Prevention and the Child Protection System

Abstract

The nation’s child protection system (CPS) has historically focused on preventing maltreatment in high-risk families, whose children have already been maltreated. But, as Jane Waldfogel explains, it has also begun developing prevention procedures for children at lower risk—those who are referred to CPS but whose cases do not meet the criteria for ongoing services.

Preventive services delivered by CPS to high-risk families, says Waldfogel, typically include case management and supervision. The families may also receive one or more other preventive services, including individual and family counseling, respite care, parenting education, housing assistance, substance abuse treatment, child care, and home visits. Researchers generally find little evidence, however, that these services reduce the risk of subsequent maltreatment, although there is some promising evidence on the role of child care. Many families receive few services beyond periodic visits by usually overburdened caseworkers, and the services they do receive are often poor in quality.

Preventive services for lower-risk families often focus on increasing parents’ understanding of the developmental stages of childhood and on improving their child-rearing competencies. The evidence base on the effectiveness of these services remains thin. Most research focuses on home-visiting and parent education programs. Studies of home visiting have provided some promising evidence. Little is as yet known about the effects of parent education.

Waldfogel concludes that researchers have much more to learn about what services CPS agencies should expand to do a better job of preventing maltreatment. Some families, especially those with mental health, substance abuse, and domestic violence problems, are at especially high risk, which suggests that more effective treatment services for such parents could help. Very young children, too, are at high risk, suggesting a potentially important role for child care—one area where the evidence base is reasonably strong in pointing to a potential preventive role. Although preventive services for the lower-risk cases not open for services with CPS are much more widespread today than in the past, analysts must explore what CPS agencies can do in this area too to ensure that they are delivering effective services.

Every state in the United States has a public child protection system (commonly known by the acronym CPS) that receives and responds to reports of child abuse and neglect. Funding for CPS agencies comes from federal, state, and sometimes county or local sources. Although these state systems vary considerably, they do share some common elements. In particular, all CPS agencies have staff and procedures in place to respond to reports of suspected child abuse and neglect, with some agencies also accepting other types of referrals or applications for services. Although CPS agencies work in partnership with other state agencies as well as community-based agencies, some core functions—in particular, receiving and responding to reports of abuse or neglect—are carried out mainly by CPS agency staff, while other functions—such as services for families or foster or group care—may be contracted out or purchased from other agencies.

Historically, the child protection system has focused most of its limited resources on preventing maltreatment and promoting permanency and well-being among children who are identified as having already been the victims of abuse or neglect. A sizable share (more than a third) of families who come to the attention of CPS are screened out at the time of the initial referral, while others have their cases closed after an investigation. The cases that receive services from CPS on an ongoing basis constitute a minority of those referred—a minority made up of families who are judged to be at highest risk.

States and localities, however, also invest some resources into services to prevent maltreatment among lower-risk families—families whose cases do not meet the criteria to be screened in, substantiated, or kept open for ongoing protective services with CPS but whose children nevertheless are at risk of becoming victims of abuse or neglect. Such services may be delivered by the CPS agency (with the case kept open on a voluntary or preventive basis) but are more commonly delivered by community-based agencies. Indeed, since the reauthorization of the federal Child Abuse Prevention and Treatment Act (CAPTA) in 2003, CPS agencies have been required to develop procedures to refer children in lower-risk families to community-based agencies or voluntary preventive services.

In this article I examine the effectiveness of both types of prevention efforts. For those focusing on families whose cases are opened for ongoing services with CPS, I describe the services provided, explore their effectiveness in preventing repeat maltreatment, and ask whether other approaches might do a better job. For efforts focused on lower-risk families whose cases are not opened or kept open for services by CPS, I consider what types of services are provided and to what types of families, how widespread the services are, how the services are funded and delivered, and how effective they are in preventing maltreatment. I conclude with suggestions for further research and policy.

Prevention Efforts for Cases Opened for Ongoing Services with CPS

Figure 1 illustrates the flow of families (and children) into the CPS system, using data from the most recent report on child maltreatment issued by the U.S. Department of Health and Human Services (DHHS).¹ Of the 6 million children (representing some 3.3 million families) reported to CPS agencies nationwide in 2006, about 60 percent were screened in for investigation or assessment and about 30 percent of those cases (roughly 20 percent of the families originally reported) were ultimately substantiated for abuse or neglect. The majority of families whose cases are substantiated (about 60 percent in 2006) go on to receive post-investigation services, whose main focus is on preventing further maltreatment, whether the family remains intact (about two-thirds of cases) or the child is placed out-of-home with kin, in foster care, or in group care (just over a third of cases).

