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Program Profile: SafeCare©

Evidence Rating: Promising - One study Promising - One study

Date: This profile was posted on May 05, 2020

Program Summary

This is a home-visitation program that aims to prevent and address factors associated with child abuse and neglect. The program is rated Promising. Parents in the SafeCare group demonstrated statistically significant decreases in depression symptoms and risk of child protective services recidivism, compared with parents in the control group. However, there were no statistically significant differences in the risk of child physical abuse among a sample of American Indian parents.

This program’s rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Description

Program Goals/Target Population
SafeCare is a home-visitation program that aims to prevent and address factors associated with child abuse and neglect by offering services targeting improved health decision-making skills, including identifying symptoms of illness or injury and seeking appropriate treatment; safety of the home environment; and parenting skills; including providing stimulating activities and positive parent-child interactions.

SafeCare is designed for parents/caregivers of children ages 0–5 who are either at risk for or have a history of child neglect and/or physical abuse or who are referred by child welfare agencies. Risk factors for child maltreatment include having young parents; parents with a history of depression, other mental health problems, substance use, or intellectual disabilities; and parents with a history of domestic violence or intimate partner violence.

Services Provided
SafeCare is a behaviorally based parenting program. The three modules of the program focus on parent-child interaction, child health, and home safety. The parent-child interaction module targets risk factors associated with neglect and physical abuse. In this module, parents learn how to increase positive interactions with their children and provide structured, engaging, and stimulating activities. The child health module targets risk factors for medical neglect. In this module, parents are taught to identify common childhood illnesses and injuries and follow a structured process to determine when and how to care for them. This module also teaches parents how to know when to take their children to see a doctor and when to seek emergency attention. The home safety module targets risk factors for environmental neglect and unintentional injury. This module teaches parents how to eliminate household hazards and about the importance of age-appropriate supervision. Family engagement, communication skills, and problem solving are emphasized throughout all modules, to promote parents’ skills acquisition and to teach them how to solve other difficulties not directly addressed by SafeCare.

Depending on the needs of each individual family and the skills of the parents at baseline, each module typically involves six weekly sessions with pre- and posttraining assessments, to confirm skills acquisition. Sessions usually last 60 to 90 minutes each. The modules begin with an observational assessment by the provider to determine the parents’ current skills and to identify which skills need further development. The provider then explains the skills and their importance verbally, models the skills through role play demonstrations, has the parents practice the skill, and then provides positive and corrective feedback. Services are typically completed with participating families in 18 weeks, but services may be abbreviated or extended based on parents’ skills mastery and other case management needs.

Key Personnel
The program is implemented by SafeCare Providers. There are no educational requirements for SafeCare providers, but the providers often have a bachelor’s or master’s degree in human services. All providers are required to participate in 32 hours of workshop training and receive post-workshop coaching to promote fidelity and proficiency in delivering SafeCare and to receive their certification. Ongoing coaching is required to keep provider certifications active. National SafeCare Training and Research Center (NSTRC) also provides trainings for coaches and trainers.

Evaluation Outcomes

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Study 1
Child Protective Services (CPS) Recidivism
Chaffin, Hecht, and colleagues (2012a) found SafeCare parents demonstrated a lower risk of CPS recidivism, compared with control group parents. This difference was statistically significant.

Study 2
Risk of Child Abuse
Chaffin, Bard, and colleagues (2012b) found no statistically significant differences in the risk of future physical child abuse between American Indian parents who received SafeCare and American Indian parents in the control group.

Depression
American Indian parents who received SafeCare demonstrated a greater decrease in depression, compared with American Indian parents in the control group. This difference was statistically significant.
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Evaluation Methodology

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Study 1
Chaffin, Hecht, and colleagues (2012a) conducted a 2 x 2 cluster experiment to examine the effectiveness of the SafeCare program on Child Protective Services (CPS) recidivism. This study took place in Oklahoma, including both rural and urban areas, between September 9, 2003, and October 1, 2006. Regions of the state (n = 6) were randomized to either implement SafeCare or continue with services as usual (SAU). SafeCare providers were trained to implement the program; SAU providers addressed similar goals and needs as SafeCare providers but were less structured and not driven by protocols. In addition, agencies within each region were randomized to receiving implementation support or coaching or to implement without coaching, thus forming a 2 x 2 design. Coaching for SafeCare providers focused on maintaining fidelity to the model via observation, scoring fidelity via standardized checklist, and providing feedback to providers. Coaching of SAU providers focused on the quality of services in general with little structure to the coaching sessions.

