Designing Evidence-Informed Family
Informed Services for Neglecting
Children & Families
Presented to the
2010 Annual Meeting of the
Translational Research on Child Neglect Consortium
and the
Brown School of Social Work
Washington University
September 23, 2010
Richard P. Barth, PhD
University of Maryland School of Social Work
Portions of the paper presented are based on research funded by the Office of the Assistant
Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human
Services, under contract 233-03-0099. Points of view or opinions in this presentation do not
necessarily represent the official position or policies of the U.S. DHHS.
Summary … In Closing
1. It’s time for real-time applications of family
information to guide practice
– Cumulative family risk is an important one
2. I’ve been wrong—oh so wrong!
– My calls for a focus on “Evidence Based
Parent Training” have been too narrow
•
MORE FOCUS NEEDED ON “EVIDENCE-BASED
FAMILY WORK”
3. There are some great starts at using family
information to guide interventions
2
Efforts toward Interdisciplinary
Practice to Prevent Child Neglect
1. Sharing Existing Information in Real Time
A. Birth Match (Matching Birth Information and CWS
History)
B. CAPTA implementation
Cross-reporting newborn substance abuse to child welfare
services
Cross-referring substantiated child abuse reports to Early
Intervention Services
2. Gathering Information that is Missing and
Putting it Right to Use
A. SEEK (A Safe Environment for Every Kid)
Family Cumulative Risk as Predictor
• Family and Community Risk has turned out to be a
highly useful predictor of development (well-being)
in NSCAW (and can be generated from routine
risk assessment)
NSCAW & NEILS Study on CAPTA and
Early Intervention Services Integration
Half of all infants and toddlers had a low score
on a developmental measure
Measured Delay =
49%
High Risk =
28% (5 or more risk factors
but no measured delay)
Lower Risk =
23% (< 5 risk factors and no
measured delay)
6
The proportion of children with a
measured delay who have a
substantiated maltreatment
report does not differ from
children investigated for
maltreatment without a
substantiated report.
7
Defining Risk
 56% have 5 or more
risk factors
Risk Factor
%
Maltreatment
100
 82% had at least 4
risk factors
Poor Parenting Skills
61
Minority Race/Ethnicity
58
Single Caregiver
48
 Virtually all had at
least 2 risk factors
(99%)
Poverty
46
Domestic Violence
40
Substance Abuse
39
Caregiver MH Problems
30
Low Caregiver Education
29
Biological/Medical Risk
22
Four or More Children
14
Teenaged Caregiver
19
 Maltreatment cooccurs with other
problems, placing
children at-risk for
developmental delay &
later school difficulties
8
36 Months After Baseline Compared To 18
Month Follow-up
•36 months after
baseline only 13%
High Risk; 42%
Measured Delay,
45% Lower Risk
•72% LR remain
the same, 22%
now with a
Measured Delay
•Only 28% of HR
classified the
same, 37% now
with Measured
Delay
Approximately 36 months after
Baseline
(3-6 years of age)
18 months
after Baseline
Measured
Delay
(42%)
High
Risk
(13%)
Lower
Risk
(45%)
Measured
Delay (50%)
57
10
33
High Risk
(29%)
37
28
35
Lower Risk
(29%)
22
6
72
(18-54 months in
age)
Diagonal = Percent unchanged
9
Families Experience Behavior Problems
• Despite their young age, young maltreated
children have relatively high levels of behavior
problems reported by their caregivers—
24% of mothers report a clinical I or E score
on CBCL, a proportion that increases from
18-months
• Yet support to families is very short term-only 13% of maltreated/substantiated
children were still receiving part C services
at 36 months
11
Family Focused Services
Dwindle by 18- & 36-Months
. parent training and
• Families are receiving
family counseling services through Child
Welfare Services or by referral.
• These services may have a child
development component but are unlikely
to be very effective in addressing
developmental disadvantages.
12
CAPTA EIS 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
• High risk children have an elevated likelihood for
poor developmental outcomes, including schoolage problems
– Children with more than 5 recognized risk factors
at baseline are almost certain to develop
measured delays that remain at 36 months
13
Other NSCAW Family Cumulative
Risk Findings
–NSCAW studies of CWS Decision
Making indicate its importance
• Family Cumulative Risk Also Has Strong
Relationship to Service Decisions
–Substantiation
–Placement into Foster Care
Family Cumulative Risk
• NSCAW : Extent of Children’s Mental
Health Problems (McCrae & Barth, 2008)
– Three clinical measures, the CBCL/YSR,TSCC, and
CDI, were combined to create a dichotomous
measure of: Clinical Mental Health Problem at
Intake (y/n)
– Risk Assessment indicators of “family cumulative
risk” (21 items) were quite accurate in predicting the
measured scores of mental health symptoms (MHS)
• Identified 75% of 2 to 6 year olds with MHS
• Identified 80% of 7 to 14 year olds with MHS
Other Examples of Important Findings
of Family Risk and Child Outcomes
16
Adverse Family/Childhood Events
Predict Violence as Adolescents
1. Has any adult in your household ever hit you so hard or so often that
you had marks or were afraid of that person? (10.4%)
2. Has any older or stronger member of your family ever touched you
sexually or had you touch them sexually? (2.6%)
3. Has any adult or other person outside the family ever touched you
sexually against your wishes or forced you to touch them sexually?
