Best Practices in Home Visiting and Parenting Groups

1. Best Practices in Home Visiting and Parenting Groups Association of Child Welfare Agencies Positive Future, Achieving Well-Being for Children & Families Sydney, August 14, 2006 Richard P. Barth School of Social Work University of Maryland Baltimore, MD 21201 rbarth@ssw.umaryland.edu

2. The Call to Change • Disappointing family preservation services • Reunifications are declining (in the US) • Reentry rates are high (20% or more) • Reinvolvement rates (including reuabuse and reentry following reunification) is higher (approaching 36% in US at 3-years) • Adoptive parents are struggling and there are high rates of displacement of adopted children into group care

3. Changing Ourselves • The reason you we are here is to change ourselves • You may think it is to confirm who you are and what you are doing, but it is not so. • If we expect the parents and children we serve to change, we must also change

4. Nothing Will Change… … unless we do. They say that time changes things, but you actually have to change them yourself (Andy Warhol).

5. Child Welfare Reform Requires Multiple Evidence-Based Changes • Everyone thinks of changing the world, but no one thinks of changing himself (Tolstoy) • You may think that it is the policy, the funder, the program manager, the service network, or the client that must change if we are to help more children and parents—but it is not simply so. • We must change all of these and the way we approach the science of behavior change.

6. Three Approaches to CWS Reform Personnel SYSTEM CWS OUTCOMES Finance Reform Professionaliism (Education, selection, experience, training) Interventions System Reform (Policy and Demonstration projects) Evidence-Based Practices (ESTs, opportunity to provide, fit, supervision) Heavily adapted from Bickman & Reimer, n.d.

7. Basic Components of Effective Parent Training • Social learning framework • Strengthening parent-child relationship • Effectively use praise and reward • Sets clear and effective limits • Reserves most significant consequences for targeted, limited behaviors • Strictly limits negative consequences • Parent Training + may have worse outcomes than parent training alone (CDC) • Addresses family as well as parent-child issues Hurlburt, M., Barth, R.P., Leslie, L. & Landsverk, J. (in press). Haskins, R., Wulczyn, F., & Webb, M. (Eds).  Research on child protection: Findings from NSCAW. Washington, DC: Brookings.

8. Delivering Effective Parent Training Programs • Detailed materials corresponding to specific, narrowly focused parenting skills • Specific means of monitoring changes in parenting practices (e.g., homework) • Parents take active, participatory role in learning and practicing skills • Minimum 15 hours of intervention and 25 hours for group format • Rigor of supervision processes to ensure program delivery with fidelity

9. Three D’s:Stages to Practice Change • Discovery of new knowledge • Development of highly effective evidence based methods • Delivery of knowledge and interventions PMT, PCIT, TIY, SafeCare development for 30 years 30 Years

10. California Clearinghouse Criteria Scientific Rating 1. Well supported, effective practice 2. Supported - efficacious practice 3. Promising practice 4. Acceptable/emerging practice 5. Evidence fails to demonstrate effect 6. Concerning practice

11. California Clearinghouse Criteria Child Welfare Relevance… Do The Studies Address: 1. Safety 2. Permanency 3. Well-being

12. Parent Training Programs SO FAR ….. NO PARENT TRAINING PROGRAMS HAVE THE HIGHEST SCIENTIFIC RATING AND CW RELEVANT RESEARCH

13. But Some are Close… • The Incredible Years • Parent-Child Interaction Therapy • Triple-P, Positive Parenting Program • Are all rated • 1 For Scientific Merit and • 2 for Relevance to Child Welfare http://www.cachildwelfareclearinghouse.org/

14. Movement Toward Bringing Evidence Based Parent Training to CWS • Good new ideas have been developed that could assist CWS • Their use will require deep involvement of CWS in implementation: • We cannot implement them all at once • We must allocate adequate resources to adapting them to CWS populations and practice parameters • We must also provide extensive supervision during implementation

15. 3 Approaches to EBP Development of PMI • The Ecological Validity Approach (Homebuilders, Healthy Families America, Family 2 Family’s Team Decision Making,& FGDM) • Develop practices in the field • Then disseminate them widely • Then try to study them • The Masterplan Approach (Nurse Home Visiting and MST) • Develop interventions in the field but then continue to replicate with tight controls prior to dissemination • Okay, but they haven’t made it to CWS, yet • The Partnering (aka, Chamberlain, Landsverk and Chaffin) Approach (Project KEEP, PCIT, SafeCare) • Adapt evidence based interventions developed by other professions in labs and artificial settings by engaging social work/child welfare collaborators in when going into the CWS field • Test in rigorous clinical trials in CWS

