Initially, these efforts focused on raising awareness of the problem and enhancing the public's understanding of behaviors that constitute abuse and neglect and their impact on child well-being Daro and Cohn-Donnelly, In recent years, broadly targeted prevention campaigns have been used to alter specific parental behaviors.
For example, the U. Campaign strategies included media coverage; the availability of a nationwide toll-free information and referral hotline; the production of television, radio, and print ads; and the distribution of informational brochures to new parents. As of , the National Center for Health Statistics reported a 50 percent drop in SIDS deaths and a decrease in stomach sleeping from 70 percent to 15 percent.
Although the evidence linking the campaign to changes in these population-level indicators is exploratory, the data are suggestive of how public education might be used to change normative practices Mitchell et al. One of the most thoroughly examined public education and awareness campaigns addressing child abuse has been the effort to prevent shaken baby syndrome, now termed abusive head trauma.
Moving beyond basic awareness, Dias and colleagues developed a universal education program on shaken baby syndrome, which they implemented in an eight-county region in western New York. The program provided information on shaking to parents of all newborns prior to the infants' discharge from the hospital. During the 6 years before the program, 40 cases of substantiated abusive head injuries were identified in the targeted New York counties—an average of 8. In the Pennsylvania comparison communities, there was no change in the number of such cases observed during the same two time periods Dias et al.
Another promising public education and awareness program, The Period of PURPLE Crying, focuses on helping parents understand and cope with the stresses of normal infant crying. The program was tested through four different types of delivery systems: More than 4, parents participated in the program. A randomized controlled trial of the program found that it succeeded in enhancing mothers' knowledge about infant crying.
While these findings are encouraging, others implementing these types of broadly targeted efforts have not achieved comparable results. The extent to which these programs can result in sustained population-level change in parenting behaviors remains unclear. In addition to the provision of direct services to new parents, increased consideration is being given to how best to use existing service delivery systems that regularly interact with families to address the potential for abuse and neglect.
For example, the medical field has long sought ways to better address healthy child development and child abuse and neglect within clinical settings. Historically, health professionals have faced barriers to using the traditional checkup appointment to carry out this responsibility. Doctors are often uncomfortable discussing sensitive issues, and they frequently lack the training to instigate such conversations and the ability to recognize key warning signs Benedetti, Additionally, adequate and comprehensive screening tools have not been made available to all primary care providers Benedetti, ; Dubowitz et al.
The Healthy Steps program, an evidence-based model that places child development specialists within selected pediatric practices, was initially created in to address this issue. Today, Healthy Steps is available in 17 states and has demonstrated consistent impacts on child health, child development and school readiness, and positive parenting practices Benedetti, ; Caughy et al.
More recently, the Safe Environment for Every Kid SEEK program was created to help health professionals address risk factors for child abuse and neglect through a training course, the introduction of a Parent Screening Questionnaire, and the addition of an in-house social worker team to work with families. Two studies were recently conducted to test existing SEEK programs: The first was a randomized trial conducted between and in resident clinics in Baltimore, Maryland.
Families enrolled in the SEEK treatment group showed significantly lower rates of abuse and neglect across all measures compared with controls Dubowitz et al. The second study, conducted 2 years later, investigated whether the program changed doctors' attitudes, behaviors, and competence in addressing child abuse and neglect among their patients Dubowitz et al.
Eighteen private practice primary care clinics participated in a cluster randomized controlled trial.
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The pediatricians in the SEEK group showed significant improvement in their abilities to address substance use, intimate partner violence, depression, and stress, and they reported higher levels of comfort and perceived competence in doing so Dubowitz et al. A focus on the community as an appropriate prevention target is supported by findings of public health surveillance efforts and research on the effects of neighborhood contexts Coulton et al.
Research using population- and community-level data underscores the pressing need to design, target, and promote preventive service programs in jurisdictions exhibiting the greatest need Putnam-Hornstein et al. Accordingly, a number of strategies have emerged that focus on ways to better coordinate and integrate services provided through multiple domains and to alter the context in which parents rear their children Daro and Dodge, The goal of such efforts is to move from simply assessing the prevention impacts on program participants to achieving population-level change by creating safe and nurturing environments for all children, as well as communities in which parents are supported through both formal services and normative values that foster mutual reciprocity.
Although such initiatives are not fully operational in any community, the goal of altering both individuals and the context in which they live potentially provides a potent programmatic and policy response Daro et al.
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In a recent review of five multicomponent community initiatives, Daro and Dodge conclude that the implementation of multifaceted interventions that combine direct service reforms with attempts to alter residents' access to and use of both formal and informal supports are promising but largely unproven. Based on comparisons of administrative data, at least some of the models they reviewed had successfully reduced reported rates of child abuse and injury to young children at the county or community level Dodge et al. When focusing on community building, several models demonstrated a capacity to mobilize volunteers and engage diverse sectors within the community, such as first responders, the faith community, local businesses, and civic groups, in preventing child abuse Daro et al.
