1. How does child maltreatment prevention work? An informed perspective for practitioners and providers Jennie G. Noll, PhD Professor, Human Development and Family Studies Director of Research & Education, Network on Child Protection & Well-being, The Pennsylvania State University Stephanie Bradley, PhD Managing Director, Evidence-based Prevention and Intervention Support Center (EPISCenter), The Prevention Research Center, The Pennsylvania State University

2. What is child maltreatment prevention? Primary – prevent maltreatment BEFORE it happens Secondary – prevent another problem that stems from child maltreatment (Intervention) Targeted – prevent child maltreatment from occurring in an at-risk group Embedded – prevent other public health problems by embedding primary prevention programs within child welfare

3. Public awareness campaigns designed to educate entire populations public service announcements TV, radio, billboards, mass distribution of brochures or other educational material working with professional groups to change the way they think about and react to opportunities for prevention Primary Prevention Efforts

4. Family home visiting programs bringing a well-planned intervention to families who need it emphasize outreach families who might be unwilling or unable to participate in more formally organized services combination of educational, supportive, or empowering goals Primary Prevention Efforts

5. Nurse Family Partnership (Olds et al, 2007) First-time disadvantaged mothers received home visits by nurses Begins prenatally and extends until child’s 2nd birthday Nurses promoted 3 aspects of maternal functioning: –health-related behaviors –maternal life course development –parental care of children Primary Prevention Efforts

6. Parent education programs organized in an “academic” way, with planned “lessons” delivered to individuals or small groups Specific educational goals (e.g.,): -pregnancy and delivery -child growth and development -parenting skills -knowledge of add’l resources Primary Prevention Efforts

7. Child education programs attempt to make children less vulnerable targets for abuse Primarily focused on sexual abuse prevention School-based or Physician-based Teach children self-protective skills “Good touch, bad touch” Primary Prevention Efforts

8. Physician administered Educates parents in pediatric or prenatal practice “I will not shake my baby” contracts Primary Prevention Efforts

9. Effective for Physical Abuse and Neglect? Home visitation (mixed results; Bell 2012 meta analysis) Nurse Family Partnership (NFP) (best) Early Start (New Zealand) (promising) Parent training programs Triple P Positive Parenting Program (promising) Physician administered Abusive head trauma education programs (promising) Enhanced pediatric care (promising) Primary Prevention Efforts

10. Effective for Physical Abuse and Neglect? Nurse Family Partnership (Olds et al, 2007) Reduced child physical abuse and neglect as measured by official child protection reports Reduced associated outcomes such as injuries in children Nurse home visitation did not prevent recurrence of physical abuse or neglect (RCT) (MacMillan et al., 2005) Primary Prevention Efforts

11. Effective for Physical Abuse and Neglect? Early Start (Fergusson et al., 2005, 2013) Reduced associated outcomes injuries and hospital admissions for child abuse and neglect Rates of child protection reports did not differ between the intervention and control groups Primary Prevention Efforts

12. Effective for Physical Abuse and Neglect? Paraprofessional home visitation e.g., Hawaii Healthy Start Program Healthy Families America Have not been shown effective in reducing child protection reports Primary Prevention Efforts

13. Home visiting programs are not uniformly effective in reducing child physical abuse and neglect (Rubin, 2013) Any home visiting program should not be assumed to reduce child abuse and neglect Every Child Succeeds (Ammerman, et al., 2013) Home-visiting maternal depression prevention program showed reduced effectiveness for mothers who were sexually abused as children Primary Prevention Efforts

14. Effective for Physical Abuse and Neglect? Triple P – Positive Parenting Program Population-level group-based supports for families use of media/information strategies consultations with parents seminars active skills training Primary Prevention Efforts

15. Effective for Physical Abuse and Neglect? Triple P – Positive Parenting Program Positive effects on substantiated child protection services reports, out-of-home placements, and reports of injuries Analysis is not clear and concerns about methods (Wilson et al., 2012) Primary Prevention Efforts

16. Effective for Physical Abuse and Neglect? Physician Administered Abusive head trauma education Positive effects from one study suggest that hospital-based educational programs can reduce abusive head injuries (shaken impact syndrome) (Dias et al., 2005) Primary Prevention Efforts

17. Effective for Physical Abuse and Neglect? Physician Administered Enhanced pediatric care program for families at risk “Safe Environment for Every Kid” (SEEK) (Dubowitz et al., 2009, 2012) Training physicians to identify family problems social worker is available Promising effects in enhancing physicians’ abilities decrease risk factors and physical abuse rates Primary Prevention Efforts

18. Effective for Sexual abuse? Unknown if educational programs reduce occurrence of child sexual abuse Some evidence that they improve children’s knowledge and protective behaviors Could have some adverse effects (Zwi et al., 2007) Primary Prevention Efforts

19. Emotional abuse? Attachment-based interventions designed to improve insensitive parenting and infant attachment insecurity No direct evidence that these interventions prevent emotional abuse (Bakersman- Kranenburg et al., 2003) Primary Prevention Efforts