(5.1%)
4. Has alcohol use by any family member repeatedly caused family,
health, job, or legal problems? (14.5%)
5. Has drug use by any family member repeatedly caused family, health,
job, or legal problems? (10.1%)
6. Has anyone in your family ever hit anyone else in the family so hard or
so often that they had marks or were afraid of that person? (11.6%)
•
3 or more Yeses, Total = 6.1% (Duke et al., 2010, MN Study)
17
Cumulative Risk & Educational
Outcomes in Philadelphia
• Odds ratios (Rouse & Fantuzzo, 2009) based
on predictions using 1, 2, or 3 family risks
(derived from administrative data from
homelessness of parent, birth risk, poverty,
child maltreatment, low maternal education)
and controlling for gender and race
• Poor Reading Achievement
• Poor Mathematics Achievement
• Second Grade Retention
1.28
1.21
1.31
Family-Informed Interventions are
Emerging
• Birth Match (MI, MD, NYC)
• Project SEEK (UMB SOM)
• Family Connections (UMB SSW)
• Child and Family Center “EcoFit”
Programs (U of OR)
19
Birth Match
• ASSUMPTION: Children born to parent(s)
who have had a previous birth result in the
involuntary termination of parental rights
(TPR) are at serious risk
– EVIDENCE is Indirect
• Conditions that result in TPR are often persistent
– Substance abuse, maternal depression, unsafe living
circumstances (Jonson-Reid et al., 2010)
• Newborns are most at risk of death from abuse
or neglect
Making Very High Risk Births Known
to Child Welfare Services (CWS)
• History
– Under PL 96-272, every child was
“entitled” to reasonable efforts to prevent
placement
• Family history did not (legally) matter
– Adoption and SAFE Families Act (1997)
• Egregious family history must lead to
consideration of “reunification bypass”
• Family history matters
Making Very High Risk Births Known
to Child Welfare Services (CWS)
• Birth Match
– MICHIGAN: When a parent who has
previously had a Termination of Parental
Rights gives birth to another child, CWS
matches births against TPR database and
commences CWS investigation
• Policy Presumption that the parent will not
continue to care for the child—requires program
manager signature to leave newborn in the home
• Daily matches
• Also now includes violent felons and sexual
perpetrators
Making Very High Risk Births Known
to Child Welfare Services (CWS)
• Birth Match
– MARYLAND: Department of Health Vital
Statistics accepts TPR lists on a weekly
basis from DSS and returns matches of
children born in the last week who were
born to mothers with prior TPRs
• A CWS “assessment” is made of the situation
– No presumption of any subsequent action
• Look back for TPRs is limited to TPRs in the
last 5 years
Making Very High Risk Births Known
to Child Welfare Services (CWS)
• NEW YORK CITY
– Administrative Policy (not law)
– NO BIRTH MATCH
– Workers who notice that a mother who has a
child in foster care is pregnant, they initiate
the investigation
– PRESUMPTION: If the home environment is
not suitable for a child then it is not suitable
for a newborn
• Requires Director override to leave newborn in
home
Using Administrative Data in Real Time
• It’s time for researchers and agency leaders to
develop real-time advantages from research
– Learning what is happening to newborns at the
very beginning of life is vitally important
WHY ONLY 3 BIRTH MATCH PROGRAMS?
– Getting family matches across systems of care
is difficult
• Health department treats birth information with an
exceptional degree of confidentiality
• Attorneys believe that CWS assessments are a
25
detriment to their adult clients
Project SEEK
• Pediatricians working to
understand family risks
• Referrals to clinic social
workers to improve care and
reduce child maltreatment
“Bright Futures” Developmental
Screening Instruments: AAP Endorsed
• Ages and Stages Questionnaire
• Battelle Developmental Inventory (BDI)
Screening Test
BUT WHAT’S
• Bayley Infant Neurodevelopmental
MISSING?
Screener (BINS)
• Brigance Screens-II
• Infant Development Inventory
• Child Development Review
• Child Development Inventory (CDI)
• Denver-II Developmental Screening Test
• Parents' Evaluation of Developmental
Status (PEDS)
What’s Missing in “Bright
Futures” Pediatric Screening?
