INSTITUTE OF MEDICINE AND
NATIONAL RESEARCH COUNCIL
OF THE NATIONAL ACADEMIES
Strategies for Scaling Tested and Effective Family-Focused Preventive Interventions to Promote Children’s Cognitive, Affective, and Behavioral Health—Workshop in Brief
On April 1–2, 2014, the Board on Children, Youth, and Families of the Institute of Medicine and the National Research Council held a 2-day workshop titled “Strategies for Scaling Tested and Effective Family-Focused Preventive Interventions to Promote Children’s Cognitive, Affective, and Behavioral Health.” The purpose of the workshop was to discuss the successes and challenges of scaling family-focused interventions. A range of settings involved in preventive family-focused interventions were highlighted, including primary care settings, schools, homes, and on the Web. Collectively this knowledge will be used to explore new and innovative ways to broaden the reach of effective programs and to generate alternative paradigms for strengthening families.
This brief summary of the workshop highlights topics raised by presenters and participants. It represents the viewpoints of the speakers and should not be viewed as the conclusions or recommendations of the workshop as a whole.1
1 The full workshop summary, speaker presentation slides, and session videos are available online, http://www.iom.edu/Activities/Children/ChildrensHealthForum/2014-APR-01.aspx.
Over the last three decades, there has been remarkable progress in creating and testing family-focused programs aimed at promoting the cognitive, affective, and behavioral health of children. These programs include universal interventions, such as those for expecting parents, as well as programs targeted to parents in challenging situations, such as low-income, single teens about to have their first babies.
Some family-focused programs have been shown to foster significantly better outcomes in children across a range of outcomes. In addition, the favorable cost–benefit ratios of some of these programs are due, in part, to the multiple and long-term effects that family-focused prevention programs targeting children can have. Other family-focused programs have shown success in smaller academic studies but have not been widely applied, or have not worked as effectively when applied to diverse real-world settings. The workshop planning committee selected family-focused programs to discuss at the workshop that have been tested and implemented across a range of settings (e.g., primary care, homes, schools, and online) and that target different time periods during development spanning prenatal development to adolescence. Box 1 contains a complete list of the programs presented at the workshop along with links to full program descriptions.
Despite the potential for widespread economic and social benefits, a challenge remains to provide family-focused interventions across child and adolescent development at sufficient scale and reach to significantly reduce the incidence and prevalence of negative cognitive, affective, and behavioral outcomes in children and adolescents nationwide.
Improved Outcomes Due to Family-Focused Preventive Interventions
Individual speakers presented findings from large-scale, well-controlled studies that demonstrated positive outcomes as a result of family-focused programs.
Margot Kaplan-Sanoff, Associate Professor of Pediatrics at Boston University School of Medicine, described Healthy Steps as an evidence-based model focused on the social and emotional well-being of young children and the prevention of mental health concerns. Healthy Steps enhances well-child care by adding a Healthy Steps Specialist to the pediatric practice team. This specialist has an advanced degree in nursing, child life, early childhood mental health, or social work, and provides the continuity of care for families between their scheduled well-child visits. Positive outcomes from the Healthy Steps program include parents having greater knowledge of infant development, better recognition of appropriate discipline, greater compliance with vaccination schedules, and increased satisfaction with their pediatric care, as well as being less likely to disengage from it. In addition, findings have shown sustained treatment effects on a range of outcomes, including that parents were more likely to report challenges with child behavior to the clinician, more likely to receive anticipatory guidance, more likely to report children were reading and looking at books more, and less likely to use severe punishment.
Keeping Foster and Kin Parents Trained and Supported (KEEP)
Patricia Chamberlain, a research scientist at the Oregon Social Learning Center, described positive outcomes from KEEP, an evidence-based support and skill enhancement education program for foster and kinship parents of children ages 5 to 12. KEEP is designed to strengthen the skills of foster parents with the aim of improving child behavior and reducing placement disruptions from foster care. KEEP has been shown to increase the chances of a positive exit from foster care (e.g., parent/child reunification), mitigate risks from a history of multiple placements, and reduce child behavior problems.
Nurse–Family Partnership (NFP)
NFP is a prenatal and infancy nurse home-visiting program targeting low-income, first-time mothers. David Olds, Director of the Prevention Research Center for Family and Child Health and founder of NFP, described large, well-controlled studies in diverse communities that found consistent improvements across a range of outcomes as a result of the NFP program, including improvements in prenatal health, reductions in children’s injuries, improvements in children’s language development and school readiness (those born to low-resource mothers), reductions in children’s behavioral problems, reductions in children’s depression, reductions in children’s substance use, reductions in maternal behavioral impairment due to substance use, increased interbirth intervals, increased maternal employment, and reduction in welfare and food stamp use.
