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HomeMy WebLinkAboutCOM 0138.001 2008-2010 Why Abolishing Hawaii Healthy Start is a Social and Familial Tsunami in the Making: The facts on Healthy Start's Effectiveness By Stephen J. Bavolek, Ph.D Executive Director Family Nurturing Centers, International Asheville. North Carolina February, 2009 Stephen J. Bavolek, Ph.D-is an internationally recognized expert in the felds of child abuse and neglect prevention and treatment, and parenting education. He is the principal author of the Nurturing Parenting Programs and Adult Adolescent Parenting Inventory designed to prevent the maltreatment of children through the promotion of nurturing parenting practices. Dr. Bavolek consults with the US Departments of the Army and Navy, New Parent Support Programs, with the Louisiana State Office of Community Services, and with numerous local and state agencies. He has won numerous national and international awards including induction into the International Guild of the Social Work Roundtable, Vienna Austria, and Honorable Mention for services and research to the handicapped by the Military Order of the Purple Heart. He consults with the Hawaii Department of Maternal Health, and is the principal author of Nurturing the Families of Hawaii, a 12 session parenting program, and the Healthy Start Nurturing Parenting Home Visiting Program, both programs offered throughout the state. Dr Bavolek is the Executive Director of the Family Nurturing Centers, International and lives in Asheville, NC with his wife and three children. Comm. No. ~ ~ ~ / Ref. To: 4resagt~ G~ Ref. Date FFR 1~ a 2~„ gn_ ~~ Many earnest workers in charity feel that social conditions could be wonderfully improved if, to every family in distress, could be sent a volunteer visitor, who would seek out and, with patience and sympathy, strive to remove the causes of need. Richmond, 1899 Development of Healthy Start in Hawaii and Nationally Highlights of Healthy Start-Hawaii Healthy Start, an internationally recognized program, was initiated in Hawaii in July of 1985 as a child abuse prevention demonstration project. The primary goal of the program was to develop a home visiting support program for families with newborns. Families who participated in the program did so voluntarily. The first program employed trained paraprofessionals who conducted home visits in a small area on Oahu. Over the years, the program quickly expanded to include other geographic areas. Healthy Start offers two major programs to families. The first program is an early identification universal screening .program where eligible families are offered home visiting services. This program is voluntary and families who agree to receive home visiting services are enrolled in Healthy Start. Families can continue to receive services until a child reaches three years of age, or five years if there is a younger sibling. The second program offered by Healthy Start is for families confirmed to have issues of child maltreatment. This program is called Enhanced Healthy Start. Enhanced Healthy Start families experience family dysfunction including child maltreatment, spousal/partner violence, drug and alcohol abuse, and mental illness including maternal depression. The purpose of Enhanced Healthy Start is to offer frequent and intense home visits to promote positive, healthy parenting and family functioning to prevent further maltreatment, and to link families to community resources to address issues of substance abuse, domestic violence and maternal depression. Highlights of Healthy Start--National Since it's inception in 1985, Hawaii Healthy Start Home Visiting Program has been recognized internationally as a model home visiting program. A five year federal initiative was launched in 1991 to develop a community based systems approach to reduce the rate of infant mortality in the United States. The initiative was also designed to improve the health and well-being of women, infants, children and their families. The initiative was largely modeled on the Hawaii Healthy Start program. Data presented on their web site by the National Center for Education in Maternal and Child Health report that there are currently 96 federally funded Healthy Start projects nationwide. 2 Why is Healthy Start in Hawaii being recommended for Abolishment? In December of 2008, the Governor of the state of Hawaii announced the abolishment of Healthy Start as acost-savings measure to balance the state budget. The decision to abolish the Hawaii Healthy Start by the Governor is a misguided action largely based on two premises: 1. The results of an old and outdated evaluation report competed nearly 10 years ago by Johns Hopkins University stating the shortcomings of Healthy Start's Home Visiting Program; and 2. Information being cited by the Governor's Office gathered by outside consultants on the relative ineffectiveness of Home Visiting Programs in general. Findings of the Johns Hopkins Study of Healthy Start's Shortcomings The primary goal of the Hopkins study was to evaluate