data and more data: exploring rct methodology marh 27, 2013 university of stirling, scotland lynn...
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Data and More Data: Exploring RCT MethodologyMarh 27, 2013
University of Stirling, Scotland
LYNN MCDONALD, MSW, PHDPROFESSOR OF SOCIAL WORK RESEARCHMIDDLESEX UNIVERSITY, LONDON
RCTs on Partnerships to EngageParents in Low-Income
Communities to Reduce Child Neglect
An Evidenced Based Parenting Programme by a Social Work
Academic
Specify a social problem; look for basic research and relevant theories from social sciences; create social interventions which can move Theories into practice and apply social research with vulnerable populations; consider multi-family groups; conduct qualitative research and feedback loops from service users and practitioners; test promising social work approaches with randomized controlled trials in distinct disadvantaged communities. Build quality assurance structures for replication and assess continuously with service user feedback.
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A Social Problem: Child Neglect
Half of safeguarding referrals are for neglectStressed and isolated families have higher risk
of both abusing and neglecting a childChild neglect causes impaired learning, poor
health, increased aggression and teenage pregnancy (5x higher than no neglect)
Children in poverty at more risk of neglect: If family lives <$15,000 versus >$30,000, 44
times more likely the child is neglected
ACE Correlates with Adult Health
ACE (Adverse Child Events) retrospective data from 3353 women (aged 47) on reports of child neglect & abuse
Correlated with increased health problems as adults Substance abuse, depression, suicide, eating disorders,
anxiety Physical health: cardiovascular, cancer, stroke, hypertension
Medical service utilization high for adults with ACE Emergency rooms, outpatient hospital, pharmacy, primary
care, specialty care
Protective factors: For Child: quality of parent-child bond For Child: one caring relationship over time to turn to when stressed For Parent: social network of support; social capital; extended family For Parent: feeling self-efficacious; empowered voice and agency
Risk factors Child neglect: no provision of shelter, food, and emotional bonds Family has chronic stress, conflict, violence, substance abuse,
depression, mental health problems Family is socially isolated from extended family, friends, neighbors Family experiences social exclusion, racism, health disparities Parents are oppressed, no control over own life, no respect, no voice Poverty, lack of housing, employment, education, health services
Risk and Protective Factors of Child Neglect
High Stress Effects a Child’s Development
Stress changes the brain and alters chemical neurotransmitters related to violence
Stress changes gene expression of childNeglect/abuse correlates with high sustained
stress (cortisol) = damaging to child’s brain High stress causes low immune systems and
children get sick more often and heal slowlyHigh stress puts child into survival mode, and
stressed children cannot learn new things: academics, mathematic, reading or writing
Caring Relationships Can Buffer the Impact of High Stress on a Child’s Development
Sustained high stress (cortisol) levels are destructive to a child’s brain development and other organs
15 minutes of one to one responsive play reduces stressHigh stress levels can be managed with a responsive
parent who shows their love and Notices child’s emotions and is tuned in to the child Is available to the child under stress Asks questions and listens Is physically soothing and touches the child Plays responsively with no bossing, and follows the child’s lead
(Sue Gerhardt, 2002,Why Love Matters)
High Stress Diverts Parental Focus on Child
Cannot focus on child’s needs; not emotionally intellectually Not enough time, no time for seeing friends/family for support Use of computers, mobile phones, TV divert focus from child Work and transport to work; employment insecurity, food
insecurity, residential instability, chronic stresses of poverty Fear of inadequate medical and dental care, support services Trapped in a dangerous neighbourhood Trapped in a dangerous relationship Daily experience of stigma and social exclusion, racism Feelings of helplessness, hopelessness, low sense of agency
