Some evidence-based family-focused programs have successfully scaled up and spread at the state or national level, and in some cases internationally as well. This chapter provides a brief description of the aims, structure, and outcomes of four such programs—Nurse–Family Partnership, The Incredible Years®, the Triple P-Positive Parenting Program, and the Keeping Foster and Kin Parents Supported and Trained (KEEP) program—as described at the workshop by program developers and implementers. Challenges that need to be addressed when scaling up programs, and how to meet those challenges, are discussed in Chapters 6 and 7.
Begun in the late 1970s, the Nurse–Family Partnership (NFP) is a program of prenatal and infancy home visiting by nurses for low-income mothers having their first babies. The NFP focuses on this group of mothers because in poverty “women experience a lot of adversity that interferes with their capacity to care for themselves and their children,” said David Olds of the Prevention Research Center for Family and Child Health at the University of Colorado at Denver, who developed the program. He added that the program’s focus on pregnant women, some of whom are adolescent, enables it to target those young mothers whose own development is not complete, and who are going through major life biological transitions because of the hormones linked to pregnancy and caring for the first child. Because the brains of adolescents are still developing, Olds noted, “the opportunities to do good and bad are particularly salient.” Olds emphasized
that the reason why the NFP has been successful in studies is because it aligns with the mother’s biological drive to protect her children.
The main goals of the NFP are to help improve
- Pregnancy outcomes by improving prenatal health;
- Children’s subsequent health and development by helping parents provide more competent care of the baby in the first 2 years of life; and
- Mothers’ health and self-sufficiency by helping them develop a vision for what their lives might be like, and helping them understand how the decisions they make for themselves will affect their ability to protect themselves or their children, with a particular focus on planning the timing of subsequent pregnancies, completing education, and finding work.
The major functions of NFP include nurturing community, organizational, and state commitment to developing the program; ongoing education of and consultation with nurses; clearly articulating what the program is designed to accomplish and the essential components of the model in visit-by-visit guidelines; monitoring and assessing program implementation through an information system that is not too burdensome; and using that information to improve the model and replication efforts, said Olds.
Large, well-controlled studies in Caucasian, African American, and Hispanic communities found that the NFP fostered improvements, including reduced prenatal tobacco use (Matone et al., 2012), reduced child abuse and neglect and child health care encounters for injuries (Kitzman et al., 1997; Olds et al., 1997), among other improvements (see Box 2-1). The program also significantly improved children’s language development (Olds et al., 2004a, 2014) and school readiness, as well as reduced their substance use and risk of entering the criminal justice system (Eckenrode et al., 2010; Kitzman et al., 2010; Olds et al., 1998). Mothers participating in the NFP experienced greater intervals between births (Olds et al., 2004b; Yun et al., 2014), improvements in employment, and had reduced use of Medicaid and other public assistance (Eckenrode et al., 2010; Olds et al., 2010).
The Washington State Institute for Public Policy estimated there is about a $17,000 return on investment with this program in Washington State (WSIPP, 2013), with a more recent analysis from the Pacific Institute for Research and Evaluation suggesting larger economic returns (Miller, 2009).1 In addition, the Coalition for Evidence-Based Policy identified
1A description of the methodology used by the Washington State Institute for Public Policy to calculate a program’s return on investment is included in Chapter 4.
- Improvements in prenatal health
- Reductions in children’s injuries
- Improvements in children’s language development and school readiness (those born to low-resource mothers)
- Reductions in children’s behavioral problems
- Reductions in children’s depression
- Reductions in children’s substance use
- Reductions in maternal behavioral impairment due to substance use
- Increased interbirth intervals
- Increased maternal employment
- Reduction in welfare and food stamp use
SOURCE: Olds, 2014.
NFP as the only early childhood program that meets its top-tier evidence standard.
After conducting a small-scale community replication, the NFP created a nonprofit organization in 1996 to implement the program nationwide and internationally. The NFP now operates in over 550 counties in 43 states, in which it serves more than 27,000 families. The NFP scale-up approach is summarized in Figure 2-1.
