Implementing Promising Initiatives to Help Children Face Chronic Adversity

Richard P. Barth, PhD, MSWUniversity of Maryland School of Social Work

National Center for Evidence Based Practice in Child Welfare

Presented at the Brookings InstitutionMay, 2014

rbarth@ssw.umaryland.edu

Overview of Today’s Commentary• The 4 Intervention Areas

– Health– Income – Child Care– Parenting (mostly)

• Implementation Opportunities & Challenges• References

Behavioral Health & Health Care• Health screening and Primary Care (PROJECT SEEK:

Dubowitz, et al., 2009)• Obama’s evidence-based home-visitation ($500

million a year)– Begin during a mother’s pregnancy addressing nutrition,

health practices, stress, and alcohol/drug/tobacco use (ADDING MORE ON PARENTING TO NFP and HFA)

– Continue through childhood, supporting positive family practices and emphasize responsive parent-child relationships, and positive non-coercive parenting practices (FAMILY CHECK UP MODEL)

Family Check Up: Assessment Driven & Tailored

Lessons Learned from Family Check Up• To prevent child behavior problems there may be a

need to intervene early and directly with:– the emotional climate of the family and parenting

relationship• Families often recognize trouble in the family but

don’t know the extent or what to do about it– Many are willing to act on the information– Families will use, and benefit from, parenting programs

• New data shows impact on behavior and academics from FCU in WIC clinics 7 years later (Dishion, et al., 2014) 5

Economic Aid Implementation• Cash assistance

– Conditional cash-transfer antipoverty program, where payment occurs after compliance with addressing preventive care.

• Greater access to food stamps• Financial Literacy for Parents• Expansion of school-based and pre-school based

nutrition programs and homelessness prevention programs, through expansion of community schools

Quality Child Care Implementation• Significant parenting program components

added to Early Head Start and Head Start– Some (e.g., ABC) are being tested now

• State licensed early childhood programs often lack any discipline policy (Longreth, Brady, & Kay, 2013).

– PBIS should become a standard (and be implemented with fidelity)

Smart Early Childhood “Training” in Graduate Education

• Toxic Stress exists and is harmful (this is now getting into curricula)– See next slides from AAP

• The impact of toxic stress can be mitigated• Psychotherapy is not the only answer:

parenting programs can also help reduce the adverse impact of toxic stress

AAP Report on Toxic Stress: 1 of 5 Main Recommendations

RECOMMENDATION 2. The growing scientific knowledge base that links childhood

toxic stress with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems, and the evidence that these disruptions can lead to lifelong impairments in learning, behavior, and both physical and mental health, should be fully incorporated into the training of all current and future physicians (and all other health service providers) [material in parentheses and bright red text not in the original].

AAP Report on Toxic Stress: 1 of 5 Main Recommendations

RECOMMENDATION 2. The growing scientific knowledge base that links childhood

toxic stress with disruptions of the developing nervous, cardiovascular, immune, and metabolic systems, and the evidence that these disruptions can lead to lifelong impairments in learning, behavior, and both physical and mental health, should be fully incorporated into the training of all current and future physicians (and all other health service providers) [material in parentheses and bright red text not in the original].

and that clarifies the reversibility of the effects of toxic stress with consistent

good quality caregiving,

Implement CAPTA Intentions

• Children who are identified as victims because they “have substantiated maltreatment” are to be referred to early intervention services– Children who are not substantiated are at equal

developmental risk– Children who are referred to CAPTA continue to get

very few services under the Early Intervention Program (based on PL 99-457) which has never been scaled up to serve these children

CAPTA Early Intervention Study: Summary

• Based on Measured Delay and/or High Risk, 79% of CWS investigated children were identified as having a measured delay or high risk status

– Children with more than 5 recognized risk factors at baseline are almost certain to develop measured delays that remain at 36 months (see graph)

– Substantiation did not explain the developmental outcomes

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Early Adversity is a Better Predictor of Behavior Problems than Prenatal Drug Exposure

• Maternal Life Style Study– Direct effects of pre-natal drug exposure on

worsening executive functioning at behavioral problems at ages 8/9 is significant.

– After controlling for ongoing adversity the relationship between drug exposure and executive functioning at ages 8/9 is .00. (Fisher et al., 2011).

