Symposium by faculty of the University of Maryland School of Social Work’s Center for Families

1. Child Neglect: Assessing the Meaning of Risk and Protective Factors and Evaluating the Cost Effectiveness of a Preventive Intervention Symposium by faculty of the University of Maryland School of Social Work’s Center for Families Eighth Annual Conference of the Society for Social Work and Research, New Orleans, January 17, 2004

2. Acknowledgements • Family Connections • Original support received from U.S.D.H.H.S. Children’s Bureau, Grant 90-CA1580* • Diane DePanfilis, PI • Howard Dubowitz & Esta Glazer-Semmel, Co-PIs *Symposium papers produced with data from this study.

3. Acknowledgements • Other Support Received by Family Connections • UMB Title IVE Education for Public Child Welfare Program • U.S.D.H.H.S., SAMHSA, Center for Substance Abuse Prevention • Georgia State University & the Hasbro Foundation • MD Department of Human Resources • MD Children’s Trust Fund • U.S.D.H.H.S. Children’s Bureau Replication grant • Annie E. Casey Foundation

4. Purpose of Symposium • Answer questions via secondary analysis of data released in 2002, presented at SSWR in 2003: • What risk and protective factors influence a caregiver’s motivation to change? • What risk and protective factors affect the quality of physical and psychological care? • How cost effective is this preventive intervention?

5. Inputs Activities Short-Term Outcomes Long-Term Outcomes Resources Services Intermediate Longer Term Outcomes Benefits *OCAN *Annie E. Casey *DHR *Title IVE Multi-Faceted Home Based Intervention -Emergency Services -Family Assessment -Outcome driven, tailored services Increase Protective Factors Decrease Risk Factors Child Safety Child Well-Being Logic Model

6. 3-Month Intervention Emergency assistance Home based counseling services Family Assessment Referrals for other services if indicated Service coordination and facilitation 9-Month Intervention Emergency assistance Home based counseling services Family Assessment Outcome driven service plans Service Referrals Service coordination and facilitation Intervention:Random assignment Social work interns followed an intervention manual to deliver services to both groups.

7. Highlights of the Original Study • Random assignment to 3- or 9-month intervention • Self-directed, computer-assisted interview • Standardized self-report measures administered at baseline, case closure, and six-month follow-up • Standardized self-report and observational measures integrated with intervention • ANOVA with Repeated Measures ITT Analyses

8. 98% female (151 females, 3 males) 86% African American Mean age= 39 years old 62% had less than high school degree 58% unemployed 19% employed full-time, 8% employed part-time, 10% in training, 5% retired 65% never married 13% separated, 10% divorced, 7% widowed, 5% married Study Sample: Caregiver Demographics

9. Average number of children in families = 3 1 child - 17% 2 children - 25% 3 children - 27% 4 or more - 31% Mean age = 9 (range 1 month to 21 years) 49% female and 51% male Relationship to caregiver 78% are children 14% are grandchildren 8% are other relative Study Sample: Child Demographics

10. Summary of Selected Results • Results for Both Groups • Reduction of risk factors (depressive symptoms, life stress, parenting stress) • Enhancement of protective factors (social support, parenting attitudes, parenting satisfaction) • Increase in Child Safety (physical and psychological care) • Increase in Child Well-Being (child behavior)

11. Summary of Selected Results (cont’d) • Comparison of Intervention Groups • 9 month intervention demonstrated greater • reduction of depressive symptoms • reduction of externalizing and internalizing child behavior

12. Neglect Symposium Paper 1: The Influence of Risk and Protective Factors on Motivation to Change atIntake Diane DePanfilis Heather Girvin Clara Daining Eighth Annual Conference of the Society for Social Work and Research, New Orleans, January 17, 2004

13. Research Question: Paper 1 • What risk and protective factors influence a caregiver’s self-report of motivation to change at Intake?

14. Rationale • Growing interest in client motivation and its connections to engagement, attrition, and outcomes. • In this sample, caregivers did not participate evenly in the intervention. • Ongoing difficulties in conceptualizing and measuring client motivation in meaningful ways. • An enhanced understanding of client motivation may contribute to the development of tailored services. • Efforts to “meet clients where they are” should include assessments of readiness.

15. Procedure • Explored the bivariate relationship between risk and protective factors and a motivation to change index • Entered variables with a significant relationship into a hierarchical regression model (n=154)

16. Measures • IVs • Block 1: # of children • Block 2: • Depressive symptoms (CES-D) • Parenting stress (PSI) • Social support (SPS) • DV • 5 item self-report index of motivation to make changes in family’s current situation

17. Findings Higher Motivation to Change (lower scores) related to: • Having more children (β = -.193, p = .012) • Lower depressive symptoms (β = .190, p = .029)

18. Findings Higher Motivation to Change NOT related to: • Parenting Stress (β =.152, p = .077) • Social Support (β = -.149, p = .073)

19. Limitations • Self-report data • Conceptualizing caregiver motivation • Motivation index (measurement challenges) • Lack of longitudinal data on caregiver motivation

20. Implications • Risk and protective factors that are related to child neglect may also shape client motivation. This finding could have important implications for practice: • Assessing client motivation • Identifying clients with an accumulation of risk/protective factors that foster/frustrate motivation • Tailoring services • Motivation and engagement as targets of intervention • Remaining questions • Directions for future research

21. Neglect Symposium Paper 2: Predictors of Caregiver Ability to Provide for the Physical and Psychological Care of their Children Carmen Morano Susan Zuravin Donna Harrington Diane DePanfilis Eighth Annual Conference of the Society for Social Work and Research, New Orleans, January 17, 2004

22. Research Question: Paper 2 • What risk and protective factors affect the quality of physical and psychological care of children at Intake?