At present, however, little information is available on how these attitudes and willingness to support one's neighbors will translate into a measurable or sustained reduction in child abuse and neglect and enhanced parental support CDC Essentials for Children, available at http: Designing and implementing a high-quality multifaceted community prevention initiative is costly.
Moving forward, policy makers need to consider the trade-offs of investing in diffuse strategies designed to alter community context versus expanding the availability of services for known high-risk individuals. For the research community, a potential area of inquiry may lie in examining key mediators of either individual- or population-level outcomes and identifying less costly ways to create these mediators within prevention efforts.
Investments in preventing child abuse and neglect increasingly are being directed to evidence-based interventions that target pregnant women, new parents, and young children. Since the NRC report was issued, the prevention field has become stronger and more rigorous both in how it defines its services and in its commitment to evaluative research.
And although greater attention is being paid to the development of home visiting interventions, the field embraces a plethora of prevention strategies. Communities and public agencies continue to demand and support broadly targeted primary prevention strategies such as school-based violence-prevention education, public awareness campaigns, and professional practice reforms, as well as a variety of parenting education strategies and support services for families facing particular challenges. None of these program approaches are perfect, and they often fail to reach, engage, and retain their full target population successfully.
Notable gaps exist in service capacity, particularly in communities at high risk and among populations facing the greatest challenges. And a substantial proportion of those families that do engage in intensive, long-term early intervention programs will exit the services before achieving their targeted program goals. That said, the committee finds the progress in prevention programming to be impressive, but the strategies employed to be underdeveloped and inadequately researched.
A broad range of evidence-based child abuse and neglect prevention programs increasingly are being supported at the community level to address the needs of different populations. Strategies such as early home visiting, targeting pregnant women and parents with newborns, are well researched and have demonstrated meaningful improvements in mitigating the factors commonly associated with an elevated risk for poor parenting, including abuse and neglect.
Promising prevention models also have been identified in other areas, including school-based violence prevention education, public awareness campaigns, parenting education, and professional practice reforms. Despite substantial progress in the development of effective prevention models, many of these models require more rigorous evaluation.
Research is needed to devise strategies for better reaching, engaging, and retaining target populations, as well as to develop the capacity to deliver services to communities at high risk and among populations facing the greatest challenges. Developing a pool of high-quality interventions is essential to address the problem of child abuse and neglect.
Equally important is understanding how best to replicate, sustain, and integrate these programs into an effective system of care. Unfortunately, in child abuse and neglect as in other areas of health, mental health, and social services, a wide gap exists between available evidence-based interventions and practices and effective methods for their dissemination, implementation, and sustainment. This is a critical concern because the potential public health benefit of these interventions will be severely limited or unrealized if they are not implemented and sustained effectively in usual-care practice, be it in child welfare, mental health, substance abuse, or primary health care settings Balas and Boren, Indeed, the success of efforts to improve services designed to support the well-being of children and families is influenced as much by the process used to implement innovative practices as by the practices selected for implementation Aarons and Palinkas, ; Fixsen et al.
It is increasingly recognized that investment in the development of interventions without attention to how they align with service systems, organizations, providers, and consumers results in poor application of evidence-based practices. Indeed, once evidence-based practices are taken to scale, the outcomes and effect sizes documented in their initial clinical trials often are not replicated. One reason for this is that complex interventions frequently are simplified over time in ways that impact key program objectives and strategies Mildon and Shlonsky, Poor implementation has been cited as the reason for weakened effects in programs addressing conduct problems Lee et al.
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If replicating an evidence-based intervention does not produce a corresponding replication of impact, the intervention cannot be expected to reduce the incidence of the problem it was designed to address. Unless incidence is significantly reduced, the dramatic cost savings purported to follow major investments in high-quality treatment and prevention services may not materialize. As evidence-based practices move from controlled settings to a real-world context, tension arises between remaining rigidly faithful to the original model and adapting it to local circumstances and needs Backer, ; Bauman et al.
Although adaptation may or may not be a deliberate choice, some form of adaptation is likely to be the rule rather than the exception in community care Aarons et al. Ideally, such adaptation does not change the core elements of evidence-based practices, that is, those required elements that fundamentally define the nature of the practices and produce their main effects Backer, ; Bauman et al.
Understanding when and how to alter a program in ways that enhance rather than diminish its effects represents a major social service challenge. Since the NRC report was issued, significant research has been conducted on how to define the concept of program fidelity, understand the role of race and culture in determining when and how to adapt evidence-based practices, identify those factors that facilitate or compromise the replication of evidence-based practices with fidelity, and clarify how research can be incorporated into the overall programming planning process.