Early Adversity is Not Irreversible– Attachment and Bio-behavioral Catch-up (Dozier et

al., 2008)

– Multi-dimensional Treatment Foster Care-Pre (Bruce et al., 2009)

– HAVE SHOWN SUCCESS WORKING WITH VERY TROUBLED ABUSIVE FAMILIES AND ABUSED CHILDREN AND SHOWN REDUCTIONS IN BI0-MARKERS OF ADVERSITY

Foster Child Bio-Markers Associated with Intensive Foster Parent Training

• Fisher and Colleagues compared children in 1. Conventional Foster Care2. Multi-Dimensional Treatment Foster Care for Pre-

Schoolers3. A Community Sample

• Results show improvements in (pictures follow):• Cortisol levels improved (not shown)• Responses to feedback (self-regulation)• Placement stability

Intervention Effects On Executive Functioning

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Bruce, Martin-McDermott, Fisher, & Fox, 2009 (under review) -12

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Children in Regular Foster Care Do Not Respond Differently to Positive and Negative Feedback

Children in MTFC-P respond more normatively

Effect Of Prior Out-of-home Placements On Permanent Placement Failures (MTFC-P Vs. Regular FC)

(Fisher, Burraston, & Pears, 2005)

RFC

MTFC-P

Prior poor and unstable history can be overcome!

Predictable Placement Moves

Actual moves for MTFC group

Implications of MTFC-Pre• Evidence-based parenting programs provide

powerful path to improved outcomes for children

• These approaches have now been shown to be very effective at improving parenting and child behavioral outcomes– at least when applied to intensive foster parent

programs• They need broader testing in family-homes

BIG Implementation Challenges

• Not a single stand alone replication of MTFC-pre• KEEP was developed as an easier to implement less

costly version of MTFC– Weekly parent calls (not daily)– No special mental health treatment for children– More than one child in a home at a time– Works with kin (not just specially trained families)

• Yet, KEEP has not been fully sustained even in San Diego where it worked beautifully for years (during a series of implementation studies)!

BIG Implementation Challenges 2• Child welfare agencies are fixated by a 5 part

view of out-of-home care: (1) foster care, (2) kinship care, (3) treatment foster care, (4) group care, and (5) adoption

• All get different services• Yet, ongoing parent training is likely to be

necessary for all of these to succeed• E.g., blended programs in which children spend part of

the week in care and part with parents at home (e.g., RE-ED) have shown success for decades

The Big Secret is Effective Work with Parents Must be Part of All Levels of

Intervention

Broader Challenge in Foster Care• Our foster parent training needs nearly a complete

overhaul– New models of implementation focus on:

• Teaching evidence based practices with active learning (e.g., actual, live cases, in groups or coaching calls, etc.)

• Ongoing coaching and fidelity checking• Outcome monitoring

– This approach does not require a waiver to be fully fundable under existing Title IVE regulations

– The reduction in units of care provided as a result of more exits should allow for greater quality (a waiver could help capture the savings of that greater quality)

Basic of Foster Family “Training”• Should be done while children are in the home—not just

before!• Should involve the best “active learning” techniques that

we know– Ongoing coaching– Parent Daily or Weekly Reports– Feedback based on improvements

• We know it can work!– Benefits cross over to additional children in the home—not

just to the ones that were the focus of KEEP group (personal communication with Joe Price and Patricia Chamberlan)

Taking KEEP to Scale

• Re-orientation of foster parent “Training” to be– Ongoing (about 15 weeks)– Skill focused – Leader is well trained and demonstrates high level

of performance via fidelity monitoring

Policy Issue: Parenting Needs are Much Larger than Foster Care

The Number of Children on Medicaid Has Grown Markedly as a result of CHIP and Affordable Care Act-related enrollments

• Now in excess of 6,000,000 children

Parent Training to Reduce Toxic Stress is a HEALTH CARE Intervention

Funding Parent Training Under ACA/Medicaid?• In CA, six reimbursement codes can be used to bill

for behavioral, social, and psychophysiological services for the prevention, treatment or management of physical health problems. – CPT 96153 – Health and behavior intervention service

provided to a group. … Group sessions typically last for 90 minutes and involve 8 to 10 patients. Each 15 minutes, face-to-face; group (2 or more patients) is billable

• Interventions might include self-monitoring or teaching cognitive-behavioral techniques, relaxation, visualization, coping and social skills, …

• WHY NOT PARENTING?

Summary (5 Points)

1. Adverse effects of early childhood toxic stress can be mitigated

2. We now have evidence based tools to address some of these effects –especially, tools that focus on more responsive and contingent parenting, applied over time

3. Yet, they do not fit into our current funding model for foster parent training, WIC, or Medicaid

Summary (5 Points)3. Child care, foster care and in-home care could all benefit from instituting more effective parenting programs—e.g., PBIS, Family Check Up, ABC, and KEEP

4. Our country needs a national initiative on parenting to understand:

a. What are the basic (common components) of effective, successful parenting?

b. What does it take to provide restorative parenting?c. How can this build on current services that include parents

but don’t teach parenting?

