SafeCare Maryland Presentation - Dr. Lutzker

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

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

II. SafeCare Program
Description

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)

• 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

• 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 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
– Observe play and 2 daily activities
– LoTTS of Bonding Behaviors
• Look, Touch, Talk, Smile
– Other Bonding Behaviors
• Holding, Rocking, Imitating
– 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
– Assess hazards in 3 rooms
– Teach parents about common hazards
– Remove and secure hazards in each room
– Encourage parental supervision
– 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

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

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
– 3 scenario role-plays
• Emergency, doctor’s appointment, care at home
– Introduce health manual
– Systematic decision making process
– Use health reference materials
– Keep good health records
– Understand prevention efforts
– 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

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

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%

V. SafeCare Implementation
and Training

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
OngoingCoaching
HVHV
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
OngoingCoaching
Ongoing
support
HVHV
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 HVHV
NSTRC (coach)
Coach
HV HVHV
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?

Contacts
John R. Lutzker, PhD
Jlutzker@gsu.edu
404-413-1284
Daniel Whitaker, PhD
Dwhitaker@gsu.edu
404-413-1282
www.safecare.org

SafeCare Maryland Presentation - Dr. Lutzker

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (7)

Semelhante a SafeCare Maryland Presentation - Dr. Lutzker

Semelhante a SafeCare Maryland Presentation - Dr. Lutzker (20)

Mais de Georgia State School of Public Health

Mais de Georgia State School of Public Health (20)

Último

Último (20)

SafeCare Maryland Presentation - Dr. Lutzker