November 30, 2004
Tuesday

Juneau, Alaska - The Alaska Department of Health and Social Services, Office of Children's Services, on Monday released the Healthy Families Alaska study conducted by Johns Hopkins University School of Medicine.

"While the results of the study were mixed, it was clear that good things happened that strengthened families' abilities to raise their children," said Marcia Kennai, Deputy Commissioner of the Office of Children's Services. "It is important to understand that the study only followed families that were enrolled during the first two years, which means that many improvements that were made in the program during the five-year period were not reflected in the results. We are very fortunate that we have this information so that as we move forward, we can be more focused."

The study reflects positive outcome findings in the areas of improvement of extremely poor home environments, lowering maternal parenting stress, improvement in knowledge of child development, improvement in empathy toward the child and improvement in the child cognitive development behavior. At the same time, the study results indicate program model shortcomings and inadequate state program oversight during the early part of the study. The study results also indicate that the program did not prevent child abuse and neglect, reduce malleable parent risks for maltreatment, improve child health and improve maternal life course or household functioning.

About two years ago, initial study findings supported program revisions which included major changes to the following areas: program data collection and analysis; home-based service provisions; development of outcome measure; grantee training in key areas of assessment, referral and communication tools; and grantee implementation of clinical consultation for substance abuse, mental health and domestic violence. The study does not reflect how those changes impacted Healthy Families participants who were enrolled after Aug. 31, 2002. It is the Office of Children's Services intent to continue to support this effort and, through a program evaluation conducted by the Division of Public Health staff, to evaluate further modifications.

Healthy Families Alaska is modeled after Healthy Families America, a nationwide voluntary, home visiting program to prevent child abuse and neglect, promote positive parent-child interaction, and support healthy growth and development. Healthy Families Alaska was initiated in 1995 and currently six grantees serve 427 families in five communities throughout the state.

In 1998, the Alaska State Legislature required a randomized control trial of the program to determine the impact of the program. The Alaska Department of Health and Social Services awarded a five-year contract to Johns Hopkins University School of Medicine to conduct the study. The study was implemented July 1, 1999, and ended July 31, 2004. The study examined how program processes were implemented as well as the impact of program services within the Office of Children's Services.

What is Healthy Families Alaska?

Healthy Families Alaska was established by the state legislature in 1995. The program, designed to prevent child abuse and neglect and improve childhood health outcomes, is based on a successful, statewide home visitor program in Hawaii. Prevent Child Abuse America, under the name "Healthy Families America," is now promoting the model nationwide. The model incorporates screening of all pregnant women and families of newborns in the service area for stressors placing their infants at risk. Those found to have significant life stressors are offered voluntary intense home visiting services for three to five years. Healthy Families programs collaborate with other organizations and agencies providing family support services in order to make maximal use of scarce resources, provide a comprehensive array of services, and avoid duplication of effort.

The program delivers intense home visitation services to families who voluntarily agree to participate in the program. These services are initiated prenatally or at the time of birth. Initially, services are offered intensely (i.e. at least once a week), with well-defined criteria for increasing or decreasing intensity of services and for over the long-term (i.e. three to five years). The program focuses on supporting the parent as well as supporting parent-child interaction and child development.

Study Design Background

The Alaska Department of Health and Social Services awarded a five-year contract to Johns Hopkins University School of Medicine to conduct the study.

• The study was implemented July 1, 1999, and ended July 31, 2004. It examined program processes (how it is implemented) as well as program outcomes (impact of program services).
• January 1, 2000 - July 31, 2001: Enrolled 325 families in the study and randomly assigned each family to either home visiting services or services normally available in the community. Conducted baseline interviews (in-depth psychosocial assessment and collection of demographics, employment and family lifestyle) at study enrollment.
• January 1, 2002 - February 28, 2004: Conducted follow-up interviews similar to baseline interview, observe parent-child interactions and assess child development when the baby reaches 24 months of age.

