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Child Maltreatment Prevention and the Power of the Home Visitor

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1 Child Maltreatment Prevention and the Power of the Home Visitor
Madeline duhaime mcclure, LCSW Executive director, Texprotects, The texas association for the protection of children | Dallas, TX April 5, 2014

2 About TexProtects Membership-based Statewide Advocacy Organization
7,400 + members statewide Advocate on behalf of abused and neglected children in 3 core areas: Investments in proven Child Abuse Prevention programs. Improvements to Child Protective Services and systems that impact abused children. Improvements to programs that heal victims. Over the past 10 years, TexProtects has led and/or assisted the passage of 37 bills, including 2 omnibus bills, and has secured over $71 million in state funds for evidence-based home visiting services.

3 University of Phoenix Stadium: 63,400 Capacity
42,091 Unduplicated Reports of Abuse in 2012. This is the University of Phoenix stadium, home to the Arizona Cardinals, Fiesta Bowl, BCS National Championship Game. It holds 63,400 people.

4 Child Maltreatment in Arizona
KIDS COUNT Data Center. (2013). Arizona Indicators. Retrieved from

5 Child Victim Rate per 1,000 Children
U.S. Department of Health and Human Services, Administration on Children, Youth and Families. (2013). Child maltreatment 2012. Washington, DC: US Government Printing Office. Retrieved from http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012.

6 Child Maltreatment Fatalities: 10-Year Trend
In 2012, 70 children in Arizona died due to abuse and neglect. The Arizona child population grew by 11.5% while child abuse fatalities increased an astounding 89.2% from 2003 to 2012. KIDS COUNT Data Center. (2013). Arizona Indicators. Retrieved from

7 Victims by Age (2012) Nationally: 1/3 if all child maltreatment victims are under the age of four U.S. Department of Health and Human Services, Administration on Children, Youth and Families. (2013). Child maltreatment 2012. Washington, DC: US Government Printing Office. Retrieved from http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012.

8 Victims by Gender & Type (2012)

9 Quick Facts According to the U.S. Department of Health and Human Services, over 80% of all child victims of maltreatment are victims of neglect 1/3 if all child maltreatment victims are under the age of four It is often difficult to prevent abuse once it has already occurred, especially neglect, therefore the prevention of abuse and neglect is key.* Neglect recidivism is very difficult to lower. Benefits of home-based neglect services have yielded discouraging results, as benefits are often small and do not translate into recidivism reduction *MacMillan, H., Thomas, B., Jamieson, E., et al. (2005). Effectiveness f home visitation by public health nurses in prevention of the recurrence of child physical abuse and neglect: A randomized controlled trial. Lancet, 365 (9473),  

10 The Importance of the Early Years and Consequences for At-Risk Children

11 Why Are the Early Years Critical?
1. Our environment as young children influences genetics (Epigenetics) 2. The first five years are critical for brain development The brain develops about 700 synapses per second (neural connections that transmit information) Brain circuits used are strengthened; those not utilized diminish (Developmental Neuroscience) *Eco-Bio-Developmental Model of Health and Human Disease* “Ecology becomes biology and together they drive development across the lifespan” -Andrew Garner, M.D., Ph.D., FAAP Garner, A. (2013). Translating Developmental Science into Healthy Lives: Realizing the Potential of Pediatrics [PowerPoint Slides].

12 Major Milestones in Brain Development
Brain Synapse Formation by Age (700 synapses per second during the early years) Pew Center on the States Home Visitation Campaign. (2000). [image adaptation] Nelson, C.A. (2000). In Jack P. Shonkoff and Deborah A. Phillips (Eds.), From Neurons to Neighborhoods: The Science of Early Childhood Development (p. 188). Washington, DC: National Research Council and Institute of Medicine, National Academy Press.

13 What is Toxic Stress? “Strong, frequent, and/or prolonged activation of the body’s stress-response system in the absence of the buffering protection of a supportive, adult relationship.” Shonkoff & Garner (2012) Shonkoff, J., & Garner, A. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1)

14 Toxic Stress Root of adult physical and mental health issues
Result of early exposure to risks: Child Maltreatment Parental Depression Parental Substance Abuse Family Violence Incarcerated Parent Slide from Brenda Jones Harden. (2014). Home Moments: Home Visiting to Address Toxic Stress [PowerPoint Slides]. Retrieved from https://s3.amazonaws.com/v3-app_crowdc/assets/events/LIcoEjkC8i/activities/Brenda_Jones_HardinPPT.original pdf.

