Preventing Child Maltreatment-What is the Evidence?

1. Preventing Child Maltreatment-What is the Evidence? Terra Frazier, DO Amy Terreros, DNP, RN, CPNP-PC Section on Child Abuse and Negelct Children’s Mercy Hospital

2. Background Henry Kempe’s 1962 “Battered Child Syndrome” article is credited with public and political attention to maltreatment Kempe gained support from local and federal policymakers to adopt a formal child abuse reporting structure Between 1963-1967 all states and DC passed reporting laws CAPTA developed in 1974

3. Purpose of Prevention Spares children from pain and long term health consequences Saves society from the direct and indirect costs of maltreatment $103 billion in 2007 (medical care, legal system, prison costs, loss of productivity) Improves society’s health and happiness

4. Types of Prevention Primary Prevention Provided to the general population Aims to stop the maltreatment before it occurs Universal focus to raise awareness Example: PSA’s, Nursery Based Prevention, public awareness campaigns

5. Types of Prevention Secondary Prevention Activities focused on high risk families who are already at risk of maltreatment (substance abuse, young age, poverty, etc) May focus on communities with these high risk factors Examples: Home Visitation Programs (NFP, Healthy Families)

6. Types of Prevention Tertiary Prevention Abuse already happened and seek to prevent reoccurrence Examples: intensive family preservation services, mental health services for victims and their families (TF-CBT)

7. Agencies U.S. Dept of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Centers (EPC) U.S. Preventive Services Task Force (USPSTF)

8. Evidence-based Practice Centers One of 14 EPC’s is under contract by USPSTF Conduct systematic reviews of the evidence on specific topics in clinical prevention Serve as the scientific basis for the USPSTF recommendations

9. USPSTF • Reviews the evidence put together by the EPC’s • Estimates the benefits and harms from each preventive service • Grade the strength of the evidence • Reach consensus about the net benefit and issue a recommendation

10. Evidence Grading A- strongly recommends B- recommends C- no recommendation for or against D- recommends against I- insufficient evidence to recommend for or against

11. USPSTF Recommendations Intended for use in the primary care setting Present providers with info about the evidence behind the recs allowing providers to make informed decision about implementation

12. USPSTF Recs on IPV/Child Abuse Screening None designed for direct administration to the child (assess parents) None have been evaluated in the primary care setting regarding cost and time Sensitivity and specificity are poor (no reference standard for detecting actual episodes of abuse) None of the screenings used a physical exam protocols

13. USPSTF Recs on IPV/Child Abuse Screening Most screening and intervention studies are confined to high risk populations Many gaps in the evidence for screening for IPV/child abuse Few studies providing data on detection and management to guide clinicians

14. USPSTF Recs on IPV/Child Abuse Screening Conclusion: no studies identified met eligibility criteria that directly addressed the effectiveness of screening in a health care setting in reducing harm and premature death and disability, or the adverse effects of screening and interventions. RCT’s of home visitation improved abuse measures and outcomes

15. Epidemiologic Trends

16. National Incidence Study of Child Abuse and Neglect-Report to Congress 26% decrease in harm standard from NIS-3 to NIS-4 (2005-2006) per 1,000 children Lower abuse rates in 0-2 age range Higher for AA than other races 81% of abuse occurred by bio parents CPS only investigated 32% of those who met harm standard

17. Prevention Modalities

18. Measuring Effectiveness • Most child abuse prevention programs have not been evaluated for effectiveness • Requires • Rigorous research methodology • Strong program evaluation component

19. What is “Effectiveness”? • Changing parental beliefs or attitudes? • Changing behaviors? • Increasing knowledge or comfort? • Reducing the incidence of child abuse • As measured by what? • State CPS database? • Hospital catchment area?

20. Child Abuse Prevention Modalities • Home Visiting • Nurse Family Partnership • Healthy Families America • Other various models • Parent Training Programs • Nursery Based Prevention for AHT • Prevention of Child Sexual Abuse

21. Home Visitation • Developed in the 1960-1970’s • Prior to Olds study home visitation by nurses had not been rigorously studied • Based on the premise that nurses are an effective means of • Reaching women reluctant to use traditional health care services • Responding flexibly to the stressful life circumstances • Improve health habits and behaviors • Ultimately, reduce rates of preterm delivery

22. NFP • Secondary form of prevention • 3 primary goals • improve the outcomes of pregnancy • improve the child’s subsequent health and development • improve families’ economic self-sufficiency • Enrolled pregnant, young, low income, first time moms • Starts during prenatal period and ends at age 2 of life (can’t enroll if infant is older than 6 weeks of age)

23. NFP- David Olds et al • RCT • Compared home visitation of nurses to routine health and development screenings • 1977, Elmira NY, semirural county • Assigned at random to 1 of 4 groups • Group 4 received home visits until the child was 2 years of age (n=116)

24. NFP- 2 year assessment During the first two years of life the NFP cohort had 80% fewer verified cases of abuse and neglect (P= .07; not statistically different) During second year of life 32% fewer ER visits In 2 years after program completion NFP kids were less likely to visit the ER for injury or ingestion Improved developmental outcomes

25. NFP 2 year assessment • NFP mom’s • Smoked less during pregnancy • Gave birth to higher birth wt babies • Better social support • Use of community services • NFP mom’s • Provided age appropriate toys • Safer home environment • Longer interval b/w pregnancies • Fewer subsequent pregnancies • More likely to work