Funding for the scale-up of the NFP was provided by a variety of sources, Olds said. The Obama Administration’s 2008 budget contained an $8.6 billion request for a home visiting program (the Maternal, Infant, and Early Childhood Home Visiting [MIECHV] program) for low-income, first-time mothers. The budget passed by Congress included $1.5 billion over a 5-year period. State and local funds, and, more recently, social impact bonds, have also supported the program’s expansion.2
The NFP is currently expanding internationally to Australia, Canada, the Netherlands, and the United Kingdom, as well as to Native American populations.
2The Patient Protection and Affordable Care Act requires a national evaluation of the MIECHV program in its early years of operation called the Mother and Infant Home Visiting Program Evaluation. The evaluation, which will be presented to Congress in 2015, will lay the foundation and framework for understanding future findings from the national evaluation (HHS, 2013).
FIGURE 2-1 Nurse–Family Partnership scale-up approach.
SOURCE: Olds, 2014.
The Incredible Years® (IY) is a group of programs designed to promote emotional and social competence and to prevent, reduce, and treat aggression and emotional problems in children aged 0 to 12 years old. IY developed seven different programs for parents; two programs for promoting children’s social and emotional development, one prevention and one treatment; and one program for training teachers in how to promote children’s social and emotional development. Carolyn Webster-Stratton of the University of Washington and founder of the IY program explained that although each of the programs can be used independently, research shows additive effects when used together.
The short-term goals of IY are to improve parent–child relationships, to decrease harsh discipline, and to promote parent support from other parents, the community, and teachers. In this way, children’s social and emotional development is strengthened and their conduct problems lessened with the long-term goal to reduce delinquency, substance abuse, and school dropout rates.
IY offers a series of training workshops for parents in which they
learn child development, positive parenting techniques, and ways to support children’s academic achievements. Teachers attend a different set of workshops where they learn strategies for building positive relationships with students and families, disciplining children, and stimulating and supporting their academic efforts (The Incredible Years®, 2014). IY programs are delivered in a variety of settings including Head Start centers, primary grade schools, mental health centers, jails, homeless shelters, businesses, and doctors’ offices.
Randomized controlled trials have shown that IY increased positive parenting and improved children’s emotional literacy, social skills, problem solving, compliance, and school readiness. IY has also been shown to decrease harsh discipline by parents and children’s conduct problems at home and in school (Azevedo et al., 2014; Gardner et al., 2006; Letarte et al., 2010; Menting et al., 2013; Perrin et al., 2014; Webster-Stratton et al., 2001, 2008). IY programs are being offered in most U.S. states, and more than 12,000 providers have been trained in the program in this country (see Figure 2-2). IY has also expanded internationally to more than 15 countries throughout the world (see Figure 2-3).
The Triple P-Positive Parenting Program (Triple P) “aims to create norms for positive parenting rather than just lament the lack of them, and to change the community context and assist parents who have the greatest needs,” Ron Prinz of the Parenting & Family Research Center at the University of South Carolina reported. Triple P, developed by Matthew Sanders and colleagues at the University of Queensland, has accumulated more than 30 years of evidence for effectiveness (Sanders et al., 2014). This program gives parents simple and practical strategies to help manage their children’s behavior, prevent problems from developing, and build strong, healthy relationships, Prinz said. The program targets five different developmental periods from infancy to adolescence. Although offered to all parents in the community, targeted and more intensive aspects of the program are only offered to parents who need it the most (see Figure 2-4). Variants of Triple P are also available for select populations, such as parents of children with developmental disabilities, parents of teens, and divorcing parents.
Triple P was designed from the outset to be implemented on a large scale, Prinz noted. The advantage of the population approach Triple P takes to offering parenting and family support is that it reduces the stigma of more targeted interventions, Prinz explained, and instead reaches out to the entire community. “If you knock on somebody’s door and say ‘I’m here to prevent child abuse,’ they’ll say, ‘why don’t you check my neighbor?’” he said.
FIGURE 2-2 The Incredible Years® (IY) provider locations in the United States.
