Using the Core Components of a Public Health Framework to Create a Child and Family Well-being System: Example from a National Effort, Thriving Families, Safer Children.

Thriving children require safe, stable, nurturing relationships and environments. When caregivers have the resources and support they need, at the appropriate time, and in culturally meaningful ways, they can structure environments and experiences for their children that optimize development. However, all too many caregivers and children experience trauma and adversity that consistently threaten such environments. The USA currently lacks a universal system of care and support for children and families leaving the child welfare system as the only option for many families to get help. This forces child welfare agencies to address problems and issues they are ill-equipped to address. In this paper, we review how a new national effort in the USA, Thriving Families, Safer Children is integrating the core components of a public health framework to create a child and family well-being system across the country. Case study examples are provided from 4 Thriving Families, Safer Children sites. Thriving Families, Safer Children sites are utilizing the core components of a public health framework to address social and structural determinants of health including systemic racism, with a strong focus on changing systems and contexts, through participatory methods of engaging those with lived expertise, to ensure the service context where families can get what they need, when they need it, with an emphasis on promoting race equity. Efforts to transform child welfare through the Thriving Families, Safer Children movement are aligned with the core components of a public health framework.

Introduction

Thriving children require safe, stable, nurturing relationships and environments (Merrick & Guinn, 2018). When caregivers have the resources and support they need, at the appropriate time, and in culturally meaningful ways, they can structure environments and experiences for their children that optimize development (Ungar, 2013). However, all too many caregivers and children experience trauma and adversity that consistently threaten such environments. Research from the Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative survey in the USA, conducted annually, with noninstitutionalized adults, has provided empirical evidence of the link between Adverse Childhood Experiences (ACEs) and health and health-risk behavior. BRFSS surveys across 23 US states demonstrates that 62% of adults report at least 1 Adverse Childhood Experience (ACE) before the age of 18, while nearly 25% report experiencing 3 or more (Merrick et al., 2018). By the age of 18 years, it is estimated that nearly one-third of US children will undergo an investigation by a child welfare agency (Kim et al., 2017). In 2019, 7.9 million children were referred to US state child welfare agencies for concerns regarding child abuse and neglect (United States Department of Health and Human Services [USDHHS], 2021). Through formal investigation from a child welfare agency, approximately 656,000 children were determined to be victims of child abuse or neglect in that year. The majority of cases substantiated by child welfare agencies are due to child neglect (61%).

Experiences of trauma and adversity are not distributed equally across the population (Feely & Bosk, 2021; Fong, 2019, 2020). Data from state BRFSS surveys show that those who identify as Black, having a low income, less than a high school education, and identified as gay, lesbian, or bisexual, are exposed to ACEs at a higher rate than their counterparts (Merrick et al., 2018). Within a sample of urban, socioeconomically diverse adults, Wade and colleagues (2016) found that experiences of ACEs were high (68% experienced at least 1 ACE before the age of 18 years) and that in addition to the original ACEs from the seminal study, these adults recalled high rates of racism, bullying, and community violence (i.e., expanded ACEs) from childhood. A recent study of a birth cohort from the state of California found that over 50% of Black and Native American children received a child welfare investigation prior to the age of 18 years (Putnam-Hornstein et al., 2021). Compared to White children, Black children are 3 times as likely to live in poverty (USDHHS, 2020), and research shows that low-income children are reported to child welfare agencies at a higher rate than their higher income counterparts (Barth et al., 2021; Kim et al., 2018).

Research on the short- and long-term negative consequences associated with experiences of trauma and adversity is well established. ACEs are associated with increased risk for health-risk behaviors (e.g., alcoholism, drug abuse, depression, suicide), disease (e.g., ischemic heart disease, cancer, liver disease) (Felitti et al., 1998), and diminished life opportunities (e.g., education, income, employment) later in life (Metzler et al., 2017). Studies on the long-term effects associated with abuse and neglect consistently find impaired mental health, physical health, social functioning, and limited economic opportunities for those who are maltreated (Henry et al., 2018; Herrenkohl et al., 2013; Jaffee et al., 2018; Klika et al., 2013). The lifetime economic burden associated with addressing the consequences of abuse or neglect are estimated at $830,928 per child victim (Peterson et al., 2018).

