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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
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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%
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Trends in Child Maltreatment in the U.S.
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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
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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
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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
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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
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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
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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.
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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.
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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.
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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.
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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.
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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
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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
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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
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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)
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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
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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
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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
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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.
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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
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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
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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
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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/
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