Evidence-Based Practices for Children Exposed to Violence: A Selection from Federal Databases

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1 Evidence-Based Practices fr Children Epsed t Vilence: A Selectin frm Federal Databases U.S. Department f Justice U.S. Department f Health and Human Services

2 Table f Cntents Federal Participant List Intrductin Matri Service Characteristics Dcument Glssary f Terms Implementatin Dcument

3 Wrkgrup Participants Children Epsed t Vilence Evidence-based Practices Clare Andersn Deputy Cmmissiner Administratin n Children, Yuth and Families U.S. Department f Health and Human Services 1250 Maryland Avenue, SW, Eighth Flr Washingtn, DC (202) Brecht Dnghue Plicy Advisr Office f the Assistant Attrney General U.S. Department f Justice 810 7th Street, NW Washingtn, DC (202) Shania Kapr Children Epsed t Vilence (CEV) Fellw Office f Juvenile Justice and Delinquency Preventin U.S. Department f Justice 810 7th St., NW Washingtn DC (202) Maryluise Kelley, Ph.D. Directr Family Vilence Preventin and Services Prgram Family and Yuth Services Bureau Administratin n Children, Yuth and Families U.S. Department f Health & Human Services 1250 Maryland Ave., SW, Eighth Flr Washingtn, DC (202) Kristen Kracke, MSW Prgram Specialist Office f Juvenile Justice and Delinquency Preventin U.S. Department f Justice 810 7th Street, NW Washingtn, DC (202) Valerie Mahlmes, Ph.D., CAS Directr Scial and Affective Develpment/Child Maltreatment & Vilence Prgram Eunice Kennedy Shriver Natinal Institute f Child Health and Human Develpment 6100 Eecutive Blvd. Rm 4B05A Bethesda, MD (301) Karl Masn Deputy Assciate Attrney General Office f the Assciate Attrney General U.S. Department f Justice 810 7th Street, NW Washingtn, DC Amanda Nugent Intern Substance Abuse and Mental Health Services Administratin U.S. Department f Health and Human Services 1 Chke Cherry Dr. Rm Rckville, MD (240)

4 Debbie Pwell Acting Assciate Cmmissiner Family and Yuth Services Bureau Administratin n Children, Yuth and Families U.S. Department f Health and Human Services 1250 Maryland Avenue, SW, Eighth Flr Washingtn, DC (202) Bryan Samuels Cmmissiner Administratin n Children, Yuth and Families U.S. Department f Health and Human Services 1250 Maryland Avenue, SW, Eighth Flr Washingtn, DC (202) Janet Saul, Ph.D. Senir Advisr fr Strategic Directins (Acting) Divisin f Vilence Preventin Natinal Center fr Injury Preventin and Cntrl Centers fr Disease Cntrl and Preventin 1600 Cliftn Rad Atlanta, Gergia (770) David DeVursney, MPP Prgram Analyst Office f Plicy, Planning & Innvatin Substance Abuse and Mental Health Services Administratin U.S. Department f Health and Human Services 1 Chke Cherry Rd. Rm Rckville, MD (240) Phelan A. Wyrick, Ph.D. Senir Advisr Office f the Assistant Attrney General Office f Justice Prgrams U.S. Department f Justice 810 7th Street, NW Washingtn, DC (202)

5 Evidence-Based Practices fr Children Epsed t Vilence: A Selectin frm Federal Databases This package f infrmatin summarizes findings and evidence frm federal reviews f research studies and prgram evaluatins t help lcalities address childhd epsure t vilence and imprve utcmes fr children, families, and cmmunities. These evidence-based practices shuld be reviewed and incrprated as practitiners and plicy makers wrk in multi-disciplinary partnerships t plan and implement services and activities t prevent and respnd t children epsed t vilence. Understanding and Integrating Evidence In general, evidence is drawn frm scial science research, statistics, and prgram evaluatins, and is distinguished by the systematic methds used t islate relatinships (e.g., between an actin and a cnsequence, r a service and an utcme). This is a different way f understanding the wrld than the understanding that cmes frm practical eperience. Rigrus scial science has the benefit f uncvering relatinships and effects that may be difficult t bserve thrugh less rigrus methds. Thrugh an understanding and healthy respect fr evidence integrated with the knwledge that cmes frm eperience and epertise, practitiners and plicy makers are mre likely t achieve the results that they seek. Surces f Evidence Subject matter eperts at the Department f Justice and the Department f Health and Human Services cllabrated in preparing this infrmatin based n reviews f eisting federal databases f evidence-based prgrams. The review was cnducted with a careful eye tward thse practices that are mst applicable t the challenge f addressing children epsed t vilence. In each case, prgrams and practices that are reviewed are supprted by multiple research studies r prgram evaluatins. This package f infrmatin is based n reviews f the fllwing databases prepared by the Office f Juvenile Justice and Delinquency Preventin (OJJDP) and the Substance Abuse and Mental Health Services Administratin (SAMHSA): SAMHSAs Natinal Registry f Evidence-Based Prgrams and Practices, SAMHSAs Natinal Child Traumatic Stress Netwrk, OJJDPs Mdel Prgrams Guide, and OJJDPs Children Epsed t Vilence Evidence-Based Guide. Using Evidence-Based Practices The best way t assure that evidence-based prgrams prduce results that will be similar t the utcmes dcumented by past evaluatins is t replicate prgram prcedures and activities with high fidelity. Guidance and infrmatin abut replicatin can be fund in this package under the heading: Supprting High Fidelity Implementatin. Sme argue against anything shrt f full replicatin f evidence-based prgrams. But there are many challenges t full replicatin, nt the least f which is that many prgrams that have dcumented results d nt have etensive implementatin manuals. As a practical matter, users are encuraged t becme familiar with the full range f evidence-based prgrams in this package and cnsider which prvide the best fit fr their needs. Users shuld seek pprtunities fr replicating r adapting them in ways that are cnsistent with lcal circumstances, culture, and resurces while still remaining faithful t the prgram cntent. Fr eample, the frm f the prgram might be changed (the type f setting in which the interventin is implemented, intrductin f meals r transprtatin, adding cultural activities), while still maintaining the functin f the prgram (e.g., the number f sessins, sessin cntent, hw ften the sessins ccur, etc.).

