how does child maltreatment prevention work?

How does child maltreatment prevention work?

An informed perspective for practitioners and providers

Jennie G. Noll, PhDProfessor, Human Development and Family StudiesDirector of Research & Education, Network on Child Protection & Well-being, The Pennsylvania State University

Stephanie Bradley, PhDManaging Director, Evidence-based Prevention and Intervention Support Center (EPISCenter), The Prevention Research Center, The Pennsylvania State University

What is child maltreatment prevention?

Primary – prevent maltreatment BEFORE it happens

Secondary – prevent another problem that stems from child maltreatment (Intervention)

Targeted – prevent child maltreatment from occurring in an at-risk group

Embedded – prevent other public health problems by embedding primary prevention programs within child welfare

Public awareness campaigns designed to educate entire populations

public service announcements TV, radio, billboards, mass distribution of

brochures or other educational material

working with professional groups to change the way they think about and react to

opportunities for prevention

Primary Prevention Efforts

Family home visiting programsbringing a well-planned intervention to families who need it

emphasize outreachfamilies who might be unwilling or unable to participate in more formally organized services

combination of educational, supportive, orempowering goals


Nurse Family Partnership (Olds et al, 2007)

First-time disadvantaged mothers received home visits by nurses

Begins prenatally and extends until child’s 2nd birthday

Nurses promoted 3 aspects of maternal functioning:–health-related behaviors–maternal life course development–parental care of children


Parent education programs organized in an “academic” way, with planned“lessons” delivered to individuals or small groups

Specific educational goals (e.g.,): -pregnancy and delivery-child growth and development-parenting skills-knowledge of add’l resources


Child education programsattempt to make children less vulnerable targets for abuse

Primarily focused on sexual abuse prevention

School-based or Physician-based

Teach children self-protective skills“Good touch, bad touch”


Physician administered Educates parents in pediatric or prenatal practice

“I will not shake my baby” contracts


Effective for Physical Abuse and Neglect?

Home visitation (mixed results; Bell 2012 meta analysis)

Nurse Family Partnership (NFP) (best)Early Start (New Zealand) (promising)

Parent training programsTriple P Positive Parenting Program (promising)

Physician administeredAbusive head trauma education programs (promising)Enhanced pediatric care (promising)


Effective for Physical Abuse and Neglect? Nurse Family Partnership (Olds et al, 2007)Reduced child physical abuse and neglect as measured by official child protection reports

Reduced associated outcomes such as injuries in children

Nurse home visitation did not prevent recurrence of physical abuse or neglect (RCT) (MacMillan et al., 2005)



Early Start (Fergusson et al., 2005, 2013)

Reduced associated outcomesinjuries and hospital admissions for child abuse and neglect

Rates of child protection reports did not differ between the intervention and control groups



Paraprofessional home visitation e.g., Hawaii Healthy Start Program Healthy Families America

Have not been shown effective in reducing child protection reports


Home visiting programs are not uniformly effective in reducing child physical abuse and neglect (Rubin, 2013)

Any home visiting program should not be assumed to reduce child abuse and neglect

Every Child Succeeds (Ammerman, et al., 2013)Home-visiting maternal depression prevention program showed reduced effectiveness for mothers who were sexually abused as children



Triple P – Positive Parenting Program

Population-level group-based supports for families

use of media/information strategiesconsultations with parents seminarsactive skills training



Triple P – Positive Parenting Program

Positive effects on substantiated child protection services reports, out-of-home placements, and reports of injuries

Analysis is not clear and concerns about methods (Wilson et al., 2012)



Physician Administered

Abusive head trauma education

Positive effects from one study suggest that hospital-based educational programs can reduce abusive head injuries (shaken impact syndrome) (Dias et al., 2005)



Physician AdministeredEnhanced pediatric care program for families at risk “Safe Environment for Every Kid” (SEEK) (Dubowitz et al., 2009, 2012)

Training physicians to identify family problems social worker is available

Promising effects in enhancing physicians’ abilities decrease risk factors and physical abuse rates


Effective for Sexual abuse?

Unknown if educational programs reduce occurrence of child sexual abuse

Some evidence that they improve children’s knowledge and protective behaviors

Could have some adverse effects(Zwi et al., 2007)


Emotional abuse?

Attachment-based interventions designed to improve insensitive parenting and infant attachment insecurity

No direct evidence that these interventions prevent emotional abuse (Bakersman-Kranenburg et al., 2003)


For Parents in the Child Welfare System

SafeCare (Chaffin et al., 2012)home-based, structured behavioral skills focused on caregiving, parenting, household management

SafeCare reduced recidivism compared with usual home-based services

Secondary Prevention Efforts

Recurrence of physical abuse and neglect

Parent-child interaction therapy (PCIT) behavioral approach to

skills training

PCIT reduced recurrence of child protection services reports of physical abuse but not neglect (Chaffin et al., 2004)

Intervention / Treatment

Impairment following sexual abuse

Trauma-focused cognitive-behavioral therapy (TF-CBT) (Cohen et al., 2004)

cognitive reframing positive imageryparent management training problem solving

Reduced internalizing and externalizing symptoms among children with PTSD symptoms


Out-of-home care

Placement in foster care and not reunifying with biological parents can lead to benefits for maltreated children

Enhanced foster care can lead to better mental health outcomes for children than traditional foster care

Conflicting evidence about kinship care compared with traditional foster care


Thinking about “Imbedded Prevention” within the child welfare system?