16. The Ecological Validity Approach Develop Practice on CWS Population Conduct Efficacy Studies in CWS Disseminate Treatment to CWS Engage CWS/Social Work

17. The Master Plan Approach Develop EBP on Non-CWS Population Adapt for CWS ??? Conduct Efficacy Studies in Non-CWS Disseminate Treatment to CWS Engage CWS/Social Work

18. The Partnering Process in CWS Develop EBP on Non-CWS Population Conduct Efficacy Studies in CWS Disseminate Treatment to CWS Conduct Effectiveness Studies Modify EBP for use in CWS Bring in CWS/Social Work

19. Four Partnering Examples • PCIT in OK (Chaffin et al, CDC]) • Project KEEP in San Diego (Chamberlain, Price and Landsverk, NIMH) • SAFECARE in OK (Chaffin and all, NIMH) • The Incredible Years (Under development for CWS testing

20. Parent Child Interaction Therapy (PCIT) • The PCIT program is for children 4 to 10 and consists of: • Relationship Enhancement: Parents are taught and 'coached' how to decrease negativity and increase consistently positive communication with their child. • Discipline: parents are taught and 'coached' the elements of effective discipline and child management skills. • Parents are taught specific skills, given the opportunity to practice these skills during therapy, then continue practicing skills until mastery is acquired and the child's behavior has improved. • PCIT is now in place in NYC (used with foster parents) several CA sites and other states • Therapists provide reports of parental competency at end of PCIT!!! ^Chaffin, M., Silovsky, J., Funderburk, B., Valle, L. A., Brestan, E. V., Balachova, T., et al. (2004). Parent-child interaction therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology, 72, 500-510.

21. PCIT, RCT in OK with PA Parents • Participating parents had history of engaging in severe physically abusive behavior. • Physical abuse re-report rates at a median of 850 days of follow-up were 19% for the PCIT group compared to 49% for a standard community parenting group. • Addition of individualized wrap-around services did not improve physical abuse re-report outcomes (and may have been counterproductive). • No differences in outcomes by age, gender or race/ethnicity Different therapists achieved comparable results. • PCIT cost more than standard approach, but the longterm savings were greater. Chaffin, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Breston, E. V., Balachova, T., et al. (2003). Physical abuse treatment outcome project: Application of parent child interaction therapy (PCIT) to physically abusive parents. Washington, D C: U. S. Department of Health and Human Services, The Administration on Children, Youth and Families, Children's Bureau, Office on Child Abuse and Neglect.

22. PCIT Adaptations • The age group had to be modified from 4-10 to 4-12 • Changing the age group also changes the way that time out needs to be taught and reinforced • Working with older and abused children was different than working with younger and conduct disordered children, insofar as there was less naturally occurring misbehavior by the abused children • Transportation was a major issue because the foster parents did not have the same motivation as biological parents have • PCIT required a much higher initial investment. Usual and customary parent training care in OK was $15 an hour for the therapist, with no prep time. Chaffin, M., Silovsky, J. F., Funderburk, B., Valle, L. A., Breston, E. V., Balachova, T., et al. (2003). Physical abuse treatment outcome project: Application of parent child interaction therapy (PCIT) to physically abusive parents. Washington, D C: U. S. Department of Health and Human Services, The Administration on Children, Youth and Families, Children's Bureau, Office on Child Abuse and Neglect.

23. Parent Management Training • 30+ years of practice and research at OSLC • Teaching parents to manage child behavior. • Rewards for positive behaviors, consequence for negative behaviors. • Randomized trials from the 1970s to 1990s found that parenting improved, changes persisted, and adolescent delinquency decreased. Patterson, G. R. (1975). Families: Applications of social learning to family life. Chaimpaign, IL: Research Press. Reid, J.B., Patterson, G. R., Snyder, J., (2002). Antisocial behavior in children and adolescents: A developmental analysis and model for intervention. Washington, DC: American Psychological Association.