15 Critical Concept: strongly associated with unhealthy lifestyles and
Childhood Adversity has Lifelong Consequences. Significant adversity in childhood is strongly associated with unhealthy lifestyles and poor health decades later

16 ACE Categories 1:4! 1:4! Women Men Total
Abuse (n=9,367) (n=7,970) (17,337) Emotional 13.1% 7.6% 10.6% Physical 27.0% 29.9% 28.3% Sexual 24.7% 16.0% 20.7% Household Dysfunction Mother Treated Violently 13.7% 11.5% 12.7% Household Substance Abuse 29.5% 23.8% 26.9% Household Mental Illness 23.3% 14.8% 19.4% Parental Separation or Divorce 24.5% 21.8% 23.3% Incarcerated Household Member 5.2% 4.1% 4.7% Neglect* Emotional 16.7% 12.4% 14.8% Physical 9.2% 10.7% 9.9% * Wave 2 data only (n=8,667) Data from 1:4! 1:4! Garner, A. (2013). Translating Developmental Science into Healthy Lives: Realizing the Potential of Pediatrics [PowerPoint Slides].

17 ACES in Arizona and Nationwide
Any more ACE outcomes: percentage with 3, 4 or 5 ACE’s? Nope-they only reported 0-2 ACEs, at least at the national and state level.

18 Defining Adversity or Stress
Positive Stress Brief, infrequent, mild to moderate intensity Most normative childhood stress Inability of the 15 month old to express their desires The 2 year old who stumbles while running Beginning school or daycare The big project in middle school Social-emotional buffers allow a return to baseline (responding to non-verbal clues, consolation, reassurance, assistance in planning) Builds motivation and resiliency Positive Stress is NOT the ABSENCE of stress Read slide. So, what then is tolerable stress?? Garner, A. (2013). Translating Developmental Science into Healthy Lives: Realizing the Potential of Pediatrics [PowerPoint Slides]. 18

19 Defining Adversity or Stress
Toxic Stress Long lasting, frequent, or strong intensity More extreme precipitants of childhood stress (ACEs) Physical, sexual, emotional abuse Physical, emotional neglect Household dysfunction Insufficient social-emotional buffering (Deficient levels of emotion coaching, re-processing, reassurance and support) Potentially permanent changes and long-term effects Epigenetics (there are life long / intergenerational changes in how the genetic program is turned ON or OFF) Brain architecture (the mediators of stress impact upon the mechanisms of brain development / connectivity) Read slide. The hallmark of toxic stress, then, is the inability to return to baseline due to insufficient SE buffering. The importance of toxic stress, is that it effects brain connectivity and functioning, potentially permanently. Toxic stress also is known to alter the way the genetic program is turned on and off. Remember the muscle analogy, and the fact that brain plasticity is a double edged sword? Well early childhood stress is particularly damaging because it sets up a vicious cycle, where… Garner, A. (2013). Translating Developmental Science into Healthy Lives: Realizing the Potential of Pediatrics [PowerPoint Slides]. 19

20 Impact of Early Stress Hyper-responsive stress response; calm/coping
CHILDHOOD STRESS Hyper-responsive stress response; calm/coping Chronic “fight or flight;” adrenaline / cortisol And remember, once the neural pathways underlying this vicious cycle are wired up and strengthened, it is much hard to mitigate their effects down the line because the brain’s plasticity is declining with age. We can summarize all of this in critical concept number 4… Changes in Brain Architecture Garner, A. (2013). Translating Developmental Science into Healthy Lives: Realizing the Potential of Pediatrics [PowerPoint Slides]. 20

