SafeCare®: An Evidence-Based Parenting Program to Prevent

Child Neglect and Abuse

John R. Lutzker, PhD Daniel J. Whitaker, PhD

National SafeCare Training and Research Center Center for Healthy Development

Institute of Public Health Georgia State University

Presentation Outline

I. SafeCare history

II. Program description

III. SafeCare research

IV. Implementing evidence-based practices

V. SafeCare training and implementation

VI. SafeCare implementation research

VII. Future directions

I. History of SafeCare

SafeCare History

• Project 12-Ways (1979 - Current)

– Illinois

– Focuses on multifaceted environmental factors contributing to serious problems for families

– Up to12 services (e.g., parent-child training, stress reduction, social support)

SafeCare History

• SafeCare (1990s)

– Began in Los Angeles CA

– Effort to make 12-Ways more disseminable

– Safety, Health, Parenting

• 2001

– Oklahoma adopts SafeCare

• 2007

– National SafeCare Training and Research Center established

National SafeCare Training & Research Center (NSTRC)

• Established 2007

– Demand for training began to rise

– Oklahoma implementations (2001 - 2011)

• Housed at the Center for Health Development at Georgia State University

• 100+ sites in 17 states

• www.safecare.org

Domestic SafeCare Sites

Also,

• Belarus

• United Kingdom

Statewide

Implementation

International Sites

II. SafeCare Program Description

One family’s experience…

SafeCare Program Description

• In-home parent-training curriculum

• Behavioral, skill-based model

• Targets parents with children ages 0-5

• Designed for high-risk families

– Focus is on preventing abuse and neglect

– Has common elements of many behavioral parent training programs (PCIT, Triple P)

SafeCare Program Description

• Teaches parents a broad range of skills • Parenting • Children’s health needs • Home safety

• Targets multiple risk factors for abuse and neglect • Positive parent-child/infant interactions • Systematic health decision-making • Supervision and home safety

• Focuses on typical daily activities • Highly structured, but flexible in its delivery

SafeCare Program Description

• 15 to 18 sessions – 5 to 6 sessions per module (3 modules total) – Typically once per week – Depends on parent’s initial skills and skill acquisition

• 1 to 1.5 hour sessions – Scheduled when assessment/training most applicable

(e.g., nap time, bath time)

• Services provided in-home – Family’s natural environment – Utilize natural opportunities to train

• SafeCare relies on behavioral principles – Reinforcement, modeling, shaping, skill practice, mastery

performance criteria

SafeCare Curriculum Overview

Note: Providers learn all 4 modules; parents receive 3 modules [Health, Safety and one parenting (PCI or PII)]

Communication and Problem Solving

• Global skill sets

• Communication skills

– HV interaction skills

– Used regardless of session

– Foundation of rapport

• Problem-solving

– Structured approach to family crises

– Used as needed

SafeCare Module Overview

Session 1 Assessment

Sessions 2-5 Training

Session 6 Re-assessment

Parent Training Process: SafeCare 4

Parent training process includes:

• Explain: Explain the skills to the parent

• Model: Show the parent what the skills look like

• Practice: Parent practices the skills

• Feedback: Give positive and corrective feedback. Continue until mastery

SafeCare Module

Parent-Child Interaction (PCI)

~1 to 5 years old

Parent-Child Interaction (PCI) Module

• For toddlers and older

• For use in play and daily activities

• Goals – Increase positive interactions

– Engage children • Good interaction skills

• Incidental teaching

– Prevent challenging child behavior • Use planned activities training

• Decrease child boredom

PCI Module Overview

• Baseline Assessment (Session 1) – Daily Activities Checklist

– Observe parent/child in play and 2 daily activities

• Training (Session 2-5) – Child Planned Activities Training—cPAT

– Independent Play

• End-of-Module Assessment (Session 6) – Re-observe three activities

Child Planned Activities Training (cPAT)

