Regular Research Article

Research on Social Work Practice

22(5) 553-566
A Multilevel Evaluation of a Comprehensive The Author(s) 2012
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Child Abuse Prevention Program DOI: 10.1177/1049731512444165
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Michael A. Lawson1, Tania Alameda-Lawson2, and

Edward C. Byrnes3

Abstract
Objectives: The purpose of this study is to examine the extent to which participation in a county-wide prevention program leads
to improvements in protective factors associated with child abuse prevention (CAP) and whether improvements in measured
protective factors relate to decreased odds of child abuse. Method: Using multilevel growth modeling, our analyses focus on
an economically poor, culturally diverse sample of 1,184 mothers who maintained their involvement in the program for at least
6 months. Results: Our results support a limited association between program participation and improvements in maternal
protective factors. Nevertheless, pursuant to the working theory of many CAP programs, improvements in maternal social
support and mental health, when evident, were significantly associated with reduced odds of child abuse. Conclusion: More
robustly specified interventions and supports are needed to enhance outcomes for the majority of families targeted by the
program, including those who present the greatest vulnerability for child abuse.

Keywords
child abuse prevention, protective factors, multilevel social work, paraprofessional social work, systems change

Background Researchers have long understood the import of these risk

As the evidence mounts regarding the cyclical costs and
problems associated with child abuse, child abuse prevention
(CAP) programs are receiving increased attention in federal,
state, and local policy circles. At the center of the current pol-
icy interest are community-/population-level CAP programs
(Daro, 2006; Gomby, 2007; LeCroy & Krysic, 2011; Printz,
Sanders, Shapiro, Whitaker, & Lutzger, 2009). These pro-
grams typically seek to engage economically poor families
with young children aged 05 years.
Economically poor families are often targeted by CAP
programs because child abuse is disproportionately reported in
economically poor communities (Freisthler, Merritt, & LaScala,
2006). Additionally, data indicate that the economic hardship,
social exclusion, and social isolation accompanying poverty are
strongly related to risk factors for child abuse (Garbarino & Barry,
1997). Chief among these risk factors are parenting attitudes that
favor corporal punishment over other forms of discipline (Chaffin
et al., 2004), previous family histories of child abuse and domestic
violence (DV; Bilukha et al., 2005; Geeraert, Noorgate, Grietans,
& Onghena, 2004; Graham-Bermann, Banyard, Lynch, DeVoe,
& Halabu, 2007), substance abuse problems (Chaffin et al.,
2004; Garbarino & Barry, 1997), social withdrawal (McCurdy,
2001, 2005; Sanders, Turner, & Markie-Dadds, 2002), and
maternal mental health/depression (Garbarino & Barry,
1997; Green, Furrer, & McCallister, 2007; Siefert, Williams,
Finlayson, Delva, & Ismail, 2007).
factors in relation to child abuse. However, they have not been
able to agree consistently on how these risk factors can or
should best be addressed through intervention. As a conse-
quence, CAP research and programming is often fragmented
according to different academic fields and disciplines.
Within this diversity of field, interventionists steeped in the
behavioral research tradition tend to target isolated risk factors
for child abuse, often by way of robustly targeted, clinically
tested, and professionally driven approaches to intervention
(e.g., Chaffin, 2004; Kolko & Swenson, 2002). Though too
numerous to detail here, countless behavioral and clinical treat-
ment programs have been developed and evaluated from this
perspectivesome of which have proven efficacious in reduc-
ing incidents of child abuse (e.g., Baydar, Reid, & Webster-
Stratton, 2003; Brotman-Miller et al., 2003; Chaffin et al.,
2004; Henggeler, Shoenwald, Rowland, & Cunningham,
2002).
1
Department of Human Development, Binghamton University (SUNY),
Binghamton, NY, USA
2
Department of Social Work, Binghamton University (SUNY), Binghamton,
NY, USA
3
School of Social Work, Eastern Washington University, Cheney, WA, USA
Corresponding Author:
Michael A. Lawson, PO Box 6000 Binghamton, NY 13902-6000, USA
Email: mlawson@binghamton.edu
554
In contrast to this important line of clinical research and pro-
gramming, other CAP programs include a broader range of ser-
vice goals, targets, and objectives. These efforts are driven
explicitly by etiological research which frames child abuse
as the result of complex transactions between multiple risk
factors and ecologies (Belsky, 1993; Cicchetti & Lynch,
1993; MacKenzie, Koch, & Lee, 2011). Accordingly, these
CAP programs endeavor to provide services with sufficient
breadth and depth to address multiple risk factors and/or mul-
tiple combinations of risk factors, simultaneously (e.g., Daro,
Howard, Tobin, & Harden, 2004; Galano, 2007; Krysik &
LeCroy, 2007; Olds, 2002).
Home visitation programs serving mothers with young
children are perhaps the most popular example of CAP pro-
grams developed from this socialecological and transac-
tional view of child abuse and its prevention (Galano,
2007). These programs typically target improvements in indi-
cators of parenting attitudes and family well-being as key
mediating mechanisms for preventing child abuse (Harding,
Galano, Martin, Huntington, & Schellenbach, 2007; Olds,
2002). Although experimental evaluations of these programs
have yielded mixed results (e.g., Duggan et al., 2007; Sweet
& Applebaum, 2004), recent studies support program effec-
tiveness with particular parent populations (LeCroy & Krysik,
2011). Specifically, young (under the age of 25), first-time
mothers, who are engaged before the start of the third trime-
ster of pregnancy, appear the most likely candidates to benefit
from home visitation programs (DuMont et al., 2008; LeCroy
& Krysik, 2011; Olds, 2002).
Toward More Comprehensive,
Community-Based Prevention Programs
Increasingly, the successes and limitations derived from
research on CAP programs are contributing to the development
of a new genus of programs and initiations, which we are call-
ing comprehensive, community-based CAP. These comprehen-
sive, community-based programs and initiatives, which are
often a part of child welfare redesign efforts, extend the reach
of most community-based programs by providing a range
of individual and clinically focused supports that are comple-
mented by both family- and systems-level interventions (e.g.,
Claiborne & Lawson, 2005). This multilevel approach to pro-
gram planning and design is intended to address the complexity
of child abuse and neglect, especially its status as a nested prob-
lem with co-occurring and interlocking causes and correlates
(e.g. MacKenzie, Kotch, & Lee, 2011).
The comprehensive, community-based CAP program exam-
ined in this study represents a first-generation effort of this
approach to comprehensively improve family-, community-,
and system-level outcomes related to child abuse. This program,
which we call safe families (SF) in this article, was implemented
in the year 2000 as a partnership between local county govern-
ment and seven community-based, nongovernmental service
agencies. It is a place-based initiative that serves nine
Research on Social Work Practice 22(5)
economically and socially vulnerable communities in an urban
region in a Western state.
SF encompasses six core program components: (a) a para-
professional home visitation program, where paraprofessional
social workers visit families with young children at least once
a week in their home; (b) a multidisciplinary/integrated ser-
vices team of social workers and mental health professionals
that collaboratively serve the needs of families served through
home visitation both in home and in agency settings; (c) a fam-
ily resource center program that provides parenting support,
child care, school readiness classes, and mental health services
to families with young children in the community; (d) a family
support collaborative, which provides collaborative leadership,
