The child abuse and neglect interventions reviewed here are aimed in part at improving The second main advance in treatment interventions is in approaches to . Questions specific to child welfare relate more to service planning and to how evidence-based intervention may actually be more effective for both child and.
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- Development of a Policy-Relevant Child Maltreatment Research Strategy
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- Development of a Policy-Relevant Child Maltreatment Research Strategy
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Effective Interventions for Child Abuse and Neglect: Added to Your Shopping Cart. Description Why are some children abused or neglected? What can be done to protect and help them? A key element of informed decision making is knowing what sort of problems are amenable to what sort of intervention, in what circumstances, and with what degree of certainty.
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Effective Interventions for Child Abuse and Neglect provides a thorough and detailed review of the available research, and makes suggestions as to how this evidence can be incorporated into professional child protection work. Geraldine Macdonald first considers the range of evaluative tools available, with illustrations from existing research studies and reviews, and appraises their respective merits and limitations.
She then describes the interplay of a range of causal factors in abuse and neglect, and considers different types of maltreatment and their potential consequences. Advisory Board's recommendation was well received by child abuse and neglect advocates, substantial federal support for this strategy has only recently been provided. In terms of direct research support, the legislation provides funding for an interdisciplinary, multicenter research forum to support scientific collaboration and infrastructure building related to home visiting research.
Beyond the broad implementation of home visiting programs, those seeking to prevent child abuse and neglect continue to design, implement, and assess a range of initiatives. These initiatives include, among others, parent education services; crisis intervention programs that provide telephone numbers for families facing an immediate crisis or seeking parenting advice, as well as crisis nurseries; education for children and adolescents on assault prevention, antibullying behaviors, and nonviolence; efforts to assess new parental concerns and service needs; public education to raise awareness and alter parental behaviors; and initiatives designed to change how health care professionals and others working directly with children recognize and respond to potential child abuse and neglect.
In addition to targeting change at the individual level, prevention efforts focus on altering community context and implementing a variety of strategies to create social service networks and social environments more conducive to positive parenting and healthy child development Daro and Dodge, Compared with early home visiting, these efforts, in general, are more diffuse and less governed by national standards or expectations. Today, prevention research is guided by a set of rigorous standards addressing research design and quality, such as the criteria for efficacy, effectiveness, and dissemination established by the Society for Prevention Research The adoption of shared evidentiary standards in the field allows for the identification and testing of programs deemed effective and suitable for replication, adoption, or dissemination.
Alternatively, these standards facilitate the identification of programs that lack a sound theoretical model or clinical base, show no effect, and should not be implemented further. This section focuses primarily on those effective prevention interventions for which evidence shows a reduction in child abuse and neglect reports and other child safety outcomes, such as a lack of reported injuries and accidents. Also identified are programs with documented effects on risk and protective factors that are correlated with child abuse and neglect, including parent characteristics, child characteristics, and the parent-child relationship.
As noted, the provision of home-based interventions at the time a woman becomes pregnant or gives birth is one of the most widely disseminated child abuse and neglect prevention strategies Daro, Although findings remain inconsistent across program models, target populations, and outcome domains, the approach continues to demonstrate impacts on the frequency of child abuse and neglect and harsh punishment Chaffin et al.
Development of a Policy-Relevant Child Maltreatment Research Strategy
Likewise, home visiting programs that engage families with older children aged have demonstrated an ability to reduce depressive symptoms, parental stress, and life stress and enhance parental competence and social support DePanfilis and Dubowitz, Findings of a year follow-up study of families enrolled in the Nurse Family Partnership's randomized clinical trials support that program's long-term positive impacts on both parents Eckenrode et al. In contrast to control families, mothers who received the program were involved in fewer substantiated reports for maltreatment, abuse, and neglect, and children were less likely to report running away or to have had contact with the juvenile justice system.
These and similar gains were most concentrated among families with the fewest material and emotional resources at the time they enrolled in the program. As noted earlier, confidence in home visiting as an effective way to address child abuse and neglect, as well as other poor child developmental and behavioral outcomes, contributed to the inclusion of the Maternal, Infant and Early Childhood Home Visitation Program in the ACA.
As of this writing, 12 home visiting models that serve young children have met the criteria for identification as an evidence-based model appropriate for this initiative in that one or more rigorous evaluations have documented impacts in one of eight core outcome domains child health; child development and school readiness; family economic self-sufficiency; linkages and referrals to other services; maternal health; positive parenting practices; reduction in child abuse and neglect; or reduction in juvenile delinquency, family violence, or crime Avellar et al.
However, only 3 of the 12 approved models have had a measurable and significant impact in reducing either child abuse or neglect reports or the incidence of harsh parenting. While home visiting programs continue to build an evidence base around a wide range of outcomes, preventing child abuse and neglect as measured by a reduction in initial or subsequent abuse and neglect reports remains an area in which consistent findings are lacking. Also, as promising models are taken to scale, sustaining their impacts is proving problematic. For example, a broad replication of the Nurse Family Partnership in Pennsylvania resulted in no significant differences in visits to hospital emergency departments for serious injuries between families enrolled in the program and a comparison group Matone et al.
