End Abuse. Embrace Hope.

Integrating Innovative Best Practices

Cincinnati, Ohio

Collaborative Structure

Terminology

• Collaboration:

– Relationships that provide opportunities for mutual benefit and results beyond what any single organization or sector could realize alone.

* Drucker Foundation, Meeting the Collaboration Challenge

History

• HealthPath Foundation of Ohio released white paper identifying 2 greatest health concerns to Ohioans: – Family violence– Oral health

• HealthPath Foundation of Ohio awarded grants to 5 Ohio communities to develop & implement collaborative and comprehensive approaches to prevent family violence

• 2001: Family Violence Prevention Project was awarded a 2-year planning grant ($150,000) and a 3-year implementation grant (250,000)– Since then leveraged over $2.5 million

History

• Lead Agency: YWCA of Greater Cincinnati

• Lead Partner: United Way of Greater Cincinnati

• Founding membership 28 agencies• Current membership 45 partners & champions

Mission StatementTo prevent and eliminate all forms of family

violence in our diverse and caring communities

• Family violence includes:– Child abuse– Children Exposed to Intimate Partner Violence– Bullying– Teen Dating Violence– Intimate partner violence– Abuse against persons with disabilities & Deaf people– Elder abuse/neglect

Collaborative Partners

• FVPP collaborating partners represent multiple interests & perspectives:– Advocates– Direct service providers– Funders– Academics– Business– Criminal justice– Faith community– Medical communities

Framework: Prevention Spectrum

Influencing Policy & Legislation

Changing Organizational Practices

Fostering Coalitions & Networks

Educating Providers

Promoting Community Education

Strengthening Individuals Knowledge & Skills

Assessing Local Needs:Each Year in Cincinnati

• 4,800 children are abused or neglected

• 7,846 reports of abuse or neglect are filed with children’s services– 1,979 children are placed in custody– Majority of cases involve domestic violence/IPV

• 7,400 adults are physically abused by an intimate partner

• 1,697 people file petitions for civil protection orders

• 2,300 seniors are abused or neglected

• 300 reports of abuse or neglect are filed with adult protective services

Children Exposed to Intimate Partner

Violence

Children Exposed to Intimate Partner Violence (CEIPV): Local Research

• Community Needs Assessment (2001 )revealed:

– Regional professionals were unaware of:

• Impact of exposure to intimate partner violence on children

• The scope of the problem

– There were not enough qualified trainers to fill the demand for training on CWWDV.

CEIPV: Local Response

• Creation of 5 phases of programming– Phase I: Train the Trainer Program– Phase II: Home Visitation Focus– Phase III: Intervention Services Community

Coordinated Response Model– Phase IV: School-Based Mental Health

Providers & Nurses Collaborative– Phase V: Community Coordinated Response

with Child Protective Services

CEIPV: Collaborative Partners

• Beech Acres Parenting Center

• Cincinnati Children’s Hospital

• Mayerson Center for Safe and Healthy Children

• Childhood Trust• Hamilton County

Juvenile Court• ProKids

• YWCA of Greater Cincinnati

• Hamilton County Jobs & Family Services: Child Protective Services

• Hamilton County Prosecutor’s Office

• Hamilton County Public Defender’s Office

Phase I: Awareness & Education

Train-the-Trainer program

Trained 35 professionals who trained 2,000+ professionals

Multi-part curriculum: Designed by national CEIPV and child maltreatment

experts: Erna Olafson, PhD, PsyD Barbara Boat, PhD Frank Putnam, M.D.

Focus: medical, psychological, social, and behavioral impacts of CEIPV.

Phase I: Structure• Trainer criteria:

– Conducted educational presentations & trainings as part of their job– Sound understanding of family violence– Organization committed to conducting 2 of 5 trainings pro bono

• 35 Trainers– Represent 16 different mental health, school-based, social service

agencies

• Learning objectives:– Understand impact of CEIPV– Recognize signs of exposure – Decrease risk factors children engaging in future acts of violence– Create supportive environment for CEIPV

Animal Abuse & Intimate Partner Violence

• Victims of family violence are 5X more likely to have their pets harmed by batterers than non-victims.

