Implementing Promising Initiatives to Help
Children Face Chronic Adversity
Richard P. Barth, PhD, MSW
University of Maryland School of Social Work
National Center for Evidence Based Practice in Child
Welfare
Presented at the Brookings Institution
May, 2014
rbarth@ssw.umaryland.edu
Overview of Today’s Commentary
• The 4 Intervention Areas
– Health
– Income
– Child Care
– Parenting (mostly)
• Implementation Opportunities & Challenges
• References
Behavioral Health & Health Care
• Health screening and Primary Care (PROJECT SEEK:
Dubowitz, et al., 2009)
• Obama’s evidence-based home-visitation ($500
million a year)
– Begin during a mother’s pregnancy addressing
nutrition, health practices, stress, and
alcohol/drug/tobacco use (ADDING MORE ON
PARENTING TO NFP and HFA)
– Continue through childhood, supporting positive family
practices and emphasize responsive parent-child
relationships, and positive non-coercive parenting
practices (FAMILY CHECK UP MODEL)
Family Check Up: Assessment Driven & Tailored
Lessons Learned from Family Check Up
• To prevent child behavior problems there may be a
need to intervene early and directly with:
– the emotional climate of the family and parenting
relationship
• Families often recognize trouble in the family but
don’t know the extent or what to do about it
– Many are willing to act on the information
– Families will use, and benefit from, parenting programs
• New data shows impact on behavior and academics
from FCU in WIC clinics 7 years later (Dishion, et al.,
2014)
5
Economic Aid Implementation
• Cash assistance
– Conditional cash-transfer antipoverty program, where
payment occurs after compliance with addressing
preventive care.
• Greater access to food stamps
• Financial Literacy for Parents
• Expansion of school-based and pre-school based
nutrition programs and homelessness prevention
programs, through expansion of community
schools
Quality Child Care Implementation
• Significant parenting program components
added to Early Head Start and Head Start
– Some (e.g., ABC) are being tested now
• State licensed early childhood programs often
lack any discipline policy (Longreth, Brady, & Kay, 2013).
– PBIS should become a standard (and be
implemented with fidelity)
Smart Early Childhood “Training” in
Graduate Education
• Toxic Stress exists and is harmful (this is now
getting into curricula)
– See next slides from AAP
• The impact of toxic stress can be mitigated
• Psychotherapy is not the only answer:
parenting programs can also help reduce the
adverse impact of toxic stress
AAP Report on Toxic Stress:
1 of 5 Main Recommendations
RECOMMENDATION 2.
The growing scientific knowledge base that links childhood
toxic stress with disruptions of the developing nervous,
cardiovascular, immune, and metabolic systems, and the
evidence that these disruptions can lead to lifelong
impairments in learning, behavior, and both physical
and mental health, should be fully incorporated into the
training of all current and future physicians (and all
other health service providers) [material in parentheses
and bright red text not in the original].
AAP Report on Toxic Stress:
1 of 5 Main Recommendations
RECOMMENDATION 2.
The growing scientific knowledge base that links childhood
clarifies nervous,
the
toxic stress with disruptions ofand
thethat
developing
reversibility
the effects
cardiovascular, immune, and
metabolicofsystems,
andofthe
toxic stress
with
evidence that these disruptions
can lead
toconsistent
lifelong
good quality
caregiving,
impairments in learning, behavior,
and both
physical
and mental health, should be fully incorporated into the
training of all current and future physicians (and all
other health service providers) [material in parentheses
and bright red text not in the original].
Implement CAPTA Intentions
• Children who are identified as victims because
they “have substantiated maltreatment” are to
be referred to early intervention services
– Children who are not substantiated are at equal
developmental risk
– Children who are referred to CAPTA continue to
get very few services under the Early Intervention
Program (based on PL 99-457) which has never
been scaled up to serve these children
CAPTA Early Intervention Study: 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
– Children with more than 5 recognized risk
factors at baseline are almost certain to
develop measured delays that remain at 36
months (see graph)
– Substantiation did not explain the
developmental outcomes
12
Early Adversity is a Better Predictor of Behavior
Problems than Prenatal Drug Exposure
• Maternal Life Style Study
– Direct effects of pre-natal drug exposure on
worsening executive functioning at behavioral
problems at ages 8/9 is significant.