Merrick et al. (2019), through the estimation of population attributable fractions, found that by preventing ACEs we could significantly reduce health-risk behaviors, disease, and improve life outcomes. Specifically, by preventing ACEs in the population, upwards of 44% of depression, 33% of smoking, 24% of heavy drinking, 15% of unemployment, 13% of heart disease, 15% of stroke, and 27% of chronic obstructive pulmonary disease could be prevented. Findings like these make a strong case for the need to prevent ACEs.

Historically, the strategy for addressing child maltreatment, and the circumstances that increase its risk, has been a reactive, after-the-fact child protection system and a host of programs and treatments designed to minimize the effects of maltreatment. This tertiary system response has done little, at a high cost, to reduce or prevent abuse and neglect from occurring (Herrenkohl et al., 2015, 2020). For example, a recent estimate from Child Trends suggests that combined spending (i.e., federal, state, local) on child welfare in state fiscal year 2018 was approximately $30 billion (Rosinsky et al., 2021). Some have argued that child protection response can exacerbate instead of improve family circumstances (see Merkel-Holguin et al., 2022).

Calls for child welfare reform have increased over the last few years both because of the sheer magnitude of trauma and adversity experienced by children and caregivers but also due to the stark racial and income disparities in the distribution of trauma, adversity, and child welfare involvement across the population. Some have gone as far as to call for the “abolition” of the child welfare system all together (Dettlaff et al., 2020; Roberts, 2022). Others point to the need for system transformation including an overhaul of child welfare practices and policies but also the integration of a public health framework to create a system of care and support, outside of formal child protection agencies, to meet the complex needs of families before abuse or neglect occurs (Herrenkohl et al., 2020; Higgins et al., 2022). This latter perspective is about addressing the conditions in which people live, including systemic racism, poverty, and the structural determinants of health and co-creating a system with those individuals who have been affected by various child and family serving systems—to provide families what they need, when they need it, in culturally and linguistically meaningful ways to avoid entry into formal child protection systems altogether. As argued by Higgins et al. (2022), such an approach requires six core components of a public health framework.

In this paper, we discuss a current movement towards the transformation of child welfare into a child and family well-being system. A partnership between individuals and communities with lived expertise with child and family serving systems, public, private, and philanthropic entities, Thriving Families, Safer Children is working to create just and equitable systems, outside of child welfare, by engaging those with lived expertise to design a system to address the social and structural determinants of inequality. After a brief review of the core components of a public health approach and history of system transformations, we provide illustrative examples from Thriving Families, Safer Children sites to highlight how the core components of a public health approach are guiding this work. In conclusion, we discuss looming challenges for the Thriving Families movement in sustaining momentum over the long term.

Public Health Framework

The Institute of Medicine (IOM, 1988, para. 2) defines public health as “what we, as a society, do collectively to assure the conditions in which people can be healthy.” The public health framework seeks to address conditions and root causes of problems like child maltreatment, often through population-based or universal strategies. This is in stark contrast to the historical approaches to addressing child maltreatment which have often been reactive and targeted only towards the highest risk individuals, families, and communities (Herrenkohl et al., 2015). For too long, the field of child maltreatment has applied individual-level solutions to what are systemic problems.

However, as Higgins et al. (2022) note, there is lack of clarity and specificity as to what it means to use a public health approach for the prevention of child maltreatment. The authors outline a framework of six “core components” necessary for a public health approach to the prevention of child abuse and neglect. These core components include what to focus on, who to intervene with, when to intervene, what works, where to base the delivery of supports and interventions, and what brings about change at scale. The authors argue that these six components must be present for successful public health prevention.