Low hope and mood, low patience, irritability, distracted, anxious
Court ordered Daily In Home Visits (3 mo)
To try to reduce placement of 0-5 child abuse and neglect cases into foster care: daily visits for three months to the home and 2x weekly intensive family therapy sessions: reduced 55% with Safe at Home
Daily coaching of one to one responsive play by a trained assistant; first listen to the parent for 15 minutes; then coach the parent for 15 minutes
Dramatic increase in child well-being; often a distressed parent swings from neglect to abuse
Court Ordered Parenting Classes, Groups
In US, 1 million reports of child neglect and abuse annually; 2/3 are substantiated
448,000 parents ordered to attend parenting classes Parenting problems of caregivers are 1 in 12 about
excessive discipline; neglect is over 50% of casesParenting programmes generally over-focus on
control alternatives to reduce excessive disciplineAgencies prefer brief, low cost groups, linear ideas Most programmes are untested with little evidence
Parenting Skills vs Stress of Social Isolation
A classic study was conducted on court ordered behavior modification parenting groups referred by the child protection workers for child abuse/neglect
Prof Robert Wahler taught behavior modification techniques with success in parenting knowledge
Six months later he assessed their use of new skillsIf they had no friends or positive extended family
social support, i.e. socially isolated, they did not use the parenting skills they had learned (insular parent)
Social capital and Stress and Child Neglect
Chronic stress and social isolation increase child neglect: stresses of poverty, social exclusion reduce parents’ ability to be responsive and parent positively
Social capital reduces stress o Social ties and inclusion buffer stress and enhances adults’
coping mechanisms leading to better mental health, less irritability & anger
Social capital
Reduces Stress
Reduces Child
Neglect
Home Environment: Words Heard by Child
Words heard by hour week year
Low income 616 62,000 3 million
Working class 1251 125,000 6 million
Professional 2153 215,000 11 million
What you hear, how you talk, how you read and write
Apply Social Work Values and Skills
Social work values of respect and shifting power Service user involvement in partnership with professionals Multi-systemic. social ecological, local contextual interventions Anti-oppressive and anti-discriminatory practice
Social work focus on quality of relationships Between individuals, parent-child bonds, within families, Lead groups of professionals in multi-agency working With socially marginalized, low income parents: social inclusion
Social work systemic strategies to build relationships Social cohesion, social trust, networking and social inclusion Coleman, 1988: ‘intergenerational closure in schools’
Families and Schools Together (FAST)
Universal voluntary parenting programme for all age 4-5 children living in disadvantaged communities
Focus on relationships, social capital and protective factors, as all parents have stress sometimes
Support all parents in practicing positive parentingTransition into school for all 4-5 year olds with FAST If a parent comes once to FAST, 80% return for 8
weekly sessions & 22 monthly multi-family meetings86% of FAST parent graduates report having made a
friend they see years later; reduce stress & isolation
Parents Co-Produce FAST as Prevention of Neglect
Respect for parent role and knowledge at every level of the FAST programme: ‘nothing about us without us’
Parents participate in training and planning FAST: co-production with multi-agency professionals: 60% flexible
Parents are on multi-agency FAST team leading groupsParents are coached to be in charge of their own familyParents are given time to form informal social networksParents graduates plan the monthly ongoing meetingsParent interview panel for evaluation FAST certification
22FAST Groups Build Protective Factors Against Child Neglect
Strengthen family unitParent-child bondParent-to-parent bondParent groupParent and communityParent and school
Ten theories into practice in FAST
Parent groups are built on Paulo Friere’s ideas of adult education groups in low income communities
Minuchin family systems theory empower executive subsystem, increase engagement, reduce conflict
Family stress theory (Hill; Boss) hope; social supportAttachment theory (Bowlby) into practice (Kogan)Parents ask children to do small tasks as imbedded
