A mixed-methods study to understand the impact of practitioner and organizational factors on fidelity of a child maltreatment prevention intervention in community-based settings.

It has been well-documented that the degree to which interventions are implemented with fidelity in typical service settings has varied. Frequently, interventions are developed and tested in highly controlled or early adopter settings. Less attention has been given to what implementation looks like in usual care, and which factors promote practitioners' ability to implement with fidelity. Individuals and organizations implementing interventions in the real world receive varying levels of external supports and may apply a new intervention unaided. The purpose of this mixed-methods study was to explore factors that support implementation as intended in local community agencies. In the quantitative phase of this study, 32 case planners implementing Family Connections (FC), a child maltreatment preventive intervention, completed a survey about their perceptions of practitioner and organizational factors related to fidelity. The survey data were connected to case-level fidelity scores to understand the relationship between perceptions and fidelity. The qualitative phase of this study involved further exploration with nine case planner interviews and two separate focus groups with supervisors and agency leadership. The results of this study suggest that supervision is a key contributor to a practitioner's ability to implement an intervention in usual care. The quantitative and qualitative results suggest supervision, including supervisors' perseverance, proactiveness, knowledge, availability, and skill reinforcement are important components of enhancing a practitioners' ability to learn and use FC. The quantitative results suggest that the level of education was positively associated with fidelity and perceptions of the intervention's limitations may be negatively related to implementation. Additional components that influence implementation for future research emerged from the qualitative phase related to system expectations and policies, individual practitioner attributes, and characteristics of the intervention. Plain Language Abstract: This mixed-methods study sought to understand the impact of practitioner and organizational factors on fidelity of a child maltreatment prevention intervention in community-based settings. The study first asked case planners about their perceptions of practitioner and organizational factors related to fidelity through an online survey. This survey was connected to case-level fidelity scores to understand the relationship between perceptions and fidelity. The qualitative phase of this study involved further exploration with nine case planner interviews and two separate focus groups with supervisors and agency leadership. The results of this study suggest that supervision is a key contributor to a practitioner's ability to implement a maltreatment prevention intervention. Both methods of the study suggest that various aspects of supervision, including supervisors' perseverance, proactiveness, knowledge, availability, and skill reinforcement are important components of enhancing a practitioner's ability to learn and use the intervention. Additional components that influence the implementation for future research emerged from the qualitative phase related to system expectations and policies, individual practitioner attributes, and characteristics of the intervention.

Family Connections: Using Collaborative Partnerships to Support Dissemination.

Spreading and sustaining evidence-informed practice in child welfare is complex. In particular, putting in place an active dissemination strategy requires the recognition of these unique challenges. The purpose of this paper is to illustrate how collaborative partnerships between individuals and organizations may represent an opportunity for more widely disseminating evidence-based practice in child welfare. The benefit of collaborative partnerships has been established as a beneficial mechanism to spread evidence-supported protocols in medicine and has been experimented with through Breakthrough Series Collaboratives in child welfare. Interagency collaborative teams to lead dissemination of evidence-informed practice in child welfare are now beginning to be examined as a method to scale-up practices more quickly. This article will use Family Connections, a multifaceted, community-based service program that works with families to help them meet the basic needs of their children and prevent child maltreatment as a case study for how collaborative partnerships can aid in dissemination.

Non-Suicidal Self-Injury--Does social support make a difference? An epidemiological investigation of a Danish national sample.

Teenagers and young adults who had experienced child maltreatment, being bullied in school and other serious life events have an increased risk of Non-Suicidal Self-Injury (NSSI), but some individuals manage to escape serious stressful life events. The research question is: does social support make a difference? A national representative sample of 4,718 persons born in 1984 were selected for an interview about their childhood, maltreatment, serious life events and social support in order to test if social support during childhood is a statistical mediator between childhood disadvantages and NSSI. The survey obtained a 67% response rate (N=2,980). The incidence rate of NSSI among this sample was estimated at 2.7% among young adult respondents. Participants with a history of child maltreatment, being bullied in school or other traumatic life events reported a rate of NSSI 6 times greater than participants without this history (odds ratio: 6.0). The correlation between traumatic life events during adolescence and NSSI is reduced when low social support is accounted for in the statistical model (p<0.01). The results indicate that social support is a partial mediator for NSSI. The reported low self-esteem indicates the importance of treating adolescents who are engaged in NSSI with respect and dignity when they are treated in the health care system. Results further imply that increasing social support may reduce the likelihood of NSSI.

Estimating staffing needs for in-home child welfare services with a weighted caseload formula.

State child welfare risk and safety assessment data were analyzed to determine three levels of in-home service that correspond to the Child Welfare League of America's (CWLA) national caseload standards and to evaluate the number of staff needed to provide services at each level. The analysis revealed that 50% additional case-carrying in-home services staff were needed to provide appropriate risk- and safety-based services to children in their own homes. Findings from this study were used by the state child welfare services agency to allocate vacant worker positions to local jurisdictions.

Trauma adapted family connections: reducing developmental and complex trauma symptomatology to prevent child abuse and neglect.

