Designing Evidence-Informed Family Informed Services for Neglecting Children & Families

1. Presented to the 2010 Annual Meeting of the Translational Research on Child Neglect Consortium and the Brown School of Social Work Washington University September 23, 2010 Richard P. Barth, PhD University of Maryland School of Social Work Designing Evidence-Informed Family Informed Services for Neglecting Children & Families Portions of the paper presented are based on research funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, under contract 233-03-0099. Points of view or opinions in this presentation do not necessarily represent the official position or policies of the U.S. DHHS.

2. Summary … In Closing • It’s time for real-time applications of family information to guide practice • Cumulative family risk is an important one 2. I’ve been wrong—oh so wrong! • My calls for a focus on “Evidence Based Parent Training” have been too narrow • MORE FOCUS NEEDED ON “EVIDENCE-BASED FAMILY WORK” • There are some great starts at using family information to guide interventions

3. Efforts toward Interdisciplinary Practice to Prevent Child Neglect • Sharing Existing Information in Real Time • Birth Match (Matching Birth Information and CWS History) • CAPTA implementation Cross-reporting newborn substance abuse to child welfare services Cross-referring substantiated child abuse reports to Early Intervention Services • Gathering Information that is Missing and Putting it Right to Use • SEEK (A Safe Environment for Every Kid)

4. Family Cumulative Risk as Predictor • Family and Community Risk has turned out to be a highly useful predictor of development (well-being) in NSCAW (and can be generated from routine risk assessment)

5. NSCAW & NEILS Study on CAPTA and Early Intervention Services Integration Half of all infants and toddlers had a low score on a developmental measure Measured Delay = 49% High Risk = 28% (5 or more risk factors but no measured delay) Lower Risk = 23% (< 5 risk factors and no measured delay)

6. The proportion of children with a measured delay who have a substantiated maltreatment report does not differ from children investigated for maltreatment without a substantiated report.

7. Defining Risk • 56% have 5 or more risk factors • 82% had at least 4 risk factors • Virtually all had at least 2 risk factors (99%) • Maltreatment co-occurs with other problems, placing children at-risk for developmental delay & later school difficulties

8. 36 Months After Baseline Compared To 18 Month Follow-up • 36 months after baseline only13%High Risk; 42% Measured Delay, 45% Lower Risk • 72% LR remain the same, 22% now with a Measured Delay • Only 28% of HR classified the same,37% now with Measured Delay Diagonal = Percent unchanged

10. Families Experience Behavior Problems • Despite their young age, young maltreated children have relatively high levels of behavior problems reported by their caregivers— 24% of mothers report a clinical I or E score on CBCL, a proportion that increases from 18-months • Yet support to families is very short term-- only 13% of maltreated/substantiated children were still receiving part C services at 36 months • Yet, support to families is very short-term

11. Family Focused Services Dwindle by 18- & 36-Months. • Families are receiving parent training and family counseling services through Child Welfare Services or by referral. • These services may have a child development component but are unlikely to be very effective in addressing developmental disadvantages.

12. CAPTA EIS Summary • Based on Measured Delay and/or High Risk, 79% of CWS investigated children were identified as having a measured delay or high risk status • High risk children have an elevated likelihood for poor developmental outcomes, including school-age problems • Children with more than 5 recognized risk factors at baseline are almost certain to develop measured delays that remain at 36 months

13. Other NSCAW Family Cumulative Risk Findings • NSCAW studies of CWS Decision Making indicate its importance • Family Cumulative Risk Also Has Strong Relationship to Service Decisions • Substantiation • Placement into Foster Care

14. Family Cumulative Risk • NSCAW : Extent of Children’s Mental Health Problems (McCrae & Barth, 2008) • Three clinical measures, the CBCL/YSR,TSCC, and CDI, were combined to create a dichotomous measure of: Clinical Mental Health Problem at Intake (y/n) • Risk Assessment indicators of “family cumulative risk” (21 items) were quite accurate in predicting the measured scores of mental health symptoms (MHS) • Identified 75% of 2 to 6 year olds with MHS • Identified 80% of 7 to 14 year olds with MHS

15. Other Examples of Important Findings of Family Risk and Child Outcomes

16. Adverse Family/Childhood Events Predict Violence as Adolescents • Has any adult in your household ever hit you so hard or so often that you had marks or were afraid of that person? (10.4%)          • Has any older or stronger member of your family ever touched you sexually or had you touch them sexually? (2.6%)          • Has any adult or other person outside the family ever touched you sexually against your wishes or forced you to touch them sexually? (5.1%)     • Has alcohol use by any family member repeatedly caused family, health, job, or legal problems? (14.5%)          • Has drug use by any family member repeatedly caused family, health, job, or legal problems? (10.1%)          • Has anyone in your family ever hit anyone else in the family so hard or so often that they had marks or were afraid of that person? (11.6%) •  3 or more Yeses, Total = 6.1% (Duke et al., 2010, MN Study)