BEFORE

Prepare in advance

Explain the activity

Explain the rules and consequences

DURING

Talk about what you are doing; incidental teaching

Use good physical interaction skills

Give choices

Praise desired behavior

Ignore minor misbehavior

Provide consequences

END

Wrap up and provide feedback

PCI Activity Cards

Materials: A variety of unbreakable cups, containers, and bowls. A variety of household items, such as small toys, socks, balls, ribbon or cloth, pencils or crayons, paper, books, and small food items such as crackers, grapes, fruit, and bread. You can choose any items that you have around the house. Suggestions: Place the cups, containers, and bowls in front of you. Hold up one container and one household item, and ask, "Will it fit?" Match some containers to items that will fit inside that container, and match some containers to items that will not fit inside. Your child will then tell you, "Yes, it will fit" or "No, it won't fit". If your child does not know, just show how the items fit or don't fit into the containers. Give your child a turn to ask you whether items will fit or not. Give some correct answers, and some wrong answers, and see if your child catches you.

Materials: A small hand mirror, or a mirror on the wall Suggestions: Make a face into the mirror. Pretend that your face is a mask, and using your hands, pretend to take your mask off and put it on the child. Ask your child to make that same face. The faces you make should show some kind of feeling, such as: Happy Afraid Hot Sad Lonely Cold Angry Worried Surprised Miserable Bored Sleepy You can also name one of these feelings, and then make the face that matches these feelings. Or, you might make a face, and then the other person should guess what feeling you are showing.

PCI Skills: Play (together and independent)

Before • Prepare in advance • Explain the activity • Explain the rules and consequences • Select short time period for activity* During • Interrupt the activity to praise the child* • Ignore minor misbehavior • Handle disruptions* • Provide consequences End • Wrap up and provide feedback • Spend individual time*

*Denote items specific to Independent Play

The hazards of not properly supervising while children play independently!

SafeCare PCI video

SafeCare Module

Parent-Infant Interaction (PII)

Birth to ~1 year old

Parent-Infant Interaction (PII) Module

• For newborns to about 1 year old

• Goals

– Promote positive interactions

– Increase parental vocalization to infant

– Promote age appropriate and stimulating activities

– Promote bonding and attachment

PII versus PCI

• PII and PCI have different foci

• PII’s main focus is on specific interaction behaviors (verbal and physical behaviors)

– cPAT steps are taught later in the module to help the parent prepare for child’s future development

• PCI focuses on Child Planned Activities Training (cPAT) as main priority

– Independent play also discussed

PII Module Overview

• Baseline Assessment (Session 1) – Observe play and 2 daily activities

• Training (Session 2-5) – LoTTS of Bonding Behaviors

• Look, Touch, Talk, Smile

– Other Bonding Behaviors • Holding, Rocking, Imitating

• End-of-Module Assessment (Session 6) – Reassess activities

PII Skills: Bonding Skills

LoTTS of Bonding Behaviors

Other Bonding Behaviors

Looking Holding

Talking Imitating

Touching Rocking

Smiling

Materials: Soap Washcloth Towel Shampoo Clothes for after bath Toys for bathtub Suggestions: Play peek-a-boo with his clothing while undressing and dressing. Trickle water from your hand or a cup onto your baby's tummy. Talk about washing and drying each body part. Imitate your baby's sounds during play. Sing bathtub songs ("Row, Row, Row your boat" or "Rubber Duckie") Smile and make eye contact with your baby. Give your baby a gentle massage on his arms, legs, and back with soapy water during the bath, or lotion or powder after the bath.

Sit with your child on your lap facing you Hold your child's hands in your own Ask questions such as, "Where is your nose?" or "Where is Mommy's mouth?" Guide your baby's hands with yours and help him point to each body part while you name it. For older children, have them point by themselves. After pointing to and naming each part, say "That's right, that's your ____!" Offer other praise and encouragement. Make silly jokes. Point to your stomach and say, "Is this my nose?" Smile and make eye contact with your child

Home Safety Module

• Rationale – Unintentional injuries are the leading cause of

injury/death in young children

– Also a leading cause of neglect reports

– Children are naturally curious and have poor impulse control

– Safe environmental and parental supervision is needed

• Goals – Remove hazards in the home environment

– Remove filth/clutter

– Promote parental supervision

Safety Module

• Help parents to:

