Community Prevention of Child Maltreatment

1
Community Prevention of Child Maltreatment

• Kenneth A. Dodge
• Presentation to the University of California
  Irvine
• April 14, 2014
• Support is appreciated from The Duke Endowment,
  the Pew Center on the States, NIDA, and NICHD.
  Colleagues are Robert Murphy, Karen ODonnell,
  Ben Goodman, Jeannine Sato, and Sue Guptil.

2
Antecedents of Chronic Youth Violence
Gustav Vigeland sculpture, Oslo, Norway
Total annual burden of child maltreatment gt 100
billion (114,000/case) Maternal, Infant, and
Early Childhood Home Visiting Program 1.5
billion Case stories1. Working single mother
2. Confused mother
3
Plan for This Presentation

• 1. Propose model of how child maltreatment occurs
• 2. Describe Durham Connects Intervention and RCT
• 3. Discuss financing of Connects and other
  programs

4
The Challenge to Change Community Rates of Child
Maltreatment

• The Duke Endowments interest and ten-year
  commitment
• Requirements in a response
• Replicable model based in developmental science
• Rigorous evaluation of impact
• Community rate of maltreatment / child well-being
  as the dependent variable
• No program had ever successfully changed
  community rates.
• Initial plan
• Formulate a model of child maltreatment based on
  study of risk and processes
• Pilot several intervention and policy ideas
• Test through a randomized controlled trial

5
Project MOM
Representative sample of 500 pregnant Durham
residents, interviewed in mid-trimester and
followed through age 36 months. 17 had been
physically abused or neglected. 9.6 reported
substance-use problems. 44 reported at least
one mental health problem. 62 reported poverty
or Medicaid. By age 26 months, 8 of offspring
had been reported as maltreated by official
record review.

6
Mothers Prenatal Hostile Attributions about
Infant Intentions Predict Later Child
Maltreatment (Berlin, Reznick, Dodge, 2013,
JAMA Pediatrics)
7
Empirically Identified Risk Factors for Early
Maltreatment(Berlin, Appleyard, Dodge, 2011,
Child Development)

Maternal Social Isolation
.14
.19
Maternal History of Abuse
Maltreatment of Offspring by Age 26 Months

• Maternal
• Processing
• of Cues
• Hostile
• Attributions
• Aggressive
• Problem Solving

.15
.23
8
Empirically Identified Risk Factors for Early
Maltreatment(Appleyard, Berlin, Rosanbalm,
Dodge, 2011, Prevention Science)

Maternal Substance Use Problems
.20
Prenatal Mental Health Problems
Maltreatment of Offspring by Age 26 Months
.16
Socioeconomic Status
-.51
9
General Model of Child Maltreatment Behavior

Deviant Parental Processing of
Infant Information -- lack of knowledge --
hostile attributions -- poor problem solving
Maltreatment of Offspring
10
General Model of Child Maltreatment Behavior

Deviant Parental Processing of
Infant Information -- lack of knowledge --
hostile attributions -- poor problem solving
Parental Lack of Connectedness --Social --
Professional
Maltreatment of Offspring
11
General Model of Child Maltreatment Behavior

RISK FACTORS Healthcare 1. parent
healthcare 2. infant healthcare 3. health
insurance Parenting/childcare 4. childcare
plans 5. par-inf relationship 6. manage infant
cry Family safety 7. material supports 8.
family violence 9. parenting difficulties Parent
mental health 10. depression 11. substance
abuse 12. emotional support
Deviant Parental Processing of
Infant Information -- lack of knowledge --
hostile attributions -- poor problem solving
Parental Lack of Connectedness --Social --
Professional
Maltreatment of Offspring
12
General Model of Prevention of Child Maltreatment

Identify families at risk Healthcare 1. parent
healthcare 2. infant healthcare 3. health
insurance Parenting/childcare 4. childcare
plans 5. par-inf relationship 6. manage infant
cry Family safety 7. material supports 8.
family violence 9. parenting difficulties Parent
mental health 10. depression 11. substance
abuse 12. emotional support
Improve parents processing patterns
Connect families to social and
professional resources as needed
Healthy Child
13
Traditional Institute of Medicine Modelof
Intervention Development (Mrazek Haggerty,
1994)

• Basic science inspires intervention
• Intervention is developed in a university setting
  
• under pristine circumstances
• Randomized controlled trial (efficacy) with
  volunteer sample
• Replicate in community setting (effectiveness
  trial)
• Scale up to other communities

14
Reasons Why Scaling Up Small Programs Has Failed

• Rarely intend to have policy impact at the outset
• Selection bias in who participates in university
  study
• Heterogeneity of population
• When scaling up, penetration and retention low
  (35-50)
• Degradation of intervention fidelity and quality
  (scale-up penalty of 50)
• Over-estimate of community capacity to meet needs
• NFP relies on nurse to assert competitive
  advantage for resources

