may be appropriate candidates for cultural adaptation. When it is determined that cultural adaptation is warranted, Lau further suggests a data-based approach to decisions on the adaptations to implement. Surface-structure adaptations (Resnicow et al., 2000) (e.g., language translation, use of videos or books that depict a cultural group, interventionists who share the same cultural background as target families) are designed to make interventions more accessible, whereas

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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deep-structure changes are designed to make interventions more effective and target underlying cultural values.

One example of this data-based approach is the cultural adaption of the evidence-based program Guiando a Niños Activos (Guiding Active Children, or GANA), a version of PCIT for Mexican American families (McCabe et al., 2005). A multistep process was used, including a review of the clinical literature on Mexican American families; identification of known barriers to treatment access and effectiveness; use of focus groups; and interviews with Mexican American mothers, fathers, and therapists to learn how PCIT could be modified to be more culturally effective. The process culminated in an expert panel review of the intervention (Lau, 2006). Another example, The Children and Families (as part of the National Child Traumatic Stress Network), addressed the treatment and service needs of traumatized Latino children and families through the creation of adaptation guidelines for practitioners and researchers. These guidelines address micro- and macro-level domains related to child abuse and neglect, including assessment, provision of therapy, communication and linguistic competence, cultural values, immigration/documentation, child welfare/resource families, service utilization and case management, diversity among Latinos, research, therapist training and support, organizational competence, system challenges, and policy (Workgroup on Adapting Latino Services, 2008). 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).

In such efforts, it is important to attend to the theoretical, implementation, and evaluation issues involved. Perhaps the data-based framework articulated by Lau (2006) can help inform a more rigorous articulation of the circumstances in which evidence-based interventions should be culturally adapted and of the methods that should be used to evaluate the adapted interventions.

The Implementation Process

Since the 1993 NRC report was issued, significant work has been done on how to define and monitor the program implementation process itself and on the critical factors related to higher-quality implementation and sustainability. Consensus exists on important key factors, such as availability of funding; leadership in implementation efforts; ongoing consultation and training, especially in the early implementation phases; and the need to address the impact of staff turnover. In many cases, however, research on these factors is lacking (Aarons et al., 2009a). Consensus also exists that multicomponent implementation strategies are needed, as many different

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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factors need to be addressed in sequence or in tandem for effective implementation that sustains public health impact (Ferlie and Shortell, 2001; Fixsen et al., 2009; Glisson and Schoenwald, 2005; Grimshaw et al., 2001; Grol and Grimshaw, 1999).

Implementation frameworks have been developed to expand and distill theories, structures, and processes into manageable approaches for understanding and identifying key facilitators of and barriers to effective implementation. Most theories provide guidance regarding implementation research and practice, while particular tenets and assumptions of frameworks require further empirical testing to determine whether they actually lead to more effective implementation (Aarons et al., 2011). Implementation researchers typically test components of models (e.g., technology-assisted coaching, organizational improvement) 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) and the use of interagency collaborative teams to scale up SafeCare across an entire large county.

To support program fidelity, effective and efficient measurement methods that can be readily utilized in usual care settings are needed (Schoenwald et al., 2011). In addition, there must be a feedback system coupled with supportive quality improvement or coaching to help providers maintain fidelity (Aarons et al., 2012). In many cases, however, little ongoing attention is paid to fidelity once an intervention has been implemented. Delivery of an intervention without attention to its fidelity fails to ensure that services are effective.

Efforts have been made to integrate fidelity assessment for psychosocial interventions in systems that involve child abuse and neglect; however, these efforts may or may not be part of implementation studies. One effectiveness trial found that incorporating ongoing coaching to direct service providers in the delivery of a child neglect intervention supported service efficacy (Chaffin et al., 2012a). This statewide trial was also examined in an implementation study that found benefits for organizations and service teams in reduced provider burnout and turnover. There is also increasing interest in the use of technology to support real-time fidelity assessment.

It is important to recognize that many program implementation efforts have occurred in the context of funded research studies. Outside research funding often covers the costs associated with initial monitoring and documentation of the implementation process, including the collection and analysis of participant-level data to document service dosage, duration, and content. In some cases, study subjects have been paid for their participation in the program and may have received reimbursement for child care

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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or transportation expenses related to their participation. As evidence-based practices move from the research venue to standard practice, some entity must pay these costs.

