2014 PCA Georgia Conference keynote by Mark Chaffin, Ph.D.

Thank you, Sandra. I've known Sandra since God was a boy. I'm betting I'm older than you, but both of us go back in this field a number of years. When I agreed to do this, I thought I'd have PowerPoint slides with charts and graphs, but Jill said you're talking at lunch, just talk about your experience. I thought about what my experience in this field really is. A lot of it is institutional memory about where we've been and where we are now. I started out as a direct service provider and continued doing that until July of this year, then moved into research. I've been primarily a researcher for about the last 25 years. Now I'm a researcher and a teacher at Georgia State. I've begun thinking about what to talk about for those who maybe aren't 35-year veterans in this field. I'll talk a bit about where we've been in child abuse and neglect, where we are now, and how our current evidence-based research might suggest new directions. Despite our advocacy habits that things are horrible and getting worse, that narrative hasn't squared with the facts for at least 20 years. The good news is that we are currently enjoying probably the lowest rates of physical and sexual abuse of children in the modern era. These have been dropping by a lot for about 25 years since the early 1990s, with drops on the order of 50 or 60% or more. These parallel drops in teen pregnancy, youth delinquency, violent crime, and serious substance abuse. Condom use is up, including among teens, and this cuts across many demographic and racial groups. The decline in physical and sexual abuse is part of larger societal trends. People say that's not what you hear on the news, but maybe the fact that we hear about these things now is part of why we're enjoying a decline because it is much more public and open to discussion. The fact that it's become increasingly rare is what makes it news. Things have changed in terms of our openness about the topic. We used to talk about raising the veil of silence, but that's no longer true. Anyone who watches Oprah or picks up a newspaper knows that partner violence is a reality. We are much more open as a society now. Why these declines have occurred is not entirely clear, but it's a relatively good time for us as a field. It may challenge us to change our advocacy narratives. We can no longer say things are horrible and getting worse. We need to say we're doing some things that are working and we need to keep it up and do them better. This is not a hopeless field. The area where we are not having much success is child neglect. Rates have been relatively stable, whereas physical and sexual abuse are down. Neglect has remained persistently stable. For the child welfare system, this means it is increasingly dominated by chronic neglect cases. Sexual abuse accounts for maybe 7-8% of all child welfare cases, physical abuse maybe 15-20%, and neglect is pushing 80% and going up. Neglect is more recurrent in nature. The single most common child welfare case is a chronic neglect case on their fourth or fifth trip through the system. Our prevention and intervention efforts have just begun to scratch the surface. Neglect is tough. Sexual abuse is a limited number of behaviors, physical abuse is a limited number of behaviors, but neglect is often the absence of something embedded deeply in social problems and inequalities. Child maltreatment cuts across all social and economic groups, but not equally. Families below the poverty line are 44 times more likely to come into child welfare than families at the median income. If you work on the front lines, you see families deeply embedded in serious grinding poverty. In our studies, the median family income was $900 a month. 35% of parents met clinical criteria for depression, about 50% had a DSM diagnosable addiction at some point, and there was a high probability of never finishing high school. These things matter when we talk about a service system characterized by child neglect. We were able to access birth certificate data and link it to child welfare data for every first-time birth in the entire state over a few years. For young women under 21 who were unemployed, had not finished high school, and had no stable relationship, between one in four and one in five had their child end up in the child welfare system within two or three years. For young women in their mid-20s who had finished high school, had some education beyond high school, were employed, and had a stable relationship, the rate was 3/10 of 1%. The bulk of what we're talking about now is primarily chronic neglect rooted in ingrained disadvantage. Disadvantage and inequality in this country are not shrinking. We are more prosperous, but that prosperity doesn't spread across all sectors. We are geom mapping hotspots of abuse and neglect, and they are clearly located in concentrated areas where half of the families will have contact with child welfare at some point. This has implications for how we think about prevention and intervention. In some ways, our news is very good, but in many ways, we have more complex and difficult problems to tackle. The good news is that science is on your side in ways it hasn't been for decades. Let me tell you a story about scurvy. 