21 Outcomes of High-Risk Children: Impact of ACES
66% 50% more likely to suffer learning disorders requiring special ed (1) 66% more likely to become involved with drugs (self anesthetizing) (2) 50% more likely to have school-related problems (3) 40% more likely to become pregnant as a teenager (4) 25% more likely to drop out of school, (5) 60% more likely to never attend college (pretty much in this order) (6) 59% greater likelihood of becoming a juvenile delinquent and (7) 70 % arrested for violent crime (8) (1) Barnett, W.S., & Masse, L.N. (2002). A benefit-cost analyses of the Abecedarian Early Childhood Intervention. New Brunswick, NJ: National Institute for Early Education Research. Retrieved from (2) Swan, N. (1998). Exploring the role of child abuse on later drug abuse: Researchers face broad gaps in information. NIDA Notes, 13(2). Retrieved from (3) Barnett, W.S., & Masse, L.N. (2002). A benefit-cost analyses of the Abecedarian Early Childhood (4) Campbell, F. A., Ramey, C. T., Pungello, E. P., Sparling, J., & Miller-Johnson, S. (2002). Early childhood education: Young adults’ outcomes from the Abecedarian project. Applied Developmental Science, 6, (5) Barnett, W.S., & Masse, L.N. (2002). A benefit-cost analyses of the Abecedarian Early Childhood (6) (7) Widom, C., & Maxfield, M. (2001). An update on the “Cycle of Violence.” Research in Brief, Washington, DC: U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. (8) Reynolds, A., Temple, J., Robertson, D., & Mann, E. (2001). Long-term effects of an early childhood intervention on educational achievement and juvenile arrest. Journal of the American Medical Association, 285(18), Barnett, W.S., & Masse, L.N. (2002).; Swan, N. (1998).; Campbell, F. A., et al. (2002).; Widom, C., & Maxfield, M. (2001); Reynolds, A., et al. (2001)

22 Cost of Doing Nothing: CDC Lifetime Costs of CA/N
Average lifetime cost per survivor: $210,012 Nearly $124 billion All from Centers of Disease Control 2012 (Fang, Brown, Florence, and Mercy study): **They estimated costs for ages 6-64 (so, a conservative estimate because most serious injuries occur before age 6 and health-related costs likely to continue past age 64) **When considering the rate of CONFIRMED new cases of abuse and child fatalities from just 2008, it is estimated that the lifetime cost to the US will be almost $124 billion This amount keeps getting renewed each year as more victims are added. **In 2010 dollars, we will spend an average of $210,012 ($222, adjusted for inflation) per survivor of abuse and almost $1.3 million ($1,350, adjusted for inflation) for each child who dies.

23 The Success of Family Support Home Visiting Programs
Reducing child maltreatment and buffering the effects of toxic stress caused by adverse childhood experiences

24 Outcomes of Home Visiting Programs
Mothers can learn to better care for themselves and have healthier relationships with the father: Months on Welfare and Using Food Stamps, Months on Medicaid, Arrests and Convictions, Days in Jail, Prenatal Smoking, Prenatal Hypertension, Depression, Domestic Violence Months Mothers Employed, Education and Job Training, Rates of Living with Father, Spacing Between Child Births

25 Outcomes of Home Visiting Programs
Parents also can learn how to better care for their children: Child Abuse and Neglect, Out of Home Placements, Child Injuries, Safety Hazards in Home, Parenting Harshness Father Involvement, Parenting Sensitivity and Interaction with Child, Parenting Knowledge, Stimulating Home Environment

26 Outcomes of Home Visiting Programs
Which ultimately can lead to better outcomes for children: Premature Deliveries, Neurodevelopmental Impairment, Language/Cognitive Delays, Psychological Maladjustment, Juvenile Arrests and Adjudication Birth Weights, Child Health, Child Behavior, School Readiness, Academic and Cognitive Performance

27 NFP-Evidence of Child Abuse Reduction Study Methodology
Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8),   Design: Randomized Controlled Trial; Elmira, New York Objective: To examine the long-term effects of NFP on women’s life course and child abuse and neglect. Participants: 400 pregnant women with no previous live births. 324 participated in the follow-up 15 years later. There were 4 treatment conditions: Treatment 1: Provided sensory and developmental screening at 12 and 24 months of age Treatment 2: Provided screening services offered in treatment 1, plus free transportation for prenatal and well-child care through the child’s 2nd birthday Treatment 3: Provided screening and transportation services offered in treatment 2; in addition to being provided a nurse who visited them in the home during pregnancy Treatment 4: Provided same services offered in treatment 3 but the nurses continued to visit through the child’s 2nd birthday Follow-up: 15 Years after birth of first child NFP is a HV program for low-income, first-time mothers and their children largely focused on improving maternal and child health for at-risk families. Goals: 1) Improve: (a) pregnancy outcomes, (b) child health and development, and (c) economic self-sufficiency of the family; (2) Reduce domestic violence; (3) Promote father involvement Home Visitor Training: Specially trained, registered nurses with Bachelor’s degrees (Master’s degrees preferred); 3 Pre-service core NFP education sessions; Annual education supplements Target Population: Low-income first time mothers willing to receive first home visit by the 28th week of pregnancy. Services continue until child turns age 2. Treatment 4 was the most inclusive group: These mothers received screenings, transportation and home visits through age 2.