26. NFP- 15 year assessment 48% reduction in child abuse and neglect 59% reduction in arrests among children 72% fewer convictions of mothers 56% reduction in emergency room visits for accidents and poisonings 67% reduction in behavioral and intellectual problems among children Cost- $4,500/family annually Net benefit to society of $34,148 (2003 figures)

27. NFP-Other Sites • 734 Primarily black women from Memphis • No differences in cases of DV, employment, marriage • Significant improvements in • Time on welfare • Children’s intellectual functioning

28. NFP-Other sites • 1178 women Denver • Plurality of Mexican-American • Compared Nurse Home Visits to Paraprofessional Home Visits • Similar effects, but… • Visits by paraprofessionals generally showed effects about half the size of those in the nurse home visit group

29. NFP-Other sites 2 year follow-up from Denver Decreased DV in nurse visit group compared to paraprofessional group Nursing group continued to perform better than paraprofessional group.

30. NFP-other sites • Multiple studies attempting to replicate the Olds studies have shown mixed results • Individual programs need rigorous study and review • Local factors may play a role in efficacy

31. NFP-Positives/Negatives • Positives • Rigorous study indicates NFP can reduce rates of maltreatment • Federal government support • Lifelong benefits • Financial benefits (Benefits – Costs = $14,411 per child) • Negatives • Variable outcomes in different sites • Requires significant initial investment and coordination

32. Parents as Teachers • Home visiting with main goal of having children ready to learn by school age • Parents are visited monthly by parent educators • Parent educators must have some college education • Visits typically begin during mother’s pregnancy and may continue until child enters kindergarten

33. Parents as Teachers • Multisite evaluation showed: • Generally small positive effects on parents • Benefits to the child by 2 years of age were weak • Total benefits minus costs per participant = $111

34. Parents as Teachers- Positives/Negatives • Positives • Well supported in the state of Missouri • Negatives - Minimal benefit to child - Small benefit to parent - Very small cost/benefit improvement

35. Healthy Families of America (HFA) Developed in 1992 by Prevent Child Abuse America and RMH Charities Home visitation model Meant to promote positive parenting, enhance child health and development and prevent child abuse and neglect

36. HFA Measured outcomes: • Reduced child maltreatment • Increased utilization of prenatal care and decreased pre-term, low weight babies • Improved parent-child interaction and school readiness • Decreased dependency on welfare, or TANF (Temporary Assistance to Needy Families) and other social services • Increased access to primary care medical services • Increased immunization rates

37. HFA Families must be screened for need by a staff member Visits begin prenatally or at birth (within 2 weeks of birth) Offer services for 3-5 years Staff are paraprofessionals, usually social workers

38. HFA RCT’s have been conducted (4 trials) Compared maternal report of parenting behaviors and abuse to substantiated CPS reports, 2 trials showed decrease in self reported behaviors assoc with CAN 2 trials showed no decrease in child abuse No decrease in childhood injury Total benefits – costs (per participant) = (- $2137)

39. HFA-Positives/Negatives • Positives • Some studies have shown improvements in parent-child interaction and other outcomes • National network • Negatives • No good evidence that the rate of maltreatment is reduced • Negative benefits minus costs

40. Every Child Succeeds (ECS) Began in 1999 as a collaborative effort by Cincinnati Children’s Hospital, Community Action Agency, and United Way of Greater Cincy 14 agencies providing home visitation 13 HFA, 1 NFP Social workers, nurses, and/or child development specialists

41. ECS Eligibility: young, low income, single and/or receiving inadequate prenatal care, factors that put kids at higher risk for delayed development, abuse and neglect, and poor academic achievement Can enroll pre/post-natal; up to 12 weeks of age Key components: success priorities, enhanced and updated curriculum, continuous quality improvement Cost: $2,700/family annually

42. ECS Outcomes 67% of children are up to date on immunizations 99% of children have a medical home 95% of children have a safe play environment 66% of mothers breastfeed 18% of pregnant mothers quit or reduced smoking 57% of mothers whose depression improved 63% of mothers complete their postpartum visits The infant mortality rate for families enrolled in the ECS program is 4.7 per 1,000 live births (compared to 11.3/1,000 for city of Cincy not enrolled)

43. ECS Positives/Negatives • Positives • Well studied • Documented positive benefits across spectrum • Doesn’t require nurses • Negatives • Requires coordination among many groups

44. SBS/AHT 2nd leading COD due to trauma in children Responsible for >95% of serious head injury in infants <1 year Mean age of victims 4 months (crying peaks 4 weeks- 15-35% mortality, permanent sequela in up to 50% Initial inpt costs $70,000 Lifetime medical costs $400,000

45. SBS/AHT Prevention Dias Primary prevention Adult learners learn better in context of major life event (birth) Upstate NY, maternity units, video teaches dangers of shaking Watched video after birth and signed commitment statement

46. SBS/AHT Prevention- Dias • f/u telephone surveys 7 months post • 25% remembered SBS w/out prompting • 98% remembered written materials • 94% remembered commitment form • Only 30% remembered video • Incidence of AHT reduced by 47% during the 5 year study period and no comparable reduction was seen in similar control county

47. Dias Nursery Based Prevention- Positives/Negatives • Positives • Simple • Cheap • Primary prevention • Negatives • Continued data collection at study site has not replicated outcomes • Addresses only one type of maltreatment

48. Period of PURPLE Crying Barr Primary prevention Watch 10 minute video/receive 11 page booklet after birth RCT in US and RCT in Canada F/u calls 2 month after discharge Showed improvement in knowledge and behavior