20. For Parents in the Child Welfare System SafeCare (Chaffin et al., 2012) home-based, structured behavioral skills focused on caregiving, parenting, household management SafeCare reduced recidivism compared with usual home-based services Secondary Prevention Efforts

21. Recurrence of physical abuse and neglect Parent-child interaction therapy (PCIT) behavioral approach to skills training PCIT reduced recurrence of child protection services reports of physical abuse but not neglect (Chaffin et al., 2004) Intervention / Treatment

22. Impairment following sexual abuse Trauma-focused cognitive-behavioral therapy (TF-CBT) (Cohen et al., 2004) cognitive reframing positive imagery parent management training problem solving Reduced internalizing and externalizing symptoms among children with PTSD symptoms Intervention / Treatment

23. Out-of-home care Placement in foster care and not reunifying with biological parents can lead to benefits for maltreated children Enhanced foster care can lead to better mental health outcomes for children than traditional foster care Conflicting evidence about kinship care compared with traditional foster care Intervention / Treatment

24. Thinking about “Imbedded Prevention” within the child welfare system? Abused children are at high risk for a host of conditions of grave public health concern: -teen pregnancy (Noll & Shenk, 2013) -obesity (Noll, et al, 2007) -substance use (Fergusson, 2010) -high-school drop out (Noll, et al, 2010) Children already in the child welfare system are prime targets for primary prevention of these problems

25. Next Steps for Sexual Abuse Sexual abuse prevention needs more attention: -understanding perpetrator -community awareness -increased resources for increased awareness -training professionals to spot outward signs Sexual-specific modules added to: -SafeCare -Adult treatments shown to be less effective for sexual abuse survivors

26. Neurocognitive mechanisms for Alcohol and Substance Abuse

27. Psychological Mechanisms for Alcohol and Substance Use

28. Specifics for substance use treatment Trauma-focused therapies not as effective for SUD patients SUD treatments not as effective for trauma victims Other examples????

29. Break Out Session

30. how does child maltreatment or child trauma affect your efforts? in what ways has maltreatment or trauma been apparent in youth you serve? what resources to address maltreatment or trauma do you have access to? what types of trauma-informed care are you/your organization using?

31. Brain Storming

32. Resources Training for TF-CBT http://tfcbt.musc.edu/ https://www.childwelfare.gov/preventing/ SafeCare http://safecare.publichealth.gsu.edu/

33. Next Steps: Data integration to implore public health investment

34. Distribution of Total Medicaid Beneficiaries and Spending Under ACA 70% of children in protective services are Medicaid eligible Ferris, et al., 2010

35. Putnam-Hornstein, 2013 The Power of Linked-data to show that children in protective services should be targeted for a host of public health problems

36. Putnam-Hornstein, 2013 Death From Unintentional Injury

37. Putnam-Hornstein, 2013 Death From Intentional Injury

38. Integrated data systems to identify high-risk kids for coordinated care

39. Partnerships for Prevention

40. Prevention Research Center (PRC) Penn State University College of Health & Human Development EPISCenter The Network on Child Protection and Well-Being Social Science Research Institute Foundational Center Affiliate Center

41. The EPISCenter is a project of the Prevention Research Center, College of Health and Human Development, Penn State University, and is funded by the Pennsylvania Commission on Crime and Delinquency and the Pennsylvania Department of Public Welfare. Multi-Agency Steering Committee (Justice, Welfare, Education, Health) Support to Community Prevention Coalitions Improve Quality of Local Innovative Programs and Practices Support to Evidence-based Prevention & Intervention Programs Intermediary and State-level Prevention Support System Evidence-based Prevention and Intervention Support Center (EPISCenter)

42. public health model: - use data - to identify and prioritize risk & protective factors - to select and implement evidence-based programs - sustain and evaluate programs - achieve public health impact

43. Evidence-based Prevention and Intervention Support Center (EPISCenter) objectives: - connecting policymakers, researchers, program developers, and communities - promoting use of the public health model - achieving public health impact in reducing youth violence, delinquency, substance use

44. The EPISCenter is a project of the Prevention Research Center, College of Health and Human Development, Penn State University, and is funded by the Pennsylvania Commission on Crime and Delinquency and the Pennsylvania Department of Public Welfare. Evidence-based Prevention and Intervention Support Center (EPISCenter) Key objectives: - connecting policymakers, researchers, program developers, and communities - achieving public health impact in reducing youth violence, delinquency, substance use

45. Data Collaborations integrating systems data (proposition*): PA Commission Crime & Delinquency (planning agency) Dept. of Public Welfare (OCYF, OMHSAS, BJJS) Juvenile Court Judges Commission - how much “overlap” in youth served by each system? - if we prevent trauma, do we prevent juv. justice involvement? research in progress: Bumbarger & Frank – investigating adult criminal justice population and preventable issues in adolescence

46. Integrated data systems to identify high-risk kids for coordinated care