6 NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Preventin/P rmtin Interventin/ Treatment Systems Respnse Alternative fr Families- Cgnitive Behaviral Therapy (AF-CBT) Frmerly knwn as Abuse Fcused-Cgnitive Behaviral Therapy Cntinuum Al's Pals: Kids Making Healthy Chices 4-16 Reductin in child/parent vilence, abuse related fear, and depressin/aniety reductin in eternalizing difficulties 0-5 (yung children) 6-12 (children) Children Epsed t Vilence Prgram Matri: Effective Prgrams Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Trauma/ Trauma Symptms Incidence Agency Prviding Surce f Infrmatin (e.g., Mdel Prgrams Guide r NREPP) Prgram Descriptin Eemplary OJJDP OJJDP CEV EBG AF-CBT is a gal-driven interventin designed t address multidimensinal risks (parent practices, child aggressin, family cnflict, and cnsequences r physical abuse). Treatment is tailred ver 16 weeks within a three-phase structure: (1) engagement and psycheducatin phase includes family needs assessment, increasing participant mtivatin, and understanding the CBT mdel; (2) individual skill building phase teaches parents alternatives t hstile, cercive, and physical punishment and teaches parents and children emtinal regulatin; (3) family applicatin phase enhances peer and scial supprts and family cmmunicatin. Each phase is cmprmises several sessins incrprating scial learning, behaviral, family systems, and cgnitive and develpmental principles. Scial cmpetence and prscial behavirs 2.9 SAMHSA NREPP Schl-based preventin prgram that develps scial-emtinal skills such as self-cntrl, prblem-slving, and healthy decisinmaking in children in preschl, kindergarten, and first grade. Thrugh fun lessns, engaging puppets, riginal music and materials, and apprpriate teaching appraches, the curriculum helps yung children regulate their feelings and behavir; creates and maintains a classrm envirnment f caring, cperatin, respect, and respnsibility; teaches cnflict reslutin and peaceful prblem-slving; prmtes appreciatin f differences and psitive scial relatinships; prevents and addresses bullying behavir; cnveys clear messages abut the harms f alchl, tbacc, and ther substances; and builds children's abilities t make healthy chices and cpe with life's difficulties. The prgram cnsists f a year-lng, 46- sessin interactive curriculum delivered by trained classrm teachers. Onging cmmunicatin with parents is als part f the prgram. Behaviral Cuples Therapy fr Alchlism and Drug Abuse (yung adults) (adults) 1) Quality f relatinship with intimate partner 2) Children's psychscial functining 3) Intimate partner vilence 4) Treatment cmpliance 1) 3.5 2) 3.7 3) 3.7 4) 3.4 SAMHSA NREPP Substance abuse treatment apprach based n the assumptins that (1) intimate partners can reward abstinence and (2) reducing relatinship distress lessens risk fr relapse. The therapist wrks with bth the persn wh is abusing substances and his r her partner t build a relatinship that supprts abstinence. Prgram cmpnents include a recvery r sbriety cntract between the partners and therapist; activities and assignments designed t increase psitive feelings, shared activities, and cnstructive cmmunicatin; and relapse preventin planning. Partners generally attend hur-lng sessins ver 5-6 mnths. Big Brthers Big Sisters (BBBS) Schl Based-Mentring (SBM) Cmmunity Based Mentring (CBM) Brief Strategic Family Therapy (BSFT) CARE (Care, Assess, Respnd, Empwer) SBM: 9-16 CBM: (children) (adlescents) (adlescent) (yung adults) SBM: Imprved academic perfrmance, behavirs, and attitudes. Mre classrm effrt and psitive scial behavirs CBM: Academic prblems Aggressin/vilence Alchl, tbacc, and ther substance use Delinquency Family functining Academic failure 1) Family functining 2) Scialized aggressin (delinquency in the cmpany f peers) 1) Sense f persnal cntrl 2) Anger management SBM: Effective CBM: Eemplary 1) 3.2 2) 3.4 1) 3.6 2) 3.5 OJJDP MPG OJJDP CEV EBG Mentrs in SBM prgrams spend mre time than CBM mentrs wrking n academics, have mre cntact with teachers, and, unlike CBM mentrs, are ften supervised by schl staff. Cmmn activities include academic activities such as tutring and talking abut schl-related tpics and nnacademic activities such as sprts, creative activities, indr games, and talking abut a range f tpics such as friends, family, the future, and the mentee s behavir. Mentrs in SBM prgrams cnsist f lder students and adults. CBM prgram is a ne-t-ne mentring prgram that takes place in a cmmunity setting and prvides lcal agencies with guidelines abut screening, matching, training, supervising, and mnitring. Mentrs in CBM prgrams usually cnsist f adults ages SBM and CBM prgrams vary in duratin and intensity. SAMHSA NREPP BSFT is a family-based interventin designed t prevent and treat child and adlescent behavir prblems. BSFT targets children and adlescents wh display r are at risk fr develping behavir prblems, including substance abuse. The gal f BSFT is t imprve a yuth s behavir prblems by imprving family interactins that are presumed t be directly related t the child s symptms, thus reducing risk factrs and strengthening prtective factrs fr adlescent drug abuse and ther cnduct prblems. BSFT is a shrt-term, prblem-riented interventin. A typical sessin lasts 60 t 90 minutes. The average length f treatment is 12 t 15 sessins ver mre than 3 mnths. SAMHSA NREPP This high schl-based suicide preventin prgram targets high-risk yuth. CARE includes a 2-hur, ne-nne cmputer-assisted suicide assessment interview fllwed by a 2-hur mtivatinal cunseling and scial supprt interventin. The cunseling sessin is delivers empathy and supprt, prvides a safe cntet fr sharing persnal infrmatin, and reinfrces psitive cping skills and help-seeking behavirs. CARE epedites access t help by cnnecting each high-risk yuth t a schl-based casewrker r a favrite teacher and establishing cntact with a parent r guardian chsen by the yuth. The prgram als includes a fllw-up reassessment f brad suicide risk and prtective factrs and a bster mtivatinal cunseling sessin 9 weeks after the initial cunseling sessin. The gals f CARE are threefld: t decrease suicidal behavirs, t decrease related risk factrs, and t increase persnal and scial assets. CASASTART (Striving Tgether t Achieve Rewarding Tmrrws, frmerly knwn as Children at Risk) 6-12 (children) (adlescents) Vilence 3.0 SAMHSA NREPP CASASTART is a cmmunity-based, schl-centered substance abuse and vilence preventin prgram. Yuth participants may remain in the prgram up t 2 years. Specific prgram bjectives f CASASTART include reducing drug and alchl use, reducing invlvement in drug trafficking, decreasing assciatins with delinquent peers, imprving schl perfrmance, and reducing vilent ffenses. CASASTART s interventin mdel is infrmed by the research literature n scial learning thery, scial strain thery, scial cntrl thery, and psitive yuth develpment. Its eight fundamental cmpnents are cmmunity-enhanced plicing, intensive case management, juvenile justice interventin, family services, after-schl and summer activities, educatin services, mentring, and the use f incentives t encurage yuth develpment activities. Each site brings tgether key stakehlders in schls, law enfrcement agencies, and scial services and health agencies t develp tailred appraches t the delivery f the cre service cmpnents cnsistent with lcal culture and practice. Child Parent Psychtherapy 0-6, plus parent(s) Imprvements in children s behavir prblems Imprvement in representatins f self and caregivers Effective OJJDP/ACYF OJJDP CEV EBG Child Parent Psychtherapy is a dyadic, relatinship-based treatment fr parents and yung children that helps restre nrmal develpmental functining in the wake f vilence and trauma by fcusing n restring the attachment relatinships that are negatively affected by vilence, establishing a sense f safety and trust within the parent-child relatinship, and addressing the c-cnstructed meaning f the event r trauma shared by parent and child. Sessins fcus n parent-child interactins t supprt and fster health cping, affect regulatin, and increased apprpriate reciprcity between parent and child. Parent guidance n develpment, behaviral management, crisis interventin, and case management are prvided as needed in an unstructured way. Recmmended interventin is 50 weekly sessin f hurs. *Althugh MST has been rates as eemplary with different ppulatins the evidence standard when used with families with at least ne parent charged with child abuse and neglect is prmising at the mment.

7 NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Preventin/P rmtin Cntinuum Interventin/ Treatment Systems Respnse Children Epsed t Vilence Prgram Matri: Effective Prgrams Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Cgnitive Behaviral 6-12/10-15 PTSD symptms, depressin symptms, Interventin fr Trauma in psychscial dysfunctin Schls (CBITS) Trauma/ Trauma Symptms Incidence Agency Prviding Surce f Infrmatin (e.g., Mdel Prgrams Guide r NREPP) Effective OJJDP NREPP, MPG/OJJDP CEV EBG Prgram Descriptin CBITS is a structured, schl-based, grup interventin designed t address PTSD, depressin, and behavir prblems related t cmmunity and family vilence. Grups (5-8 students/grup) incrprate cgnitivebehaviral skills (e.g., relaatin training, changing disruptive/unhelpful thughts, imprving prblem-slving) with epsure activities aimed at prcessing traumatic events, wrking thrugh traumatic grief, r addressing traumatic memries thrugh the use f age-apprpriate didactic instructin, games, rle-plays, wrksheets, and hmewrk assignments. Individuals are supprted with supplemental individual sessins t help reduce psttraumatic stress. Parents are invited t attend tw educatinal sessins and teachers are invited t ne educatinal sessin t help fster resilience thrugh establishing supprt fr students. Early Risers "Skills fr Success" 6-12 (children) (adults) 1) Academic cmpetence and achievement 2) Behaviral self-regulatin 3) Scial cmpetence 4) Parental investment in the child 1) 3.4 2) 3.5 3) 3.4 4) 3.2 SAMHSA NREPP The prgram targets elementary schl children (ages 6 t 10) wh are at high risk fr early develpment f cnduct prblems, including substance use (i.e., wh display early aggressive, disruptive, r nncnfrmist behavirs). It fcuses n imprving scial relatins (including family and schl relatins) fr aggressive children and preventing/mitigating aggressive behavir. Familias Unidas 6-12 (children) (adlescents) (adults) 1) Family functining 2) Behavir prblems 3) Eternalizing disrders 1) 3.9 2) 3.9 3) 3.8 SAMHSA NREPP This family-based interventin is fr Hispanic families with children ages The prgram is designed t prevent cnduct disrders; use f illicit drugs, alchl, and cigarettes; and risky seual behavirs by imprving family functining. Familias Unidas is guided by ecdevelpmental thery, which prpses that adlescent behavir is affected by a multiplicity f risk and prtective prcesses perating at different levels (i.e., within family, within peer netwrk, and beynd), ften with cmpunding effects. The prgram is als influenced by culturally specific mdels develped fr Hispanic ppulatins in the United States. The interventin is delivered primarily thrugh multiparent grups, which aim t develp effective parenting skills, and family visits, during which parents are encuraged t apply thse skills while interacting with their adlescent. The multiparent grups, led by a trained facilitatr, meet in weekly 2-hur sessins fr the duratin f the interventin. Families and Schls Tgether (FAST) 0-5 (yung children) 6-12 (children) 1) Child prblem behavirs 2) Child scial skills and academic cmpetencies 1) 3.7 2) 3.7 SAMHSA NREPP FAST is a multifamily grup interventin designed t build relatinships between families, schls, and cmmunities t increase well-being amng elementary schl children. The prgram s bjectives are t enhance family functining, prevent schl failure, prevent substance misuse by children and ther family members, and reduce the stress that children and parents eperience in daily situatins. Participants in the multifamily grup wrk tgether t enhance prtective factrs fr children, including parent-child bnding, parent invlvement in schls, parent netwrks, family cmmunicatin, parental authrity, and scial capital, with the aim f reducing the children s aniety and aggressin and increasing their scial skills and attentin spans. Functinal Family Therapy 6-12/13-21 Reductin in families' hstile interactins, (FFT) reductins in new ffending and entry fr yunger siblings f targeted yuth, treatment csts, fster care, and residential placement Eemplary OJJDP MPG/OJJDP CEV EBG FFT is a family-based preventin and interventin prgram fr dysfunctinal yuth that has been applied successfully in a variety f multiethnic, multicultural cntets t treat a range f high-risk yuth and their families. It integrates several elements (established clinical thery, empirically supprted principles, and etensive clinical eperience) int a clear and cmprehensive clinical mdel. The FFT mdel allws fr successful interventin in cmple and multidimensinal prblems thrugh clinical practice that is fleibly structured and culturally sensitive. The mdel includes specific phases: engagement/mtivatin, behavir change, and generalizatin. Engagement and mtivatin are achieved thrugh decreasing the intense negativity ften characteristic f high-risk families. The behavir change phase aims t reduce and eliminate the prblem behavirs and accmpanying family relatinal patterns thrugh individualized behavir change interventins (skill training in family cmmunicatin, parenting, prblem-slving, and cnflict management). The gal f the generalizatin phase is t increase the family s capacity t adequately use multisystemic cmmunity resurces and t engage in relapse preventin. FFT ranges frm an average f 8 t 12 1-hur sessins fr mild cases and incrprates up t 30 sessins f direct service fr families in mre difficult situatins. Sessins are generally spread ver a 3-mnth perid and can be cnducted in clinical settings, as an utpatient therapy, and as a hme-based mdel. Gd Behavir Game (GBG) Healthy Families America (HFA) 6-10 Imprvement in early risk behavirs f attentin/cncentratin prblems and shy and aggressive behavir, and academic functining 0-2/3-5 Epsure t vilence and effects f epsure t vilence (e.g., PTSD symptms) Eemplary OJJDP MPG/OJJDP CEV EBG This classrm management strategy is designed t imprve aggressive/disruptive classrm behavir and prevent later criminality. The prgram is universal and can be applied t general ppulatins f early elementary schl children, althugh the mst significant results have been fund fr children demnstrating early high-risk behavir. It is implemented when children are in early elementary grades t prvide them with the skills they need t respnd t later, pssibly negative, life eperiences and scietal influences. GBG imprves teachers ability t define tasks, set rules, and discipline students and allws students t wrk in teams in which each individual is respnsible t the rest f the grup. Befre the game begins, teachers clearly specify thse disruptive behavirs (e.g., verbal and physical disruptins, nncmpliance) that, if displayed, will result in a team s receiving a checkmark n the bard. By the end f the game, teams that have nt eceeded the maimum number f marks are rewarded, whereas teams that eceed this standard receive n rewards. Effective OJJDP MPG/OJJDP CEV EBG HFA seeks t prevent child maltreatment, thereby limiting the amunt f vilence children are epsed t in the hme and cmmunity. After screening a cmmunity ppulatin, at-risk families are prvided hme visitatin services. Services include bth prenatal and pstnatal cmpnents. Apprved prenatal curriculum typically fcuses n develping healthy maternal behavirs, aviding risky health behavirs, and supprting healthy fetal develpment. Pstnatal hme visits highlight child develpment, prmte parental well-being and develpment, and supprt parent-child interactin thrugh the use f instructin, mdeling, and activities. Amunt f services vary by family; hme visits start n a weekly basis but are mdified based n degree f risk and prgress. *Althugh MST has been rates as eemplary with different ppulatins the evidence standard when used with families with at least ne parent charged with child abuse and neglect is prmising at the mment.