17. Cumulative Risk & Educational Outcomes in Philadelphia • Odds ratios (Rouse & Fantuzzo, 2009) based on predictions using 1, 2, or 3 family risks (derived from administrative data from homelessness of parent, birth risk, poverty, child maltreatment, low maternal education) and controlling for gender and race • Poor Reading Achievement 1.28 • Poor Mathematics Achievement 1.21 • Second Grade Retention 1.31

18. Family-Informed Interventions are Emerging • Birth Match (MI, MD, NYC) • Project SEEK (UMB SOM) • Family Connections (UMB SSW) • Child and Family Center “EcoFit” Programs (U of OR)

19. Birth Match • ASSUMPTION: Children born to parent(s) who have had a previous birth result in the involuntary termination of parental rights (TPR) are at serious risk • EVIDENCE is Indirect • Conditions that result in TPR are often persistent • Substance abuse, maternal depression, unsafe living circumstances (Jonson-Reid et al., 2010) • Newborns are most at risk of death from abuse or neglect

20. Making Very High Risk Births Known to Child Welfare Services (CWS) • History • Under PL 96-272, every child was “entitled” to reasonable efforts to prevent placement • Family history did not (legally) matter • Adoption and SAFE Families Act (1997) • Egregious family history must lead to consideration of “reunification bypass” • Family history matters

21. Making Very High Risk Births Known to Child Welfare Services (CWS) • Birth Match • MICHIGAN: When a parent who has previously had a Termination of Parental Rights gives birth to another child, CWS matches births against TPR database and commences CWS investigation • Policy Presumption that the parent will not continue to care for the child—requires program manager signature to leave newborn in the home • Daily matches • Also now includes violent felons and sexual perpetrators

22. Making Very High Risk Births Known to Child Welfare Services (CWS) • Birth Match • MARYLAND: Department of Health Vital Statistics accepts TPR lists on a weekly basis from DSS and returns matches of children born in the last week who were born to mothers with prior TPRs • A CWS “assessment” is made of the situation • No presumption of any subsequent action • Look back for TPRs is limited to TPRs in the last 5 years

23. Making Very High Risk Births Known to Child Welfare Services (CWS) • NEW YORK CITY • Administrative Policy (not law) • NO BIRTH MATCH • Workers who notice that a mother who has a child in foster care is pregnant, they initiate the investigation • PRESUMPTION: If the home environment is not suitable for a child then it is not suitable for a newborn • Requires Director override to leave newborn in home

24. Using Administrative Data in Real Time • It’s time for researchers and agency leaders to develop real-time advantages from research • Learning what is happening to newborns at the very beginning of life is vitally important WHY ONLY 3 BIRTH MATCH PROGRAMS? • Getting family matches across systems of care is difficult • Health department treats birth information with an exceptional degree of confidentiality • Attorneys believe that CWS assessments are a detriment to their adult clients

25. Project SEEK • Pediatricians working to understand family risks • Referrals to clinic social workers to improve care and reduce child maltreatment

26. “Bright Futures” Developmental Screening Instruments: AAP Endorsed • Ages and Stages Questionnaire • Battelle Developmental Inventory (BDI) Screening Test • Bayley Infant Neurodevelopmental Screener (BINS) • Brigance Screens-II • Infant Development Inventory • Child Development Review • Child Development Inventory (CDI) • Denver-II Developmental Screening Test • Parents' Evaluation of Developmental Status (PEDS) BUT WHAT’S MISSING?

27. What’s Missing in “Bright Futures” Pediatric Screening? • Family (Parent) Well-Being Measures • The future isn’t bright if your parent is suffering • SEEK Parent Screening Questionnaire (PSQ3): Safe Environment for Every Kid

28. SEEK: Easy as 1, 2, 3 … 4 • Medical residents who received specialtraining (on the importance of family risks for preventing maltreatment, some resources, and motivational interviewing) • Parent Screening Questionnaire (SEEK) completed in waiting room • Referral to asocial worker (1 per every 7 physicians • Parent and child (0-5)

29. SEEK Study Design 1118 parents approach, 35% refused or excluded, 23% did not complete protocol. Final 308 (T) and 250 (C)

30. SEEK Items • Do you need the phone number for Poison Control? • Do you need a smoke detector for your home? • Does anyone smoke tobacco at home? • In the last year, did you worry that your food would run out before you got money or Food Stamps to buy more? • In the last year, did the food you bought just not last and you didn’t have money to get more? • Do you often feel your child is difficult to take care of? • Do you sometimes find you need to hit or spank your child?

31. SEEK Items (continued) • Lately, have you often felt down, depressed, or hopeless? • Lately, have you felt very little interest or pleasure in things you used to enjoy? • Have you ever been in a relationship in which you were physically hurt or threatened by a partner? • Have you ever felt you should cut down on drinking or drug use? • Have you ever felt your partner should cut down on drinking or drug use? • Are there any other problems you’d like help with today? For more information about SEEK, umm.edu/pediatrics/seek_project.htm

32. SEEK Social Work Procedures • The intervention clinics have a social worker who worked closelywith the residents and families • Residents and parents chosewhether to involve the social worker • Pediatric management often involvedguidance and support in the clinic and referrals to communityagencies

33. SEEK: Sample and Results • 93% African American, 87% Single • 32% Employed (38% < HS Education) • Fewer adults than children in the homes • 93% received Medical Assistance MAJOR RESULTS: After onset of the SEEKintervention, there were fewer CPS reports among interventionfamilies (19.2% vs 13.3%; P < .05); 69% of reports were for neglect.