Participants were eligible if they were considered maltreating caregivers and referred by child welfare agencies. Typically, to be included in SafeCare, participants had to have 1) at least one preschool-aged child, and 2) an absence of an untreated substance abuse disorder. However, this study took place within a more inclusive services system, and families were considered eligible if they had at least one child younger than age 12 and without regard to substance use. The total study sample included 2,175 parents. Nearly all of the participants (91 percent) were women, 31 percent were married, and the average age was 29.4 years. A majority (67 percent) were white/non-Hispanic, 16 percent were American Indian, 9 percent were African American, and 5 percent were Hispanic. Of the total sample, 41 percent reported past sexual abuse, 40 percent reported past physical abuse, and 22 percent reported being removed from their own parents during their childhood. Most of the households (82 percent) fell below the federal poverty line.

In total, 53 percent of the parents were assigned to the SafeCare treatment group (n = 1,153), and 47 percent of the parents were assigned to the services-as-usual control group (n = 1,022). Twenty-eight percent of the parents in the total sample were assigned to the SafeCare uncoached condition, 25 percent were assigned to the SafeCare coached condition, 23 percent were assigned to the services-as-usual uncoached condition, and 24 percent were assigned to the services-as-usual coached condition. For the CrimeSolutions.gov review of this program, the outcomes that were scored were those pertaining to the direct comparisons between all families who received SafeCare (both coached and uncoached) and all families who received services as usual (coached and uncoached). Due to significant differences in attributes between treatment and control groups that might affect the effectiveness of the intervention, the study authors controlled for the following variables: 1) a historical risk variable (derived from historical American Indian cases and 12 raw variables such as gender, education, and age), and 2) a county-level report for proneness. This allowed for a more direct comparison of recidivism outcomes.

Data for CPS recidivism were collected from past and follow-up CPS reports. The average follow-up time was 6 years, and a recidivism event was defined as any CPS report filed after study enrollment. Of the entire sample, 69 percent of participants had one or more recidivism events, 52 percent had two or more, and 37 percent had three or more. Two-level recurrent event survival models were used to model recidivism outcomes. The study authors did not conduct subgroup analyses.

Study 2
Chaffin, Bard, and colleagues (2012b) examined a subsample from the larger study (Study 1, Chaffin, Hecht, et al. 2012a, described above), but specifically looked at the effectiveness of the SafeCare program among American Indian parents. Of the original 2,175 parents involved in the larger sample of families, 354 reported American Indian ethnicity and were analyzed for this study. Of this sample, the mean age was 29, and 94 percent were female. The majority (68 percent) lived in small communities, 18 percent lived in urban communities, and 14 percent lived in rural communities. Nearly half (43 percent) self-reported being physically abused as a child, 41 percent self-reported being sexually abused as a child, and 23 percent reported being removed from their own parents at some point during their childhood. In their current households, 45 percent reported some history of domestic violence and had an average of three prior referrals to child welfare. Of those referrals, 93 percent involved child neglect, 19 percent involved physical abuse, and 5 percent involved sexual abuse.

The authors utilized the same treatment and control groups as Study 1. Of the subsample of American Indian parents, 60.5 percent of the parents were assigned to the treatment group (n = 214), and 39.5 percent were assigned to the control group (n = 140). In total, 18 percent were assigned to the services-as-usual/uncoached condition, 21.5 percent to the services-as-usual/coached condition, 30.5 percent to the SafeCare/uncoached condition, and 30 percent to the SafeCare/coached condition. For the CrimeSolutions.gov review of this program, the outcomes that were scored were those pertaining to the direct comparisons between all families who received SafeCare (both coached and uncoached) and all families who received services as usual (coached and uncoached). Due to significant differences in attributes between treatment and control groups that might affect the effectiveness of the intervention, the study authors controlled for the following variables: 1) a historical risk variable (derived from historical American Indian cases and 12 raw variables such as gender, education, and age), and 2) a county-level report for proneness. This approach mirrored the methods to control for differences used in the full study and allowed for a more direct comparison of welfare recidivism outcomes (Chaffin, Hecht, et al. 2012a)

Data were collected in the participant households by an independent research assistant using Audio Computer Assisted Self-Interview (ACASI). Measures were collected from participants at baseline, around the end of services, and 6 months after service exit. The outcomes of interest were parents’ symptoms of depression and child abuse risk. Symptoms of depression were measured by the Beck Depression Inventory, a 21-item multiple choice questionnaire that is self-completed. Child abuse risk was measured by the Child Abuse Potential Inventory, a 160-item agree/disagree questionnaire that is self-reported. Piecewise latent growth curve models were used to analyze the data. The study authors did not conduct subgroup analyses.
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Cost

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The Washington State Institute for Public Policy (WSIPP) has estimated the cost of SafeCare to be $1,950 (in 2010 dollars) per client. This is an estimated benefit-to-cost ratio of $20.80 for SafeCare (WSIPP 2019).
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Implementation Information

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SafeCare is disseminated by the National SafeCare Training and Research Center. SafeCare Provider workshops are conducted with a low trainer-to-trainee ratio (one trainer to six trainees) and follow a similar structure to the parenting program, including instructional presentations, modeling of skills, practicing of skills, and trainer feedback. Workshops typically last 4 days. SafeCare trainees receive coaching and in-field implementation support for 6 months post-workshop. Trainees receive certification after they complete six sessions (two training sessions in each of the three modules) and demonstrate mastery to their coaches. The role of the SafeCare coaches is to provide extra support to the home visitors, including observing sessions, scoring fidelity, and providing feedback. Coaches are all previous certified providers and are required to complete a 2-day workshop (Georgia State University School of Public Health N.d.).