– Understand the importance of a safe home

– Know the types of hazards in homes

– Know ways to remove household hazards

– Understand the importance of supervision

Reduce Hazards

Super-vision

Fewer child

injuries

Safety Module Overview

• Baseline Assessment (Session 1)

– Assess hazards in 3 rooms

• Training (Session 2-5)

– Teach parents about common hazards

– Remove and secure hazards in each room

– Encourage parental supervision

• End-of-Module Assessment (Session 6)

– Reassess 3 rooms

Safety Hazard Categories

1)Poisons

2)Choke

3)Suffocation

4)Drowning

5)Fire/Electrical

6) Fall/Activity Restriction

7) Sharp Object

8) Firearm

9) Crush

10) Organic/Allergen

Example of Household Hazards

Identifying What’s Accessible

• A hazard is accessible if it is: – Within arms reach as child stands on floor

– Within arms reach as child stands or climbs on adjacent objects

– In an open or unlocked container or space

– Is not secured by a childproof cap, latch, or lock

Removal of Hazards

• Hazards may be made inaccessible by one of three methods:

– Using childproof latches

– Using locks

– Placing items out of reach

• Filth/clutter may be improved by:

– Reducing items not belonging

– Reducing unclean areas

SafeCare Safety

SafeCare Module

Health

Health Module

• Goals

– Teach parents to recognize and assess when children are sick or injured

– Learn how to care for sick/injured children at home vs. call the doctor vs. go to ER.

– Learn how to use SafeCare Health Manual

– Learn to keep good health care records

Health Module

• Baseline Assessment (Session 1) – 3 scenario role-plays

• Emergency, doctor’s appointment, care at home

– Introduce health manual

• Training (Session 2-5) – Systematic decision making process – Use health reference materials – Keep good health records – Understand prevention efforts

• End-of-Module Assessment (Session 6) – 3 scenarios types

Sample Role-Play Scenario Card

SCENARIO 1

Your baby has been cranky and whiny for a couple of days. Last night,

your baby woke up coughing. Your baby’s nose has been running and

you notice he/she has been sneezing all day today.

SafeCare Health Manual

• Important Health Information Charts

• Caring for Your Child at Home

• Calling the Nurse/Doctor

• Emergency Situations

• Planning and Prevention

• The A to Z Symptom Guide

SafeCare health session…

III. SafeCare Research

Designs/questions for the real world

• Sequential research efforts – Single-case, quasi-experimental, randomized,

implementation studies • No lab-based studies

• Research to date answers four critical questions: – Do parenting skills improve after parents receive

SafeCare?

– Does SafeCare prevent future cases of child maltreatment?

– How do families respond to SafeCare, including families with diverse backgrounds?

– How do providers respond to SafeCare?

Does SafeCare result in positive changes in parents skills?

Answer: YES

Home Safety Parent-Child Interaction

Single case studies on SC modules

Safety

• Tertinger, D.A., Greene, B.F. & Lutzker, J.R. (1984). Home safety: Development and validation of one component of an

ecobehavioral treatment program for abused and neglected children. Journal of Applied Behavior Analysis, 17, 159-174.

• Barone, V.J., Greene, B.F., & Lutzker, J.R. (1986). Home safety with families being treated for child abuse and neglect.

Behavior Modification, 10, 93-114.

• Mandel, U., Bigelow, K. M., & Lutzker, J. R. (1998). Using video to reduce home safety hazards with parents reported for child

abuse and neglect. Journal of Family Violence, 13(2), 147-161.

• Metchikian, K.L., Mink, J.M., Bigelow, K.M., Lutzker, J.R., & Doctor, R.M. (1999). Reducing home safety hazards in the homes

of parents reported for neglect. Child and Family Behavior Therapy, 3, 23-34.

Health

• Delgado, L.E. & Lutzker, J.R. (1988). Training young parents to identify and report their children's illnesses. Journal of Applied

Behavior Analysis, 21, 311-319.

