Safe Care Widescale Implementation of an EvidenceBased Practice
Safe. Care®: Widescale Implementation of an Evidence-Based Practice to Prevent Child Maltreatment John R. Lutzker, Ph. D. Director, Center for Healthy Development Visiting Professor, Institute of Public Health College of Health and Human Sciences Georgia State University
Child Maltreatment In 2006, 905, 000 children experienced child maltreatment in the US (12. 1 per 1, 000) 1, 530 children in the US died from abuse or neglect in 2006 (78% <age 4; 44. 2% <age 1); 41. 1% from neglect, 22. 4% from abuse, 31. 4% from multiple types Physical Abuse 16% Sexual Abuse 8. 8% Emotional Abuse 6. 6% Neglect 66. 3%
Trends in Child Maltreatment in the U. S.
A brief history of Safe. Care Project 12 -Ways : 1979 Project Ecosystems : 1986 - 2001 Safe. Care development : 1994 -1998 CDC & Oklahoma Studies: 2001 Marcus Institute & NSTRC birth: 2005 -2008 Move to GSU: August 2008
Safe. Care Model Overview In-home parent-training model to prevent child maltreatment Behavioral, skill-based model, that focuses on three skills 1. 2. 3. Health Safety Parent-child interactions Structured problem -solving taught for other issues Counseling skills reviewed with Safe. Care trainees 5
Safe. Care model overview Safe. Care® is typically 18 -20 sessions Typically, weekly for 90 minutes Can be conducted alone or integrated into other services Each module is conducted over 5 -6 sessions Modules can be conducted in any order Health is often first
Safe. Care Overview Structure of each module 1) Initial assessment using structured checklists (1 session) 2) Skill training (4 -5 sessions) � Explain—model—practice—feedback sequence 3) Final assessment to ensure learning (1 session) The use of structured assessment allows the provider to “see” change and measure it objectively Validated tools exist for measuring change
III. Safe. Care Research A number of lines of research support the efficacy/effectiveness of Safe. Care® Single- Case Studies of Behavior Change Non-experimental Group Studies of Behavior Change Quasi-Experimental comparison studies Site-Randomized & Case-Randomized Studies are in progress Populations included in research High-risk parents Parents reported for child maltreatment Children with autism and related disabilities Adults with intellectual disabilities
III. Safe. Care: Initial Research evidence Many single-case validation studies and social validity studies (60+) Safety • Tertinger, D. A. , Greene, B. F. & Lutzker, J. R. (1984). Home safety: Development and validation of one component of an ecobehavioral treatment program for abused and neglected children. Journal of Applied Behavior Analysis, 17, 159 -174. • Barone, V. J. , Greene, B. F. , & Lutzker, J. R. (1986). Home safety with families being treated for child abuse and neglect. Behavior Modification, 10, 93 -114. • Mandel, U. , Bigelow, K. M. , & Lutzker, J. R. (1998). Using video to reduce home safety hazards with parents reported for child abuse and neglect. Journal of Family Violence, 13(2), 147 -161. • Metchikian, K. L. , Mink, J. M. , Bigelow, K. M. , Lutzker, J. R. , & Doctor, R. M. (1999). Reducing home safety hazards in the homes of parents reported for neglect. Child and Family Behavior Therapy, 3, 23 -34. Health • Delgado, L. E. & Lutzker, J. R. (1988). Training young parents to identify and report their children's illnesses. Journal of Applied Behavior Analysis, 21, 311 -319. • Watson-Perczel, M. , Lutzker, J. R. , Green, B. F. , & Mc. Gimpsey, B. J. (1988). Assessment and modification of home cleanliness among families adjudicated for child neglect. Behavioral Modification, 12(1), 57 -81. • Bigelow, K. M. , & Lutzker, J. R. (2000). Training parents reported for or at risk for child abuse and neglect to identify and treat their children’s illnesses. Journal of Family Violence, 15(4), 311 -330. Parent-Child Interactions • Lutzker, J. R. , Megson, D. A. , Webb, M. E. , & Dachman, R. S. (1985). Validating and training adult-child interaction skills to professionals and to parents indicated for child abuse and neglect. Journal of Child and Adolescent Psychotherapy, 2, 91 -104. • Mc. Gimsey, J. F. , Lutzker, J. R. , & Greene, B. F. (1994). Validating and teaching affective adult-child interaction skills. Behavior Modification, 18(2), 198 -213. • Bigelow, K. M. , & Lutzker, J. R. (1998). Using video to teach planned activities to parents reported for child abuse. Child & Family Behavior Therapy, 20(4), 1 -14.
Home safety data Metchikian, K. L. , Mink, J. M. , Bigelow, K. M. , Lutzker, J. R. , & Doctor, R. M. (1999). Reducing home safety hazards in the homes of parents reported for neglect. Child and Family Behavior Therapy, 3, 23 -34. Health care skills Bigelow, K. M. , & Lutzker, J. R. (2000). Training parents reported for or at risk for child abuse and neglect to identify and treat their children’s illnesses. Journal of Family Violence, 15(4), 311 -330.
Single case studies: Planned activities training Bigelow, K. M. , & Lutzker, J. R. (1998). Using video to teach planned activities to parents reported for child abuse. Child & Family Behavior Therapy, 20(4), 1 -14.