governance, and management for the six community-based
organizations and five government service agencies involved
in the program; (e) a lead intermediary organization that pro-
vides staff and training support to the initiative; and (f) a lead
government fiscal agent that provides additional administrative
support, including the complex blending of federal, state, and
local funding streams that support the program.
Collectively, these program components are designed to
provide a comprehensive web of support for program families.
At the root of this comprehensive support system are home
visitation services provided by social workers, with the major-
ity of these in-home supports provided by paraprofessionals.
These home visitors aim to promote several parent competen-
cies, including the development of effective and developmen-
tally appropriate parenting practices, as well as enhanced
family use of health and mental health services in the commu-
nity. Additionally, through home visitation, both professional
and paraprofessional social workers actively encourage family
use of other support services in the community, including, but
not limited to, family involvement in formal and informal ser-
vices and activities provided out of the neighborhood family
resource center.
Although the SF program admits families into the program
provided that they have a child in the home aged 05 years, the
program primarily targets expectant or new mothers. For this
reason, the overwhelming majority of parents involved in the
SF program are new or expectant moms, with 95% of the pro-
gram sample including mothers who began participating in the
program before their baby reached 6 months of age.
Participants are recruited voluntarily into the SF program
through four methods. First, parent and family referrals are
frequently made through the family resource centers run by
the community-based partners of the initiative. Second, child
protective services (CPS) refer clients to the program, often
as a part of differential response. Third, human service provi-
ders in the region, which collaborate with the SF program, rec-
ommend the program to their clients. Fourth and finally,
participants of SF program refer other community members
to the SF program, essentially engaging in word-of-mouth
recruiting.
In this article, we evaluate the practices and processes of
SF within the context of the programs theory of change for
preventing child abuse. Accordingly, our inquiry begins by
Lawson et al.
examining how program participation relates to improve-
ments in maternal competencies (e.g., protective factors)
thought to prevent child abuse, with particular attention
toward how program involvement relates to changes in par-
enting attitudes, maternal social support, and maternal mental
health (e.g., Gomby, 2005, 2007; Harding et al., 2007; Krysic
& LeCroy, 2007). Our analyses conclude by examining the
extent to which changes in maternal protective factors are
associated with decreased odds of child abuse. Our research
objectives are as follows:
Research Objective 1: To examine how comprehensive CAP
programs, like SF, might best succeed at preventing child
abuse.
Research Objective 2: To examine whether family participa-
tion in SF services helps enhance those protective factors
(e.g. improvements in parenting attitudes, maternal social
support, and maternal mental health) associated with
reducing and/or preventing incidents of child abuse.
Research Objective 3: To examine what family characteris-
tics, including family risk and background factors, relate
to changes in protective factors/outcomes.
Research Objective 4: To examine whether changes in mater-
nal protective factors are associated with reduced odds of
child abuse for families who participate in the SF program.
Method
Data Collection
The primary data for this study are extracted from a database
maintained by a local evaluation firm. This firm has been respon-
sible for evaluating SF since its inception over a decade ago. In
addition to maintaining the same evaluator, SF has preserved its
original evaluation and program design. This consistency in
design allows for a unique longitudinal examination of how pro-
gram participation relates to changes in CAP outcomes.
Before data extraction began, the Eastern Washington
University (EWU) Institutional Review Board (IRB) for
Human Subjects Research approved the study procedures. This
IRB was selected because EWU is the home institution of the
third author who was closely involved with the data extraction
and management procedures. The protocol approved by the
IRB included (1) the understanding that there would be no con-
tact between any program participant and any member of the
evaluation team; and (2) that during their enrollment in the pro-
gram all participants consented to deidentified data about them
and their program participation potentially being shared with
external program evaluators.
The SF data set includes a broad range of demographic and
service data on each family while they are active in the pro-
gram, such as family income, parent education, and family size,
as well as the frequency, intensity, and duration of program ser-
vices. The data base also includes child abuse allegation and
investigation data from CPS, as well as results from several
psychosocial assessments that are widely used in the literature
555
to measure mediators of child abuse and CAP, including
indices of mothers mental health, social support, and parenting
attitudes (e.g., Dumont et al., 2008).
Each assessment is initially administered to families during
separate home visits that occur within the first 45 days of pro-
gram entry. Paraprofessional home visitors then readminister
each assessment every 36 months. Program leaders view this
strategy of administering each assessment separately as neces-
sary because they believe it spares families from having to
complete five or six assessments in one sitting. However, from
a research perspective, this process also complicates an under-
standing of how assessment results relate to one another, partic-
ularly if and/or when results from each assessment are not
stable over time.
Sample
Nearly 10,000 families participated in the SF program between
2000 and 2007. Since the evaluation design focused on changes
in risk and protective factors within a longitudinal design, our
analyses are restricted to 1,184 mothers who maintained their
involvement in the program for at least 6 months and therefore
had completed at least three administrations of the assessment
instruments that measured their parenting attitudes, social sup-
port, and mental health. This sampling strategy allows for the
evaluation to focus on participants who had sustained engage-
ment in SF program services. Moreover, by selecting mothers
who have assessment results at three or more time points, we
are also more reliably able to estimate changes in maternal
protective factors during their involvement in the program
(Raudenbush & Bryk, 2002). While we recognize that this
method of purposive sampling diverges from the typical
intent-to-treat approach found in many experimental stud-
ies of CAP programs (e.g., Duggan et al., 2007), we view the
study of highly engaged families as an important first step in
testing the underlying assumptions and/or theory of change of
similarly broad and complex programs.
Measures
The measures applied in this evaluation were specifically
selected during program development to serve two functions.
First, these consistent assessments of risk and protective factors
afforded program staff an opportunity to balance educational,
counseling, and resource brokering services at the individual case
level. Additionally, applying these assessment tools on a contin-
uous basis afforded a case-level assessment of client progress and
allowed for empirical testing of the SF programs effectiveness in
mitigating risk and enhancing protective factors. Moreover, as we
detailed in the following section, each of these measures connect
with factors associated with child abuse and neglect.
Risk and Protective Factors
Descriptions of all of the assessments used in this study as well
as their reliability coefficients for each administration are
556 Research on Social Work Practice 22(5)