8 NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Preventin/P rmtin Cntinuum Interventin/ Treatment Systems Respnse Children Epsed t Vilence Prgram Matri: Effective Prgrams Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Trauma/ Trauma Symptms Incidence Agency Prviding Surce f Infrmatin (e.g., Mdel Prgrams Guide r NREPP) Prgram Descriptin Hmebuilders 0-18 Children reunified with their family in a shrter amunt f time either by spending mre time with them r mving hme 70% f children wh were in the prgram remained hme, cmpared with 47% f children Effective OJJDP OJJDP CEV EBG Hmebuilders is a hme and cmmunity-based intensive family preservatin services treatment prgram designed t avid unnecessary placement f children and yuth int fster care, grup care, psychiatric hspitals, r juvenile justice facilities. Gals are t reduce child abuse and neglect, family cnflict, and child behavir prblems and t teach families the skills they need t prevent placement r successfully reunify with their children. Prgram mdel engages families by delivering services in their natural envirnment, at times in the cntrl grup when they are mst receptive t learning and by enlisting them as partners in assessment, gal setting, and treatment planning. Reunificatin cases ften require case activities related t reintegrating the child int the hme and cmmunity. Eamples include helping the parent find childcare, enrlling the child in schl, refurbishing the child's bedrm, and helping the child cnnect with clubs, sprts, r ther cmmunity grups. Duratin f 6 weeks with hur sessins per week is recmmended. Incredible Years 0-5 (yung children) 6-12 (children) (adults) 1) Psitive and nurturing parenting 1) 3.7 2) Harsh r negative parenting 2) 3.7 3) Child behavir prblems 3) 3.7 4) Child psitive behavirs, scial cmpetence, 4) 3.7 and schl readiness skills 5) 3.6 5) Parent bnding and invlvement with teacher and schl SAMHSA/OJJD P NREPP, MPG/OJJDP CEV EBG Prgram cntains curricula fr parents, teachers, and children and emphasizes the imprtance f the family as well as teacher scializatin prcesses, especially thse affecting yung children. The parents r teachers behavirs must be changed, s the children s scial interactins can be altered. The gal is t prmte healthy parenting practices and avid aversive parenting practices t prevent miscnduct and prmte resilience fr at-risk children. There are many studies n this prgram. Sme material n the applicatin f this prgram t children in the welfare system is available. Kids Club and Mms Empwerment 3-5, 6-12, Child/family well-being; child attitudes abut vilence; eternalizing behavir Effective ACYF/OJJDP OJJDP CEV EBG The Kids Club is mst effective when ffered with the Mms Empwerment. The Kids Club is a small grup interventin in which children share their eperiences and learn they are nt alne. Activities fcus n displacement f emtins thrugh stries, films, and plays t affect changes in knwledge, beliefs, and attitudes abut family vilence and emtinal adjustment in the face f vilence and scial behavir within the small grup. Mms Empwerment ffers a small grup parenting cmpnent fcused n parenting and discipline and parental scial and emtinal adjustment in the face f family vilence. Life Skills Training (LST) (adlescents) Universal vilence and delinquency preventin 4 SAMHSA NREPP This schl-based prgram aims t prevent alchl, tbacc, and marijuana use as well as vilence by targeting majr scial and psychlgical factrs that prmte the initiatin f substance use and ther risky behavirs. LST is based n bth the scial influence and cmpetence enhancement mdels f preventin. Cnsistent with this theretical framewrk, LST addresses multiple risk and prtective factrs and teaches persnal and scial skills that build resilience and help yuth navigate develpmental tasks, including the skills necessary t understand and resist pr-drug influences. LST prvides infrmatin relevant t the imprtant life transitins that adlescents and yung teens face, using culturally sensitive and develpmentally and ageapprpriate language and cntent. Linking the Interests f Families and Teachers (LIFT) 6-11 Effective parenting in the hme, decrease in aggressive behavirs with peers at schl and n the playgrund, increase in teachers psitive impressins f child scial skills Eemplary OJJDP MPG/OJJDP CEV EBG LIFT is a research-based interventin prgram designed t prevent the develpment f aggressive and antiscial behavirs in children in the elementary schl setting (particularly first graders and fifth graders). Child scial skills training sessins are held during the regular schl day and are brken int distinct segments. The first segment includes classrm instructin and discussin abut specific scial and prblemslving skills, skills practice in small and large grups, free play in the cntet f a grup cperatin game, and review and presentatin f daily rewards. The secnd segment includes a frmal class prblem-slving sessin and free play and rewards. Mtivatinal Interviewing (MI) ) Alchl use 2) Negative cnsequences/prblems assciated with alchl use 3) Drinking and driving 4) Alchl-related injuries 5) Drug use 6) Retentin in treatment 1) 3.4 2) 3.5 3) 3.5 4) 3.4 5) 3.3 6) 3.9 SAMHSA NREPP This prgram uses a gal-directed, client-centered cunseling style fr eliciting behaviral change by helping clients eplre and reslve ambivalence. The peratinal assumptin in MI is that ambivalent attitudes r lack f reslve is the primary bstacle t behaviral change, s the eaminatin and reslutin f ambivalence becmes its key gal. MI has been applied t a wide range f prblem behavirs related t alchl and substance abuse as well as health prmtin, medical treatment adherence, and mental health issues. Multidimensinal Treatment Fster Care (MTFC) 3-18 Decreased hmicide rate, decreased rate f nnlethal crime Eemplary 1) 2.8 2) 3.1 MPG/OJJDP CEV EBG MPG/OJJDP CEV EBG MTFC wrks with yuth epsed t vilence, including maltreatment that is prminent amng yuth especially female juvenile ffenders and children receiving child welfare services. MTFC serves as an alternative t residential care r a grup setting, where yuth are placed with trained fster families wh receive nging supprt thrugh weekly grup meetings and daily check-ins. Typically n mre than tw yuth are placed in a hme at a time, and placements are typically 6-9 mnths. Yuth receive individual therapy and nging behaviral caching. Bilgical parents r ther after-placement caregivers are simultaneusly prvided training and supprt t prepare fr the yuth's transitin back int the hme. MTFC incrprates basic cmpnents f the Oregn Parent Training Mdel, and fster families and parents learn hw t encurage new behavirs and develp psitive relatinships, set apprpriate limits using timeuts and fair discipline, engage in effective prblem-slving, and cnsistently mnitr their yuth's behavir and scial interactins. *Althugh MST has been rates as eemplary with different ppulatins the evidence standard when used with families with at least ne parent charged with child abuse and neglect is prmising at the mment.

