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The Example of FAST: Developing An Evidence Based Social Work Intervention

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Title: The Example of FAST: Developing An Evidence Based Social Work Intervention


1
The Example of FAST Developing An Evidence Based
Social Work Intervention
  • JSWEC, Cambridge, UK, July 10, 2008
  • Lynn McDonald, MSW, PhD, Reader in Social Work,
    School of Health Sciences and Social Care, Brunel
    University, London

2
Start with a Social Problem
  • Identify the need
  • Identify the gaps in services
  • Plan a strategy with service users and experts
  • Pilot, evaluate, adapt, focus groups, feedback
  • Replicate with more sites, evaluate, refine
  • Undertake randomized controlled trials

3
Young Mothers
  • Stigmatized,socially excluded in local
    communities
  • Highlighted in government policies as a social
    problem whose problem is this?
  • Under-serviced population hard to engage young
    mothers in treatment, services, or parent
    education with blaming attitudes held by middle
    class social workers and nurses whose problem is
    this?

4
Gaps in Services for Babies
  • If a teen parent in US comes once, 60-80 do not
    return for more services for their babies
  • Lack of strength based services for teen mother
  • Lack of extended family support services
  • Lack of outreach to fathers of new baby
  • New brain research on infant development

5
A Social Problem Outcomes of Babies of Young
Mothers
  • UK 5 year evaluation of Sure Start initiative in
    high need communities for babies (0-5), mothers
    and families
  • Baby outcomes of young mothers in Sure Start
    showed lower functioning when compared to baby
    outcomes in comparison communities

6
The Need
  • Low income, socially excluded, highly stressed,
    adolescents girls, who may also show increases in
    depression, anxiety, drug use, school failure,
    conduct disorder, anti-social behaviors
  • New mothers who are depressed, stressed, socially
    isolated, have infants at increased risk for
    delays in cognitive emotional development, and
    neglect and/or physical abuse (not related to age
    of mother)

7
Some Lessons I Learned
  • Working with court ordered families of teenage
    delinquents, single parents of a child reported
    for child abuse or neglect, or isolated families
    of a disabled child, showed each family to be a
    social system with unique balance of power,
    conflict and cohesive relationships
  • Key to direct work was to join respectfully with
    the parent first, and to join respectfully with
    the youth, before working to shift power and
    strengthen relationships to enhance childs well
    being and safety

8
From Intense In-Home Interventions to
Multi-Family Groups
  • Community based, multi-family groups which are
    systemically based to build relationships and
    reduce family conflict could be more efficient
    but could they possibly be effective?
  • Key to partnership was joining respectfully with
    the young parents, and with the grandparents, to
    support and empower the young parent, for the
    sake of the infantss well being

9
The Need
  • Milwaukee, WI, has highest rate of teen age
    pregnancy in US highest in western world
  • SE London (Lewisham, Soutwark, Lambeth) has
    highest rate of young mothers in Europe
  • Why? Could it be related to low social capital of
    young mothers in certain local communities?
  • What about the infants? What about support for
    the young parents and efforts towards social
    inclusion?

10
The Need
  • Family systems generic profiles of young mothers
    perceived social isolation disengaged family
    relationships unresolved conflicts family
    history of neglect/abuse and young mothering
  • Professionals ignore strengths of extended
    family side with the young mother and baby
    against her grandmother and father blame the
    young mother
  • Result Lack of successful engagement of young
    mothers, lack of protection of new babies

11
Deadly combination
  • High Family Stress High Social Isolation
  • Strongest Single Predictor of
    Child abuse and Neglect
  • Add stress of Welfare To Work Movement

High Family Stress High Social Isolation High
risk of child abuse and neglect
12
Disengaged, stressed and Conflicted
Her Mom
His Mom
Her Dad
His Dad
Teen Mom
Babys father
Girl friends
Girl friends
Her Baby
13
High stress and conflict
Her Mom
His Mom
Her Dad
His Dad
Girl friends
Teen Mom
Babys father
Girl friends
Her Baby
Social worker
More isolation and dependency
14
If a new mother is
  • Depressed
  • Conflicted
  • Isolated
  • Stressed
  • RISK TO BABY child abuse and neglect

