Data and More Data: Exploring RCT MethodologyMarh 27, 2013

University of Stirling, Scotland

LYNN MCDONALD, MSW, PHDPROFESSOR OF SOCIAL WORK RESEARCHMIDDLESEX UNIVERSITY, LONDON

RCTs on Partnerships to EngageParents in Low-Income

Communities to Reduce Child Neglect

An Evidenced Based Parenting Programme by a Social Work

Academic

Specify a social problem; look for basic research and relevant theories from social sciences; create social interventions which can move Theories into practice and apply social research with vulnerable populations; consider multi-family groups; conduct qualitative research and feedback loops from service users and practitioners; test promising social work approaches with randomized controlled trials in distinct disadvantaged communities. Build quality assurance structures for replication and assess continuously with service user feedback.

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A Social Problem: Child Neglect

Half of safeguarding referrals are for neglectStressed and isolated families have higher risk

of both abusing and neglecting a childChild neglect causes impaired learning, poor

health, increased aggression and teenage pregnancy (5x higher than no neglect)

Children in poverty at more risk of neglect: If family lives <$15,000 versus >$30,000, 44

times more likely the child is neglected

ACE Correlates with Adult Health

ACE (Adverse Child Events) retrospective data from 3353 women (aged 47) on reports of child neglect & abuse

Correlated with increased health problems as adults Substance abuse, depression, suicide, eating disorders,

anxiety Physical health: cardiovascular, cancer, stroke, hypertension

Medical service utilization high for adults with ACE Emergency rooms, outpatient hospital, pharmacy, primary

care, specialty care

Protective factors: For Child: quality of parent-child bond For Child: one caring relationship over time to turn to when stressed For Parent: social network of support; social capital; extended family For Parent: feeling self-efficacious; empowered voice and agency

Risk factors Child neglect: no provision of shelter, food, and emotional bonds Family has chronic stress, conflict, violence, substance abuse,

depression, mental health problems Family is socially isolated from extended family, friends, neighbors Family experiences social exclusion, racism, health disparities Parents are oppressed, no control over own life, no respect, no voice Poverty, lack of housing, employment, education, health services

Risk and Protective Factors of Child Neglect

High Stress Effects a Child’s Development

Stress changes the brain and alters chemical neurotransmitters related to violence

Stress changes gene expression of childNeglect/abuse correlates with high sustained

stress (cortisol) = damaging to child’s brain High stress causes low immune systems and

children get sick more often and heal slowlyHigh stress puts child into survival mode, and

stressed children cannot learn new things: academics, mathematic, reading or writing

Caring Relationships Can Buffer the Impact of High Stress on a Child’s Development

Sustained high stress (cortisol) levels are destructive to a child’s brain development and other organs

15 minutes of one to one responsive play reduces stressHigh stress levels can be managed with a responsive

parent who shows their love and Notices child’s emotions and is tuned in to the child Is available to the child under stress Asks questions and listens Is physically soothing and touches the child Plays responsively with no bossing, and follows the child’s lead

(Sue Gerhardt, 2002,Why Love Matters)

High Stress Diverts Parental Focus on Child

Cannot focus on child’s needs; not emotionally intellectually Not enough time, no time for seeing friends/family for support Use of computers, mobile phones, TV divert focus from child Work and transport to work; employment insecurity, food

insecurity, residential instability, chronic stresses of poverty Fear of inadequate medical and dental care, support services Trapped in a dangerous neighbourhood Trapped in a dangerous relationship Daily experience of stigma and social exclusion, racism Feelings of helplessness, hopelessness, low sense of agency

Low hope and mood, low patience, irritability, distracted, anxious

Court ordered Daily In Home Visits (3 mo)

To try to reduce placement of 0-5 child abuse and neglect cases into foster care: daily visits for three months to the home and 2x weekly intensive family therapy sessions: reduced 55% with Safe at Home

Daily coaching of one to one responsive play by a trained assistant; first listen to the parent for 15 minutes; then coach the parent for 15 minutes

Dramatic increase in child well-being; often a distressed parent swings from neglect to abuse