24. Parent Management Training to MTFC No Manual but Lots of Materials • Living with Children (Gerald Patterson, 1974) • Families: Applications of Social Learning to Family Life (Patterson, 1975) • Families and Adolescents Living Together (Forgatch and Patterson, 2005 revision) • Much clinical work with high risk children living at home, funded by NIJ • Many seminal papers identifying key processes involved in families that have troubled children MTFC PMT

25. MTFC: Randomized Studies • 1996 application to “regular” foster care: (Chamberlain, Moreland and Reid, 1996) randomly assigned MTFC group had: • Fewer placement disruptions • Fewer foster parents dropping out of providing care • Fewer child problem behaviors in follow-up • Female delinquency processes and outcomes (Chamberlain 1999): 80 girls randomly assigned to MTFC or Group Care had fewer arrests. • Recent development of MTFC-P (Phil Fisher’s work on MTFC for behaviorally disordered pre-schoolers)

26. Foster Parent Consultant Family Therapist ‘Daily Report’ Caller STAFF Child Therapist Behavioral Skills Trainer Child Psychiatrist Home Preschool/school Case Manager Contexts Community MTFC-P Emphasizes 3 Domains: Caregiver-Child Relationship Case Management Child Needs

27. Effect of prior out-of-home placements on permanent placement failures, MTFC-P vs. regular foster care RFC MTFC-P (Fisher, Burraston, & Pears, 2005)

28. Morning cortisol levels by group, baseline to 15 months Community TFC-P Regular FC Fisher, Stoolmiller, Levine, & Gunnar (in prep)

29. Feedback Responsiveness at Fz by Group and Trial Type CC MTFC-P Correct Incorrect Correct Incorrect Correct Incorrect RFC Children in MTFC-P develop more typical responsiveness to feedback Group: F(2, 31) = 1.80, ns Interaction: F(2, 31) = 5.11, p < .05

30. MTFC to Foster Care: Project KEEP • MTFC with randomized treatment and control groups • Foster children ages 5 to 12 who are experiencing a new placement (first time or change of placement) and their foster parents • 640 sets of foster children/parents have been enrolled so far including: • 333 Experimental treatment group • 305 Control group • 40% are kinship homes A collaboration between the: San Diego Health and Human Services Agency, Child and Adolescent Services Research Center, Oregon Social Learning Center, Funded by the NIMH

31. How is KEEP Different than MTFC or Standard Foster Care? • Uses Parental Daily Report (PDR) to repeatedly assess behavior problems. • PDR helps identify challenges to Foster/kinship parents and tailor the intervention to be relevant • Weekly support and training in behavior management. Relates problems the foster/kin parents are having in their homes to intervention strategies (>80% attendance). • Follows up with those problems • Stipend: Foster/kin parents get $15/week to cover expenses plus day care and snacks during training

32. Project KEEP Findings So Far • Process • Foster/kin parents tolerate about as much child problem behaviors as non-system families do –5 problem behaviors a day • PDR data is feasible to collect and is well tolerated by foster and kin parents (PDR is a new tool for child welfare services to make parent training more relevant) • Outcomes • Children with foster parents who participated in Project Keep were less likely to disrupt • Project Keep children were more likely to go home to family, relatives, or adoption • These two outcomes taken together produced a statistically significant positive effect on exits (see next slide)

33. Project KEEP: %of Exit Type by Group • Children whose foster parents participated in Project KEEP were almost twice as likely to leave foster care for reunification or adoption. • Children whose foster parents were not using project KEEP were more likely to run away, disrupt, or have another negative exit from care.

34. Project KEEP: CWS Real World Modifications • More than one child to a home, at times • Children were already in home when training was completed • Adherence to protocols was not as sharp as with highly trained and experienced OSLC MTFC providers • The intervention could be called MTFC-lite”

35. Project SafeCare • Trial in Oklahoma has promising preliminary findings (Mark Chaffin, PI) • Neglecting families that get SafeCarewhen the parent trainer gets high levels of supervision are having fewer re-reports of neglect than: • Families getting SafeCare without intensive supervision • Families getting services as usual Lutzker, J. R., & Bigelow, K. M. (2002). Reducing child maltreatment: A guidebook for parent services. New York, NY: The Guilford Press, describes the “SafeCare” Intervention

36. Project SafeCare • RCT in Oklahoma (2X2 Design) • SafeCare vs. Usual Care • Intensive Supervision vs. Usual Supervision • Home-based set of skills-based parent training interventions • Includes a set of twelve protocols focused on building parent skills in the areas of • parent-child interaction, • self-control training • general parenting training • money management, and others.  • infant and child health care, • and home safety and cleanliness.  