SOURCE: Webster-Stratton, 2014.
FIGURE 2-3 Scaling up delivery of The Incredible Years®: Countries where training occurs.
SOURCE: Webster-Stratton, 2014.
FIGURE 2-4 Triple P: Multi-level system.
SOURCE: Prinz, 2014.
Triple P is applied within a number of sectors, including education, health care, mental health, and juvenile justice systems, and it relies on the existing workforce to carry out its programs. According to Prinz, anyone with a professional capacity to work with parents, including child care directors, teachers, counselors, social workers, and psychologists, can implement Triple P programs, with more intensive interventions reserved for those with the most professional capacity for them.
To make it more scalable, Triple P provides multiple formats that can be delivered in different ways to match parents’ needs, said Prinz. These formats include individual brief consultations; large group parenting seminars; longer individual programming that is delivered in the home, clinic, or center; and media and communication exposure. It also offers an online format. “By not putting all our eggs in one basket, we increase the likelihood we are going to reach many different parents and match their idea of what a program should be about in terms of how it works,” Prinz said.
Triple P is also efficient, he noted, because the less intensive and least costly levels of it are offered more widely, with high-cost interventions reserved for those who need it the most. For example, media and communication strategies are applied more broadly, whereas more intensive family interventions are offered for a select group. Prinz said that Triple P takes the approach of starting with more succinct programming and then
adding additional program elements as needed. Efficiency is also gained with Triple P by using the same parenting intervention to simultaneously address several different problems, including child maltreatment and school misconduct, that all share parenting issues. In addition, the program offers multiple pathways for scaling. “It’s the kind of thing where you can do it in pieces and build it further,” Prinz noted.
Meta-analyses of the efficacy of Triple P and a variant of the program for parents of children with developmental disabilities (Stepping Stones Triple P) show positive effects on children’s social, emotional, and behavioral outcomes, parenting practices, parenting satisfaction and efficacy, and child–parent relationships (Sanders et al., 2014; Tellegen and Sanders, 2013). The Washington State Institute for Public Policy determined that for children in the child welfare system, there is nearly a $9 return on investment with Triple P. Triple P is currently available in at least 28 states and 26 countries.
Keeping Foster and Kin Parents Supported and Trained (KEEP) is an evidence-based support and skill enhancement education program for foster and kinship parents of children aged 5 to 12. Many foster children have complex and serious behavioral and mental health problems that put them at risk for negative long-term outcomes. Patricia Chamberlain from the Oregon Social Learning Center reported that KEEP is designed to strengthen the skills that foster parents have with the aim of reducing child behavior and emotional problems and subsequent placement disruptions from foster care.
KEEP is typically applied to small groups of foster parents who attend sessions that focus on practical research-based parenting techniques. KEEP groups are led by a facilitator and a co-facilitator (often foster parents) who are trained and supervised to skillfully implement the program staying true to the validated model. KEEP does not use a “one-size-fits-all” curriculum. While the facilitators draw from an established protocol manual, they tailor each session to the specific needs, circumstances, and priorities of participating parents and their children. Each week, the facilitators gather specific information about the children’s current behaviors by telephone. This information is then incorporated into the weekly sessions to make sure the group is both current and relevant (OSLC, 2014). KEEP has been shown to increase the chances of a positive exit from foster care (e.g., parent/child reunification) and mitigate the risk-enhancing effect of a history of multiple placements (Price et al., 2008) as well as reduce child behavior problems (Chamberlain et al., 2008).
Because of the success of KEEP in Oregon, where it was developed, and in San Diego where there was a large-scale effectiveness trial (Chamberlain et al., 2008), Chamberlain was asked to develop a similar program for the New York City foster care system. Caseworkers ran the groups. The aims of this program, which is called Child Success NYC, were to decrease foster placement disruptions, decrease the length of foster care stay, increase the permanency for foster children, and have them placed more often with relatives without coming back into the foster care system. For the initiative to be cost neutral, Child Success NYC had to achieve a 20 percent improvement in each of these four outcomes. The outcomes are still under investigation.
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