An Applied Public Health Approach

21st Arizona Child Abuse Prevention Conference July 21, 2015 Randy Ahn, PhD, MLIS Implementation Consultant, Triple P America

Cricket Mitchell, PhD Triple P AZ Coordinator, Prevent Child Abuse Arizona

Triple P AZ

Imagine a Community… 2

Where ALL of the adults who interact with children: Parents Family members Child care providers Teachers, doctors, nurses, clergy, and neighbors Actively engage in preventing child maltreatment before an incident of abuse or neglect occurs.

Imagine a Community… 3

Where there is a wide continuum of prevention activities that extends well beyond providing direct services to individual families… A continuum that includes public education efforts to change social norms and behavior, neighborhood activities that engage parents, and public policies and institutions that support families. When this imagined community is realized, child maltreatment prevention is clearly a Public Health Priority Zimmerman, F., & Mercy, J. A. (2010). A Better Start: Child Maltreatment Prevention as a Public Health Priority. Zero to Three Journal, 30(5), 4–10.

Don’t be scared of the big picture! You have done this before with smoking cessation, teen pregnancy, child car seats, water safety, gun safety…

Child Welfare System 4

Front Door * Reporting* Investigation* Assessment*

Back Door * Permanency services* Reunification Adoption Emancipation After care

Foster Care

Prevention*

Alternative/Differential Response*

Courts*

Historic focus: 1970s – child safety/out of home placements 1990s – child safety/family preservation/permanency planning 2000s – child safety/family preservation/permanency planning/child well-being

AZ 2014 CAN reports: 48,042

AZ 2014 In placement: 17,000+

AZ 2014 in Head Start: 18,080

* Area highlighted for improvement in Arizona Department of Child Safety Independent Review , Chapin Hall, University of Chicago, June 2015

Child Well-being A composite of biopsychosocial variables related to positive outcomes

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A public health approach does not mean transferring responsibility from one public agency to another or relegating this entirely to non-profits.

No one sector has a lock on child well-being approaches

The ACE Study (Adverse Childhood Experiences) is about you and me… V. Felliti, MD, Co-PI

Trauma-informed communities… child well-being-informed communities???

What is Triple P?

Triple P – Positive Parenting Program Triple P is an evidence-based public health approach for improving parenting practices and child welfare outcomes within a population.

3141 Counties Population: 312,958,930 Estimated Underserved Population: 20.8%

Across the US

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Triple P Interventions – breadth and intensity

Intensive family intervention

Broad parent training

Cohen’s d

S = 0.2 M = 0.5 L = 0.8 child

parent

parent

parent

parent

parent

child

child

child

child

Narrow parent training

Brief consultations

Media strategy

Overall parenting practices = 0.58 Overall child outcomes = 0.47 2014 Triple P Meta-analysis (n = 16,009)*

* Sanders, M. R., Kirby, J. N., Tellegen, C. L., & Day, J. J. (2014). The Triple P-Positive Parenting Program: A systematic review and meta-analysis of a multi-level system of parenting support. Clinical Psychology Review, 34(4), 337–357. http://doi.org/10.1016/j.cpr.2014.04.003

Parent anger management, divorce/separation, stress and coping, anti obesity

Improving parent-child relationships, encouraging and teaching positive behaviors, managing misbehavior,

Concrete ways of handling common behavior problems and developmental challenges

Outreach seminars to groups, raising resilient kids, principles of positive parenting

Outreach and media strategy for de-stigmatizing parent education and facilitating referrals

Tiered interventions enable different service delivery providers to offer the program and gives families options in receiving parenting information.

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Triple P Parenting Strategies

Promoting positive relationships Brief quality time, talking to children, affection

Encouraging desirable behavior Praise, positive attention, engaging activities

Teaching new skills and behaviors Modelling, incidental teaching, ask-say-do, behavior charts

Managing misbehavior Ground rules, directed discussion, planned ignoring, clear, calm instructions, logical consequences, quiet time, time-out

Skills are taught using modeling, practice, and self-reflective exercises. Parents select skills to improve and child behaviors to monitor.

