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What Kinds of Community-Based Interventions are Available for Individuals with ACEs? How Effective are They?

One strand of research focuses on community-based interventions for individuals with ACEs. We are especially interested in what kinds of interventions are available in the community, the extent to which these interventions are based on evidence, the effectiveness of these interventions, and factors that influence their effectiveness.

How well are the courts serving maltreated children and their families? (completed project)

This was the first project that Dr. Karatekin conducted after she switched her focus to child welfare. We examined court documents of maltreated children in Hennepin County, MN (which includes Minneapolis) to examine how well the court system was serving maltreated children and their families.  In Minnesota, approximately 2/3rds of maltreatment reports get screened out, and approximately 2/3rds of those who get screened in are referred to a voluntary program (Family Assessment). The remaining 1/3rd (relatively higher-risk cases) are routed to a traditional investigation track, and 1/3rd of these children end up in juvenile court. We coded publicly available court documents on these cases. Although the court case can be viewed as a form of intervention for maltreated children, there is little research in this area, and Hennepin County is not collecting adequate data to determine if the families' needs are being met by the courts.

This project was completed in collaboration with Richard Gehrman, who founded an advocacy organization to improve the child welfare system in Minnesota (Safe Passage for Children of Minnesota), Jamie Lawler (a graduate student at ICD at the time), law students (from the University of Minnesota, University of St. Thomas, and Hamline University), and undergraduate students at the U of M. 

We presented preliminary results at the biennial meeting of the Society for Research in Child Development in April, 2013, in Seattle, WA, and at the "One Child, Many Hands" conference in June, 2013, in Philadelphia, PA. We also communicated the results to Department of Human Services, Children’s Law Center, Children’s Defense Fund, the Star Tribune, and the state legislature, with the goal of changing some of the court practices based on the data we analyzed. One paper on court performance measures was accepted for publication in Children and Youth Services Review, another paper at Juvenile and Family Court Journal, and another at the Journal of Public Child Welfare. .

In addition, we (along with others) made written and oral presentations to the State Supreme Court in March, 2015, to maintain public access to social worker and guardian ad litem reports in CHIPS cases. The Court later agreed to maintain public access.

What kinds of services are being provided in the community to families involved with the child welfare system? (completed)

There is little information collected by the county or state regarding the interventions provided to maltreated children and their families and even less information on the effectiveness of these interventions. Thus, to obtain a picture of services provided to maltreated children in the community, Dr. Karatekin interviewed administrative staff from over 30 agencies in Hennepin County, MN, serving children and families involved with the child welfare system.  The questions focused on the organizational context of the services, the characteristics of the clients and the service providers, the nature of the interventions and the degree to which they were evidence-based, and accountability of the organizations to stakeholders. The paper detailing the results of this survey was published in Child and Adolescent Social Work Journal in 2013 and shared with Hennepin county commissioner.

Although the organizations in the study provide a wide variety of services, staff noted the inadequacy of resources in the community. The organizations were undergoing many changes; although a third had significant losses in the past year, a majority were implementing new programs or expanding existing ones. Their challenges included funding, families with increasingly greater needs, and finding qualified staff. African Americans and Native Americans were overrepresented in their clientele, and other racial/ethnic groups underrepresented. Drop-out rates were quite high. A variety of interventions are used by these organizations, including both evidence- and non-evidence-based, and fidelity is not monitored closely. Many of the organizations are collecting outcome data, but the quality of these data varies widely, and funding is based on outcomes for only half of them. Thus, organizations are not typically held accountable for the outcomes of the families they serve. Frequently mentioned recommendations included improving the practices of CPS (Child Protective Services) workers' practices, enhancing communication between caseworkers and the organizations and between child welfare and other governmental sectors.

To what extent is an integrated services model effective in reducing child maltreatment and improving academic outcomes? (completed)

In this project, we evaluated a county-run integrated services program in Anoka County, MN (Partnerships for Family Success). The program serves families dependent on multiple government services (e.g., unemployment, disability services, child welfare) and is aimed at reducing their dependence on these services. The goal of the study was to determine if the program has been effective in improving 2-year child welfare and educational outcomes of children, as compared with a community comparison group. This study was conducted in collaboration with program staff in Anoka County (Jeff McDonald and Jill Uecker), and with Kristy Piescher, Ph.D. and Saahoon Hong, Ph.D. at Minn-Link at the Center for Advanced Studies in Child Welfare at the University of Minnesota. It was supported by a grant from the Institute of Child Development.

The paper was published in 2014 in Children and Youth Services Review. We found that although the child welfare outcomes were very promising, the educational performance of the children from the program was lagging behind. As a result of this project, staff have changed their practices to place more emphasis on the educational outcomes of the children.

