SafeCare Maryland Presentation - Dr. Lutzker


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Dr. John R. Lutzker, Director for the Center for Health Development, Associate Dean for Faculty, and Professor of Public Health at GSU, along with Dr. Whitaker, Director of the National SafeCare® Training and Research Center, Professor and Director of the Division of Health Behavior & Promotion in the Institute of Public Health at GSU, were invited to speak at the School of Social Work, University of Maryland. During this annual alumni seminar, Dr. Lutzker and Dr. Whitaker presented the historical and future trajectory of SafeCare, an evidence based program that prevents child abuse and neglect.

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SafeCare Maryland Presentation - Dr. Lutzker

  1. 1. SafeCare®: An Evidence-BasedParenting Program to PreventChild Neglect and AbuseJohn R. Lutzker, PhDDaniel J. Whitaker, PhDNational SafeCare Training and Research CenterCenter for Healthy DevelopmentInstitute of Public HealthGeorgia State University
  2. 2. Presentation OutlineI. SafeCare historyII. Program descriptionIII. SafeCare researchIV. Implementing evidence-based practicesV. SafeCare training and implementationVI. SafeCare implementation researchVII. Future directions
  3. 3. I. History of SafeCare
  4. 4. SafeCare History• Project 12-Ways (1979 -Current)– Illinois– Focuses on multifacetedenvironmental factorscontributing to seriousproblems for families– Up to12 services (e.g.,parent-child training, stressreduction, social support)
  5. 5. SafeCare History• SafeCare (1990s)– Began in Los Angeles CA– Effort to make 12-Ways moredisseminable– Safety, Health, Parenting• 2001– Oklahoma adopts SafeCare• 2007– National SafeCare Training andResearch Center established
  6. 6. National SafeCare Training & ResearchCenter (NSTRC)• Established 2007– Demand for training began to rise– Oklahoma implementations (2001 - 2011)• Housed at the Center for HealthDevelopment at Georgia State University• 100+ sites in 17 states•
  7. 7. Domestic SafeCare SitesAlso,• Belarus• United KingdomStatewideImplementation
  8. 8. International Sites
  9. 9. II. SafeCare ProgramDescription
  10. 10. One family’s experience…
  11. 11. SafeCare Program Description• In-home parent-training curriculum• Behavioral, skill-based model• Targets parents with children ages 0-5• Designed for high-risk families– Focus is on preventing abuse and neglect– Has common elements of many behavioralparent training programs (PCIT, Triple P)
  12. 12. SafeCare Program Description• Teaches parents a broad range of skills• Parenting• Children’s health needs• Home safety• Targets multiple risk factors for abuse andneglect• Positive parent-child/infant interactions• Systematic health decision-making• Supervision and home safety• Focuses on typical daily activities• Highly structured, but flexible in its delivery
  13. 13. SafeCare Program Description• 15 to 18 sessions– 5 to 6 sessions per module (3 modules total)– Typically once per week– Depends on parent’s initial skills and skill acquisition• 1 to 1.5 hour sessions– Scheduled when assessment/training most applicable(e.g., nap time, bath time)• Services provided in-home– Family’s natural environment– Utilize natural opportunities to train• SafeCare relies on behavioral principles– Reinforcement, modeling, shaping, skill practice, masteryperformance criteria
  14. 14. SafeCare Curriculum OverviewNote: Providers learn all 4 modules; parents receive 3modules [Health, Safety and one parenting (PCI or PII)]
  15. 15. Communication and Problem Solving• Global skill sets• Communication skills– HV interaction skills– Used regardless of session– Foundation of rapport• Problem-solving– Structured approach to family crises– Used as needed
  16. 16. SafeCare Module OverviewSession 1AssessmentSessions 2-5TrainingSession 6Re-assessment
  17. 17. Parent Training Process: SafeCare 4Parent training process includes:• Explain: Explain the skills to the parent• Model: Show the parent what the skillslook like• Practice: Parent practices the skills• Feedback: Give positive and correctivefeedback. Continue until mastery
