Targeting All Parents

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Nearly 15 years ago, first lady Hillary Clinton popularized the old African proverb, “It takes a village to raise a child.”

Lately, a raft of new research has focused on a related but narrower question: Does it take a village to prevent child abuse and neglect? Or, phrased another way, do community-wide prevention and intervention strategies – as opposed to strategies relying solely on direct services to individual families – offer the more promising avenue for reducing child maltreatment?

The answer: Not necessarily. But done right – the Australian way – community-wide support for better parenting can make a dramatic and cost-effective difference.

In an article for the fall 2009 issue of Future of Children, Deborah Daro of the Chapin Hall Center for Children and Kenneth Dodge of Duke University spelled out the logic behind attacking child maltreatment at the community level, rather than one family at a time.

“Child abuse prevention efforts have histori¬cally focused on developing and disseminating interventions that target individual parents,” wrote Daro and Dodge. “[But] it is increasingly recognized that environmental forces can overwhelm even well-intended parents, that communities can support parents in their role and that public expenditures might be most cost-beneficial if directed toward community strategies.”

Yet, when Daro and Dodge examined the research on five leading community child abuse-prevention approaches nationwide, four had limited or no evidence of effectiveness.

However, the fifth model – the Positive Parenting Program (a.k.a. “Triple P”) – has been shown to improve factors related to child maltreatment (such as parental stress, coercive parenting practices, and child behavior problems) in a steady stream of scientific studies dating back nearly 30 years.

Developed in Australia by the University of Queensland’s Matthew Sanders, Triple P aims to reduce child maltreatment by boosting the quality of parenting in entire communities. Triple P promotes stronger parenting through a multi-layered program that includes:

• A universal media campaign to spread awareness of effective parenting practices and encourage utilization of available parenting support services.

• Consultations, parenting seminars and brief counseling services for parents whose families have moderate needs and low risk for abuse and neglect.

• More intensive training and family intervention services for parents whose families have more serious needs and face greater risks.

The model “offers a whole suite of parenting and family support strategies to help any and all parents in the community with the task of parenting,” says Ronald Prinz, a University of South Carolina psychologist who recently completed a trial of Triple P.

The Design

When the study began in 2003, Prinz randomly assigned nine medium-sized South Carolina counties to implement Triple P and another nine counties to maintain their existing services and serve as controls.

Each of the counties implementing Triple P publicized and promoted available parenting services through radio, newspapers, school newsletters, mass mailings, press releases, presentations and a website. Public education is critical, Prinz says, because the vast majority of parents at risk for abusing their kids are never known to authorities and can’t be recruited into direct service programs. Also, says Prinz, the media campaign helps to “normalize” parent-training programs, reducing the stigma parents may feel about participating.

The Triple P counties also conducted outreach and provided training on positive parenting principles to all staff members working in systems that routinely interact with parents and children, such as schools, pre-schools, child care centers, mental health and social service departments and medical facilities. The nine Triple P counties trained a total of 649 service providers.

From surveys, Prinz found that after two years, one in six parents in the participating counties was aware of the Triple P project, while about 11,000 of the 85,000 families with at least one child ages 0-8 in the participating counties received either brief or intensive parenting assistance.

Results

In January 2009, Prinz published the results of the South Carolina Triple P experiment in the journal Prevention Science. Five years after launching the project, Triple P counties had far better results than comparison counties on each of the three outcomes measured:

• Although the number of substantiated child maltreatment cases per 1,000 children increased in both Triple P and comparison counties – for unknown reasons, maltreatment rates rose sharply throughout South Carolina during the measurement period – the increase was much smaller in Triple P counties (8 percent) than control counties (35 percent).

• Out-of-home foster care placements declined 12 percent in Triple P counties but grew 44 percent in control counties.

• The number of emergency room visits and hospital admissions resulting from child maltreatment declined 18 percent in Triple P counties but rose 20 percent in control counties.

Each of these results was statistically significant, despite the small number of counties involved. Prinz estimated that for a community with a child population of 100,000, the results would translate into 688 fewer substantiated cases of child maltreatment, 240 fewer foster care placements, and 60 fewer children requiring emergency room care or hospitalization due to child maltreatment injuries.

These findings are particularly important, Prinz argues, because the South Carolina study is the first to assign entire geographic areas randomly and show population-wide effects for reducing child maltreatment. “We showed that if you really go after parenting for a whole community, you can make a real difference in child maltreatment for an entire population.”

In a related article for Children and Youth Services Review in 2008, Prinz and colleagues found that Triple P was cost-effective, requiring an up-front investment of just $12.49 per child under 12 in any given community to support both a media campaign and training for child and youth workers. Given the high public costs (nearly $200,000) associated with each child maltreatment case, they estimated that communities implementing Triple P would recoup their up-front investments in less than one year.

Compared with others …

Triple P’s success contrasts sharply with other community-focused prevention initiatives examined by Daro and Dodge, who found:

• Mixed results for a project (Durham Family Initiative) seeking to integrate existing children’s services into a coordinated county-wide system of care and employing outreach workers to engage parents living in particularly troubled neighborhoods.

• No published results for a foundation-funded effort (Strengthening Families Initiative, not to be confused with Karol Kumpfer’s Strengthening Families Program) aimed at strengthening the capacity of formal child care centers in seven states to engage parents, identify risks and needs, and provide support to help parents avoid contact with the child welfare system.

• No change in child maltreatment rates from an initiative (Strong Communities) to promote new attitudes and expectations among parents and other community members and encourage them to help each other and take collective responsibility for the well-being of neighborhood children.

• Few positive effects from a model (Community Partnerships for Protecting Children) aimed at reforming local child protective services systems and connecting formal service providers with leaders, residents and community-based organizations in the neighborhoods they serve.

While the South Carolina study will have to be replicated in other locations in order to substantiate its findings, the Triple P results also compare favorably with home visitation programs. Though such programs have grown increasingly popular in recent years, the British journal, The Lancet, reported last year that “[most] early childhood home-visiting programmes … have not been shown to reduce physical abuse and neglect.”

The notable exception is the Nurse Family Partnership project, which lowered child maltreatment substantially in one major trial and reduced child injuries in another. However, the program is only designed to serve first-time, low-income mothers, a small slice of the population at risk for potential child maltreatment. Also, the Nurse-Family Partnership treatment involves 75 home visits over two years, as opposed to a maximum of 15 home visits in the most intensive Triple P intervention.

Prinz calls himself an admirer of the Nurse-Family Partnership, which has also documented many benefits unrelated to child maltreatment, and he sees no reason a community cannot implement both Triple P and Nurse-Family Partnership. But, he warns, “if you burn up all of your resources on [Nurse-Family Partnership], and you have nothing left for the rest of the families in the community … that’s a problem. …

“You need a blended community-wide strategy.”