What are the some of the barriers to the implementation of evidence-based community interventions for maltreating parents? (completed)

We worked with Keri Pinna, Ph.D., a post-doc at ICD at the time and currently Assistant Professor at Saint Catherine University, on a project examining barriers to the implementation of an intervention program aimed at maltreating parents (Triple P).  Dr. Pinna, Ashley Hirillal (a former lab member who graduated from the U of M), and Dr. Karatekin wrote a paper that summarizes the perceptions of the caseworkers who referred families to the intervention on how well the intervention met the families’ needs. We presented the results to Child Protective Services and collaborated with them to finalize the manuscript, which was published at the Journal of Public Child Welfare.

During the focus groups, caseworkers indicated that they were concerned about the adequacy of Triple P for addressing cultural issues (including issues related to inner city life) and the complexity of the cases they see. Caseworkers were also worried that service providers were not matched to clients in terms of cultural and racial/ethnic characteristics. Results have implications for the training of referral sources for evidence-based interventions in the community.


What Kinds of Interventions Do Individuals with ACEs Seek? How Effective are They?

A second strand of research focuses on the kinds interventions that individuals with ACEs actually seek and the extent to which they benefit from these interventions..

What are the health care utilization patterns of maltreated children? (manuscripts under review/in preparation/in presss)

We have recently finished a study in which we examined diagnoses and health care use of maltreated youth through a review of electronic health records in the Fairview medical system. We used the Clinical Data Repository of the Clinical and Translational Science Institute at the U of M to conduct this study. Iris Borowsky, M.D., Ph.D., and Andrew Barnes, M.D., M.P.H., from the Department of Pediatrics at the U of M, Susan Mason, Ph.D., MPH, from Epidemiology, are collaborating on this project. Brandon Almy, a graduate student at the Institute of Child Development, is helping out with the conceptualization of the study and findings, and the coding has been done by undergraduates in Child Psychology and Psychology (Brittney Bekkers, Khanh Duong, Sereen Waletski, Sophia Burch, Michael Retzer, Mariam Amirikian, Ashna Patel, and Shiyi Han). We have prepared three manuscripts summarizing the data: one on the rarity of maltreatment-related diagnoses in electronic health records (currently in press in Clinical Pediatrics), a second one on the health care utilization patterns of maltreated children (currently in revision), and a third on the children's diagnoses (in preparation).

What kinds of health-related interventions do college students seek? What kinds of interventions do they find helpful? (manuscripts under review/in press)

To follow up our previous study of health in college students, we conducted a study in Fall, 2015, to examine interventions used by college students with and without ACEs. We asked them whether they find these interventions useful, reasons for their satisfaction or dissatisfaction with the interventions, and the kinds of problems they have that they are not seeking help for. Tori Simenec, B.S. helped out with this study, and Rohini Ahluwalia, Ph.D., from the marketing department at the Carlson School of Management, has been a collaborator. One paper from this project is currently under review, one paper is in press at the Journal of Interpersonal Violence, and we are currently working on another one.

Do ACEs predict response to different kinds of interventions in college students? (manuscript in preparation)

In Spring 2016, we started a study with undergraduates in which we will test whether ACEs, along with several other variables, predict response to group physical health programs at the Recreation & Wellness Center and services provided by the Disability Resource Center. Lauren Zima, Sophia Burch, Alex van Buren, and Susan Mathew were involved in this project in Spring, 2016, and Allison Anding helped with it in Spring, 2017. The key goal was to determine whether ACEs can predict whether the students will benefit from these diverse health-related programs. Maria Hill is currently working on the manuscript that will report our findings.

Do ACEs predict response to different kinds of messages about interventions in college students? (manuscript in preparation)

In Spring 2016 and 2017, we collected data for a study in which we tested whether ACEs predict response to different kinds of messages about stress-related interventions in undergraduates. Alex Mueller and Mehdi Khan helped out with this study, and Rohini Ahluwalia, Ph.D., from the marketing department at the Carlson School of Management, is a collaborator. The key goal is to determine what kinds of messages about interventions might be most effective in attracting students with ACEs. We are currently working on the manuscript.

 


What are the Consequences and Associated Features of ACEs?

A third line of research focuses on the consequences and associated features of ACEs.

What are some mechanisms by which ACEs affect the health of college students? (completed)

We studied the relation between ACEs and mental and physical health in college students and potential psychological mediators of this relationship.  We collected data from approximately 250 participants in 2013-14.  Tori Simenec and I presented the preliminary results of this study at the Biennial Meeting of the Society for Research in Human Development in Austin, TX, in March 2014. The publication is now in press in Stress and Health.