• Family (Parent) Well-Being Measures
– The future isn’t bright if your parent is
suffering
• SEEK Parent Screening Questionnaire
(PSQ3): Safe Environment for Every Kid
SEEK: Easy as 1, 2, 3 … 4
1.Medical residents who received special
training (on the importance of family risks
for preventing maltreatment, some
resources, and motivational interviewing)
2.Parent Screening Questionnaire (SEEK)
completed in waiting room
3.Referral to a social worker (1 per every 7
physicians
4.Parent and child (0-5)
29
SEEK Study Design
1118 parents approach, 35% refused or excluded, 23%
did not complete protocol. Final 308 (T) and 250 (C)
30
SEEK Items
1. Do you need the phone number for Poison
Control?
2. Do you need a smoke detector for your home?
3. Does anyone smoke tobacco at home?
4. In the last year, did you worry that your food would
run out before you got money or Food Stamps to
buy more?
5. In the last year, did the food you bought just not
last and you didn’t have money to get more?
6. Do you often feel your child is difficult to take care
of?
7. Do you sometimes find you need to hit or spank
your child?
SEEK Items (continued)
8. Lately, have you often felt down, depressed, or
hopeless?
9. Lately, have you felt very little interest or pleasure in
things you used to enjoy?
10.Have you ever been in a relationship in which you
were physically hurt or threatened by a partner?
11.Have you ever felt you should cut down on drinking
or drug use?
12.Have you ever felt your partner should cut down on
drinking or drug use?
13.Are there any other problems you’d like help with
today?
For more information about SEEK, umm.edu/pediatrics/seek_project.htm
SEEK Social Work Procedures
• The intervention clinics have a social
worker who worked closely with the
residents and families
• Residents and parents chose whether to
involve the social worker
• Pediatric management often involved
guidance and support in the clinic and
referrals to community agencies
33
SEEK: Sample and Results
•
•
•
•
93% African American, 87% Single
32% Employed (38% < HS Education)
Fewer adults than children in the homes
93% received Medical Assistance
MAJOR RESULTS:
After onset of the SEEK intervention, there were
fewer CPS reports among intervention families
(19.2% vs 13.3%; P < .05); 69% of reports
were for neglect.
34
Family Connections Core Practice
Components
1. Home visiting family intervention
2. Advocacy
3. Service coordination with referrals targeted
toward risk and protective factors; and
4. Multi-family supportive and recreational activities.
5. Tailored and direct trauma-informed services to
help families reduce risks, maximize protective
factors, and achieve service outcomes and goals.
35
Family Connections
• Preliminary results from a cross site evaluation by
James Bell Associates (JBA) indicate that similar
positive changes in risk and protective factors over
time were observed in 8 programs replicating FC
• Families that were purposefully served for longer
(9-12 months) versus shorter (3-6 months)
achieved greater improvements in parenting
attitudes and child behavior.
– Families served by workers who implement FC with
a higher degree of fidelity also achieve greater
change in family and child level outcomes.
36
8-Site Replication Results So Far
• FC holds promise for promoting family well-being
by reducing risk factors and increasing protective
factors for preventing child neglect
• Better outcomes were achieved when the
levels of implementation fidelity were higher
Filene, Smith & Kass (June, 2010). Presentation to Society for Prevention
37
Research, Denver.
Family Check Up
38
Family Check Up
• The intervention services are family
centered
• They address and support parents of children
and adolescents in the change process.
• They focus on supporting parents’ leadership
role in their children’s lives.
• The intervention services are family
assessment driven
• Decisions about how to tailor interventions to
individual and family needs are based on
careful assessments of the child and family at
home and the child in school.
39
Family Check Up
• Lessons Learned from Family Check Up
– To prevent child behavior problems there
may be a need to intervene early and directly
with:
• (a) the emotional climate of the family and
• (b) the emotional climate of the parenting
relationship.
• These facets of child and family dynamics
are highly interrelated and often need to be
addressed together
40
Prevention of Child Abuse Occurrence,
Recurrence, & Impairment Must be Family
Focused
FAMILY
FOCUS
NFP, Early Start (NZ),
Triple P (AUS)
Source: MacMillan et al. (2009). Lancet
41
Family Data: Waste Not, Want Not
We waste untold amounts of family data
• Birth data is overprotected and underused
• (Nearly) every state collects risk assessment data and
then fails to put it into play with administrative data
• Every state collects family based foster care and
adoption licensing and home study data but fails to use
that information to understand placement outcomes
• Every state collects TANF addresses and adoption
subsidy data and address payment data for families
but fails to keep track of when subsidy change
requests are frequent or address changes are
frequent—perhaps signaling family instability
Opportunism and Incrementalism
• Gregg Bloche (2007) and Janet Bronstein
(2008), writing about health care, have argued
that system reform is most likely to arise in an
incremental manner from existing institutional
arrangements.
