The Lifelong Impacts of Childhood Trauma

Report
How does child maltreatment
prevention work?
An informed perspective for practitioners and providers
Jennie G. Noll, PhD
Professor, Human Development and Family Studies
Director of Research & Education, Network on Child Protection & Well-being,
The Pennsylvania State University
Stephanie Bradley, PhD
Managing Director, Evidence-based Prevention and Intervention Support Center
(EPISCenter), The Prevention Research Center, The Pennsylvania State University
What is child maltreatment prevention?
Primary – prevent maltreatment BEFORE it happens
Secondary – prevent another problem that stems
from child maltreatment (Intervention)
Targeted – prevent child maltreatment from
occurring in an at-risk group
Embedded – prevent other public health problems
by embedding primary prevention programs
within child welfare
Primary Prevention Efforts
Public awareness campaigns
designed to educate entire populations
public service announcements
TV, radio, billboards, mass distribution of
brochures or other educational material
working with professional groups to change
the way they think about and react to
opportunities for prevention
Primary Prevention Efforts
Family home visiting programs
bringing a well-planned intervention to families
who need it
emphasize outreach
families who might be unwilling or unable to
participate in more formally organized services
combination of educational, supportive, or
empowering goals
Primary Prevention Efforts
Nurse Family Partnership (Olds et al, 2007)
First-time disadvantaged mothers received home
visits by nurses
Begins prenatally and extends until child’s 2nd birthday
Nurses promoted 3 aspects of maternal functioning:
–health-related behaviors
–maternal life course development
–parental care of children
Primary Prevention Efforts
Parent education programs
organized in an “academic” way, with planned
“lessons” delivered to individuals or small groups
Specific educational goals (e.g.,):
-pregnancy and delivery
-child growth and development
-parenting skills
-knowledge of add’l resources
Primary Prevention Efforts
Child education programs
attempt to make children less vulnerable targets
for abuse
Primarily focused on sexual abuse prevention
School-based or Physician-based
Teach children self-protective skills
“Good touch, bad touch”
Primary Prevention Efforts
Physician administered
Educates parents in pediatric or prenatal practice
“I will not shake my baby” contracts
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Home visitation (mixed results; Bell 2012 meta analysis)
Nurse Family Partnership (NFP) (best)
Early Start (New Zealand) (promising)
Parent training programs
Triple P Positive Parenting Program (promising)
Physician administered
Abusive head trauma education programs (promising)
Enhanced pediatric care (promising)
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Nurse Family Partnership (Olds et al, 2007)
Reduced child physical abuse and neglect as
measured by official child protection reports
Reduced associated outcomes such as injuries in
children
Nurse home visitation did not prevent recurrence of
physical abuse or neglect (RCT) (MacMillan et al., 2005)
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Early Start (Fergusson et al., 2005, 2013)
Reduced associated outcomes
injuries and hospital admissions for child
abuse and neglect
Rates of child protection reports did not differ
between the intervention and control groups
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Paraprofessional home visitation
e.g., Hawaii Healthy Start Program
Healthy Families America
Have not been shown effective in reducing
child protection reports
Primary Prevention Efforts
Home visiting programs are not uniformly
effective in reducing child physical abuse and
neglect (Rubin, 2013)
Any home visiting program should not be
assumed to reduce child abuse and neglect
Every Child Succeeds (Ammerman, et al., 2013)
Home-visiting maternal depression prevention
program showed reduced effectiveness for
mothers who were sexually abused as children
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Triple P – Positive Parenting Program
Population-level group-based supports for families
use of media/information strategies
consultations with parents
seminars
active skills training
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Triple P – Positive Parenting Program
Positive effects on substantiated child protection
services reports, out-of-home placements, and
reports of injuries
Analysis is not clear and concerns about methods
(Wilson et al., 2012)
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Physician Administered
Abusive head trauma education
Positive effects from one study suggest that
hospital-based educational programs can
reduce abusive head injuries (shaken impact
syndrome) (Dias et al., 2005)
Primary Prevention Efforts
Effective for Physical Abuse and Neglect?
Physician Administered
Enhanced pediatric care program for families at risk
“Safe Environment for Every Kid” (SEEK)
(Dubowitz et al., 2009, 2012)
Training physicians to identify family problems
social worker is available
Promising effects in enhancing physicians’ abilities
decrease risk factors and physical abuse rates
Primary Prevention Efforts
Effective for Sexual abuse?
Unknown if educational programs reduce
occurrence of child sexual abuse
Some evidence that they improve children’s
knowledge and protective behaviors
Could have some adverse effects
(Zwi et al., 2007)
Primary Prevention Efforts
Emotional abuse?
Attachment-based interventions designed to
improve insensitive parenting and infant
attachment insecurity
No direct evidence that these interventions
prevent emotional abuse (BakersmanKranenburg et al., 2003)
Secondary Prevention Efforts
For Parents in the Child Welfare System
SafeCare (Chaffin et al., 2012)
home-based, structured behavioral skills focused
on caregiving, parenting, household
management
SafeCare reduced recidivism compared with
usual home-based services
Intervention / Treatment
Recurrence of physical abuse and neglect
Parent-child interaction therapy (PCIT)
behavioral approach to skills training
PCIT reduced recurrence of child protection
services reports of physical abuse but not
neglect (Chaffin et al., 2004)
Intervention / Treatment
Impairment following sexual abuse
Trauma-focused cognitive-behavioral therapy
(TF-CBT) (Cohen et al., 2004)
cognitive reframing
positive imagery
parent management training
problem solving
Reduced internalizing and externalizing
symptoms among children with PTSD symptoms
Intervention / Treatment
Out-of-home care
Placement in foster care and not reunifying with
biological parents can lead to benefits for maltreated
children
Enhanced foster care can lead to better mental health
outcomes for children than traditional foster care
Conflicting evidence about kinship care compared with
traditional foster care
Thinking about “Imbedded Prevention”
within the child welfare system?