• Children with substantiated physical abuse, along with other inhabitants of the home, are 10X more likely to be bitten by the family dog.

• Dog bites to children are the 3rd leading cause of emergency room visits.

Exposure to Battering & IQ

• Children age 5 who were exposed to high levels of family violence had IQs that were, on average, 8 points lower than unexposed children.

• Chronic lead exposure decreases children’s IQs on average 3 or 4 points.

(Koenen, et al, 2003; Putnam, 2003)

Abnormal Inter-Hemispheric Connections in Maltreated Children

• • Corpus Callosum - mid sagital region and areas 4, 5, 6, & 7 were smaller in maltreated children with PTSD

• • Decrease correlates with: Intrusive thoughts, avoidance, hyperarousal & dissociation

• Effects boys > girls

Orbital Prefrontal Cortex

Amygdala

Ventral Prefrontal Cortex

Trauma Impacts Key Structures Underlying Emotional Regulation

Dorsolateral Cortex

Anterior Cingulate

Why Do Some Battered Women Stay?

• Violence, stalking, & emotional abuse increases after women leave– Greatest risk of being murdered when they leave

• Batterers often harangue, beat, or rape ex-partners during child visitation exchange

• Homelessness

• Women stay in order to keep the children alive

• Many women stay in order to keep the pets alive

• Batterer has threatened to sue for custody if they leave– Batterers more likely to sue for custody than non batterers.

When batterers do sue, family courts award batterers custody at same rates they award custody to non batterers.

Traumatized Children: Social & Emotional Impact

• Affect dysregulation (depression, mood swings, panic attacks, affect liability)

• Attentional problems (ADHD, impulsivity, hypervigilence)

• Disturbances in sense of self and identity (suicidality, self-mutilation, low self-esteem, risk taking, alter personalities, depersonalization)

• Impaired stress response : sensitivity to traumatic reminders, alterations in neuroendocrine stress response

• Use and abuse of substances to regulate mood, sense of self, and behavior

• Interpersonal and relationship problems (attachment disorders, social withdrawal, promiscuity, antisocial behavior, spouse abuse, parenting problems)

Phase I: Outcomes

• Data analyzed independently by a team of psychologists and staff members using SPSS 12.0 (Norusis, 2004)

• Trainer effectiveness evaluated utilizing a workshop evaluation

• Participant knowledge, attitudes, skills were assessed utilizing a pre-post test evaluation

Training Evaluation

• Kirkpatrick’s Model (Kirkpatrick, 1994)– The majority of training

evaluations adhere to Kirkpatrick’s model

– Optimal evaluation of a training program occurs at 4 levels: (1) Reaction, (2) Learning, (3) Transfer of Learning, (4) Systems Impact

(Kirkpatrick, D.L. (1994). Evaluating Training Programs: The Four Levels. San Francisco, CA: Berrett-Koehler.)

Phase I: Outcomes

2005 Training Sessions

Level of Understanding of this Topic Before and After Training

27.5%

1.8%

44.3% 48.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

low little some a lot high

Level of Understanding

Level of UnderstandingBEFORELevel of UnderstandingAFTER

To

tal

Pe

rce

nta

ge

o

f R

ati

ng

s

29.3% of participants said they knew a lot about the topic or had a high level of understanding before the training

92.8% of participants said they knew a lot about the topic or had a high level of understanding before the training

Phase I: Outcomes

55

95

0

20

40

60

80

100

Awareness of Three Local Resources

8597

0

20

40

60

80

100

Knowledge of Reaction If Someone Discloses Abuse

Pre-Test: 54.4% agree; Post-Test: 94.6% agree

62

95

0

20

40

60

80

100

Ways to Intervene with Children & Families

28

89

0

20

40

60

80

100

Signs & Symptoms Children May Experience

Phase I: Outcomes

Phase I: Outcomes

22.7%

4.5%

27%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Recommend apolicy

Start a program Advocate for apolicy

Follow-up Survey

Phase II: Home Visitation

• Smaller group of trainers

• 2 Prong training– Training #1: CEIPV 101– Training #2: Role plays and resources

• Created simple, customized tools for home visitors to review with young mothers – Healthy Relationship Discussion Flow-Chart– “Red Flags/Green Flags” – United Way 211 Magnets– Recipes for a Happy Healthy Home Magnets

