July 20, 2010 The Brookings Institution Washington, DC

1. Richard P. Barth, PhDUniversity of MarylandSchool of Social WorkPresented ToPreventing Child Abuse in an Age of Budget DeficitsA Future of Children Event July 20, 2010 The Brookings Institution Washington, DC Child Abuse Prevention Campaigns: “Just Enough” Parent Education Campaigns

2. Overview • Developing a campaign of effective targeted parent education services is central to improved child abuse prevention • Triple P is the international leader in developing such a campaign • Neither short- nor long- term cost-effectiveness has yet been established, but important pieces are in place • Determination of cost effectiveness should also include preventing conduct problems • Parenting programs deserve singular attention

3. Getting Parent Education On-Track Parent education serves > 800,000 children who have had contact with CWS each year Parent education programs have also shown efficacy in reducing conduct problems—but no national estimates are available on numbers of children or families served Most child abuse related parent education does not use a a strong evidence-base brand

4. Parenting First Cumulative Risk Models • Cumulative risk models of child abuse appear to fit the data better than broader ecological models (Begle, Dumas, & Hansen, 2010) • Cumulative risk indicators include many parent-focused indicators: • Parent abused as child • Child’s behavior is viewed as disruptive • Parent attributes bad behavior to child • Parental dissatisfaction with role

5. Cost-Effectiveness Improves with Targeting • Generally, cost-effectiveness is improved by better targeting • Fast Track, a multi-level community-based preventive intervention for conduct problems • Study was not cost-effective according to policy maker’s willingness to pay • Fast Track was cost-effective only for youth—if at high risk for behavioral problems (Foster & Jones, 2007)

6. Multifaceted, Multi-level Campaigns Builds on a varied history of success of public health campaigns that promote targeting Triple P is the best exemplar Multiple levels correspond to parent need and interest Common language Cross-profession and agency consistency Preliminary results are positive

7. Substantial Flexibility Within Levels Level 5: Enhanced Triple P Enhanced, Pathways Level 4: Standard Triple P Standard, Standard Stepping Stones, Group, Group Teen, Self-Directed Level 3: Primary Care Triple P Primary Care, Primary Care Teen Level 2: Selected Triple P Seminar, Individual Support, Teen Level 1: Universal Triple P Media (PSAs and TV)

8. Multiple Levels of Intervention A multilevel system increases a parent’s options • Some parents participate in Triple P as a media intervention (Level 1); • Others attend a seminar series on positive parenting (Level 2) • Many attend a four-session individual program with professional provider (Level 3) • Some attended a more intensive group or individual program (Level 4) • Others required an enhanced individual intervention that addresses parental attribution and anger (Level 5)

9. Prinz’ South Carolina Test of Triple P

10. Absolute Changes in South Carolina^ • Substantiated CM cases = 8% absolute increase in treatment group, smaller than in control group • Out-of-home placements 4.27 3.75 = 12% absolute reduction • Child CM injuries (hosp & ER) 1.73 1.41 = 18% absolute reduction ^Note that increases of CM were greater in the control group and out of home placements and CM injuries increased in the control group counties

11. Child Conduct Problems The proportion of children involved with CWS who have behavior problems is substantial. 42% of children who come to the CWS have behavior problems at the clinical level at entrance (Burns et al., 2004) The special education, mental health, and related costs of conduct problems are substantial (Knapp et al., 2001; Scott, 2007; Cohen, 1999)

12. Multiple Pathways to Savings Reduction in Child Abuse Service Costs Effective Parent Training Reduction in Disruptive Behavior Disorders

13. Costs of Triple P • The costs of the universal media and communication component totaled less than $1.00 per child in the population. • The costs of training service providers to deliver at other intervention levels were quite modest ($11.74 on a per child basis) (Foster, et al., 2008) • Rough estimates suggest that these costs could be recovered in a single year by as little as a 10% reduction in the rate of abuse and neglect.