Abused children are at high risk for a host of conditions of grave public health concern:

-teen pregnancy (Noll & Shenk, 2013)-obesity (Noll, et al, 2007)-substance use (Fergusson, 2010)-high-school drop out (Noll, et al,

2010)

Children already in the child welfare system are prime targets for primary prevention of these problems

Next Steps for Sexual Abuse

Sexual abuse prevention needs more attention:-understanding perpetrator-community awareness-increased resources for increased

awareness-training professionals to spot outward signs

Sexual-specific modules added to:-SafeCare-Adult treatments shown to be less

effective for sexual abuse survivors

Maltreatment

HPA axisdysregulation

Brainmaldevelopment

Neurocognitiveimpairment

High-risk Social/Emotionalfunctioning

Outcomes: Alcohol, tobacco substance use

Neurocognitive mechanisms for Alcohol and Substance Abuse

Psychological Mechanisms for Alcohol and Substance Use

Trauma

PTSD

Re-experiencing

symptoms

Avoidantsymptoms

Arousalsymptoms

Numbingsymptoms

Alcohol and Substance Abuse

Specifics for substance usetreatment

Trauma-focused therapies not as effective for SUD patients

SUD treatments not as effective for trauma victims

Other examples????

Break Out Session

• how does child maltreatment or child trauma affect your efforts?

• in what ways has maltreatment or trauma been apparent in youth you serve?

• what resources to address maltreatment or trauma do you have access to?

• what types of trauma-informed care are you/your organization using?

Brain Storming

Resources

Training for TF-CBThttp://tfcbt.musc.edu/

https://www.childwelfare.gov/preventing/

SafeCarehttp://safecare.publichealth.gsu.edu/

http://tfcbt.musc.edu/

http://tfcbt.musc.edu/



http://safecare.publichealth.gsu.edu/

Next Steps:

Data integration to implore public health investment

Distribution of Total Medicaid Beneficiaries and Spending

63%

37%

90%

10%

Under ACA70% of children in

protective services are Medicaid eligible

Ferris, et al., 2010

Putnam-Hornstein, 2013

The Power of Linked-data to show that children in protective services should be

targeted for a host of public health problems


Death From Unintentional Injury


Death From Intentional Injury

Integrated data systems to identify high-risk kids for coordinated care

Electronic Med Records: 1. Hospitalizations 2. ER visits 3. Vitals / Dx -T1D -BMI 95th% 4. STI

Criminal Justice:1. Self

2. Parent

Census Data: 1. high risk zip code 2. crime stats 3. poor schools 4. few parks 5. other

Public Schools: 1. missed days 2. poor grades/test scores 3. dropouts 4. truancy 5. other

Program A Program B Program C

CPS:sexual abuse

physical abuseneglect

1 2 3 4 5 6 7 8

Partnerships for Prevention

Prevention Research Center (PRC)

Penn State University

College of Health & Human Development

EPISCenter

The Network on Child Protection and Well-Being

Social Science Research Institute

Foundational Center

Affiliate Center

The EPISCenter is a project of the Prevention Research Center, College of Health and Human Development, Penn State University, and is funded by the Pennsylvania Commission on Crime and Delinquency and the Pennsylvania Department of Public Welfare.

Multi-Agency Steering Committee(Justice, Welfare, Education, Health)

Support to Community Prevention

Coalitions

Improve Quality of Local Innovative Programs and

Practices

Support to Evidence-based

Prevention & Intervention Programs

Intermediary and State-level Prevention Support System

Evidence-based Prevention and Intervention Support Center (EPISCenter)


public health model:- use data- to identify and prioritize risk & protective factors- to select and implement evidence-based

programs- sustain and evaluate programs

- achieve public health impact


objectives:- connecting policymakers, researchers, program developers, and

communities

- promoting use of the public health model

- achieving public health impact in reducing youth violence, delinquency,

substance use

The EPISCenter is a project of the Prevention Research Center, College of Health and Human Development, Penn State University, and is funded by the Pennsylvania Commission on Crime and Delinquency and the Pennsylvania Department of Public Welfare.


Key objectives:- connecting policymakers, researchers, program developers, and

communities- achieving public health impact in

reducing youth violence, delinquency, substance use

Data Collaborationsintegrating systems data (proposition*):PA Commission Crime & Delinquency (planning agency)Dept. of Public Welfare (OCYF, OMHSAS, BJJS)Juvenile Court Judges Commission- how much “overlap” in youth served by each system?- if we prevent trauma, do we prevent juv. justice involvement?

research in progress:Bumbarger & Frank – investigating adult criminal justice population and preventable issues in adolescence

Integrated data systems to identify high-risk kids for coordinated care

Electronic Med Records: 1. Hospitalizations 2. ER visits 3. Vitals / Dx -T1D -BMI 95th% 4. STI

Criminal Justice:1. Self

2. Parent

Census Data: 1. high risk zip code 2. crime stats 3. poor schools 4. few parks 5. other

Public Schools: 1. missed days 2. poor grades/test scores 3. dropouts 4. truancy 5. other

Program A Program B Program C

CPS:sexual abuse

physical abuseneglect

1 2 3 4 5 6 7 8

how does child maltreatment prevention work?

Documents