28 NFP-Child Abuse Prevention Outcomes
Whole Sample During the 15-year period after the birth of their first child, in contract to the comparison group, women who were visited by nurses during pregnancy AND infancy were identified as perpetrators of abuse significant less often (0.29 vs verified reports). Results are even more significant for the low-SES unmarried sample (0.11 vs. 0.53). Incidence Dependent Variables Treatment 1 and 2 Treatment 3 Treatment 4 Treatment 1 &2 vs. 4 (95% CI) Substantiated Reports of Child Abuse and Neglect 0.54 0.35 0.29 0.77* (0.34 to 1.19) Low-SES Unmarried Sample Incidence Dependent Variables Treatment 1 and 2 Treatment 3 Treatment 4 Treatment 1 &2 vs. 4 (95% CI) Substantiated Reports of Child Abuse and Neglect 0.53 0.63 0.11 1.61* (0.87 to 2.35) * P=<0.01 (P=<0.05 equals statistical significance) Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8),  

29 POSITIVE PARENTING PROGRAM-TRIPLE P
Level 1: Universal Triple P/ Targets ALL parents Media-based Parent Information Campaign Level 2: Selected Triple P / Targets 60% of parents Brief Selective Intervention (e.g., Family practitioners provide information; Large group seminars) Level 3: Primary Care Triple P /Targets 33% of parents Narrow Focus Parent Training (e.g., therapy sessions, telephone calls, group sessions) Level 4: Standard & Group Triple P / Targets 9% of parents Broad Focus Parent Training (similar to levels 2 & 3 - more intense interactions)) Level 5: Enhanced Triple P / Targets 2% of parents Behavioral family intervention (intense, individually tailored, adds home visits) Triple P uses a public health approach to prevent child emotional, behavioral, and developmental problems. There are 5 levels of intervention differing in terms of intensity and modes of assistance. Goals: (1) To promote family independence and health, non-violent protective and nurturing environments and child development, growth and health and social competencies (2) Reduce child abuse, mental illness, behavior problems, delinquency and homelessness (3) Enhance parent competence, resourcefulness and self-sufficiency Home Visitor Training: Professional practitioners with a post-secondary degree; must attend accredited training courses Target population: Parents or caregivers of a child ages birth to age 16 who are at-risk for child maltreatment

30 Triple P-Study Methodology
Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The U.S. Triple P system population trial. Prevention Science, 10(1),   Design: Population Level Randomized Controlled Trial; 18 counties in South Carolina Objective: To evaluate the impact of implementing Triple P with the existing workforce on population indicators related to child maltreatment (i.e., rates of substantiated child maltreatment, child out-of-home placements, and child hospitalizations and ER visits for maltreatment injuries). Participants: 18 counties in South Carolina. 9 counties received System Triple P while the 9 received SAU. In addition, dissemination involved Triple P Professional training for the existing workforce (649 service providers). This training was 2-3 days. Follow-up: 1 year

31 Triple P Outcomes-Evidence of Child Abuse Reduction
35% reduction in hospitalizations and emergency room visits for child injuries 44% reduction in out-of-home placements 28% reduction in substantiated cases of abuse Triple P Counties Control Counties Pre-Intervention Post-Intervention Statistical Significance Effect Size Substantiated CM 10.86 11.74 11.12 15.06 P<0.03 1.09 Out-of-home Placements 4.27 3.75 3.10 4.46 P<0.01 1.22 Child CM Injuries 1.73 1.41 1.69 P<0.02 1.14 Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The U.S. Triple P system population trial. Prevention Science, 10(1),   Triple P Counties Control Counties