15
If a new mother is
  • Happy
  • Connected
  • Supported
  • Feels Effective

16
New Mother Doing Infant Massage
Massage reduces stress (cortisol), increases
serotonin and dopamine in infant brain (Field,
2005)
17
Desired Outcomes for the Babyemotional,
cognitive, and physical
18
To be responsive to her child, a mother needs
family support
19
Can Social Workers Build Social Capital for Teen
Mothers in UK?
  • Review of social science theory and research
  • Collaborate with service users and professionals
    to plan the group intervention to build social
    relationships, reduce conflict
  • Refined an evidence based, widely replicated
    multi-family group approach
  • Pilot an adapted form in a local UK community

20
Babies
Theory
  • Social ecological theory of child development
  • Social capital theory trust and reciprocity
  • Family stress theory
  • Family systems theory
  • Small groups theory
  • Community development theory group voices
  • New Brain Research child development theory

21
Babies
Babies
Program Design Elements
  • Doing activities and talking together, chance to
    express opinions, develop judgment and
    communicate with one another without conflict
  • 2 ½ hrs. sessions, weekly for 8 weeks, 1 year
    monthly, 8 weekly, 1 year monthly
  • Enhances Home Visitation Programs/with
    appropriate referrals to community services

22
Planning Teams 50 -50 Service
Users and Professionals
  • Peer Teen Mother of Infant
  • Grandmother of a Teen Mother
  • Young Father of an Infant
  • Occupational Therapists (Instructs infant
    massage)
  • Social Worker Therapist (Not from Child Welfare)
  • Public Health Nurse (Recruitment Infant Care)
    or
  • (also Father Outreach Specialist)

23

Babies
Team members
Team must be Culturally representative
of Families being served
Milwaukee
24
Multi-family Groups
  • Build supportive, non-conflicted relationships of
    young mother across her social ecology with
  • Other new young mothers
  • Her own baby (0-3)
  • Her mother/parent (or adult mentor gt21)
  • Other grandmothers of babies
  • The babies father
  • Home visiting and other community agencies

25
Family Systems For the Sake of the Baby
  • Strategic use of our disposition to like babies,
    as an opportunity to try and repeat new family
    routines
  • Interrupt family conflict in safe, public setting
    and gradually increase M-D dyad time without
    conflict
  • Practice resolving generic conflicts with
    unrelated cross generational, discussions in
    small groups
  • Peer supports for Grand-Mothers, Mothers, Fathers
  • Gradually introduce positive and reciprocal
    exchanges to build mother-grandmother cohesion

26
Uses Experiential Learning
27
Includes Fathers
28
Includes Grandmothers and/or Grandfathers
29
Respects parents as primary prevention agents
30
FAST BabiesSession
  • Family Table Time
  • Choices Activity
  • Baby FAST Hello
  • Music FAST Song
  • Scenario Discussion
  • Participants breakout into groups of four
  • No one can be related
  • Different scenarios for every group

New Mothers Group -infant massage -floor
play -reading
New Fathers Group
Grandmothers or mentors Group
Meal Time Lottery
Closing Circle Announcements RAIN
31
Choices Activity
32
Music FAST Song
33
Scenario Discussion Groups
34
New Mother's Nurturing Group
35
Infant Massage
Improves babies sleep, immune system, mental
health and the bond between mother/child

36
Grandmothers/mentors support group
37
Fathers' Support Group
38
Group Meal
39
Family Lottery
40
Rain Closing Circle
41
Program Incentives
  • free meal
  • free transportation
  • free child care
  • support meetings
  • crafts
  • baby Massage
  • social support and social inclusion
  • 50 family prizes (lottery)

42
Evaluation of MFG for Babies
  • Pre post evaluations with two raters
  • Missouri-3 sites and Wisconsin-10 sites
  • Use of standardized instruments with established
    validity and reliability
  • Statistical analyses is it significant change?
  • Service user perspective what was it like for
    your baby? For you? For your family?