In addition, increased attention is being paid to the costs of interventions relative to their overall impact, resulting in an increased demand for more consistent and comparable methods of quantifying and tracking program expenditures and their long-term impacts on public budgets. This section summarizes this body of research and identifies those areas in need of additional study. At the most basic level, faithfully replicating programs that have been found effective in rigorous experimental studies is believed to result in a higher likelihood of achieving desired outcomes than replicating programs that lack a strong evidentiary base Fixsen et al.
Investing in direct service programs with a proven track record offers policy makers a hedge on their investment and provides increased confidence that outcomes also can be replicated. Central to this hypothesis, however, is ensuring that sites replicating a model maintain fidelity to its original design and intent.
As replication of evidence-based programs becomes more commonplace, it is increasingly important to design and implement frameworks for defining program fidelity, as well as data management systems that can track the implementation process at the level of specificity needed to ensure consistent replication. Researchers use several theoretical frameworks to define fidelity and address issues of appropriate modification.
In summarizing work in this area, Carroll and colleagues identify five elements of implementation fidelity: The rise of implementation science and the need to replicate and scale up evidence-based programs with fidelity across a range of disciplines has led to the development of a number of frameworks identifying an array of factors that should be considered to ensure that replication is faithful to both the structure and intent of the original model Bagnato et al. These factors include an appropriate target population, staff skills and training, supervision, caseloads, curriculum, and service dosage and duration, as well as the manner in which services are provided and participants are engaged in the service delivery process.
Maintaining fidelity is especially important in practice-based research networks and learning collaboratives because it allows networks to gauge outcomes that can be used to make necessary practice and science improvements. Attention to these factors is necessary both in the initial planning process and throughout implementation.
The importance of cultural processes in shaping human functioning is increasingly being recognized.
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It is therefore critical to understand whether child abuse and neglect interventions are effective with ethnic minority youth who are at risk for or experience child abuse or neglect. A number of scholars have argued that culture matters in the development and testing of prevention and intervention strategies, as well as in the replication and adaptation of evidence-based practices for distinct populations or groups e.
According to this perspective, the culturally related processes underlying parenting and sociocultural risks that can lead to or exacerbate abuse and neglect must be considered to ensure the social validity and practical application of an intervention Lau, Another body of literature comprises evaluation of evidence-based interventions with ethnic minority youth and families, focusing on such questions as 1 Are evidence-based interventions effective for ethnic minority youth?
Huey and Polo, , This literature is still in its infancy. As discussed earlier in this chapter, the extant literature shows that evidence-based interventions delivered to African American and Latino youth can be effective for additional discussion of this issue, see Huey and Polo, , Of note, only four interventions have shown effectiveness with ethnic minority youth across multiple trials: In addition to these interventions targeting mental health and adjustment problems, a child welfare intervention targeting American Indian parents Chaffin et al.
Evidence-based interventions appear to work equally well for African American and Latino youth and European American youth, indicating no consistent effects of moderation Huey and Polo, Although most of the interventions investigated in these studies did not explicitly target ethnic minority youth who were abused and neglected, those interventions that did explicitly include this population yielded similar findings regarding effectiveness, moderation, and the impact of cultural adaptation.
However, the discussion of cultural elements in reports on evidence-based interventions varies considerably Huey and Polo, , which may impede understanding of the impact of cultural adaptation; in particular, reporting of the development and evaluation of many culturally adapted interventions is characterized by a relative lack of theory and conceptual framing.
Thus, more research is needed to test key assumptions and hypotheses regarding minority youth and the effectiveness of interventions. A critical gap in this literature is that evidence-based interventions have been tested primarily with African American and Latino youth; with few exceptions, little is known about the effectiveness of evidence-based interventions with Asian American and American Indian youth.
For example, there have been few studies on the effectiveness of home visiting models that involve structured, protocol-driven approaches with families in tribal communities Del Grosso et al. One noteworthy effort is the randomized controlled trial of Family Spirit, modeled on Healthy Families America, which found that a family-strengthening home visiting program delivered by paraprofessionals significantly increased mothers' child care knowledge and involvement Walkup et al. To illustrate these issues, interventions targeting American Indian and Alaska Native families and communities need to take account of their history, culture, and tribal diversity DeBruyn et al.
Thus, addressing child abuse and neglect and trauma among these populations presents unique opportunities to develop culturally sensitive interventions that align with traditional circular and contextual world views and to adapt or enhance evidence-based practices that are based in authentic practitioner-researcher partnerships Poupart et al.
One prominent example, Project Making Medicine, provides training in the clinical treatment of child physical and sexual abuse based on the cultural adaptation of TF-CBT. Entitled Honoring Children, Mending the Circle, the curriculum features an indigenous orientation to well-being and the use of traditional healing practices. Cultural adaptations to family preservation approaches involve using genograms, wraparounds, talking circles, kinship care, healing ceremonies, and traditional adoptions with Native families.