Table 1. Description of Assessment Instruments

Assessment Instrument Description Chronbachs Alpha

Adult Adolescent Parenting
Index (AAPI-2)
Maternal Social Suppport Index
(MSSI)
The Center for Epidemiological
Studies Depression Scale
(CES-D)
Conflict Tactics Scale (CTS-2)
CAGE Questionnaire
40 items measuring parenting and child rearing 1st Administration 0.79
attitudes. The AAPI-2 provides indices of 2nd Administration 0.78
risk for child abuse in five areas related to Final Administration 0.81
abuse and neglect: Inappropriate expectac-
tions of children, parental lack of empathy
toward childrens needs, strong belief in the
use of corporal punishment, reversing
parent-child role responsibility, and
oppresssing childrens power and
independence
21 items questioning mothers social support 1st Administration 0.71
networks and their satisfaction with that 2nd Administration 0.72
support in several areas, such as kinship Final Administration 0.69
relationships, primary male relationships,
community involvement, and help with daily
tasks.
20 items measuring major components of 1st Administration 0.82
mental health and depression, including 2nd Administration 0.82
depressed mood, feelings of guilt and Final Administration 0.84
worthlessness, feelings of helplessness, loss
of appetite, and sleep distrurbance.
39 items measuring violence along five 1st Administration 0.79
dimensions: Negotiation, psychological 2nd Administration 0.79
aggression, physical assault, sexual coercion, Final Administration 0.81
and injury. The CTS has subscales indicating
levels of severity of violence (e.g. moderate
or severe)
Four items measuring recent substance use in No summative score
the following areas, forming the CAGE Reliability coefficients can not be
acronym: Requests by others to Cut down meaningfully calculated.
subsance use, Annoyance to criticisms by
other regarding sbustance use; Respondelt
Guilt about substance use, and using
substances in the morning as an Eye opener.

presented as Table 1. Each assessment is widely used in the
evaluation research literature on CAP to assess parental risk
and protective factors related to child abuse (e.g., Duggan et
al., 2007; Dumont et al., 2008). We use the assessments col-
lected by the programs evaluators to measure the following
risk and protective factors:
Mothers parenting attitudes. Parenting attitudes are measured
as mothers composite scores on the Adult Adolescent Parent-
ing Inventory-2 (Bavolek & Keene, 1999). The scale asks par-
ents the extent to which they agree with statements like
Spanking children when they misbehave teaches them how
to behave and Parents who encourage their children to talk
to them only end up listening to complaints. Higher scores
indicate more positive parenting attitudes.
Maternal social support. Social support is measured by moth-
ers composite score on the Maternal Social Support Index
(McCurdy, 2001; Pascoe & Earp, 1984). The scale asks mothers
questions related to affective and instrumental forms of support,
including if people help them, like them, or care for their
children. Higher scores indicate better social support.
Maternal mental health. Mental health is measured by the
Center for Epidemiological Studies Depression scale (CES-
D; Clark, Mahoney, Clark, & Eriksen, 2002; Radloff, 1977).
The CES-D asks participants how often in the last week they
felt lonely, sad, fearful, or experienced other depres-
sive symptoms. In this study, the CES-D is reverse coded so
that higher or increasing scores on the CES-D indicate better
maternal mental health.
Domestic violence. DV is measured by the Conflict Tactics
scale (CTS; Tuomi Jones, Ji, Beck, & Beck, 2002). This scale
assesses the degree of DV in the home and includes different
subscales of severity (e.g., moderate, severe, etc.). Items on
the CTS include My partner called me fat or ugly, I
destroyed something that belonged to my partner, I passed
out from being hit on the head by my partner. In this study,
DV is a dichotomous variable, coded as 1 if mothers had a
severe DV score.
Lawson et al. 557