– After controlling for ongoing adversity the
relationship between drug exposure and executive
functioning at ages 8/9 is .00. (Fisher et al., 2011).
Early Adversity is Not Irreversible
– Attachment and Bio-behavioral Catch-up (Dozier et
al., 2008)
– Multi-dimensional Treatment Foster Care-Pre
(Bruce et al., 2009)
– HAVE SHOWN SUCCESS WORKING WITH VERY
TROUBLED ABUSIVE FAMILIES AND ABUSED
CHILDREN AND SHOWN REDUCTIONS IN BI0MARKERS OF ADVERSITY
Foster Child Bio-Markers Associated
with Intensive Foster Parent Training
• Fisher and Colleagues compared children in
1. Conventional Foster Care
2. Multi-Dimensional Treatment Foster Care for PreSchoolers
3. A Community Sample
• Results show improvements in (pictures follow):
• Cortisol levels improved (not shown)
• Responses to feedback (self-regulation)
• Placement stability
Intervention Effects On Executive Functioning
CC
Correct
Incorrect
16
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12
16
14
12
10
10
8
8
6
6
4
4
2
2
0
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-200
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Correct
Incorrect
MTFC-P
100
200
300
400
500
600
700
800
-200
-100 -2 0
-4
-4
-6
-6
-8
-8
-10
-10
-12
-12
Children in Regular Foster Care
Do Not Respond Differently to
Positive and Negative Feedback
RFC
100
200
300
400
16
500
600
700
800
Correct
Incorrect
14
12
10
8
6
4
Children in MTFC-P respond more
normatively
2
0
-200
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-4
-6
Bruce, Martin-McDermott, Fisher, & Fox, 2009
(under review)
-8
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-12
100
200
300
400
500
600
700
800
Effect Of Prior Out-of-home Placements On
Permanent Placement Failures (MTFC-P Vs. Regular FC)
RFC
MTFC-P
Predictable
Placement Moves
Actual moves for MTFC group
(Fisher, Burraston, & Pears, 2005)
Prior poor and unstable history
can be overcome!
Implications of MTFC-Pre
• Evidence-based parenting programs provide
powerful path to improved outcomes for
children
• These approaches have now been shown to
be very effective at improving parenting and
child behavioral outcomes
– at least when applied to intensive foster parent
programs
• They need broader testing in family-homes
BIG Implementation Challenges
• Not a single stand alone replication of MTFC-pre
• KEEP was developed as an easier to implement
less costly version of MTFC
–
–
–
–
Weekly parent calls (not daily)
No special mental health treatment for children
More than one child in a home at a time
Works with kin (not just specially trained families)
• Yet, KEEP has not been fully sustained even in San
Diego where it worked beautifully for years
(during a series of implementation studies)!
BIG Implementation Challenges 2
• Child welfare agencies are fixated by a 5 part
view of out-of-home care: (1) foster care, (2)
kinship care, (3) treatment foster care, (4) group
care, and (5) adoption
• All get different services
• Yet, ongoing parent training is likely to be
necessary for all of these to succeed
• E.g., blended programs in which children spend part of
the week in care and part with parents at home (e.g., REED) have shown success for decades
The Big Secret is Effective Work with
Parents Must be Part of All Levels of
Intervention
Broader Challenge in Foster Care
• Our foster parent training needs nearly a
complete overhaul
– New models of implementation focus on:
• Teaching evidence based practices with active learning (e.g.,
actual, live cases, in groups or coaching calls, etc.)
• Ongoing coaching and fidelity checking
• Outcome monitoring
– This approach does not require a waiver to be fully
fundable under existing Title IVE regulations
– The reduction in units of care provided as a result of
more exits should allow for greater quality (a waiver
could help capture the savings of that greater quality)
Basic of Foster Family “Training”
• Should be done while children are in the home—not
just before!
• Should involve the best “active learning” techniques
that we know
– Ongoing coaching
– Parent Daily or Weekly Reports
– Feedback based on improvements
• We know it can work!