This intervention also incorporates tribal elders and extended family in the use of specific cultural approaches, such as storytelling, sweat lodges, feasts, and use of Native languages Bigfoot and Funderburk, The effectiveness of these adaptations of clinical tools and interventions merits further research. In sum, the field of evidence-based interventions for cultural minority populations is still developing. Research is needed on understudied populations, as well as on key assumptions, hypotheses, and implementation issues of culturally adapted evidence-based interventions.
Guidelines on when to consider making a cultural adaptation and how specifically to do so would provide important support for the field. Lau offers an evidence-based approach to making such decisions. More specifically, populations that face unique sociocultural contexts of risk or resilience that differ from those targeted by the original evidence-based intervention may be appropriate candidates for cultural adaptation. When it is determined that cultural adaptation is warranted, Lau further suggests a data-based approach to decisions on the adaptations to implement.
Surface-structure adaptations Resnicow et al. A multistep process was used, including a review of the clinical literature on Mexican American families; identification of known barriers to treatment access and effectiveness; use of focus groups; and interviews with Mexican American mothers, fathers, and therapists to learn how PCIT could be modified to be more culturally effective.
The process culminated in an expert panel review of the intervention Lau, Another example, The Children and Families as part of the National Child Traumatic Stress Network , addressed the treatment and service needs of traumatized Latino children and families through the creation of adaptation guidelines for practitioners and researchers. Child welfare staff were trained to implement a systems of care approach—an existing evidence-based framework—to improve practice and service delivery for immigrant Latino children at the system level Dettlaff and Rycraft, In such efforts, it is important to attend to the theoretical, implementation, and evaluation issues involved.
Perhaps the data-based framework articulated by Lau can help inform a more rigorous articulation of the circumstances in which evidence-based interventions should be culturally adapted and of the methods that should be used to evaluate the adapted interventions. Since the NRC report was issued, significant work has been done on how to define and monitor the program implementation process itself and on the critical factors related to higher-quality implementation and sustainability.
Consensus exists on important key factors, such as availability of funding; leadership in implementation efforts; ongoing consultation and training, especially in the early implementation phases; and the need to address the impact of staff turnover. In many cases, however, research on these factors is lacking Aarons et al. Consensus also exists that multicomponent implementation strategies are needed, as many different factors need to be addressed in sequence or in tandem for effective implementation that sustains public health impact Ferlie and Shortell, ; Fixsen et al. Implementation frameworks have been developed to expand and distill theories, structures, and processes into manageable approaches for understanding and identifying key facilitators of and barriers to effective implementation.
Most theories provide guidance regarding implementation research and practice, while particular tenets and assumptions of frameworks require further empirical testing to determine whether they actually lead to more effective implementation Aarons et al. Implementation researchers typically test components of models e. Notable exceptions include studies of system-level implementation in the context of child welfare, such as the use of community development teams to scale up multidimensional treatment foster care in multiple counties Chamberlain et al.
To support program fidelity, effective and efficient measurement methods that can be readily utilized in usual care settings are needed Schoenwald et al. In addition, there must be a feedback system coupled with supportive quality improvement or coaching to help providers maintain fidelity Aarons et al. In many cases, however, little ongoing attention is paid to fidelity once an intervention has been implemented. Delivery of an intervention without attention to its fidelity fails to ensure that services are effective.
Efforts have been made to integrate fidelity assessment for psychosocial interventions in systems that involve child abuse and neglect; however, these efforts may or may not be part of implementation studies. One effectiveness trial found that incorporating ongoing coaching to direct service providers in the delivery of a child neglect intervention supported service efficacy Chaffin et al. This statewide trial was also examined in an implementation study that found benefits for organizations and service teams in reduced provider burnout and turnover.
There is also increasing interest in the use of technology to support real-time fidelity assessment. It is important to recognize that many program implementation efforts have occurred in the context of funded research studies. Outside research funding often covers the costs associated with initial monitoring and documentation of the implementation process, including the collection and analysis of participant-level data to document service dosage, duration, and content. In some cases, study subjects have been paid for their participation in the program and may have received reimbursement for child care or transportation expenses related to their participation.
As evidence-based practices move from the research venue to standard practice, some entity must pay these costs. Increasingly, evidence-based practice models are factoring into their per-participant cost projections those expenses associated with initial and ongoing training for direct service staff, supervisory standards, and data reporting requirements. State agencies or community-based service providers seeking to implement these models are required to cover these costs as part of purchasing the program. It remains unclear whether these program-driven standards will be sufficient to sustain program fidelity and quality over time and achieve the level of participant engagement required to both sustain program fidelity and replicate outcomes.