the effectiveness of Hawaii Healthy Start. Among the findings cited was insufficient handling of families experiencing three conditions: mental health issues (particularly maternal depression), drug and alcohol abuse, and family violence. The Hopkins report attributed the program's shortcomings to home visitors' lack of skills and supervision in dealing with risk factors for abuse and neglect, and their failure to properly link families to necessary professional services While this report is cited by those who wish to abolish Healthy Start in Hawaii, the authors of the Hopkins report acknowledge that "similar service programs in Hawaii and across the nation have limited objective evidence of how services are delivered and results achieved." Facts: The Overall Proven Effectiveness of Healthy Start Today, Hawaii Healthy Start is a statewide program with 19 sites serving approximately 4,000 families during 2007. Of the families who received services for 12 months or more in 2007, 99% did not have a confirmed report for child abuse or neglect. Healthy Start is an effective child abuse and neglect prevention program. Facts: The History and Proven Effectiveness of Home Visiting Programs Home visiting programs have become the most recommended and widely practiced strategy for child abuse prevention in the country. They are an effective and cost saving means for delivering services to families in need. In spite of the widespread acceptance of the importance and effectiveness of home visiting programs nationwide, the Governor's office is citing information to the contrary generated from studies conducted nearly 15 years ago. Home visiting programs designed to provide information or to offer health care and psychological services to families are not new. A review of the literature states that home visitation programs have existed since Elizabethan times in England and in the United States since the late 1890s. A comprehensive literature review of the effectiveness of home visitation programs indicates: • Home visitation programs are more popular today than ever. Although specific program models vary somewhat in structure and format, home visitation programs are designed to reduce risk factors and build protective factors. • As many as 200,000 children and families are enrolled in home visitation programs nationwide each year. 3 Several states have been recognized for their statewide home visitation parenting programs. The Office of Community Services in Louisiana has been successful in reducing recidivism rates for neglecting families by adding a home visiting component to their group based parenting program. The US Department of Defense requires all military branches of the service to offer home-visiting parenting programs to all new parents and their spouses. Home visitation programs can have positive effects for parents and families if the programs are carefully planned and attention is paid to the needs and circumstances of participating families. Several studies cited in the literature demonstrated that children of home-visitation parents are less likely to be brought to the emergency room with serious injuries or for medical care suffering from conditions consistent with abuse and neglect. Home visiting programs for children with medical risks do frequently lead to benefits in cognitive and motor development. Additional benefits often cited in many studies were the positive changes in the interaction of parents and their children and/or conduciveness of the home environments to child rearing. Infants whose families did not receive home visiting were 2.5 times more likely to die in infancy compared with infants whose families received home visiting. Evidence for the effectiveness of home visiting programs is as good as or better than the evidence for the effectiveness of many other program models which exist to serve children and families. Improvements to the Hawaii Healthy Start Home Visiting Program Begun 2008 In January 1, 2008, the Hawaii Department of Maternal and Child Health launched a comprehensive initiative to improve the services to families enrolled in Healthy Start and Enhanced Healthy Start. Four specific goals were identified to address the findings of the Hopkins report: 1. Hire Child Development Specialists and Clinical Supervisors for each of the Healthy Start sites to help staff deal with families experiencing severe family dysfunction. 2. Provide additional training to Healthy Start staff to help identify and link services to families with mental health, drug and alcohol and domestic violence issues. 3. Select an existing evidence-based parenting program that would meet the needs of Healthy Start and Enhanced Healthy Start Hawaiian families. 