Families living in urban poverty, enduring chronic and complex traumatic stress, and having difficulty meeting their children's basic needs have significant child maltreatment risk factors. There is a paucity of family focused, trauma-informed evidence-based interventions aimed to alleviate trauma symptomatology, strengthen family functioning, and prevent child abuse and neglect. Trauma Adapted Family Connections (TA-FC) is a manualized trauma-focused practice rooted in the principles of Family Connections (FC), an evidence supported preventive intervention developed to address the glaring gap in services for this specific, growing, and underserved population. This paper describes the science based development of TA-FC, its phases and essential components, which are based on theories of attachment, neglect, trauma, and family interaction within a comprehensive community-based family focused intervention framework.

Assessing the cost-effectiveness of Family Connections.

OBJECTIVE: To assess the cost-effectiveness of two alternate forms of Family Connections (FC), a child neglect prevention program, in relation to changes in risk and protective factors and improvements in child safety and behavioral outcomes. METHODS: In the original FC study, a sample of 154 families (473 children) in a poor, urban neighborhood, who met risk criteria for child neglect, were randomly assigned to receive either a 3- or 9-month intervention. CPS reports and self-report and observational data on risk and protective factors, safety, and behavioral outcomes were collected prior to, at the end of, and 6-months post intervention. The current study compared the costs of delivering the 3- or 9-month intervention in relation to reported improvements in risk and protective factors, safety, and behavioral outcomes for each group. RESULTS: The 3-month intervention was more cost effective than the 9-month intervention in relation to positive changes in risk and protective factors and child safety. However, cost-effectiveness analysis indicated that the 9-month intervention was more cost effective (CE ratio=$276) than the 3-month intervention (CE ratio=$337) in relation to improved unit changes in the child's behavior between baseline and 6 months after service closure. CONCLUSIONS: This study successfully explored the cost-effectiveness of the FC intervention in relation to its intended outcomes. More extensive cost analyses are currently being conducted in the replication of this program in multiple jurisdictions across the United States. PRACTICE IMPLICATIONS: Practitioners in community-based programs must make difficult decisions about the optimal length of time to serve children and families. Prevention programs may be more competitive for funding when they have demonstrated cost-effectiveness. Study results indicated that a 3-month intervention was more cost effective than a 9-month intervention in enhancing protective factors and reducing the risk of child neglect; 9-month intervention was more cost effective than 3-month intervention in reducing problematic child behavior. Further research is needed before practitioners should consider these findings in relation to their own decisions about the timing of service closures.

Family connections: a program for preventing child neglect.

Family Connections was a demonstration program specifically designed to prevent child neglect. This article describes the development of prevention strategies and the assessment of outcomes for families who received two versions of the intervention. The sample included 154 families (473 children) in a poor, urban neighborhood who met risk criteria for child neglect and who were randomly assigned to receive either a 3- or 9-month intervention. Self-report and observational data were analyzed using analyses of variance (ANOVA) with repeated measures. Results for the entire sample indicated positive changes in protective factors (parenting attitudes, parenting competence, social support); diminished risk factors (parental depressive symptoms, parenting stress, life stress); and improved child safety (physical and psychological care of children) and behavior (decreased externalizing and internalizing behavior). Results further reflected no advantage of the 9-month intervention for improving parenting adequacy. Further testing of the intervention with other target populations is being conducted.

Housing characteristics and adequacy of the physical care of children: an exploratory analysis.

This study explored the relationship between housing conditions and the adequacy of the physical care of children. The sample included 106 caregivers who were participating in a neglect prevention demonstration project in a low-income, inner-city neighborhood. Children who lived with caregivers who had unsafe housing conditions were less likely to receive adequate physical care. Findings confirm the importance of addressing concrete housing conditions as part of an ecological approach to preventing child neglect.

The neglect scale: confirmatory factor analyses in a low-income sample.

The Neglect Scale is an easy-to-administer, retrospective, self-report measure of neglect. Research conducted by Straus and colleagues with college students indicates that this scale has a high level of internal consistency reliability and moderate construct validity. The purpose of this article is to examine the reliability and validity of the Neglect Scale when used with a low-income, inner-city sample. The sample included 151 women who were participating in a neglect prevention demonstration project. The Neglect Scale was completed as part of a computer-administered baseline interview before services were provided. To assess whether the 20-item, four-factor structure reported by Straus et al. fit the data from this sample, a confirmatory factor analysis was performed; the model did not fit the data well. Additional analyses identified a model that did fit the data well and suggest that the Neglect Scale is a promising self-report measure.

The effect of services on the recurrence of child maltreatment.

OBJECTIVE: Building on a previous model of recurrence, this study examined the relationship of services on the hazard of child maltreatment recurrence during CPS intervention for families who were provided continuing intervention following a confirmed index report of physical abuse or neglect. METHOD: This nonconcurrent prospective study selected 434 subject families who met study eligibility requirements from 1181 families randomly selected from the 2902 families who had experienced a substantiated report of child abuse or neglect during the sampling year. Data were collected and coded from archival sources for 5 years following the index report. Each record was coded by two research analysts to increase inter-rater reliability. Data were analyzed with the Cox Proportional Regression Model. RESULTS: Case characteristics that predicted recurrence were: child vulnerability, family stress, partner abuse, and social support deficits. After examining the potential effect of nine service-related variables only attendance at services predicted recurrence while controlling for other variables in the model. Families who were noted to attend the services identified in their service plans were 33% less likely to experience a recurrence of child maltreatment while their case was active with CPS. CONCLUSIONS: Implications of this and other research suggests that actively engaging families in a helping alliance and helping them accept and receive services may reduce the likelihood of future maltreatment.