9 Children Epsed t Vilence Prgram Matri: Effective Prgrams NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Preventin/P rmtin Cntinuum Interventin/ Treatment Systems Respnse Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Multisystemic Therapy (MST) Nte: Has been adapted with evidence f effectiveness fr juvenile ffenders, child abuse and neglect, and yuth with prblem seual behavirs By ppulatin f fcus: Juvenile ffenders- 1) Perceived family functining-chesin 2) Pst-treatment arrest rates 3) Lng-term arrest rates 4) Lng-term incarceratin rates 5) Self-reprted criminal activity Child abuse and neglect Parents mre likely t demnstrate mre adaptive parental cntrl strategies, imprved bserved parent-child interactin, and psitively rerganizing family behavir patterns Yuth with prblem seual behavirs Decreased recidivism fr vilent and seual ffenses amng ffending yuth; imprved parent-child interactin; reductin in parents' psychiatric symptmlgy; gains in family relatins, peer relatins, and individual psychiatric symptms amng yuth 1) Incarceratin and ther ut-f-hme placement 2) Family and peer relatins 3) Delinquent activities ther than prblem seual behavirs By ppulatin f fcus: Juvenile ffenders- 1) 3.0 2) 2.9 3) 3.0 4) 3.1 5) 3.2 *Child abuse and neglect- Prmising Yuth with prblem seual behavirs- Eemplary/ 1) 3.8 2) 3.6 3) 3.9 Trauma/ Trauma Symptms Incidence Agency Prviding X X SAMHSA OJJDP Surce f Infrmatin (e.g., Mdel Prgrams Guide r NREPP) NREPP, MPG/OJJDP CEV EBG Prgram Descriptin MST, riginally develped t treat serius juvenile ffenders (seual and vilent ffenses), is an intensive family- and cmmunity-based prgram intended t prvide a multifaceted apprach t treatment. It was develped frm scial-eclgical and family systems theries, purprts that yuth antiscial behavir results frm discnnects within r acrss verlapping systems in which families live. Acknwledging that prblems arise frm multiple influences (e.g., family cnflict, pr schl relatins), the MST therapist bases his/her wrk n nine cre principles, seeking t identify current patterns cntributing t the issue, emphasize family strengths and resurces, and empwer caregivers and families t effectively functin acrss all systems in which they interact. Nurse-Family Partnership 0-5 (yung children) (adlescents) (yung adults) (adults) 1) Child injuries and maltreatment 1) 3.5 Fewer child injuries, harmful ingestins, days f Eemplary hspitalizatins due t injuries; lwer rates f CAN, fewer criminal behavirs and substance use prblems amng mthers SAMHSA, MPG/OJJDP CEV EBG MPG, NREPP Nurse-Family Partnership targets lw-incme, first-time mthers. Visiting nurses prvide services in-hme, beginning during pregnancy and lasting until the child is 2 years ld. The verall gals f the prgram are t imprve the prenatal health f the mther, and therefre f the baby; imprve the early care f the infant/tddler, and therefre imprve his/her health and develpment; and wrk with the mther n her wn persnal develpment with special attentin t the areas f wrk, schl, and family planning. Althugh this prgram was designed t target brad health utcmes fr lw-incme families, sme f the findings shw significant psitive effects n reducing child abuse and neglect, as well as ther negative utcmes mst highly assciated with child abuse and neglect (e.g., parent and child rates f arrest and delinquency). Nurturing Parenting Prgrams (NPP) 6-12 (children) (adults) 1) Family interactin 2) Recidivism f child abuse and neglect 3) Children s behavir and attitudes tward parenting 1) 3.2 2) 2.9 3) 3.0 SAMHSA, OJJDP NREPP, OJJDP CEV EBG The gals f NPP are t: Increase parents sense f self-wrth, persnal empwerment, empathy, bnding, and attachment. Increase the use f alternative strategies t harsh and abusive disciplinary practices. Increase parents knwledge f age-apprpriate develpmental epectatins. abuse and neglect rates. NPP instructin is based n psycheducatinal and cgnitive-behaviral appraches t learning and fcuses n "re-parenting" r helping parents learn new patterns f parenting t replace their eisting, learned, abusive patterns. Grup sessins cmbine cncurrent separate eperiences fr parents and children with shared "family nurturing time." In hme-based sessins, parents and children meet separately and jintly during a 90- minute lessn nce per week fr 15 weeks. Olweus Bullying Preventin Prgram 6-14 Decrease in perpetratin and victimizatin; decrease in fighting and vandalism; increase in psitive scial climate in schl, rder, and discipline in schl; and better scial relatinships and attitudes tward schl Effective CDC/OJJDP MPG/OJJDP CEV EBG This prgram was develped t prmte the reductin and preventin f bullying behavir and victimizatin prblems. The prgram is based n an eclgical mdel, intervening with a child s envirnment n many levels: the individual children wh are bullying and being bullied, the families, the teachers and students within the classrm, the schl as a whle, and the cmmunity. The main arena fr the prgram is the schl, and schl staff has the primary respnsibility fr intrducing and implementing the prgram. Schls are prvided nging supprt by prject staff. Adult behavir is crucial t the success f the Olweus Bullying Preventin Prgram. T achieve the prgram s gals, tw cnditins must be met: adults at schl and, t sme degree, at hme must becme aware f the etent f bully victim prblems; adults must engage themselves in changing the situatin. Parent-Child Interactin Therapy (PCIT) 0-5 (yung children) 6-12 (children) (adults) 1) Parent-child interactin 2) Recurrence f physical abuse 1) 3.2 2) 3.9 SAMHSA NREPP This treatment prgram fr yung children with cnduct disrders places emphasis n imprving the quality f the parent-child relatinship and changing parent-child interactin patterns. PCIT was develped fr children ages 2-7 with eternalizing behavir disrders. In PCIT, parents are taught specific skills t establish r strengthen a nurturing and secure relatinship with their child while encuraging prscial behavir and discuraging negative behavir. This treatment has tw phases, each fcusing n a different parent-child interactin: child-directed interactin and parent-directed interactin. In each phase, parents attend ne didactic sessin t learn interactin skills and then attend a series f caching sessins with the child in which they apply these skills. *Althugh MST has been rates as eemplary with different ppulatins the evidence standard when used with families with at least ne parent charged with child abuse and neglect is prmising at the mment.