compliance requests (social learning theory)Systematically reinforce attendance (learning
theory)Family school and community (social ecology theory)
NICHD Social Capital FAST Project
Social ecological theory of child development (Bronfenbrenner)
CHILD
NICHD Social Capital FAST Project
Social ecological theory of child development (Bronfenbrenner)
CHILD
family
NICHD Social Capital FAST Project
Social ecological theory of child development (Bronfenbrenner)
CHILD
family
school
NICHD Social Capital FAST Project
Social ecological theory of child development (Bronfenbrenner)
CHILD
family
school
neighborhood
Experiential learning through parent led repeated activities (no “teaching” or
lecturing)
Family Scribbles GameFamily Scribbles Game
Family FlagFamily Flag
Feeling CharadesFeeling Charades
Parent-child bonds built in play activity and rehearsals of parental
responsiveness to child
Special Play
Building Social Capital through Schools
Every child goes to school; invite whole familiesJames Coleman sociologist Univ of Chicago
studied schools and developed a theory of social capital Children get to know one another at school Children know their parents at home If parents become friends with their children’s school
friends, that is ’ intergenerational closure’, a powerful form of social capital
If the average parent at a school knows 4-5 other parents, that school has high social capital
FAST builds intergenerational closure at schools
Randomised controlled trials on FAST
Collaborations with other researchers from medicine, public health, sociology, psychology, who were interested in impact of a social intervention
5 RCTs on FAST completed with low income families Abt Associates, (2001); Kratochwill, et al, (2004); McDonald et
al, (2006), Kratochwill et al.(2009), Gamoran & Turley (2013) Funding from NIH (NIDA, NICHD), SAMHSA, DOJ, DOE
Positive child behavioural and mental health (SDQ) outcomes over 1 and 2 years, across domains of child social ecology (child, family, school, community)
Randomized Controlled Trial: Can FAST Build Social Capital
Ruth N. López Turley, Rice UniversityAdam Gamoran, Alyn Turner, and Rachel Fish
University of Wisconsin-Madison
This research was supported by NICHD grant no. R01HD051762-01A2. Its contents are the responsibility of the authors and do not necessarily represent the official views of the supporting agency.
Social Capital
By “social capital,” we mean relations of trust, mutual expectations, and shared values embedded in social networks
The paper addresses conceptual as well as causal ambiguity
This presentation focuses on causal inference
An Intervention Approach to Addressing Causal Ambiguity
Random assignment is the best way to sort out causal ambiguity
We cannot randomly assign families to social capital
Instead we randomly assign schools to a social-capital-building intervention
We test whether school assignment to the intervention boosts social capital for families
The InterventionFamilies and Schools Together
(FAST) research-based after-school program
universally recruited 1st grade families 8 weeks of weekly meetings at schools 2 years of monthly meetings
designed to strengthen bonds parents and school staff parents and other parents parents and children
Social Capital
Data
Demographic characteristics of the child and the child’s parents
Pre-FAST measures of social capitalSchool characteristicsParent-parent network social capital Child socio-emotional and problem behaviors
reported by 1st grade teachers
Statistical Methods
FAST as an indicator of social capital Intent to Treat: Two-Level Model Treatment on the Treated: Two-Level Complier Average
Causal Effect Model
Intervention Outcomes
FAST graduates compared
Across 26 schools, on average 44 families attended at least one FAST session
Across 26 randomly assigned control schools, there were no FAST sessions
Of the families who completed FAST (5 sessions), characteristics were collated
In the control schools, a comparable group was created with similar characteristics
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Methods
COMPLIERSWOULD BE COMPLIERS
NON-COMPLIERS
WOULD BE NON-
COMPLIERS
FAST Comparison
Treatment on the treated(TOT)
Intent to treat(ITT)
4949
ITT Effects on Social Capital
OutcomeEffect size Est/S.E. P-value
Intergenerational Closure 0.13 3.02 0.003