Other studies also have raised concern about the extent to which home visiting services are able to prevent the recurrence of physical abuse or neglect MacMillan et al. For the past several years, a number of states and local communities have explored ways of extending support to a greater proportion of newborns and their parents.
In contrast to targeted approaches that limit services to parents identified as high risk, these more universal initiatives are built on a public health model aimed at altering the context in which parents raise their children. Specifically, these initiatives offer comprehensive assessments and a limited number of service contacts to all parents or all first-time parents living within a specific geographic area e. Assessments of the impacts of this approach have found that families are receptive to offers of such assistance and are able to access additional services in a more timely and appropriate manner Dodge et al.
At least one randomized study of this approach, conducted in Durham County, North Carolina, found that families with access to an initial nurse home visit at the time their child was born were less likely to use hospital emergency room services; less likely to present with anxiety; and more likely to exhibit positive parenting behaviors, to have strong community connections, and to participate in higher-quality out-of-home care Dodge et al. Additional research is required to fully understand the implementation challenges associated with such universal strategies and their ultimate impacts on parental behaviors and child outcomes.
Improving parents' capacity to meet the developmental and emotional needs of their children has long been viewed as an effective strategy for preventing child abuse and neglect Helfer, ; Kempe, Parenting education programs designed to increase knowledge of child development, enhance care, promote positive parent-child interaction and emotional sensitivity, and address child discipline and behavior management are considered a strong theoretical and practical approach to reducing risk and strengthening protective factors Barth et al.
Since parenting education programs can occur in diverse settings, including both home-based and center-based models, and often include additional service components, such as child care services and family support groups, it is difficult to distinguish those impacts that may be attributable to specific parenting education activities Barth, ; Reynolds et al. Further, the populations utilizing these programs are diverse. While unique challenges are faced by parents and families dealing with difficult circumstances, such as substance abuse, mental illness, poverty, domestic violence, or divorce, and those parenting a child with behavioral or developmental difficulties, these parents would not all be expected to engage in abusive or neglectful behavior in the absence of parenting education services.
An assessment of parenting education models by the California Evidence-Based Clearinghouse for Child Welfare identified several social learning-based educational efforts with robust results supported by repeated randomized controlled trials, including two that are often cited as demonstrating strong potential to reduce the risk for child abuse and Participants in Webster-Stratton's The Incredible Years, a multifaceted and developmentally based curriculum for parents, teachers, and children delivered in both primary school and early education settings, demonstrated more positive affective responses and a corresponding decrease in the use of harsh discipline, reduced parental depression, and improved self-confidence and better communication and problem solving within the family Daro and McCurdy, ; Gardner et al.
Significant aspects of the model include group-based training in parenting skills; classroom management training for teachers; and peer support groups for parents, children, and teachers. Triple P, mentioned earlier, is another well-established and well-researched parent management training program. Based on social learning theory, research on child and family behavior therapy, and developmental research on parenting in everyday contexts, each intervention is designed to reduce child behavior problems by teaching healthy parenting practices and how to recognize negative or destructive practices.
Parents are taught self-monitoring, self-determination of goals, self-evaluation of performance, and self-selection of change strategies Daro and Dodge, , p. A geographically randomized study illustrated the effectiveness of Triple P at a population level Prinz et al. Triple P was implemented in 18 randomized medium-sized southeastern U. Additionally, multiple randomized controlled trials of the model in various cultural contexts have found it to have positive impacts on parent-reported child behavior problems, reducing dysfunctional parenting and improving parental competence Bor et al.
Most recently, those examining parenting education programs have focused on identifying those elements of the programs that appear to have the most consistent impact on participant outcomes Barth et al. A meta-analysis conducted by the Centers for Disease Control and Prevention on training programs for parents of children aged identified components of programs that have a positive impact on acquiring parenting skills as demonstrated by increased use of effective discipline and nurturing behaviors CWIG, The 77 studies selected for the review all assessed parenting programs that incorporate active learning strategies such as completing homework assignments, modeling, or practicing skills.
Among the 14 content and program delivery characteristics examined, the factors most frequently associated with positive outcomes were teaching parents emotional communication skills, helping them acquire positive parent-child interaction skills, and giving them opportunities to demonstrate and practice these skills while observed by a service provider CWIG, ; Kaminski et al.
The study also found small program effects on parent behaviors and skills outcomes with those programs having ancillary services. The researchers hypothesized that these ancillary services were a burden for the parents and program staff, and could impede skills development focused on parent-child interactions. In contrast to efforts designed to alter the behavior of adults who might commit child abuse or neglect, a category of prevention programs that emerged in the s was designed to alter the behavior of potential victims CWIG, Initially, such efforts focused exclusively on providing children information on physical and sexual assault; how to avoid risky situations; and if abused, how to respond.