37. Project SafeCare in OK Data are Preliminary & Approximate

38. Project SafeCare Modifications • Extensive supervision is needed following instruction • Appears to work best with “neglect” cases, requiring that cases be sorted by maltreatment type prior to referral • Requires that services be in the home

39. The Incredible Years (TIY) • Carolyn Webster Stratton (U.W.) developed; she is a nurse and psychologist who also trained at OSLC and is very interested in developing TIY for child welfare work • The Incredible Years Home: http://www.incredibleyears.com • Office of Juvenile Justice and Delinquency Prevention-exemplary best practice program: http://www.ncjrs.org/html/ojjdp/2000_6_3/contents.html • Strengthening Families: http://www.strengtheningfamilies.org/html/programs_1999/03_IY_PTCTS.html

40. Parent Training • 4 Program blocks, covering ages 2-12. • Developmentally appropriate training for: • Discipline and limit-setting • Problem-solving • Encouraging + behaviors • Increasing school engagement and achievement • Communication • Materials include videotapes, books, “homework,” reminder magnets and notes for fridge, posters.

41. Child Training AND • Small groups for aggressive children: • Counselor or therapist-administered. • 20-22 weeks, groups of about 6 children • Dina Dinosaur Curriculum: • Classroom-based, teacher-administered. • Emphasis on academic and social skills (following the rules, problem-solving, understanding feelings). • 60 lessons, administered 2-3 times per week. • Includes Circle Time and small group activities.

42. Key Features Of TIY • Children and Parents are Both Learning the Same Skills in Groups • Self control and anger management • Giving “time out” (accepting “time out”) • It’s Enjoyable for All CWS HAS ALMOST NO PARENT TRAINING RESOURCES THAT OCCUPY PARENTS AND CHILDREN TOGETHER BUT DO NOT REQUIRE THEM TO BE TOGETHER

43. Needed Adaptations • The full version is 22-weeks long, which will be too long for many attorneys who will want their clients to only agree to go to parenting classes that they can complete before their 3-month hearing • The child and parent groups require therapists, whereas most public agencies only have therapists for the parents (if at all) and child care for the children • Although there is content on parental monitoring it does not integrate child welfare law • The age range of 4-8 is narrow and it would be difficult for many agencies to generate classes of parents with children in that age range.

44. Partnering, after EBP Development, is Not the Only Way • ACT (PACT) developed by social workers and disseminated with fidelity • MST developed in the field, manualized, and provided with extensive supervision, so that fidelity is acceptable • Intensive family reunification services adapted from Homebuilders by social workers (Walton) and tested in Utah

45. Why Should We Invest in Parent Training? • Because we have a revolving foster and group care door that lets in too much harm and too many costs • Because we are struggling to maintain quality foster and group care homes • Because children want to be with their parents, siblings, and kin and

46. Excellent Parent Training Would Help Balance the Responsibility & Opportunity to Change OPPORTUNITY RESPONSIBILITY Opportunity to Learn New Parenting Skills that Mattered Responsibility to Learn New Parenting Skills that Mattered

47. How Much Does Parent Training Matter? • 60+% of all child welfare involved cases in US get parent training • Whether or not you complete parent training is often a central issue in determining parent’s rights to retain or regain custody of their children • Caregivers in NSCAW indicate that they had positive responses to the child welfare workers but not to the services that they referred them to.

48. What Should We Invest In? • Ideas • Demonstration Projects • Randomized Clinical Trials • Testing of Interventions for Infants and Mothers • Testing of service delivery models

49. Expanding Evidence-Based Practices • Changing funding practices, by: • Tie funding, and reimbursement for CWS to objective outcomes rather than inputs (NOT YET) • Use differential payment structures favoring best practices delivered with fidelity (FOR PARENT TRAINING) • Targeted funding of EBP implementation projects (e.g,. EBP uptake grants), to provide agencies with the necessary start-up capital to migrate to best practice models (YES) Chaffin, M. & Friedrich, W. (2004). Evidence-based treatments in child abuse and neglect. Children & Youth Services Review, 26, 1097-1103.

50. Expanding Evidence-Based Practices • Increase advocacy and social demand for best practices by disseminating cautiously derived(emphasis is mine) information to: • funding organizations, • governing boards, • third-party payers, • parents, • and professional organizations Chaffin, M. & Friedrich, W. (2004). Evidence-based treatments in child abuse and neglect. Children & Youth Services Review, 26, 1097-1103.