10 NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Preventin/P rmtin Cntinuum Interventin/ Treatment Systems Respnse Children Epsed t Vilence Prgram Matri: Effective Prgrams Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Parenting Thrugh Change (PTC) 6-12 (children) (yung adults) (adults) 1) Academic functining 2) Delinquency 1) 3.8 2) 3.6 Trauma/ Trauma Symptms Incidence Agency Prviding Surce f Infrmatin (e.g., Mdel Prgrams Guide r NREPP) Prgram Descriptin X SAMHSA NREPP PTC is a thery-based interventin t prevent internalizing and eternalizing cnduct behavirs and assciated prblems and prmte healthy child adjustment. Based n the Parent Management Training-- Oregn Mdel, PTC prvides recently separated single mthers with 14 weekly grup sessins t learn effective parenting practices including skill encuragement, limit-setting, prblem-slving, mnitring, and psitive invlvement. PTC als includes strategies t help parents decrease cercive echanges with their children and use cntingent psitive reinfrcements (e.g., praise, incentives) t prmte prscial behavir. Parenting Wisely ) Child prblem behavirs 2) Parental knwledge, beliefs, and behavirs 3) Parental sense f cmpetence 1) 2.7 2) 2.7 3) 2.8 SAMHSA NREPP Parenting Wisely is a set f interactive, cmputer-based training prgrams fr parents f children. Based n scial learning, cgnitive behaviral, and family systems theries, the prgrams aim t increase parental cmmunicatin and disciplinary skills. The riginal Parenting Wisely prgram, American Teens, is designed fr parents whse preteens and teens are at risk fr r are ehibiting behavir prblems such as substance abuse, delinquency, and schl drput. Parents use a self-instructinal prgram n an agency s persnal cmputer, either n site r at hme, using the CD-ROM r nline frmat. During each f nine sessins, users view a vide enactment f a typical family struggle and then chse frm a list f slutins representing different levels f effectiveness, each f which is prtrayed and critiqued thrugh interactive questins and answers. Each sessin ends with a quiz. All nine sessins can be cmpleted in 2 t 3 hurs. Parents als receive wrkbks cntaining prgram cntent and eercises t prmte skill building and practice. Perry Preschl Prject (High Scpe Curriculum) 3-4 Less antiscial behavir and miscnduct Delinquency and crime rates fr the children in the prgram were significantly lwer than fr thse in the cntrl grup Eemplary OJJDP MPG/OJJDP CEV EBG This high-quality educatin is fr disadvantaged children ages 3 t 4 t imprve their capacity fr future success in schl and in life. The interventin breaks the link between childhd pverty and schl failure by prmting yung children s intellectual, scial, and physical develpment. By increasing academic success, the Perry Preschl Prject is able t imprve emplyment pprtunities and wages and t decrease crime, teenage pregnancy, and welfare use. The prgram cnsists f a 30-week schl year. During that year there is a daily 2½-hur classrm sessin and a weekly 1½-hur hme visit. The hme visits are a way t invlve the mther in the educatinal prcess and enable her t prvide her child with supprt. They als serve t etend what the child has learned in schl t the hme. Teachers rganize grup meetings f mthers and fathers with children in the prgram. Primary Prject 0-5 (yung children) 6-12 (children) 1) Peer sciability 2) Behavir cntrl 3) Adaptive assertiveness 1) 3.2 2) 3.3 3) 3.3 SAMHSA NREPP This schl-based prgram prvides early detectin and preventin f schl adjustment difficulties in children ages 4-9. The prgram begins with screening t identify children with early schl adjustment difficulties (e.g., mild aggressin, withdrawal, and learning difficulties) that interfere with learning. Fllwing identificatin, children are referred t a series f ne-n-ne sessins with a trained paraprfessinal wh uses develpmentally apprpriate child-led play and relatinship techniques t help adjustment t the schl envirnment. Children generally are seen weekly fr minutes fr weeks. Targeted utcmes fr children in Primary Prject include increased task rientatin, behavir cntrl, assertiveness, and peer scial skills. Prject Supprt 3-5, 6-12 Child/family well-being; safety Effective OJJDP/ACYF OJJDP CEV EBG Prject Supprt is designed t be implemented in-hme within the initial stages f transitin ut f a dmestic abuse shelter. It was develped t target child cnduct prblems that ften accmpany epsure t dmestic vilence and t assist maternal self-efficacy in dealing with these difficulties. The main gals f the interventin are t prvide direct supprt t mthers and children as they make the transitin frm shelter t independent living and t teach mthers effective strategies t manage a child's cnduct difficulties when there is evidence f clinically significant cnduct prblems with at least ne child between the ages 4 and 9. Prlnged Epsure Therapy PTSD symptms, depressin symptms, scial functining Eemplary OJJDP MPG/OJJDP CEV EBG Prlnged epsure therapy has been shwn t be highly effective fr reducing the symptms f PTSD assciated with seual and nnseual assault, including avidance, intrusin, and arusal. Mrever, fr mst clients, gains in symptm reductin during treatment are maintained at 12 mnths fllwing treatment. Prmting Alternative Thinking Strategies (PATHS), PATHS Preschl 0-5 (yung children) 6-12 (children) 1) Emtinal knwledge 2) Internalizing behavirs 3) Eternalizing behavirs 4) Depressin 5) Neurcgnitive capacity 6) Learning envirnment 7) Scial-emtinal cmpetence 1) 2.5 2) 2.5 3) 2.9 4) 3.2 5) 2.8 6) 2.6 7) 2.8 X X SAMHSA NREPP PATHS and PATHS Preschl are schl-based preventive interventins fr children in elementary schl r preschl. The interventins are designed t enhance areas f scial-emtinal develpment such as selfcntrl, self-esteem, emtinal awareness, scial skills, friendships, and interpersnal prblem-slving skills while reducing aggressin and ther behavir prblems. Skill cncepts are presented thrugh direct instructin, discussin, mdeling, strytelling, rle-playing activities, and vide presentatins. The elementary schl PATHS curriculum is available in tw units: the PATHS Turtle Unit fr kindergarten and the PATHS Basic Kit fr grades 1-6. The curriculum includes t 30-minute lessns designed t be taught by regular classrm teachers apprimately 3 times per week ver the curse f a schl year. PATHS Preschl, an adaptatin f PATHS fr children ages 3 t 5, is designed t be implemented ver a 2-year perid. Its lessns and activities highlight writing, reading, strytelling, singing, drawing, science, and math cncepts and help students build the critical cgnitive skills necessary fr schl readiness and academic success. The PATHS Preschl prgram can be integrated int eisting learning envirnments and adapted t suit individual classrm needs. Recnnecting Yuth: A Peer Grup Apprach t Building Life Skills (RY) (adlescents) (yung adults) 1) Schl perfrmance 2) Mental health risk and prtective factrs 1) 3.3 2) 3.3 SAMHSA NREPP This schl-based preventin prgram fr students teaches skills t build resilience against risk factrs and cntrl early signs f substance abuse and emtinal distress. Eligible students must have either fewer than the average number f credits earned fr all students in their grade level at their schl, high absenteeism, and a significant drp in grades during the prir semester r a recrd f drpping ut f schl. Eligible students may shw signs f multiple prblem behavirs, such as substance abuse, aggressin, depressin, r suicidal ideatin. The prgram incrprates several scial supprt mechanisms fr participating yuth: scial and schl bnding activities t imprve teens' relatinships and increase their repertire f safe, healthy activities; develpment f a crisis respnse plan detailing the schl system's suicide preventin appraches; and parent invlvement, including active parental cnsent fr their teen's participatin and nging supprt f their teen's RY gals. *Althugh MST has been rates as eemplary with different ppulatins the evidence standard when used with families with at least ne parent charged with child abuse and neglect is prmising at the mment.

