The Durham Family Initiative: A Preventive System of Care

Abstract

This article describes the Durham Family Initiative (DFI), an innovative effort to bring together child welfare and juvenile justice systems to reach DFI’s goal of reducing the child abuse rate in Durham, North Carolina, by 50% within the next 10 years. DFI will follow principles of a preventive system of care (PSoC), which focuses on nurturing the healthy parent-child relationship. A community collaborative of government agency directors has signed a memorandum of agreement to implement the PSoC principles. The researchers will use multiple methods to evaluate DFI’s efficacy.

Most scientifically evaluated efforts at child abuse prevention have occurred at the level of the individual child or family (e.g., Bugental et al., 2002; Olds, 1997). These studies have shown that families targeted for intervention can be successfully deterred from abusing their children; however, these studies provide little guidance for policymakers who wish to lower the rate of abuse for an entire community. Community-wide efforts must be concerned with how to bring evidence-based programs to scale, match families with programs, marshal the necessary financial and human capital to sustain a community-wide effort, and evaluate the effectiveness of their overall effort.

Government agencies, especially juvenile justice and child welfare systems, must work together to implement individual-level best practices to have community-wide effects, but relatively little scientific research has been directed to guide or evaluate their efforts. This article describes the Durham Family Initiative (DFI), which is a systematic new attempt to lower the rate of child abuse for the entire community of Durham, North Carolina, by 50% over the next decade.

Child Maltreatment: A Public Health Emergency

Child maltreatment is an urgent public health problem, especially for America’s youngest citizens. In the United States in 1999, agencies identified 826,000 children, or almost 12 of every 1,000, as victims of child abuse or neglect (U.S. Department of Health and Human Services [HHS], Administration on Children, Youth and Families, 2001). The highest victimization rates, 13.9 per 1,000, occur among children between birth and age 3. Children younger than 1 year old account for the largest proportion (42.6%) of the maltreatment fatalities.

National victimization rates reflect official, legally defined cases, but they underestimate the extent to which children are victims of physical aggression. A recent anonymous telephone study, in which researchers interviewed a nationally representative group of 1,000 parents about their disciplinary practices using the Parent-Child Conflict Tactics Scale, revealed much higher rates of severe physical assault of children (4.9% of the population) in the last 12 months than those indicated by official statistics (Straus, Hamby, Finkelhor, Moore, & Runyan, 1998).

Dodge, Bates, and Pettit (1990) took another approach to measuring child abuse in the community. They conducted in-home private interviews with a random sample of mothers and fathers of 585 five-year-old children in three communities. They estimated that 11.8% of all 5-year-olds had experienced physical maltreatment that reached the level that would ordinarily be reportable to child protective services. These findings corroborate the impressions and anecdotes of countless front-line social workers, judges, and law enforcement personnel that much more child maltreatment occurs than is officially counted (Putnam, 2000).

Child maltreatment is a pressing public health problem not only because it results in acute physical injuries but also because it exacts far-reaching costs in other areas of public concern, including victims’ mental health and the continued perpetration of violence. The earlier in the child’s life that maltreatment occurs, the more likely it is to recur (HHS, 1999) and the greater the physical, psychological, and social costs to the victimized child (Cicchetti & Toth, 1995; Keiley, Howe, Dodge, Bates, & Pettit, 2001). This cycle of violence leads victims of abuse to be over-represented in the juvenile justice system. Lansford et al. (2002) found that physically maltreated children are three to four times more likely than their peers to commit violent acts and enter the juvenile justice system.

The Public Health Approach to Prevention

The public health approach to preventing child maltreatment affords numerous opportunities and challenges that are less evident at the individual level. First, researchers are increasingly reporting secular trend data in child maltreatment at the community level (e.g., Chalk, Gibbons, & Scarupa, 2002), highlighting abuse as a community-level problem for local policymakers and community leaders. Such data provide comparison groups for evaluation and focus attention at the community level.

Second, a community approach highlights causal factors in abuse that operate at the community level (e.g., Coulton, Korbin, & Su, 1999), including local cultural norms about parenting (Deater-Deckard & Dodge, 1997), economic conditions of poverty (Drake & Pandey, 1996), and poor access to social services (Melton, Thompson, & Small, 2002), which provide a distal context for the occurrence of abuse in a family.

A community approach also emphasizes community interventions that optimize conditions favorable to healthy child development (Daro & Harding, 1999), such as increasing community-agency funding for prevention, improving collaboration among community-level government agencies that serve children and families, and mobilizing neighborhoods to monitor abuse more carefully and provide social support and respite care for high-risk families (Melton & Barry, 1994).