250-300 years ago, the scourge of the seven seas was scurvy. Navies lost more sailors to scurvy than to combat. Around 1750, a Scottish physician did one of the first randomized control trials. He randomly assigned men with scurvy to different treatments, one of which was fresh citrus fruit. The men given citrus got remarkably better. He replicated the trial and got similar results. An English nobleman repeated the study and got the same results and began to advocate for fresh citrus on ships. But of course, that didn't happen. Established physicians had their own favorite cures. Others said it was too difficult to change what they'd always done, so they boiled the limes down to a syrup, which destroyed the vitamin C. It took until the middle of the 20th century for all ships to carry fresh citrus. There ain't no more scurvy. The moral is that there's often a big gap between what science can offer and getting it into the hands of people. That is the challenge of our times. We have replicated randomized trials of evidence-based parenting programs that can reduce recidivism from over 50% to under 20%. We have these technologies on the shelf. Getting them out into the field is difficult. That is the challenge of our time: implementation, dissemination, scale-up, and sustainability. I'll give you a personal story of failure. We trained 106 providers in a parenting model. A year later, those 106 providers had seen a grand total of six cases with the new model. We learned that training does not equal implementation. The challenge is how to build our service systems to take up these effective models, get them into the hands of people, and get them utilized. We need funding systems that support these services, referral networks, and make them accessible. This is part of my interest in joining a Department of Public Health. Public health is about population-level impact. Psychology is about effect size on one case. Public health is about raising the tide for everybody. Reach trumps effect size. The classic example is the Surgeon General's warning on cigarettes. I thought it was stupid, but millions and millions of people read it. We've begun to look at approaches with higher reach. In South Carolina, a group did a trial where they put basic parenting information in the media, through pediatric primary care, and in communities. They saw population-level drops in child abuse and neglect. These are the kinds of things we can look at. Where do we go from here? We have a number of models that are reasonably effective. When I first got involved, we could identify one evidence-based treatment. Now there are about 15 and climbing. What do the more effective models have in common? They don't always match up with what we've always believed. Comprehensive services are often touted, but most of the best-performing services are more focused. They address things with greater depth and intensity, not breadth. Often less is more. Years of multiple programs can erode benefit. Families get less overwhelmed when they can concentrate on priorities. Some of the more effective interventions are relatively brief, around 14-18 visits. This is different from the 2-3-5 year programs of the 1980s. If this is true, it's good news because we can serve a lot more people. Quality matters. Model fidelity matters. Our traditional way of funding services incentivizes volume over quality. Evidence-based services cost more per contact but use fewer contacts and put more resources into quality control, ultimately being less expensive. This requires realigning reimbursement systems, which is hard. These are managerial, systemic, and political challenges as much as technical ones. In child abuse prevention, to achieve broader reach, we need to figure out managerial and organizational structures to increase volume and reach. A nurse home visitor costs about $100,000 a year and sees six or seven clients a week. A hospice nurse sees about 25 contacts a week. We need to increase efficiency. I sometimes wonder what would happen if we brought in a logistics manager from FedEx. They also make home visits. I'll bet they would have some ideas. In closing, I told my wife I was going to talk to a group from Georgia. She said there are obligatory things every transplant has to talk about. I could talk about the humidity, or why such polite people drive like they're playing Mortal Kombat on the freeway. But I've come to appreciate other things. I went on a bicycle ride near Fairburn and discovered Georgia has hills. Oklahoma is flat. 60 miles in Oklahoma is easy; 60 miles through the hills on a bicycle is not. At the end, a woman asked what I'd like to drink. I said tea, and she handed me a glass that tasted like concentrate syrup. When you're really tired and sweating, there's nothing like a good glass of sweet tea. I am pleased to be in a place that has sweet tea, and I look forward to working with all of you. Thank you for inviting me.