Increasingly, evidence-based practice models are factoring into their per-participant cost projections those expenses associated with initial and ongoing training for direct service staff, supervisory standards, and data reporting requirements. State agencies or community-based service providers seeking to implement these models are required to cover these costs as part of purchasing the program. It remains unclear whether these program-driven standards will be sufficient to sustain program fidelity and quality over time and achieve the level of participant engagement required to both sustain program fidelity and replicate outcomes.

Integration of Research into Practice

Most implementation plans for evidence-based practices include methods for transferring research evidence from the program developers to potential users. Some of these models focus explicitly on the use of research evidence (Honig and Coburn, 2008; Kennedy, 1984; Nutley et al., 2007); in other cases, the use of research evidence is embedded in broader processes of innovation, including the dissemination and implementation of evidence-based practices (Fixsen et al., 2005; Greenhalgh et al., 2004).

Many of these models represent typologies of research use. For instance, several researchers have distinguished between an instrumental model, in which “use” consists of making a decision, and research evidence is assumed to be instructive to that decision, and a conceptual model, in which “use” consists of thinking about the evidence. Whereas the central feature of the instrumental model is the decision, the central feature of the conceptual model is the human information processor. Hence, the instrumental model focuses on the outcome of using evidence, while the conceptual model focuses on the process of using evidence (Kennedy, 1984).

Conceptual models of evidence acknowledge that the use of research evidence to make or support decisions is often a collective endeavor rather than an activity performed by any individual decision maker (Spillane et al., 2001). This collective endeavor involves the utilization of social capital (Honig and Coburn, 2008; Spillane et al., 2001), social networks (Valente, 1995; Valente et al., 2003), and the exchange of knowledge or information between researchers and practitioners and within networks of practitioners (Lomas, 2000; Mitton et al., 2007; Nutley et al., 2007).

Preliminary research (Palinkas et al., 2012) 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-

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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net searches) was the most frequently accessed source of information on evidence-based practices, followed by local experts and knowledgeable personal contacts. Feasibility of implementation was the primary criterion used to evaluate this evidence. However, further research is needed to identify components of feasibility that may drive implementation decisions.

Capacity to Identify Costs and Cost-Effectiveness Across Approaches

Policy makers, program administrators, and researchers increasingly acknowledge the importance of understanding the costs, cost-effectiveness, and returns on investment of child abuse and neglect programs.

Policy makers want information on costs and how they compare with outcomes of interest for determining how to allocate scarce resources; program administrators want to identify which programs to implement; and researchers are interested in economic evaluation because it makes their program evaluations more comprehensive (Corso and Lutzker, 2006; Courtney, 1999). The demand for economic analysis is evident in strategic planning being developed at the federal level. In the Centers for Disease Control and Prevention’s research plan for injury and violence prevention, for example, a top priority is to describe the use and impact of service delivery as well as the costs of interventions for child abuse and neglect. (Corso and Filene, 2009, p. 78)

Assessment of the economic costs of implementing an intervention is called programmatic cost analysis. The process involves the systematic collection, categorization, and analysis of intervention delivery costs, including those entailed during the preimplementation (developing the program delivery infrastructure) and implementation (delivering the program) phases (Corso and Filene, 2009). A standardized methodology for determining costs for child abuse and neglect interventions does not currently exist, although guidelines available in other fields could be applied (Foster et al., 2003, 2007; Haddix et al., 2003; Yates, 2009). 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.

Once the costs of a program have been determined, they can be compared with a program’s expected and realized short- and long-term outcomes. This comparison of costs with outcomes is referred to as economic evaluation and includes a number of analyses, such as benefit-cost analysis and return on investment, whereby outcomes are valued in monetary terms, and cost-effectiveness analysis, whereby outcomes are valued in natural units, such as cases of child abuse and neglect prevented or improvements in quality of life. Although some guidelines for conducting economic evalu-

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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ations do exist for community-level interventions in general (Haddix et al., 2003; Shiell et al., 2008), the literature is sparse on how specifically to conduct economic evaluations of family and child development interventions.

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 cost analyses (Corso and Filene, 2009) or economic evaluations have been conducted in this area since the 1993 NRC report was issued (Barlow et al., 2007; Dalziel and Segal, 2012; DePanfilis et al., 2008; Karoly et al., 1998; McIntosh et al., 2009; Olds, 1993). More studies have focused specifically on economic evaluation of interventions designed to improve outcomes for children at risk for or currently involved in the child welfare system (these studies are systematically reviewed and summarized by Goldhaber-Fiebert and colleagues [2011]).