23. Procedure • Conducted two hierarchical regression models with data from the baseline interview: • First step: Social support variables entered • Second step: Caregiver characteristic variables entered • Model 1: Physical care (N=99) • Model 2: Psychological care (N=95)

24. Measures • IVs • Block 1: • Sense of Community (subscale PNS) • Social Support (SPS) • Block 2: • Depressive symptoms (CES-D) • Motivation to Change • Mental Health (FRS) • Substance Abuse (FRS) • DVs • Physical Care (CWBS) • Psychological Care (CWBS)

25. Findings Better Physical Care* was related to: • More neighborhood support (β = .283, p = .019) • Lower motivation for change (β = .264, p = .021) • Better caregiver mental health (β = -.212, p = .053) • Fewer caregiver substance abuse problems (β = -.242, p = .025) *The Final Model accounted for 22% variance in physical care

26. Implications for Practice • Improve mental health assessment and treatment of all caregivers • Provide systemic substance abuse treatment • Advocate for and facilitate the strengthening of neighborhood support

27. Neglect Symposium Paper 3: Assessing the Cost-Effectiveness of a Child Neglect Preventive Intervention Jim Kunz Diane DePanfilis Eighth Annual Conference of the Society for Social Work and Research, New Orleans, January 17, 2004

28. Research Question: Paper 3 • How cost effective is a longer preventive intervention in relation to a shorter, more intensive intervention?

29. Aims of Presentation • Differentiate between cost-effectiveness and cost-benefit • Which of the two approaches (FC-3 or FC-9) is most cost-effective? • What are implications of analysis for future research?

30. Analytical Question Source: Levin & McEwan, Cost-Effectivenss Analysis, 2nd ed.

31. Measure of Outcomes Source: Levin & McEwan, Cost-Effectivenss Analysis, 2nd ed.

32. Strengths Source: Levin & McEwan, Cost-Effectivenss Analysis, 2nd ed.

33. Weaknesses Source: Levin & McEwan, Cost-Effectivenss Analysis, 2nd ed.

34. Procedure • Calculate the costs associated with two interventions: • FC3 – Family Connections for 3 months • FC9 – Family Connections for 9 months • Develop cost effectiveness ratios for FC3 and FC9 • Compare ratios between groups

35. calculate the average cost per client during a typical month • apportion the average cost between variable & fixed costs • determine # of hours of service for FC3 & FC9 • apportion variable costs between FC3 & FC9 • sum up variable & fixed costs for each group to obtain the average per-month cost per client in each group • multiply the average cost per client by the number of months served. Calculation of Cost: Methodology

36. We calculated total costs incurred in February 2000. We picked this month to avoid unusual expenses associated with the start-up of the project. In this month, 54 families (both 3-month and 9-month) were served at a total cost of $15,748, yielding an average monthly cost per client of $292. 1. Calculating the average monthly cost per client

37. 2. Apportioning average cost between variable (e.g., staff time) and fixed costs We determined that of the $292 spent per client, $258 was used to pay for staff time, which varied between the two groups, and $34 was used for fixed costs associated with each group.

38. 3. Determining the amount of staff time spent providing either direct or indirect service

39. 4. Apportioning variable costs between the 3-month and 9-month clients Based on the previous table , we apportioned the variable cost for any two clients ($584) as follows: 57%, or $333, for a 3-month client and 43%, or $251, for a 9-month client.

40. 5. Summing up variable and fixed costs for each group to obtain average monthly cost per client in each group

41. 6. Deriving total average cost per client for each intervention We multiplied the monthly average cost for 3-month clients by three to obtain an average cost for 3-month client of $1,101, compared to an average cost for 9-month client of $2,565 ($285*9).

42. 9-month intervention cost approximately 2.3 times as much as 3-month intervention • Above ratio reflects more intensive service provided to 3-month clients (if not, then 9-month intervention would have cost 3 times as much) • Above ratio suggests that 9-month outcomes that do not improve by as much as a factor of 2.3 over 3-month outcomes will not be as cost-effective Calculation of Cost: Implications for Cost-Effectiveness

43. For outcomes that did not improve over time, cost-effectiveness analysis is inappropriate • For outcomes that improved over time but for which there were no significant differences between groups, we can assume that FC3 was more cost-effective • For outcomes in which there were significant differences between groups, we calculated cost-effectiveness ratios (lower ratio implies more cost-effective alternative) Calculating Cost-Effectiveness Ratios

44. Cost-Effectiveness Ratios: Depressive Symptoms

45. Cost-Effectiveness Ratios: CBCL Internalizing

46. Cost-Effectiveness Ratios: CBCL Externalizing

47. For most interventions (for which there were no significant differences between groups), FC3 was more cost-effective. • FC9 was more cost-effective for 2 of the 3 outcomes for which there were significant differences. • CBCL Internalizing and Externalizing Scores • FC9 was slightly less cost-effective in bringing about change in depressive symptoms. Conclusions

48. Directions for Future Research • Complete additional psychometric testing of motivation index. • Assess alternative conceptualizations (and measures) of client motivation. • Explore possible associations among client motivation, other risk/protective factors, and/or outcomes.

49. Directions for Future Research • Evaluate primary prevention strategies for improving neighborhood support • Evaluate targeted systemic change strategies to reduce caregiver substance abuse • Evaluate FC change strategies with other at risk populations

50. Directions for Future Research • May want to analyze cost-effectiveness among those who completed program • In future projects (e.g. FC-I), capture more accurate cost data for program alternatives • Consider undertaking cost-benefit analysis (difficult to do but has advantages over cost-effectiveness)