Court Ordered Parenting Classes, Groups

In US, 1 million reports of child neglect and abuse annually; 2/3 are substantiated

448,000 parents ordered to attend parenting classes Parenting problems of caregivers are 1 in 12 about

excessive discipline; neglect is over 50% of casesParenting programmes generally over-focus on

control alternatives to reduce excessive disciplineAgencies prefer brief, low cost groups, linear ideas Most programmes are untested with little evidence

Parenting Skills vs Stress of Social Isolation

A classic study was conducted on court ordered behavior modification parenting groups referred by the child protection workers for child abuse/neglect

Prof Robert Wahler taught behavior modification techniques with success in parenting knowledge

Six months later he assessed their use of new skillsIf they had no friends or positive extended family

social support, i.e. socially isolated, they did not use the parenting skills they had learned (insular parent)

Social capital and Stress and Child Neglect

Chronic stress and social isolation increase child neglect: stresses of poverty, social exclusion reduce parents’ ability to be responsive and parent positively

Social capital reduces stress o Social ties and inclusion buffer stress and enhances adults’

coping mechanisms leading to better mental health, less irritability & anger

Social capital

Reduces Stress

Reduces Child

Neglect

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Neurons Connected by Life Experiences: Synapses & Dendrites

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Neural Networks form with Repetition & Emotional Intensity

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Sculpting: Neurological Pruning of Non-connected Neurons

Home Environment: Words Heard by Child

Words heard by hour week year

Low income 616 62,000 3 million

Working class 1251 125,000 6 million

Professional 2153 215,000 11 million

What you hear, how you talk, how you read and write

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3 months6 months9 months12 months3 years

Ages of Neurological Pruning

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6 years9 years12 years15 years

Ages of Neurological Pruning

Apply Social Work Values and Skills

Social work values of respect and shifting power Service user involvement in partnership with professionals Multi-systemic. social ecological, local contextual interventions Anti-oppressive and anti-discriminatory practice

Social work focus on quality of relationships Between individuals, parent-child bonds, within families, Lead groups of professionals in multi-agency working With socially marginalized, low income parents: social inclusion

Social work systemic strategies to build relationships Social cohesion, social trust, networking and social inclusion Coleman, 1988: ‘intergenerational closure in schools’

Families and Schools Together (FAST)

Universal voluntary parenting programme for all age 4-5 children living in disadvantaged communities

Focus on relationships, social capital and protective factors, as all parents have stress sometimes

Support all parents in practicing positive parentingTransition into school for all 4-5 year olds with FAST If a parent comes once to FAST, 80% return for 8

weekly sessions & 22 monthly multi-family meetings86% of FAST parent graduates report having made a

friend they see years later; reduce stress & isolation

Parents Co-Produce FAST as Prevention of Neglect

Respect for parent role and knowledge at every level of the FAST programme: ‘nothing about us without us’

Parents participate in training and planning FAST: co-production with multi-agency professionals: 60% flexible

Parents are on multi-agency FAST team leading groupsParents are coached to be in charge of their own familyParents are given time to form informal social networksParents graduates plan the monthly ongoing meetingsParent interview panel for evaluation FAST certification

22FAST Groups Build Protective Factors Against Child Neglect

Strengthen family unitParent-child bondParent-to-parent bondParent groupParent and communityParent and school

Ten theories into practice in FAST

Parent groups are built on Paulo Friere’s ideas of adult education groups in low income communities

Minuchin family systems theory empower executive subsystem, increase engagement, reduce conflict

Family stress theory (Hill; Boss) hope; social supportAttachment theory (Bowlby) into practice (Kogan)Parents ask children to do small tasks as imbedded

compliance requests (social learning theory)Systematically reinforce attendance (learning

theory)Family school and community (social ecology theory)

NICHD Social Capital FAST Project

Social ecological theory of child development (Bronfenbrenner)

CHILD

NICHD Social Capital FAST Project

Social ecological theory of child development (Bronfenbrenner)

CHILD

family

NICHD Social Capital FAST Project

Social ecological theory of child development (Bronfenbrenner)

