Community Prevention
of Child Maltreatment
Kenneth A. Dodge
Presentation to the University of California Irvine
April 14, 2014
Support is appreciated from The Duke Endowment, the Pew Center on the States, NIDA, and NICHD.
Colleagues are Robert Murphy, Karen O’Donnell, Ben Goodman, Jeannine Sato, and Sue Guptil.
Antecedents of Chronic Youth Violence
Gustav Vigeland sculpture, Oslo, Norway
Total annual burden of child maltreatment: > $100 billion ($114,000/case)
Maternal, Infant, and Early Childhood Home Visiting Program: $1.5 billion
Case stories:1. Working single mother; 2. Confused mother
Plan for This Presentation
1. Propose model of how child maltreatment occurs
2. Describe Durham Connects Intervention and RCT
3. Discuss financing of Connects and other programs
The Challenge to Change Community
Rates of Child Maltreatment

The Duke Endowment’s interest and ten-year commitment

Requirements in a response:



Replicable model based in developmental science
Rigorous evaluation of impact
Community rate of maltreatment / child well-being as the dependent variable

No program had ever successfully changed community rates.

Initial plan:



Formulate a model of child maltreatment based on study of risk and processes
Pilot several intervention and policy ideas
Test through a randomized controlled trial
Project MOM
Representative sample of 500 pregnant Durham
residents, interviewed in mid-trimester and followed
through age 36 months.
17% had been physically abused or neglected.
9.6% reported substance-use problems.
44% reported at least one mental health problem.
62% reported poverty or Medicaid.
By age 26 months, 8% of offspring had been
reported as maltreated by official record review.
Mothers’ Prenatal Hostile Attributions about Infant Intentions
Predict Later Child Maltreatment
(Berlin, Reznick, & Dodge, 2013, JAMA Pediatrics)
Empirically Identified Risk Factors
for Early Maltreatment
(Berlin, Appleyard, & Dodge, 2011, Child Development)
Maternal
Social
Isolation
.14*
.19*
Maltreatment
of Offspring
by Age
26 Months
Maternal
History
of Abuse
.15*
Maternal
Processing
of Cues
-Hostile
Attributions
-Aggressive
Problem Solving
.23*
Empirically Identified Risk Factors
for Early Maltreatment
(Appleyard, Berlin, Rosanbalm, & Dodge, 2011, Prevention Science)
Maternal
Substance
Use
Problems
.20*
Prenatal
Mental
Health
Problems
.16*
-.51*
Socioeconomic
Status
Maltreatment
of Offspring
by Age
26 Months
General Model of Child Maltreatment Behavior
Deviant
Parental
Processing
of
Infant
Information
-- lack of
knowledge
-- hostile
attributions
-- poor
problem
solving
Maltreatment
of Offspring
General Model of Child Maltreatment Behavior
Parental
Lack of
Connectedness
--Social
-- Professional
Deviant
Parental
Processing
of
Infant
Information
-- lack of
knowledge
-- hostile
attributions
-- poor
problem
solving
Maltreatment
of Offspring
General Model of Child Maltreatment Behavior
RISK FACTORS
Healthcare:
1. parent healthcare
2. infant healthcare
3. health insurance
Parenting/childcare:
4. childcare plans
5. par-inf relationship
6. manage infant cry
Family safety:
7. material supports
8. family violence
9. parenting difficulties
Parent mental health:
10. depression
11. substance abuse
12. emotional support
Parental
Lack of
Connectedness
--Social
-- Professional
Deviant
Parental
Processing
of
Infant
Information
-- lack of
knowledge
-- hostile
attributions
-- poor
problem
solving
Maltreatment
of Offspring
General Model of Prevention of Child Maltreatment
Identify families
at risk
Healthcare:
1. parent healthcare
2. infant healthcare
3. health insurance
Parenting/childcare:
4. childcare plans
5. par-inf relationship
6. manage infant cry
Family safety:
7. material supports
8. family violence
9. parenting difficulties
Parent mental health:
10. depression
11. substance abuse
12. emotional support
Connect
families
to social
and
professional
resources
as needed
Improve
parents’
processing
patterns
Healthy
Child
Traditional Institute of Medicine Model
of Intervention Development
(Mrazek & Haggerty, 1994)

Basic science inspires intervention

Intervention is developed in a university setting
under pristine circumstances

Randomized controlled trial (efficacy) with volunteer sample

Replicate in community setting (effectiveness trial)

Scale up to other communities
Reasons Why Scaling Up
Small Programs Has Failed

Rarely intend to have policy impact at the outset

Selection bias in who participates in university study

Heterogeneity of population

When scaling up, penetration and retention low (35-50%)

Degradation of intervention fidelity and quality (“scale-up penalty” of 50%)

Over-estimate of community capacity to meet needs
 NFP relies on nurse to assert competitive advantage for resources
Model of Universal Parent Intervention
1. Top down policy:
-- Preventive System of Care
-- Align resources
-- Screen all families
2. Bottom up with families:
-- Assess to identify
risks/needs
-- Improve community
connectedness
-- “Teach” cognitions
Three Steps to Durham Connects
1. Connect with family



Universal recruitment at birthing hospital
Home visit(s) by public health nurse
Assess 12 risk factors, quantify risk
2. Connect family with community, as needed

Professional, paraprofessional, and natural
3. So that parents can connect with infant

Improve cognitions, parent-infant relationship
Durham Connects

Piloted for three years before RCT.

Per-family cost of about $700, delivered universally.

4-7 intervention contacts with triaging.