43
Retention Rates 64 completed
  • Traditional strategies not effective for young
    mothers estimates are 60-80 drop out, after
    coming once
  • Engagement with multi-generational, systemic,
    multi-family group, strengths based approach
  • Planned by teams of service users working with
    professionals, who locally, culturally adapt MFG
  • In 13 low-income, high need, MO and WI
    communities, consistently high retention If
    young mother came once, only 36 dropped out,

44
Teen Mothers Report on Changes in Parental
Distress (PSI)Missouri Initiative
45
Grandmothers Reports on Changes of Teen Mothers
Moodiness (SIPA)Missouri Initiative
46
Demographics Wisconsin sites
  • 6 inner city, 4 rural, 10 low income WI sites
  • 130 families came once 83 families returned(64)
  • 83 mothers and babies, 22 fathers, 66
    grandmothers, total of 254 people graduated
  • Average age of mothers 19 years child 2 years
  • Only 43 of mothers completed 8th grade
  • None of mothers/fathers completed high school

47
Relationship Outcomes
  • Significant improvement (plt.03) of relationship
    of young mothers with their babies
  • Significant increase (plt.05) of nurturing
    efficacy reported by young mothers
  • Significant increase (plt.02) of family
    expressiveness reported by young mothers

48
Grandmothers
  • Significant improvement (plt.01) of commun-ication
    of grandmothers with young mothers
  • Significant increase in time grandmothers
    reported spending with new grandchild

49
Fathers
  • 50 of fathers reported living in same household
    with the baby
  • 100 of fathers reported increase in amount of
    time spent taking care of their babies

50
Need for Randomized Trial
  • After quantitative evaluations of pre-post
    outcomes of 10 multi-family groups for young
    mothers, some significant improvements
  • After feedback loops from 180 service users of 13
    MFG, program is improved significantly
  • Now need for randomized controlled study to
    examine the FAST babies vs. control groups

51
MFG Retention Rates
52
Teacher Reported Aggressiveness Scores -
CBCL
Pre
Post
Follow-up
53
Teacher Reported Anxiety Scores - CBCL
Pre
Post
Follow-up
54
VALUES MATTER!
  • Social work is a profession which applies social
    science research to urgent social problems
  • Social work demonstrates its values of social
    justice, anti-oppressive practice, and
    anti-discriminatory practice in the practice of
    our work
  • Service user involvement at all levels of
    practice provides feedback to improving our
    practice
  • Outcome evaluation also provides feedback loop

55
VALUES MATTER!!
  • Traditional cultural community approaches to
    supporting children and families are tested by
    time
  • Perhaps strategies which improve child well being
    are not tested with RCTs. Does that matter?
  • If a proven program does not seem respectful to
    parents or elders, nor tolerant of
    cultural/religious differences, or does not
    address poverty and social exclusion? Does that
    matter?
  • Are proven models adaptable to local sites? Too
    expensive? Effective over time? Does that matter?

56
VALUES MATTER!!
  • Do we as social workers have standards for
    reviewing interventions to assess whether they
    reflect social work values?
  • If a certain group has power, what if using a
    program further supports their powerful role but
    disempowers parents? Can power be shared?
  • Is requiring parent involvement and service
    user/carers at every level a social work core
    value?