Figure 1.

Pathways for Children Reported to CPS in 2006

Source: U.S. Department of Health and Human Services, Child Maltreatment 2006 (Washington: U.S. Government Printing Office, 2008).

As figure 1 shows, some 380,000 children were provided with in-home services in 2006 as a result of their cases having been reported, investigated, and substantiated by CPS that year (that number excludes children whose cases were opened for services before 2006 and who continue to receive services from CPS). An even larger number of children—roughly 650,000—was provided with in-home services by CPS as a result of their cases having been reported and investigated but not substantiated by CPS (again, that number excludes children whose cases were opened for services before 2006). At first glance it may seem surprising that more unsubstantiated than substantiated cases were kept open for in-home services. But so many more cases are unsubstantiated than are substantiated that even though the unsubstantiated cases receive services at a lower rate, the total number receiving services is larger. It is also important to note that some children whose cases are not substantiated have in fact been maltreated. Following the differential response systems put in place over the past decade by many states, some CPS agencies now provide a family “assessment,” in place of an investigation, for low- and moderate-risk cases. In these assessments the focus is on developing a service plan for the family, rather than identifying a perpetrator and producing a substantiation decision.²

The services delivered to intact families typically include case management and supervision by a CPS worker (or perhaps a worker from an agency under contract with CPS), often supplemented by one or more other preventive services. The specific services delivered to any given family depend on the family’s assessed need, the willingness of family members to engage in and accept particular services, and the availability of services in their area. According to DHHS, post-investigation services may include “individual counseling, case management, family-based services (services provided to the entire family such as counseling or family support), [and other] in-home services” as well as “foster care services, and court services.” Intact families may also receive what DHHS categorizes as preventive services, which may include “respite care, parenting education, housing assistance, substance abuse treatment, daycare, home visits, individual and family counseling, and home maker help.”³

Researchers know remarkably little about how effective post-investigation and preventive services are in stopping maltreatment among the families whose cases are opened for services with CPS. Although a few studies have found that maltreatment is less likely to recur in open cases that receive services than in those that do not, most studies find that, if anything, families that receive services are more likely to be re-reported and substantiated subsequently.⁴ For example, analyses of data on 1.4 million children from nine states from the National Child Abuse and Neglect Data System (NCANDS) find that one-third of the children were re-reported within five years. Children who received post-investigation services were more likely to be re-reported than those who did not receive services. This finding applied alike to children whose cases had and had not been substantiated (and in fact was more pronounced for those who had not been substantiated initially).⁵ Similarly, analyses of data on roughly 3,000 children from the National Survey of Child and Adolescent Well-Being (NSCAW), a nationally representative sample of children reported to CPS, find that nearly a quarter of the children whose cases were opened for in-home services were re-reported within eighteen months, and that children were more likely to be re-reported if their families received parenting services.⁶

Such findings are the opposite of what one would expect if post-investigation services were effective at preventing maltreatment. But the findings may be misleading for several reasons. One problem is selection bias. If CPS systems are operating efficiently, the families who receive services should be the ones whose children are at highest risk of maltreatment and hence whose cases are at highest risk of being re-reported or re-substantiated. Estimates that do not take selection bias into account may erroneously interpret a recurrence of maltreatment after service receipt as an effect of service receipt. Another potential source of bias is the “surveillance effect.”⁷ Clients whose cases are opened for services may be at higher risk of being reported because they have more frequent contact with CPS workers and service providers rather than because they have higher levels of maltreatment.

Because existing research is not designed to address these two potential sources of bias, it is not possible to conclude that the links it finds between service delivery and heightened risk of reporting or substantiation are causal. But neither does the research provide much evidence that services provided by CPS reduce the risk of subsequent maltreatment.