Birthing-hospital visit
1-3 home visits between 3-8 weeks of infant age
1-2 contacts with a community service provider
Follow-up one month later
Community resources aligned to improve capacity
(e.g., Cribs for Kids, Mentors, bus routes, DSS worker)

Agency MoA to follow a Preventive System of Care.
Evaluation Design for Durham Connects

Randomly assign by even-odd birthdate




4,780 births between 7-1-09 and 12-31-10
Recruit even birthdates into intervention
No contact with controls
Analyze by intent-to-treat


Administrative record review of all births
Random sample (n=686, 80.0% participation) from birth
records for in-home interview at age 6 mos.
Implementation Findings

Penetration



80.0% of families agree
Of these, 85.9% complete
Fidelity to protocol


Independent rater for 11%
85% compliance by nurse
Scoring of Risk
Nurse scores each of 12 risk factors on 4-point scale
“1” indicates no risk
“2” indicates minor risk, resolved by nurse
“3” indicates considerable risk, referral
“4” indicates imminent risk, emergency
-- Inter-rater reliability of scoring of risk: Kappa = .69
45% of families score at least one “3”
49% of families score “2”s but no higher
6% of families score all “1”s
39% of all families connected to community service
Number of Community Connections
Reported at Age 6 months
(Dodge et al., 2013, Amer J Pub Health)
Effect Size = .28,
p < .01
Impacts at Age 6 Months
(Dodge et al., 2013, Pediatrics)
1. Mother-reported positive parenting behaviors
-- higher for intervention than control
(ES = .25, p < .01)
2. Blinded observer-rated mother parenting quality
-- higher for intervention than control
(ES = .23, p < .05)
3. Child care center quality rating (when in care)
-- higher for intervention than control
(ES = .85, p < . 01)
Impacts at at Age 6 Months
(Dodge et al., 2013, Pediatrics)
4. Mother-rated father-infant relationship
-- better for intervention
(ES=.21, p<.07)
5. Observer-rated home safety
-- better for intervention
(ES=.22, p<.05)
6. Prob of mother clinical anxiety
-- lower for intervention
(OR=.65,p<.04)
Overall Emergency Health Care Services
Reported at Age 6 months
(Dodge et al., 2013 Pediatrics)
1.5
1
Intervention
Control
0.5
0
ES = .26,
p < .001
Score is sum of # of hospital nights plus # of emergency visits
Mediation of Intervention Effect on
Emergency Health Care Services
(Goodman, Dodge, et al., 2012)
Intervention
C = -0.36*
-------------Cʹ = -0.29†
0.11**
0.11**
Mother
Mental
Health
-0.24†
Child EM
Care Use
-0.29†
Parent-Child
Relationship
Quality
Mean Cumulative Number of Emergency Care
Episodes across First 12 Months of Life
1.8
(Dodge et al., 2013, Pediatrics)
1.6
Control
Families
Cummulative Emergency Episodes
1.4
DC Families
1.2
1
0.8
0.6
Effect size = .28
p < .001
0.4
0.2
0
0
1
2
3
4
5
6
7
8
Infant Age in Months
9
10
11
12
Mean Cumulative Number of Emergency Care
Episodes across First 12 Months of Life
1.8
(Dodge et al., 2013, Pediatrics)
1.6
Control
Families
Cummulative Emergency Episodes
1.4
DC Families
Intervention effect is 59% reduction
˅------------------------------------------------˅
1.2
1
0.8
0.6
Effect size = .28
p < .001
0.4
0.2
0
0
1
2
3
4
5
6
7
8
Infant Age in Months
9
10
11
12
Mean Cumulative Number of Emergency Care
Episodes across First 12 Months of Life
1.8
(Dodge et al., 2013, Pediatrics)
1.6
Control
Families
Cummulative Emergency Episodes
1.4
DC Families
Intervention effect is 59% reduction
˅------------------------------------------------˅
1.2
1
Intervention effect is 31% more reduction
˅--------------------------------------------------˅
0.8
0.6
Effect size = .28
p < .001
0.4
0.2
0
0
1
2
3
4
5
6
7
8
Infant Age in Months
9
10
11
12
Cumulative Emergency Care at Age 12 Months
(Dodge et al., 2013, Pediatrics)
ES=.19
Interaction Effect p<.001
Cumulative Emergency Care at Age 12 Months
(Dodge et al., 2013, Pediatrics)
ES=.22
Cumulative Emergency Care at Age 12 Months
(Dodge et al., 2013, Pediatrics)
ES=.36
Interaction Effect p<.01
DC Impact at Age 24-Months
Mean Cumulative Number of ED Care Episodes
Birth - 24-Months
3
Cumulative Emergency Care Episdoes
2.5
Control Families
DC Families
2
1.5
1
0.5
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Child Age in Months
Benefit-Cost Analysis of Intervention
Impact at Age 12 Months
Durham Connects intervention costs: $700/assigned family
Emergency Care Outcome Costs:
$ 423 per emergency visit
$3,722 per hospital night
BCR DC =
(OCC - OCI)
___________
(ICI
-
ICC)
CONTROL
x .83 = $ 351
x .74 = $ 2,754
($3,105 - $697)
= ____________
DC
x .68 = $288
x .11 = $409
= $ 3.44
$700
For Durham, NC:
3,187 resident births/year
Total emergency care costs without DC:
Durham Connects would cost:
Durham Connects would yield savings of:
$ 9,895,635
$ 2,230,900
$ 7,674,296
Financing Early Intervention
Barriers to Medicaid payment
- Risk
- No upfront capital
Private investor solution:
Social Impact Bonds
- started in UK
- 3 in U.S., more coming
- NYC by Bloomberg
- Utah by Goldman/Pritzker
- SC by Goldman/Pritzker
$250mil fund by Goldman Sachs
Current Plans
1. Continue follow-up of RCT
through age 66 months.
2. New RCT now ongoing.
3. Disseminate to 4 rural
NC counties.
4. Arrange financing in NC.