Meta-analyses and evaluations of these programs found they were effective in conveying safety information to children and imparting skills to avoid or lower the risk of assault Berrick and Barth, ; Daro, ; MacMillan et al. It remains unclear, however, to what extent these programs can alter adult behavior and responsiveness or change institutional culture in ways that reduce the likelihood of children being victimized and if they are, having their case addressed in an appropriate and transparent manner Daro, More recently, the focus of these universal education programs has expanded to encompass issues of bullying and aggressive behavior, particularly among elementary and middle school students.
While the immediate goal of these interventions is to reduce levels of bullying and aggressive behavior among children and youth, accomplishing this goal might potentially contribute to a reduction in these behaviors in adulthood, thereby reducing levels of child abuse. A Cochrane review of school-based violence prevention programs targeting children identified as being or at risk of being aggressive found that aggressive behavior was significantly reduced in the intervention groups compared with the control groups in 34 trials with data on this outcome, and that positive impacts were maintained in the seven studies reporting month follow-up data Mytton et al.
These programs also may impact the response of bystanders to bullying behavior. A randomized controlled trial of a whole-school intervention provided universally to students by teachers found that the program moderated the developmental trend of increasing peer-reported victimization, self-reported aggression, and aggressive bystanding compared with schools randomly assigned to the control group. The program also moderated a decline in empathy and an increase in the percentage of children victimized compared with the other intervention conditions Fonagy et al.
Likewise, an observational study of playground interactions in schools randomly assigned to a bullying prevention program found declines in bullying and argumentative behavior, increases in agreeable interactions, and a trend toward reduced destructive bystander behaviors Frey et al. While not well researched, the observed impacts on children's response to acts of peer aggression and their increased willingness to speak up and support the victim may have implications for subsequent reductions in various forms of child abuse and neglect.
Adolescents and young adults who become increasingly comfortable with the concept of actively resisting aggression toward their peers may be more likely to support normative standards by which such behavior toward children is less tolerated and individuals feel more empowered to seek ways to stop it.
A consistent feature of child abuse and neglect prevention programming has been the development of public awareness campaigns. Initially, these efforts focused on raising awareness of the problem and enhancing the public's understanding of behaviors that constitute abuse and neglect and their impact on child well-being Daro and Cohn-Donnelly, In recent years, broadly targeted prevention campaigns have been used to alter specific parental behaviors.
For example, the U. Campaign strategies included media coverage; the availability of a nationwide toll-free information and referral hotline; the production of television, radio, and print ads; and the distribution of informational brochures to new parents. As of , the National Center for Health Statistics reported a 50 percent drop in SIDS deaths and a decrease in stomach sleeping from 70 percent to 15 percent.
Although the evidence linking the campaign to changes in these population-level indicators is exploratory, the data are suggestive of how public education might be used to change normative practices Mitchell et al. One of the most thoroughly examined public education and awareness campaigns addressing child abuse has been the effort to prevent shaken baby syndrome, now termed abusive head trauma. Moving beyond basic awareness, Dias and colleagues developed a universal education program on shaken baby syndrome, which they implemented in an eight-county region in western New York.
The program provided information on shaking to parents of all newborns prior to the infants' discharge from the hospital. During the 6 years before the program, 40 cases of substantiated abusive head injuries were identified in the targeted New York counties—an average of 8. In the Pennsylvania comparison communities, there was no change in the number of such cases observed during the same two time periods Dias et al. Another promising public education and awareness program, The Period of PURPLE Crying, focuses on helping parents understand and cope with the stresses of normal infant crying.
The program was tested through four different types of delivery systems: More than 4, parents participated in the program. A randomized controlled trial of the program found that it succeeded in enhancing mothers' knowledge about infant crying. While these findings are encouraging, others implementing these types of broadly targeted efforts have not achieved comparable results.
The extent to which these programs can result in sustained population-level change in parenting behaviors remains unclear. In addition to the provision of direct services to new parents, increased consideration is being given to how best to use existing service delivery systems that regularly interact with families to address the potential for abuse and neglect. For example, the medical field has long sought ways to better address healthy child development and child abuse and neglect within clinical settings. Historically, health professionals have faced barriers to using the traditional checkup appointment to carry out this responsibility.
Doctors are often uncomfortable discussing sensitive issues, and they frequently lack the training to instigate such conversations and the ability to recognize key warning signs Benedetti, Additionally, adequate and comprehensive screening tools have not been made available to all primary care providers Benedetti, ; Dubowitz et al.
The Healthy Steps program, an evidence-based model that places child development specialists within selected pediatric practices, was initially created in to address this issue. Today, Healthy Steps is available in 17 states and has demonstrated consistent impacts on child health, child development and school readiness, and positive parenting practices Benedetti, ; Caughy et al. More recently, the Safe Environment for Every Kid SEEK program was created to help health professionals address risk factors for child abuse and neglect through a training course, the introduction of a Parent Screening Questionnaire, and the addition of an in-house social worker team to work with families.