Learning Aids Parent workbooks Videos Tip Sheets Books/booklets

Cor

e st

rate

gies

Strategies are consistent across service delivery mode Parents may learn and practice strategies: At home At service providers Online Self-help book 1 on 1 in person Seminars audience Small Groups

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Sample Parenting Strategies

Planned Ignoring for Tantrums • e.g. for use with toddlers under

the age of 2 years exhibiting inappropriate behavior

• Even negative attention can be reinforcing

• Plan to ignore minor problematic behaviors so as to not reinforce or strengthen them

• As soon as children begin to behave appropriately, praise them

Strategies • Based on a

cognitive-behavioral perspective

• Research-informed

• Easy to understand

• Simple to implement

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Sample Parenting Strategies

Setting a Good Example

Ground Rules

Planned Ignoring

Incidental Teaching

• Based on a cognitive-behavioral perspective • Research-informed • Easy to understand • Simple to implement

GIVE INSTRUCTION

WAIT FOR 5 SECONDS

CHILD DOES AS ASKED

PRAISE

CHILD DOES NOT DO AS ASKED

REPEAT INSTRUCTION

Most challenging strategy: How to properly give a time out

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Increasing Self Regulation and Self-sufficiency

As environmental demands increase, poor self regulatory skills are related to numerous problems: Small problems get bigger Problems in childhood are related to problems in adulthood. It is more difficult to address problems later in life further downstream

Adversity

Toxic stress

Child adjustment and behavior problems

Adult health and behavioral health disorders

Community burden of disease We don’t have a self-regulation dial! But we can and will find other fast ways of handling stress…

calm

vigilant asleep

excited

alert

frantic

sleepy

dreaming

Degeneration of brain and body systems

Parents can prevent adversity and buffer stress in children

The HERO Project at Cherokee Nation

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Configuring Triple P Interventions

Intensive family intervention

Broad parent training

Narrow parent training

Brief consultations

Media strategy

Human Service Providers

Engagement: Determining the fit; can Triple P reach your aspirations? (scale of operations, targeted populations, program outcomes)

Implementation Planning: Staging, scaling, and organization readiness (Admin, Data,

Clinical Supports)

Mental Health

Behavioral Health

Primary Care Substance Abuse

Domestic Violence

Shelters

Schools

Libraries

Early Childhood Ed

Faith-based

Tribes

Public Health Child Welfare

Courts

Child care

Community clinics

Special Ed

Developmental Disabilities

Military

Promotores

Corrections

Probation

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Human Capital: Workforce Development

Current Skill Set

Access to target population

Motivation and Experience

Organization role

Protected time

Organizational support

What is needed? Experience in working with children and families and a desire to learn the program.

Triple P Accreditation Sanctioned by the University of Queensland, Australia. It is recognized worldwide.

Efficiency matters Caseloads: Families/year across interventions Client and staff attrition rates

?

What is a military jet’s most valuable asset?

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CDC Triple P US Population Trial

Key Findings 22% fewer out of home placements per year (240 fewer/100,000)2

16% fewer hospitalizations/ER visits for child maltreatment injuries/year (60 fewer/100,000)2

17% fewer substantiated child abuse cases/year (688 fewer/100,000)2

Doing the Math Consider the Heckman Equation: Invest + Develop + Sustain = GAIN or visit WSIPP Cost-benefit Results: ttp://www.wsipp.wa.gov/BenefitCost

1. Prinz, R. J., Sanders, M. : R., Shapiro, C. J., Whitaker, D. J., & Lutzker, J. R. (2009). Population--based prevention of child maltreatment: The U.S. Triple P System Population Trial. Prevention Science,10(1), 1-12.

2. Standardized prevention rates per 100,000 children ages 0-8 yrs.

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Thinking about population reach can - lead to reduction in CAN prevalence rates - increase the efficiencies of organizations - decrease cost of service delivery

- build cross-sector partnerships - destigmatize parent education - outreach and intervene at the same time

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Overview of The Local Scene… 16

Triple P gaining momentum in AZ A review of current funding and initiatives Prevent Child Abuse Arizona and Triple P AZ statewide

coordination role Toward a Positive Parenting Continuum of Care Next steps…

Triple P AZ Current Program Funding and Initiatives

Five organizations have recently received dedicated funding for Triple P training and/or Implementation Prevent Child Abuse Arizona Capacity Building Initiative funded by the Steele Foundation

More detail will be provided in today’s presentation…

Maricopa County Department of Public Health Healthy Start Program funded by the Maternal and Child Health

Division of the Health Resources and Services Administration Trained their home visiting staff in Triple P Level 2 and Level 3

Interventions Opened available training slots to other community-based organizations

Overlap with organizations trained in Level 4 interventions through the PCA Arizona Capacity Building Initiative Devereux, Family Involvement Center, and LSS-SW – Family SPOT