Why are CPS services for families in open cases not more effective in promoting child safety and preventing future maltreatment? Recent analyses of data from the National Survey of Child and Adolescent Well-Being (NSCAW) and its companion survey, Caring for Children in Child Welfare (CCCW), provide some clues. One possible explanation is that many families receive few services beyond periodic visits by usually over-burdened caseworkers.⁸ Another possible explanation is that services are poor in quality and insufficient in quantity. For example, although rigorous research has proved several parent training programs effective, fewer than half of families whose cases are opened for services receive any parent training at all. Those who do get training typically receive only fifteen or fewer hours of training from a program that has not been proven effective. Nor is the training they receive monitored to ensure that it is being implemented as intended.⁹

Given the poor overall track record of today’s preventive services, the question arises whether other types of services are or could be more effective in reducing the risk of maltreatment. To date, however, evidence on that question is quite limited.

One indirect way to answer the question is to extrapolate from the characteristics of families whose children are known to be at high risk of recurring maltreatment. For instance, studies have found that families in which parents have substance abuse, domestic violence, or mental health problems are more likely than others to be re-reported, suggesting that developing and delivering more effective treatment services for such parents (as discussed in other articles in this volume) could help prevent further maltreatment.¹⁰

Young children are also at high risk for repeated maltreatment. For example, both the NCANDS and NSCAW studies discussed above found that the risk of re-reporting was highest for the youngest children (in particular, infants and toddlers) and decreased sharply with age. That pattern suggests a potentially important role for services such as child care. Although research on how child care functions within CPS is limited, the broader evidence base on child care suggests that it could be important in reducing the risk of maltreatment.

Child care has long been a core service provided to open CPS cases with the explicit intent of helping to prevent maltreatment.¹¹ The Alaska CPS agency, for instance, explains that “protective day care services provide day care to children of families where the children are at risk of being abused or neglected. The services are designed to lessen that risk by providing child care relief, offering support to both the child and parents, monitoring for occurring and reoccurring maltreatment, and providing role models to families.”¹² Such care is also expected to enhance the development of children who might otherwise be at risk for poor outcomes. The Illinois CPS agency, for instance, says: “Day care services are provided to high-risk families whose children are in open … cases; they are used to prevent and reduce parental stress that may lead to child abuse or neglect. The services also help children to develop properly and enable families to remain together.”¹³

The developmental benefits of child care are well documented. High-quality care has been shown to improve the cognitive development of disadvantaged children and may also improve their social functioning.¹⁴ Researchers have not yet conducted formal evaluations of whether child care prevents maltreatment among families whose cases are open with CPS.¹⁵ But studies of Head Start and other child care programs suggest that child care services can help reduce maltreatment.

Head Start, a compensatory early education program for low-income children, has been in operation since 1965 and now serves nearly 1 million preschool-aged children annually (including about 62,000 children under age three in the Early Head Start program, begun in 1994).¹⁶ Head Start was recently the subject of a randomized study that evaluated, among other outcomes, its effect on parenting and discipline. The findings indicated that parents of three-year-olds who had been randomly assigned to Head Start were less likely than control group parents to report spanking their child in the previous week and also reported spanking less frequently, with particularly pronounced effects for teen mothers (though there were no significant effects for parents of four-year-olds).¹⁷ Although using spanking as a marker for potential child maltreatment requires caution, these findings are nevertheless promising.

Another randomized study found that Early Head Start improved parenting and reduced spanking by both mothers and fathers.¹⁸ Parents of children assigned to Early Head Start were less likely than control group parents to have spanked their child in the previous week. The share of mothers spanking fell most (10 percent) among children in center-based programs but also fell (5 percent) among those in home-based programs.

Similarly, a random-assignment study of the Infant Health and Development Program (IHDP), an early child care program for low-birth-weight children, found reduced spanking by mothers in the previous week, although the effect was confined to boys.¹⁹

Also suggestive of a potentially protective role of Head Start and other formal child care is evidence from an observational study of children from the Early Childhood Longitudinal Study-Kindergarten (ECLS-K) cohort, a large nationally representative sample of children entering kindergarten in the fall of 1998.²⁰ In that study, parents of disadvantaged children who had attended Head Start before kindergarten were more likely to report that they never used spanking, and also reported less domestic violence in their home, than parents of children who had not attended child care. Parents whose children had attended Head Start or other center-based child care were also more likely to say they would not use spanking in a hypothetical situation. The study’s authors speculated that having a child attend Head Start or other center-based child care may have reduced parents’ use of physical discipline by relieving parental stress, by exposing parents to alternative forms of discipline, and by making the children more visible to potential reporters (for example, child care providers) who would be aware if they were being maltreated.