Most implementation plans for evidence-based practices include methods for transferring research evidence from the program developers to potential users. Some of these models focus explicitly on the use of research evidence Honig and Coburn, ; Kennedy, ; Nutley et al. Many of these models represent typologies of research use. Whereas the central feature of the instrumental model is the decision, the central feature of the conceptual model is the human information processor. Hence, the instrumental model focuses on the outcome of using evidence, while the conceptual model focuses on the process of using evidence Kennedy, Conceptual models of evidence acknowledge that the use of research evidence to make or support decisions is often a collective endeavor rather than an activity performed by any individual decision maker Spillane et al.
This collective endeavor involves the utilization of social capital Honig and Coburn, ; Spillane et al. Preliminary research Palinkas et al. Feasibility of implementation was the primary criterion used to evaluate this evidence. However, further research is needed to identify components of feasibility that may drive implementation decisions. Policy makers, program administrators, and researchers increasingly acknowledge the importance of understanding the costs, cost-effectiveness, and returns on investment of child abuse and neglect programs.
Policy makers want information on costs and how they compare with outcomes of interest for determining how to allocate scarce resources; program administrators want to identify which programs to implement; and researchers are interested in economic evaluation because it makes their program evaluations more comprehensive Corso and Lutzker, ; Courtney, The demand for economic analysis is evident in strategic planning being developed at the federal level.
In the Centers for Disease Control and Prevention's research plan for injury and violence prevention, for example, a top priority is to describe the use and impact of service delivery as well as the costs of interventions for child abuse and neglect. Corso and Filene, , p. Assessment of the economic costs of implementing an intervention is called programmatic cost analysis.
The process involves the systematic collection, categorization, and analysis of intervention delivery costs, including those entailed during the preimplementation developing the program delivery infrastructure and implementation delivering the program phases Corso and Filene, A standardized methodology for determining costs for child abuse and neglect interventions does not currently exist, although guidelines available in other fields could be applied Foster et al.
To address this need, efforts are under way at the Children's Bureau within the Administration for Children and Families to develop a manual on how to conduct programmatic cost analyses specifically within the child welfare community. Once the costs of a program have been determined, they can be compared with a program's expected and realized short- and long-term outcomes. This comparison of costs with outcomes is referred to as economic evaluation and includes a number of analyses, such as benefit-cost analysis and return on investment, whereby outcomes are valued in monetary terms, and cost-effectiveness analysis, whereby outcomes are valued in natural units, such as cases of child abuse and neglect prevented or improvements in quality of life.
Although some guidelines for conducting economic evaluations do exist for community-level interventions in general Haddix et al. Despite the need for information on the economic cost and impact of implementing child and family development or child abuse and neglect prevention programs, few cost analyses Corso and Filene, or economic evaluations have been conducted in this area since the NRC report was issued Barlow et al.
More studies have focused specifically on economic evaluation of interventions designed to improve outcomes for children at risk for or currently involved in the child welfare system these studies are systematically reviewed and summarized by Goldhaber-Fiebert and colleagues []. Remaining challenges to conducting programmatic cost analysis and economic evaluation in the fields of child abuse and neglect intervention and child welfare include the need for 1 the development and consistent use of standardized methodology for assessing program costs; 2 multisite assessment of programs in which program-, provider-, and community-level variables may impact program-level costs and outcomes; 3 better tools for assessing the impact of child abuse and neglect on health-related quality of life, which is an important outcome measure in economic evaluations within other health fields; 4 assessment of the long-term costs of child abuse and neglect to determine the potential benefits of prevention and successful child welfare services; and 5 the development and use of model-based economic evaluations to support decision making within the child welfare system Goldhaber-Fiebert et al.
As policy makers place greater emphasis on evidence-based decision making and the implementation of programs that have been proven effective through rigorous evaluation, research will be needed to understand how these high-quality interventions are replicated, adapted to diverse populations, and incorporated into the overall service delivery system.
At present, little is known about the most effective strategies for ensuring that evidence-based practices are replicated with fidelity to their intent and structural elements. Central here is determining which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations.
Equally important is understanding the costs associated with the emphasis on replicating with fidelity in terms of 1 monitoring the service delivery process; 2 providing the required levels of supervision and infrastructure support, including the development of data collection systems; and 3 determining how the data will be integrated into subsequent practice and policy decisions. Despite a growing body of theoretical and applied research in the area, a wide gap exists between available evidence-based interventions and practices for treating and preventing child abuse and neglect and methods of effective dissemination, implementation, and sustainment of those interventions.
It is increasingly recognized that investment in developing interventions alone, without attention to how they align with service systems, organizations, providers, and consumers, results in poor application of evidence-based practices. Therefore, more research is needed to support the translation of model programs for effective use in real-world settings. Little is known about the most effective strategies for ensuring that evidence-based interventions are replicated with fidelity to their intent and structural elements.
Further research is needed to determine which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations. More research is needed on the development of evidence-based interventions for cultural minority populations, with a particular focus on understudied populations. Also needed is research that carefully examines key assumption, hypotheses, and implementation issues of culturally adapted evidence-based interventions. Guidelines on when to consider making a cultural adaptation and what the specific adaptation should be would provide important support to the field.
