Transcript Lynn McDonald`s Presentation Slides

RCTs on Partnerships to Engage
Parents 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
An Evidenced Based Parenting
Programme by a Social
Work
Academic
2
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.
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
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
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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
Risk and Protective Factors of Child Neglect
 Protective factors:
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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
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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
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
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
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(Sue Gerhardt, 2002,Why Love Matters)
High Stress Diverts Parental Focus on Child
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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
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Low hope and mood, low patience, irritability, distracted, anxious
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;
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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
Court Ordered Parenting Classes, Groups
 In US, 1 million reports of child neglect and abuse
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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
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)
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
Reduces Child
Neglect
 Social capital reduces stress
o Social ties and inclusion buffer stress and enhances adults’ coping
mechanisms leading to better mental health, less irritability & anger
Neurons Connected by Life
Experiences: Synapses & Dendrites
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Neural Networks form with
Repetition & Emotional Intensity
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Sculpting: Neurological Pruning
of Non-connected Neurons
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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
Ages of Neurological Pruning
17
years
3
63months
12
months
9
Ages of Neurological Pruning
18
12
years
69 years
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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’
Families and Schools Together (FAST)
 Universal voluntary parenting programme for all age
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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
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: coproduction 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
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 Parents
graduates plan the monthly ongoing meetings
 Parent
interview panel for evaluation FAST certification
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FAST Groups Build Protective
Factors Against Child Neglect
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 Strengthen family unit
 Parent-child bond
 Parent-to-parent bond
 Parent group
 Parent and community
 Parent and school
Ten theories into practice in FAST
 Parent groups are built on Paulo Friere’s ideas of
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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)
Social ecological theory of child
development (Bronfenbrenner)
CHILD
NICHD Social Capital FAST Project
Social ecological theory of child
development (Bronfenbrenner)
family
CHILD
NICHD Social Capital FAST Project
Social ecological theory of child
development (Bronfenbrenner)
school
family
CHILD
NICHD Social Capital FAST Project
Social ecological theory of child
development (Bronfenbrenner)
neighborhood
school
family
CHILD
NICHD Social Capital FAST Project
Social ecological theory of child
development (Bronfenbrenner)
neighborhood
school
family
CHILD
Experiential learning through parent led
repeated activities (no “teaching” or lecturing)
Family Scribbles Game
Family Flag
Feeling Charades
Parent-child bonds built in play activity and
rehearsals of parental responsiveness to child
Special Play
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
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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
Partnership
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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
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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)
Randomized Controlled Trial:
Can FAST Build Social Capital
R u t h N . L ó p e z Tu r l e y , R i c e U n i v e r s i t y
A d a m G a m o r a n , A l y n Tu r n e r, a n d R a c h e l F i s h
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.
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
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 socialcapital-building intervention
 We test whether school assignment to the
intervention boosts social capital for families
The Intervention
 Families and Schools Together (FAST)
 research-based after-school program
Social
st
 universally recruited 1 grade families
Capital
8 weeks of weekly meetings at schools
 2 years of monthly meetings
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designed to strengthen bonds
parents and school staff
 parents and other parents
 parents and children
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Research Design
Phoenix
FAST
Control
San Antonio
Data
 Demographic characteristics of the child and the