As noted, measuring the effects of child care on spanking is not the same as measuring its effects on maltreatment. One quasi-experimental evaluation of the Chicago Child-Parent Centers, however, addresses maltreatment directly. The study found that children in the program, which provides care to children from disadvantaged neighborhoods during the two years before kindergarten, had only half as many court petitions related to maltreatment as did children in similar neighborhoods that did not have the program.²¹

Another potentially promising approach to prevention is “differential response,” which, as noted, entails greater CPS flexibility in responding to allegations of abuse. States are increasingly coming to believe that they can effect more lasting change in lower-risk cases by providing services that are engaging for families and attentive to their needs rather than by using a more traditional adversarial investigative response.²² What does the evidence show?

A recent review of the as-yet limited research base suggests the promise of a differential response approach in preventing future maltreatment.²³ The strongest evidence comes from a random-assignment study in Minnesota that found that cases assigned to the alternative response track were less likely to be re-reported subsequently than cases assigned to the investigative track, a finding that was linked to the alternative response track’s provision of increased services to families.²⁴ The evaluation and an accompanying process study provided many indications that families were more engaged. For example, workers delivering an alternative response reported that only 2 percent of caregivers were uncooperative at initial contact, as compared with 44 percent of those in investigation track cases.

Minnesota is exceptional in that funding from the McKnight Foundation allowed it to expand services to low-risk families. Families receiving the alternative response were more likely to have their cases opened for services (36 percent vs. 15 percent). They were more likely to receive not only the types of services, such as counseling, that are traditionally prescribed and paid for by CPS, but also services, such as assistance with employment, welfare programs, and child care, from other community resources not funded by CPS.

At the one-year follow-up, families in Minnesota’s alternative response group reported less financial stress and stress associated with relationships with other adults, as well as fewer problems with drug abuse and less domestic violence. Effects on other outcomes for the children and families, however, were few.

It should be noted that the study does not establish which of the Minnesota results were due to the added funding. Most states using differential response have not had extra resources. And the reforms in those other states, while yielding some promising evidence, have not been subject to a random-assignment evaluation.

In addition to altering service delivery for cases opened with CPS, differential response reforms also increase the likelihood that CPS will refer to community-based agencies the cases that are not opened. An explicit part of the alternative assessment approach is working with families to identify their service needs and to make appropriate referrals.

Some differential response models also explicitly set out a preventive track for reports that should be handled by community-based agencies instead of CPS right from the outset. A further impetus to such referrals was the 2003 Child Abuse Prevention and Treatment Act (CAPTA) requirement that states develop the ability to refer children who are not at imminent risk of harm to community organizations or voluntary child protective services. Both differential response and the new CAPTA requirement, then, are likely to have increased the number of lower-risk families receiving some kind of preventive services from community-based agencies, without being open for services with CPS. I turn to this group of families next.

Prevention Efforts for Lower-Risk Families Not Opened or Kept Open for Services with CPS

Figure 1 highlights (in italics) three groups of children in lower-risk cases not opened or kept open for services with CPS. The three groups are: the 2.4 million children annually reported to CPS but screened out; the roughly 1.75 million children annually whose cases are reported to CPS and screened in but not substantiated and not kept open for services with CPS; and the roughly 400,000 children annually whose cases are substantiated but not kept open for services with CPS. Some of these children receive preventive services from community-based agencies (which may or may not be funded by CPS), but data are not available on precisely how many children from each group do so. Another group—not shown in the figure—that receives preventive services from community-based agencies consists of children who are not reported to CPS but whose families apply voluntarily or are advised to do so by someone in the community (these cases are sometimes called “open referrals” because they do not need to be referred by CPS to be served and funded).

The federal Department of Health and Human Services, in its annual report on child maltreatment, distinguishes between children receiving preventive services and those receiving post-investigative services. The distinction perhaps suggests that their data on children receiving preventive services mainly capture children from the above groups—children receiving preventive services funded by CPS even though their cases are not open for services with CPS (while post-investigative services would refer to children whose cases were substantiated and kept open for services). In 2006, state CPS agencies reported a total of 3.8 million children receiving preventive services.²⁵ Some of these children were referred to CPS in 2006; others were referred earlier; and still others were served without having been referred to CPS at all (the so-called “open referrals”).