Table 2. Variable Blocks, Names, and Descriptions

Block Variable Name Variable Type Description

Outcomes
Child Abuse (SCAR) Dichotomous Substantiated Child Abuse Report from CPS
Parenting Attitudes Continuous Composite AAPI-2 Score
Maternal Social Support Continuous Total MSSI Score
Maternal Depression Continuous Total CES-D Score
Indicators of Risk
Child Abuse History Dichotomous Previous History of CPS Referral
(whether substantiated or not)
Risky Parenting Attitudes Dichotomous AAPI-2 Score in the Bottom Quartile
(Entry and Exit) of Study Sample
Weak Social Support Dichotomous MSSI Score in the Bottom Quartile
(Entry and Exit) of Study Sample
Maternal Depression Dichtomous CES-D Score of or exceeding -16
(Entry and Exit)
Severe Domestic Violence Dichomotous Positive Response to a Severe
(Entry and Exit) Domestic Violence Item on CTS
Substance Abuse Dichotomous Positive Response to Any Item
(Entry and Exit) in the CAGE Inventory
Indicators of Protection and Change
Strong Parenting Attitudes Dichotomous AAPI-2 Score in the Top Quartile
(Entry and Exit) of Study Sample
Strong Social Support Dichotomous MSSI score in the Top Quartile
(Entry and Exit) of Study Sample
Strong Mental Health Dichotomous CES-D score in the Top Quartile
Demographic Variables
Pregnant Dichotomous Mother Pregnant at Program Entry
Number of Kids in Household Continuous Number of Children in Household
Additional Children Born in Program Continuous Number of Children Born in program
not including initial child
Maternal Age Under 25 Dichotomous Mother under 25 years of Age at Entry
First Time Mother Dichotomous First Time Mother of Newborn
Black Dichotomous African American Ethnicity
Hispanic Dichotomous Hispanic or Latino Ethnicity
White Dichotomous European and Euro-American Ethnicity
English Language Learner Dichotomous English as 2nd Language in the Home
Program Participation
Multi-Disciplinary Team Continuous Number of Times the Multi-Disicplinary
Service Team Staffed the Family
Family Resource Center Participation Continuous Total Number of FRC Activities
Referrals to Outside Agencies Continuous Number of Referrals Made from the
Program to Services External to it
Home Visitation Frequency Continuous Total Number of Home Visits Received
Home Visitation Duration Continuous Number of Months Involved in Program
Home Visitation Intensity Continuous Average Length of Home Visits (Minutes)

Substance abuse. Substance abuse history is measured using
the 4-item CAGE questionnaire (Ashman, Schwartz, Cantor, Hib-
bard, & Gordon, 2004). Items include I occasionally use alcohol
or drugs when I wake up in the morning and It bothers me when
people tell me not to use alcohol or drugs. Mothers with a non-
zero score on the questionnaire have substance use habits indica-
tive of substance abuse problems (Ashman et al., 2004).
Substantiated child abuse reports (SCAR). Two child abuse
variables are included in the program data set. The first, CPS
History, is coded 1 if parents have previous substantiated
reports of child abuse prior to program entry. The second,
SCAR, is coded 1 if parents have a SCAR either during the
program or within 1 year of program exit.
Conceptual Organization of Variables
A comprehensive list and description of all the predictor vari-
ables used in this study is presented as Table 2. Because of the
large number of data points included in the programs data
base, we organized all predictor variables conceptually into
hierarchical categories or blocks. These blocks were used to
structure our overall model-building strategy.
The first block of variables includes those risk factors that
the literature suggests are correlated with abuse and abusive
558
behavior (e.g., Belsky, 1993). The second block includes
variables that may serve as protective factors or assets that par-
ents may possess prior to or develop during their time in the
program. These protective factors or resources are presumed
to reduce the risk of child abuse (Waller, 2001). The third block
includes those demographic factors that may account for varia-
tion in the outcome variables of interest, including race and
ethnicity, the number of children in the household, the number
of children born during the program, the language spoken in
the home, and maternal age. Finally, the fourth block of vari-
ables includes program factors and service variables, includ-
ing the frequency, intensity, and duration of home visits,
participation in the multidisciplinary and integrated services
team, and participation in activities at each sites neighbor-
hood family resource center.
Analytic Approach
Our analytic approach consists of two complementary
approaches to analysis. In our initial models, we use hierarch-
ical linear modeling (HLM; Raudenbush & Bryk, 2002) to esti-
mate two-level growth models for each of the three protective
factors of interest: parenting attitudes, social support, and men-
tal health. This hierarchical approach to estimating changes in
protective factors is appropriate for two reasons. First, because
the SF program model implicates several nested processes
(e.g., families share a model of family services, which are pro-
vided by a shared pool of service providers who provide their
services within shared community-based service sites), the data
violate the ordinary least squares assumption of independence.
HLM accounts for these nested dependencies.
Second, unlike mixed model repeated measures analysis of
variance, which fixes change across individuals, HLM struc-
tures repeated measures as nested within persons. HLM thus
affords needed flexibility in modeling parents average growth
trajectories, given that SF does not administer its assessments
at rigidly prescribed time points (Raudenbush & Bryk, 2002).
Ultimately, we fit three distinct growth models (e.g., slope
and intercept models) for each protective factor of interest as
estimated for person i, in service site j, at time t. The final inter-
cept score,p0i, represents the assessment score on the protective
factor of interest when mothers exit the program. The estimated
growth parameter for each assessment, p1i, is the estimated
change in score for each protective outcome for every 6 months
of program participation. The temporal variable, Time in
6-month intervals, is uncentered so that the intercept p0i rep-
resents the average assessment score at program exit.
At Level 2, we include several predictor variables for
improvements in each protective factor of interest, including
vectors of family demographic variables; a vector of dummy
variables that measure violent histories, substance abuse, and
parent low scores on assessments; a vector of protective fac-
tors defined by parent scores on assessments; and a vector of
program participation variables. Finally, we fix the influence
of site-level effects on each slope and outcome/intercept
by including site dummies at Level 2. We use the largest
Research on Social Work Practice 22(5)
program site, Site 4, as the reference category. Each site
dummy is entered uncentered, while each predictor variable
is grand-mean centered.
Our final set of models estimates the average effect of
changes in protective factors on the odds of receiving a SCAR.
Here, we use the computer program M-Plus 6.0 (Muthen &
Muthen, 2009) to extend the modeling framework used in
HLM to also include SCAR as an outcome variable. For this
expanded outcome model, we examine whether changes in pro-
tective factors predict decreased odds for SCAR, controlling
for mothers assessments scores at program entry; previous
histories of child abuse, DV, and substance abuse; program
involvement and service variables; as well as maternal age
and ethnicity. As with our previous HLM models, all covari-
ates are grand-mean centered and our standard errors are clus-
tered around the Site_ID variable.
Limitations
Data for this study reflect participants self-reports on several
assessment instruments. Consequently, our results are prone
to several different forms of bias including social desirability
bias, cultural disparity bias, as well as regression bias. Another
important source of bias in our study involves problems of
endogeneity. Endogeneity bias is evident when an explanatory
variable is correlated with the error term. In our data, these cor-
relations are considered unavoidable for two primary reasons.
First, neither our sample nor the overall program sample is ran-
domly drawn which introduces threats related to omitted vari-
ables that are correlated with the error term. Second, pursuant to
the extant literature, maternal risk and protective factors may be
recursive such that changes in one factor may co-occur with
changes in others (e.g., Garbarino & Barry, 1997). These sources
of bias inhibit our ability to assess the direction of causality. It is
quite feasible that the predictor variables in a model are actually
caused by the outcome variables. Additionally, our use of a sin-
gle group design does not allow us to ascertain what growth tra-
jectories would have been in the absence of SF program services.
Future research utilizing random assignment of participants to
service and control groups would mitigate some of the afore-
mentioned biases and strengthen our ability to arrive at causal
conclusions. We therefore interpret the following results as
solely relational, not causal, while holding other factors constant
that may importantly affect examined relationships.
Results
Descriptive statistics for all variables are presented in Table 3.
As shown, the program engages a culturally diverse population
of families: 49% of the program sample is Hispanic, 21% is
White, and 20% is African American. Half of the families
report speaking a primary language other than English.
In general, families enter the SF program with notable men-
tal health constraints. Nearly 45% of the program population
enters the program with a CES-D score exceeding 16, indicat-
ing clinical depression. However, only a very small percentage
Lawson et al. 559