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) the development and consistent use of standardized methodology for assessing program costs; (2) multisite assessment of programs in which program-, provider-, and community-level variables may impact program-level costs and outcomes; (3) better tools for assessing the impact of child abuse and neglect on health-related quality of life, which is an important outcome measure in economic evaluations within other health fields; (4) assessment of the long-term costs of child abuse and neglect to determine the potential benefits of prevention and successful child welfare services; and (5) the development and use of model-based economic evaluations to support decision making within the child welfare system (Goldhaber-Fiebert et al., 2011).

The Bottom Line

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 high-quality interventions are replicated, adapted to diverse populations, and incorporated into the overall service delivery system. At present, little is known about the most effective strategies for ensuring that evidence-based practices are replicated with fidelity to their intent and structural elements. Central here is determining which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations. Equally important is understanding the costs associated with the emphasis on replicating with fidelity in terms of (1) monitoring the service delivery process; (2) providing the required levels of supervision and infrastructure support, including the development of data

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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collection systems; and (3) determining how the data will be integrated into subsequent practice and policy decisions.

Finding: Despite a growing body of theoretical and applied research in the area, a wide gap exists between available evidence-based interventions and practices for treating and preventing child abuse and neglect and methods of effective dissemination, implementation, and sustainment of those interventions. It is increasingly recognized that investment in developing interventions alone, without attention to how they align with service systems, organizations, providers, and consumers, results in poor application of evidence-based practices. Therefore, more research is needed to support the translation of model programs for effective use in real-world settings.

Finding: Little is known about the most effective strategies for ensuring that evidence-based interventions are replicated with fidelity to their intent and structural elements. Further research is needed to determine which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations.

Finding: More research is needed on the development of evidence-based interventions for cultural minority populations, with a particular focus on understudied populations. Also needed is research that carefully examines key assumption, hypotheses, and implementation issues of culturally adapted evidence-based interventions. Guidelines on when to consider making a cultural adaptation and what the specific adaptation should be would provide important support to the field.

Finding: Significant advances have been achieved in how the program implementation process itself is defined and monitored and in the identification of critical factors related to higher-quality implementation and sustainability. Consensus exists on key factors, but in many cases, research on these factors is lacking. 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 programmatic cost analyses or economic evaluations in this area. This type of research is needed to guide policy makers and program administrators.

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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BUILDING AN INTEGRATED SYSTEM OF CARE

As the discussion in this chapter has made clear, several of the challenges faced in replicating promising programs and their outcomes lie in the process by which programs are designed and implemented. Equally important, however, is considering the programs’ institutional, organizational, and political context. Elements of this broader infrastructure can support or complicate the implementation and sustainability of a promising approach (Tibbits et al., 2010; Wandersman et al., 2008).

Social service programs benefit from an array of elements that strengthen their capacity to deliver high-quality services consistently. These elements have been organized conceptually into three groups: (1) foundational infrastructure (planning and collaboration); (2) implementation infrastructure (operations and workforce development); and (3) sustaining infrastructure (fiscal capacity, community and political support, communications, and evaluation) (Paulsell et al., 2012).

Child abuse and neglect is a complex issue with diverse causal pathways, manifestations, and affected populations. Therefore, multiple high-quality interventions are needed to address it. An effective response to the problem would be facilitated by a more explicit focus on building an infrastructure that can support the most promising interventions as they emerge and link them in ways that maximize their collective impact.

Unfortunately, limited research has been conducted on the potential impact of infrastructure reforms on program implementation and participant outcomes. Although efforts aimed at enhancing the knowledge and skills of the workforce in order to strengthen organizational capacity to support evidence-based practices or at reducing barriers to service access through better interagency coordination make sense, relatively little is known about how to accomplish these improvements. This section briefly reviews the literature on the impact of organizational culture and interagency networks on the implementation and sustainability of evidence-based programs.

Organizational Culture

The quality of services provided to families and children is influenced not only by the rigor of a program’s design and its implementation but also by the organizations in which services are embedded. Studies of organizational context have found associations between an organizational culture and climate and participant outcomes (Glisson and Hemmelgarn, 1998). 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).