Two studies were recently conducted to test existing SEEK programs: The first was a randomized trial conducted between and in resident clinics in Baltimore, Maryland. Families enrolled in the SEEK treatment group showed significantly lower rates of abuse and neglect across all measures compared with controls Dubowitz et al. The second study, conducted 2 years later, investigated whether the program changed doctors' attitudes, behaviors, and competence in addressing child abuse and neglect among their patients Dubowitz et al. Eighteen private practice primary care clinics participated in a cluster randomized controlled trial.
The pediatricians in the SEEK group showed significant improvement in their abilities to address substance use, intimate partner violence, depression, and stress, and they reported higher levels of comfort and perceived competence in doing so Dubowitz et al. A focus on the community as an appropriate prevention target is supported by findings of public health surveillance efforts and research on the effects of neighborhood contexts Coulton et al. Research using population- and community-level data underscores the pressing need to design, target, and promote preventive service programs in jurisdictions exhibiting the greatest need Putnam-Hornstein et al.
Accordingly, a number of strategies have emerged that focus on ways to better coordinate and integrate services provided through multiple domains and to alter the context in which parents rear their children Daro and Dodge, The goal of such efforts is to move from simply assessing the prevention impacts on program participants to achieving population-level change by creating safe and nurturing environments for all children, as well as communities in which parents are supported through both formal services and normative values that foster mutual reciprocity.
Description
Although such initiatives are not fully operational in any community, the goal of altering both individuals and the context in which they live potentially provides a potent programmatic and policy response Daro et al. In a recent review of five multicomponent community initiatives, Daro and Dodge conclude that the implementation of multifaceted interventions that combine direct service reforms with attempts to alter residents' access to and use of both formal and informal supports are promising but largely unproven. Based on comparisons of administrative data, at least some of the models they reviewed had successfully reduced reported rates of child abuse and injury to young children at the county or community level Dodge et al.
When focusing on community building, several models demonstrated a capacity to mobilize volunteers and engage diverse sectors within the community, such as first responders, the faith community, local businesses, and civic groups, in preventing child abuse Daro et al. At present, however, little information is available on how these attitudes and willingness to support one's neighbors will translate into a measurable or sustained reduction in child abuse and neglect and enhanced parental support CDC Essentials for Children, available at http: Designing and implementing a high-quality multifaceted community prevention initiative is costly.
Moving forward, policy makers need to consider the trade-offs of investing in diffuse strategies designed to alter community context versus expanding the availability of services for known high-risk individuals. For the research community, a potential area of inquiry may lie in examining key mediators of either individual- or population-level outcomes and identifying less costly ways to create these mediators within prevention efforts. Investments in preventing child abuse and neglect increasingly are being directed to evidence-based interventions that target pregnant women, new parents, and young children.
Since the NRC report was issued, the prevention field has become stronger and more rigorous both in how it defines its services and in its commitment to evaluative research. And although greater attention is being paid to the development of home visiting interventions, the field embraces a plethora of prevention strategies.
Communities and public agencies continue to demand and support broadly targeted primary prevention strategies such as school-based violence-prevention education, public awareness campaigns, and professional practice reforms, as well as a variety of parenting education strategies and support services for families facing particular challenges.
None of these program approaches are perfect, and they often fail to reach, engage, and retain their full target population successfully. Notable gaps exist in service capacity, particularly in communities at high risk and among populations facing the greatest challenges. And a substantial proportion of those families that do engage in intensive, long-term early intervention programs will exit the services before achieving their targeted program goals.
That said, the committee finds the progress in prevention programming to be impressive, but the strategies employed to be underdeveloped and inadequately researched. A broad range of evidence-based child abuse and neglect prevention programs increasingly are being supported at the community level to address the needs of different populations. Strategies such as early home visiting, targeting pregnant women and parents with newborns, are well researched and have demonstrated meaningful improvements in mitigating the factors commonly associated with an elevated risk for poor parenting, including abuse and neglect.
Promising prevention models also have been identified in other areas, including school-based violence prevention education, public awareness campaigns, parenting education, and professional practice reforms.
Despite substantial progress in the development of effective prevention models, many of these models require more rigorous evaluation. Research is needed to devise strategies for better reaching, engaging, and retaining target populations, as well as to develop the capacity to deliver services to communities at high risk and among populations facing the greatest challenges.
Developing a pool of high-quality interventions is essential to address the problem of child abuse and neglect. Equally important is understanding how best to replicate, sustain, and integrate these programs into an effective system of care. Unfortunately, in child abuse and neglect as in other areas of health, mental health, and social services, a wide gap exists between available evidence-based interventions and practices and effective methods for their dissemination, implementation, and sustainment.
This is a critical concern because the potential public health benefit of these interventions will be severely limited or unrealized if they are not implemented and sustained effectively in usual-care practice, be it in child welfare, mental health, substance abuse, or primary health care settings Balas and Boren, Indeed, the success of efforts to improve services designed to support the well-being of children and families is influenced as much by the process used to implement innovative practices as by the practices selected for implementation Aarons and Palinkas, ; Fixsen et al. It is increasingly recognized that investment in the development of interventions without attention to how they align with service systems, organizations, providers, and consumers results in poor application of evidence-based practices.