The community approach does not ignore the importance of more proximal levels of analysis and intervention, such as the family, nor does it ignore the necessity to attend to more distal levels, such as the larger culture or the higher level of specific state and federal policies regarding funding streams and practices.

How Child Abuse Occurs

Repucci, Woolard, and Fried (1999) lamented that although child abuse prevention programs are increasingly attending to empirical evidence, few prevention programs have a solid theoretical basis. DFI is driven by an empirically supported theory of how child abuse occurs in a parent-child dyadic interaction, with family-, neighborhood-, community-, and state-level factors contributing to it. It is an integration of social-cognitive (Azar, 1997; Dix & Lochman, 1990) and ecological (Daro, 1998) models that dominate the field. The theory drives the selection of targets for intervention at the individual, family, neighborhood, community, and policy levels.

Although no child ever deserves to be harmed, the abusive parent-child interaction often begins with a child’s misbehavior, such as noncompliance, hostility, or failure to complete a task. The parent responds with cognitions (e.g., attributions that the child is intentionally disobeying the parent) and emotions (e.g., anger toward the child, feelings of incompetent powerlessness as a parent, memories of one’s own childhood) that lead to escalations in conflict and, ultimately, to aggressive actions toward the child. The parent responds to the stimulus of a child’s misbehavior in sequential steps that are similar to the steps followed in problem solving (Newell & Simon, 1972). Dodge (1986) and Dodge and Pettit (2003) described similar steps in the cognitive-emotional processes that lead to aggressive behavior by youth.

The steps include encoding and interpreting the child’s misbehavior, deciding on a behavioral response to the misbehavior, and enacting the response. Parents who abuse their child are likely to

• attend selectively to their child’s misbehavior, ignoring the child’s many positive behaviors and assets;

• interpret the child’s misbehavior as a power-grabbing, hostile, intentional act toward the parent. The parent ignores alternate interpretations that take into account the child’s age, limited abilities, emotional fragility, and immaturity;

• access from memory physically abusive responses to the child’s misbehavior, rather than competent, nonaggressive ways to discipline;

• evaluate an aggressive response as the most appropriate parental response in this circumstance, fail to evaluate that an aggressive response could cause irreparable harm, or fail to inhibit such a response; and

• enact aggressive responses with ease, while being unable to enact competent alternatives.

A growing body of empirical research supports the assertions in this theory that parents who engage in harmful physical discipline are characterized by one or more of the cognitive-emotional processes (e.g., Bugental & Johnston, 2000; Nix et al., 1999).

An understanding of the proximal mechanisms in parental abusive behavior may lead to interventions targeted directly at these processes (e.g., Bugental et al., 2002), but even more promising is the possibility that it may lead to interventions for the antecedent conditions that foster these processes. The proposed theory stipulates that these conditions operate at the individual, family, neighborhood, and community levels.

At the individual level, a history of abusive experiences or problems in attachment relationships in one’s own childhood may pave the way for biased, emotionally laden, unskilled parenting (Bugental et al., 2002). Interventions that address a parent’s resolution of these issues may improve his or her parenting behavior.

At the family level, poverty, disorganization, family violence, and marital stress interfere with competent processing of parent-child interactions (Pinderhughes, Zelli, Dodge, Bates, & Pettit, 2000), leading to harsh parenting. Interventions for improving family conditions are predicated on the empirical relation between these conditions and abusive parenting (McLoyd, 1990).

At the neighborhood level, parents who are socially isolated, lack social support, and lack social sources of monitoring and feedback on their parenting are most likely to perpetuate erroneous beliefs (Daro, 1998). Likewise, parents who receive informal respite care from friends and neighbors may be able to defuse volatile parent-child interactions.

At the community level, the lack of coordination among social service agencies may result in some parents not receiving the financial support and mental health services that could help them develop the parenting skills that they require. Preventive intervention could be directed to any of these levels that contribute to child abuse; furthermore, directing interventions to all of these levels may maximize the likelihood of having a real effect on the entire community. These premises have guided DFI’s development.

The Context of Durham, North Carolina

Durham is an urban community of 223,000 people from ethnically diverse backgrounds, with large white and African American populations and a rapidly growing Latino population. It is a community of extremes, with high rates of poverty and inadequate services for many families as well as rich resources afforded by the presence of major universities and Research Triangle Park. North Carolina’s official rates of child maltreatment are substantially higher than national averages. In North Carolina in 1999, 19 per 1,000 children were maltreatment victims (HHS, 2001). Child maltreatment rates in Durham County are even higher, with 56 per 1,000 children reported for child abuse or neglect (North Carolina Child Advocacy Institute, 2002). Consistent with national data, young children in Durham are disproportionately likely to be victimized. In FY 2000–2001,54% of children with an initial substantiated report of child abuse or neglect were between birth and age 6.