32 SafeCare-Study Methodology
Chaffin, M., Hecht, D., Bard, D., Silovsky, J. F., & Beasley, W. H. (2012). A statewide trial of the SafeCare home-based services model with parents in child protective services. Pediatrics, 129(3),     Design: Randomized Controlled Trial; Scaled-up statewide trial in Oklahoma Participants: Participants in 6 regions (2175). Randomized to receive SafeCare or Services as Usual (SAU) Objective: The study was designed to compare maltreatment recidivism (recurrence) between participants who were referred by CPS to home-based SafeCare services or to comparable home-based services, but without SafeCare modules (SAU) Follow-up: Approximately 6 years SafeCare is a manualized, structured behavioral skills training home visiting model that provides direct skill training to parents in child behavior management and planned activities training, home safety training, and child health care skills to prevent child maltreatment. 1) parent/child interaction, basic caregiving structure and parenting routines 2) home safety 3) child health Home Visitor Credentials: No specific education requirements; all home visitors must complete a multi-day workshop delivered by NSTRC trainers; additional training required to become coach or trainer Target Population: Parents of children 0 – 5 years of age that are at-risk for child abuse and neglect or have a history of child maltreatment This study is a RCT. The SAU in the study received very similar types and dosage of services, but in a less structured and more discussion oriented manner. One maltreating parent per household was enrolled. Eligible parents were all nonsexual abusers referred to the program by CPS. Data Collection: Past and future CPS reports were extracted from the statewide CPS database. Matches were for the study participants as the perpetrator.

33 SafeCare-Outcomes Recidivism of child abuse occurred less frequently (26%) for those who received SafeCare home visiting compared to SAU. The SAU group received home-based services comparable to SafeCare but without the SafeCare modules. It is likely the effect size would have been even larger is the SAU would have been weaker or meant no services were provided. According to the study findings, a home-based service system treating 1,000 cases could prevent estimated first-year recurrences of abuse by adopting the SafeCare model. recidivism of abuse occurs less frequently (26%) for the SafeCare population. Chaffin, M., Hecht, D., Bard, D., Silovsky, J. F., & Beasley, W. H. (2012). A statewide trial of the SafeCare home-based services model with parents in child protective services. Pediatrics, 129(3),  doi: /peds  

34 Healthy Families-Study Methodology
DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, A., Rodriguez, M., & Dorabawila, V. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse & Neglect, 32(3),  Design: Randomized Controlled Trial; New York Objective: To evaluate the effects of Healthy Families on parenting behaviors in the first 2 years of life Participants: 1173 families at-risk for child abuse and neglect; Participants were assigned to HFNY or control group (received information and referrals to other services). There was a subgroup, which included first-time mothers under the age of 19 who were enrolled in HFNY at 30 weeks of pregnancy The remaining women were referred to as the “diverse subgroup” Follow-up: 2 years Data was collected through a review of CPS records and maternal interviews at baseline and the child’s first and second birthday.

35 Healthy Families-Outcomes
Mother’s abusive and neglectful parenting behaviors toward children by treatment group: Prevention subgroup Prevalence Year 2 P value Control HFNY % Confidence Interval Minor Physical Aggression Prevention Group 70.02 51.04 0.02 Psychological Aggression 81.08 73.92 ns Harsh Parenting (past week) 61.93 40.95 Substantiated Abuse or Neglect 7.42 3.36 At the child’s second year of life, participants (mothers) in HFNY reported significantly fewer acts of physical aggression % harsh parenting Lower levels of CA/N during first and second year of life but it was not statistically significant DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, A., Rodriguez, M., & Dorabawila, V. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse & Neglect, 32(3), 

36 Nurturing Parenting Program-Study Methodology
Maher, E. J., Marcynyszyn, L. A., Corwin, T. W. & Hodnett, R. (2011). Dosage matters: The relationship between participation in the Nurturing Parenting Program for infants, toddlers, and preschoolers and subsequent child maltreatment. Children and Youth Services Review, 33, Design: Quasi-Experimental; Louisiana Objective: To examine the relationship between NPP dosage and child maltreatment Participants: 528 caregivers who attended the NPP in ten family resource centers across Louisiana's child welfare population between Oct and April NPP was offered to all families with children under 6 with child abuse and/or neglect allegations Follow-up: 6 months and 2 years Nurturing Parenting Program is a parent education program identified as holding promise for effectiveness in child welfare. It is designed to assess, prevent, and treat maltreatment by developing nurturing parenting skills as a counter to the key constructs of abusive and neglectful parenting. Goals: (1) Prevent recidivism of families receiving social services, (2) Lower rate of teenage pregnancies, (3) Reduce rate of juvenile delinquency and alcohol abuse, (4) Stop intergenerational cycle of child abuse by teaching positive parenting behaviors Home Visitor Credentials: Para- or professionals trained in fields such as social work, education, or psychology. Target Population: Families at risk of abuse and neglect. Serve families with children birth to age 18, with a more targeted p

