Current Research and Evaluation

What Is Prevention?
From the Winter 2004 issue of Voice, the quarterly publication of Casey Family Services. To view the entire issue, go to caseyfamilyservices.org.

by Carol Ripple, Senior Research Associate

Most social service workers would likely agree that "prevention" is a more appealing approach than its counterpart, "treatment." But if prevention means stopping problems before they start, how does it apply to Casey Family Services? After all, most children and families who come to Casey are already troubled, so it might seem that the prevention ship has already sailed. In its fullest sense, though, prevention has a broader meaning that emphasizes the promotion of well-being and health for all. From this perspective, programs offered by Casey Family Services -- from the least intensive to the most extensive -- are preventive.

Why does it help to think in terms of prevention? Whereas treatment addresses disease and deficit, prevention emphasizes the potential to overcome adversity. It is about anticipating risk and taking action to avoid poor outcomes. Despite this positive, strengths-based, health-promoting approach, and despite the typically higher cost of treatment, national policy and practice are more focused on responding to crisis (treatment) than on prevention (Ripple & Zigler, 2003).

Framing services as prevention, then, recognizes the strengths and potential of children and families. But how can prevention apply to the wide array of child welfare services? One way is to describe prevention as a system of three levels -- primary, secondary, and tertiary -- adapted from the field of public health (the terms universal, selected, and indicated are also used). Each of these levels describes programs aimed at distinct groups of people, based on their level of risk.

Primary or universal prevention efforts are designed for general populations, such as children and families in a particular school, community, income, or age level. The aim is to enhance protective factors and prevent the onset of particular problems. Primary prevention strategies usually address fundamental challenges to child and family well-being such as health, poverty, or domestic violence.

Activities in Family Resource Centers, such as those operated by Casey Family Services in Baltimore, Maryland, Massachusetts, New Hampshire, and Rhode Island are examples of primary prevention. Before- and after-school programs offer homework help, nutritious foods, and a safe place while parents are at work (see Voice, Spring 2003). These activities are designed to pre-vent poor school adjustment and a range of problems associated with unsupervised out-of-school time, such as delinquency and substance use.

Helping low-income parents access the Earned Income Tax Credit (EITC) may be the most effective way to fight poverty (Johnson, 2001), which is a major risk factor for child abuse and family instability (Bethea, 1999). Initiatives at Casey Family Services and the Annie E. Casey Foundation increase awareness of EITC and help eligible families apply for the credit (Voice, Spring 2003). By directly addressing poverty, this primary prevention approach has the potential to enhance child and family well-being.

Secondary or selected prevention is more targeted toward specific subgroups expected to be at higher risk for particular problems. As with primary prevention, children have not yet shown evidence of specific problems, but they are known to be at higher risk than more generally defined groups. Secondary prevention approaches recognize the heightened risk status of the target groups, then seek to reduce the effect of the risk.

Casey Family Services' Family Connections in Bridgeport, Connecticut, is a secondary prevention program that works with families affected by HIV/AIDS. Services are designed to prevent the disruption that can occur when current stability and future permanence needs of children in these families are not addressed. Maine's Family
Preservation is a secondary prevention program that works to prevent familial destabilization and child maltreatment among young families who, based on their history of mental illness, domestic violence, or past child maltreatment, are at high risk for child trauma.

Tertiary or indicated prevention approaches target specific individuals who have already shown signs of specific problems. The aim in these programs is to prevent the progression of difficulties and, in child welfare programs, to reduce the chance of familial dissolution. Tertiary prevention is sometimes compared with treatment because of the higher level of problems among the target group, and because more intensive services are needed.

Despite the name, thinking about Treatment Foster Care as prevention emphasizes he potential to maintain placement stability and prevent the development of additional or continued adjustment problems even among seriously troubled children. Family Reunification is another example of tertiary prevention: Although families have already experienced problems severe enough to cause disruption, the program seeks to prevent long-term placement by supporting reunification.

Thinking about programs like these from the point of view of prevention is positive in several ways. It shifts the emphasis toward action and anticipation of problems, and away from reaction and costly treatment after the fact (though reaction still has its place, particularly for the most troubled children and families). It emphasizes strength and potential, rather than deficit and disability. Even though prevention may not be embraced as a national strategy to improve child and family well-being, the focus of programs like these at Casey Family Services is a model for similar efforts everywhere.

Resources
Bethea, L. (1999, March). Primary prevention of child abuse. American Family Physician, 1577-97. Available online at http://www.aafp.org/afp.

Johnson, N. (2001). A hand up: How state Earned Income Tax Credits help working families escape poverty in 2001. Washington, DC: Center for Budget and Policy Priorities.

Ripple, C. H., & Zigler, E. (2003). Research, policy, and the federal role in prevention initiatives for children. American Psychologist, 58 (6/7), 482-490.