RCTs on Partnerships to Engage Parents in Low-Income Communities to Reduce Child Neglect

1. RCTs on Partnerships to EngageParents in Low-Income Communities to Reduce Child Neglect Data and More Data: Exploring RCT Methodology Marh 27, 2013 University of Stirling, Scotland LYNN MCDONALD, MSW, PHD PROFESSOR OF SOCIAL WORK RESEARCH MIDDLESEX UNIVERSITY, LONDON

2. An Evidenced Based Parenting Programme by a Social Work Academic Specify a social problem; look for basic research and relevant theories from social sciences; create social interventions which can move Theories into practice and apply social research with vulnerable populations; consider multi-family groups; conduct qualitative research and feedback loops from service users and practitioners; test promising social work approaches with randomized controlled trials in distinct disadvantaged communities. Build quality assurance structures for replication and assess continuously with service user feedback.

3. A Social Problem: Child Neglect • Half of safeguarding referrals are for neglect • Stressed and isolated families have higher risk of both abusing and neglecting a child • Child neglect causes impaired learning, poor health, increased aggression and teenage pregnancy (5x higher than no neglect) • Children in poverty at more risk of neglect: • If family lives <$15,000 versus >$30,000, 44 times more likely the child is neglected

4. ACE Correlates with Adult Health • ACE (Adverse Child Events) retrospective data from 3353 women (aged 47) on reports of child neglect & abuse • Correlated with increased health problems as adults • Substance abuse, depression, suicide, eating disorders, anxiety • Physical health: cardiovascular, cancer, stroke, hypertension • Medical service utilization high for adults with ACE • Emergency rooms, outpatient hospital, pharmacy, primary care, specialty care

5. Risk and Protective Factors of Child Neglect • Protective factors: • For Child: quality of parent-child bond • For Child: one caring relationship over time to turn to when stressed • For Parent: social network of support; social capital; extended family • For Parent: feeling self-efficacious; empowered voice and agency • Risk factors • Child neglect: no provision of shelter, food, and emotional bonds • Family has chronic stress, conflict, violence, substance abuse, depression, mental health problems • Family is socially isolated from extended family, friends, neighbors • Family experiences social exclusion, racism, health disparities • Parents are oppressed, no control over own life, no respect, no voice • Poverty, lack of housing, employment, education, health services

6. High Stress Effects a Child’s Development • Stress changes the brain and alters chemical neurotransmitters related to violence • Stress changes gene expression of child • Neglect/abuse correlates with high sustained stress (cortisol) = damaging to child’s brain • High stress causes low immune systems and children get sick more often and heal slowly • High stress puts child into survival mode, and stressed children cannot learn new things: academics, mathematic, reading or writing

7. Caring Relationships Can Buffer the Impact of High Stress on a Child’s Development • Sustained high stress (cortisol) levels are destructive to a child’s brain development and other organs • 15 minutes of one to one responsive play reduces stress • High stress levels can be managed with a responsive parent who shows their love and • Notices child’s emotions and is tuned in to the child • Is available to the child under stress • Asks questions and listens • Is physically soothing and touches the child • Plays responsively with no bossing, and follows the child’s lead (Sue Gerhardt, 2002,Why Love Matters)

8. High Stress Diverts Parental Focus on Child • Cannot focus on child’s needs; not emotionally intellectually • Not enough time, no time for seeing friends/family for support • Use of computers, mobile phones, TV divert focus from child • Work and transport to work; employment insecurity, food insecurity, residential instability, chronic stresses of poverty • Fear of inadequate medical and dental care, support services • Trapped in a dangerous neighbourhood • Trapped in a dangerous relationship • Daily experience of stigma and social exclusion, racism • Feelings of helplessness, hopelessness, low sense of agency • Low hope and mood, low patience, irritability, distracted, anxious