Findings indicated that ACEs predicted worsening of mental health over the course of a semester and suggested current number of stressors as a mediator of the relationship between ACEs and mental health. Results suggest that screening for ACEs might help identify students at high risk for deterioration in mental health. Results further suggest that stress-related interventions would be beneficial for students with high levels of ACEs and point to the need for more research and strategies to increase help-seeking in college students.

To what extent do ACEs predict academic performance in college? (data collection in progress)

In Fall 2016, we started a study in which we are testing whether ACEs predict different aspects of academic performance in college, and whether ACEs do a better job of prediction compared to more traditional measures. Hee Jeong Kim, and Sereen Waletski assisted with this project, and we are collaborating with Nidhi Kohli, Ph.D., M.Ed., on the statistical aspects.

What are the characteristics of children who are aggressive toward their parents and siblings? How do parents cope with this behavior? (manuscripts under review)

We collected data in 2014 on parent- and sibling-directed aggression by children living at a domestic violence shelter.  We conducted this project in collaboration with Tamara Stark, Director of Youth and Family Services at the Tubman Center, the largest provider of domestic violence services in MN.  Michelle Brown, third-year graduate student at the Institute of Child Development, is taking a lead role in publishing this research. Kaylan Wurm, Patty Holdahl, and Alex Van Buren, who were undergraduates at the time at the U of M, conducted most of the interviews, and Hami Lee entered most of the data. Two papers first-authored by Michelle Brown have been submitted for publication.

We found that the most common forms of aggression perpetrated against parents were physical, verbal, and emotional, whereas physical and verbal aggression were the most common types perpetrated against siblings. Additionally, many of the children were engaged in both parent- and sibling-directed aggression. Many were both victims of violence and victimizers themselves. These results highlight the importance of avoiding characterizing youth as either victims or victimizers and point to a need to consider the complexities of their behavior. Not surprisingly, we also found high levels of health problems in both the parents and the children. The majority of parents were seeking help for their children's aggression and they reported that they found the help they received from professional and non-professional services equally effective. These results have implications for service providers working with families exposed to domestic violence.

What are some of the factors that predict re-victimization? (manuscript under review)

Michelle Brown collected data in 2014-15 for a study that examines risk factors for repeat victimization.  In particular, she examined whether parenting style, perceived social support, or the response of the first person to know about the initial victimization (e.g., maltreatment or bullying experiences) moderated the relationship between initial and later victimization. In addition recruiting undergraduates from the University of Minnesota, Michelle also recruited participants from Tubman Center. She presented preliminary results from the Tubman participants at the Annual National Black Graduate Conference in Psychology in May, 2016, and has recently submitted the manuscript.


How to screen for ACEs to Improve Detection and Early Intervention?

A recent line of collaborative research is focusing on how to screen for ACEs in diverse settings.

How to screen for ACEs in pediatric primary care settings? (initial stages)

Andrew Barnes, M.D., M.P.H., from the Department of Pediatrics and we have just started collaborating with a multi-site group, spearheaded by Lindsay Acheson Thompson from the College of Medicine at the University of Florida, in an effort to develop a screener for ACEs in pediatric primary care settings. We are currently co-authoring a review paper on ACEs screening instruments used in pediatric settings.

How to increase recognition and follow-up evaluation of sentinel injuries for physical abuse in 0- to 6-month-olds? (completed)

Dr. Karatekin recently participated in a collaborative, inter-disciplinary quality improvement project at Fairview Hospitals at the University of Minnesota aimed at improving recognition and follow-up evaluation of sentinel injuries in 0- to 6-month-olds in order to prevent recurrence of physical maltreatment.

How good is an expanded ACEs measure that could be used in screening undergraduates? (data collection in progress)

We have expanded the original ACEs measure by adding to it items from the Juvenile Victimization Questionnaire of Dr. Finkelhor. We are currently assessing the test-retest reliability of this expanded measure in undergraduates, as well its ability to predict mental health and stress over several months and its convergent validity with several other measures of trauma.

How to screen for ACEs in health care settings in the community? (initial stages)

We have recently started a collaboration with Anna Lynn, MPP, at the Community and Family Health Division of the Minnesota Department of Health. We co-led a workshop on "Exploring Practical Applications of ACEs in a Clinic Setting" at the Integrated Behavioral Healthcare Conference in April, 2017. We have just started a collaboration with CentraCare in St. Cloud, MN, in which we will be exploring the impact of ACEs on treatment for depression, and another collaboration with Phalen Clinic in St. Paul, MN, in which we will be examining ACEs and other traumatic events in the clinic population. We are currently looking to find other community partners for a study on screening for ACEs in health care settings.