– Benefits cross over to additional children in the home—not
just to the ones that were the focus of KEEP group (personal
communication with Joe Price and Patricia Chamberlan)
Taking KEEP to Scale
• Re-orientation of foster parent “Training” to be
– Ongoing (about 15 weeks)
– Skill focused
– Leader is well trained and demonstrates high level
of performance via fidelity monitoring
Policy Issue: Parenting Needs are
Much Larger than Foster Care
The Number of Children on Medicaid Has Grown
Markedly as a result of CHIP and Affordable Care
Act-related enrollments
• Now in excess of 6,000,000 children
Parent Training to Reduce Toxic Stress
is a HEALTH CARE Intervention
Funding Parent Training Under ACA/Medicaid?
• In CA, six reimbursement codes can be used to bill
for behavioral, social, and psychophysiological
services for the prevention, treatment or
management of physical health problems.
– CPT 96153 – Health and behavior intervention service
provided to a group. … Group sessions typically last for 90
minutes and involve 8 to 10 patients. Each 15 minutes,
face-to-face; group (2 or more patients) is billable
• Interventions might include self-monitoring or teaching
cognitive-behavioral techniques, relaxation, visualization, coping
and social skills, …
• WHY NOT PARENTING?
Summary (5 Points)
1. Adverse effects of early childhood toxic stress can be
mitigated
2. We now have evidence based tools to address some of
these effects –especially, tools that focus on more
responsive and contingent parenting, applied over
time
3. Yet, they do not fit into our current funding model for
foster parent training, WIC, or Medicaid
Summary (5 Points)
3. Child care, foster care and in-home care could all
benefit from instituting more effective parenting
programs—e.g., PBIS, Family Check Up, ABC, and KEEP
4. Our country needs a national initiative on parenting to
understand:
a. What are the basic (common components) of
effective, successful parenting?
b. What does it take to provide restorative parenting?
c. How can this build on current services that include
parents but don’t teach parenting?
5. Existing statutory vehicles exist to achieve this
Thank you for this opportunity
We, together, can make the changes
our parents and children need!
References
Barth, R.P., & Liggett-Creel, K. (2014). Common components of parenting programs for children birth to eight years of
age involved with child welfare services. Children and Youth Services Review, 40, 6-12.
Brennan, L. M., Shelleby, E. C., Shaw, D. S., Gardner, F., Dishion, T. J., & Wilson, M. (2013). Indirect effects of the family
check-up on school-age academic achievement through improvements in parenting in early childhood. Journal of
Educational Psychology, 105(3), 762-773.
Bruce, J., McDermott, J. M., Fisher, P. A., & Fox, N. A. (2009). Using Behavioral and Electrophysiological Measures to
Assess the Effects of a Preventive Intervention: A Preliminary Study with Preschool-Aged Foster Children.
Prevention Science, 10(2), 129-140.
Dishion, T. J., Brennan, L. M., Shaw, D. S., McEachern, A. D., Wilson, M. N., & Jo, B. (2014). Prevention of Problem
Behavior Through Annual Family Check-Ups in Early Childhood: Intervention Effects From Home to Early
Elementary School. Journal of Abnormal Child Psychology, 42(3), 343-354.
Dozier, M., Peloso, E., Lewis, E., Laurenceau, J. P., & Levine, S. (2008). Effects of an attachment-based intervention on the
cortisol production of infants and toddlers in foster care. [Article]. Development and Psychopathology, 20(3), 845859. doi: 10.1017/s0954579408000400
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. Pediatrics, 123(3), 858-864. doi: 10.1542/peds.2008-1376
Fisher, P. A., & Stoolmiller, M. (2008). Intervention effects on foster parent stress: Associations with child cortisol levels.
[Article]. Development and Psychopathology, 20(3), 1003-1021. doi: 10.1017/s0954579408000473
Fisher, P. A., Lester, B. M., DeGarmo, D. S., Lagasse, L. L., Lin, H., Shankaran, S., . . . Higgins, R. (2011). The combined
effects of prenatal drug exposure and early adversity on neurobehavioral disinhibition in childhood and
adolescence. Development and Psychopathology, 23(3), 777-788.
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