History of Community-based Strategies/Initiatives for Preventing Abuse and Neglect

In 1993, the US Advisory Board on Child Abuse and Neglect published a report, outlining a national strategy for the prevention of child abuse and neglect (US Advisory Board on Child Abuse and Neglect, 1993). In this report, leading child abuse experts argued that the current child protection system was not creating safe, more prosperous opportunities for children and families. Instead, they argued that child protection had become a costly, reactive, punitive system that did not remediate problems but instead implicated families for problems that clearly had roots in structural and societal failures.

The system that is intended to help and protect abused and neglected children does little to mitigate the nightmare. Instead of emphasizing prevention of maltreatment, America’s child protection system usually steps in when damage has already been done. Instead of easing tensions within families and bringing them closer together, the system too often exacerbates those tensions. Instead of helping children, the system tends to funnel children into a process over which they have no control and that doesn’t necessarily act in their best interests. (p. 12)

What was proposed by the advisory board was a radical transformation of child protection, one in which communities were supported in a way that facilitated family and child well-being. As the advisory board noted, this novel approach to child abuse prevention needed to be comprehensive in nature (i.e., multi-sector), neighborhood-based, child-centered, and family-focused. What this meant in practice was that child abuse prevention required greater investment in the strengthening of neighborhoods, a complete reorientation in the ways in which human services were delivered, greater clarity on the role of the federal government in supporting prevention; societal norms change that moved the country away from complacency and towards caring and compassion for children, families, and communities; and a strengthening of the knowledge base about the causes, consequences, and prevention of child abuse and neglect.

The advisory board was cautiously optimistic about their new, bold strategy for child abuse prevention. As noted in their final report, the advisory board stated,

implementing this strategy will not be easy. It means altering long-held beliefs on how best to address the problem of child abuse and neglect. It means a wholesale reorientation of thinking, with less emphasis on after-the fact investigation and more on treatment and prevention. (p. 17)

Since the recommendations of the advisory board, there have been multiple community-based strategies advanced to prevent child maltreatment. In their review of the literature, Daro and Dodge (2009) identified five community-based child maltreatment prevention initiatives: Triple-P, Strengthening Families Initiative, Durham Family Initiative, Strong Communities, and Community Partnerships for Protecting Children. Each of these initiatives shares a balance of community mobilization and norms change with identification and expansion of available services to meet the needs of children and families. As Daro and Dodge note, successful child maltreatment prevention includes a balance of social capital development and service expansion and coordination. Too much emphasis on norms change and too little attention to the service array and one could end up with a community where demand for voluntary services far exceeds the supply. On the other hand, too much investment in building community services absent a simultaneous strategy to address societal norms in support of service utilization, and there is more supply of services than there is demand. The authors conclude with optimism and caution for community-based child maltreatment prevention initiatives. Chief among their recommendations for the success of such initiatives is having a realistic vision for the cost and time associated with mobilizing a community change initiative. Furthermore, the authors highlight the need for strong theoretical and conceptual models to guide these initiatives. In doing so, initiatives are better positioned to create rigorous evaluation plans to understand what components and strategies are most successful for bringing about population-level change on key program outcomes.

Thriving Families, Safer Children

In early 2020, the U.S. Children’s Bureau, Casey Family Programs, the Annie E. Casey Foundation, and Prevent Child Abuse America (PCA America) [National Partners] joined together in partnership with parents, youth, community organizations, and child welfare agencies across the country with a goal to create a just and equitable child and family well-being system. Known simply as Thriving Families, Safer Children, the partnership is committed to directly addressing structural and social determinants of health, including systemic racism. While discussion by the partners regarding system transformation occurred prior to the COVID-19 pandemic, the effects of COVID-19 accelerated the need for a child and family well-being system. The pandemic exposed the need for localized community-based support for families that focus on whole health and primary prevention.