9. Court ordered Daily In Home Visits (3 mo) • To try to reduce placement of 0-5 child abuse and neglect cases into foster care: daily visits for three months to the home and 2x weekly intensive family therapy sessions: reduced 55% with Safe at Home • Daily coaching of one to one responsive play by a trained assistant; • first listen to the parent for 15 minutes; • then coach the parent for 15 minutes • Dramatic increase in child well-being; often a distressed parent swings from neglect to abuse

10. Court Ordered Parenting Classes, Groups • In US, 1 million reports of child neglect and abuse annually; 2/3 are substantiated • 448,000 parents ordered to attend parenting classes • Parenting problems of caregivers are 1 in 12 about excessive discipline; neglect is over 50% of cases • Parenting programmes generally over-focus on control alternatives to reduce excessive discipline • Agencies prefer brief, low cost groups, linear ideas • Most programmes are untested with little evidence

11. Parenting Skills vs Stress of Social Isolation • A classic study was conducted on court ordered behavior modification parenting groups referred by the child protection workers for child abuse/neglect • Prof Robert Wahler taught behavior modification techniques with success in parenting knowledge • Six months later he assessed their use of new skills • If they had no friends or positive extended family social support, i.e. socially isolated, they did not use the parenting skills they had learned (insular parent)

12. Social capital and Stress and Child Neglect • Chronic stress and social isolation increase child neglect: stresses of poverty, social exclusion reduce parents’ ability to be responsive and parent positively • Social capital reduces stress • Social ties and inclusion buffer stress and enhances adults’ coping mechanisms leading to better mental health, less irritability & anger Social capital Reduces Stress Reduces Child Neglect

13. Neurons Connected by Life Experiences: Synapses & Dendrites

14. Neural Networks form with Repetition & Emotional Intensity

15. Sculpting: Neurological Pruning of Non-connected Neurons

16. Home Environment: Words Heard by Child Words heard by hour week year Low income 616 62,000 3 million Working class 1251 125,000 6 million Professional 2153 215,000 11 million What you hear, how you talk, how you read and write

17. Ages of Neurological Pruning 3 years 3 months 6 months 12 months 9 months

18. Ages of Neurological Pruning 9 years 12 years 6 years 15 years

19. Apply Social Work Values and Skills • Social work values of respect and shifting power • Service user involvement in partnership with professionals • Multi-systemic. social ecological, local contextual interventions • Anti-oppressive and anti-discriminatory practice • Social work focus on quality of relationships • Between individuals, parent-child bonds, within families, • Lead groups of professionals in multi-agency working • With socially marginalized, low income parents: social inclusion • Social work systemic strategies to build relationships • Social cohesion, social trust, networking and social inclusion • Coleman, 1988: ‘intergenerational closure in schools’

20. Families and Schools Together (FAST) • Universal voluntary parenting programme for all age 4-5 children living in disadvantaged communities • Focus on relationships, social capital and protective factors, as all parents have stress sometimes • Support all parents in practicing positive parenting • Transition into school for all 4-5 year olds with FAST • If a parent comes once to FAST, 80% return for 8 weekly sessions & 22 monthly multi-family meetings • 86% of FAST parent graduates report having made a friend they see years later; reduce stress & isolation

21. Parents Co-Produce FAST as Prevention of Neglect • Respect for parent role and knowledge at every level of the FAST programme: ‘nothing about us without us’ • Parents participate in training and planning FAST: co-production with multi-agency professionals: 60% flexible • Parents are on multi-agency FAST team leading groups • Parents are coached to be in charge of their own family • Parents are given time to form informal social networks • Parents graduates plan the monthly ongoing meetings • Parent interview panel for evaluation FAST certification

22. FAST Groups Build Protective Factors Against Child Neglect • Strengthen family unit • Parent-child bond • Parent-to-parent bond • Parent group • Parent and community • Parent and school

23. Ten theories into practice in FAST • Parent groups are built on Paulo Friere’s ideas of adult education groups in low income communities • Minuchin family systems theory empower executive subsystem, increase engagement, reduce conflict • Family stress theory (Hill; Boss) hope; social support • Attachment theory (Bowlby) into practice (Kogan) • Parents ask children to do small tasks as imbedded compliance requests (social learning theory) • Systematically reinforce attendance (learning theory) • Family school and community (social ecology theory)