CHILD

family

school

NICHD Social Capital FAST Project

Social ecological theory of child development (Bronfenbrenner)

CHILD

family

school

neighborhood

Social ecological theory of child development (Bronfenbrenner)

family

school

neighborhood

CHILD

Experiential learning through parent led repeated activities (no “teaching” or

lecturing)

Family Scribbles GameFamily Scribbles Game

Family FlagFamily Flag

Feeling CharadesFeeling Charades

Parent-child bonds built in play activity and rehearsals of parental

responsiveness to child

Special Play

Building Social Capital through Schools

Every child goes to school; invite whole familiesJames Coleman sociologist Univ of Chicago

studied schools and developed a theory of social capital Children get to know one another at school Children know their parents at home If parents become friends with their children’s school

friends, that is ’ intergenerational closure’, a powerful form of social capital

If the average parent at a school knows 4-5 other parents, that school has high social capital

FAST builds intergenerational closure at schools

Partnership

+ + +

+ + +

+ + + +

Randomised controlled trials on FAST

Collaborations with other researchers from medicine, public health, sociology, psychology, who were interested in impact of a social intervention

5 RCTs on FAST completed with low income families Abt Associates, (2001); Kratochwill, et al, (2004); McDonald et

al, (2006), Kratochwill et al.(2009), Gamoran & Turley (2013) Funding from NIH (NIDA, NICHD), SAMHSA, DOJ, DOE

Positive child behavioural and mental health (SDQ) outcomes over 1 and 2 years, across domains of child social ecology (child, family, school, community)

Randomized Controlled Trial: Can FAST Build Social Capital

Ruth N. López Turley, Rice UniversityAdam Gamoran, Alyn Turner, and Rachel Fish

University of Wisconsin-Madison

This research was supported by NICHD grant no. R01HD051762-01A2. Its contents are the responsibility of the authors and do not necessarily represent the official views of the supporting agency.

Social Capital

By “social capital,” we mean relations of trust, mutual expectations, and shared values embedded in social networks

The paper addresses conceptual as well as causal ambiguity

This presentation focuses on causal inference

An Intervention Approach to Addressing Causal Ambiguity

Random assignment is the best way to sort out causal ambiguity

We cannot randomly assign families to social capital

Instead we randomly assign schools to a social-capital-building intervention

We test whether school assignment to the intervention boosts social capital for families

The InterventionFamilies and Schools Together

(FAST) research-based after-school program

universally recruited 1st grade families 8 weeks of weekly meetings at schools 2 years of monthly meetings

designed to strengthen bonds parents and school staff parents and other parents parents and children

Social Capital

Research Design

San AntonioPhoenix

FAST

Control

Data

Demographic characteristics of the child and the child’s parents

Pre-FAST measures of social capitalSchool characteristicsParent-parent network social capital Child socio-emotional and problem behaviors

reported by 1st grade teachers

Statistical Methods

FAST as an indicator of social capital Intent to Treat: Two-Level Model Treatment on the Treated: Two-Level Complier Average

Causal Effect Model

Intervention Outcomes

FAST graduates compared

Across 26 schools, on average 44 families attended at least one FAST session

Across 26 randomly assigned control schools, there were no FAST sessions

Of the families who completed FAST (5 sessions), characteristics were collated

In the control schools, a comparable group was created with similar characteristics

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Methods

COMPLIERSWOULD BE COMPLIERS

NON-COMPLIERS

WOULD BE NON-

COMPLIERS

FAST Comparison

Treatment on the treated(TOT)

Intent to treat(ITT)

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ITT Effects on Social Capital

OutcomeEffect size Est/S.E. P-value

Intergenerational Closure 0.13 3.02 0.003

Shared Expectations with Other Parents

0.33 3.28 0.001

Intervention Social Capital

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TOT Effects on Social Capital