57
Values Groups Co- Led by Parents and
Professionals
  • Parent role respected at every level
  • Parents part of the planning team
  • Coaching to support parents to be in charge of
    their children in sessions
  • Support local parents to form informal social
    network of relationships
  • Parents lead monthly meetings 2yrs.
  • Parent graduate panel evaluates team

58
Value Reduce Social Exclusion
  • After school, multi-family group approach engages
    parents of young children and increases parent
    involvement at schools
  • Cultural representation of teams reflects culture
    and ethnicity of the families
  • Shared governance structures bring service users
    and professionals to plan together

59
Native American Review Evidence
  • Leaders in US representing several Indian
    nations, from tribal government and academia,
    reviewed a government list of 65 evidence based
    programmes, and chose which ones they wished to
    pilot
  • 3 SAMHSA model programs were selected by the
    Native Americans leaders

60
Harvard Review of Evidence Based Family
Strengthening Programs
  • October 2006, Harvard School of Education
  • Reviews 13 evidence based family programs to
    identify best practices
  • Lessons focus on parent-child bonding,
    recruitment and retention of families, staff
    preparation for working with families, and
    implementing the programs effectively.

61
Center for Mental Health Services Report to US
Congress on Child Mental Health
  • Summer, 2007
  • Urgency of intervening early children with
    prevent to mental health problems
  • Identifies 12 evidence based model prevention
    programmes with good child mental health outcomes
  • Recommends these to all communities

62
Social Workers and Prevention
  • Progressive legislation, e.g. Every Child Matters
  • Provide substantial funding to resource policies
  • Train workforce to provide support for all
    children well-being through preventative
    multi-agency initiatives social work and
    education and health
  • Select one from a list of evidence based models
    of prevention to pilot, adapt, and evaluate
    locally
  • Include parents in planning, training, and
    decision making about prevention services for
    children

63
Parent Involvement Strategy Positive Parent
Outreach
Mailings Home Visits Invitations
SCHOOL
Parent
Parent Attendance at school functions
64
Systemic Relationship-Based Parent Involvement
  • - Parent is the center of the model
  • - Focus is on empowering the parent to support
    their child
  • - Presumes that parents need strong relationships
    to effectively support child, including
  • 1- Relationships with other parents
  • 2- Strong family relationships
  • 3- Relationships with the resources of the
    school
  • 4- Relationships with community resources

65
Multi-family Groups
Babies
  • Applies social sciences research in the community
    to build social relationships across multiple
    social systems

66
Increased Serotonin
  • promotes feelings of well being
  • helps us sleep
  • elevates the pain threshold
  • helps protect the heart

67
Decreased Serotonin
  • Irritability
  • Violence and aggression
  • Depression
  • Feelings of hopelessness

68
What Lowers Serotonin?
  • TV viewing
  • High stress
  • Low social status
  • Onset of Puberty
  • Fighting/violence

69
What Raises Serotonin?
  • Positive touch
  • Social status
  • Social connectedness
  • Certain foods
  • Prozac
  • Ecstacy

70
Dopamine
  • Self efficacy mastery power
  • Reward center positive hits
  • Addictions research cocaine, nicotine,
    alcohol, gambling, sex
  • Ritalin

71
Neural Pruning in Brain Types
72
Neural Pruning in Brain Types
73
Neural Pruning in Brain Types
74
Ages of Neurological Pruning
3 years
3 months
6 months
9 months
12 months
75
What Fires Together, Wires Together
  • When different parts of the brains synapses fire
    at the same time, dendrites connect them
  • Seeing pictures in a book, hearing a Mothers
    description, sitting in a lap, saying things
    aloud
  • More complex, repeated dendritic connections in
    the brain will enrich the childs functioning

76
Ages of Neurological Pruning
9 years
12 years
6 years
15 years
77
Lessons of New Brain Research
  • Urgency of early intervention with infants
  • Strengthen neuro-transmitters of serotonin
    through positive touch and social interaction
  • Strengthen neuro-transmitters of dopamine through
    experiences of self-efficacy and praise
  • Repetition of positive interactions (300X) will
    thicken dendrites and prevent neurological
    pruning of unused synapses and dendrites

78
Applying the New Brain Research
  • How do we deliver the results of New Brain
    Research into the new babies brains?
  • Most effective way is through the Mother!
  • Mothers touch, voice, and smile will mean more
    to the babys dendrites than a strangers

