Combining Evidence-Based Programming with a Public Health Strategy for Child Well-Being
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Transcript of Combining Evidence-Based Programming with a Public Health Strategy for Child Well-Being
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Combining Evidence-Based Programmingwith a Public Health Strategy
for Child Well-Being
Ron Prinz, Ph.D.Professor and Director
Parenting & Family Research CenterUniversity of South Carolina
Creating Safe Environments—Advocacy, Prevention, and Support for Children in Arizona
Arizona PBS, Phoenix, April 9, 2013
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Acknowledgments
• Funding from:– Centers for Disease Control and Prevention– National Institute of Child Health & Human
Development (NICHD/NIH)– National Institute on Drug Abuse (NIDA/NIH)
• Consultant to:– Centers for Disease Control and Prevention– Triple P International (joint venture with the University
of Queensland)
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ACE study
• Demonstrates– Long-term, corrosive impact of childhood adverse life
events on health and development• Underscores need for
– Prevention of adverse childhood experiences– Promotion of child well-being
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Prevention: Two-fold focus
1. Mitigate impact of childhood adverse events
2. Prevent adverse experiences during childhood
For parenting intervention/support--
How do we achieve both goals concurrently?
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1. Mitigation of adverse events
• Improve implementation of evidence-based programs and practices
• Examples:– Trauma-focused CBT– Pathways Triple P– SafeCare– Shaken Baby Prevention Project
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2. Prevent adverse experiences
• Several of the adverse events link to parent/family variables
• Improvement of parenting is critical• Need:
– a broad strategy to reach many parents– public health approach
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Applying a public health strategy to
prevention of child maltreatment and
other adverse experiences
• Rationale• What is required• Is it possible?• Is it cost prohibitive?
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Main goal of prevention
Prevalencereduction
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Rationale
1. Parenting difficulties are widespread
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Underestimation of child abuse
• Des Runyan and colleagues conducted a random household telephone survey of parents
• Self-reported incidence of physical abuse: 40 times greater
than official records
Theodore, Chang, Runyan et al. (2005). Epidemiologic features of the physical and sexual maltreatment of children in the Carolinas. Pediatrics, 115, 331-3337.
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Widespread parenting practices
• Our own random household telephone survey of 3,600 parents of children under 8 years old
• 49% reported heavy reliance on coercive discipline strategies for child misbehavior
• 10% reported they spanked using an object on a frequent or very frequent basis
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Key argument
• Child maltreatment is severely detrimental to child development
• Problematic parenting is a continuum much broader than official abuse
• Goal is to improve child well-being for many children
Child maltreatment prevention, then, requires broad reach
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Rationale
1. Problematic parenting is widespread2. Need to sidestep the issue of stigma
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Institute of Medicine underscores:
• Endorsing a population health perspective
• Providing families with easy access to evidence-based preventive interventions
• Minimizing stigma
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Diminish stigma by
• Normalizing parent support• Adopt intervention content appealing to broad
range of parents• Avoid compartmentalizing parent support:
– example: “Hi, I’m with the Child Abuse agency—can I be of help?”
– instead: “Every parent faces challenges. What are your concerns as a parent? ”
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Rationale
1. Problematic parenting is widespread2. Need to sidestep the issue of stigma3. Creation of efficiencies by addressing
multiple goals through parenting/family intervention
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Address multiple goals
with the same parenting intervention system:
• Prevention of children’s social, emotional and behavioral problems
• Prevention of risk for academic failure, substance abuse, and delinquency
• Promotion of readiness for school• and of course, prevention of child maltreatment
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Rationale
1. Problematic parenting is widespread2. Need to sidestep the issue of stigma3. Creation of efficiencies by addressing multiple
goals through parenting/family intervention4. Draw on a variety of strategies to reach
wide segments of the population
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Make use of
• Multiple access points (organizations, agencies, settings)
• Variety of formats to match parental preferences• Media strategies that do not require substantial
professional time
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What is required for a public health
approach
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Requirements
• Interventions with broad reach• Tapping multiple formats and modalities
(including media strategies)• Multiple levels of programming intensity• Make use of the principle of minimum sufficiency• Drawing on evidence-supported parenting
strategies• Make use of existing workforces• Cost effective and efficient
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Is a public health approach to child maltreatment prevention
possible?
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Example
• The Triple P system of parenting and family support interventions
• Designed to build towards achieving community-wide impact
• Another example: The Purple Crying Program for prevention of shaken baby syndrome
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Triple P
• Not a single program• Triple P is:
– system of parenting interventions– broad strategy for parenting and family support at a
population level• Multi-level system with varying levels of program
intensity• Covering a wide variety of delivery formats and
modalities• Developed by Matt Sanders and colleagues at the
University of Queensland• University of Queensland owns Triple P
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A blended model of prevention
Universal approachesAll parents in target/high
need areasAll parents of children with a defined problem
Targeted approaches
Maltreating parentsOffenders
Parents living in povertySingle parentsMental health
Tiered multilevel system of parenting
support
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Triple P System
Level 5
Level 4
Level 3
Level 2
Level 1
Intensive family Intervention………................
