Best Practices

Best practices for disseminating early childhood maltreatment evidence-based care: The LAUNCHing ABC in NC Project

Joint endeavor by two universities examines the feasibility of a Learning Collaborative-based model that can be tested through a randomized control trial.

By Karen Appleyard Carmody, PhD, Mary Dozier, PhD, Lisa Amaya-Jackson, MD, Robert A. Murphy, PhD, and Ashley Alvord

Child maltreatment is a serious public health problem, particularly for infants and young children. In the United States in 2010, 695,000 children, more than 9.2 of every 1,000 (0.92 percent), were identified as victims of abuse or neglect (U.S. Department of Health and Human Services [US DHHS], 2011). Victimization rates among children between birth and age one were over twice as high (2.06 percent). The largest proportion of maltreatment-related fatalities (79.4 percent) occurred among children younger than four years old (US DHHS, 2011). Child maltreatment portends an array of problematic outcomes, including depression and other internalizing problems (Johnson et al., 2002; Toth, Manly & Cicchetti, 1992), aggression and violence (Kotch et al., 2008; Lansford et al., 2007), and problematic parenting of one’s own children (Berlin, Appleyard & Dodge, 2011; Dixon, Brown & Hamilton-Giachritsis, 2005; Noll, Trickett, Harris & Putnam, 2009). The earlier in a child’s life that maltreatment occurs, the more likely it is to recur, and the more detrimental its developmental sequelae (Cicchetti, Toth & Maughan, 2000; Keiley, Howe, Dodge, Bates & Pettit, 2001).

The impact of child maltreatment underscores the need for evidence-based prevention and intervention programs to enhance children’s development. Access to such evidencebased programs focused on early childhood parent-child relationships and maltreatment is very limited, however. This article will provide an overview of one intervention designed for this population, Attachment and Biobehavioral Catch-up, and an effort underway to disseminate this model to community providers using an implementation science-based approach.

Attachment and Biobehavioral Catch-up: Meeting the Needs of Young High-Risk Children

Attachment and Biobehavioral Catch-up (ABC; Dozier, Lindheim & Ackerman, 2005), developed by Dr. Mary Dozier at the University of Delaware, is an intervention designed to meet the needs of young children who have experienced maltreatment or who have experienced early childhood attachment disruptions placing them at risk for maltreatment. With its roots in attachment theory and research, ABC is a manualized, brief model consisting of 10 sessions delivered to parents and infants in their homes. ABC addresses four issues identified as important for children who have experienced adversity: (a) parental nurturance, (b) following the child’s lead, (c) delighting in the child, and (d) non-threatening, non-frightening caregiving behavior. Sessions provide in-the-moment feedback as well as video feedback to the parent, resulting in a more responsive and predictable environment for the child and enhanced, healthy interactions for both child and caregiver.

Results from two randomized trials (one with infants in foster care and their parents, a second with neglected infants and their biological mothers) indicate that ABC:

  1. Enhances attachment security and reduces attachment disorganization (Bernard, Dozier, Bick & Carlson, 2012)

  2. Helps normalize diurnal patterns of cortisol regulation (Dozier, Bernard & Gordon, 2012)

  3. Enhances children’s executive functioning (Lewis- Morrarty, Dozier, Bernard, Moore &Terraciano, 2012).

The program has received California Evidence-Based Clearinghouse ratings of “promising research evidence” and “high relevance to child welfare population” (CEBC, 2009).