OutcomeEffect size Est/S.E. P-value

Intergenerational Closure 0.35 2.83 0.005

Shared Expectations with Other Parents

0.97 2.93 0.003

Intervention Social Capital

Low Drop Out Rates for Low Income Parents

Retention rates: if a family comes once to FAST, on average 80% will complete 6 or more of 8 weekly FAST meetings & graduate to lead 22 monthly groups; 72% inner city, low income, single parent, African American

families with emotionally disturbed children 80% rural, Indian reservations, low-income families with

universal recruitment of all children 85% urban, Mexican American immigrants, low income,

universal recruitment of all children 90% risk for special education with behavior problems, low-

income, mixed cultural backgroundsHowever, if a family comes once to a child mental

health clinic, 40-60% (Kazdin, 2001) will drop out; if family is low income or socially marginalized > 60% drop out

Effects of FAST- child at home

Source: Kratochwill et al. (2009) (CBCL Externalizing Scale)

d=.42

Effects of FAST-family domain

Effects of FAST- school domain

Lists of Evidence Based Practice EBP

UN United Nations Office of Drugs and Crime (2010) Family skills Programme (FAST is 11 of 23 based on RCTs) FAST has highest on retention rates of low-income parents

UK National Academy of Parenting Practitioners Number 7 of parenting programmes for training

workforce

US government lists for evidence based practice Child abuse and neglect prevention Child mental health promotion Substance abuse prevention Juvenile delinquency prevention

Since 2010, 2,268 whole UK families completed 6+ of 8 FAST sessions, graduated to monthly sessions;

77% of the families lived on Very Low-Incomes

(under £20,000 annually)

18 UK families per FAST; 81% retention; 107 schools in low-income communities

Highest % Parents Reporting on FAST Impact

1.Parental self-efficacy which is related to parent empowerment77% of parents who graduated from FAST reported increased parental self efficacy

2.Parent Child relationship is enhanced; attachment is deepends;70% of parents reported improvement of this relationship3. Reciprocal ties in community-mutuality of being helped and of helping others who are raising young children

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UK Aggregate of Pre-Post FAST & Cross Domain Reports of Relationships

Parent-Child Bond increased 11% ****Family Conflict reduced -22% ****Family relationships increased 16%****Parent to parent reciprocity 31% ****

Provide support +28%---Receive support +32%

Parent involvement in school 33% ****

UK Parents Report Changes Pre FAST and Post FAST on UK Parents Report Changes Pre FAST and Post FAST on Child’s Mental Health at homeChild’s Mental Health at home

Strengths & Difficulties Questionnaire (Goodman, 1997)Strengths & Difficulties Questionnaire (Goodman, 1997)

=P<.10(10% change due to chance)

=P<.05 (5% change due to chance)

P<.01 (1% change due to chance)

P<.001 (0.1% change due to chance)

UK Teachers Report Changes Pre and Post FAST on UK Teachers Report Changes Pre and Post FAST on Child’s Mental Health at School Child’s Mental Health at School

Strengths & Difficulties Questionnaire (Goodman, 1997)Strengths & Difficulties Questionnaire (Goodman, 1997)

=P<.10(10% change due to chance)

=P<.05 (5% change due to chance)

P<.01 (1% change due to chance)P<.001 (0.1% change due to chance)

Pre Post Child Well-Being SDQ Statistically Significant Changes****

Parent Report Emotional -20%Conduct -18%Hyperactivity -13%Peer problems -10%Total problems -15%Impact -25%

Teacher ReportPro-social +10%Emotional -20%Conduct -20%Hyperactivity -15%Peer problems -16%Total problems -17%Impact -27%

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Can FAST Prevent Child Neglect? We Need More Rigorous Research Data To

Prove it.

Child neglect (ACE) prevention can be at a community level Multi-agency working includes health, education, social care Health inequalities and education disparities result from

stress of poverty, family stress and social isolation, and neglect

Effects of chronic stress from poverty, social isolation and social exclusion of parents increase irritability/child neglect

Service user/carer involvement (and cultural representation) can co-produce local outreach and engagement strategies

Evaluation of impact of social work interventions at local levels improves practice to reduce stress, social exclusion and neglect

Need an RCT on FAST which is community wide with good neglect records over time—time for another partnership