Indeed, once evidence-based practices are taken to scale, the outcomes and effect sizes documented in their initial clinical trials often are not replicated. One reason for this is that complex interventions frequently are simplified over time in ways that impact key program objectives and strategies Mildon and Shlonsky, Poor implementation has been cited as the reason for weakened effects in programs addressing conduct problems Lee et al. If replicating an evidence-based intervention does not produce a corresponding replication of impact, the intervention cannot be expected to reduce the incidence of the problem it was designed to address.
Unless incidence is significantly reduced, the dramatic cost savings purported to follow major investments in high-quality treatment and prevention services may not materialize. As evidence-based practices move from controlled settings to a real-world context, tension arises between remaining rigidly faithful to the original model and adapting it to local circumstances and needs Backer, ; Bauman et al. Although adaptation may or may not be a deliberate choice, some form of adaptation is likely to be the rule rather than the exception in community care Aarons et al.
Ideally, such adaptation does not change the core elements of evidence-based practices, that is, those required elements that fundamentally define the nature of the practices and produce their main effects Backer, ; Bauman et al. Understanding when and how to alter a program in ways that enhance rather than diminish its effects represents a major social service challenge.
Since the NRC report was issued, significant research has been conducted on how to define the concept of program fidelity, understand the role of race and culture in determining when and how to adapt evidence-based practices, identify those factors that facilitate or compromise the replication of evidence-based practices with fidelity, and clarify how research can be incorporated into the overall programming planning process.
In addition, increased attention is being paid to the costs of interventions relative to their overall impact, resulting in an increased demand for more consistent and comparable methods of quantifying and tracking program expenditures and their long-term impacts on public budgets. This section summarizes this body of research and identifies those areas in need of additional study. At the most basic level, faithfully replicating programs that have been found effective in rigorous experimental studies is believed to result in a higher likelihood of achieving desired outcomes than replicating programs that lack a strong evidentiary base Fixsen et al.
Investing in direct service programs with a proven track record offers policy makers a hedge on their investment and provides increased confidence that outcomes also can be replicated. Central to this hypothesis, however, is ensuring that sites replicating a model maintain fidelity to its original design and intent. As replication of evidence-based programs becomes more commonplace, it is increasingly important to design and implement frameworks for defining program fidelity, as well as data management systems that can track the implementation process at the level of specificity needed to ensure consistent replication.
Researchers use several theoretical frameworks to define fidelity and address issues of appropriate modification. In summarizing work in this area, Carroll and colleagues identify five elements of implementation fidelity: The rise of implementation science and the need to replicate and scale up evidence-based programs with fidelity across a range of disciplines has led to the development of a number of frameworks identifying an array of factors that should be considered to ensure that replication is faithful to both the structure and intent of the original model Bagnato et al.
These factors include an appropriate target population, staff skills and training, supervision, caseloads, curriculum, and service dosage and duration, as well as the manner in which services are provided and participants are engaged in the service delivery process. Maintaining fidelity is especially important in practice-based research networks and learning collaboratives because it allows networks to gauge outcomes that can be used to make necessary practice and science improvements.
Attention to these factors is necessary both in the initial planning process and throughout implementation. The importance of cultural processes in shaping human functioning is increasingly being recognized. It is therefore critical to understand whether child abuse and neglect interventions are effective with ethnic minority youth who are at risk for or experience child abuse or neglect.
A number of scholars have argued that culture matters in the development and testing of prevention and intervention strategies, as well as in the replication and adaptation of evidence-based practices for distinct populations or groups e. According to this perspective, the culturally related processes underlying parenting and sociocultural risks that can lead to or exacerbate abuse and neglect must be considered to ensure the social validity and practical application of an intervention Lau, Another body of literature comprises evaluation of evidence-based interventions with ethnic minority youth and families, focusing on such questions as 1 Are evidence-based interventions effective for ethnic minority youth?
Huey and Polo, , This literature is still in its infancy. As discussed earlier in this chapter, the extant literature shows that evidence-based interventions delivered to African American and Latino youth can be effective for additional discussion of this issue, see Huey and Polo, , Of note, only four interventions have shown effectiveness with ethnic minority youth across multiple trials: In addition to these interventions targeting mental health and adjustment problems, a child welfare intervention targeting American Indian parents Chaffin et al.
Evidence-based interventions appear to work equally well for African American and Latino youth and European American youth, indicating no consistent effects of moderation Huey and Polo, Although most of the interventions investigated in these studies did not explicitly target ethnic minority youth who were abused and neglected, those interventions that did explicitly include this population yielded similar findings regarding effectiveness, moderation, and the impact of cultural adaptation.
However, the discussion of cultural elements in reports on evidence-based interventions varies considerably Huey and Polo, , which may impede understanding of the impact of cultural adaptation; in particular, reporting of the development and evaluation of many culturally adapted interventions is characterized by a relative lack of theory and conceptual framing.