5. Existing statutory vehicles exist to achieve this

Thank you for this opportunity

We, together, can make the changes our parents and children need!

ReferencesBarth, R.P., & Liggett-Creel, K. (2014). Common components of parenting programs for children birth to eight years of age

involved with child welfare services. Children and Youth Services Review, 40, 6-12.

Brennan, L. M., Shelleby, E. C., Shaw, D. S., Gardner, F., Dishion, T. J., & Wilson, M. (2013). Indirect effects of the family check-up on school-age academic achievement through improvements in parenting in early childhood. Journal of Educational Psychology, 105(3), 762-773.

Bruce, J., McDermott, J. M., Fisher, P. A., & Fox, N. A. (2009). Using Behavioral and Electrophysiological Measures to Assess the Effects of a Preventive Intervention: A Preliminary Study with Preschool-Aged Foster Children. Prevention Science, 10(2), 129-140.

Dishion, T. J., Brennan, L. M., Shaw, D. S., McEachern, A. D., Wilson, M. N., & Jo, B. (2014). Prevention of Problem Behavior Through Annual Family Check-Ups in Early Childhood: Intervention Effects From Home to Early Elementary School. Journal of Abnormal Child Psychology, 42(3), 343-354.

Dozier, M., Peloso, E., Lewis, E., Laurenceau, J. P., & Levine, S. (2008). Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care. [Article]. Development and Psychopathology, 20(3), 845-859. doi: 10.1017/s0954579408000400

Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. (2009). Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model. Pediatrics, 123(3), 858-864. doi: 10.1542/peds.2008-1376

Fisher, P. A., & Stoolmiller, M. (2008). Intervention effects on foster parent stress: Associations with child cortisol levels. [Article]. Development and Psychopathology, 20(3), 1003-1021. doi: 10.1017/s0954579408000473

Fisher, P. A., Lester, B. M., DeGarmo, D. S., Lagasse, L. L., Lin, H., Shankaran, S., . . . Higgins, R. (2011). The combined effects of prenatal drug exposure and early adversity on neurobehavioral disinhibition in childhood and adolescence. Development and Psychopathology, 23(3), 777-788.

Goldhaber-Fiebert, J. D., Bailey, S. L., Hurlburt, M. S., Zhang, J. J., Snowden, L. R., Wulczyn, F., . . . Horwitz, S. M. (2012). Evaluating Child Welfare Policies with Decision-Analytic Simulation Models. Administration and Policy in Mental Health and Mental Health Services Research, 39(6), 466-477. doi: 10.1007/s10488-011-0370-z

Kerr, J., Price, M., Kotch, J., Willis, S., Fisher, M., & Silva, S. (2012). Does contact by a family nurse practitioner decrease early school absence? The Journal of School Nursing, Vol. 28, No. 1 (38-46). DOI: 10.1177/1059840511422818

Li, J. L., & Julian, M. M. (2012). Developmental Relationships as the Active Ingredient: A Unifying Working Hypothesis of "What Works" Across Intervention Settings. [Article]. American Journal of Orthopsychiatry, 82(2), 157-166. doi: 10.1111/j.1939-0025.2012.01151.x

Longstreth, S., Brady, S., & Kay, A. (2013). Discipline Policies in Early Childhood Care and Education Programs: Building an Infrastructure for Social and Academic Success. Early Education and Development, 24(2), 253-271. doi: 10.1080/10409289.2011.647608

McLoyd, V. C. (1989). Socialization and development in a changing economy: The effects of paternal job and income loss on children. American Psychologist, 44, 293–302. doi:10.1037/0003-066X.44.2.293

Romero, M.,& Lee, Y. (2008). The influence of maternal and family risk on chronic absenteeism in early schooling. National Center for Children in Poverty, Columbia University Mailman School of Public Health. Retrieved January, 10, 2009, from www.aecf.org

Van Ryzin, M. J., Stormshak, E. A., & Dishion, T. J. (2012). Engaging Parents in the Family Check-Up in Middle School: Longitudinal Effects on Family Conflict and Problem Behavior Through the High School Transition. [Article]. Journal of Adolescent Health, 50(6), 627-633. doi: 10.1016/j.jadohealth.2011.10.255

References