Shared Expectations with Other Parents
0.33 3.28 0.001
Intervention Social Capital
5050
TOT Effects on Social Capital
OutcomeEffect size Est/S.E. P-value
Intergenerational Closure 0.35 2.83 0.005
Shared Expectations with Other Parents
0.97 2.93 0.003
Intervention Social Capital
Low Drop Out Rates for Low Income Parents
Retention rates: if a family comes once to FAST, on average 80% will complete 6 or more of 8 weekly FAST meetings & graduate to lead 22 monthly groups; 72% inner city, low income, single parent, African American
families with emotionally disturbed children 80% rural, Indian reservations, low-income families with
universal recruitment of all children 85% urban, Mexican American immigrants, low income,
universal recruitment of all children 90% risk for special education with behavior problems, low-
income, mixed cultural backgroundsHowever, if a family comes once to a child mental
health clinic, 40-60% (Kazdin, 2001) will drop out; if family is low income or socially marginalized > 60% drop out
Lists of Evidence Based Practice EBP
UN United Nations Office of Drugs and Crime (2010) Family skills Programme (FAST is 11 of 23 based on RCTs) FAST has highest on retention rates of low-income parents
UK National Academy of Parenting Practitioners Number 7 of parenting programmes for training
workforce
US government lists for evidence based practice Child abuse and neglect prevention Child mental health promotion Substance abuse prevention Juvenile delinquency prevention
Since 2010, 2,268 whole UK families completed 6+ of 8 FAST sessions, graduated to monthly sessions;
77% of the families lived on Very Low-Incomes
(under £20,000 annually)
Highest % Parents Reporting on FAST Impact
1.Parental self-efficacy which is related to parent empowerment77% of parents who graduated from FAST reported increased parental self efficacy
2.Parent Child relationship is enhanced; attachment is deepends;70% of parents reported improvement of this relationship3. Reciprocal ties in community-mutuality of being helped and of helping others who are raising young children
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UK Aggregate of Pre-Post FAST & Cross Domain Reports of Relationships
Parent-Child Bond increased 11% ****Family Conflict reduced -22% ****Family relationships increased 16%****Parent to parent reciprocity 31% ****
Provide support +28%---Receive support +32%
Parent involvement in school 33% ****
UK Parents Report Changes Pre FAST and Post FAST on UK Parents Report Changes Pre FAST and Post FAST on Child’s Mental Health at homeChild’s Mental Health at home
Strengths & Difficulties Questionnaire (Goodman, 1997)Strengths & Difficulties Questionnaire (Goodman, 1997)
=P<.10(10% change due to chance)
=P<.05 (5% change due to chance)
P<.01 (1% change due to chance)
P<.001 (0.1% change due to chance)
UK Teachers Report Changes Pre and Post FAST on UK Teachers Report Changes Pre and Post FAST on Child’s Mental Health at School Child’s Mental Health at School
Strengths & Difficulties Questionnaire (Goodman, 1997)Strengths & Difficulties Questionnaire (Goodman, 1997)
=P<.10(10% change due to chance)
=P<.05 (5% change due to chance)
P<.01 (1% change due to chance)P<.001 (0.1% change due to chance)
Pre Post Child Well-Being SDQ Statistically Significant Changes****
Parent Report Emotional -20%Conduct -18%Hyperactivity -13%Peer problems -10%Total problems -15%Impact -25%
Teacher ReportPro-social +10%Emotional -20%Conduct -20%Hyperactivity -15%Peer problems -16%Total problems -17%Impact -27%
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Can FAST Prevent Child Neglect? We Need More Rigorous Research Data To
Prove it.
Child neglect (ACE) prevention can be at a community level Multi-agency working includes health, education, social care Health inequalities and education disparities result from
stress of poverty, family stress and social isolation, and neglect
Effects of chronic stress from poverty, social isolation and social exclusion of parents increase irritability/child neglect
Service user/carer involvement (and cultural representation) can co-produce local outreach and engagement strategies
Evaluation of impact of social work interventions at local levels improves practice to reduce stress, social exclusion and neglect
Need an RCT on FAST which is community wide with good neglect records over time—time for another partnership