4. Implement the revised Healthy Start program statewide. Healthy Start Nurturing Parenting Program The Nurturing Parenting Program for Parents and their Infants, Toddlers and Preschoolers was selected as the evidence based program for implementation in Healthy Start programs statewide. The Nurturing Program was selected for the following reasons: 4 • The Nurturing Parenting Programs are evidence based programs recognized by SAMHSA, the Substance Abuse and Mental Health Services Administration, and NREPP, the National Registry for Evidence Based Programs and Practices. • With over 25 years of research, families completing the program have demonstrated significant improvements in the parenting practices, family interaction patterns, and parent-child bonding. Longitudinal research studies have shown a low rate of re-abuse rates among families who were referred to the program by Social Services. • The Nurturing Programs are family based programs designed to work with parents and their children of different ages to prevent child maltreatment through the promotion of nurturing parenting practices. The program selected by Healthy Start was the Nurturing Program for Parents and their Infants, Toddlers and Preschoolers. • The Nurturing Program curriculum addresses the issues of mental health, drug and alcohol use and abuse, and domestic violence, issues that the Hopkins study cited as short comings of the current Healthy Start programming. • The Nurturing Programs are utilized throughout the US and other countries. Additionally, the Department of Defense (DOD) of the US Government has selected the Nurturing Program as their program of choice for their New Parent Support Programs in US Navy and US Army installations worldwide. Nurturing Programs have the flexibility for adapting the delivery of the content for the varied cultures of Hawaii. Pilot Study to Measure the Effectiveness of the Nurturing Parenting Curriculum To test the effectiveness of the Nurturing Parenting curriculum on improving the parenting and child rearing practices of parents enrolled in Healthy Start, an experimental and control group research design was implemented. Hilo Healthy Start was selected to serve as the pilot (experimental) site and would implement the Nurturing curriculum to existing and incoming parents. Maui Healthy Start was selected as the control site and would continue their current programming to all parents. Parents at both sites would complete pre and posttest assessments as one way to measure the impact of the curriculum. Assessment Inventories Two inventories were selected to administer: The Adult-Adolescent Parenting Inventory (AAPI-2) and the Nurturing Skills Competency Scale (NSCS). The AAPI-2 is a widely respected, valid and reliable norm reference inventory designed to assess parenting beliefs and practices. Responses to the AAPI-2 provide an index of risk for child maltreatment in five parenting constructs that represent high-risk and abusive parenting patterns: • Construct A: Inappropriate parental expectations of children's growth and development. • Construct B: Parental lack of empathy in recognizing and responding to children's needs. • Construct C: Strong parental belief in the use of physical punishment as a means of disciplining children. 5 Construct D: Reversing parent-child family roles where children are required to be aware of and attend to the needs of the parents. • Construct E: Oppressing children's power and independence where strict obedience to parental demands is required. The Nurturing Skills Competency Scale (NSCS) is a criterion reference inventory designed to evaluate current and past individual and family functioning, in addition to parent's understanding and utilization of proven and effective parenting practices. Responses to the NSCS provide information in six domains: A. About Me. Assessment of current life conditions including education, employment, income, age, number of children, etc. B. About My Childhood. Assessment of past abuse histories, quality of childhood relationships with mother and father figures, history of witnessing violence between parents, drug and alcohol abuse, etc. C. About My Spouse. Assessment of spousal relations including spousal abuse, history of childhood abuse, history of alcohol abuse, quality of spousal relationship, etc. D. About My Family. Assessment of abuse of children, drug and alcohol abuse, quality of parent- child relationships, etc. E. My Knowledge of Nurturing Parenting Practices. Twenty multiple-choice questions assessing parents understanding of appropriate nurturing parenting practices. F. Utilization of Nurturing Parenting Practices. A 20 item rating scale that measures the frequency use of nurturing parenting practices. Information generated from the NSCS allows parents and professionals to assess the quality of current family life and the likelihood of nurturing parenting practices being consistently utilized and effective in building positive parent-child relationships. Staff Training in Hilo and Maui Training Healthy Start staff in Hilo and Maui began in January 2008. The Healthy Start program staff in Maui (the control group) received a one day training on the administration and scoring of the AAPI-2 and the NSCS. The Hilo staff (the experimental group) underwent a three day intensive training experience on the philosophy, practices and implementation of Nurturing Parenting Program, in addition to the training on the administration of the AAPI-2 and NSCS. The staffs at both Hilo and Maui Healthy Start Programs were required to complete the AAPI-2 and the NSCS assessments prior to administering the inventories to the parents. The functional purpose of the assessing staffs at both agencies was three fold: 1. To provide staff with the same experience of responding to the parenting inventories and to increase their awareness of the items, results and accompanying level of difficulty. 