• Watson-Perczel, M., Lutzker, J. R., Green, B. F., & McGimpsey, B. J. (1988). Assessment and modification of home cleanliness

among families adjudicated for child neglect. Behavioral Modification, 12(1), 57-81.

• Bigelow, K. M., & Lutzker, J. R. (2000). Training parents reported for or at risk for child abuse and neglect to identify and treat

their children’s illnesses. Journal of Family Violence, 15(4), 311-330.

Parent-Child Interactions

• Lutzker, J.R., Megson, D.A., Webb, M.E., & Dachman, R.S. (1985). Validating and training adult-child interaction skills to

professionals and to parents indicated for child abuse and neglect. Journal of Child and Adolescent Psychotherapy, 2, 91-104.

• McGimsey, J. F., Lutzker, J. R., & Greene, B. F. (1994). Validating and teaching affective adult-child interaction skills. Behavior

Modification, 18(2), 198-213.

• Bigelow, K. M., & Lutzker, J. R. (1998). Using video to teach planned activities to parents reported for child abuse. Child & Family Behavior

Therapy, 20(4), 1-14.

Does SafeCare prevent child maltreatment for families who

participate in the program?

Answer: YES

SafeCare CA evaluation

• 82 families

• CPS reports over 3 years:

– SafeCare: 15%

– Family Preservation: 44%

• What does this mean?

– 68% reduction in future

reports to CPS for

families who completed

SafeCare

Gershater-Molko. R.M., Lutzker, J.R., & Wesch, D. (2002). Using recidivism data to evaluate Project SafeCare: Teaching bonding, safety, and health care skills to parents. Child Maltreatment, 7, 277-285.

Oklahoma Statewide trial

• Began in 2001

• 6 service regions in OK assigned to SC or SAU

• Providers receive SC training or do SAU – Also coaching assigned to teams or not

• Primary Outcome: CPS referrals

OK Statewide trial: Design

SAU, Monitored SafeCare,

Monitored

SAU, Not Monitored

SafeCare, Not Monitored

SAU SafeCare

Yes

No

Monitoring or coaching

OK trial: Sample

• N = 2175

• 91% women

• 67% white, 16% American Indian, 9% African American

• Mean of 2.8 children

• 82% below poverty line

• 4.7 prior CPS reports

OK Statewide SC trial: results

} SafeCare

} SAU

Recidivism

• SafeCare decreased re-reports by 26% for families with children 0-5 • With a re-report rate of 45% annually, SC prevented 64-104 reports

Does SafeCare work with Diverse Families?

Answer: YES

OK American Indian Study

• A subpopulation of 354 American Indian parents

• Outcomes included:

– Recidivism reduction among SafeCare parents was found to be equivalent with full sample for cases

– Significant reductions in Parental Depression

– Higher consumer ratings of

• cultural competency

• working alliance

• service quality

• service benefit

• Findings support using SafeCare with American Indians

• Manualized, structured, evidence-based model can be effective and culturally acceptable for American Indians.

SafeCare Enrollment and Completion

• Families assigned to SafeCare were much more likely to enroll in services (80% vs. 49%) and complete those services (49% vs. 21%).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Enrollment Completion

SafeCare SAU

Damashek, A., Doughty, D., Ware, L., & Silovsky, J. (2011). Predictors of Client Engagement and Attrition in Home-Based Child Maltreatment Prevention Services. Child Maltreatment, 16(1), 9-20.

SafeCare return on investment

From the Washington State Institute of Public Policy, April 2012

http://www.wsipp.wa.gov/pub.asp?docid=12-04-1201

SafeCare Research Summary

• Compared to other services, SafeCare – Improves parenting skills

– Reduces child maltreatment reports

– Is acceptable to parents with high levels of satisfaction

– Applicable across culturally groups

– Very high return on investment

– Is well-liked by providers who are trained to do it

IV. Implementing evidence based practices (EBP)

What is Implementation?

• From Fixsen et al “A specified set of activities designed to put an activity or program of known dimensions into practice

– “set of activities”

– “program of known dimension”

• The “to” in “research to practice”

Why is implementation important?