Table 3. Descriptive Statisticsy

Variables Mean SD Min Max

Outcome Variable
Child Abuse 0.08 0.29 0 1
Parenting Attitudes Score at Entry 134.81 19.07 70 194
Parenting Attitudes Score at Exit 141.92 17.97 85 200
Social Support Score at Entry 20.2 5.67 2 35
Social Support Score at Exit 20.95 4.97 5 34
Maternal Mental Health Score at Entry 15.55 11.06 0 57
Maternal Mental Health Score at Exit 11.36 10.1 0 52
Indicators of Risk
Prior CPS Involvement 0.05 0.22 0 1
History of Severe Domestic Violence 0.1 0.3 0 1
Domestic Violence Present at Exit 0.08 0.38 0 1
Substance Abuse at Entry 0.08 0.27 0 1
Substance Abuse at Exit 0.03 0.18 0 1
Risky Parenting Attitudes at Entry 0.25 0.43 0 1
Risky Parenting Attitudes at Exit 0.27 0.44 0 1
Low Social Support at Entry 0.3 0.46 0 1
Low Social Support at Exit 0.27 0.44 0 1
Maternal Depression at Entry 0.43 0.5 0 1
Maternal Depression at Exit 0.26 0.44 0 1
Demographic Factors
First Time Mother 0.35 0.47 0 1
Maternal Age Under 25 0.5 0.5 0 1
Asian 0.07 0.3 0 1
White 0.19 0.4 0 1
Black 0.19 0.39 0 1
Hispanic 0.55 0.5 0 1
ELL 0.55 0.5 0 1
Program Participation
MDT Participation 10.47 4.95 0 31
FRC Participation 10.82 27.29 0 467
Home Visitation Frequency 62.7 32.58 6 307
Home Visitatation Duration 33.3 15.97 5.76 92.81
yDummy variables were included in this table to provide a complete overview of the study variables.
These dummy variables can be identified by their minimum and maximum values of 0 and 1.
To identify the percent of cases positive for each dummy variable, multiply the mean by 100.

of the program population experience the most severe vulner-
abilities associated with child abuse (e.g., Garbarino & Barry,
1997). Only 5% of program families enter the program with pre-
vious CPS involvement, while only 8% of the program popula-
tion report severe DV histories and substance abuse problems.
Examining Changes in Protective Factors
To examine how participation in the program relates to growth
in parenting attitudes, social support, and mental health, we
analyzed three distinct hierarchical linear growth models for
each protective factor of interest. Results from these analyses
are presented in Tables 4, 5, and 6 for social support, mental
health, and parenting attitudes, respectively. In each of these
tables, we include three model estimates. In the first model,
we estimate the baseline, average growth that mothers experi-
ence on each protective factor for every 6 months they are
involved in the program. In our second set of models, we esti-
mate mothers average growth for each assessment when
family demographics and program service variables are entered
as covariates. In the third and final model in each table, we esti-
mate how mothers risk and protective factors are associated
with changes in protective factors adjusting for family demo-
graphics and program services. In each of these final models,
we pay particular attention to the influence of prior CPS invol-
vement, severe DV history, and substance abuse history on
changes in protective factors, due to their established relation-
ship with child abuse (Chaffin, 2004). For all estimated models,
model fit is evaluated with respect to improvements in the pro-
portion of variance explained at Level 2, as noted at the bottom
of each table.
Baseline Results
Results from each baseline model (Column 1) in Tables 4 and 5
demonstrate a very small average 6-month growth coefficient for
social support and mental health. On average, 6 months of partic-
ipation in the program corresponds with less than a one-quarter
560 Research on Social Work Practice 22(5)

Table 4. HLM for Maternal Social Support with Variance Components (n1184) y

I II III

Model For Final Social Support

Social Support Final Intercept 20.97** 20.97** 20.95**
Prior CPS Involvement 0.42
History of Severe Domestic Violence 1.53**
Substance Abuse History 0.48
Maternal Depression at Entry .74*
Asian 0.35 0.07
Black 0.51 0.63
Hispanic 0.17 0.01
First Time Mother 0.99* 0.32
Maternal Age Under 25 0.03 0.03
Home Visitation Duration 0.06 0.01
Home Visitation Frequency 0.02 0.02
Multi-Disciplinary Team 0.01 0.02
Family Resource Center 0.03 0.07
Model for Growth Rate
Social Support Change 0.09* 0.09* 0.06
Prior CPS Involvement 0.04
History of Severe Domestic Violence .31*
Substance Abuse History 0.05
Maternal Depression at Entry 0.06
Asian 0.29 0.12
Black 0.45* 0.03
Hispanic 0.03 0.22
First Time Mother 0.07 0.01
Maternal Age Under 25 0.03 0.05
Home Visitation Duration 0.07 0.07
Home Visitation Frequeny 0.06 0.06
Multi-Disciplinary Team 0.001 0.01
Family Resource Center 0.004 0.004
Unconditional Social Support
Within Person Variance 41.00%
Between Person Variance 58.00%
Final Model Final Status Variance roj Growth Rate Variance r1j
Social Support
Unconditonal 17.7**** 0.28****
Conditional 10.18**** 0.21****
Proportion of Var Explained at Level2 42.00% 25.00%