79
A mother's eyes are a baby's skies
80
Social Ecology of Child Development
  • child

81
Social Ecology of Child Development
family
  • child

82
Social Ecology of Child Development
school
family
  • child

83
Social Ecology of Child Development
Neighborhood Community
school
family
  • child

84
Social Ecology of Child Development
neighborhood
school
family
  • child

85
Anticipated Baby Outcomes
  • Will test in rigorous research with control
    groups
  • Secure Attachment to Mother
  • Serotonin and Dopamine
  • - Stress Levels (Cortisol)
  • - Child Neglect and Child Abuse

86
Values Based Evidence Based
  • Culturally representative local team with 50-50
    service users and providers are encouraged to
    adapts the processes to fit local community norms
  • 60 of what happens is locally determined
  • 40 of the multi-family group time is core
    components and the same across all sites
  • Evaluation shows benefits of respecting parents
    , values of family support and community
    ownership combined with theory and research based
    activities

87
Babies
Multigenerational Multi-family Groups To Engage
and Support Young Parents Values Based and
Evidence Based
88
Applying The New Brain Research
Babies
89
Parent Involvement StrategySystemic
Relationship-based Engagement
  • School as a site of parent involvement
  • Focus is on systemic relationship-building

Other Parents
Child
S C H O O L
PARENT
Community Agency Staff
School staff
90
Bonding Bridging
Family Dyad Peers Dyad Family Community
91
Impact of Behavior Difficulties on Childs
Learning in Classes
n150 plt.01
26 decrease
92
Teacher-reported Academic Performance (CBCL)
N359
NIDA study of FAST in 10 urban schools
93
Teacher Ratingsof Academic Competence (SSRS)
N54
OERI Study of FAST in rural American Indian
schools
94
One Year Follow-up Teacher Ratings
Plt.05
95
Teacher Reported Aggressiveness Scores -
CBCL
Pre
Post
Follow-up
96
We think Social Workers Can Build Social Capital
with Systemic MFG
  • Outreach home visits to invite and engage
  • Weekly dosage important need six doses
  • Time for personalized dyad interaction needed
  • Repetition, safety, routine structures supports
    making the non-conflicted deeper relationships
  • Fun, positive, creative activities important
  • 4 year FU 86 reported making a new friend

97
www.fastprogram.orgUniversity of
Wisconsin-Madison
  • Please contact us for more information
  • FAST multi-family groups are replicated by
    trained teams of social workers and service users
  • Over 800 communities do FAST in 45 states in US,
    in each of the Canadian provinces, many locations
    in Australia, and in Germany, Austria, and Russia
  • Contact us to collaborate to do RCT research!!

98
Social Work and Social Capital
  • March 21, 2006
  • Lynn McDonald, MSW, PhD
  • Visiting Research Fellow to PACE, Goldsmiths
    College, London, UK
  • University of Wisconsin-Madison, Wisconsin Center
    for Education Research

99
Can Social Workers Build Social Capital for
Young Mothers and Improve Infant Outcomes?
  • February 23, 2006
  • Lynn McDonald, MSW, PhD, Visiting Research Fellow
  • PACE, Goldsmiths College
  • University of London

100
Multi-family Groups with Young Teen Mothers of
Infants (0-3)
  • March 8, 2006
  • Family Therapy Seminar, IOP, London, UK
  • Lynn McDonald, MSW, PhD
  • Visiting Research Fellow to IOP
  • University of Wisconsin-Madison, Wisconsin Center
    for Education Research

101
SOCIAL WORK AND SOCIAL CAPITAL
  • Tuesday, March 21, 2006
  • PACE, Goldsmiths College
  • University of London

102
Social Scientists Study Social Capital
  • Political scientists
  • Economists
  • Sociologists
  • Anthropologists
  • Psychologists