• “Children cannot benefit from an intervention they don’t experience” (Karen Blasé, 2009)

• Implementation relates to outcomes

– Durlak & DuPre (2008) review of 500+ studies

– greater implementation = better outcomes

• Program effect sizes tend to diminish with dissemination

– Example: MST effect sizes drop from large (d = .81) to small (d = .26) as the program disseminated

– Implementation is a way to try to ensure outcomes

The typical implementation…

A rigorous implementation…

• Readiness (multi-level)

• Workshop training

• Support/coach/TA

• Ongoing data collection

• Program evaluation

• Management of adaptations

Implementation stages

From Fixsen et al, 2005

1. Exploration/adoption – thinking about adopting a new program

2. Program installation – choose/hire staff; initial training; contracts in place

3. Initial implementation – staff begin the practice; needs lots of TA and coaching

4. Full operation – new practice is fully integrated

5. Innovation – experimentation; avoid drift

6. Sustainability – sustaining the practice; funding is critical; staff turnover; new training needed

Workshop + in-field coaching significantly increases use of new skills

Knowledge Able to perform

skill Use in

Classroom

Discussion in workshop

10% 5% 0

Demonstration in workshop

30% 20% 0%

Practice in workshop

60% 60% 5%

Live coaching 95% 95% 95%

What affects implementation?

V. SafeCare Implementation and Training

SC implementation process

SafeCare readiness process

• We’re still learning…

• Who is the organization pursuing training?

– Public or private?

• Meetings & calls, send information, application for training

– Is SafeCare appropriate for your population?

– Organization commitment (top & bottom)?

– Have staff been selected?

– Have staff been briefed, and what do they think?

– Who are your referral sources? Have they been briefed?

– What is the payment structure for SafeCare delivery?

– Can you comply with implementation model?

• Develop a training plan

• Site visit and orientation

SafeCare Training: 3 levels

• Home visitor – Provides SafeCare to families

• Coach – Provides ongoing fidelity

monitoring and support to HV

– Coaching is required

– Coaches must complete HV certification

• Trainer – Trains new HV and coaches

within their organization

– Support coaches

– Trainers must complete HV and Coach certifications first

HV

Coach

Trainer

Why coaching?

• Coaching = Fidelity monitoring + feedback

• Coaching is needed for implementation with fidelity

• Without coaching, providers ‘drift’

• Coaches are meant to become the local experts on SafeCare

Initial training and implementation

Home visitor training

• Allows staff to deliver SafeCare to families

• 4 day workshop + in-field skill demonstration

• Home visitors always receive “coaching”

Coach training • Allows staff to provides ongoing coaching to HV, a

requirement for implementation

• Coach trainees must first complete HV Training

• Coach training: 1-day workshop + in-field skill demonstration

• All SafeCare implementation is coached

Initial Implementation

NSTRC faculty and training staff

Initial workshop Training

Ongoing coach support and monitoring for 1 year

Coach

HV

Ongoing Coaching

HV HV

Implementation team

Sustaining SafeCare

Trainer training

• SafeCare Trainer training allows sites to train new home visitors and coaches within their organization

• Trainer candidates must have completed HV and Coach training

• Three day workshop + observation of first training

• Recertification every 2 years.

Sustaining SafeCare

NSTRC

SafeCare Trainer

HV

Workshop Training

Ongoing Coaching

Ongoing support

HV HV

Implementation team

Coach

Implementation challenges

• Too few referrals

• Inappropriate referrals

– Public system challenges

• Innovating but not “exnovating”

• Poor fit between SC and service system

• System funding issues

• Staff have too little time for work

• Staff unprepared for roles (coach, trainer)

Implementation lessons learned

• Start slow and pilot

• Prepare, prepare, prepare

• Understand what staff, organizations, and systems are already doing

• Don’t disseminate expertise too quickly

• Focus more on funds for service delivery than funds for training

• Ensure public systems are on board

VI. SafeCare Implementation

Research

SC Implementation research

About implementation research

• Different than outcomes research

– Different outcomes

– N’s, power, nesting

– Few standardized measures

– Few empirically supported theoretical models

• Similarities to outcomes research

– All the basics apply

RCT of Trainer training

• CDC funded, translation grants

• What level of support is needed by external trainers to produce high quality HVs & coaches?