The Incredible Years® (IY)
IY is a group of programs designed to promote positive emotional and social development in young children ages 0 to 12 years old. IY developed seven different programs aimed at parents; two programs for children, one prevention and one treatment; and one teacher training program. Carolyn Webster-Stratton, Professor Emeritus at the University of Washington and founder of The Incredible Years® Series for Parents, Children, and Teachers, presented findings from randomized controlled trials that showed that IY increased positive parenting practices and improved children’s social skills, problem solving, ability to control anger, and school readiness. IY has also been shown to decrease harsh discipline by parents, as well as children’s conduct problems at home and in school.
Programs Presented at the Workshop
Advanced Parenting Education in Pediatric Settings (APEP)
Autism Navigator (online program)
Familias Unidas and Familias Unidas Online
The Incredible Years®
Keeping Foster and Kin Parents Trained and Supported (KEEP)
Parent Management Training Oregon Model
Triple P—Positive Parenting Program and Triple P Online
Triple P—Positive Parenting Program
Ron Prinz of the Parenting & Family Research Center at the University of South Carolina described meta-analyses of the efficacy of Triple P and Stepping Stones Triple P, a variant of the program for parents of children with developmental disabilities. These meta-analyses demonstrated positive effects on children’s social, emotional, and behavioral outcomes; parenting practices; parenting satisfaction and efficacy; and child–parent relationships. In addition, The Washington State Institute for Public Policy determined that for children in the child welfare system, there is nearly a $9 return on investment with Triple P.
Family-Focused Preventive Interventions in Pediatric Settings
Pediatric practices have emerged as important settings to implement family-focused programs. Kaplan-Sanoff described some of the advantages to providing family-focused programs aimed at promoting children’s mental, emotional, and behavioral health within pediatric settings, including
- Pediatric primary care can be a powerful point of entry into services because it offers a window of opportunity for families to learn not only about their child, but also about themselves as parents.
- Pediatricians have high credibility and are trusted by parents; therefore, they can be valuable agents for validating positive parenting practices.
- Care provided in a pediatric setting is nonstigmatizing because everyone with a child goes to a pediatrician, not just those with problems.
- One of the best ways to help children is to help their parents. Primary care is a setting in which the well-being of both parents and children may be addressed.
- Primary care is relatively accessible and affordable.
- Offering family-focused programs in a pediatric setting may allow for high program recruitment and retention rates.
There are also challenges to delivering a program in a primary pediatric setting, such as time constraints for office visits, training of pediatricians, confidentiality issues, and misaligned billing mechanisms.
Kaplan-Sanoff noted that pediatricians’ time is limited, so they tend to welcome a program when specialists (who may be nurses, social workers, or other types of nonphysician providers) are brought in as part of the care team, which helps to minimize burden on physicians. Ellen C. Perrin of the Tufts University School of Medicine added that the American Academy of Pediatrics (AAP) and the American Academy of Child and Adolescent Psychiatry are currently interested in expanding team-based care, which would allow for more creativity in implementing family-focused interventions.
Another challenge is the lack of a clear billing structure for these services, said Thomas Dishion of Arizona State University. If the issue of billing could be solved, Dishion suggested, pediatrics is a fantastic setting for delivering services to promote children’s cognitive, affective, and behavioral health.
Vera Frances Tait from AAP said that the organization looks for models to make the business case both for getting the services that children and families need, and for proper payment for what is provided, particularly for prevention but also for treatment. One way to create and test those models, Tait suggested, is via the Center for Medicare & Medicaid Innovation, which evaluates projects for their use of innovative payment and service delivery models to reduce program expenditures while preserving or enhancing the quality of care in Medicare, Medicaid, and the Children’s Health Insurance Program.
Thomas Boat of the University of Cincinnati added that a lack of training on family-focused programs in pediatric practices is impeding the extent to which pediatricians are applying this approach to serving families. Practitioners in medicine do what they were taught to do, Boat said, and pediatricians, nurses, and social workers are not being sufficiently trained about these programs.
In addition to health care staff receiving the right training, Dishion added, national associations for school counselors, social workers, and other relevant professionals could have exposure to family-focused prevention programs as part of their training standards.
Recently pediatric training has begun to include some limited training in developmental behavioral pediatrics, Perrin said. She added that side-by-side training is key to team-based care, wherein training programs include pediatricians, social workers, and psychologists who all learn side-by-side about collaboration.