• They assert that we should be opportunists,
keeping our eyes open for examples of local
changes and established local arrangements
to improve the quality of care.
43
Opportunism and Incrementalism
• So, what can we learn from this approach of
examining local developments?
• To try and test a variety of ways to achieve
work with “Family Data”:
– birth records, administrative children’s services
and health records, measurement feedback
systems, brief assessments, co-located
services, and family centered case
management reimbursement mechanisms
– You can think of more
44
The Grass Isn’t Greener
on the “other side” or on
“your side” -- it’s greener
where you water it…
We have to more
thoroughly water family
assessment and data
integration if we will be
powerful interventionists
45
Thank You Very Much
Additional Questions or
Comments?
46
Partial References
Berrick, J. D., Choi, Y., D'Andrade, A., & Frame, L. (2008). Reasonable Efforts? Implementation
of the Reunification Bypass Provision of ASFA. [Article]. Child Welfare, 87(3), 163-182.
Bloche, M. G. (2007). A graveyard for grand theory. [Article]. Health Affairs, 26(6), 1534-1536.
doi: 10.1377/hlthaff.26.6.1534
Bronstein, J. M. (2008). Policy levers that improve low income children's access to mental health
services. [Editorial Material]. Medical Care, 46(6), 555-557.
Chambers, R. M., & Potter, C. C. (2009). Family Needs in Child Neglect Cases: A Cluster
Analysis. [Article]. Families in Society-the Journal of Contemporary Social Services, 90(1),
18-27. doi: 10.1606/1044-3894.3841.
DePanfilis, D., Dubowitz, H., & Kunz, J. (2008). Assessing the cost-effectiveness of Family
Connections. Child Abuse & Neglect, 32(3), 335-351.
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. [Article]. Pediatrics,
123(3), 858-864. doi: 10.1542/peds.2008-1376.
Duke, N. N., Pettingell, S. L., McMorris, B. J., & Borowsky, I. W. (2010). adolescent violence
perpetration: associations with multiple types of adverse childhood experiences. [Article].
Pediatrics, 125(4), E778-E786. doi: 10.1542/peds.2009-0597.
Filene, JH, Smith, E. G, & Kass, L. (2010). Implementation of an evidence-based child neglect
prevention program: findings from a multi-site replication of Family Connections. Presented
at the Society for Prevention Research, Denver, CO, June 3, 2010.
Gonzalez, A., & MacMillan, H. L. (2008). Preventing child maltreatment: An evidence-based
47
update. [Article]. Journal of Postgraduate Medicine, 54(4), 280-286.
References
Jonson-Reid, M., Chung, S., Way, I., & Jolley, J. (2010). Understanding service use and victim
patterns associated with re-reports of alleged maltreatment perpetrators. [Article]. Children
and Youth Services Review, 32(6), 790-797. doi: 10.1016/j.childyouth.2010.01.013.
Linville D, Chronister K, Dishion T, et al. A Longitudinal Analysis of Parenting Practices, Couple
Satisfaction, and Child Behavior Problems. Journal of Marital & Family Therapy [serial
online]. April 2010;36(2):244-255. Available from: SocINDEX with Full Text, Ipswich, MA.
Accessed September 9, 2010.
MacMillan, H. L., Wathen, C. N., Barlow, J., Fergusson, D. M., Leventhal, J. M., & Taussig, H.
N. (2009). Child Maltreatment 3 Interventions to prevent child maltreatment and associated
impairment. [Article]. Lancet, 373(9659), 250-266.
Manning, M., Homel, R., & Smith, C. (2010). A meta-analysis of the effects of early
developmental prevention programs in at-risk populations on non-health outcomes in
adolescence. [Article]. Children and Youth Services Review, 32(4), 506-519. doi:
10.1016/j.childyouth.2009.11.003.
McCrae, J. S., & Barth, R. P. (2008). Using cumulative risk to screen for mental health problems
in child welfare. [Article]. Research on Social Work Practice, 18(2), 144-159. doi:
10.1177/1049731507305394.
Rouse, H. L., & Fantuzzo, J. W. (2009). Multiple risks and educational well being: A populationbased investigation of threats to early school success. [Article]. Early Childhood Research
Quarterly, 24(1), 1-14. doi: 10.1016/j.ecresq.2008.12.001
Williams, J. H., Van Dorn, R. A., Bright, C. L., Jonson-Reid, M., & Nebbitt, V. E. (2010). Child
48
Maltreatment and Delinquency Onset Among African American Adolescent Males. [Article].
Research on Social Work Practice, 20(3), 253-259. doi: 10.1177/1049731509347865