2. To assess the effectiveness of the three day trainings on Healthy Start staff for improving their understanding and application of nurturing parenting knowledge and skills. 6 3. To assess the level of nurturing parenting competence among staff attending the trainings in comparison to parents who participated in the experimental (Hilo) and control (Maui) pilot sites. Findings of Pilot Study: Effectiveness of the Healthy Start Nurturing Parenting Program---Parents The Pilot Study ran from March 1, 2008 to October 15, 2008. Data generated from the administration of the inventories to parents attending Healthy Start in Hilo and Maui produced the following results. AAPI-2 and NSCS Findings--Parents A total of 193 parents in Hilo and 132 parents in Maui completed the assessments. • In both sites, females accounted for the majority of parents participating in the programs: Hilo 88% and Maui 90%. • Pacific Islanders were the single largest group in both sites: Hilo 39% and Maui 33%. • In Hilo, 46% of the parents were single, high school graduates (37%), and earning less than $15,000 annually (57%). In Maui, 40% of the parents indicated they were single, high school graduates (41%) and earning less than $15,000 annually (52%). • 52% of the parents in Hilo and 44% of the parents in Maui indicated they were abused or neglected as children by someone inside or outside their family. The average posttest scores for the Hilo parents were higher in each of the five parenting constructs in comparison to parents in Maui. Simply, Hilo parents who participated in the Nurturing Program had stronger and more nurturing parenting beliefs than Maui who received the usual Healthy Start program. The posttest average scores for the Hilo parents were higher than their pretest scores in all five parenting constructs. What this means is that Hilo parents attending the Nurturing classes from March 08 to October 08 improved their parenting beliefs. Maui parents had increased posttest scores in three of the five parenting constructs during that same time period. • As measured by the AAPI, the number of high risk families in Hilo dropped significantly. That is, the percentage of families at risk for practicing abusive and neglecting parenting practices were lower when they were tested in October OS in comparison to their March 08 scores. As measured by the NSCS, the posttest scores for both Hilo and Maui parents showed increases in their knowledge of appropriate parenting practices and increased use of these practices. However, the Hilo findings showed greater growth in these areas. AAPI-2 and NSCS Findings-Staff Beginning October 2008 through January 2009, staff at all 19 Healthy Start sites participated in three day training workshops. The purpose of the workshops was twofold: 1. Based on the results of the Pilot Research Study, the program was ready to launch statewide. State and Local Administrations of all Healthy Start sites, the Home Visitors, the Child 7 Development Specialists and the Clinical Staff together would participate as a coordinated team in implementing the new parenting curriculum. 2. Address the issues of the Johns Hopkins study and make a plan to handle families experiencing mental health, substance abuse and domestic violence. The AAPI-2 and NSCS was administered to all staff at the beginning and end of the three day training workshops. Results indicate: 191 Healthy Start Staff participated in the training workshops: 95% female and 5% male. • 30% of the staff indicate they were White, 24% Asian, 18% Pacific Islanders, 7% Hispanic , 3% Black and 19% Other. • 34% of the staff indicated they were 31 to 40 years old; 24% were 41 to 50 years old; 25% over 50 years old; approximately 17% indicated they were 26 and younger. 54% of the staff is married. Of this population, 35% indicated the quality of their relationship with their partner was above average, 20% average and 45% below average. 