37 Nurturing Parenting Program-Outcomes
Dosage matters. Maher, E. J., Marcynyszyn, L. A., Corwin, T. W. & Hodnett, R. (2011). Dosage matters: The relationship between participation in the Nurturing Parenting Program for infants, toddlers, and preschoolers and subsequent child maltreatment. Children and Youth Services Review, 33,  

38 Home Visiting to Prevent Child Maltreatment-Starts at Pregnancy
Home Visitors are in a unique position to prevent child abuse and neglect in the home, as they are in the home during critical developmental periods of the child Home-visitors need to assess for safety of the environment of the client during pregnancy: Most dangerous time for IPV When a young woman becomes pregnant before she’s ready to take care of a child, the risk factors for the entire family escalates.  She may have a family background of low wages, welfare, or worse-an abusive pattern that , without intervention, she may be fated to repeat.  “Terrible things can be prevented and good things can be made to happen with the involvement of home visitors with these families early in their lives.” Quote from David Olds, PhD, Founder of Nurse-Family Partnership.

39 Home Visiting to Prevent Child Maltreatment: Home Safety
HV can identify hazardous objects in the home and improve the overall safety of the home environment Demonstrate and teach safe behaviors including safe sleep, car seat safety Pillows, blankets and stuffed animals should be removed from the crib to prevent babies from suffocating. Covers, pillows, bumper pads, positioning devices, soft mattresses and toys in the crib are associated with the risk of sudden infant death syndrome, a common concern among parents of infants. Immediate feedback opportunity to provide families critical guidance Plants the seeds for a safe environment for the baby. “When we go into homes and we see cribs that have stuff in them, it’s one thing to say it to somebody, but it’s another thing to go into the baby’s room and go, you know, this isn’t a great thing to have in the crib, and let me tell you why. It makes it so much more effective to be standing there with somebody.” Texas HV

40 Home Visitor Breaking Cycle of Maltreatment
Physical, emotional abuse and neglect are often a cycle: many children grow up with parents who were mistreated themselves and don’t know how to parent any differently. If parents don’t know what’s appropriate discipline and what’s inappropriate, they might not identify their own parent’s parenting practices as inappropriate-May think ignoring a crying child or spanking an infant is normal “discipline”. Neglect is the most common type of child maltreatment such as putting/leaving a child in a dangerous situation, or not meeting the basic physical and emotional needs of a child.

41 Reducing Physical Abuse
One of the most important tips Home Visitors pass on to young parents is that if a baby is crying inconsolably, it’s OK to take a time out and emotionally regroup. Mothers consider quieting and comforting the baby as her “job” —if they can’t, they feel there’s something wrong with them. Important to tell Mom’s and Dad’s it’s OK to put the baby down in a safe place and walk away. Period of PURPLE Crying, and give them strategies for managing stressful periods when the baby just will not stop fussing. Peak of Crying Unexpected Resists Soothing Pain-like Face Long Lasting Evening

42 Reducing Physical Abuse
The Period of PURPLE Crying is an acronym that explains that crying is a normal part of every infant’s development from about 2 weeks of age until about 3 to 4 months of age. Teaching young moms and dads that babies are born to cry: That they may cry X many hours a day, it normalizes crying, so it can reduce stress. Home Visitors can minimize shaken baby syndrome (form of abusive head trauma and inflicted traumatic brain injury often resulting from violently shaking an infant). Peak of Crying Unexpected Resists Soothing Pain-like Face Long Lasting Evening

43 Promoting Parent-Child Interaction to reduce child maltreatment risk
PIVOT (Victor Bernstein) Use family stressor to transition parent to focus on infant’s development Focus on parental affect and infants’ response to affect Use cognitive-behavioral strategies to address negative mood/behavior Explore parents’ early childhood experience with parents Address psychological significance of child to parent Use moment-to-moment interactions to promote parental attunement Help parents find joy in interaction with infant! Slide from Brenda Jones Harden. (2014). Home Moments: Home Visiting to Address Toxic Stress [PowerPoint Slides]. Retrieved from https://s3.amazonaws.com/v3-app_crowdc/assets/events/LIcoEjkC8i/activities/Brenda_Jones_HardinPPT.original pdf.