What was learned and actions taken during the study

The study helped program staff and state administrators better understand the characteristics of families serviced by the program. Eighty-five percent had at least one of three major risk factors for child abuse and neglect: domestic violence, substance abuse and problems with mental health.

The Healthy Families Alaska/America model as originally designed made it difficult to address underlying psychosocial risks for child maltreatment and support parents in reducing these risks.

• Late 2001: State program staff worked with program managers to identify underdeveloped components of the program and to design enhancements to strengthen the program and support parents in addressing the major risk factors for child maltreatment. These included:
  • Clarifying program goals
  • Implementing informed consent for assessment
  • Implementing motivational interviewing to provide a means for program staff to talk with families about their risks
  • Changing policy for family service plan development to include discussion of parental risks
  • Requiring clinical consultation from the fields of substance abuse, mental health, and domestic violence for programs
• March 2002: Began to implement multidimensional program changes including retraining of the work force, policy development and implementation, and hiring of clinical consultants. Programs have made considerable progress in actualizing these changes.
• Program enhancements occurred too late in the process to be reflected in study outcomes. Further, study findings in Alaska and recent published findings of the Hawaii Healthy Start program (foundation of Healthy Families America/Alaska) suggest additional changes and/or new strategies are needed for preventing child abuse and neglect in high-risk families.

Study Implications

• Healthy Families Alaska/America is a family support program designed to support all new parents in their role. As such, it does not address depression, mental illness and domestic violence-major risks for child abuse and neglect. Yet the model targets at-risk parents, through the Kempe Family Stress Checklist (program eligibility tool). This represents a mismatch between the target population and the intervention.
• A number of experts in the field of child abuse prevention have suggested that family support programs are currently "underpowered" to address risks of child abuse related to mental health, substance abuse and domestic violence. Programs do not have protocols for addressing these issues nor staff with the clinical skills to intervene or guide others in appropriate interventions.
• Family Preservation Programs provide services to parents who have come to the attention of child protection programs. Family Preservation Services aim to strengthen families. Interventions include case management, counseling/therapy, education, skill building, advocacy, and provision of concrete services for families with problems. Though designed for individuals who have already come to the attention of child protection services, elements of Family Preservation Program interventions may be appropriate for the at-risk population served by Healthy Families Alaska.
• It is important to note that Healthy Families Alaska (Healthy Families America) programs serve at-risk families who voluntarily agree to services. It is essential that the program makes sense in the eyes of the targeted families. Families are in various stages of recognizing the negative impacts of their behavioral risks on parenting. The challenge is for the program to support parents in recognizing the risks and developing motivation to voluntarily make changes in their lives so that they can nurture their children. This requires skill in introducing the program to the family and conveying how it will be of benefit to the family to participate as well as sophistication in implementation.
• Our intentions are to complete a careful examination of the model and potential enhancements and use this information to strengthen the intervention, especially in the area of parental-risk reduction. The 2002 program reforms undertaken midway through the study (based on parent characteristics and program process findings) were carefully designed to support parents in reducing risks. This was an important first step in designing and implementing a stronger intervention. The study outcome findings (2004) point to the need for additional changes.
• Rapp and Poertner note, "The organization that performs is the one that clearly defines its mission, purpose, and performance and commits all its knowledge, resources, and talents to getting it done.i The State of Alaska committed resources to examine scientifically, the results of implementation of the Healthy Families Alaska program, replication of a widely promoted child abuse prevention program (Healthy Families America). The model, in Alaska, shows no impact on child abuse and neglect. The study has helped identify major shortcomings of the model.
• Alaska is ideally placed to design and implement program reforms that bring us closer to preventing child maltreatment in at-risk families. The study design assured a partnership between the researchers and programs. The programs have faced the disappointments of the study outcomes and are eager to use what they have learned to strengthen the program using a theory-based, scientifically sound intervention to reduce risks. In study implementation, the State has developed a strong relationship with Hopkins study staff; developed the capacity to monitor program achievements; and have the intellect, technical ability, and commitment necessary to craft effective interventions.
  

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