This relationship between organizational culture and program imple-

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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mentation is reciprocal. The implementation of evidence-based practices can adversely impact organizations by adding to the workload of an already overworked labor force or by leading to increased employee turnover as staff are asked to change their practices and adopt new strategies that may restrict their sense of control over the therapeutic process (Glisson et al., 2008; Sheidow et al., 2007; Woltmann et al., 2008). On the other hand, organizations also can benefit from the implementation of evidence-based practices. These benefits include enhanced professional identity, improved client outcomes, and the gratification of contributing to a process of knowledge generation (Aarons and Palinkas, 2007; Palinkas and Aarons, 2009). One statewide study of implementing evidence-based practices found that ongoing fidelity coaching predicted decreased staff burnout and reduced staff turnover (Aarons et al., 2009b).

These benefits aside, the culture of evidence-based practices that stems from an empirically based research perspective and the culture of child abuse and neglect practice may be at odds, engendering a gap that must be bridged if effective implementation is to be achieved (Palinkas et al., 2009). Even something as basic as the reporting of child abuse and neglect may be impacted by organizational context (Ashton, 2007). 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).

While some of the above-mentioned studies assess or deliberately alter organizational context, others examine or cite organizational context as important in the implementation of evidence-based practices (Kolko et al., 2012). Yet while there have been calls for increased attention to organizational context in the dissemination and implementation of evidence-based practices (Chaffin, 2006; Kessler et al., 2005), much research remains to be done on how organizational context in child abuse and neglect settings impacts the implementation process.

Interagency Networks

Although many factors influence the diffusion of evidence-based practices in general, “researchers have consistently found that interpersonal contacts within and between organizations and communities are important influences on the adoption of new behaviors” (Brekke et al., 2007; Palinkas et al., 2005, 2011, p. 8; Rogers, 2003). Based on diffusion of innovations theory (Rogers, 2003) and social learning theory (Bandura, 1986), Valente’s (1995) social network thresholds model calls for identification and matching of champions within peer networks that manage organizational agenda setting, change, and evaluation of change (e.g., data collection, evaluation,

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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and feedback) and use information technology processes consistent with continuous quality improvement strategies (Palinkas et al., 2011).

Studies and meta-analyses have shown that both the influence of trusted others in one’s personal network and access and exposure to external information are important influences on rates of adoption of innovative practices (Palinkas et al., 2011). Across a series of studies, Valente and colleagues found that individuals who were most innovative almost always had the highest exposure to external influences (Valente and Davis, 1999; Valente et al., 2003, 2007). Although external influence played a crucial role in bringing an innovation to an individual’s attention, it was usually the persuasion of trusted others that finally convinced the individual to adopt the innovation (Valente, 1995). Other empirical studies have confirmed the importance and influence of opinion leaders (e.g., Jung et al., 2003). It has also been hypothesized that leaders in dense or centralized groups may have more power than leaders not in such groups (Valente, 2006), although this has not been found in all influence networks (Valente et al., 2007).

Applying this theoretical framework to child abuse and neglect, Palinkas and colleagues (2011) 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. Networks expose leaders to information about evidence-based practices and opportunities to adopt them, and also influence decisions to adopt. In that study, individuals in counties at the same stage of implementation of multidimensional treatment foster care accounted for 83 percent of all network ties. Networks in counties that decided not to implement a specific evidence-based practice had no extracounty ties. Implementation of multidimensional treatment foster care at the 2-year follow-up of a randomized controlled trial funded by the National Institute of Mental Health was associated with the size of the county, urban versus rural counties, and in-degree centrality (i.e., the extent to which others interacted with specific network members).

Successful, large-scale incorporation of evidence-based practices in existing child-serving systems is likely to involve multiple levels of constituents, in part because the new practices affect multiple stakeholders in the funding, planning, coordination, delivery, and receipt of services. Further, the successful implementation of many evidence-based practice models requires substantial interagency linkages.

In their report from the Blueprints programs, Mihalic and colleagues (2004) found these linkages to be a crucial factor in whether the programs had stable funding, a stable referral base, and coordinated case planning activities, especially for youth involved in multiple systems. In addition to

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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interagency coordination, these linkages often include system-level factors that impact the implementing organization’s operation; that relate to federal and state laws and regulations; and that impact larger human resource decisions (e.g., collocation of staff from multiple agencies), access to funding streams, and contracting issues.