More information about this program can be found at the program’s website: https://safecare.publichealth.gsu.edu/
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Other Information (Including Subgroup Findings)

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In 2012, SafeCare received a final program rating of Inconclusive Evidence based on a review of a study by Gershater-Molko and colleagues (2002). In 2019, a review of two new studies (Chaffin et al. 2012a; Chaffin et al. 2012b) was conducted, using the updated CrimeSolutions.gov Program Scoring Instrument. This review resulted in a final program rating of Promising.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Chaffin, Mark, Debra Hecht, David Bard, Jane F. Silovsky, and William Howard Beasley. 2012a. “A Statewide Trial of the SafeCare Home-Based Services Model With Parents in Child Protective Services.” Pediatrics 129(3):509–15.

Study 2
Chaffin, Mark, David Bard, Dolores Subia Bigfoot, and Erin J. Maher. 2012b. “Is a Structured, Manualized, Evidence-Based Treatment Protocol Culturally Competent and Equivalently Effective Among American Indian Parents in Child Welfare?" Child Maltreatment 17(3):242–52.
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Additional References

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These sources were used in the development of the program profile:

Edwards, Anna, and John R. Lutzker. 2008. “Iterations of the SafeCare Model: An Evidence-Based Child Maltreatment Prevention Program.” Behavior Modification 32(5):736–56.

Georgia State University School of Public Health. N.d. SafeCare.
https://safecare.publichealth.gsu.edu/files/2015/04/Overview-of-SafeCare-brochure-3-16-15.pdf

Gershater-Molko, Ronit M., John R. Lutzker, and David Wesch. 2002. “Using Recidivism Data to Evaluate Project SafeCare: Teaching Bonding, Safety, and Health Care Skills to Parents.” Child Maltreatment 7(3):277–85. (This study was reviewed but did not meet CrimeSolutions.gov criteria for inclusion in the overall program rating.)

Gershater-Molko, Ronit M., John R. Lutzker, and David Wesch. 2003. “Project SafeCare: Improving Health, Safety and Parenting Skills in Families Reported for, and At-Risk for Child Maltreatment.” Journal of Family Violence 18(6):377–86.

Guastaferro, Kate, and John R. Lutzker. 2019. “A Methodological Review of SafeCare.” Journal of Child and Family Studies 28(12):3268–85.

Hubel, Grace S., Whitney L. Rostad, Shannon Self-Brown, and Angela D. Moreland. 2018. “Service Needs of Adolescent Parents in Child Welfare: Is an Evidence-Based, Structured, In-Home Behavioral Parent Training Protocol Effective?” Child Abuse & Neglect 79:203–12.

Jabaley, Julie J., John R. Lutzker, Daniel J. Whitaker, and Shannon Self-Brown. 2011. “Using iPhones to Enhance and Reduce Face-to-Face Home Safety Sessions Within SafeCare: An Evidence-Based Child Maltreatment Prevention Program.” Journal of Family Violence 26(5):377–85.

Lutzker, John R., Alexander J. Tymchuk, and Kathryn M. Bigelow. 2001. “Applied Research in Child Maltreatment: Practicalities and Pitfalls.” Children’s Services: Social Policy, Research and Practice 4(3):141–56.

WSIPP [Washington State Institute for Public Policy]. 2019. “SafeCare.” Olympia, Wash.: Washington State Institute for Public Policy.
https://www.wsipp.wa.gov/BenefitCost/Program/160
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Program Snapshot

Age: 18 - 70

Gender: Both

Race/Ethnicity: Black, American Indians/Alaska Native, Hispanic, White

Geography: Rural, Urban

Setting (Delivery): Home

Program Type: Conflict Resolution/Interpersonal Skills, Family Therapy, Parent Training, Children Exposed to Violence, Violence Prevention

Targeted Population: Children Exposed to Violence, Families

Current Program Status: Active

Program Director:
Shannon Self-Brown
National SafeCare Training and Research Center
Phone: 404.413.1387
Fax: 404.413.1299
Website
Email

Program Director:
Daniel Whitaker
National SafeCare Training and Research Center
Phone: 404.413.1387
Fax: 404.413.1299
Website
Email