  18. 18. SafeCare ModuleParent-Child Interaction (PCI)~1 to 5 years old
  19. 19. Parent-Child Interaction (PCI) Module• For toddlers and older• For use in play and daily activities• Goals– Increase positive interactions– Engage children• Good interaction skills• Incidental teaching– Prevent challenging child behavior• Use planned activities training• Decrease child boredom
  20. 20. PCI Module Overview• Baseline Assessment (Session 1)– Daily Activities Checklist– Observe parent/child in play and 2 dailyactivities• Training (Session 2-5)– Child Planned Activities Training—cPAT– Independent Play• End-of-Module Assessment (Session 6)– Re-observe three activities
  21. 21. Child Planned Activities Training (cPAT)BEFOREPrepare in advanceExplain the activityExplain the rules andconsequencesDURINGTalk about what you aredoing; incidental teachingUse good physical interactionskillsGive choicesPraise desired behaviorIgnore minor misbehaviorProvide consequencesENDWrap up and providefeedback
  22. 22. PCI Activity CardsMaterials:A variety of unbreakable cups, containers, and bowls.A variety of household items, such as small toys, socks,balls, ribbon or cloth, pencils or crayons, paper, books, andsmall food items such as crackers, grapes, fruit, and bread.You can choose any items that you have around the house.Suggestions:Place the cups, containers, and bowls in front of you.Hold up one container and one household item, and ask,"Will it fit?"Match some containers to items that will fit inside thatcontainer, and match some containers to items that will notfit inside. Your child will then tell you, "Yes, it will fit" or"No, it wont fit".If your child does not know, just show how the items fit ordont fit into the containers.Give your child a turn to ask you whether items will fit ornot. Give some correct answers, and some wrong answers,and see if your child catches you.Materials:A small hand mirror, or a mirror on the wallSuggestions:Make a face into the mirror.Pretend that your face is a mask, and using your hands,pretend to take your mask off and put it on the child.Ask your child to make that same face.The faces you make should show some kind of feeling,such as:Happy Afraid HotSad Lonely ColdAngry Worried SurprisedMiserable Bored SleepyYou can also name one of these feelings, and then makethe face that matches these feelings.Or, you might make a face, and then the other personshould guess what feeling you are showing.
  23. 23. PCI Skills: Play (together andindependent)Before• Prepare in advance• Explain the activity• Explain the rules and consequences• Select short time period for activity*During• Interrupt the activity to praise the child*• Ignore minor misbehavior• Handle disruptions*• Provide consequencesEnd• Wrap up and provide feedback• Spend individual time**Denote items specific to Independent Play
  24. 24. The hazards of not properly supervising while children playindependently!
  25. 25. SafeCare PCI video
  26. 26. SafeCare ModuleParent-Infant Interaction (PII)Birth to ~1 year old
  27. 27. Parent-Infant Interaction (PII) Module• For newborns to about 1 year old• Goals– Promote positive interactions– Increase parental vocalization to infant– Promote age appropriate and stimulatingactivities– Promote bonding and attachment
  28. 28. PII versus PCI• PII and PCI have different foci• PII’s main focus is on specific interactionbehaviors (verbal and physical behaviors)– cPAT steps are taught later in the module tohelp the parent prepare for child’s futuredevelopment• PCI focuses on Child Planned ActivitiesTraining (cPAT) as main priority– Independent play also discussed
  29. 29. PII Module Overview• Baseline Assessment (Session 1)– Observe play and 2 daily activities• Training (Session 2-5)– LoTTS of Bonding Behaviors• Look, Touch, Talk, Smile– Other Bonding Behaviors• Holding, Rocking, Imitating• End-of-Module Assessment (Session 6)– Reassess activities
  30. 30. PII Skills: Bonding SkillsLoTTS of BondingBehaviorsOther BondingBehaviorsLooking HoldingTalking ImitatingTouching RockingSmiling