In 2000, the Durham Youth Coordinating Board (2000) and the Center for Child and Family Policy at Duke University completed a community needs assessment, State of Durham’s Children 2000. This report recommended that prevention of child abuse and neglect become one of the three top priorities for the community. Planners created DFI in response to this report, with a stated goal of reducing the rate of child abuse in Durham by 50% over the next decade. Generous funding by the Duke Endowment has catalyzed this effort, which will continue at least through the next 10 years.

DFI and the Preventive System of Care

DFI is based on principles of a system of care (SoC), which researchers have defined as a comprehensive spectrum of mental health and other necessary services and supports organized into a coordinated network to meet the diverse and changing needs of children, youth, and families. An HHS (1999) report noted that SoC was the best practice standard for the delivery of services and supports for children with serious or complex mental health needs and their families.

Researchers in North Carolina developed many SoC principles as a part of the state’s services to violent youth at risk for entry into the juvenile justice system, under court order following the class-action suit Willie M. et al, v. James Hunt et al. (Dodge, Kupersmidt, & Fontaine, 2000). An innovation of DFI is the creation of a comprehensive preventive system of care (PSoC). PSoC staff borrow the principles of service delivery that workers have used to treat parents and children with mental disorders and implement them to prevent the occurrence of child abuse and neglect.

An agency implements an SoC based on a set of core values and principles that stipulate that services and supports should be child centered and family focused; neighborhood and community based; and responsive to the cultural, racial, and ethnic strengths of the children and families the agency serves. Families should

• have access to a comprehensive array of services and supports that advance strengths and address physical, emotional, social, spiritual, and educational needs;

• receive individualized services and supports in accordance with their unique strengths and needs, guided by one integrated, individualized service plan;

• receive services and supports in the least restrictive, most normative environment that is appropriate and safe;

• be full participants in all aspects of the planning and delivery of their services and supports;

• receive services and supports that are integrated, are linked among agencies and providers, and promote common mechanisms for planning, developing, and coordinating services;

• receive case management to ensure that workers deliver services and supports in a coordinated, therapeutic manner so that the services respond to families’ changing needs;

• have the benefit of prevention, early identification, and intervention to enhance the likelihood of positive outcomes;

• have their rights protected through effective advocacy; and

• receive services without regard to race, religion, national origin, gender, sexual orientation, physical disability, or other characteristics, with services and supports that are sensitive and responsive to cultural differences and unique needs.

Key Concepts in DFI’s PSoC

A PSoC is customized to make use of a community’s own resources to meet that community’s specific needs. PSoCs’ configurations, resources, and relationships are diverse. DFI’s PSoC is characterized by key components necessary to operationalize core values and guiding principles.

A Broad Array of Services and Supports

Families at risk of child abuse need an array of community-based service options that go beyond traditional outpatient, inpatient, and residential treatment center services. In a PSoC, the service array also includes services such as crisis outreach, home-based services, therapeutic family and foster care, family support and education, and respite care.

Child and Family Teams

Families need a flexible mixture of formal agency services and informal supports, such as parent training, faith-based groups, or mentoring by a family friend, to approach seamlessness in care. The child and family team is the heart of PSoC, building a team unique for each family and composed of people who are important in the family’s everyday lives. Using a wraparound approach, front-line service providers and others who play a key role for the family work together as one team with one primary plan. Families work as full partners with a case manager or service coordinator to ensure effective, outcomes-based implementation of the plan.

Collaborative Management, Support, and Accountability

The comprehensive, effective care families need requires multiagency and community efforts. Providers must work together with families and communities in a reciprocal way, finding and building common goals, concretely promoting collaboration, implementing best practices, and decreasing fragmentation. For child and family teams to succeed, community leaders and local agency decisionmakers must also work together as a team.

An essential component of a PSoC is a community coalition (locally referred to as a community collaborative) that promotes necessary collaboration at the practice, program, and system levels. A collaborative is a diverse governance team that brings together decisionmakers and stakeholders to drive, manage, and monitor each community’s PSoC. A similar structure at the state level ensures that communities, providers, children, and families have the necessary support and resources to implement their local PSoC successfully.

Development of Social Capital

Social capital refers to the institutions, relationships, and norms that shape the quality and quantity of a society’s social interactions (Putnam, 2000). Increasing evidence shows that social cohesion is critical for societies to prosper economically and for development to be sustainable. The broadest view of social capital includes the social and political environment that shapes social structure and enables norms to develop. This analysis extends the importance of social capital to formalized institutional relationships and structures, such as government, law, the court system, and civil and political liberties.