Significant advances have been achieved in how the program implementation process itself is defined and monitored and in the identification of critical factors related to higher-quality implementation and sustainability. Consensus exists on key factors, but in many cases, research on these factors is lacking. Consensus also exists that multicomponent implementation strategies are needed to address the challenges of effective implementation. Despite the need for information on the economic cost and impact of implementing child and family development or child abuse and neglect prevention programs, few studies have conducted programmatic cost analyses or economic evaluations in this area.
This type of research is needed to guide policy makers and program administrators. As the discussion in this chapter has made clear, several of the challenges faced in replicating promising programs and their outcomes lie in the process by which programs are designed and implemented. Equally important, however, is considering the programs' institutional, organizational, and political context. Elements of this broader infrastructure can support or complicate the implementation and sustainability of a promising approach Tibbits et al.
Social service programs benefit from an array of elements that strengthen their capacity to deliver high-quality services consistently. These elements have been organized conceptually into three groups: Child abuse and neglect is a complex issue with diverse causal pathways, manifestations, and affected populations. Therefore, multiple high-quality interventions are needed to address it. An effective response to the problem would be facilitated by a more explicit focus on building an infrastructure that can support the most promising interventions as they emerge and link them in ways that maximize their collective impact.
Unfortunately, limited research has been conducted on the potential impact of infrastructure reforms on program implementation and participant outcomes. Although efforts aimed at enhancing the knowledge and skills of the workforce in order to strengthen organizational capacity to support evidence-based practices or at reducing barriers to service access through better interagency coordination make sense, relatively little is known about how to accomplish these improvements.
This section briefly reviews the literature on the impact of organizational culture and interagency networks on the implementation and sustainability of evidence-based programs. The quality of services provided to families and children is influenced not only by the rigor of a program's design and its implementation but also by the organizations in which services are embedded. Studies of organizational context have found associations between an organizational culture and climate and participant outcomes Glisson and Hemmelgarn, Organizational culture also can result in improved service engagement, reduced staff turnover, and improved child outcomes, independent of the implementation of evidence-based practices Glisson et al.
This relationship between organizational culture and program implementation is reciprocal. The implementation of evidence-based practices can adversely impact organizations by adding to the workload of an already overworked labor force or by leading to increased employee turnover as staff are asked to change their practices and adopt new strategies that may restrict their sense of control over the therapeutic process Glisson et al.
On the other hand, organizations also can benefit from the implementation of evidence-based practices.
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These benefits include enhanced professional identity, improved client outcomes, and the gratification of contributing to a process of knowledge generation Aarons and Palinkas, ; Palinkas and Aarons, One statewide study of implementing evidence-based practices found that ongoing fidelity coaching predicted decreased staff burnout and reduced staff turnover Aarons et al. These benefits aside, the culture of evidence-based practices that stems from an empirically based research perspective and the culture of child abuse and neglect practice may be at odds, engendering a gap that must be bridged if effective implementation is to be achieved Palinkas et al.
Even something as basic as the reporting of child abuse and neglect may be impacted by organizational context Ashton, Thus, for example, an examination of child sexual abuse in the Catholic Church implicates a strong organizational culture as a major factor limiting the institution's appropriate response to the problem Keenan, While some of the above-mentioned studies assess or deliberately alter organizational context, others examine or cite organizational context as important in the implementation of evidence-based practices Kolko et al.
Yet while there have been calls for increased attention to organizational context in the dissemination and implementation of evidence-based practices Chaffin, ; Kessler et al. Based on diffusion of innovations theory Rogers, and social learning theory Bandura, , Valente's social network thresholds model calls for identification and matching of champions within peer networks that manage organizational agenda setting, change, and evaluation of change e.
Studies and meta-analyses have shown that both the influence of trusted others in one's personal network and access and exposure to external information are important influences on rates of adoption of innovative practices Palinkas et al. Across a series of studies, Valente and colleagues found that individuals who were most innovative almost always had the highest exposure to external influences Valente and Davis, ; Valente et al.
Although external influence played a crucial role in bringing an innovation to an individual's attention, it was usually the persuasion of trusted others that finally convinced the individual to adopt the innovation Valente, Other empirical studies have confirmed the importance and influence of opinion leaders e. It has also been hypothesized that leaders in dense or centralized groups may have more power than leaders not in such groups Valente, , although this has not been found in all influence networks Valente et al. Applying this theoretical framework to child abuse and neglect, Palinkas and colleagues found that the social networks of county-level child welfare, mental health, and juvenile justice system leaders and staff play a significant role in the implementation of evidence-based practices for abused and neglected youth.