24. Social ecological theory of child development (Bronfenbrenner) child NICHD Social Capital FAST Project

25. Social ecological theory of child development (Bronfenbrenner) child family NICHD Social Capital FAST Project

26. Social ecological theory of child development (Bronfenbrenner) child school family NICHD Social Capital FAST Project

27. Social ecological theory of child development (Bronfenbrenner) child neighborhood school family NICHD Social Capital FAST Project

28. Social ecological theory of child development (Bronfenbrenner) child neighborhood school family

29. Experiential learning through parent led repeated activities (no “teaching” or lecturing) Family Scribbles Game Family Flag Feeling Charades

30. Parent-child bonds built in play activity and rehearsals of parental responsiveness to child Special Play

31. Building Social Capital through Schools • Every child goes to school; invite whole families • James Coleman sociologist Univ of Chicago studied schools and developed a theory of social capital • Children get to know one another at school • Children know their parents at home • If parents become friends with their children’s school friends, that is ’ intergenerational closure’, a powerful form of social capital • If the average parent at a school knows 4-5 other parents, that school has high social capital • FAST builds intergenerational closure at schools

37. Partnership

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39. Randomised controlled trials on FAST • Collaborations with other researchers from medicine, public health, sociology, psychology, who were interested in impact of a social intervention • 5 RCTs on FAST completed with low income families • Abt Associates, (2001); Kratochwill, et al, (2004); McDonald et al, (2006), Kratochwill et al.(2009), Gamoran & Turley (2013) • Funding from NIH (NIDA, NICHD), SAMHSA, DOJ, DOE • Positive child behavioural and mental health (SDQ) outcomes over 1 and 2 years, across domains of child social ecology (child, family, school, community)

40. Randomized Controlled Trial: Can FAST Build Social Capital Ruth N. López Turley, Rice University Adam Gamoran, Alyn Turner, and Rachel Fish University of Wisconsin-Madison This research was supported by NICHD grant no. R01HD051762-01A2. Its contents are the responsibility of the authors and do not necessarily represent the official views of the supporting agency.

41. Social Capital • By “social capital,” we mean relations of trust, mutual expectations, and shared values embedded in social networks • The paper addresses conceptual as well as causal ambiguity • This presentation focuses on causal inference

42. An Intervention Approach to Addressing Causal Ambiguity • Random assignment is the best way to sort out causal ambiguity • We cannot randomly assign families to social capital • Instead we randomly assign schools to a social-capital-building intervention • We test whether school assignment to the intervention boosts social capital for families

43. The Intervention • Families and Schools Together (FAST) • research-based after-school program • universally recruited 1st grade families • 8 weeks of weekly meetings at schools • 2 years of monthly meetings • designed to strengthen bonds • parents and school staff • parents and other parents • parents and children Social Capital

44. Research Design Phoenix San Antonio FAST Control

45. Data • Demographic characteristics of the child and the child’s parents • Pre-FAST measures of social capital • School characteristics • Parent-parent network social capital • Child socio-emotional and problem behaviors reported by 1st grade teachers

46. Statistical Methods • FAST as an indicator of social capital • Intent to Treat: Two-Level Model • Treatment on the Treated: Two-Level Complier Average Causal Effect Model Outcomes Intervention

47. FAST graduates compared • Across 26 schools, on average 44 families attended at least one FAST session • Across 26 randomly assigned control schools, there were no FAST sessions • Of the families who completed FAST (5 sessions), characteristics were collated • In the control schools, a comparable group was created with similar characteristics

48. Methods Treatment on the treated (TOT) Intent to treat (ITT) FAST Comparison

49. ITT Effects on Social Capital Social Capital Intervention 49

50. TOT Effects on Social Capital Social Capital Intervention 50