Most evidence-based practice implementation studies that focus on interorganizational collaboration fail to consider the wider context within which collaboration occurs, including such factors as the involvement of external stakeholders, sociopolitical processes, and the roles of relationships and leadership (Horwath and Morrison, 2007). Increasingly, this context is characterized by government mandates and fiscal realities that require collaboration in the form of integrative multidisciplinary practice in the delivery of children’s services (Ehrle et al., 2004; Hogan and Murphey, 2002). In a sociopolitical climate in which organizations face increasing budget restrictions and are challenged to do more with less, collaboration across agencies and organizations appears to be critical for successful implementation of evidence-based practices. In turn, an understanding of effective collaboration appears to be at the core of many evidence-based practices developed to improve outcomes in child-serving systems (Prince and Austin, 2005).

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. Although many consider such collaboration to be essential to the delivery of a complex array of services (Jones et al., 2004; Lippitt and van Til, 1981; Stroul and Friedman, 1986), others have questioned its usefulness on both theoretical (Scott, 1985) and empirical (Glisson and Hemmelgarn, 1998; Longoria, 2005) grounds. Several studies have pointed to improved access to services and improved outcomes associated with interagency collaboration (Bai et al., 2009; Cottrell et al., 2000; Hurlburt et al., 2004). However, Glisson and Hemmelgarn (1998) found that efforts to coordinate the services of public child-serving agencies in Tennessee were negatively associated with the quality of services provided. And Chuang and Wells (2010) found that while interagency sharing of administrative data increased the odds of youth receiving inpatient behavioral health services, having a single agency accountable for youth care increased the odds of receiving both inpatient and outpatient services.

In part, this inconsistency in findings may be attributable to differences in the definition and operationalization of key terms. For instance, some researchers have distinguished among collaboration, cooperation, coordination, and networking, whereas others have used these terms interchangeably (Grace et al., 2012; Hodges et al., 1999). Others view interagency collaboration as an aspect of organizational culture, defined as “the way things are done in an organization” (Glisson, 2007, p. 739).

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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Specific factors that have been found to contribute to successful interagency collaboration for child welfare and other agencies include shared goals, a high level of trust, mutual responsibility, open lines of communication, and strong leadership (Johnson et al., 2003; Weinberg et al., 2009). Barriers to effective collaboration include deeply ingrained mistrust and continued lack of other agencies’ values, goals, and perspectives; different organizational priorities; confusion over how services should be funded and who has jurisdiction over participants; and difficulty in tracking cases across organizations (Conger and Ross, 2006; Green et al., 2008; Sedlak et al., 2006).

The Bottom Line

Treatment and prevention programs generally are delivered by public agencies or community-based organizations. The operating culture within these entities has an impact on the quality of services and the extent to which evidence-based practices will be implemented and sustained over time. Research suggests that a degree of reciprocity exists between service models and their host agencies. 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 evidence-based models to accommodate an agency’s limited resources contribute to poor implementation and reduced impacts. Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of the agencies in which such models and approaches are embedded and how these factors impact service implementation.

Equally important is developing a research base that can inform the process of building a collaborative culture and a set of working relationships across the institutions and community-based agencies that constitute the child maltreatment response system. Because child abuse and neglect is a complex, multifaceted problem with myriad causes, promising treatment and prevention strategies lie within a variety of disciplines and multiple institutions. Additional research is needed to understand how these multiple institutional resources can be integrated in ways that reinforce the impact of these individual strategies in the most efficient and cost-effective manner.

Finding: Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of the agencies in which such models and

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

approaches are embedded and how these factors impact service implementation.

Finding: Multiple high-quality interventions and strategies must be sustained to address child abuse and neglect—a complex problem with diverse causal pathways, manifestations, and affected populations. An effective response to the problem would be facilitated by a more explicit focus on building an infrastructure that can support the most promising interventions as they emerge and link them in ways that maximize their collective impact.

Finding: Because child abuse and neglect are complex, multifaceted problems with myriad causes, a variety of disciplines and multiple institutions support treatment and prevention programs. Additional research is needed to understand how these multiple institutional resources can be integrated in ways that reinforce the impact of individual strategies in the most efficient and cost-effective manner.

Finding: Limited research has been conducted on the impact of infrastructure reforms on program implementation and participant outcomes. More research is needed to determine how best to direct efforts aimed at enhancing the knowledge and skills of the workforce, strengthening organizational capacity to support evidence-based practices, and reducing barriers to service access through better interagency coordination.

CONCLUSIONS

Significant advances in the development of child abuse and neglect treatment and prevention strategies have been realized since the 1993 NRC report was issued. This work has been informed by the growing body of research on the causes and consequences of abuse and neglect, as well as research assessing the efficacy and effectiveness of interventions. In the treatment domain, TF-CBT, a brief structured program based on well-established theory and treatment elements, has been tested extensively and found to be effective with children affected by abuse and other traumatic experiences. 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. As this chapter has reported, outcomes include not only improvements in behavior problems caused by child abuse and neglect but also reduced need for subsequent child welfare involvement.