  31. 31. Materials:SoapWashclothTowelShampooClothes for after bathToys for bathtubSuggestions:Play peek-a-boo with his clothing while undressing anddressing.Trickle water from your hand or a cup onto your babystummy.Talk about washing and drying each body part.Imitate your babys sounds during play.Sing bathtub songs ("Row, Row, Row your boat" or"Rubber Duckie")Smile and make eye contact with your baby.Give your baby a gentle massage on his arms, legs, andback with soapy water during the bath, or lotion orpowder after the bath.Sit with your child on your lap facing youHold your childs hands in your ownAsk questions such as, "Where is your nose?" or"Where is Mommys mouth?"Guide your babys hands with yours and help himpoint to each body part while you name it. For olderchildren, have them point by themselves.After pointing to and naming each part, say "Thatsright, thats your ____!" Offer other praise andencouragement.Make silly jokes. Point to your stomach and say, "Isthis my nose?"Smile and make eye contact with your child
  32. 32. Home Safety Module• Rationale– Unintentional injuries are the leading cause ofinjury/death in young children– Also a leading cause of neglect reports– Children are naturally curious and have poor impulsecontrol– Safe environmental and parental supervision isneeded• Goals– Remove hazards in the home environment– Remove filth/clutter– Promote parental supervision
  33. 33. Safety Module• Help parents to:– Understand the importance of a safe home– Know the types of hazards in homes– Know ways to remove household hazards– Understand the importance of supervisionReduceHazardsSuper-visionFewerchildinjuries
  34. 34. Safety Module Overview• Baseline Assessment (Session 1)– Assess hazards in 3 rooms• Training (Session 2-5)– Teach parents about common hazards– Remove and secure hazards in each room– Encourage parental supervision• End-of-Module Assessment (Session 6)– Reassess 3 rooms
  35. 35. Safety Hazard Categories1)Poisons2)Choke3)Suffocation4)Drowning5)Fire/Electrical6) Fall/Activity Restriction7) Sharp Object8) Firearm9) Crush10) Organic/Allergen
  36. 36. Example of Household Hazards
  37. 37. Identifying What’s Accessible• A hazard is accessible if it is:– Within arms reach as child stands on floor– Within arms reach as child stands or climbs onadjacent objects– In an open or unlocked container or space– Is not secured by a childproof cap, latch, or lock
  38. 38. Removal of Hazards• Hazards may be made inaccessible by oneof three methods:– Using childproof latches– Using locks– Placing items out of reach• Filth/clutter may be improved by:– Reducing items not belonging– Reducing unclean areas
  39. 39. SafeCare Safety
  40. 40. SafeCare ModuleHealth
  41. 41. Health Module• Goals– Teach parents to recognize and assess whenchildren are sick or injured– Learn how to care for sick/injured children athome vs. call the doctor vs. go to ER.– Learn how to use SafeCare Health Manual– Learn to keep good health care records
  42. 42. Health Module• Baseline Assessment (Session 1)– 3 scenario role-plays• Emergency, doctor’s appointment, care at home– Introduce health manual• Training (Session 2-5)– Systematic decision making process– Use health reference materials– Keep good health records– Understand prevention efforts• End-of-Module Assessment (Session 6)– 3 scenarios types
  43. 43. Sample Role-Play Scenario CardSCENARIO 1Your baby has been cranky and whiny for a couple of days. Last night,your baby woke up coughing. Your baby’s nose has been running andyou notice he/she has been sneezing all day today.
  44. 44. SafeCare Health Manual• Important Health Information Charts• Caring for Your Child at Home• Calling the Nurse/Doctor• Emergency Situations• Planning and Prevention• The A to Z Symptom Guide
  45. 45. SafeCare health session…
  46. 46. III. SafeCare Research
  47. 47. Designs/questions for the real world• Sequential research efforts– Single-case, quasi-experimental, randomized,implementation studies• No lab-based studies• Research to date answers four critical questions:– Do parenting skills improve after parents receiveSafeCare?– Does SafeCare prevent future cases of childmaltreatment?– How do families respond to SafeCare, including familieswith diverse backgrounds?– How do providers respond to SafeCare?