*p<.05, **p<.01,
y Coefficients of Site Dummies Not Shown

point gain in mothers social support and mental health scores. Program Services and Outcomes
While statistically significant, these nonzero average gains corre-
In Column 2 of Tables 46, we estimate the change in protec-
spond to less than a point increase in mothers social support and
tive factors when program service variables are entered into
mental health score for 2 years of program involvement.
each HLM. In each case, our results do not support a relation-
Although the baseline growth trajectories for mental health
ship between any form of participation in the program (e.g.,
and social support are practically flat, the estimated baseline
home visitation, multidisciplinary team, or family resource
growth model for parenting attitudes depicted in Table 6, Col-
center participation) and significant improvements in protec-
umn 1, indicates improvement. Here, an average mother in the
tive factors, all else equal. These results indicate that the
program is expected to benefit from a near two-point increase
variability of change in protective factors is not generally or
in parenting attitudes score for every 6 months of involvement
directly related to increased participation in program services.
in the program. When extrapolated over 2 years, this is an aver-
However, readers should be mindful that, absent a comparison
age improvement in parenting attitudes of about one third of a
group, these results should be interpreted with caution. For
standard deviation. Apparently, activities carried out by home
instance, absent intervention, mothers social support and
visitors and project staff assist some parents in fostering parent-
mental health scores/status could have decreased over the
ing attitudes, which research suggests are protective for child
same time frame.
abuse (Bavolek & Keane, 1999).
Lawson et al. 561

Table 5. HLM for Maternal Mental Health with Variance Components (n1184) y

I II III

Model For Final Status

Mental Health Final Intercept 12.37** 12.36** 12.69**
Prior CPS Involvement 4.75*
History of Severe Domestic Violence 2.35*
Substance Abuse History 2.16*
Low Social Support at Entry 2.96**
Asian 0.57 0.21
Black 0.51 0.37
Hispanic 0.26 0.31
First Time Mother 1.24* 0.52
Maternal Age Under 25 0.18 0.18
Home Visitation Duration 0.05 0.01
Home Visitation Frequency 0.05 0.04
Family Resource Center 0.06 0.06
Multi-Disciplinary Team 0.07 0.05
Model for Growth Rate
Mental Health Change 0.23** 0.12 0.07
Prior CPS Involvement 0.13
History of Severe Domestic Violence 0.13
Substance Abuse History 0.09
Low Social Support at Entry 0.01
Asian 0.22 0.11
Black 0.52 0.49
Hispanic 0.31 0.22
First Time Mother 0.12 0.11
Maternal Age Under 25 0.09 0.11
Home Visitation Duration 0.006 0.005
Home Visitation Frequency 0.007 0.007
Family Resource Center 0.005 0.005
Multi-Disciplinary Team 0.01 0.01
Unconditional Mental Health
Within Person Variance 46.00%
Between Person Variance 54.00%
Final Model Final Status Variance roj Growth Rate Variance r1j
Mental Health
Unconditonal 67.04** 1.98**
Conditional 41.96** 1.48**
Proportion of Var Explained at Level2 37.00% 25.00%

*p<.05, **p<.01
y
Coefficients of Site Dummies Not Shown

Presenting Problems and Changes in Protective Factors
As indicated in the literature, families who are challenged by
histories of violence and/or substance abuse problems are
known to be particularly vulnerable to experiencing child abuse
(Garbarino & Barry, 1997). As a result, improving protective
factors and resources for these families would appear to be a
central priority for CAP programs. However, as demonstrated
in Column 3 of Tables 46, our data do not support positive
relationships between any of these severe risk factors and
improvements in protective competencies. In fact, in most
cases, prior CPS involvement, severe DV history, and sub-
stance abuse history predict below average scores on final
assessments, as well as slightly negative growth trajectories
on assessments, all else equal. Collectively, these results sug-
gest that programs like SF should consider providing an
alternative, or supplemental, array of supports and services
to families who present the most severe risks for child abuse
upon program entry.
Examining Relationships Between Risk/Protective Factors
and Child Abuse Outcomes
Table 7 presents the results from our final multilevel growth
model, which examines relationships between program partici-
pation, family characteristics, changes in maternal protective
factors, and SCAR. This model reflects the most parsimonious
and best fitting model as evaluated by a log-likelihood ratio test.
Pursuant to the extant literature on child abuse, families with
previous histories of child abuse have nearly 2.5 times the odds
of experiencing a SCAR, all else equal. This vulnerability is
562 Research on Social Work Practice 22(5)

Table 6. HLM for Parenting Attitudes with Variance Componens (n1184) y

I II III

Model for Final Parenting Attitudes

Parenting Attitudes Final Intercept 145.03** 145.02** 143.08**
Prior CPS Involvement 1.16
History of Severe Domestic Violence 0.39
Substance Abuse History 0.25
Asian 0.86 0.51
Black 0.37 1.39
Hispanic 0.15 0.36
First Time Mother 0.38 32
Maternal Age Under 25 0.06 0.31
Home Visitation Duration 0.009 0.009
Home Visitation Frequency 0.06 0.04
Family Resource Center 0.07 0.06
Multi-Disciplinary Team 0.03 0.02
Model for Growth Rate
Parenting Change 1.97** 1.96** 1.32**
Prior CPS Involvement 0.75
History of Severe Domestic Violence 0.63*
Substance Abuse History 0.55
Asian 0.08 0.31
Black 0.11 0.28
Hispanic 0.03 0.3
First Time Mother 0.33 0.75
Maternal Age Under 25 0.03 0.04
Home Visitation Duration, 0.06 0.06
Home Visitation Frequency 0.06 0.01
Family Resource Center 0.05 0.02
Multi-Disciplinary Team 0.05 0.04
Unconditional Parenting Attitudes
Within Person Variance 53.00%
Between Person Variance 47.00%
Final Model Final Status Variance roj Growth Rate Variance r1j
Parenting Attitudes
Unconditonal 156.01**** 5.2****
Conditional 103**** 2.09****
Proportion of Var Explained at Level2 34.00% 59.00%