Phase II: Outcomes• Trained 130+ Home Visitors = 6,500+ clients annually

– Every Child Succeeds– Healthy Moms & Babes– Home Instruction for Parents of Preschool Youngsters– Health Department– Hamilton County Jobs and Family Services

• 90%+ identified signs and symptoms of children exposed to intimate partner violence

• 90%+ identified appropriate resource and referrals for moms and children

• 100% of home visitation programs created systems based change mandating training on impact of children exposed to intimate partner violence

Phase III: CCR Structure

• Coordinated response models between 3 family violence organizations and child abuse agencies

– Parent-Child Interaction Therapy (Cincinnati Children’s Medical Center)

– Amend Adolescent (YWCA of Greater Cincinnati)

– Families in Transition Program (Beech Acres Parenting Center)

• Referrals made from legal system, child protective services, school system, hospitals, social service and community organizations.

Parent-Child Interaction Therapy: Cincinnati Children’s Hospital

• Evidence-based treatment model for traumatized children with complex needs

• Highly specified, step-by-step, live-coached sessions with both parent and child.

• Children lack coping mechanisms & bond with victimized mother is severely damaged.

• Mothers learn skills through didactic sessions & using transmitter/receiver system in which the parent is coached in specific play with the child.

Parent-Child Interaction Therapy

• 20 sessions on relationship-enhancing skills & positive discipline/ compliance skills

• Parent is taught & coached in Praise, Reflection, Imitation, Description, and Enthusiasm (PRIDE)

• Skills gradually expanded from structured implementation in treatment to structured sessions in home to more unstructured situations and finally to use in public situations

• Skills observed & coached via one-way mirror

• Behaviors coded & charted on graph & mothers provided with immediate feedback about progress and skill mastery.

• Families participate in 1, 3, 6, and 12 month booster sessions

Amend Adolescent: YWCA of Greater Cincinnati

• 10 week psycho/social educational group sessions

• Utilized best practice curriculum: Aggression Replacement Training

• 11-17 year old high-risk adolescents

• Session focus:– CEIPV impact– Teen dating violence (interconnection)– Sexism– Abuse of power – Non-violent conflict resolution– Peer pressure– Positive coping skills

• Parents/guardians required to attend adult concurrent group sessions

Families in Transition:Beech Acres Parenting Center

• Children Group sessions: 5-17 years old

• Role-play, art, writing activities, & group discussion– Isolation reduction– Self-esteem enhancement– Coping skills– Feeling identification

• Adult Survivor Group Sessions: Role-play, video & discussion– Impact on CEIPV– Communication skills– Support, counseling, and safety planning

Phase III: Program Model Outcomes

PCIT •Parent masters skills of child-directed & parent-directed intervention

•Parent rating of child on the Eyberg Child Behavior Inventory falls to normal levels

•Scores on Parenting Stress Inventory change in a positive direction

•100%•100%

•100%

Amend Adolescent

•Increase knowledge of power & control dynamics

•Increase self-esteem & feelings of self-worth

•Increased social competency and empathy

•90%•85%•80%

Families in Transition

•Increase awareness of community resources & impact of CEFV

•Identify key indicators of healthy and unhealthy relationships

•Learn to cope effectively w/stress associated w/family violence

•Women in family violence situations report being able to set, manage and implement a safety plan for her and her children.

•90%•90%•80%•70%

Phase IV: School-Based Mental Health Structure

• Strategic collaboration among school based mental health providers, nurses, and school leaders

• FVPP trained school teams on impact of CEIPV

• FVPP provides follow-up TA to discuss school cases and responses

• FVPP funds wrap-around services to schools (i.e. Amend Adolescent)

Phase V: Child Protective Services Training Structure

• Partnership between Hamilton County Jobs Family Services Child Protective Services and family violence workers

• Revamped 10 year HCJFS policy and protocol manual for family violence & CEIPV

• Launched training of all levels of staff– 2010 trained nearly 180 staff on family

violence dynamics, impact on children, and trauma-informed response/referral system

– 2011 Slated to train 70-100 new hires

Questions?

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