  48. 48. Does SafeCare result in positivechanges in parents skills?Answer: YES
  49. 49. Home SafetyParent-ChildInteraction
  50. 50. Single case studies on SC modulesSafety• Tertinger, D.A., Greene, B.F. & Lutzker, J.R. (1984). Home safety: Development and validation of one component of anecobehavioral treatment program for abused and neglected children. Journal of Applied Behavior Analysis, 17, 159-174.• Barone, V.J., Greene, B.F., & Lutzker, J.R. (1986). Home safety with families being treated for child abuse and neglect.Behavior Modification, 10, 93-114.• Mandel, U., Bigelow, K. M., & Lutzker, J. R. (1998). Using video to reduce home safety hazards with parents reported for childabuse and neglect. Journal of Family Violence, 13(2), 147-161.• Metchikian, K.L., Mink, J.M., Bigelow, K.M., Lutzker, J.R., & Doctor, R.M. (1999). Reducing home safety hazards in the homesof parents reported for neglect. Child and Family Behavior Therapy, 3, 23-34.Health• Delgado, L.E. & Lutzker, J.R. (1988). Training young parents to identify and report their childrens illnesses. Journal of AppliedBehavior Analysis, 21, 311-319.• Watson-Perczel, M., Lutzker, J. R., Green, B. F., & McGimpsey, B. J. (1988). Assessment and modification of home cleanlinessamong families adjudicated for child neglect. Behavioral Modification, 12(1), 57-81.• Bigelow, K. M., & Lutzker, J. R. (2000). Training parents reported for or at risk for child abuse and neglect to identify and treattheir children’s illnesses. Journal of Family Violence, 15(4), 311-330.Parent-Child Interactions• Lutzker, J.R., Megson, D.A., Webb, M.E., & Dachman, R.S. (1985). Validating and training adult-child interaction skills toprofessionals and to parents indicated for child abuse and neglect. Journal of Child and Adolescent Psychotherapy, 2, 91-104.• McGimsey, J. F., Lutzker, J. R., & Greene, B. F. (1994). Validating and teaching affective adult-child interaction skills. BehaviorModification, 18(2), 198-213.• Bigelow, K. M., & Lutzker, J. R. (1998). Using video to teach planned activities to parents reported for child abuse. Child & Family BehaviorTherapy, 20(4), 1-14.
  51. 51. Does SafeCare prevent childmaltreatment for families whoparticipate in the program?Answer: YES
  52. 52. SafeCare CA evaluation• 82 families• CPS reports over 3years:– SafeCare: 15%– Family Preservation:44%• What does this mean?– 68% reduction in futurereports to CPS forfamilies who completedSafeCareGershater-Molko. R.M., Lutzker, J.R., & Wesch, D. (2002). Using recidivism data to evaluate ProjectSafeCare: Teaching bonding, safety, and health care skills to parents. Child Maltreatment, 7, 277-285.
  53. 53. Oklahoma Statewide trial• Began in 2001• 6 service regions in OK assigned to SC or SAU• Providers receive SC training or do SAU– Also coaching assigned to teams or not• Primary Outcome: CPS referrals
  54. 54. OK Statewide trial: DesignSAU, MonitoredSafeCare,MonitoredSAU, NotMonitoredSafeCare, NotMonitoredSAU SafeCareYesNoMonitoringor coaching
  55. 55. OK trial: Sample• N = 2175• 91% women• 67% white, 16% American Indian, 9%African American• Mean of 2.8 children• 82% below poverty line• 4.7 prior CPS reports
  56. 56. OK Statewide SC trial: results} SafeCare} SAURecidivism• SafeCare decreased re-reports by 26% for families with children 0-5• With a re-report rate of 45% annually, SC prevented 64-104 reports
  57. 57. Does SafeCare work with DiverseFamilies?Answer: YES
  58. 58. OK American Indian Study• A subpopulation of 354 American Indian parents• Outcomes included:– Recidivism reduction among SafeCare parents was found to beequivalent with full sample for cases– Significant reductions in Parental Depression– Higher consumer ratings of• cultural competency• working alliance• service quality• service benefit• Findings support using SafeCare with American Indians• Manualized, structured, evidence-based model can be effective andculturally acceptable for American Indians.
  59. 59. SafeCare Enrollment and Completion• Families assigned toSafeCare were much morelikely to enroll in services(80% vs. 49%) andcomplete those services(49% vs. 21%).0%10%20%30%40%50%60%70%80%90%Enrollment CompletionSafeCare SAUDamashek, A., Doughty, D., Ware, L., & Silovsky, J. (2011). Predictors of Client Engagement andAttrition in Home-Based Child Maltreatment Prevention Services. Child Maltreatment, 16(1), 9-20.