System leaders develop and maintain networks of information and advice based on roles, responsibilities, geography, and friendship ties. Networks expose leaders to information about evidence-based practices and opportunities to adopt them, and also influence decisions to adopt. In that study, individuals in counties at the same stage of implementation of multidimensional treatment foster care accounted for 83 percent of all network ties. Networks in counties that decided not to implement a specific evidence-based practice had no extracounty ties.
Implementation of multidimensional treatment foster care at the 2-year follow-up of a randomized controlled trial funded by the National Institute of Mental Health was associated with the size of the county, urban versus rural counties, and in-degree centrality i. Successful, large-scale incorporation of evidence-based practices in existing child-serving systems is likely to involve multiple levels of constituents, in part because the new practices affect multiple stakeholders in the funding, planning, coordination, delivery, and receipt of services.
Further, the successful implementation of many evidence-based practice models requires substantial interagency linkages. In their report from the Blueprints programs, Mihalic and colleagues found these linkages to be a crucial factor in whether the programs had stable funding, a stable referral base, and coordinated case planning activities, especially for youth involved in multiple systems. In addition to interagency coordination, these linkages often include system-level factors that impact the implementing organization's operation; that relate to federal and state laws and regulations; and that impact larger human resource decisions e.
Most evidence-based practice implementation studies that focus on interorganizational collaboration fail to consider the wider context within which collaboration occurs, including such factors as the involvement of external stakeholders, sociopolitical processes, and the roles of relationships and leadership Horwath and Morrison, Increasingly, this context is characterized by government mandates and fiscal realities that require collaboration in the form of integrative multidisciplinary practice in the delivery of children's services Ehrle et al.
In a sociopolitical climate in which organizations face increasing budget restrictions and are challenged to do more with less, collaboration across agencies and organizations appears to be critical for successful implementation of evidence-based practices. In turn, an understanding of effective collaboration appears to be at the core of many evidence-based practices developed to improve outcomes in child-serving systems Prince and Austin, An extensive literature exists on the nature of interagency collaboration for the delivery of health and human services in general and child welfare services in particular.
Although many consider such collaboration to be essential to the delivery of a complex array of services Jones et al. Several studies have pointed to improved access to services and improved outcomes associated with interagency collaboration Bai et al. However, Glisson and Hemmelgarn found that efforts to coordinate the services of public child-serving agencies in Tennessee were negatively associated with the quality of services provided.
And Chuang and Wells found that while interagency sharing of administrative data increased the odds of youth receiving inpatient behavioral health services, having a single agency accountable for youth care increased the odds of receiving both inpatient and outpatient services. In part, this inconsistency in findings may be attributable to differences in the definition and operationalization of key terms. For instance, some researchers have distinguished among collaboration, cooperation, coordination, and networking, whereas others have used these terms interchangeably Grace et al.
Specific factors that have been found to contribute to successful interagency collaboration for child welfare and other agencies include shared goals, a high level of trust, mutual responsibility, open lines of communication, and strong leadership Johnson et al.
Barriers to effective collaboration include deeply ingrained mistrust and continued lack of other agencies' values, goals, and perspectives; different organizational priorities; confusion over how services should be funded and who has jurisdiction over participants; and difficulty in tracking cases across organizations Conger and Ross, ; Green et al. Treatment and prevention programs generally are delivered by public agencies or community-based organizations.
The operating culture within these entities has an impact on the quality of services and the extent to which evidence-based practices will be implemented and sustained over time. Research suggests that a degree of reciprocity exists between service models and their host agencies. In some instances, the rigor and quality of these innovations may alter the standards of practice throughout an agency, thereby improving the overall service delivery process and enhancing participant outcomes.
In other cases, organizations that provide little incentive for staff to adopt new ideas or reduce the dosage or duration of evidence-based models to accommodate an agency's limited resources contribute to poor implementation and reduced impacts. Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of the agencies in which such models and approaches are embedded and how these factors impact service implementation.
Equally important is developing a research base that can inform the process of building a collaborative culture and a set of working relationships across the institutions and community-based agencies that constitute the child maltreatment response system. Because child abuse and neglect is a complex, multifaceted problem with myriad causes, promising treatment and prevention strategies lie within a variety of disciplines and multiple institutions. Additional research is needed to understand how these multiple institutional resources can be integrated in ways that reinforce the impact of these individual strategies in the most efficient and cost-effective manner.
Multiple high-quality interventions and strategies must be sustained to address child abuse and neglect—a complex problem with diverse causal pathways, manifestations, and affected populations. Because child abuse and neglect are complex, multifaceted problems with myriad causes, a variety of disciplines and multiple institutions support treatment and prevention programs. Additional research is needed to understand how these multiple institutional resources can be integrated in ways that reinforce the impact of individual strategies in the most efficient and cost-effective manner.
Limited research has been conducted on the impact of infrastructure reforms on program implementation and participant outcomes. More research is needed to determine how best to direct efforts aimed at enhancing the knowledge and skills of the workforce, strengthening organizational capacity to support evidence-based practices, and reducing barriers to service access through better interagency coordination.