Abused children are at high risk for a host of
conditions of grave public health concern:
-teen pregnancy (Noll & Shenk, 2013)
-obesity (Noll, et al, 2007)
-substance use (Fergusson, 2010)
-high-school drop out (Noll, et al, 2010)
Children already in the child welfare system
are prime targets for primary prevention of
these problems
Next Steps for Sexual Abuse
Sexual abuse prevention needs more attention:
-understanding perpetrator
-community awareness
-increased resources for increased awareness
-training professionals to spot outward signs
Sexual-specific modules added to:
-SafeCare
-Adult treatments shown to be less effective
for sexual abuse survivors
Neurocognitive mechanisms for
Alcohol and Substance Abuse
Outcomes:
Alcohol, tobacco
substance use
Maltreatment
HPA axis
dysregulation
Brain
maldevelopment
High-risk Social/
Emotional
functioning
Neurocognitive
impairment
Psychological Mechanisms for Alcohol and
Substance Use
PTSD
Reexperiencing
symptoms
Avoidant
symptoms
Alcohol and
Substance Abuse
Trauma
Numbing
symptoms
Arousal
symptoms
Specifics for substance use
treatment
Trauma-focused therapies not as effective for SUD
patients
SUD treatments not as effective for trauma victims
Other examples????
Break Out Session
•
•
•
•
how does child maltreatment or child
trauma affect your efforts?
in what ways has maltreatment or trauma
been apparent in youth you serve?
what resources to address maltreatment or
trauma do you have access to?
what types of trauma-informed care are
you/your organization using?
Brain Storming
Resources
Training for TF-CBT
http://tfcbt.musc.edu/
https://www.childwelfare.gov/preventing/
SafeCare
http://safecare.publichealth.gsu.edu/
Next Steps:
Data integration to implore public
health investment
Distribution of Total Medicaid Beneficiaries and
Spending
10%
63%
90%
37%
Ferris, et al., 2010
Under ACA
70% of children in
protective services are
Medicaid eligible
The Power of Linked-data to show that children
in protective services should be targeted for a
host of public health problems
Putnam-Hornstein, 2013
Death From Unintentional Injury
Putnam-Hornstein, 2013
Death From Intentional Injury
Putnam-Hornstein, 2013
Integrated data systems to identify
high-risk kids for coordinated care
Program A
Program B
Criminal Justice:
1. Self
2. Parent
2
Census Data:
1. high risk zip code
2. crime stats
3. poor schools
4. few parks
5. other
Electronic Med
Records:
1. Hospitalizations
2. ER visits
3. Vitals / Dx
-T1D
-BMI 95th%
4. STI
CPS:
sexual abuse
physical abuse
neglect
1
Program C
3
4
5
Public Schools:
1. missed days
2. poor grades/test scores
3. dropouts
4. truancy
5. other
6
7
8
Partnerships for Prevention
Penn State University
Social Science Research Institute
College of Health & Human Development
Prevention Research Center (PRC)
EPISCenter
The Network on Child Protection and
Well-Being
Foundational Center
Affiliate Center
Evidence-based Prevention and Intervention Support
Center (EPISCenter)
Multi-Agency Steering Committee
(Justice, Welfare, Education, Health)
Intermediary and State-level Prevention Support System
Support to
Community Prevention
Coalitions
Support to
Evidence-based
Prevention & Intervention Programs
Improve Quality of
Local Innovative Programs and
Practices
The EPISCenter is a project of the Prevention Research Center, College of Health and Human Development, Penn State University,
and is funded by the Pennsylvania Commission on Crime and Delinquency and the Pennsylvania Department of Public Welfare.
Evidence-based Prevention and Intervention Support
Center (EPISCenter)
public health model:
- use data
- to identify and prioritize risk & protective factors
- to select and implement evidence-based programs
- sustain and evaluate programs
- achieve public health impact
Evidence-based Prevention and Intervention Support
Center (EPISCenter)
objectives:
- connecting policymakers, researchers,
program developers, and communities
- promoting use of the public health model
- achieving public health impact in
reducing youth violence, delinquency,
substance use
Evidence-based Prevention and Intervention Support
Center (EPISCenter)
Key objectives:
- connecting policymakers, researchers,
program developers, and communities
- achieving public health impact in
reducing youth violence, delinquency,
substance use
The EPISCenter is a project of the Prevention Research Center, College of Health and Human Development, Penn State University,
and is funded by the Pennsylvania Commission on Crime and Delinquency and the Pennsylvania Department of Public Welfare.
Data Collaborations
integrating systems data (proposition*):
PA Commission Crime & Delinquency (planning agency)
Dept. of Public Welfare (OCYF, OMHSAS, BJJS)
Juvenile Court Judges Commission
- how much “overlap” in youth served by each system?
- if we prevent trauma, do we prevent juv. justice
involvement?
research in progress:
Bumbarger & Frank – investigating adult criminal justice
population and preventable issues in adolescence
Integrated data systems to identify
high-risk kids for coordinated care
Program A
Program B
Criminal Justice:
1. Self
2. Parent
2
Census Data:
1. high risk zip code
2. crime stats
3. poor schools
4. few parks
5. other
Electronic Med
Records:
1. Hospitalizations
2. ER visits
3. Vitals / Dx
-T1D
-BMI 95th%
4. STI
CPS:
sexual abuse
physical abuse
neglect
1
Program C
3
4
5
Public Schools:
1. missed days
2. poor grades/test scores
3. dropouts
4. truancy
5. other
6
7
8

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