Strategies for Meeting Scale-Up Challenges
Despite the scale-up successes reported at the workshop and the recent expansion of family-focused prevention programs into new settings, the potential of many evidence-based interventions is often not fully realized, several speakers pointed out. Workshop participants described strategies to facilitate the scale-up of effective family-focused preventive programs.
Generating demand. Several participants noted programs tend to be more successful if there is consumer support for them; local, agency, and political champions of them; and if the right program is matched to the right organization.
Agency, provider, and workforce incentives. Dishion suggested providing incentives for host agencies and for the leaders that are championing adopting evidence-based practices.
Building capacity. Building capacity of program providers involves ongoing training and coaching of staff. Mary Jane Rotheram-Borus of the David Geffen School of Medicine at the University of California, Los Angeles, reported that Chorpita and Daleiden have identified a dozen basic skills (self-monitoring, problem solving, cognitive styles, goal setting, praise rewards, assertiveness, attention, modeling, monitoring, relaxation, response cost, and mirroring) that are needed for 80 percent of all child and adolescent evidence-based interventions. Webster-Stratton pointed out that in addition to the initial training for staff, there needs to be ongoing coaching, consultations, or supervision by accredited coaches, mentors, or trainers.
Providing a supportive infrastructure. David Hawkins, Social Work Endowed Professor of Prevention at the University of Washington School of Social Work, noted the need to create the organizational capacity, demand, and infrastructure necessary for dissemination and implementation. In addition, it is necessary to monitor implementation while allowing some flexibility to achieve objectives, he said. Brian Bumbarger, Founding Director of EPISCenter, emphasized the need for infrastructure support to ensure quality improvement at the individual, provider, community, and state levels. Ruth Perou, Lead Behavioral Scientist at the Centers for Disease Control and Prevention, suggested sharing tools, strategies, and technologies that facilitate scale-up. Mary Ann McCabe, American Psychological Association, suggested there are opportunities available through capitalizing on new digital technologies.
Building sustainable funding. Programs will not be implemented properly and maintained in the long-term unless they acquire sustainable funding. Several sources for that funding were discussed at the workshop, including service grants; tiered evidence-based funding and Pay for Success grants; public–private partnerships; braided funding from different agencies; and new reimbursement options under the Patient Protection and Affordable Care Act (ACA). McCabe suggested designing evidence-based programs for the funding streams that can support them in a range of settings where children and families receive services.
Researching implementation strategies. Several participants noted the lack of evidence-based implementation strategies and suggested more research be done in this area. Lauren Supplee, Director of the Division of Family Strengthening at the Administration for Children and Families, suggested gathering more empirical evidence on capacity building; effectiveness across different populations and contexts; workforce qualities needed to implement particular interventions with fidelity; moderating factors for quality implementation at scale; and economic costs and benefits of implementing at scale.
Scale-up and implementation of family-focused prevention programs are sometimes aided by intermediary entities. Summarized below are strategies used by intermediary entities to aid scale-up of evidence-based family-focused prevention programs that were discussed at the workshop.
Invest in Kids
Invest in Kids works to improve the health and well-being of vulnerable children and families throughout Colorado. In partnership with local communities, Invest in Kids identifies, implements, and works to sustain evidence-based prevention programs. Lisa A. Hill, Executive Director of Invest in Kids, described strategies used by this intermediary organization, including
- Partner with the local community to ascertain what services best match the needs of that particular community.
- Conduct a national search for the most appropriate evidence-based and cost-effective programs.
- Lobby state and local legislators, using data, to demonstrate the need for and expected outcomes of selected programs.
- Build political support and investment by local leadership.
- Provide ongoing support and monitoring of program implementation.
Evidence-Based Prevention and Intervention Support (EPIS) Center
EPISCenter supports the dissemination, quality implementation, sustainability, and impact assessment of a menu of effective prevention and treatment intervention programs. EPISCenter also conducts original translational research to advance the science and practice of evidence-based prevention. Bumbarger described strategies used by this entity, including
- Disseminate evidence-based interventions to address strategically identified needs in specific populations and tailor the scale-up approach to the needs and capacity of that particular intervention.
- Support providers before a program is adopted to build capacity for implementation and knowledge of what will be needed to evaluate program implementation and effectiveness.
- Provide the prevention infrastructure necessary to have a population-level health impact, including data infrastructure to assess needs, monitor progress, and track implementation.
- Assume responsibility for solving any challenges to effective scale-up of interventions, whether faced by program developers, program implementers, and/or program funders.
SAMHSA (Substance Abuse and Mental Health Services Administration) Strategic Prevention Framework
SAMHSA provides grants to states, localities, and tribes to develop the infrastructure necessary to support the development of a coordinated strategic plan for the prevention programs they provide. Strategic framework plans are required to include a data-based prevention assessment and outcome evaluation. Clarese Holden from SAMHSA’s Division of State Programs described strategies of this grant program, including
- Provide grants to states, jurisdictions, and tribes to create strategic plans for prevention programs, including support for coordination and infrastructure building, that are specific to the needs of the given community.