44 Parent-Child Interaction: The Importance of Play
Follow child’s lead Use interactive toys Use toys/objects in the home Engage in symbolic play Narrate play Introduce turn-taking Express positive emotions Identify teachable interactions Address developmental benefits Use self-expression/cultural activities Slide from Brenda Jones Harden. (2014). Home Moments: Home Visiting to Address Toxic Stress [PowerPoint Slides]. Retrieved from https://s3.amazonaws.com/v3-app_crowdc/assets/events/LIcoEjkC8i/activities/Brenda_Jones_HardinPPT.original pdf.

45 Home Visitors Power to Prevent Abuse/Neglect
Home visitors act as advocates by making the topic of abuse and neglect a common discussion in home visitation. “If we’re not educating and advocating about the prevalence of child abuse for the 0-3 population, then we have no chance at preventing it. People don’t make perfect decisions in the heat of the moment, but if they can have some education and awareness of child abuse, I think they’re more sensitive in their response, or are more prone to ask for help.” Texas Home Visitor

46 The Power of the Home Visitor
Help teach parents appropriate developmental milestones of children, which in turn can limit unrealistic expectations of children that often can lead to child maltreatment (potty training, communication, etc.) Educate parents on proper feeding, mirroring, playtime to enhance healthy attachment reduce RAD Teach parents stress management and emotional refueling, self care. Help teach parents the importance of a stimulating home environment and Instructing parents on the importance of speaking to the baby to reduce cognitive delays and deficits decreasing neglect The home visitor cannot underestimate the power of role playing as a top teaching aid with the parent and the power of modeling behavior and interactions with the baby and family members, demonstrating self-care, organization, stress management and establish a trusting relationships.

47 Contact Information Madeline McClure, LCSW Executive Director TexProtects, The Texas Association for the Protections of Children 2904 Floyd St., Suite C Dallas, TX 75204

48 References Chaffin, M., Hecht, D., Bard, D., Silovsky, J. F., & Beasley, W. H. (2012). A statewide trial of the SafeCare home-based services model with parents in child protective services. Pediatrics, 129(3),  doi: /peds Child and Adolescent Health Measurement Initiative (2013). “Overview of Adverse Child and Family Experiences among US Children.” Data Resource Center, supported by Cooperative Agreement 1‐U59‐MC06980‐01 from the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB). Available at www.childhealthdata.org. Revised 5/10/2013.  DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, A., Rodriguez, M., & Dorabawila, V. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse & Neglect, 32(3),  doi: /j.chiabu Garner, A. (2013). Translating Developmental Science into Healthy Lives: Realizing the Potential of Pediatrics [PowerPoint Slides]. Harden, B. J. (2014). Home Moments: Home Visiting to Address Toxic Stress [PowerPoint Slides]. Retrieved from https://s3.amazonaws.com/v3- app_crowdc/assets/events/LIcoEjkC8i/activities/Brenda_Jones_HardinPPT.original pdf. MacMillan, H., Thomas, B., Jamieson, E., et al. (2005). Effectiveness f home visitation by public health nurses in prevention of the recurrence of child physical abuse and neglect: A randomized controlled trial. Lancet, 365 (9473),   Maher, E. J., Marcynyszyn, L. A., Corwin, T. W. & Hodnett, R. (2011). Dosage matters: The relationship between participation in the Nurturing Parenting Program for infants, toddlers, and preschoolers and subsequent child maltreatment. Children and Youth Services Review, 33, doi: /j.childyouth   Olds, D. L., Eckenrode, J., Henderson, C. R., Kitzman, H., Powers, J., Cole, R., Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278(8), Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based prevention of child maltreatment: The U.S. Triple P system population trial. Prevention Science, 10(1), doi: /s Shonkoff, J., & Garner, A. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1) U.S. Department of Health and Human Services, Administration on Children, Youth and Families. (2013). Child maltreatment  Washington, DC: US Government Printing Office. Retrieved from http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment.


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