Learning Collaborative Methodology: Meeting the Dissemination Needs of Early Childhood Practitioners

Access to evidence-based treatments (EBTs) focused on early childhood maltreatment, such as ABC, is limited. Many barriers to the adoption of EBTs (e.g., inadequate training and supervision, limited resources, wariness of change, challenges in transforming policies and procedures) prevent such widespread dissemination (Amaya-Jackson & DeRosa, 2007). Moreover, traditional didactic trainings, which are focused on transferring knowledge about a clinical intervention, do not effectively translate EBTs from the laboratory to sustainable community clinical practice (Fixsen, Naoom, Blase, Friedman & Wallace, 2005). Developed by the UCLADuke National Center for Child Traumatic Stress (NCCTS), the Learning Collaborative Model on Adoption & Implementation of EBTs integrates established quality improvement and implementation science methods with fidelitygrounded clinical training to address these barriers (Ebert, Amaya-Jackson, Markiewicz & Burroughs, 2008). Successful adoption and implementation of new practices require assessment of organizational readiness for change, involvement of senior management, attention to fidelity through continuous supervision, and testing and practice of a series of incremental changes prior to widespread use. These strategies are central to the Learning Collaborative methodology (Markiewicz, Ebert, Ling, Amaya-Jackson & Kiesel, 2006). The Learning Collaborative features three training tracks, for clinicians, supervisors, and senior leaders, designed to address all levels of agency or system involvement needed to fully support adoption and sustainability. Figure 1 summarizes the steps and timeline involved in a typical Learning Collaborative. A growing body of literature supports the effectiveness of Learning Collaboratives, such as successful implementation of EBTs and high model fidelity by clinicians, enhanced client outcomes corresponding to higher model fidelity, and increased organizational capacity to support and sustain EBTs (Amaya-Jackson, 2010; Ebert, Amaya-Jackson, Markiewicz & Fairbank, 2012a & 2012b).

Bringing Together Developmental Science and Implementation Science: The LAUNCHing ABC in NC Project

A collaborative endeavor between the University of Delaware and Duke University’s Center for Child & Family Health (CCFH) seeks to disseminate ABC, and thereby enhance early childhood developmental outcomes for children at risk of maltreatment, through a pilot training and dissemination project guided by Learning Collaborative methodology called LAUNCHing ABC in NC. The program is funded by a contract with a local county that is seeking to enhance early childhood services through a SAMHSA LAUNCH grant. The primary objective of LAUNCHing ABC in NC is to examine the feasibility of a Learning Collaborative-based model for dissemination of ABC, which can then be tested through a randomized control trial. Based on prior ABC and implementation science research, the central hypothesis is that children will benefit more (i.e., show better developmental outcomes) from evidence-based treatments (i.e., ABC) supported by effective training models and implementation supports (i.e., Learning Collaborative methodology). The rationale for the proposed research is that once it is known how EBTs such as ABC are best translated into community practice, dissemination of ABC can be more successfully and sustainably achieved, resulting in enhanced prevention and treatment of maltreatment and its maladaptive sequelae.

In collaboration with Dr. Mary Dozier at the University of Delaware, faculty from Duke’s CCFH are currently enrolling 10 clinicians from three North Carolina counties in a pilot “Learning Community” to be trained in ABC as well as quality improvement skills in order to develop sustainable ABC programs. Over the course of 12 months, service providers and agency leaders will attend three face-to-face learning sessions with intensive clinical and implementation training. Interspersed with the face-to-face sessions, service delivery and implementation-focused action periods will allow ABC providers and agencies to put knowledge into practice with regular case consultation, group calls, and data collection and reporting. Providers will complete three ABC cases with weekly clinical consultation and fidelity monitoring. Agency administrators will develop implementation plans with monthly consultation calls to monitor agency support for the model. Data or “metrics” on client functioning, clinician adherence and fidelity, and agency implementation activities will be regularly reported and tracked throughout the process. The pilot data gathered from 30 participant families at pre- and post-assessment as well as from ABC providers and agency administrators during the course of services will be used to develop a randomized control trial examining the Learning Collaborative approach compared with training as usual.

The proposed project offers an innovative and novel approach to disseminating an EBT to prevent and intervene with young children at risk for maltreatment and to promote young child mental health. The results are expected to have an important positive impact on the public health problem of early childhood maltreatment by improving the quality of training for community early childhood intervention providers and increasing their use of evidence-based practices with model fidelity. In turn, this work will promote positive developmental and mental health outcomes and prevent mental health disorders in young high-risk children.

The National Center for Child Traumatic Stress (NCCTS) Learning Collaborative Model


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