15
Model of Universal Parent Intervention

• 1. Top down policy
• -- Preventive System of Care
• -- Align resources
• -- Screen all families
• 2. Bottom up with families
• -- Assess to identify risks/needs
• -- Improve community connectedness
• -- Teach cognitions

16
Three Steps to Durham Connects

• 1. Connect with family
• Universal recruitment at birthing hospital
• Home visit(s) by public health nurse
• Assess 12 risk factors, quantify risk
• 2. Connect family with community, as needed
• Professional, paraprofessional, and natural
• 3. So that parents can connect with infant
• Improve cognitions, parent-infant relationship

17
Durham Connects

• Piloted for three years before RCT.
• Per-family cost of about 700, delivered
  universally.
• 4-7 intervention contacts with triaging.
• Birthing-hospital visit
• 1-3 home visits between 3-8 weeks of infant age
• 1-2 contacts with a community service provider
• Follow-up one month later
• Community resources aligned to improve capacity
• (e.g., Cribs for Kids, Mentors, bus routes, DSS
  worker)
• Agency MoA to follow a Preventive System of Care.

18
Evaluation Design for Durham Connects

• Randomly assign by even-odd birthdate
• 4,780 births between 7-1-09 and 12-31-10
• Recruit even birthdates into intervention
• No contact with controls
• Analyze by intent-to-treat
• Administrative record review of all births
• Random sample (n686, 80.0 participation) from
  birth records for in-home interview at age 6 mos.

19
Implementation Findings

• Penetration
• 80.0 of families agree
• Of these, 85.9 complete
• Fidelity to protocol
• Independent rater for 11
• 85 compliance by nurse

20
Scoring of Risk
Nurse scores each of 12 risk factors on 4-point
scale 1 indicates no risk 2 indicates minor
risk, resolved by nurse 3 indicates
considerable risk, referral 4 indicates
imminent risk, emergency -- Inter-rater
reliability of scoring of risk Kappa .69 45
of families score at least one 3 49 of
families score 2s but no higher 6 of
families score all 1s 39 of all
families connected to community service
21
Number of Community Connections Reported at Age
6 months (Dodge et al., 2013, Amer J Pub Health)
Effect Size .28, p lt .01
22
Impacts at Age 6 Months(Dodge et al., 2013,
Pediatrics)

• Mother-reported positive parenting behaviors
• -- higher for intervention than control
• (ES .25, p lt .01)
• Blinded observer-rated mother parenting quality
• -- higher for intervention than control
• (ES .23, p lt .05)
• 3. Child care center quality rating (when in
  care)
• -- higher for intervention than control
• (ES .85, p lt . 01)

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Impacts at at Age 6 Months(Dodge et al., 2013,
Pediatrics)

4. Mother-rated father-infant relationship --
better for intervention (ES.21, plt.07) 5.
Observer-rated home safety -- better for
intervention (ES.22, plt.05) 6. Prob of
mother clinical anxiety -- lower for
intervention (OR.65,plt.04)
24
Overall Emergency Health Care ServicesReported
at Age 6 months (Dodge et al., 2013 Pediatrics)
ES .26, p lt .001
Score is sum of of hospital nights plus of
emergency visits
25
Mediation of Intervention Effect on Emergency
Health Care Services(Goodman, Dodge, et al.,
2012)
26
(No Transcript)
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Intervention effect is 59 reduction ?------------
------------------------------------?
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Intervention effect is 59 reduction ?------------
------------------------------------?
Intervention effect is 31 more
reduction ?---------------------------------------
-----------?
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Cumulative Emergency Care at Age 12 Months
(Dodge et al., 2013, Pediatrics)
ES.19
Interaction Effect plt.001
30
Cumulative Emergency Care at Age 12 Months
(Dodge et al., 2013, Pediatrics)
ES.22
31
Cumulative Emergency Care at Age 12 Months
(Dodge et al., 2013, Pediatrics)
ES.36
Interaction Effect plt.01
32
DC Impact at Age 24-Months
33
Benefit-Cost Analysis of Intervention Impact at
Age 12 Months

Durham Connects intervention costs 700/assigned
family Emergency Care Outcome Costs
CONTROL DC 423 per emergency visit x .83
351 x .68 288 3,722 per hospital
night x .74 2,754 x .11 409 (OCC
- OCI) (3,105 - 697) BCR DC
___________ ____________ 3.44
(ICI - ICC) 700 For Durham,
NC 3,187 resident births/year Total emergency
care costs without DC 9,895,635 Durham
Connects would cost 2,230,900 Durham
Connects would yield savings of 7,674,296
34
Financing Early Intervention
Barriers to Medicaid payment - Risk - No
upfront capital Private investor
solution Social Impact Bonds - started in UK -
3 in U.S., more coming - NYC by Bloomberg -
Utah by Goldman/Pritzker - SC by
Goldman/Pritzker 250mil fund by Goldman Sachs
35
Current Plans

• 1. Continue follow-up of RCT
• through age 66 months.
• 2. New RCT now ongoing.
• 3. Disseminate to 4 rural
• NC counties.
• 4. Arrange financing in NC.