  60. 60. SafeCare return on investmentFrom the Washington State Institute of Public Policy, April2012
  61. 61. SafeCare Research Summary• Compared to other services, SafeCare– Improves parenting skills– Reduces child maltreatment reports– Is acceptable to parents with high levels of satisfaction– Applicable across culturally groups– Very high return on investment– Is well-liked by providers who are trained to do it
  62. 62. IV. Implementing evidencebased practices (EBP)
  63. 63. What is Implementation?• From Fixsen et al “A specifiedset of activities designed toput an activity or program ofknown dimensions intopractice– “set of activities”– “program of knowndimension”• The “to” in “research topractice”
  64. 64. Why is implementation important?• “Children cannot benefit from an interventionthey don’t experience” (Karen Blasé, 2009)• Implementation relates to outcomes– Durlak & DuPre (2008) review of 500+ studies– greater implementation = better outcomes• Program effect sizes tend to diminish withdissemination– Example: MST effect sizes drop from large (d = .81) tosmall (d = .26) as the program disseminated– Implementation is a way to try to ensure outcomes
  65. 65. The typical implementation…
  66. 66. A rigorous implementation…• Readiness (multi-level)• Workshop training• Support/coach/TA• Ongoing data collection• Program evaluation• Management of adaptations
  67. 67. Implementation stagesFrom Fixsen et al, 20051. Exploration/adoption – thinking about adopting a newprogram2. Program installation – choose/hire staff; initial training;contracts in place3. Initial implementation – staff begin the practice; needslots of TA and coaching4. Full operation – new practice is fully integrated5. Innovation – experimentation; avoid drift6. Sustainability – sustaining the practice; funding iscritical; staff turnover; new training needed
  68. 68. Workshop + in-field coaching significantly increases use of newskillsKnowledgeAble to performskillUse inClassroomDiscussion inworkshop10% 5% 0Demonstration inworkshop30% 20% 0%Practice inworkshop60% 60% 5%Live coaching 95% 95% 95%
  69. 69. What affects implementation?
  70. 70. V. SafeCare Implementationand Training
  71. 71. SC implementation process
  72. 72. SafeCare readiness process• We’re still learning…• Who is the organization pursuing training?– Public or private?• Meetings & calls, send information, application for training– Is SafeCare appropriate for your population?– Organization commitment (top & bottom)?– Have staff been selected?– Have staff been briefed, and what do they think?– Who are your referral sources? Have they been briefed?– What is the payment structure for SafeCare delivery?– Can you comply with implementation model?• Develop a training plan• Site visit and orientation
  73. 73. SafeCare Training: 3 levels• Home visitor– Provides SafeCare to families• Coach– Provides ongoing fidelitymonitoring and support to HV– Coaching is required– Coaches must complete HVcertification• Trainer– Trains new HV and coacheswithin their organization– Support coaches– Trainers must complete HV andCoach certifications firstHVCoachTrainer
  74. 74. Why coaching?• Coaching = Fidelity monitoring + feedback• Coaching is needed for implementation withfidelity• Without coaching, providers ‘drift’• Coaches are meant to become the localexperts on SafeCare
  75. 75. Initial training and implementationHome visitor training• Allows staff to deliver SafeCare to families• 4 day workshop + in-field skill demonstration• Home visitors always receive “coaching”Coach training• Allows staff to provides ongoing coaching to HV, arequirement for implementation• Coach trainees must first complete HV Training• Coach training: 1-day workshop + in-field skill demonstration• All SafeCare implementation is coached
  76. 76. Initial ImplementationNSTRC faculty andtraining staffInitial workshopTrainingOngoing coach support andmonitoring for 1 yearCoachHVOngoingCoachingHVHVImplementation team
  77. 77. Sustaining SafeCareTrainer training• SafeCare Trainer training allows sites totrain new home visitors and coacheswithin their organization• Trainer candidates must have completedHV and Coach training• Three day workshop + observation of firsttraining• Recertification every 2 years.