103
Social Workers?
  • Social Workers apply social science research to
    address urgent social problems and issues
  • With service users, develop, implement and assess
    interventions based on theory and research
  • Advocate for and ask questions about social
    justice
  • Study strategies for building social capital and
    for empowering voices of socially excluded groups

104
What is Social Capital
  • Trusting relationships, reciprocal exchanges,
  • Maintaining relationships across time
  • Bonding within and bridging across groups
  • Intergenerational closure, hubs of 4-5
  • Strong links, weak ties
  • Norms and sanctions for social behavior

105
Benefits of Social Capital
  • Positive community engagement and voting
  • Increased longevity (3-5 years) and health
  • Improved educational outcomes for children
  • Improved local economy, employment levels
  • Reduced neighborhood crime and drug abuse
  • Reduced child abuse and neglect
  • Considered to not be expensive outside market

106
Critiques of Social Capital
  • Focus on relationships, not on power structure
  • Does not shift power to disempowered
  • Focus on social connections rather than group
    voices of change to challenge social system
  • Norms and sanctions of high social capital can
    inhibit individual self expression

107
Social Capital vs. Social Isolation
  • Social isolation is worse for health than smoking
  • Social exclusion is experienced as intensely as
    being kicked in the stomach (MRI brain imaging)
  • Extended families and stable villages in
    coherent, traditional societies are rich in
    social capital
  • Immigrants choose for something in new country,
    and turn away from their past social capital (US)

108
US Social Capital Decreases
  • Robert Putnam, Political Scientist, Harvard
  • Data on 500,000 in US over 40 years
  • Documented steep decline in social capital
  • Why now? He hypothesized and analyzed
  • TV viewing

109
A Social Problem Outcomes of Babies of Young
Mothers
  • UK recently completed 5 year evaluation of Sure
    Start initiative in high need communities for
    babies (0-5), mothers and families
  • Baby outcomes of young mothers in Sure Start
    showed lower functioning when compared to baby
    outcomes in comparison communities
  • Why? Social exclusion at Sure Start?

110
Young Mothers
  • Stigmatized,socially excluded in local
    communities
  • Highlighted in government policies as a social
    problem whose problem is this?
  • Under-serviced population hard to engage young
    mothers in treatment, services, or parent
    education with blaming attitudes held by middle
    class social workers and nurses whose problem is
    this?

111
The Need
  • Low income, socially excluded, highly stressed,
    adolescents girls, who may also show increases in
    depression, anxiety, drug use, school failure,
    conduct disorder, anti-social behaviors
  • New mothers who are depressed, stressed, socially
    isolated, have infants at increased risk for
    delays in cognitive emotional development, and
    neglect and/or physical abuse (not related to age
    of mother)

112
Applying the New Brain Research
  • Family Support America
  • Sunday, March 26, 2006
  • Hilton, Chicago, Illinois

113
SAMHSA Model Program
  • Not parent education
  • Not family therapy
  • Is family support
  • Includes parent education
  • Includes family systems approach
  • Includes family stress reduction

114
New Brain Research
  • Decade of the New Brain Research
  • Neuro Magnetic Resonance Imaging
  • Neurons, Synapses, Dendrites
  • What Fires Together Wires Together
  • Neuro transmitters Serotonin, Dopamine
  • Use It or Lose It implications for babies

115
Basic Brain Functioning
  • Dendrites
  • Close up of dendrite
  • Neuro-transmitters
  • (serotonin, dopamine)

116
Pregnancy rates
PAXIS Institute www.paxis.org
117
Applying the New Brain Research
  • How do Busy Mothers decide to spend their
    precious time on The New Brain Research
  • With family support! With respectful values!
  • With research based, tested, outreach and
    engagement strategies, e.g. locally adapted
    multi-family groups FAST Babies

118
Babies
Activities
  • Family Table, Greetings, Music
  • Choices Game for sake of the baby
  • Small Group Scenarios Discussion
  • New Mother Group/infant massage
  • Grandmother group
  • Father group
  • Group meal/lottery/Rain
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