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
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With respect to prevention, strategies such as early home visiting targeting pregnant women and parents with newborns are well researched and have demonstrated meaningful improvements in factors commonly associated with an elevated risk for poor parenting, including abuse and neglect. Promising prevention models also have been identified in other areas, including school-based education in violence prevention, public awareness campaigns, parenting education programs, and professional practice reforms. As in the past, communities continue to invest in and support a broad continuum of prevention services that address the needs of different populations and utilize different institutional resources. In contrast to the reality in 1993, policy makers and practitioners have a much stronger pool of candidate programs on which to draw in both remediating the impacts of abuse and neglect and reducing its incidence.

Also important is tracking the long-term, second-generation effects of current interventions. Few program evaluations have tracked participants longitudinally, and even fewer have examined the potential effects of high-quality treatment and prevention services on the parenting practices and abuse or neglect potential of children whose parents receive these interventions. Such research is needed to determine the most promising investments.

Improving the performance of evidence-based programs is the subject of considerable ongoing theoretical and applied research designed to increase understanding of how interventions are implemented, replicated, and sustained. 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 high-quality interventions can best be replicated, adapted to diverse populations, and incorporated into the overall service delivery system.

At present, little is known about the most effective strategies for ensuring that evidence-based practices are replicated with fidelity to their intent and structural elements. Central to this discussion is determining which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations. Equally important is understanding the costs associated with an emphasis on replicating with fidelity in terms of (1) monitoring the service delivery process; (2) providing the required levels of supervision and infrastructure support, including the development of time-sensitive data collection systems; and (3) determining how the data will be integrated into subsequent practice and policy decisions.

Research suggests that a degree of reciprocity exists between service

Suggested Citation:"6 Interventions and Service Delivery Systems." Institute of Medicine and National Research Council. 2014. New Directions in Child Abuse and Neglect Research. Washington, DC: The National Academies Press. doi: 10.17226/18331.
×

models and their host agencies. In some instances, the rigor and quality of 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 evidence-based models to accommodate an agency’s limited resources contribute to poor implementation and reduced impacts. Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of the agencies in which such efforts are embedded and how these factors impact service implementation.

Finally, this chapter’s review underscores the absence of research on the question of system reform and the infrastructure required to institutionalize and support it. Little research exists on how best to improve interventions and agency performance in the areas of workforce development, data management, and system integration. Although some preliminary research has been conducted in the area of system integration, clarity is lacking on which strategies are most effective in building a collaborative culture and set of working relationships across public institutions and between these institutions and the community-based agencies that constitute the child abuse and neglect response system. Because child abuse and neglect is a complex, multifaceted problem with myriad causes, a variety of disciplines and multiple institutions support treatment and prevention programs. Additional research is needed to understand how these multiple institutional resources can be integrated in ways that reinforce the impact of individual strategies in the most efficient and cost-effective manner.

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Each year, child protective services receive reports of child abuse and neglect involving six million children, and many more go unreported. The long-term human and fiscal consequences of child abuse and neglect are not relegated to the victims themselves -- they also impact their families, future relationships, and society. In 1993, the National Research Council (NRC) issued the report, Under-standing Child Abuse and Neglect, which provided an overview of the research on child abuse and neglect. New Directions in Child Abuse and Neglect Research updates the 1993 report and provides new recommendations to respond to this public health challenge. According to this report, while there has been great progress in child abuse and neglect research, a coordinated, national research infrastructure with high-level federal support needs to be established and implemented immediately.

New Directions in Child Abuse and Neglect Research recommends an actionable framework to guide and support future child abuse and neglect research. This report calls for a comprehensive, multidisciplinary approach to child abuse and neglect research that examines factors related to both children and adults across physical, mental, and behavioral health domains--including those in child welfare, economic support, criminal justice, education, and health care systems--and assesses the needs of a variety of subpopulations. It should also clarify the causal pathways related to child abuse and neglect and, more importantly, assess efforts to interrupt these pathways. New Directions in Child Abuse and Neglect Research identifies four areas to look to in developing a coordinated research enterprise: a national strategic plan, a national surveillance system, a new generation of researchers, and changes in the federal and state programmatic and policy response.

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