According to DHHS, preventive services “are designed to increase parents’ and other caregivers’ understanding of the developmental stages of childhood and to improve their child-rearing competencies.” As noted, examples of preventive services include “respite care, parenting education, housing assistance, substance abuse treatment, daycare, home visits, individual and family counseling, and home maker help.”²⁶

Funding for preventive services for lower-risk cases comes from several different sources.²⁷ The most common source reported by states in 2006—covering nearly 30 percent of children receiving preventive services nationwide—was Promoting Safe and Stable Families funding under Title IV-B of the Social Security Act. The second most common source—covering nearly 20 percent nationally—was the Social Services Block Grant (SSBG) under Title XX of the Social Security Act. Community-Based Child Abuse Prevention (CBCAP) grants under Title II of the Child Abuse Prevention and Treatment Act (CAPTA) covered roughly 15 percent, while funds from the Basic State Grant under Title I of CAPTA covered just over 5 percent. Other federal or state programs funded the remaining 30 percent of preventive services for children.²⁸ States vary considerably in the funding sources they use. New York, for example, relied on SSBG funding for 85 percent of its preventive services in 2006, while Texas relied exclusively on Promoting Safe and Stable Families funding.

Table 1.

Federal Funding for Preventive Services for Children Whose Cases Are Not Open with CPS, 2006

DHHS does not track total dollars spent on these preventive services for lower-risk families, but it is possible to create some rough estimates using other data.²⁹ Thus, of the $410 million appropriated in 2006 for the Promoting Safe and Stable Families program (the single largest source of funding for preventive services nationally, as noted), a reasonable estimate is that about 60 percent, or roughly $250 million, went for preventive services such as family support and prevention and family preservation (with the remainder going for other services such as reunification and adoption planning).³⁰ With regard to the SSBG (the second largest funding source for preventive services nationally), program data indicate that roughly one-fifth of the $1.7 billion allocated in 2006, or about $340 million, was devoted to preventive services (about 13 percent was devoted to child welfare services other than foster care, with another 8 percent devoted to child care).³¹ With regard to the CBCAP program, here we can assume that most (if not all) of the total $42 million available in 2006 went to preventive services, because that is the main focus of the program. (These estimates are summarized in table 1.)

Little information is available about spending on specific types of preventive service programs, such as respite care and parent education. One exception is home-visiting programs, which have been a subject of increased interest in Congress and which received an additional $10 million in federal funding in 2008, under an initiative designed to expand support for empirically validated models of home visiting such as the Nurse-Family Partnership.³²

The above data on spending for prevention refer only to federal funding and do not include funding from state and local sources. Federal dollars represent only half the funds spent on overall child welfare services and a much smaller share of funding for preventive services, which are more likely than other types of child welfare services to rely on state and local funding.³³ In 2004, states spent a total of $9 billion on child welfare services, while localities spent at least $2.5 billion.³⁴ Most of these state and local dollars, however, went for services such as foster care, with only a small portion going for preventive services.

Although prevention programs have expanded rapidly and now exist in all fifty states, researchers still know little about their effectiveness. In 2003, a review conducted by DHHS noted that most of the research focused on just two types of prevention programs—home visiting and parent education.³⁵ The evidence base on home visiting programs, as discussed in other articles in this volume, is promising. Although not all home visiting programs have been demonstrated to be effective, randomized evaluations of the Nurse-Family Partnership program have found decreased rates of child maltreatment among the group randomly assigned to receive home visits. Regarding parent education programs, perhaps the most commonly provided type of prevention services, the DHHS review concluded: “The record is neither rich nor, on the whole, particularly compelling. However, a few studies have demonstrated positive findings. Many of the existing studies in this area rely on outcomes that do not include actual maltreatment reports, but focus on short-term gains in knowledge, skills, or abilities. Thus, taken as a whole, little is known about the impact of these programs on child maltreatment in the long term.”³⁶

When the same DHHS review invited nominations for effective programs, only one—the University of Maryland’s Family Connections program for at-risk families with children aged five to eleven—met their two standards for effectiveness: having been evaluated by a study using a random-assignment design and having demonstrated significant effects on protective and risk factors for child abuse and neglect. Two other programs were reported to be effective, although they lacked a random-assignment evaluation. Both deliver augmented parenting and family support services in child care settings. One is the Circle of Security parenting program in Head Start and Early Head Start in Spokane, Washington; the other is the Families and Centers Empowered Together (FACET) family support program in child care centers in high-risk neighborhoods in Wilmington, Delaware. Given the promising evidence on the role of child care in preventing maltreatment reviewed above, these programs—which explicitly aim to increase the protective role of child care settings—are potentially promising and worth close attention.