Thus, more research is needed to test key assumptions and hypotheses regarding minority youth and the effectiveness of interventions. A critical gap in this literature is that evidence-based interventions have been tested primarily with African American and Latino youth; with few exceptions, little is known about the effectiveness of evidence-based interventions with Asian American and American Indian youth. For example, there have been few studies on the effectiveness of home visiting models that involve structured, protocol-driven approaches with families in tribal communities Del Grosso et al.
One noteworthy effort is the randomized controlled trial of Family Spirit, modeled on Healthy Families America, which found that a family-strengthening home visiting program delivered by paraprofessionals significantly increased mothers' child care knowledge and involvement Walkup et al. To illustrate these issues, interventions targeting American Indian and Alaska Native families and communities need to take account of their history, culture, and tribal diversity DeBruyn et al.
Thus, addressing child abuse and neglect and trauma among these populations presents unique opportunities to develop culturally sensitive interventions that align with traditional circular and contextual world views and to adapt or enhance evidence-based practices that are based in authentic practitioner-researcher partnerships Poupart et al. One prominent example, Project Making Medicine, provides training in the clinical treatment of child physical and sexual abuse based on the cultural adaptation of TF-CBT.
Entitled Honoring Children, Mending the Circle, the curriculum features an indigenous orientation to well-being and the use of traditional healing practices. Cultural adaptations to family preservation approaches involve using genograms, wraparounds, talking circles, kinship care, healing ceremonies, and traditional adoptions with Native families. This intervention also incorporates tribal elders and extended family in the use of specific cultural approaches, such as storytelling, sweat lodges, feasts, and use of Native languages Bigfoot and Funderburk, The effectiveness of these adaptations of clinical tools and interventions merits further research.
In sum, the field of evidence-based interventions for cultural minority populations is still developing. Research is needed on understudied populations, as well as on key assumptions, hypotheses, and implementation issues of culturally adapted evidence-based interventions. Guidelines on when to consider making a cultural adaptation and how specifically to do so would provide important support for the field.
Lau offers an evidence-based approach to making such decisions. More specifically, populations that face unique sociocultural contexts of risk or resilience that differ from those targeted by the original evidence-based intervention may be appropriate candidates for cultural adaptation. When it is determined that cultural adaptation is warranted, Lau further suggests a data-based approach to decisions on the adaptations to implement. Surface-structure adaptations Resnicow et al.
Development of a Policy-Relevant Child Maltreatment Research Strategy
A multistep process was used, including a review of the clinical literature on Mexican American families; identification of known barriers to treatment access and effectiveness; use of focus groups; and interviews with Mexican American mothers, fathers, and therapists to learn how PCIT could be modified to be more culturally effective.
The process culminated in an expert panel review of the intervention Lau, Another example, The Children and Families as part of the National Child Traumatic Stress Network , addressed the treatment and service needs of traumatized Latino children and families through the creation of adaptation guidelines for practitioners and researchers. Child welfare staff were trained to implement a systems of care approach—an existing evidence-based framework—to improve practice and service delivery for immigrant Latino children at the system level Dettlaff and Rycraft, In such efforts, it is important to attend to the theoretical, implementation, and evaluation issues involved.
Perhaps the data-based framework articulated by Lau can help inform a more rigorous articulation of the circumstances in which evidence-based interventions should be culturally adapted and of the methods that should be used to evaluate the adapted interventions. Since the NRC report was issued, significant work has been done on how to define and monitor the program implementation process itself and on the critical factors related to higher-quality implementation and sustainability. Consensus exists on important key factors, such as availability of funding; leadership in implementation efforts; ongoing consultation and training, especially in the early implementation phases; and the need to address the impact of staff turnover.
In many cases, however, research on these factors is lacking Aarons et al. Consensus also exists that multicomponent implementation strategies are needed, as many different factors need to be addressed in sequence or in tandem for effective implementation that sustains public health impact Ferlie and Shortell, ; Fixsen et al. Implementation frameworks have been developed to expand and distill theories, structures, and processes into manageable approaches for understanding and identifying key facilitators of and barriers to effective implementation.
Most theories provide guidance regarding implementation research and practice, while particular tenets and assumptions of frameworks require further empirical testing to determine whether they actually lead to more effective implementation Aarons et al. Implementation researchers typically test components of models e.
Notable exceptions include studies of system-level implementation in the context of child welfare, such as the use of community development teams to scale up multidimensional treatment foster care in multiple counties Chamberlain et al. To support program fidelity, effective and efficient measurement methods that can be readily utilized in usual care settings are needed Schoenwald et al. In addition, there must be a feedback system coupled with supportive quality improvement or coaching to help providers maintain fidelity Aarons et al.
In many cases, however, little ongoing attention is paid to fidelity once an intervention has been implemented. Delivery of an intervention without attention to its fidelity fails to ensure that services are effective. Efforts have been made to integrate fidelity assessment for psychosocial interventions in systems that involve child abuse and neglect; however, these efforts may or may not be part of implementation studies.
