1. 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 SafeCare®: Widescale Implementation of an Evidence-Based Practice to Prevent Child Maltreatment

2. 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 Neglect 66.3% Sexual Abuse 8.8% Emotional Abuse 6.6% Physical Abuse 16%

3. Trends in Child Maltreatment in the U.S.

4. A brief history of SafeCare  Project 12-Ways : 1979  Project Ecosystems : 1986 - 2001  SafeCare development : 1994-1998  CDC & Oklahoma Studies: 2001  Marcus Institute & NSTRC birth:2005-2008  Move to GSU: August 2008

5. 5 SafeCare Model Overview  In-home parent-training model to prevent child maltreatment  Behavioral, skill-based model, that focuses on three skills 1. Health 2. Safety 3. Parent-child interactions  Structured problem -solving taught for other issues  Counseling skills reviewed with SafeCare trainees

6. SafeCare model overview  SafeCare® 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

7. SafeCare 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

8. III. SafeCare Research  A number of lines of research support the efficacy/effectiveness of SafeCare®  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

9. III. SafeCare: 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., & McGimpsey, 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. McGimsey, 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.

10. 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.

11. 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.

12. Group data: Project 12-ways  Examined over 700 families receiving SafeCare or other CPS services from 1979-1984  Examined recidivism rates  SafeCare families = 21.3%  Other CPS services = 28.5%  Reduction in recidivism= 25%  Other analyses suggest that SafeCare families were more difficult than non-SafeCare 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.

13. Group studies: SafeCare 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 SafeCare: Teaching bonding, safety, and health care skills to parents. Child Maltreatment, 7, 277-285.

14. SafeCare 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 SafeCare based on its neglect focus  Implementation began ~ 2002

15. Oklahoma Statewide trial (PI: Mark Chaffin)  6 service regions in OK assigned to SafeCare or SAU  Providers receive SC training or do SAU  Regions 1,2, & 3 = SafeCare; 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

16. OK statewide trial: preliminary outcomes Also, turnover among SafeCare caseworkers was half (16%) of non-SafeCare caseworkers (31%) Reduction in neglect for SafeCare group, but only when fidelity was monitored through coaching

17. Oklahoma: Prevention study  High risk families in OK City randomly assigned to receive either SafeCare-based services or standard mental health treatment  SC workers were trained in SafeCare, motivational interviewing and domestic violence services  Parents had IPV, substance use, and/or mental health problems  SafeCare workers were BA level; SAU has Masters degrees Initial Results: SafeCare 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)

18. 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 SafeCare 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

19. Current SafeCare Training efforts EffortSourceFunds/timelineNSTRC role SafeCare Training in GAGA DHR/CFC1 million over 2 yearsPI Washington State training contractWA State DSS$76k over 1 yearPI San Diego trainingUW of SD150k over 3 yearsPI SafeCare & PATAnnie E Casey35k over 1 yearPI SafeCare & HF GA and GCAAPAM BlankPendingPI Reducing CM in GAOJJDP1.0 million over 1 year PI Expanding training in CAACF2 million over 5 yearsPI Expanding OK SafeCare preventionACF2 million over 5 yrsconsult SafeCare with incarcerated momsNIHM Belarus trainingCCFNone

20. SafeCare: Research grants NSTRC’s Research EffortSourceFunds/timelineNSTRC Role NSTRC center grantDoris Duke1.3 million over 3 years PI Comparison of trainer/coach training models CDC1.3 million over 3 years PI Technology in training and fidelity monitoring CDC with Emory Pending (750k over 5 years) PI Cascading diffusion in San DiegoCDC1 million over 3 years Co-I Expanding OK SafeCare preventionACFConsult over 5 years Consult Computer delivered SafeCare (Wayne State) CDC2 million over 5 years Consult Cell-phone enhanced PAT (U of Kansas) CDC2 million over 5 years Consult

21. Focus of NSTRC 1. Increase awareness and use of SafeCare  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 SafeCare.

22. SafeCare 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

23. SafeCare Training Model  Home visitor – provides SafeCare services  Coach – provides ongoing coaching for HV to ensure fidelity to the model  Coaching required for SafeCare implementation  Trainer – trains new HV and coaches  Trainers must practice SafeCare and coaching  Trainers support coaches who monitor the fidelity of home visitors HV training Coach Trainer

24. SafeCare 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 SafeCare with other EBP  Understand policy aspects of increasing EBP in child welfare settings  Understand adaptions for cultural groups

25. Contact John R. Lutkzer, PhD, Jlutzker@GSU.EDU Director, Center for Healthy Development, GSU SafeCare Web site: www.NSTRC.orgwww.NSTRC.org Center for Healthy Development Website: http://chhs.gsu.edu/chd/ http://chhs.gsu.edu/chd/