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Triple P AZ Current Program Funding and Initiatives

Five organizations (cont’d)… Partnership between Maricopa County Department of

Public Health and Phoenix Children’s Hospital Parenting Education funded by First Things First

Expansion training to provide Stepping Stones Level 4 Triple P interventions

Lutheran Social Services of the Southwest – Family SPOT Parenting Education funded by First Things First

Implementation supports for Levels 2, 3 and 4 Triple P interventions Training has been provided through PCA Arizona Steele Foundation

Capacity Building Initiative and MCDPH

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Triple P AZ Current Program Funding and Initiatives

Ongoing Triple P AZ implementation… ASU Parenting Young Children Project NIH-funded study of increasing parental engagement in school-

based parenting programs Triple P (Level 4 Group) selected as parenting program

Approximately 80 previously-trained Triple P practitioners in AZ Confirmation of current implementation for two organizations

Child Crisis Center (Mesa) Level 2 Seminars

Devereux Level 4 Group, primarily Spanish-Speaking

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Triple P AZ Current Program Funding and Initiatives

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Triple P Online (TPOL) Pilot sanctioned by Northern Arizona Regional Behavioral Health Authority (NARBHA) Dan Davidson, PhD, BCBA-D, LBA

Behavioral Consultation Services of Northern Arizona, LLC (BCSNA)

Level 4 Triple P intervention provided in self-guided web-based format

‘Enhanced TPOL’ will provide follow-up support via telephone

Triple P AZ Capacity Building Initiative

2-year Steele Foundation grant to Prevent Child Abuse (PCA) Arizona to build capacity for providing Triple P intervention services to AZ families

Funding allows for two cohorts to be trained, a total of 40 Level 4 Triple P Practitioners 20 practitioners in Level 4 Standard Triple P Service delivery target of 25 families per practitioner, per year

20 practitioners in Level 4 Group Triple P Service delivery target of 30 families per practitioner, per year

Practitioners will be accredited by December, 2015 Funding supports a statewide coordination role, Triple P

AZ Coordinator

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Triple P AZ Capacity Building Initiative

Ten community-based organizations have had staff trained in Triple P Level 4 Interventions through the PCA Arizona Steele Foundation Capacity Building Initiative Casa de Los Ninos Cradle 2 Crayons Devereux Family Involvement Center Jewish Family & Children’s Service Lutheran Social Services of the Southwest – Family SPOT Phoenix Children’s Hospital SAGE Community Foundation (Easter Seals Blake Foundation) West Valley Child Crisis Center West Yavapai Guidance Clinic

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Triple P AZ Capacity Building Initiative

Practitioners selected for training in Triple P Level 4 Interventions, and their respective organizations, will… Participate and complete all training, consultation and

accreditation activities Collect uniform data for measuring performance and

outcomes and submit to PCA Arizona Purchase their own Triple P implementation resources Be willing and able to serve the target number of

families for each level/intervention

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Triple P AZ Capacity Building Initiative

PCA Arizona Triple P Coordinator and Triple P America Implementation Consultant will… Provide ongoing support and technical assistance to

organizations and practitioners Hold monthly calls with organizational leads Ensure peer network opportunities to support

practitioners Support program evaluation activities, in partnership

with NAU

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Triple P AZ Evaluation 25

Evaluation protocol developed for Level 4 interventions funded through PCA Arizona Steele Foundation Capacity Building Initiative Child- and Family-Level Evaluation Systems-Level Evaluation

Commitment from others to implement PCA Arizona Level 4 Child- and Family-level evaluation protocol Devereux BCNSA/NARBHA Triple P Online Pilot

Triple P AZ Parent- and Child-Level Program Evaluation for Level 4 Standard and Level 4 Group Evaluation Question

Who is served by Triple P AZ?

What services are provided?

What are the clinical outcomes? Are parents satisfied?

What data are collected or what measure is administered?

Parent and child demographics

First and last dates of service and total # of Triple P groups or sessions

Eyberg Child Behavior Inventory (ECBI)

Parenting and Family Adjustment Scales (PAFAS)

Depression Anxiety Stress Scales - 21 Items (DASS-21)

Client Satisfaction Questionnaire (CSQ)

When is this collected or administered?

Pre-Triple P Pre- and Post-Triple P

Pre- and Post- Triple P

Pre- and Post- Triple P

Pre- and Post- Triple P

Post-Triple P

How is the data collected?