• Randomized trial – Compare trainers with ‘usual’ support versus

‘enhanced’ support

• Outcomes – Trainer performance

– Coach performance

– HV performance

– Family uptake

RCT of coaching dissemination

HV HV HV

NSTRC (coach)

Coach

HV HV HV

NSTRC

Purveyor Local

Managing adaptations

• Dynamic Adaptation Process (Aarons, PI) – Adaptation team helps manage adaptation in

a planful way

– Team is researchers, purveyors, provider

– Identify adaptable elements of the intervention

• Randomized trial – DAP vs. usual ‘ad-hoc’ adaptation

– 6 CA counties in CA; ~ 72 providers; 720 families

VII. SafeCare: The future

1. Content development

2. Training innovations

3. Utilization of SafeCare

– Service systems

– With other interventions programs

Content development

• SafeCare is “modularized”

– Pieces can be separated

– New pieces can be added

• Several, skill-based modules could be added to address additional problems

• Center grant under review

• Return to Project 12-Ways?

Addressing Child problem behaviors

• Deb Hecht, NIH funded • Goal: to help parents address problem behaviors,

especially among older children • Why address problem behaviors? • Techniques

– Functional analysis – Ignoring minor misbehavior – Praising appropriate behavior – Use of time out

• Developed and pilot-tested 2008-10 – Intervention significantly decreased ECBI scores

• Additional funding being sought for larger trial

Violence

• Jane Silovksy, ACF funded • Why address violence? • Focus is on healthy relationships

– Intimates and others (relatives, friends, co-workers) – Based on PREP and 4th R

• Skill development in several areas – Relationship choices/decisions – Assertive communication – Couple problem solving – Effective arguing

• Intervention is not for “Intimate terrorism” • Trial is underway

2. Implementation innovations

• SafeCare hybrid training • Can a web-based training course reduce workshop training

time and cost?

Computer-enhanced SC delivery

• R21 (Self-Brown, PI) to develop system to employ computers to assist providers with EBP delivery

• Computers will: – deliver interactive EBP assessments, content, and

video to clients

– guide for the provider-led portions of the session based on client data.

• R21 will allow for development, and feasibility trial – Mini-RCT

– Primary Outcome- Implementation Success

Remote real time coaching

• Using tablets/smart phones for remote real time coaching

• Coaching can synchronous vs. ‘asynchronous ’ • Better confidentiality – no recording

Data decision support tools

• Expand portal to allow real time client data entry via smartphones/tablets

• Will allow provider and clients to visualize behavior change – Graphing function

• Referral sources can be pushed

• Sites can generate site level reports

• NSTRC and sites can generate program evaluation reports – Is SC more effective with different type of

families?

– Are some providers more effective than others

– Are there site differences?

3. SafeCare utilization and impacts

• In what service systems is SafeCare most effective?

– Within child welfare

– Outside of child welfare

• What adaptations are needed?

• What other practices are needed?

• Can practices be successfully blended?

Blending SafeCare and PAT

• The PATSCH study (GA and NC)

– Braided curriculum delivered to highest risk families

enrolled in PAT

– Why SafeCare and PAT make sense together

– Randomized trial with 2 year follow up

– Some adaptations made on both PAT and SafeCare

International dissemination

• Lots of variation in capacity – Resource poor countries may lack capacity to

implement SC

– Is there a more “basic” training that could be offered that would still benefit families

• Variation in service systems – Health care system

• Language issue – How does translation and language barriers

affect dissemination?

QUESTIONS?

Contacts

John R. Lutzker, PhD

Jlutzker@gsu.edu 404-413-1284

Daniel Whitaker, PhD Dwhitaker@gsu.edu

404-413-1282

www.safecare.org