Broad focused parenting skills training………...
Narrow focus parenting skills training………….
Brief parenting advice……………………………
Media and communication strategy…………….
Breadth of reach
Intensity of intervention
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Core Principles of Positive ParentingSource: Sanders, M.R., Markie-Dadds, C., & Turner, K.M.T. (1997). Positive Parenting. Brisbane: Families International Publishing
Core principles
1Safe engaging environment
2Responsive
learning environment
3Assertive discipline 4
Reasonable expectations
5Taking care
of self
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17 Specific Parenting Skills
Promoting apositive
relationship• Brief quality time• Talking to children
• Affection
Teaching new skills and behaviors
• Modeling• Incidental teaching
• ASK, SAY, DO• Behavior charts
Encouraging desirable behavior• Praise
• Positive attention• Engaging activities
Managing misbehavior• Ground rules
• Directed discussion• Planned ignoring
• Clear, calm instructions• Logical consequences
• Quiet time• Time out
Specific skills
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In practical terms
• Triple P aims to help parents reduce reliance on coercive and counter-productive parenting, such as:– Yelling or berating– Spanking/hitting– Humiliating– Criticizing in harsh language– Disregarding unsafe situations– Inflicting pain or discomfort
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• Triple P aims to increase positive parenting, such as:– Setting clear and simple rules (including limit setting)– Recognizing and celebrating child behaviors (small
steps, goal achievement, effort, prosociality)– Parent staying calm, focused, facilitative– Frequent use of engaging interactions, affection– Replacing criticism with positive parenting strategies
(differential attending, constructive coaching, modeling)
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Key facets of Triple P evidence base
• Many randomized trials (> 100 studies)– On levels, variants, and components of Triple P
interventions– Conducted in many settings, with diverse populations,
in several countries– To date, over 300 investigators have contributed to
the conduct and publication of Triple P studies• Two population-level outcome studies:
– Every Family prevention study (Sanders et al., 2008)– U.S. Triple P System Population Trial (Prinz et al.,
2009)
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U.S. Triple P System Population Trial
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Basic thrust
• Place randomization trial (counties randomly assigned to Triple P versus usual programming)
• Disseminate Triple P system to entire communities– Making use of existing workforces in several venues– Implement all levels of the Triple P system, including
media intervention• Reduce prevalence of child-maltreatment related
indicators
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Population reach of Triple P
• Eligible population: 85,000 families with at least one child birth to 8 years of age
• Direct delivery of Triple P for approximately 14% of those households
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Significant effects
Counties receiving Triple P showed:
1. Lower rates of child out-of-home (foster care) placements
2. Lower rates of hospital-treated maltreatment injuries
3. Slowed growth of substantiated maltreatment
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Is a public health approach cost prohibitive?
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Benefit-cost analysis (child welfare)
Washington State Institute for Public Policy directed by health economist Steve Aos• Examined Triple P benefits and costs in the
context of the child welfare system• Triple P system (all five levels)• Benefit to Cost Ratio (return on one dollar
investment)
$6.06
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Conclusion
• Two-pronged approach:– Use evidence-based programs to mitigate trauma– Adopt public health approach for prevention of
adverse events• Public-health approach to parenting/family
support– Blended prevention combining universal, selected,
and indicated prevention, as well as treatment– De-stigmatized approach to achieve multiple goals
with the same system of parenting interventions– Strive for reduction in the prevalence of childhood
adverse events
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ReferencesPrinz, R. J., Sanders, M. R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population-based
prevention of child maltreatment: The U.S. triple P system population trial. Prevention Science, 10(1), 1-12.
Foster, E. M., Prinz, R. J., Sanders, M. R., & Shapiro, C. J. (2008). The costs of a public health infrastructure for delivering parenting and family support. Children and Youth Services Review, 30(5), 493-501.
Prinz, R. (2009). Dissemination of a multilevel evidence-based system of parenting interventions with broad application to child welfare populations. Child Welfare: Journal of Policy, Practice, and Program, 88(1), 127-132.
Sanders, M. R. (2012). Development, evaluation, and multinational dissemination of the Triple P—Positive Parenting Program. Annual Review of Clinical Psychology, 8, 1-35.
Sanders, M. R., & Prinz, R. J. (2008). Using the mass media as a population level strategy to strengthen parenting skills. Journal of Clinical Child and Adolescent Psychology, 37(3), 609-621.
Lee, S., Aos, S., Drake E.., et al. (2012). Return on investment: Evidence-based options to improve statewide outcomes (Document No. 12-04-1201). Olympia: Washington State Institute for Public Policy.