Group data: Project 12 -ways Examined over 700 families receiving Safe. Care or other CPS services from 1979 -1984 Examined recidivism rates Safe. Care families = 21. 3% Other CPS services = 28. 5% Reduction in recidivism= 25% Other analyses suggest that Safe. Care families were more difficult than non-Safe. Care families Lutzker, J. R. , & Rice, J. M. (1987). Using recidivism data to evaluate project 12 -ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect. Journal of Family Violence, 2(4), 283 -290.
Group studies: Safe. Care California Families: current involvement with child welfare After 36 -months SC: 15% recidivism/first - time reports SAU: 44% recidivism/ first -time reports 75% reduction in reports to CPS for maltreatment Gershater-Molko. R. M. , Lutzker, J. R. , & Wesch, D. (2002). Using recidivism data to evaluate Project Safe. Care: Teaching bonding, safety, and health care skills to parents. Child Maltreatment, 7, 277 -285.
Safe. Care Oklahoma Two trials initiated ~ 2002 Statewide trial Prevention project History OUHSC evaluated Oklahoma’s CHBS �Current services were having little impact Asked to help choose something new Selected Safe. Care based on its neglect focus Implementation began ~ 2002
Oklahoma Statewide trial (PI: Mark Chaffin) 6 service regions in OK assigned to Safe. Care or SAU Providers receive SC training or do SAU Regions 1, 2, & 3 = Safe. Care; 4, 5 & 6 = SAU Half of each get “fidelity monitoring” or coaching Outcomes: CPS referrals + intermediate variables Economic evaluation to test cost effectivenes of coaching
OK statewide trial: preliminary outcomes Reduction in neglect for Safe. Care group, but only when fidelity was monitored through coaching Also, turnover among Safe. Care caseworkers was half (16%) of non-Safe. Care caseworkers (31%)
Oklahoma: Prevention study High risk families in OK City randomly assigned to receive either Safe. Care-based services or standard mental health treatment SC workers were trained in Safe. Care, motivational interviewing and domestic violence services Parents had IPV, substance use, and/or mental health problems Safe. Care workers were BA level; SAU has Masters degrees Initial Results: Safe. Care families had: Less depression Reduction in Child Abuse Potential scores (CAPI) More satisfaction with services Believe services more culturally relevant Prevention of first time CM was reduced by ~ 25% (p =. 06)
Other Ongoing Research Efforts Kansas Cell Phone study (Judy Carta) Can engagement and ‘dosage’ of PAT be enhanced with use of cell phones? Wayne State University (Steve Ondersma) Can Safe. Care be delivered directly to families via a computer-based intervention? San Diego diffusion study (Mark Chaffin) Examining trainer training in a non-experimental way GA. CDC grant to study statewide trainer-training implementation
Current Safe. Care Training efforts Effort Source Funds/timeline NSTRC role Safe. Care Training in GA GA DHR/CFC 1 million over 2 years PI Washington State training contract WA State DSS $76 k over 1 year PI San Diego training UW of SD 150 k over 3 years PI Safe. Care & PAT Annie E Casey 35 k over 1 year PI Safe. Care & HF GA and GCAAP AM Blank Pending PI Reducing CM in GA OJJDP 1. 0 million over 1 year PI Expanding training in CA ACF 2 million over 5 years PI Expanding OK Safe. Care prevention ACF 2 million over 5 yrs consult Safe. Care with incarcerated moms NIHM Belarus training CCF None
Safe. Care: Research grants NSTRC’s Research Effort Source Funds/timeline NSTRC Role NSTRC center grant Doris Duke 1. 3 million over 3 years PI Comparison of trainer/coach training models CDC 1. 3 million over 3 years PI Technology in training and fidelity monitoring CDC with Emory Pending (750 k over 5 years) PI Cascading diffusion in San Diego CDC 1 million over 3 years Co-I Expanding OK Safe. Care prevention ACF Consult over 5 years Consult Computer delivered Safe. Care (Wayne State) CDC 2 million over 5 years Consult Cell-phone enhanced PAT (U of Kansas) CDC 2 million over 5 years Consult
Focus of NSTRC 1. Increase awareness and use of Safe. Care Increase trainings 2. Standardize training methods and develop train-the-trainer model 3. Implementation/translation research Empirical test aspects of training model Use technology to increase efficiency of training and fidelity monitoring Understand what factors influence organizational, provider, and family uptake of Safe. Care.
Safe. Care Training model philosophy Fidelity is key Fidelity is the extent to which the critical features of a program are implemented as intended Deviating from a model may reduce effectiveness Deviations vs. innovations How to improve/maintain fidelity Training manuals with clear descriptions Formal training of facilitators Ongoing support and consultation for program providers Ongoing fidelity monitoring & coaching
Safe. Care Training Model Home visitor – provides Safe. Care services Coach – provides ongoing coaching for HV to ensure fidelity to the model Coaching required for Safe. Care implementation Trainer – trains new HV and coaches Trainers must practice Safe. Care and coaching Trainers support coaches who monitor the fidelity of home visitors Trainer Coach HV training
Safe. Care Center: Future directions Refine training model Research grants to test aspects of model Use technology to make training & implementation cheaper Technology-based training, coaching, and fidelity monitoring Health economics work to understand the cost/benefit ratio of Understand fit of Safe. Care with other EBP Understand policy aspects of increasing EBP in child welfare settings Understand adaptions for cultural groups
Contact John R. Lutkzer, Ph. D, Jlutzker@GSU. EDU Director, Center for Healthy Development, GSU Safe. Care Web site: www. nstrc. org Center for Healthy Development Website: http: //chhs. gsu. edu/chd/
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