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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
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
Intervention
Outcomes
FAST graduates compared
47
 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
Methods
Treatment on the
treated
(TOT)
COMPLIERS
WOULD BE
COMPLIERS
Intent to treat
(ITT)
NON-COMPLIERS
FAST
WOULD BE
NON-COMPLIERS
Comparison
ITT Effects on Social Capital
Outcome
Effect
size
Est/S.E. P-value
Intergenerational
Closure
0.13
3.02
0.003
Shared Expectations
with Other Parents
0.33
3.28
0.001
Intervention
Social
Capital
49
49
TOT Effects on Social Capital
Outcome
Effect
size
Est/S.E. P-value
Intergenerational
Closure
0.35
2.83
0.005
Shared Expectations
with Other Parents
0.97
2.93
0.003
Intervention
Social Capital
50
50
Low Drop Out Rates for Low Income Parents
 Retention rates: if a family comes once to FAST, on
average 80% will complete 6 or more of 8 weekly FAST
meetings & graduate to lead 22 monthly groups;
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72% inner city, low income, single parent, African American families
with emotionally disturbed children
80% rural, Indian reservations, low-income families with universal
recruitment of all children
85% urban, Mexican American immigrants, low income, universal
recruitment of all children
90% risk for special education with behavior problems, low-income,
mixed cultural backgrounds
 However, if a family comes once to a child mental health
clinic, 40-60% (Kazdin, 2001) will drop out; if family is
low income or socially marginalized > 60% drop out
Effects of FAST- child at home
d=.42
Source: Kratochwill et al. (2009) (CBCL Externalizing Scale)
Effects of FAST-family domain
Family adaptability
Post: 8 weeks
27
26
26
25
23
22
21
20
FAST
Source: Kratochwill et al. (2009) (FACES )
d=.66
25
25
24
23
Pre
Control
Effects of FAST- school domain
106
Teacher ratings of social skills
in classroom
104
102
100
100
98
Post: 2 year
d=.26
104
102
Pre
97
96
94
FAST
Comparison group
(parenting pamphlets)
Source: McDonald et al. (2006) (using Social Skills Rating Scale-Gresham& Elliot)
Lists of Evidence Based Practice EBP
 UN United Nations Office of Drugs and Crime (2010)
 Family skills Programme (FAST is 11 of 23 based on RCTs)
 FAST has highest on retention rates of low-income parents
 UK National Academy of Parenting Practitioners
 Number 7 of parenting programmes for training workforce
 US government lists for evidence based practice
 Child abuse and neglect prevention
 Child mental health promotion
 Substance abuse prevention
 Juvenile delinquency prevention
Since 2010, 2,268 whole UK families
completed 6+ of 8 FAST sessions,
graduated to monthly sessions;
77% of the families lived on
Very Low-Incomes
(under £20,000 annually)
18 UK families per FAST; 81% retention;
107 schools in low-income communities
90
80
70
60
50
40
30
20
10
0
Cycle 1
Cycle 3
Cycle 5
Cycle 7
Average
Highest % Parents Reporting on FAST Impact
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1.Parental self-efficacy
which is related to parent
empowerment
 77% of parents who
graduated from FAST
reported increased
parental self efficacy
2.Parent Child relationship
is enhanced; attachment is
deepends;
 70% of parents reported
improvement of this
relationship
3. Reciprocal ties in
community-mutuality of
being helped and of
helping others who are
raising young children
UK Aggregate of Pre-Post FAST & Cross
Domain Reports of Relationships
 Parent-Child Bond increased 11% ****
 Family Conflict reduced -22% ****
 Family relationships increased 16%****
 Parent to parent reciprocity 31% ****
 Provide support +28%---Receive support +32%
 Parent involvement in school 33% ****
UK Parents Report Changes Pre FAST and Post FAST
on Child’s Mental Health at home
Strengths & Difficulties Questionnaire (Goodman, 1997)
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11.75
12
10
9.35
8.6
8
8.6
8.17
7.69
British Average
6
Pre FAST
4
4
1.9
2
2.55
1.92
1.6
2.36
1.79
4.44
3.61
1.4
2.38
2.01
Post FAST
0.3
0.960.82
0
Pro-social
Emotional
=P<.10(10% change due to chance)
=P<.05 (5% change due to chance)
Conduct
Hyperactivity Peer Problems
Total
Impact
P<.01 (1% change due to chance)
P<.001 (0.1% change due to chance)
UK Teachers Report Changes Pre and Post FAST
on
Child’s Mental Health at School
Strengths & Difficulties Questionnaire (Goodman, 1997)
=P<.10(10% change due to chance)
=P<.05 (5% change due to chance)
P<.01 (1% change due to chance)
P<.001 (0.1% change due to chance)
Pre Post Child Well-Being
SDQ Statistically Significant Changes****
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Parent Report
 Emotional -20%
 Conduct -18%
 Hyperactivity -13%
 Peer problems -10%
 Total problems -15%
 Impact -25%
Teacher Report
 Pro-social +10%
 Emotional -20%
 Conduct -20%
 Hyperactivity -15%
 Peer problems -16%
 Total problems -17%
 Impact -27%
Can FAST Prevent Child Neglect? We Need
More Rigorous Research Data To Prove it.
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Child neglect (ACE) prevention can be at a community level
Multi-agency working includes health, education, social care
Health inequalities and education disparities result from stress
of poverty, family stress and social isolation, and neglect
Effects of chronic stress from poverty, social isolation and
social exclusion of parents increase irritability/child neglect
Service user/carer involvement (and cultural representation)
can co-produce local outreach and engagement strategies
Evaluation of impact of social work interventions at local levels
improves practice to reduce stress, social exclusion and neglect
Need an RCT on FAST which is community wide with good
neglect records over time—time for another partnership