11 NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Preventin/P rmtin Cntinuum Interventin/ Treatment Systems Respnse Children Epsed t Vilence Prgram Matri: Effective Prgrams Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Richmnd Decreased hmicide rate, decreased rate f Cmprehensive Hmicide nnlethal crime Initiative Trauma/ Trauma Symptms Incidence Agency Prviding Surce f Infrmatin (e.g., Mdel Prgrams Guide r NREPP) Prgram Descriptin Effective OJJDP MPG The Richmnd (Calif.) Cmprehensive Hmicide Initiative is a prblem-riented plicing prgram cmpsed f a brad cllectin f enfrcement and nnenfrcement strategies designed t reduce hmicide. The initiative departed frm the traditinal plice definitin f hmicide as a unique ffense in which the apprpriate plice rle is largely limited t after-the-fact investigatin, instead recgnizing that hmicide preventin is a critical plice respnsibility that can best be accmplished by identifying the paths that frequently lead t hmicide and clsing them by intervening early. With this new definitin in mind, the initiative members develped a plan cncentrated n specific prblem areas, including targeting dmestic vilence, enhancing investigative capabilities, intervening in the lives f at-risk yuth, and targeting utdr- gun-, drug-, and gang-related vilence. Eamples f the nnenfrcement strategies, which emphasize yuth and preventin, include cllabrating with the cmmunity and public agencies in crime-reductin planning and cllabrating with the Battered Wmen's Alternatives and the Rape Crisis Calitin t supprt prgrams and practices t reduce dmestic vilence and eamples f traditinal investigative and enfrcement functins including btaining the assistance f the Drug Enfrcement Administratin, the FBI, and the Califrnia Bureau f Narctics Enfrcement in targeting vilence-prne members f the drug culture. SAFEChildren 6-12 (children) (adults) 1) Child prblem behavirs 2) Parental invlvement in child's educatin 1) 3.6 2) 3.6 SAMHSA NREPP This family-fcused preventive interventin is designed t increase academic achievement and decrease risk fr later drug abuse and assciated prblems such as aggressin, schl failure, and lw scial cmpetence. It targets first-grade children and their families living in inner-city neighbrhds. The interventin has tw cmpnents. The first is a multiple-family grup apprach that fcuses n parenting skills, family relatinships, understanding and managing develpmental and situatinal challenges, increasing parental supprt, skills and issues in engaging as a parent with the schl, and managing issues such as neighbrhd prblems (e.g., vilence) as well as family participatin in 20 weekly sessins (2 t 2.5 hurs each) led by a trained, prfessinal family grup leader. The secnd cmpnent is a reading tutring prgram fr the child. Safe Dates (8th and 9th graders) Seual vilence perpetratin; findings cnsistent at 4-year fllw-up Eemplary CDC/OJJDP MPG/OJJDP CEV EBG This is a schl-based prgram t stp r prevent the initiatin f psychlgical, physical, and seual abuse n dates r between individuals invlved in a dating relatinship. Its gals are t change adlescent dating vilence nrms and gender-rle nrms, imprve cnflict reslutin skills fr dating relatinships, prmte victims and perpetratrs beliefs in the need fr help and awareness f cmmunity resurces fr dating vilence, prmte help-seeking by victims and perpetratrs, and imprve peer help-giving skills. San Dieg Breaking Cycles (SDBC) Children's peer relatinships, schl attendance and perfrmance, decreased delinquent behavir, reduced likelihd f drug use ver 18 mnths Effective OJJDP MPG/OJJDP CEV EBG SDBC cmprises tw cmpnents: preventin and graduated sanctins. Each cmpnent includes services relevant fr children epsed t vilence and fcuses n the early identificatin f yuth at risk fr delinquency; the prvisin f graduated family-centered, cmmunity-based treatments; and the terminatin f the cyclic substance abuse and vilence amng juveniles. The preventin cmpnent includes a cmprehensive assessment cnducted by a multiagency cmmunity assessment team that identifies strengths and risks f the yuth and family and links them with cmmunity scial supprts. The graduated sanctins cmpnent is accessed via curt rders and prvided t yuth at-risk fr ut-f-hme placement. It includes the prvisin f psycheducatinal grups fr yuth and families, individual and family therapy and substance abuse cunseling, and ther cmmunity supprts. Strengthening Families Prgram (SFP) Nte: Has als been adapted with evidence f effectiveness fr parents and yuth ages (children) (adlescents) (adults) 1) Children's internalizing and eternalizing behavirs 2) Parenting practices/parenting efficacy 3) Family relatinships Adaptatin fr parents and yuth age ) Schl success 2) Aggressin 1) 3.1 2) 3.1 3) 3.1 Adaptatin fr parents and yuth ages ) 2.9 2) 3.0 SAMHSA NREPP This family skills training prgram is designed t increase resilience and reduce risk factrs fr behaviral, emtinal, academic, and scial prblems in children. SFP cmprises three life-skills curses delivered in 14 weekly, 2-hur sessins. Parenting skills sessins are help parents learn t increase desired behavirs in children by using attentin and rewards, clear cmmunicatin, effective discipline, substance use educatin, prblem slving, and limit setting. Children s life skills sessins help children learn effective cmmunicatin, understand their feelings, imprve scial and prblem-slving skills, resist peer pressure, understand the cnsequences f substance use, and cmply with parental rules. Family life skills sessins help families engage in structured family activities, practice therapeutic child play, cnduct family meetings, learn cmmunicatin skills, practice effective discipline, reinfrce psitive behavirs in each ther, and plan family activities tgether. Trauma Fcused- Cgnitive Behaviral Therapy (TF-CBT) 3 t 21 1) Child behavir prblems 2) Child symptms f PTSD 3) Child depressin 4) Child feelings f shame 5) Parental emtinal reactin t child's eperience f seual abuse 6) Persnal and prscial behavirs 1) 3.8 2) 3.6 3) 3.8 4) 3.7 5) 3.7 6) 2.9 Eemplary SAMHSA/OJJD P NREPP, OJJDP CEV EBG TF-CBT is a structured, weekly cnjint child and parent psychscial therapy fr children and yuth with emtinal/behaviral difficulties assciated with vilence epsure and trauma. It fcuses n prviding a safe, trusting envirnment where children and parents build skills in cping, stress reductin, and management f verwhelming emtins and traumatic grief. The cre cmpnents (PRACTICE) include psycheducatin abut childhd trauma, relevant vilence, PTSD, and parent guidance; relaatin skills individualized t the child and parent; affective mdulatin skills adapted t the child, family, and culture; cgnitive cping including cnnecting thughts, feelings, and behavirs related t the trauma; cmpleting a trauma narrative; in-viv epsure t reduce aniety; cnjint parent-child sessins t practice skills and enhance trauma-related discussins; and enhancing persnal safety and ptimal develpment thrugh prviding safety and scial skills training as needed. Triple P (Psitive Parenting Prgram) 0-8 (yung children) 1) Negative and disruptive child behavirs 2) Negative parenting practices as a risk factr fr later child behavir prblems 3) Psitive parenting practices as a prtective factr fr later child behavir prblems 1) 2.9 2) 2.9 3) 3.0 X X SAMHSA, CDC, OJJDP NREPP The prgram is aimed at reducing cercive parenting, including maltreatment. A recent randmized ppulatin trial f Triple P in 18 cunties in Suth Carlina shwed significant reductins in substantiated child maltreatment, child maltreatment injuries, and ut-f-hme placements fr thse in the Triple P cunties. Within the Triple P system, the Pathways Triple P adjunctive interventin prvides a fur-sessin adjunct t standard r enhanced grup r individual Triple P fr parents wh have abused r are at risk f maltreating their children. *Althugh MST has been rates as eemplary with different ppulatins the evidence standard when used with families with at least ne parent charged with child abuse and neglect is prmising at the mment.

12 Children Epsed t Vilence Prgram Matri: Prmising Prgrams NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Cntinuum Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Trauma/ Trauma Symptms Incidence Agency Prviding Surce f Infrmatin (e.g. Mdel Prgrams Guide r NREPP) Prgram Descriptin Preventin/ Prmtin Interventin/ Treatment Systems Respnse Child and Family Traumatic Stress Interventin (CFTSI) 7-18 Prevent the develpment f Chrnic PTSD in children Prmising ACYF NCTSN Fur-sessin caregiver-child early interventin fr children with recent epsure (30 days) t a ptentially traumatic event. Sessins invlve assessment fr trauma and PTSD fr caregiver and child, using infrmatin frm the assessments t identify key issues, imprve caregiver-child cmmunicatin, select and practice behaviral skill mdules as hmewrk, ther supprtive measures and determine net steps at final sessin. Cmbined Parent Child CBT 4-17 CEV relevant; Limited Data Prmising OJJDP NCTSN Cnsists f 16 sessins that aim t empwer parents t effectively parent in a nn-cercive manner, imprve parent-child relatinships, assist children in healing frm their abusive eperiences, and enhance the safety f family members. The treatment cnsists f 3 cmpnents: (1) Parent Interventins, (2) Child Interventins, and (3) Parent-Child. DV Hme Visitatin 0-18 Trauma-related symptms Prmising ACYF OJJDP CEV EBG A jint prject f the Yale Child Study Center and the New Haven Plice Department that prvides enhanced law enfrcement, cmmunity-based advcacy, and mental health services t families affected by dmestic vilence, in an effrt t increase children s safety and decrease negative psychlgical effects f epsure t dmestic vilence. The prject cnducts utreach hme visits by teams f advcates and patrl fficers. At the initial hme visit, the team and nn-ffending parent identify issues affecting family safety. Eye Mvement Desensitizatin and Reprcessing (EMDR) 2-17 reactivity t traumatic memries, reduce trauma symptms Prmising SAMHSA OJJDP CEV EBG An 8-phase psychtherapy treatment riginally designed t alleviate the symptms f trauma. During the EMDR trauma prcessing phases, the client attends t emtinally disturbing material in brief sequential dses that include the client s beliefs, emtins, and bdy sensatins assciated with the traumatic event while simultaneusly fcusing n an eternal stimulus. X Family Centered Treatement (FCT) 5-21 Lwer residential placements and decrease in duratin f placement in first year Prmising OJJDP MPG / OJJDP CEV EBG Intensive in-hme service treatment especially well suited fr high-risk juveniles nt respnding t typical cmmunity-based services r fund t need institutinal placement, as well as thse returning frm incarceratin r institutinal placement. A primary gal is t keep yuth in the cmmunity and divert them frm further penetratin int the juvenile justice system. FCT is different frm ther traditinal in-hme family therapy r cunseling prgrams in that it is family fcused rather than client fcused. Treatment services cncentrate n prviding a fundatin that maintains family integrity, capitalizes n the yuth s and family s inherent resurces (i.e., skills, values, and cmmunicatin patterns), develps resiliency, and demands respnsibility and accuntability. Multimdality Trauma Treatment Trauma- Fcused Cping (MMTT) 18-Sep Beneficial effects f treatment fr reducing PTSD, depressin, aniety, and anger Prmising OJJDP NCTSN A skills-riented, cgnitive behaviral treatment (CBT) apprach fr children epsed t single incident trauma and targets psttraumatic stress disrder (PTSD) and cllateral symptms f depressin, aniety, anger, and eternal lcus f cntrl. It was designed as a peermediating grup interventin in schls. It has been shwn t be easily adaptable fr use as grup r individual treatment in clinic ppulatins as well. Partners with Families and Children: Spkane 0-5 (Early childhd) (Adult) 1: Interpersnal vilence within families 2: Parenting stress 3: Child behavir prblems 4: Caregiver-child attachment 5: Service access Prmising SAMHSA NREPP Families with children under 30 mnths referred by child prtective services, law enfrcement, r ther public health agencies due t chrnic child neglect r risk f child maltreatment. A multidisciplinary interventin based n wraparund service principles and attachment thery. Its characteristic features are intensive case management using an integrated system f care apprach; n-site resurces fr gender-specific, integrated parental substance abuse and mental health services; parental caching t imprve parent-child interactins and relatinships; and a cmmitment t prvide services as lng as the family wants and benefits frm services