The DHHS review also highlights two essential characteristics of effective prevention programs—of whatever type. The first is that the program be delivered in sufficient dosage. In the prevention area, as in other areas of social policy, successful programs are often implemented with less intensity or for a shorter time than the original model specifies, thus diluting the effectiveness of the program and leading to disappointing results. The second essential characteristic is the ability of frontline staff to engage with families to encourage them to agree to participate in services and to continue participating. But engaging families is also extremely difficult because many of the target families are socially isolated and may distrust helping professionals, however well-intentioned. Thus, recruiting and training effective prevention staff is a common challenge.

Looking Ahead: Suggestions for Further Research and Policy

It is now widely accepted that CPS has an important role to play in preventing maltreatment not just among the relatively high-risk cases opened for services, but also among the lower-risk families who come to its attention but do not meet the thresholds for case opening or continuing service delivery. Failing to prevent maltreatment among open cases is a signal that CPS intervention has failed in its primary role of promoting child safety and well-being among the most vulnerable group of children. And failing to refer lower-risk families for effective preventive services represents a missed opportunity to intervene before the risk of maltreatment escalates into full-blown abuse or neglect, saving children needless suffering while also saving CPS and other agencies the costs that would be entailed by a subsequent report, investigation, and ongoing service delivery.

How well are CPS agencies doing at prevention? We know from the federal Child and Family Services Reviews that in 2005, 6.6 percent of open CPS cases nationally experienced a new incident of substantiated maltreatment within six months of being opened.³⁷ That rate, although somewhat lower than it was a few years previously, still exceeds the 6 percent target set by the Child and Family Service Reviews, and state CPS agencies are actively trying to lower it. But existing research sheds little light on what types of services might be most effective in meeting that goal. As other analysts have noted, CPS agencies provide “a somewhat haphazard set of services that aim to help abusive families and their children … [with] a shortage of effective intervention programs to provide needed services [and] a dearth of prevention services.”³⁸

Program data—and common sense—suggest that any intervention that aims to prevent maltreatment must be intensive, and its frontline staff must be able to engage with families. But beyond that, researchers have much more to learn about what types of services should be expanded if CPS agencies are to do a better job of preventing maltreatment among their open cases. The demographics of recurrence suggest that some families, especially those with mental health, substance abuse, and domestic violence problems, are at higher risk than others, pointing to issues that services will need to address effectively if they are to reduce the risk of maltreatment. The demographics of recurrence also point to young children as being particularly at risk, suggesting a potentially important role for such services as child care. Indeed, child care is one area where the evidence base is reasonably strong in pointing to a potential preventive role. This is certainly an area where further experimentation would be worthwhile.

With regard to the lower-risk cases not open for services with CPS but referred to preventive services, the good news is that such services seem to be much more widespread today than in the past, reflecting the expanded availability of federal and other funds as well as the increased recognition that a one-size-fits-all investigative response will not meet the needs of all families referred to CPS. Nevertheless, challenges remain. Analysts have much to learn about what CPS agencies can do to support and monitor preventive programs to ensure that they are delivering effective services.³⁹ They also have much to learn about coordinating services across the many types of community agencies that may play a role in prevention.⁴⁰

Although the evidence base on preventive programs for lower-risk families remains fairly thin, with a few exceptions such as the results from randomized studies of the Nurse-Family Partnership program, programs and evaluations in this area are expanding rapidly. Both DHHS and the federal Centers for Disease Control and Prevention are actively reviewing program effectiveness and spurring states to commission and participate in program evaluations. It seems the nation may be on the threshold of an exciting new era in the provision of prevention programs. To take fullest advantage of the opportunities this expansion of interest is likely to offer, it is worth keeping a few principles in mind. The first is that if studies are to yield reliable evidence documenting that programs successfully prevent maltreatment, they must use randomized designs whenever possible and must measure maltreatment outcomes. The second is that policy makers must keep in mind the lessons learned from past efforts, in particular, the importance of dosage and family engagement. As tempting as it may be to cut corners and save dollars, there is no substitute for systematically implementing and evaluating promising interventions. If not, we could well find ourselves a decade from now with no more evidence on prevention in CPS than we have today.