John R. Lutzker, Ph.D.

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SafeCare Widescale Implementation of an
Evidence-Based Practice to Prevent Child
Maltreatment

• John R. Lutzker, Ph.D.
• Director, Center for Healthy Development
• Visiting Professor, Institute of Public Health
• College of Health and Human Sciences
• Georgia State University

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Child Maltreatment
Sexual Abuse 8.8
Physical Abuse 16

• In 2006, 905,000 children experienced child
  maltreatment in the US (12.1 per 1,000)
• 1,530 children in the US died from abuse or
  neglect in 2006 (78 ltage 4 44.2 ltage 1) 41.1
  from neglect, 22.4 from abuse, 31.4 from
  multiple types

Emotional Abuse 6.6
Neglect 66.3
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Trends in Child Maltreatment in the U.S.
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A brief history of SafeCare

• Project 12-Ways 1979
• Project Ecosystems 1986 - 2001
• SafeCare development 1994-1998
• CDC Oklahoma Studies 2001
• Marcus Institute NSTRC birth2005-2008
• Move to GSU August 2008

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SafeCare Model Overview

• In-home parent-training model to prevent child
  maltreatment
• Behavioral, skill-based model, that focuses on
  three skills
• Health
• Safety
• Parent-child interactions
• Structured problem -solving taught for other
  issues
• Counseling skills reviewed with SafeCare trainees

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SafeCare model overview

• SafeCare is typically 18-20 sessions
• Typically, weekly for 90 minutes
• Can be conducted alone or integrated into other
  services
• Each module is conducted over 5-6 sessions
• Modules can be conducted in any order
• Health is often first

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SafeCare Overview

• Structure of each module
• Initial assessment using structured checklists (1
  session)
• Skill training (4-5 sessions)
• Explainmodelpracticefeedback sequence
• Final assessment to ensure learning (1 session)
• The use of structured assessment allows the
  provider to see change and measure it
  objectively
• Validated tools exist for measuring change

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III. SafeCare Research

• A number of lines of research support the
  efficacy/effectiveness of SafeCare
• Single- Case Studies of Behavior Change
• Non-experimental Group Studies of Behavior Change
• Quasi-Experimental comparison studies
• Site-Randomized Case-Randomized Studies are in
  progress
• Populations included in research
• High-risk parents
• Parents reported for child maltreatment
• Children with autism and related disabilities
• Adults with intellectual disabilities

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III. SafeCare Initial Research evidence

• Many single-case validation studies and social
  validity studies (60)
• 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
  childrens 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.

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Home safety data
Health care skills
Bigelow, K. M., Lutzker, J. R. (2000). Training
parents reported for or at risk for child abuse
and neglect to identify and treat their
childrens illnesses. Journal of Family Violence,
15(4), 311-330.
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.
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Single case studies Planned activities training
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.
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Group data Project 12-ways

• Examined over 700 families receiving SafeCare or
  other CPS services from 1979-1984
• Examined recidivism rates
• SafeCare families 21.3
• Other CPS services 28.5
• Reduction in recidivism 25
• Other analyses suggest that SafeCare families
  were more difficult than non-SafeCare families

Lutzker, J. R., Rice, J. M. (1987). Using
recidivism data to evaluate project 12-ways An
ecobehavioral approach to the treatment and
prevention of child abuse and neglect. Journal of
Family Violence, 2(4), 283-290.
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Group studies SafeCare California

• Families current involvement with child welfare
• After 36-months
• SC15 recidivism/first -time reports
• SAU 44 recidivism/ first-time reports
• 75 reduction in reports to CPS for maltreatment

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.
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SafeCare Oklahoma

• Two trials initiated 2002
• Statewide trial
• Prevention project
• History
• OUHSC evaluated Oklahomas CHBS
• Current services were having little impact
• Asked to help choose something new
• Selected SafeCare based on its neglect focus
• Implementation began 2002

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Oklahoma Statewide trial (PI Mark Chaffin)

• 6 service regions in OK assigned to SafeCare or
  SAU
• Providers receive SC training or do SAU
• Regions 1,2, 3 SafeCare 4,5 6 SAU
• Half of each get fidelity monitoring or
  coaching
• Outcomes CPS referrals intermediate variables
• Economic evaluation to test cost effectivenes of
  coaching

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OK statewide trial preliminary outcomes
Reduction in neglect for SafeCare group, but only
when fidelity was monitored through coaching
Also, turnover among SafeCare caseworkers was
half (16) of non-SafeCare caseworkers (31)
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Oklahoma Prevention study

• High risk families in OK City randomly assigned
  to receive either SafeCare-based services or
  standard mental health treatment
• SC workers were trained in SafeCare, motivational
  interviewing and domestic violence services
• Parents had IPV, substance use, and/or mental
  health problems
• SafeCare workers were BA level SAU has Masters
  degrees
• Initial Results SafeCare families had
• Less depression
• Reduction in Child Abuse Potential scores (CAPI)
• More satisfaction with services
• Believe services more culturally relevant
• Prevention of first time CM was reduced by 25
  (p .06)

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Other Ongoing Research Efforts

• Kansas Cell Phone study (Judy Carta)
• Can engagement and dosage of PAT be enhanced
  with use of cell phones?
• Wayne State University (Steve Ondersma)
• Can SafeCare be delivered directly to families
  via a computer-based intervention?
• San Diego diffusion study (Mark Chaffin)
• Examining trainer training in a non-experimental
  way
• GA. CDC grant to study statewide
  trainer-training implementation

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Current SafeCare Training efforts
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SafeCare Research grants
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Focus of NSTRC

• Increase awareness and use of SafeCare
• Increase trainings
• Standardize training methods and develop
  train-the-trainer model
• Implementation/translation research
• Empirical test aspects of training model
• Use technology to increase efficiency of training
  and fidelity monitoring
• Understand what factors influence organizational,
  provider, and family uptake of SafeCare.

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SafeCare Training model philosophy

• Fidelity is key
• Fidelity is the extent to which the critical
  features of a program are implemented as intended
• Deviating from a model may reduce effectiveness
• Deviations vs. innovations
• How to improve/maintain fidelity
• Training manuals with clear descriptions
• Formal training of facilitators
• Ongoing support and consultation for program
  providers
• Ongoing fidelity monitoring coaching

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SafeCare Training Model

• Home visitor provides SafeCare services
• Coach provides ongoing coaching for HV to
  ensure fidelity to the model
• Coaching required for SafeCare implementation
• Trainer trains new HV and coaches
• Trainers must practice SafeCare and coaching
• Trainers support coaches who monitor the fidelity
  of home visitors

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SafeCare Center Future directions

• Refine training model
• Research grants to test aspects of model
• Use technology to make training implementation
  cheaper
• Technology-based training, coaching, and fidelity
  monitoring
• Health economics work to understand the
  cost/benefit ratio of
• Understand fit of SafeCare with other EBP
• Understand policy aspects of increasing EBP in
  child welfare settings
• Understand adaptions for cultural groups

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Contact

• John R. Lutkzer, PhD,
• Jlutzker_at_GSU.EDU
• Director, Center for Healthy Development, GSU
• SafeCare Web site www.NSTRC.org
• Center for Healthy Development Website
  http//chhs.gsu.edu/chd/