13 Children Epsed t Vilence Prgram Matri: Prmising Prgrams NREPP: Natinal Registry f Effective Preventin Prgrams: NCTSN: Natinal Child Traumatic Stress Netwrk: MPG: Mdel Prgrams Guide: OJJDP CEV EBG: Office f Juvenile Justice and Delinquency Preventin Child Epsure t Vilence Evidence Based Guide: Cntinuum Prgram Name Age Range Outcme Indicatr Evidence Standard (Rating) Increase Resilience Trauma/ Trauma Symptms Incidence Agency Prviding Surce f Infrmatin (e.g. Mdel Prgrams Guide r NREPP) Prgram Descriptin Preventin/ Prmtin Interventin/ Treatment Systems Respnse Real Life Heres 6-12 (Childhd) (Adlescent) 1) Feelings f security with primary caregiver 2) Prblem behavirs Prmising SAMHSA NREPP Based n cgnitive behaviral therapy mdels fr treating psttraumatic stress disrder (PTSD) in schl-aged yuth. Fcuses n rebuilding attachments, building the skills and interpersnal resurces needed t reintegrate painful memries, fstering healing, and restring hpe. The prtcl cmpnents include safety planning, trauma psycheducatin, skill building in affect regulatin and prblem slving, cgnitive restructuring f beliefs, nnverbal prcessing f events, and enhanced scial supprt. Secnd Step 6-12 (Childhd) 1) Scial cmpetence and prscial behavir 2) Incidence f negative, aggressive, r antiscial behavirs 1) 2.4 2) 2.4 SAMHSA NREPP, OJJDP CEV EBG Classrm-based scial-skills prgram that teaches sciemtinal skills aimed at reducing impulsive and aggressive behavir while increasing scial cmpetence. Builds n cgnitive behaviral interventin mdels integrated with scial learning thery, empathy research, and scial infrmatinprcessing theries. Cnsists f in-schl curricula, parent training, and skill develpment. Seeking Safety fr Adlescents Adlescents Child/family well-being; substance use, trauma-related symptms, psychpathlgy Prmising ACYF NREPP The prgram is a present-fcused cping skills therapy designed fr use with adlescents with PTSD and substance abuse disrders. The prgram cnsists f 25 tpics that address cgnitive, behaviral and interpersnal dmains. Each ffers a safe cping skill fr tpics including asking fr help, cping with triggers, detaching frm emtinal pain, etc. Seual Abuse, Family Educatin & Treatment (SAFE-T) 6-12 / d recidivism fr seual assualt charges; reduced criminal behavir; reduced epsure and amelirated effects f epsure Prmising OJJDP MPG / OJJDP CEV EBG SAFE-T is a seual ffender specific treatment prgram, therefre, its primary utcmes are reprted recidivism rates. Frm quasieperimental studies f adlescent seual ffenders (with mstly child r peer victims), SAFE-T has been effective in reducing lng-term recidivism rates f seual, vilent, prperty, and ther ffenses, thereby reducing rates f seual and nn-seual vilence in the cmmunity thrugh preventin. Further, almst half f seual ffenders (43%) receiving SAFE-T treatment have reprted a histry f seual victimizatin. Structured Psychtherapy fr Adlescents Respnding t Chrnic Stress (SPARCS) Overall functining, cnductrelated prblems, cping respnses, PTSD symptms Prmising ACYF NCTSN Primarily a cgnitive-beahaviral therapy and dialectical behaviral therapy; interventin delivered in a grup setting t address the needs f chrnically traumatized adlescents wh may still be living with nging stress and eperiencing prblems with affect regulatin and impulsivity, self-perceptin, relatinships, smatizatin, dissciatin, numbing and avidance and struggles with their wn purpse and meaning in life as well as wrldviews that make it difficult fr them t see a future fr themselves. Delivered in ne hur sessins. Trauma Systems Therapy (TST) 6-19 Traumatic stress symptms, family and schl related prblems Prmising ACYF NCTSN Targeted at children and adlescents wh are having difficulty regulating their emtins as a result f the interactin betweeen the traumaatic eperience and stressrs in the scial envirnment, TST has up t five phases: Surviving, Stabilizing, Enduring, Understanding and Transcending. Treatment mdules include: Hme and Cmmunity-based Services, Services Advcacy, Emtinal Regulatin and Skills Training, Cgnitive Prcessing and Psychpharmaclgy.

14 Service Characteristics with Evidence-Based Supprt fr Children Epsed t Vilence Service characteristics are the distinguishing features f a prgram r prgram cmpnent. Service characteristics include the length, intensity and frequency f service, the service recipient, the type f apprach r mdality, the lcatin, the cmbinatin f varius prgram cmpnents and characteristics, etc. In reviewing the research literature n evidence-based prgrams, cmmn characteristics have emerged in the findings that have been shwn t supprt success r reduce the effectiveness f prgrams. This paper highlights tw types f service characteristics. The first list belw is f facilitatrs, thse characteristics that are cmmn acrss a range f prgrams that are assciated with better utcmes. The secnd list is f barriers, r thse characteristics that can prevent prgrams frm being successful. The third list included belw is f cmmn service and system gaps dcumented as practical implicatins discussed in the research literature. These are areas that are underdevelped in many systems, which yu may cnsider addressing thrugh the adptin f new evidence-based practices r shifts in yur system and currently ffered services. Facilitatrs These are characteristics cmmn acrss successfully implemented evidencebased practices. Cmbined Hme and Center-based appraches Multi-Mdal Treatment Appraches-- The cmbinatin f mre than ne type f treatment such as individual, family, and advcacy services. Parent-Child Dual apprach Bth in ensuring safety f all and in effective service delivery, a cmbined parent-child apprach is essential. Simultaneus treatment f mthers and children is cnsistently dcumented as an key service feature in a large number f studies in preventin and interventin. Parent Training and Psych-Educatinal Services-- In bth Preventin and Interventin, it is imprtant fr all prviders t share critical infrmatin with parents abut signs, symptms and impacts f epsure t vilence as well as strategies fr prviding apprpriate supprt and services. Develpmentally and culturally apprpriate services Barriers These are barriers that may hinder prgress in service and system refrms. Attritin and Retentin as a barrier t bth practice and research: The difficulty f engaging and retaining families in services is a critical service barrier acrss all types f services. It is particularly challenging when children have been epsed t vilence because families with c-ccurring vilence eperiences have many safety cncerns and pressing needs. 1

15 Mandated Reprting: One critical service barrier in the area f CEV, particularly in the area f treatment, is the cncern by prviders that having t make a referral fr child maltreatment will disslve the treatment relatinship between the prvider and the caregiver and will result in attritin hwever sme early evidence is emerging that demnstrates that with prper training n when and hw t reprt with families in treatment, families can be effectively retained in services and reprting can be effectively managed withut sacrificing treatment. Parental Mtivatin and Epectatins May Effect Participatin: Emerging evidence suggests that parents are mre likely t stay engaged in services fr children with eternalizing behavirs. Psych-educatinal supprts t parents regarding the identificatin and understanding f their children s internalizing behavirs may be specifically needed. Lack f Evidence in Practice: Mre infrmatin, training and awareness abut evidencebased practice is needed. Currently, emerging evidence suggests that evidence-infrmed practices are underutilized and that it is imprtant t integrate research knwledge with the judgment and epertise that cmes frm practice. Cmmn service and system gaps There are several cmmn gaps acrss the service systems that are supprted in the literature as practical implicatins in the research that bear highlighting in an evidence-infrmed apprach. Service delivery systems including prviders and advcates need t rerient and reframe wrk in the area f children s epsure t vilence frm the perspective f the child and their family using a set f key principles: trauma-infrmed; safety-fcused; culturally and develpmentally apprpriate. Safety and well-being first: Nt all children epsed t vilence will develp trauma r trauma symptms hwever their vilence epsure and these incidences matter. All children wh are epsed t vilence are at increased risk fr further vilence incidences and ther types f vilent incidents. The mre types f epsures a yuth has the higher the risks and the greater the likelihd f trauma and ther negative utcmes. Service prviders and systems need t ask a brad range f questins t fully understand the scpe f vilence eperiences fr children and families and t ensure safety fr all---the safety f the child and the safety f any ther victims in the child s family. In cases f dmestic vilence, ensuring the dual safety f bth the child and the adult victim is paramunt. Trauma-infrmed and trauma-specific care: Children epsed t vilence are ften invlved in service systems that serve ppulatins with high rates f epsure t traumatic events. Children wh have eperienced a traumatic event r multiple events and are eperiencing negative psychlgical symptms may need trauma specific treatment such as Trauma Fcused Cgnitive Behavir Therapy r Epsure Therapy. At the same time, 2

16 services shuld be trauma-infrmed, with an appreciatin fr the high prevalence f traumatic eperiences in persns receiving them, and a thrugh understanding f the prfund neurlgical, bilgical, psychlgical and scial effects f trauma and vilence n individuals. A trauma-infrmed apprach can help staff reduce rates f re-traumatizatin and engage children and families that have eperienced trauma. Prgrams that address the substance abuse and mental health needs f parents: The substance use and mental health prblems f parents can interfere with their ability t parent, and may be related t child maltreatment. Systems shuld take steps t get parents cnnected t screening and services fr behaviral health prblems. Supprts fr parents: Frmal and infrmal supprts fr parents can imprve utcmes fr children. This can cme thrugh evidence based practices like the Strengthening Families Prgram, specific services like respite care, r parent supprt grups thrugh cmmunity rganizatins. Strng cnnectins acrss educatin, health and scial service systems, prviders and advcates: Better service crdinatin can enable earlier identificatin f prblems, reduced service redundancy, and imprved quality f care thrugh wraparund r similar mdels. Schls especially play a key rle fr children, given the large amunt f time that children spend in schl and the strng ptential fr service delivery and crdinatin in the schl setting. Availability f persnnel t serve minrity ppulatins: The lack f prviders with the necessary backgrund and skills necessary t prvide culturally apprpriate care can inhibit the success f prgrams. Service systems can wrk t address this issue by prviding training abut cultural differences, ensuring that services are ffered by staff wh speak the language f thse being served, and wrking t recruit wrkers with a similar backgrund t the ppulatin being served. 3