*p<.05, **p<.01
y
Coefficients of Site Dummies Not Shown

also evident in families who have previous histories of DV.
These families have odds of receiving a SCAR that are nearly
50% higher than families with mothers who do not have
violent histories, ceteris paribus. Additionally, and perhaps
surprisingly, families with reported histories of substance
abuse were not more vulnerable to SCAR than other families.
This finding gives rise to important questions regarding the
predictive validity of the CAGE instrument for assessing vul-
nerability for SCAR at intake.
Most significantly, and pursuant to our research objectives,
Table 7 shows that improvements in maternal mental health
and social support relate negatively and significantly to SCAR.
Specifically, every unit increase of social support and mental
health change experienced in the project (in 6-month intervals)
results in about a 25% decrease in the odds of experiencing a
SCAR. This is a significant finding because it empirically sup-
ports the general working theory of change behind many CAP
programs. In this respect, program designers, practitioners, and
policy makers may consider improvements in these maternal
resources as protective for child abuse. The key remaining
issue is to explore how these outcome improvements might
become more prevalent for families throughout the program.
Discussion and Applications to Practice
Toward Helping Comprehensive Programs Become More
Comprehensive
In this study, we refer to SF as a comprehensive, community-
based CAP program. We advance this moniker because SF is
designed to reduce community-wide incidents of child abuse
through a multilevel intervention strategy that includes multi-
ple agencies, multiple services, and at times, multiple service
systems. Although this service structure appears to represent
a considerable strength of the program, a review of the program
data set, as well as program records and previous evaluations,
Lawson et al. 563

Table 7. Protective Factors and Child Abuse Outcomes Yet, it also seems plausible that this approach to service
deliverythough it might be quite helpfulmay not be