Significant advances in the development of child abuse and neglect treatment and prevention strategies have been realized since the NRC report was issued. This work has been informed by the growing body of research on the causes and consequences of abuse and neglect, as well as research assessing the efficacy and effectiveness of interventions. In the treatment domain, TF-CBT, a brief structured program based on well-established theory and treatment elements, has been tested extensively and found to be effective with children affected by abuse and other traumatic experiences.
Equally important has been the successful application of a number of well-established parent management training programs to children and families involved in the child welfare system. Again, these are programs with well-established theory and large bodies of knowledge. As this chapter has reported, outcomes include not only improvements in behavior problems caused by child abuse and neglect but also reduced need for subsequent child welfare involvement.
With respect to prevention, strategies such as early home visiting targeting pregnant women and parents with newborns are well researched and have demonstrated meaningful improvements in factors commonly associated with an elevated risk for poor parenting, including abuse and neglect. Promising prevention models also have been identified in other areas, including school-based education in violence prevention, public awareness campaigns, parenting education programs, and professional practice reforms. As in the past, communities continue to invest in and support a broad continuum of prevention services that address the needs of different populations and utilize different institutional resources.
In contrast to the reality in , policy makers and practitioners have a much stronger pool of candidate programs on which to draw in both remediating the impacts of abuse and neglect and reducing its incidence. Also important is tracking the long-term, second-generation effects of current interventions. Few program evaluations have tracked participants longitudinally, and even fewer have examined the potential effects of high-quality treatment and prevention services on the parenting practices and abuse or neglect potential of children whose parents receive these interventions.
Such research is needed to determine the most promising investments. Improving the performance of evidence-based programs is the subject of considerable ongoing theoretical and applied research designed to increase understanding of how interventions are implemented, replicated, and sustained.
The most pressing questions relate to how to take interventions to scale in the public mental health, child welfare, and community-based service settings where children who have experienced child abuse or neglect and families in need of preventive services receive their care. As policy makers place greater emphasis on evidence-based decision making and the implementation of programs that have been proven effective through rigorous evaluation, research will be needed to understand how these high-quality interventions can best be replicated, adapted to diverse populations, and incorporated into the overall service delivery system.
Central to this discussion is determining which service attributes are most essential to achieving the desired impacts and therefore should not be altered and which can or should be modified to address the needs of specific subpopulations. Equally important is understanding the costs associated with an emphasis on replicating with fidelity in terms of 1 monitoring the service delivery process; 2 providing the required levels of supervision and infrastructure support, including the development of time-sensitive data collection systems; and 3 determining how the data will be integrated into subsequent practice and policy decisions.
In some instances, the rigor and quality of innovations may alter the standards of practice throughout an agency, thereby improving the overall service delivery process and enhancing participant outcomes.
Maximizing the impact of evidence-based models and proven approaches will require more explicit attention to the organizational strengths and weaknesses of the agencies in which such efforts are embedded and how these factors impact service implementation. Finally, this chapter's review underscores the absence of research on the question of system reform and the infrastructure required to institutionalize and support it. Galezewski, Exposure to Violence: Who is Most Effected and Why?
Portwood, Protecting Children in Their Homes: Effective Prevention Programs and Policies. Ceci, Interviewing Child Victims: Sweeney, Missing and Abducted Children. Issues of Concern for Minors in Cyberspace. Bering, Snakes, Spiders, Strangers: Lampinen, Protecting Children from Violence: Historical Roots and Emerging Trends: Nielsen Book Data Publisher's Summary Providing an evidence-based understanding of the causes and consequences of violence against children, experts in the field examine the best practices used to help protect children from violence.
Various types of violence are reviewed including physical and sexual abuse, cyber- bullying, human trafficking, online predators, abductions, and war. In addition, it reviews the various perpetrators of such violence including parents and relatives, strangers, other children, and societal institutions. The possible outcomes of such violence including physical injuries, death, depression, anxiety, post-traumatic stress disorders, and damage to the social fabric of the local community are also explored.
To enhance accessibility, each contributor addresses common themes: Opening case studies dramatically illustrate the human cost of abuse and neglect Empirically driven estimates of the scope of problem to better understand who is at risk and why Empirically driven testing of interventions to maximize effectiveness of programs How current research compares to public perception and the impact on public policy The worldwide problem of violence against children Evidence-based recommendations for reducing violence against children.
The book opens with a review of the history of the problem, the methodological approaches used to study it, and current "best practice" prevention strategies. The methods used to identify peer victims are then explored. Next child eyewitness memory is examined including the most effective techniques for maximizing the retrieval of information. This is followed by the research on missing and abducted children including the effectiveness of recovery programs such as supermarket campaigns and forensic age profiles.