34. Family Connections Core Practice Components • Home visiting family intervention • Advocacy • Service coordination with referrals targeted toward risk and protective factors; and • Multi-family supportive and recreational activities. • Tailored and direct trauma-informed services to help families reduce risks, maximize protective factors, and achieve service outcomes and goals.

35. Family Connections • Preliminary results from a cross site evaluation by James Bell Associates (JBA) indicate that similar positive changes in risk and protective factors over time were observed in 8 programs replicating FC • Families that were purposefully served for longer (9-12 months) versus shorter (3-6 months) achieved greater improvements in parenting attitudes and child behavior.  • Families served by workers who implement FC with a higher degree of fidelity also achieve greater change in family and child level outcomes. 

36. 8-Site Replication Results So Far • FC holds promise for promoting family well-being by reducing risk factors and increasing protective factors for preventing child neglect • Better outcomes were achieved when the levels of implementation fidelity were higher Filene, Smith & Kass(June, 2010). Presentation to Society for Prevention Research, Denver.

37. Family Check Up

38. Family Check Up • The intervention services are family centered • They address and support parents of children and adolescents in the change process. • They focus on supporting parents’ leadership role in their children’s lives. • The intervention services are family assessment driven • Decisions about how to tailor interventions to individual and family needs are based on careful assessments of the child and family at home and the child in school.

39. Family Check Up • Lessons Learned from Family Check Up • To prevent child behavior problems there may be a need to intervene early and directly with: • (a) the emotional climate of the family and • (b) the emotional climate of the parenting relationship. • These facets of child and family dynamics are highly interrelated and often need to be addressed together

40. Prevention of Child Abuse Occurrence, Recurrence, & Impairment Must be Family Focused FAMILY FOCUS NFP, Early Start (NZ), Triple P (AUS) Source:MacMillan et al. (2009). Lancet

41. Family Data: Waste Not, Want Not We waste untold amounts of family data • Birth data is overprotected and underused • (Nearly) every state collects risk assessment data and then fails to put it into play with administrative data • Every state collects family based foster care and adoption licensing and home studydata but fails to use that information to understand placement outcomes • Every state collects TANF addresses and adoption subsidy data and address payment data for families but fails to keep track of when subsidy change requests are frequent or address changes are frequent—perhaps signaling family instability

42. Opportunism and Incrementalism • Gregg Bloche (2007) and Janet Bronstein (2008), writing about health care, have argued that system reform is most likely to arise in an incremental manner from existing institutional arrangements. • They assert that we should be opportunists, keeping our eyes open for examples of local changes and established local arrangements to improve the quality of care.

43. Opportunism and Incrementalism • So, what can we learn from this approach of examining local developments? • To try and test a variety of ways to achieve work with “Family Data”: • birth records, administrative children’s services and health records, measurement feedback systems, brief assessments, co-located services, and family centered case management reimbursement mechanisms • You can think of more

44. The Grass Isn’t Greener on the “other side” or on “your side” -- it’s greener where you water it…We have to more thoroughly water family assessment and data integration if we will be powerful interventionists

45. Thank You Very Much Additional Questions or Comments?

46. Partial References Berrick, J. D., Choi, Y., D'Andrade, A., & Frame, L. (2008). Reasonable Efforts? Implementation of the Reunification Bypass Provision of ASFA. [Article]. Child Welfare, 87(3), 163-182. Bloche, M. G. (2007). A graveyard for grand theory. [Article]. Health Affairs, 26(6), 1534-1536. doi: 10.1377/hlthaff.26.6.1534 Bronstein, J. M. (2008). Policy levers that improve low income children's access to mental health services. [Editorial Material]. Medical Care, 46(6), 555-557. Chambers, R. M., & Potter, C. C. (2009). Family Needs in Child Neglect Cases: A Cluster Analysis. [Article]. Families in Society-the Journal of Contemporary Social Services, 90(1), 18-27. doi: 10.1606/1044-3894.3841. DePanfilis, D., Dubowitz, H., & Kunz, J. (2008). Assessing the cost-effectiveness of Family Connections. Child Abuse & Neglect, 32(3), 335-351. Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009). Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model. [Article]. Pediatrics, 123(3), 858-864. doi: 10.1542/peds.2008-1376. Duke, N. N., Pettingell, S. L., McMorris, B. J., & Borowsky, I. W. (2010). adolescent violence perpetration: associations with multiple types of adverse childhood experiences. [Article]. Pediatrics, 125(4), E778-E786. doi: 10.1542/peds.2009-0597. Filene, JH, Smith, E. G, & Kass, L. (2010). Implementation of an evidence-based child neglect prevention program: findings from a multi-site replication of Family Connections. Presented at the Society for Prevention Research, Denver, CO, June 3, 2010. Gonzalez, A., & MacMillan, H. L. (2008). Preventing child maltreatment: An evidence-based update. [Article]. Journal of Postgraduate Medicine, 54(4), 280-286.

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