64% are college graduates and post-college graduates 27% of the staff indicated they were abused as children by a person outside their family while 45% indicated they were abused by a person inside their family. The posttest mean (average) scores of the staff on the AAPI showed improved posttest scores in four of the five AAPI parenting constructs. Mean scores in Construct E: Power and Independence essentially showed little change. All five construct posttest mean scores were in the above average range. Approximately 95% of the Healthy Start Staff express positive nurturing parenting beliefs. Approximately 4% to 5% of the staff expressed parenting beliefs that fall in the unacceptable or high risk area. As measured by the NSCS, posttest scores indicate that Healthy Start staff increased their knowledge of Nurturing Parenting practices and in their use of Nurturing Parenting Skills as a result of attending the three day training. Summary and Conclusions Based on preliminary review of the information generated from the Pilot study, the following conclusions can be made from the findings: Launch the Healthy Start Nurturing Program Statewide The data generated from the Pilot Study and the training of the Healthy Start staff substantiated the decision to launch the new Nurturing Parenting Healthy Start Program statewide. Healthy 8 Start staffs as well as administrators exude a new found enthusiasm for implementing the new curriculum to help families state-wide. Families are Self-Referring for Help Parents attending the Nurturing Parenting Program classes in Hilo from March to October 08 had higher posttest scores on all five of the parenting constructs in comparison to their pretest scores. Participation in the Nurturing Classes makes a difference in building their positive parenting practices. Eliminating parenting classes for parents volunteering to improve their interactions with their children is a misguided and reckless decision. The single most sought after goal in the helping profession is for individuals and families to refer themselves for services. Self referrals save lives and money when families and individuals voluntarily seek help. By providing services to families who are experiencing family dysfunction including child abuse and neglect, spousal/partner abuse, substance abuse and/or maternal depression but who seek help, success rates are generally higher because parents are motivated to improve. Reduction of High Risk Cases is Primary Prevention • After completing just 6 months of instruction, the percentage of high risk families for spousal and child maltreatment in Hilo went down dramatically. Reducing the percentage of families at risk reduces the percentage of families likely to be reported for child abuse and neglect. Reducing the number of reported abuse and neglect cases, in turn, reduces children's injuries and deaths. Research on the impact of adversive childhood experiences indicates that a multi- level system providing universal access to parenting support to all families in the community is a cost savings realized in less than one year. The Reports of Child Abuse and Neglect are grossly Underestimated • The percentage of parents in Hilo and Maui who reported being abused as children is alarmingly high. In Hilo, 52% of the parents indicated they were abused and neglected as children while 44% of the parents in Maui reported they were maltreated as children. However, research examining the adversive effects of childhood indicates that child abuse and neglect are grossly underestimated. According to the study, maltreatment is generally 40 times greater than reported. Utilizing this figure, the actual incidence of abuse among parents attending Healthy Start in Hilo is 20% higher or 72% and in Maui not 44% but rather 60%. A Tsunami of Social and Familial Problems is on the Horizon for Hawaii • There is no denying that Healthy Start has not only been a model program for the State of Hawaii, but also nationally and internationally. Families have been profiting from participating in Healthy Start programs for nearly 25 years. Perhaps the data in the early stages of the program weren't gathered properly to claim scientifically that the effects of participating in Healthy Start are significantly proven to prevent child maltreatment, or bring couples back together and save marriages and broken families, or help the new Moms struggling with post partum depression. Does it really take scientific evidence to understand that when people are down and out and have a place to go for help, the feeling that one is not alone is therapeutic enough to immediately improve the quality of life for all involved? • The economic times that have hit Hawaii require sanctuaries families can attend for support and education. Rates of family dysfunction are increasing daily. Stress is the one variable that is common to all dysfunctions. Children in the early stages of their lives are not capable of 9 understanding the stressful issues adults face, but rather suffer them. Exposure to early and continuous stress effects children's brains in ways that changes brain chemistry, as Dr Dennis Embry at the Paxis Institute states "wildly increasing the risk of abuse of virtually every substance from tobacco, alcohol, illegal drugs to prescription drugs." Abolishing Healthy Start in Hawaii will bring a tsunami of social and familial problems. Whatever short term monetary gain is achieved by abolishing the program will be quickly needed for services that the families will demand. In the long and short term, investing in Healthy Start is investing in the health and welfare of current and future generations of Hawaiians. 10