One effectiveness trial found that incorporating ongoing coaching to direct service providers in the delivery of a child neglect intervention supported service efficacy Chaffin et al. This statewide trial was also examined in an implementation study that found benefits for organizations and service teams in reduced provider burnout and turnover. There is also increasing interest in the use of technology to support real-time fidelity assessment.
It is important to recognize that many program implementation efforts have occurred in the context of funded research studies. Outside research funding often covers the costs associated with initial monitoring and documentation of the implementation process, including the collection and analysis of participant-level data to document service dosage, duration, and content. In some cases, study subjects have been paid for their participation in the program and may have received reimbursement for child care or transportation expenses related to their participation.
As evidence-based practices move from the research venue to standard practice, some entity must pay these costs. Increasingly, evidence-based practice models are factoring into their per-participant cost projections those expenses associated with initial and ongoing training for direct service staff, supervisory standards, and data reporting requirements. State agencies or community-based service providers seeking to implement these models are required to cover these costs as part of purchasing the program.
It remains unclear whether these program-driven standards will be sufficient to sustain program fidelity and quality over time and achieve the level of participant engagement required to both sustain program fidelity and replicate outcomes. Most implementation plans for evidence-based practices include methods for transferring research evidence from the program developers to potential users.
Some of these models focus explicitly on the use of research evidence Honig and Coburn, ; Kennedy, ; Nutley et al. Many of these models represent typologies of research use. Whereas the central feature of the instrumental model is the decision, the central feature of the conceptual model is the human information processor. Hence, the instrumental model focuses on the outcome of using evidence, while the conceptual model focuses on the process of using evidence Kennedy, Conceptual models of evidence acknowledge that the use of research evidence to make or support decisions is often a collective endeavor rather than an activity performed by any individual decision maker Spillane et al.
This collective endeavor involves the utilization of social capital Honig and Coburn, ; Spillane et al. Preliminary research Palinkas et al. Feasibility of implementation was the primary criterion used to evaluate this evidence. However, further research is needed to identify components of feasibility that may drive implementation decisions.
Policy makers, program administrators, and researchers increasingly acknowledge the importance of understanding the costs, cost-effectiveness, and returns on investment of child abuse and neglect programs. Policy makers want information on costs and how they compare with outcomes of interest for determining how to allocate scarce resources; program administrators want to identify which programs to implement; and researchers are interested in economic evaluation because it makes their program evaluations more comprehensive Corso and Lutzker, ; Courtney, The demand for economic analysis is evident in strategic planning being developed at the federal level.
In the Centers for Disease Control and Prevention's research plan for injury and violence prevention, for example, a top priority is to describe the use and impact of service delivery as well as the costs of interventions for child abuse and neglect. Corso and Filene, , p.
Assessment of the economic costs of implementing an intervention is called programmatic cost analysis. The process involves the systematic collection, categorization, and analysis of intervention delivery costs, including those entailed during the preimplementation developing the program delivery infrastructure and implementation delivering the program phases Corso and Filene, A standardized methodology for determining costs for child abuse and neglect interventions does not currently exist, although guidelines available in other fields could be applied Foster et al.
To address this need, efforts are under way at the Children's Bureau within the Administration for Children and Families to develop a manual on how to conduct programmatic cost analyses specifically within the child welfare community. Once the costs of a program have been determined, they can be compared with a program's expected and realized short- and long-term outcomes.
This comparison of costs with outcomes is referred to as economic evaluation and includes a number of analyses, such as benefit-cost analysis and return on investment, whereby outcomes are valued in monetary terms, and cost-effectiveness analysis, whereby outcomes are valued in natural units, such as cases of child abuse and neglect prevented or improvements in quality of life. Although some guidelines for conducting economic evaluations do exist for community-level interventions in general Haddix et al. Despite the need for information on the economic cost and impact of implementing child and family development or child abuse and neglect prevention programs, few cost analyses Corso and Filene, or economic evaluations have been conducted in this area since the NRC report was issued Barlow et al.
More studies have focused specifically on economic evaluation of interventions designed to improve outcomes for children at risk for or currently involved in the child welfare system these studies are systematically reviewed and summarized by Goldhaber-Fiebert and colleagues []. Remaining challenges to conducting programmatic cost analysis and economic evaluation in the fields of child abuse and neglect intervention and child welfare include the need for 1 the development and consistent use of standardized methodology for assessing program costs; 2 multisite assessment of programs in which program-, provider-, and community-level variables may impact program-level costs and outcomes; 3 better tools for assessing the impact of child abuse and neglect on health-related quality of life, which is an important outcome measure in economic evaluations within other health fields; 4 assessment of the long-term costs of child abuse and neglect to determine the potential benefits of prevention and successful child welfare services; and 5 the development and use of model-based economic evaluations to support decision making within the child welfare system Goldhaber-Fiebert et al.
As policy makers place greater emphasis on evidence-based decision making and the implementation of programs that have been proven effective through rigorous evaluation, research will be needed to understand how these high-quality interventions are replicated, adapted to diverse populations, and incorporated into the overall service delivery system.