Implementation of government programs ultimately depends less on authority and control than on mobilizing policy stakeholders, including policy recipients. The less the social capital, the more difficult such mobilization becomes. At the extreme, in a society with very low social capital, administrators are much more apt to find reliance on authority and control necessary, with resulting low governmental effectiveness.

At the other extreme, in a society with very high social capital, many problems are taken care of by social networking outside of government, and when administrators address any remaining problems through governmental intervention, they find a rich array of implementation allies. DFI is building social capital by working at three levels in Durham: neighborhoods, service-providing agencies, and community leaders.

Strategies to Strengthen Children and Families

Screening High-Risk Families and Delivering Preventive Services

Maximizing the success of DFI and similar efforts in other communities depends in part on improving methods for identifying families at risk of child abuse and neglect and matching services and supports accordingly. Voids in both the scientific knowledge of risk and protective factors for child abuse and neglect and the screening and triage practices of local and national child abuse prevention programs hinder effective service delivery. Early, systematic collection of risk indices can significantly improve the identification of high-risk families that might benefit from prevention services.

DFI aims to screen every pregnant woman in Durham for risk of child abuse. In 2001, approximately 3,700 infants were born to Durham residents. Almost all births occurred at one of two hospitals, and practitioners already use many risk-screening instruments. Almost every social service and health care agency providing prevention or child and family support services has its own screening and referral instrument, with considerable duplication in the information collected by each instrument. Although many questions these instruments ask fit with the existing evidence base in terms of the most salient risk factors (e.g., the mother’s childrearing history, past maltreatment of children, substance use), what is sorely lacking is (a) an explicit theoretical basis for the screening items used; (b) systemization in when, where, and by whom the screen is administered; and (c) identification of assets, strengths, and protective factors that a caseworker can use as the basis for prevention and the promotion of healthy relationships.

DFI has established a community partnership, the DFI Collaborative, to collaborate on the design, implementation, and evaluation of the community-wide instrument for identifying families at risk of child abuse and neglect. Development of the instrument included reviewing existing scientific evidence and considering current community screening practices to select items for an interview that community practitioners could administer to women at their first prenatal check-up.

The instrument addresses nine domains that are key to healthy child development and predictive of child maltreatment:

• parents’ ages and occupations;

• parents’ marital status and languages spoken;

• family structure, household composition, family income, insurance, and public assistance;

• mother’s past interactions with the Department of Social Services Office of Child Protection Services, if any;

• marital or partnership quality, including domestic violence;

• parents’ physical and mental health and social support;

• mother’s prenatal smoking and alcohol or drug use;

• mother’s life history, including her own experience of childhood maltreatment, conduct disorder behaviors, and psychotherapy; and

• mother’s skills and sense of efficacy in parenting.

The results of the screening will lead to a triaging of high-risk families into evidence-based prevention services that will range from treatment for substance use or psychiatric impairment to nurse-practitioner home visiting that follows protocols that Olds (1997) developed. To evaluate the efficacy of novel prevention services for subgroups of high-risk families, random assignment of families to different services will occur.

Early Intervention Services (EIS)

These services include family therapies and case management. The model for all services makes the assumption that the child’s well-being is dependent on his or her parents and that the family’s well-being is dependent on support and resources in its neighborhood and community. At-risk families often need support services on multiple levels of the child and family system, including but not limited to mental health services. For that reason, many referrals to EIS result in the formation of a child and family team, consistent with the PSoC approach.

Neighborhood and Community Development

Although DFI will eventually reach all of Durham’s 122 neighborhoods, researchers identified 6 high-risk neighborhoods based on administrative data on risk factors and geocoding of past abuse cases. The researchers randomly assigned three neighborhoods to receive neighborhood services between 2003 and 2004, with the remaining three scheduled to receive these services beginning in 2005. Researchers assigned targeted neighborhoods a full-time community coordinator, who is charged with increasing local social capital by organizing community volunteers into an ongoing leadership group. This group monitors children’s progress and identifies neighborhood needs, recruits volunteers who will act as local mentors for young mothers, and builds a network of citizens who will monitor families and provide support when needed.

Collaboration Among Government Agencies

To deliver preventive services using PSoC to all high-risk families in Durham, government agencies must agree to follow similar principles and to coordinate their efforts. Toward this end, a collaborative group of agency directors, including the heads of the child welfare and juvenile justice systems as well as the public schools, health department, courts, and mental health system, and representatives from county government, began meeting in 2002. In short time, this group gathered official support from the Durham County commissioners, and all agency directors signed a memorandum of agreement indicating that their agencies would follow the SoC principles described here in all of their service provision. The group meets regularly to implement these principles and reach toward a common data-sharing system that will improve efficiency and coordination across agencies.

