An informed perspective for practitioners and providers
Jennie G. Noll, PhD
Professor, Human Development and Family Studies
Director of Research & Education, Network on Child Protection & Well-being,
The Pennsylvania State University
Stephanie Bradley, PhD
Managing 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

Primary Prevention Efforts
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 programs bringing a well-planned intervention to families who need it emphasize outreach families who might be unwilling or unable to participate in more formally organized services combination of educational, supportive, or empowering goals

Primary Prevention Efforts
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

Primary Prevention Efforts
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

Primary Prevention Efforts
Child education programs attempt 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”

Primary Prevention Efforts
Physician administered
Educates parents in pediatric or prenatal practice
“I will not shake my baby” contracts

Primary Prevention Efforts
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 programs
Triple P Positive Parenting Program (promising)
Physician administered
Abusive head trauma education programs (promising)
Enhanced pediatric care (promising)

Primary Prevention Efforts
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)

Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Early Start (Fergusson et al., 2005, 2013)
Reduced associated outcomes injuries and hospital admissions for child abuse and neglect
Rates of child protection reports did not differ between the intervention and control groups

Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Paraprofessional home visitation e.g., Hawaii Healthy Start Program
Healthy Families America
Have not been shown effective in reducing child protection reports

Primary Prevention Efforts
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

Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Triple P – Positive Parenting Program
Population-level group-based supports for families use of media/information strategies consultations with parents seminars active skills training

Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
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)

Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
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)

Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Physician Administered
Enhanced 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

Primary Prevention Efforts
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)

Primary Prevention Efforts
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)

Secondary Prevention Efforts
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

Intervention / Treatment
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 imagery parent management training problem solving
Reduced internalizing and externalizing symptoms among children with PTSD symptoms

Intervention / Treatment
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
-SafeCare to:
-Adult treatments shown to be less effective for sexual abuse survivors

Maltreatment
HPA axis dysregulation
Brain maldevelopment
Neurocognitive impairment
High-risk Social/
Emotional functioning
Outcomes:
Alcohol, tobacco
substance use

Psychological Mechanisms for Alcohol and
Substance Use
PTSD
Reexperiencing symptoms
Avoidant symptoms
Trauma
Alcohol and
Substance Abuse
Numbing symptoms
Arousal symptoms

Trauma-focused therapies not as effective for SUD patients
SUD treatments not as effective for trauma victims
Other examples????

• 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?

Ferris, et al., 2010
Distribution of Total Medicaid Beneficiaries and
Spending
10%
63%
Under ACA
70% of children in protective services are
Medicaid eligible
90%
37%

The Power of Linked-data to show that children in protective services should be targeted for a host of public health problems
Putnam-Hornstein, 2013

Putnam-Hornstein, 2013
Death From Unintentional Injury

Putnam-Hornstein, 2013
Death From Intentional Injury

Integrated data systems to identify high-risk kids for coordinated care
Program A
Criminal Justice :
1. Self
2. Parent
CPS: sexual abuse physical abuse neglect
Program B Program C
Electronic Med
Records:
1. Hospitalizations
2. ER visits
3. Vitals / Dx
-T1D
-BMI 95 th
%
4. STI
Census Data:
1. high risk zip code
2. crime stats
3. poor schools
4. few parks
5. other
P ublic Schools:
1. missed days
2. poor grades/test scores
3. dropouts
4. truancy
5. other
1 2 3 4 5 6 7 8

Penn State University
Social Science Research Institute
College of Health & Human Development
Prevention Research Center (PRC)
The Network on Child Protection and
Well-Being
Foundational Center
EPISCenter
Affiliate Center

Evidence-based Prevention and Intervention Support
Center (EPISCenter)
Multi-Agency Steering Committee
(Justice, Welfare, Education, Health)
Intermediary and State-level Prevention Support System
Support to
Community Prevention
Coalitions
Support to
Evidence-based
Prevention & Intervention Programs
Improve Quality of
Local Innovative Programs and
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.
Practices

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

Evidence-based Prevention and Intervention Support
Center (EPISCenter) 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

Evidence-based Prevention and Intervention Support
Center (EPISCenter)
Key objectives:
connecting policymakers, researchers , program developers, and communities
- 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.

Data Collaborations integrating 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
Program A
Criminal Justice :
1. Self
2. Parent
CPS: sexual abuse physical abuse neglect
Program B Program C
Electronic Med
Records:
1. Hospitalizations
2. ER visits
3. Vitals / Dx
-T1D
-BMI 95 th
%
4. STI
Census Data:
1. high risk zip code
2. crime stats
3. poor schools
4. few parks
5. other
P ublic Schools:
1. missed days
2. poor grades/test scores
3. dropouts
4. truancy
5. other
1 2 3 4 5 6 7 8