  78. 78. Sustaining SafeCareNSTRCSafeCareTrainerHVWorkshopTrainingOngoingCoachingOngoingsupportHVHVImplementation teamCoach
  79. 79. Implementation challenges• Too few referrals• Inappropriate referrals– Public system challenges• Innovating but not “exnovating”• Poor fit between SC and service system• System funding issues• Staff have too little time for work• Staff unprepared for roles (coach, trainer)
  80. 80. Implementation lessons learned• Start slow and pilot• Prepare, prepare, prepare• Understand what staff, organizations, andsystems are already doing• Don’t disseminate expertise too quickly• Focus more on funds for service deliverythan funds for training• Ensure public systems are on board
  81. 81. VI. SafeCare ImplementationResearch
  82. 82. SC Implementation researchAbout implementation research• Different than outcomes research– Different outcomes– N’s, power, nesting– Few standardized measures– Few empirically supported theoretical models• Similarities to outcomes research– All the basics apply
  83. 83. RCT of Trainer training• CDC funded, translation grants• What level of support is needed by externaltrainers to produce high quality HVs & coaches?• Randomized trial– Compare trainers with ‘usual’ support versus‘enhanced’ support• Outcomes– Trainer performance– Coach performance– HV performance– Family uptake
  84. 84. RCT of coaching disseminationHV HVHVNSTRC (coach)CoachHV HVHVNSTRCPurveyor Local
  85. 85. Managing adaptations• Dynamic Adaptation Process (Aarons, PI)– Adaptation team helps manage adaptation ina planful way– Team is researchers, purveyors, provider– Identify adaptable elements of theintervention• Randomized trial– DAP vs. usual ‘ad-hoc’ adaptation– 6 CA counties in CA; ~ 72 providers; 720families
  86. 86. VII. SafeCare: The future1. Content development2. Training innovations3. Utilization of SafeCare– Service systems– With other interventions programs
  87. 87. Content development• SafeCare is “modularized”– Pieces can be separated– New pieces can be added• Several, skill-based modules could beadded to address additional problems• Center grant under review• Return to Project 12-Ways?
  88. 88. Addressing Child problem behaviors• Deb Hecht, NIH funded• Goal: to help parents address problem behaviors,especially among older children• Why address problem behaviors?• Techniques– Functional analysis– Ignoring minor misbehavior– Praising appropriate behavior– Use of time out• Developed and pilot-tested 2008-10– Intervention significantly decreased ECBI scores• Additional funding being sought for larger trial
  89. 89. Violence• Jane Silovksy, ACF funded• Why address violence?• Focus is on healthy relationships– Intimates and others (relatives, friends, co-workers)– Based on PREP and 4th R• Skill development in several areas– Relationship choices/decisions– Assertive communication– Couple problem solving– Effective arguing• Intervention is not for “Intimate terrorism”• Trial is underway
  90. 90. 2. Implementation innovations• SafeCare hybrid training• Can a web-based training course reduce workshop trainingtime and cost?
  91. 91. Computer-enhanced SC delivery• R21 (Self-Brown, PI) to develop system to employcomputers to assist providers with EBP delivery• Computers will:– deliver interactive EBP assessments, content, andvideo to clients– guide for the provider-led portions of the sessionbased on client data.• R21 will allow for development, and feasibilitytrial– Mini-RCT– Primary Outcome- Implementation Success
  92. 92. Remote real time coaching• Using tablets/smart phones for remote real timecoaching• Coaching can synchronous vs. ‘asynchronous ’• Better confidentiality – no recording
  93. 93. Data decision support tools• Expand portal to allow real time clientdata entry via smartphones/tablets• Will allow provider and clients tovisualize behavior change– Graphing function• Referral sources can be pushed• Sites can generate site level reports• NSTRC and sites can generate programevaluation reports– Is SC more effective with different type offamilies?– Are some providers more effective thanothers– Are there site differences?
  94. 94. 3. SafeCare utilization and impacts• In what service systems is SafeCare mosteffective?– Within child welfare– Outside of child welfare• What adaptations are needed?• What other practices are needed?• Can practices be successfully blended?
  95. 95. Blending SafeCare and PAT• The PATSCH study (GA and NC)– Braided curriculum delivered to highest risk familiesenrolled in PAT– Why SafeCare and PAT make sense together– Randomized trial with 2 year follow up– Some adaptations made on both PAT and SafeCare
  96. 96. International dissemination• Lots of variation in capacity– Resource poor countries may lack capacity toimplement SC– Is there a more “basic” training that could beoffered that would still benefit families• Variation in service systems– Health care system• Language issue– How does translation and language barriersaffect dissemination?
  97. 97. QUESTIONS?
  98. 98. ContactsJohn R. Lutzker, PhDJlutzker@gsu.edu404-413-1284Daniel Whitaker,