Financing of Prevention Services

DFI’s financial resources are not nearly sufficient to support the array of prevention services that Durham must implement. Due to current economic constraints, rather than support the indiscriminate proliferation of funded programs, DFI aims to reform policies so that a higher proportion of government funds are directed toward prevention services. Possible targets of these reforms include the Medicaid contract between the state and the federal government, private insurance carriers, local philanthropic organizations, and state and local budgets.

Plans and Challenges in Evaluation

Researchers will adapt DFI’s evaluation from the approaches Connell, Kubisch, Schorr, and Weiss (1999) described. Evaluating DFI using scientifically rigorous procedures will prove a real challenge for numerous reasons, beginning with the fact that the site was not randomly assigned. Nonetheless, researchers will evaluate DFI anyway, because its goals include the development of a community model that can be described and transported to other communities and the measurement of change over time on community-wide ecologically valid outcomes.

How to Describe DFI for Transportability

DFI is a loose collection of innovations that follow from a common theoretical model Rather than implement all interventions from the top down, a guiding principle is that DFI will generate many new ideas by recruiting community agency leaders, practitioners, and volunteers. Although this process will ensure optimal fit between the program and local circumstances, as well as maximize local commitment, it presents a challenge for the documentation of implementation, which is the first component of this evaluation.

A novel system is in place to interview key DFI participants regularly to document their action steps. These steps will be compiled into component “stories” that will accompany specific program instruments and manuals. The planners will share materials among key participants for feedback and revision. They will use the final product in the dissemination of the program to another community in North Carolina. This dissemination will offer another opportunity to refine how researchers describe DFI.

Measures to Quantify the Community’s Level of Child Abuse

Researchers will use standard indices of officially reported rates of alleged and substantiated physical abuse, sexual abuse, and neglect by age groups, but these indices have many flaws that limit their validity as a measure of community-wide behavior. Two notable flaws include underrepresentation of the true level of abuse and the potential for direct manipulation of reporting patterns. DFI is not oriented toward overtly reducing the propensity of mandated reporters to make their reports. In fact, it is hypothesized that the early years of the initiative will bring an increase in the number of reports, given that a stated goal is to increase sensitivity of citizens to the occurrence of harm to children. Ultimately, however, it is hypothesized that the official rates will decrease by 50% by 2012.

Evaluators will supplement these indices by other community-wide scores, including rates of visits to hospital emergency rooms and pediatric practitioners for injuries to children, as well as perceptions of community leaders and citizens of the magnitude of the problem of abuse. Another innovative measure will come from anonymous surveys of parents. Interviewers will ask them to report on their parenting practices. Straus et al. (1998) used this method in anonymous telephone calls to 1,000 parents. These parents reported higher rates of abusive behavior than official records would suggest. This method has already been applied to a sample of 270 Durham families with children from birth to age 5 to obtain a base rate in 2002 prior to DFI’s initiation. Workers will repeat telephone or door-to-door surveys biannually throughout DFI’s existence to document change across time.

Selection of Comparison Groups

Because Durham was not assigned randomly, the evaluation of intervention effectiveness will rely on measurement of change across time, supplemented by comparison with matched communities across North Carolina. Based on demographic characteristics of size, ethnicity, poverty, and distribution of family structure, as well as official rates of child abuse, researchers have identified five comparison counties that they will monitor across time to the extent that resources allow measurement. They will subject one comparison county to the surveys described previously.

To the extent that ethical and practical constraints allow, researchers will test several of DFI’s components through random-assignment studies within Durham. The evaluation of the neighborhood-level intervention involves six high-risk neighborhoods randomly assigned to receive intervention immediately or beginning in 2005. Researchers will evaluate some specific family-level prevention services through random-assignment studies in which families receive either a minimal level of intervention or an enhanced intervention that has a theoretical base but lacks rigorous empirical testing.

Summary and Conclusion

DFI will implement and test a novel approach to the community-level prevention of child abuse. The etiological model that guides this initiative is based on an integrated cognitive and ecological theory of how child abuse events occur in the family and community context. The prevention model is based on principles borrowed from SoC, which have been formulated into a novel PSoC. The evaluation will integrate random-assignment studies with measurements of community-level change across time.

DFI represents an opportunity to apply best practices in prevention science with best practices in the delivery of mental health services at the community level. Its contribution will be not only the test of whether it reaches its goal of reducing child abuse by 50% in the next decade but also whether effective methods and practices integrate service delivery across the child welfare and juvenile justice systems.