- Encourage and support assessment, capacity building, planning, implementation, evaluation, cultural competence, and sustainability.
Project LAUNCH (Linking Actions for Unmet Needs in Children)
Project LAUNCH is a SAMHSA grant program designed to promote the social, emotional, behavioral, and physical health of young children from birth to 8 years of age. Project LAUNCH grantees employ five core strategies: developmental assessment, integration of behavioral health into primary care settings, home visiting, mental health consultation, and family strengthening and parent skills training. Holden described additional strategies of this grant program, including
- Focus on both systems improvement and implementation of evidence-based prevention programs.
- Foster collaboration across sectors.
- Enhance and expand programs rather than reinvent them.
- Infuse mental health knowledge and expertise into all early childhood settings.
PROSPER (PROmoting School-community-university Partnerships to Enhance Resilience)
PROSPER facilitates sustained, high-quality delivery of evidence-based programs that reduce risky youth behaviors, enhance positive youth development, and strengthen families. This delivery system links university-based prevention researchers with two established program delivery systems within a state—the Cooperative Extension System at the Land Grant University and the public school system. Richard Spoth of the Partnerships in Prevention Science Institute described strategies used by this approach, including
- Small, strategic community teams and university prevention researchers form partnerships.
- Prevention coordinators provide ongoing, proactive technical assistance, and act as a liaison between community teams and university researchers.
- Provide training on rigorous and continuous monitoring of program implementation quality.
- Gain efficiency through program sustainability.
New York State Office of Mental Health’s (NYSOMH’s) Clinic Technical Assistance Center
NYSOMH’s Clinic Technical Assistance Center (CTAC) aids all 350 of the NYSOMH-licensed clinics serving children and families in building their capacity to provide higher-quality services. Kimberly Hoagwood, Director of CTAC, described some of the strategies used:
- Determine the most appropriate training topics and formats for each NYSOMH clinic.
- Offer technical assistance through webinars, in-person consultation, and learning collaboratives on business practices, organizational capacity, leadership support, and evidence-based practices.
- Work with clinics to ascertain how adoption of a program will affect productivity and budget (e.g., billing for services).
- Support continuous collection of quality improvement data on implemented programs.
The REACH Institute of Arizona State University offers infrastructure support to program providers. Dishion described some strategies used by the REACH Institute:
- Online capacity for low-cost training.
- Digital platforms for data collection and delivery of program protocols.
- Reduce upfront expenses for agencies as they adopt new programs.
Washington State Institute for Public Policy (WSIPP)
WSIPP carries out practical, nonpartisan research—at legislative direction—on issues of importance to Washington State. Stephanie Lee, Senior Research Associate at WSIPP, described strategies used by this organization:
- Meta-analyze rigorous evaluations of programs and policies designed to improve public outcomes in a range of areas that are of legislative interest.
- Apply a consistent, cross-cutting approach to computing benefits, costs, and risk.
- Assess whether an evidence-based program will yield a positive return on investment, if implemented.
- Evaluate economic costs and benefits of implementing an evidence-based program.
DISCLAIMER: This workshop in brief has been prepared by Tara Mainero, rapporteur, as a factual summary of what occurred at the meeting. The statements made are those of the authors or individual meeting participants and do not necessarily represent the views of all meeting participants, the planning committee, or the National Academies.
REVIEWERS: To ensure that it meets institutional standards for quality and objectivity, this workshop in brief was reviewed by J. David Hawkins, School of Social Work, University of Washington, and Thomas F. Boat, University of Cincinnati College of Medicine and Cincinnati Children’s Hospital Medical Center. Chelsea Frakes, Institute of Medicine, served as review coordinator.
SPONSORS: This workshop was partially supported by American Academy of Pediatrics; the American Board of Pediatrics; the American Orthopsychiatric Association; the American Psychological Association; the Annie E. Casey Foundation; Autism Speaks; the Centers for Disease Control and Prevention; the Department of Justice Office of Juvenile Justice and Delinquency Prevention; the Hogg Foundation for Mental Health; the National Institutes of Health; the Robert Wood Johnson Foundation; the Society for Child and Family Policy and Practice; the Society of Clinical Child and Adolescent Psychology; the Society of Pediatric Psychology; the Substance Abuse and Mental Health Services Administration; and the William T. Grant Foundation.
For additional information regarding the workshop, visit http://www.iom.edu/childrenshealthforum.