Model For Child Abuse Outcomes (odds ratios) y (OR)
powerful enough to alter some of the broader socioeconomic
constraints to family well-being. As research indicates, moth-
Risk Factors ers who experience poverty-related constraints, such as eco-
Prior CPS Involvement 2.43** nomic, housing, and employment barriers, are particularly
History of Severe Domestic Violence .48** vulnerable to hardships which, if left unchecked, may affect
Substance Abuse History 0.007
their interactions and relationships with families, friends, and
Assessment/Protective Score at Entry
Parenting Attitudes Intercept at Entry 0.001 others in the community (Freisthler, Merrit, & LaScala, 2006;
Social Support Intercept at Entry 0.032 Leventhal & Brooks-Gunn, 2000; Ross, Reynolds, & Geis,
Mental Health Intercept at Entry 0.016 2000). What is more, when mothers poverty-related con-
Change in Protective Factors straints include previous histories of family violence and/or
Parenting Attitudes Growth Coefficient 0.001 substance abuse, then the potential for family social isolation and
Social Support Growth Coefficient .27* mental health difficulty is known to deepen (e.g., Chaffin, 2004;
Mental Health Growth Coefficient .26*
Freisthler, Merrit, & LaScala, 2006; Ross, Reynolds, &
Demographic Variables
Asian 0.001 Geis, 2000).
Black .28* Thus, a chief need identified by this study is for programs
Hispanic 0.26 like SF to robustly target constraints to maternal social support
First Time Mother 0.03 and mental health, including those, which are associated with
Maternal Age Under 25 0.2 living in poverty. To do so, policy makers and program leaders
Program Variables can and should build from the broad, collaborative and organi-
Home Visitation Duration 0.004
zational structure of SF to develop a range of services which
Home Visitation Frequency 0.01
Multi-Disciplinary Team 0.01 program and case managers can leverage/tailor to meet partic-
Family Resource Center 0.03 ular family strengths and/or needs. As our data indicate, fami-
lies who enter the SF program with some of the most
*p<.05, **p<.01, formidable vulnerabilitiessuch as previous histories of child
y Standard Errors Clustered Around Site_ID Variable
abuse, DV, and substance abuseappear to struggle with
social support and mental health throughout their time in the
suggests that the overwhelming majority of service units program. In this respect, best-evidence efforts like Project
provided by the program are delivered weekly by paraprofes- SafeCare, which successfully serve families with previous his-
sional social workers who serve the program as home visitors tories of child abuse and DV (Gershater-Molko, Lutzker, &
(see also Daro, 2006). Wesch, 2003), provide important case examples for how para-
According to program documents, home visitors of SF are professional social work services can be bolstered for the most
charged with providing three general kinds of support ser- vulnerable CAP program participants.
vices to each family during weekly home visits. The first At the same time, our results indicate that program leaders
responsibility is to provide information and feedback to par- should strive to further advance the social development and
ents regarding their parenting and, within, the developmental connections of families who do not demonstrate severe risks
needs of their young child/children. The second key respon- or constraints, but who identify themselves as needing addi-
sibility is to improve family access to medical services by tional support by virtue of their ongoing participation in the
providing direct (e.g., transportation) and indirect (schedul- program. Given the relationship between improvements in
ing, referral) support in ways that can remove important bar- social support, mental health, and reduced odds for child
riers and constraints. The third general responsibility is to abuse found here, creating systematic opportunity for social
provide emotional and problem-solving support to each fam- interaction among program participants, especially those who
ily and, as appropriate, provide direct linkages and referrals live in the same neighborhood communities, may represent an
to other community resources that may address some of the important first step toward developing the community-based
most immediate and/or most pressing family stressors, chal- social networks needed to reduce child abuse on a broader
lenges, and concerns. scale (Leventhal & Brooks-Gunn, 2000; Ross, Reynolds, &
Given this overall approach, it seems reasonable to conclude Geis, 2000). Presumably, this would involve providing fewer
that mothers who enter the program with weak social support home visits for some families while increasing participation
might significantly increase their social and emotional connec- in collective activities at a neighborhood community or
tions to others by receiving weekly in-home assistance from a family resource center. Additionally, developing better links
caring home visitor. It also seems reasonable to conclude that between home visitation services and occupational develop-
mothers who enter the program with mental health constraints ment programs and supports would seem to improve the
might improve their sense of well-being by having a home visi- programs chances of protecting families from the social iso-
tor help them better manage basic, but nonetheless critical, lation and distress, which may accompany economic, job, and
aspects of their daily lives. housing constraints (Wilson, 1997).
564
Enhancing Vertical Alignments
One of the key challenges facing prevention and health promo-
tion programs concerns the tendency of program benefits or
effects to fade out over time (Landsverk et al., 2002; Olds
et al., 2004, 2007). As research indicates, the capacity of CAP
programs to prevent child abuse tends to dissipate 2 years
following program involvement (Olds, 2002). Moreover, con-
cerns about the sustainability of CAP program effects are not
relegated to child abuse alone; questions also remain regarding
the capacity of programs to promote long-term gains in protec-
tive competencies and resources, including long-term enhance-
ments in childrens health, mental health, and school readiness
outcomes (Landsverk et al., 2002; Ramey & Ramey, 2000).
With these issues in mind, several states have recently
developed P-16 (preschool through college), B-16 (birth
through college), and Cradle to Career councils (Mokher,
2010). These efforts are driven by the notion that families with
young children, particularly those who live in ethnically con-
centrated, low-income communities, may need a continuum
of longitudinal (vertical) supports and services if they are to
experience optimal physical health, mental health, and educa-
tional success throughout the early life course (Education
Commission of the States, 2006, 2007a, 2007b). Thus, the pri-
mary goal of these councils is to examine how existing service
systems can be better aligned and connected vertically, starting
with prenatal services and then continuing throughout child-
hood, adolescence, and beyond (Lawson, 2010).
Within this policy context, SF has been structured to target
cross-systems change and service integration as a key way to
support families with co-occurring needs and vulnerabilities.
In this sense, most of the systems integration work undertaken
by SF may be classified as horizontal: Diverse service provi-
ders from multiple disciplines are convened with the purpose
of meeting families existing needs for comprehensive services.
While horizontal, cross-systems collaboration is certainly
important; our data indicate that the development of vertical
systems of support is also needed to further promote the
long-term well-being of program families.
For instance, our results indicate that mothers who present
the greatest presenting problems at program entry tend to leave
the program significantly below the sample mean on key
protective factors for child abuse. For these families, their
continued below average scores on key protective resources
would appear to foreshadow long-term vulnerability to child
abuse and other poor developmental outcomes for their chil-
dren (Garbarino & Barry, 1997).
Thus, in order for programs like SF to help realize long-term
benefits, outcomes, and cost savings, improved vertical system
alignments should be further developed and/or prioritized. This
means developing partnerships that facilitate a systematic
hand off process for families to other systems of care follow-
ing their exit from the program. Examples of other relevant sys-
tems of care include early childhood education services,
employment services, schools, and other community-based
organizations, which might further support the welfare and
Research on Social Work Practice 22(5)
well-being of SF families through late childhood, early adoles-
cence, and beyond. To the extent that programs like SF can suc-
cessfully forge these vertical partnerships and connections,
prospects for enhanced longitudinal outcomes, including policy
support and sustainability, may be enhanced.
Fostering Continuous Program Improvement
Although the quantitative methods employed in this article
offer insight into some of the more complex nuances of the
SF program, the practical limitations of our post hoc, nonex-
perimental design merit further attention. For instance,
although we include conventional measures of service dosage
(e.g., the frequency, intensity, and duration of program involve-
ment) in our design, the paraprofessional social work practices
that comprise the SF intervention remain less than transparent.
This insufficient attention toward the specific social work prac-
tices utilized in SF was also evident in other evaluations of the
effort. These evaluations were also narrowly focused on the
relationship between service outputs and family outcomes,
albeit with less sophisticated statistical methods.
Consequently, in order to better help practitioners under-
stand the strengths and limitations of their service designs,
additional data and data collection strategies are needed. Here,
recent works such as the evaluation of the New York State
Healthy Families program (DuMont et al., 2010) show how
quantitative evaluations can be meaningfully augmented by
observational and qualitative methods. More concretely, these
efforts show how qualitative and observational data can be ana-
lyzed in ways that more directly inform program planning, in-
service training, and continuous program improvement than
what retrospective, quantitative designs can provide alone.
Beyond facilitating improvements within particular pro-
grams, mixed methods evaluations also carry the potential to
inform and enhance scale-up to other communities. As detailed
by the implementation research literature (e.g., Durlak &
DuPre, 2008), efforts to scale-up similarly complex programs
require an acute understanding of how particular program prac-
tices relate to particular program outcomes for particular fam-
ily populations. Moreover, generating nuanced, detailed, and
contextual descriptions of the relationships between CAP prac-
tices, program outputs, mediators, and outcomes figure to be
central to the development of the still nascent field of CAP.
Summary
The comprehensive services and framework included in the SF
initiative represents an important point of departure for the
emergent field of CAP. Results from this study indicate that the
prevention of child abuse and the promotion of family compe-
tencies involve dynamic, fluid, and multilevel processes that
may not be addressed sufficiently through isolated (e.g.,
home-based) and/or one-size-fits-all interventions (Daro,
2006). Instead, results from this study suggest that meaningful,
broad-based approaches to working with vulnerable popula-
tions may be best addressed through a continuum of
Lawson et al.
comprehensive supports that include targeted clinical interven-
tions for the most vulnerable as well as more social development-
oriented approaches to improving family well-being.
Currently, SF appears to represent a first-generation model
for how these comprehensive models may initially develop and
function. Results from this study suggest that the next genera-
tion of these programs should provide additional depth and
breadth of support if they wish to meet the complexities asso-
ciated with diverse family needs, strengths, and community
contexts. To the extent that prevention-focused efforts can be
further complemented by improved linkages to early childhood
education centers, schools, faith-based institutions, and other
formal and informal communities of care, then the promise
of prevention in improving outcomes and reducing long-term
costs to society may be better realized.
Acknowledgment
The authors are grateful for the helpful comments and criticisms pro-
vided by Katherine Masyn, Hal Lawson, and Reviewers from
Research on Social Work Practice on previous versions of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
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