17 Glssary f Terms These definitins are intended fr practical usage and t supprt the terms and language used in this evidence-based tl. They are nt fficial definitins f the U.S. Department f Justice r the U.S. Department f Health and Human Services and d nt supersede any eisting statutry r regulatry definitins. Assessment Assessment may be either frmal r infrmal. Frmal assessment invlves the use f tls such as questinnaires, surveys, checklists, and rating scales. Infrmal assessment usually lacks such structure r rganizatin and may include an interview and series f questins. Assessments are used t gain an understanding f an individual s current level f functining r symptms t guide service planning needs. Child Maltreatment Child maltreatment includes all types f abuse and neglect f a child yunger than 18 by a parent, caregiver, r anther persn in a custdial rle (e.g., clergy, cach, teacher). There are fur cmmn types f abuse: Physical abuse is the use f physical frce, such as hitting, kicking, shaking, burning, r ther shw f frce against a child. Seual abuse invlves engaging a child in seual acts. It includes fndling, rape, and epsing a child t ther seual activities. Emtinal abuse refers t behavirs that harm a child s self-wrth r emtinal well-being. Eamples include name calling, shaming, rejectin, withhlding lve, and threats. Neglect is the failure t meet a child s basic needs. These needs include husing, fd, clthing, educatin, and access t medical care. Children s Epsure t Vilence (CEV) Bradly defined, CEV invlves being a direct victim f r a witness t vilence, crime, abuse, r ther vilent incidents in the hme, schl, r cmmunity. Epsure may als include being epsed t the aftermath f a vilent incident r event. Cmple Trauma Cmple trauma refers t the dual prblem f epsure t traumatic events and the impact f this epsure n immediate and lng-term utcmes. Cmple trauma can refer t eperiences f multiple traumatic events that ccur within a care-giving system including the scial envirnment that is suppsed t be a surce f safety and stability fr children. Often cmple trauma epsure refers t the simultaneus r sequential ccurrences f child maltreatment that may include emtinal abuse and neglect, seual abuse, physical abuse, and epsure t dmestic vilence that is chrnic and begins in early childhd. Mrever, the initial traumatic eperiences (e.g., parental neglect, emtinal abuse) and the resulting emtinal dysregulatin, lss f a safety, lss f directin, and inability t detect r respnd t danger cues ften lead t subsequent trauma epsure (e.g., physical and seual abuse, cmmunity vilence). 1

18 Cntinuum f Care Cntinuum f care includes a system f service prviders and first respnders wrking tgether t prvide a smth transitin f services fr children and families. Cmmunities prvide different types f treatment prgrams and services fr children and families eperiencing trauma r ther mental health issues. The cmplete range f prgrams and services is referred t as the cntinuum f care, usually fllwing a mdel frm identificatin and referral t assessment, interventin, and treatment. Preventin and crisis respnse may als be included as part f the cntinuum addressing children epsed t vilence. Crisis Respnse Crisis respnse is the first respnders appraches t a crisis and includes tw cmpnents: (1) reducing trauma with immediate interventin and supprt and (2) increasing families access t services. Dmestic Vilence Dmestic vilence can be defined as a pattern f abusive behavirs in any relatinship that is used by ne intimate partner t gain r maintain pwer and cntrl ver anther intimate partner. Dmestic vilence can be physical, seual, emtinal, ecnmic, r psychlgical actins r threats f actins that influence anther persn. This includes any behavirs that intimidate, manipulate, humiliate, islate, frighten, terrrize, cerce, threaten, blame, hurt, injure, r wund smene (Office n Vilence Against Wmen [OVW] definitin). Incidents f inter-spusal physical r emtinal abuse perpetrated by ne spuse r parent figure n the ther spuse r parent figure in the child s hme envirnment (U.S. Department f Health and Human Services definitin). Nte: Dmestic vilence is ften used interchangeably with family vilence r intimate partner vilence. OVW makes a clear distinctin between dmestic vilence and family vilence; the latter refers t vilence between r against family r husehld members rather than ne intimate partner against anther. See Intimate Partner Vilence belw. Effective In general, when implemented with sufficient fidelity, effective prgrams demnstrate adequate empirical findings using a sund cnceptual framewrk and a high-quality evaluatin design (quasi-eperimental). This definitin is used by the CEV Prgram Matri in the Mdel Prgrams Guide (MPG) and the Office f Juvenile Justice and Delinquency Preventin s (OJJDP s) Children Epsed t Vilence Evidence-Based Guide (CEV EBG). 2

19 Evidence Based Evidence-based appraches t preventin r treatment are based in thery and have undergne scientific evaluatin. Different levels f evidence eist based n hw many and what types f evaluatin have been dne. Fr eample, a strategy that was tested with tw randmized cntrlled trials has a higher level f evidence than a strategy that was tested in ne quasi-eperiment. Evidence-based appraches differ frm appraches that are based n traditin, cnventin, r belief r appraches that have never been rigrusly evaluated. Eemplary In general, when implemented with a high degree f fidelity, eemplary prgrams demnstrate rbust, empirical findings using a reputable cnceptual framewrk and an evaluatin design f the highest quality (eperimental). This definitin is used by the CEV Prgram Matri in the MPG and the OJJDP s CEV EBG. Eperimental Design An eperimental design is ne in which the interventin is cmpared with ne r mre cntrl r cmparisn cnditins, subjects are randmly assigned t study cnditins, and data are cllected at bth pre-test and pst-test r at pst-test nly. The eperimental study design is cnsidered the mst rigrus f the three types f designs (eperimental, quasieperimental, and pre-eperimental). Incidence Incidence indicates the frequency r rate f ccurrence f a health-related event r episde during a particular perid and usually refers t the number f new episdes f the event during that perid. Interventin* The standard definitin fr interventin cnsists f influencing frces r acts that may mdify a given state f affairs. In behaviral health, an interventin may cnsist f an utside prcess that effects r mdifies an individual s behavirs, situatins, cgnitins, r emtinal states. Interventin is ften used interchangeably with the terms treatment and therapy, general terms referencing sessins held between a prfessinal (which may include a mental health prfessinal such as a psychiatrist, psychlgist, scial wrker, r nurse with training and epertise in the art f helping a patient psychlgically) and a client. 3

20 Intimate Partner Vilence (IPV) IPV is a serius, preventable public health prblem that affects millins f Americans. The term intimate partner vilence describes physical, psychlgical, r seual harm by a current r frmer partner r spuse. This type f vilence can ccur amng heterseual r same-se cuples and des nt require seual intimacy. IPV can vary in frequency and severity. It ccurs n a cntinuum, ranging frm ne hit that may r may nt impact the victim t chrnic, severe battering. There are fur main types f intimate partner vilence: Physical vilence is the intentinal use f physical frce with the ptential fr causing death, disability, injury, r harm. Physical vilence includes, but is nt limited t, scratching; pushing; shving; thrwing; grabbing; biting; chking; shaking; slapping; punching; burning; use f a weapn; and use f restraints r ne s bdy, size, r strength against anther persn. Psychlgical/emtinal vilence invlves trauma t the victim caused by acts, threats f acts, r cercive tactics. Psychlgical/emtinal abuse can include, but is nt limited t, humiliating the victim, cntrlling what the victim can and cannt d, withhlding infrmatin frm the victim, deliberately ding smething t make the victim feel diminished r embarrassed, islating the victim frm friends and family, and denying the victim access t mney r ther basic resurces. Psychlgical/emtinal vilence is thught t have ccurred when there has been prir physical r seual vilence r prir threat f physical r seual vilence. Stalking is ften included amng this type f IPV. Stalking generally refers t harassing r threatening behavir that an individual engages in repeatedly, such as fllwing a persn, appearing at a persn s hme r place f business, making harassing phne calls, leaving written messages r bjects, r vandalizing a persn's prperty (Tjaden & Thennes, 1998). Seual vilence is divided int three categries: (1) use f physical frce t cmpel a persn t engage in a seual act against his r her will, whether r nt the act is cmpleted; (2) an attempted r cmpleted seual act invlving a persn wh is unable t understand the nature r cnditin f the act, t decline participatin, r t cmmunicate unwillingness t engage in the seual act (e.g., because f illness, disability, the influence f alchl r drugs, intimidatin r pressure); and (3) abusive seual cntact. Threats f physical r seual vilence use wrds, gestures, r weapns t cmmunicate the intent t cause death, disability, injury, r physical harm. Natinal Registry f Evidence-based Prgrams and Practices (NREPP) Evidence Standard Rating NREPP evidence standard rating measures the quality f research fr an interventin s reprted results using the fllwing criteria: (1) reliability f measures; (2) validity f measures; (3) interventin fidelity; (4) missing data and attritin; (5) ptential cnfunding variables; and (6) apprpriateness f analysis. Each interventin utcme is rated n a 4-pint scale fr each criterin; the pints are added t create an verall scre fr each utcme. Fr mre infrmatin, g t 4

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