At present, little is known about the most effective strategies for ensuring that evidence-based practices are replicated with fidelity to their intent and structural elements. Central here is determining which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations.
Equally important is understanding the costs associated with the emphasis on replicating with fidelity in terms of 1 monitoring the service delivery process; 2 providing the required levels of supervision and infrastructure support, including the development of data collection systems; and 3 determining how the data will be integrated into subsequent practice and policy decisions.
Despite a growing body of theoretical and applied research in the area, a wide gap exists between available evidence-based interventions and practices for treating and preventing child abuse and neglect and methods of effective dissemination, implementation, and sustainment of those interventions. It is increasingly recognized that investment in developing interventions alone, without attention to how they align with service systems, organizations, providers, and consumers, results in poor application of evidence-based practices.
Therefore, more research is needed to support the translation of model programs for effective use in real-world settings. Little is known about the most effective strategies for ensuring that evidence-based interventions are replicated with fidelity to their intent and structural elements. Further research is needed to determine which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations.
More research is needed on the development of evidence-based interventions for cultural minority populations, with a particular focus on understudied populations. Also needed is research that carefully examines key assumption, hypotheses, and implementation issues of culturally adapted evidence-based interventions. Guidelines on when to consider making a cultural adaptation and what the specific adaptation should be would provide important support to the field. Significant advances have been achieved in how the program implementation process itself is defined and monitored and in the identification of critical factors related to higher-quality implementation and sustainability.
Consensus exists on key factors, but in many cases, research on these factors is lacking. Consensus also exists that multicomponent implementation strategies are needed to address the challenges of effective implementation. Despite the need for information on the economic cost and impact of implementing child and family development or child abuse and neglect prevention programs, few studies have conducted programmatic cost analyses or economic evaluations in this area. This type of research is needed to guide policy makers and program administrators. As the discussion in this chapter has made clear, several of the challenges faced in replicating promising programs and their outcomes lie in the process by which programs are designed and implemented.
Equally important, however, is considering the programs' institutional, organizational, and political context. Elements of this broader infrastructure can support or complicate the implementation and sustainability of a promising approach Tibbits et al. Social service programs benefit from an array of elements that strengthen their capacity to deliver high-quality services consistently. These elements have been organized conceptually into three groups: Child abuse and neglect is a complex issue with diverse causal pathways, manifestations, and affected populations.
Therefore, multiple high-quality interventions are needed to address it. An effective response to the problem would be facilitated by a more explicit focus on building an infrastructure that can support the most promising interventions as they emerge and link them in ways that maximize their collective impact. Unfortunately, limited research has been conducted on the potential impact of infrastructure reforms on program implementation and participant outcomes. Although efforts aimed at enhancing the knowledge and skills of the workforce in order to strengthen organizational capacity to support evidence-based practices or at reducing barriers to service access through better interagency coordination make sense, relatively little is known about how to accomplish these improvements.
This section briefly reviews the literature on the impact of organizational culture and interagency networks on the implementation and sustainability of evidence-based programs. The quality of services provided to families and children is influenced not only by the rigor of a program's design and its implementation but also by the organizations in which services are embedded.
Studies of organizational context have found associations between an organizational culture and climate and participant outcomes Glisson and Hemmelgarn, Organizational culture also can result in improved service engagement, reduced staff turnover, and improved child outcomes, independent of the implementation of evidence-based practices Glisson et al. This relationship between organizational culture and program implementation is reciprocal. The implementation of evidence-based practices can adversely impact organizations by adding to the workload of an already overworked labor force or by leading to increased employee turnover as staff are asked to change their practices and adopt new strategies that may restrict their sense of control over the therapeutic process Glisson et al.
On the other hand, organizations also can benefit from the implementation of evidence-based practices. These benefits include enhanced professional identity, improved client outcomes, and the gratification of contributing to a process of knowledge generation Aarons and Palinkas, ; Palinkas and Aarons, One statewide study of implementing evidence-based practices found that ongoing fidelity coaching predicted decreased staff burnout and reduced staff turnover Aarons et al.
These benefits aside, the culture of evidence-based practices that stems from an empirically based research perspective and the culture of child abuse and neglect practice may be at odds, engendering a gap that must be bridged if effective implementation is to be achieved Palinkas et al. Even something as basic as the reporting of child abuse and neglect may be impacted by organizational context Ashton, Thus, for example, an examination of child sexual abuse in the Catholic Church implicates a strong organizational culture as a major factor limiting the institution's appropriate response to the problem Keenan, While some of the above-mentioned studies assess or deliberately alter organizational context, others examine or cite organizational context as important in the implementation of evidence-based practices Kolko et al.
Yet while there have been calls for increased attention to organizational context in the dissemination and implementation of evidence-based practices Chaffin, ; Kessler et al. Based on diffusion of innovations theory Rogers, and social learning theory Bandura, , Valente's social network thresholds model calls for identification and matching of champions within peer networks that manage organizational agenda setting, change, and evaluation of change e.