14. Short-Term Cost-Savings of Preventing Child Abuse and Behavioral Disorders Generally, not well-estimated—little attention has been given to the short-term service costs of: intake, court costs, placement/classroom moves, multi-disciplinary team staffing, and mental health services Chaffin et al. found > $3,600 savings per family in reductions in costs for new child abuse investigations after re-abuse allegations

15. Conclusions re Risk Factors • Specific forces that impair parenting are readily identifiable • Parent education may be a helpful direct intervention for several of these conditions • Relatively little work has been done to determine how parent education could be constructed and delivered to prevent child abuse among persons with these risk factors

16. Long Term Cost of Child Abuse • About $100,000 per child (Corso and Lutzker, 2006) or according to Foster et al., about $186,000 per family (Foster et al., 200x). • Corso and Fertig (2010) cost of $65 billion, per child, is closer • Triple P is likely to be cost effective if it results in more than a 10% reduction in child abuse • The reduction may have been achieved in South Carolina, see Triple P cost-savings estimator—which uses Cohen’s estimate of $200,000 savings for “high risk youth”

17. Long-term Cost of Conduct Problems • Knapp and Scott: 3 Groups (UK), prospective study to adulthood • Conduct Problem children 3.5Xs the cost of non conduct problem children • Conduct disordered children 3Xs the cost of conduct problem children • Cohen (1999) prevention of “at-risk” youth status could save $2,000,000

18. Appeal of Parenting Education • Evidence based practice has “efficiency cache” • “The Nanny”, “Wife Swap”, and “Teen Mom” are new TV shows that have proven popular • Triple P has its own TV material, 6-episode observational documentary: Driving Mum and Dad Mad, that shows a family benefiting from Triple P

19. Funding Feasibility of Increasing Parent Education in an Age of Deficits • The public understands that some changes in brain and bodily functioning are hugely expensive to reverse, if reversible • BUT, Parent education does not have a “home” and is passed around between health, child welfare, schools, and mental health—depending on the intensity of the problem • A single continuum of parenting education care would better allow for multiple investors

20. Future Development of Parent Training • A dedicated source of funding for parent education is critical to advancing evidence-based parenting programs • The cost of failure to prevent, falls on many agencies, yet few agencies contributeto prevention • Funding of parent training program development should be predictable so that the field can grow • Funding should not, ultimately, be divided by “in-home” or “out of home” as many of the best parenting programs include both

21. Future Development of Parent Training • A dedicated source of funding for parent education is critical to advancing evidence-based parenting programs • Implementation funding should not be divided by CWS or Education or Mental Health because parenting programs serve several masters • UK has established the “National Academy of Parenting Practitioners” to develop training in evidence-based services • Adequately accelerating parent education will require innovation at the State and Federal level

22. Questions ??? Comments ??? THANK YOU

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24. References (Continued) Goldfine, M.E., Wagner, S.M., Branstetter, S.A., & Mcneil, C.B. (2008). Parent-Child Interaction Therapy: An examination of cost-effectiveness. Journal of Early and Intensive Behavior Intervention, 5(1), 119-141. Horwitz, S. M., Chamberlain, P., Landsverk, J., & Mullican, C. Improving the mental health of children in child welfare through the implementation of evidence-based parenting interventions. Administration and Policy in Mental Health and Mental Health Services Research, 37(1-2), 27-39. McCarthy, P. & Kerman, B. Inside the belly of the beast: How bad systems trump good programs. Administration and Policy in Mental Health and Mental Health Services Research, 37(1-2), 167-172. Mihalopoulos, C., Sanders, M. R., Turner, K. M. T., Murphy-Brennan, M., & Carter, R. (2007). Does the triple P-Positive Parenting Program provide value for money? Australian and New Zealand Journal of Psychiatry, 41(3), 239-246. Nowak, C. & Heinrichs, N. (2008) A comprehensive meta-analysis of Triple P-Positive Parenting Program using hierarchical linear modeling: Effectiveness and moderating variables. Clinical Child and Family Psychology Review, 11, 114-144. Prinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-Based Prevention of Child Maltreatment: The US Triple P System Population Trial. Prevention Science, 10(1), 1-12. Scott, S. National dissemination of effective parenting programmes to improve child outcomes. British Journal of Psychiatry, 196(1), 1-3. Thomas, R., & Zimmer-Gembeck, M. J. (2007). Behavioral outcomes of parent-child interaction therapy and triple p-positive parenting program: A review and meta-analysis. Journal of Abnormal Child Psychology, 35(3), 475-495. Ward, H. (2008). Costs and consequences of placing children in foster care. London: Jessica Kingsley.