Part of thorough clinical assessment

Service delivery documentation

Parent-completed questionnaire

Parent-completed questionnaire

Parent-completed questionnaire

Parent-completed questionnaire

Why is this collected?

To describe the parents and children served through Triple P AZ

To describe the Triple P services provided

To measure frequency of child behavior problems and extent to which they are problematic to parents

To measure parenting practices and family adjustment

To measure parents' depression, anxiety and stress

To measure parents' satisfaction with participation in Triple P

How long does it take to collect?

2-3 minutes 1-2 minutes 5-10 minutes 5-10 minutes 2-4 minutes 3-5 minutes

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Triple P AZ Clinical Measures

Common set of core clinical measures used by Triple P AZ Level 4 practitioners

Child Behavior

Parenting Style

Family Rel

Parent Adj

ECBI Eyberg Child

Behavior Inventory

PAFAS Parenting and Family

Adjustment Scales

DASS-21 Depression, Anxiety and Stress Scales

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Triple P AZ System-Level Program Evaluation Evaluation Question

What are the characteristics of organizations who have practitioners trained through Triple P AZ?

What are the characteristics of practitioners who are trained through Triple P AZ?

What data are collected or what measure is administered?

Select subscales from the Organizational Readiness for Change and Organizational Climate Measures

Practitioner education and training

Evidence-Based Practice Attitudes Scale - Short Version (EBPAS-15)

When is this collected or administered?

At the time practitioners are trained in Triple P; and, one year after Triple P implementation

At the time practitioners are trained in Triple P

At the time practitioners are trained in Triple P; and, one year after Triple P implementation

How is the data collected?

Survey of administrative leads and practitioners within participating organizations

Survey of practitioners within participating organizations

Survey of practitioners within participating organizations

Why is this collected?

To measure organizational factors that may be related to and may be impacted by implementation of Triple P

To describe the practitioners implementing Triple P

To measure practitioner attitudes that may be related to and may be impacted by implementation of Triple P

How long does it take to collect?

10-12 minutes 1-2 minutes 3-5 minutes

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Triple P AZ Evaluation 29

Commitment from Maricopa County Department of Public Health and Phoenix Children’s Hospital to contribute to statewide evaluation for Level 2 and Level 3 interventions

As part of statewide coordination, PCA Arizona’s Triple P AZ Coordinator is reaching out to all Triple P Practitioners in AZ to engage in common evaluation protocol All Levels of Triple P

Triple P AZ Interventions – Toward a Positive Parenting Continuum of Care

Breadth of Reach

Intensity of Intervention

Level 4

Broad Parenting Skills Training Level 4 Standard and/or Level 4 Group: ASU Parenting Young Children Project, Casa de Los Ninos, Cradle 2 Crayons, Devereux, Family Involvement Center, LSS-SW Family SPOT, Jewish Family & Children’s Service, Phoenix Children’s Hospital, SAGE Community Foundation (Blake Easter Seals), West Valley Child Crisis Center, West Yavapai Guidance Clinic Stepping Stones: MCDPH and PCH Enhanced TPOL Pilot: BCNSA/NARBHA

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Triple P AZ Interventions – Toward a Positive Parenting Continuum of Care

Breadth of Reach

Intensity of Intervention

Level 3 Narrow Focus Parenting Skills Training Level 3 Primary Care and Level 3 Discussion Groups: Maricopa County Department of Public Health, Devereux, Family Involvement Center, LSS-SW – Family SPOT

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Triple P AZ Interventions – Toward a Positive Parenting Continuum of Care

Breadth of Reach

Intensity of Intervention Level 2 Brief Parenting Advice Level 2 Seminars: Maricopa County Department of Public Health, Child Crisis Center (Mesa), Devereux, Family Involvement Center, LSS-SW– Family SPOT

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Triple P AZ – Partnerships In Building a Positive Parenting Continuum of Care

BCNSA EC

Next Steps: • Support practitioners in implementing model-adherent Triple P

and collecting data for statewide evaluation • Share lessons learned and successes

• Quantitative evaluation findings • Stories from families and practitioners

• Seek additional funding, including public-private partnerships, for expanding the Positive Parenting Continuum of Care in AZ

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Randy Ahn, PhD, MLIS Implementation Consultant, Triple P America email: Randy@triplep.net Cricket Mitchell, PhD Triple P AZ Coordinator, Prevent Child Abuse Arizona email: TripleP@pcaaz.org

Triple P AZ 34