The partners came together as leaders in child welfare system re-design efforts, and in the prevention of child abuse and neglect to foster and advance a national effort to change the nature of the child welfare system in the USA. Representing public, private, and philanthropic sectors, the original partners of Thriving Families agreed that system reform, one which addresses the social and structural determinants of inequality, requires new partnerships and new ways of collaboration. Early on, the partners agreed to a set of guiding principles (see Table 1), not a specific program or practice model, which included an explicit focus on race/equity, co-design with lived expert leaders of this new child and family well-being system, and commitments to creating a system of care and support that addresses child, family, and community need in timely and culturally relevant ways. Similar to initiatives like Strong Communities (see Melton & McLeigh, 2020; Kimbrough-Melton & Melton, 2015), Thriving Families uses the guiding principles as a framework for action, not as a prescriptive recipe for implementation. Activities across Thriving Families sites may differ yet adhere to the guiding principles of the movement.

Table 1

Guiding principles of Thriving Families, Safer Children

1. Supporting families and communities by promoting physical, emotional, and economic well-being and enhancing well-being environments

2. Supporting parents, caregivers, and youth with lived experience as leaders in this work and co-creating solutions together

3. Utilizing data to guide structural and systemic responses

4. Deepening innovative partnerships and cross-sector collaborations

5. Promoting equity and healing through whole family and community approaches and creating a new system free of systemic racism that values all families

6. Building capacity for cross-cultural and cross-sector dialogue, systems thinking for social change, and human-centered design

7. Prioritizing social determinants of health

8. Building trusting relationships at the community, local, state, and national levels to shift the trajectory of the child welfare system

In this paper, we use the term “lived expertise” instead of “lived experience.” In our work, the latter refers to an accumulation of distinct, intimate, personal experiences with a child and family serving system. The former refers to honoring, valuing, and respecting of those experiences such that those experiences qualify the person as an “expert” in that area. From the outset, the national partners ensured constituent representation was present at all levels of the initiative (i.e., executive team, operating committee, design team, workgroups), including caregivers with experience in the child welfare system as well as former system-involved youth. These groups constitute the main leadership committees of the initiative and have voice and representation of those with lived expertise.

The national and constituent partners recognized that the work of Thriving Families, Safer Children across the country would need to occur in phases. As such, the partners developed a tiered model of implementation which included a first and second round of Thriving Families sites. All child welfare agencies in the USA were invited to apply for selection into Thriving Families. Four sites were selected to join round one of the Thriving Families, Safer Children movement based on having a clear vision to co-create a child and family well-being system in collaboration with community stakeholders and driven by the voice of individuals with lived experiences. Round 1 is a multi-year, intensive effort promoting and supporting the creation of a constituent-informed and designed child and family well-being system—including a focus within regions, counties, and municipalities to build communities centered on child and family well-being. Round 1 sites receive in-depth, ongoing technical assistance and direct support from national partners to help remove high-level systemic barriers and, wherever possible, reduce administrative burdens, funding restrictions, and other impediments to flexible and creative programing, supports, and services. The four round one sites include Los Angeles County (California), Colorado, Nebraska, and South Carolina.

Round two sites are participating in a larger learning cohort to develop strategies that transform their existing child welfare system and build the infrastructure to support and strengthen community led child and family well-being in local communities. Round two is a coordinated effort to bring a collective of sites together that are committed to taking on specific system and policy-level solutions in partnership with the national partners. Eighteen additional sites were selected for round two (see Fig. 1).

Fig. 1

Thriving Families, Safer Children sites. Round 1 sites noted in orange; round 2 sites noted in green

Many learning opportunities have been created for all Thriving Families sites. A series of virtual learning sessions on race equity, engaging young people, primary prevention, establishing Family Resource Centers and more have been hosted over the past two years. These learning sessions are intended to provide congruence in efforts across the sites and provide an opportunity for knowledge exchange to strengthen the entire Thriving Families movement. There is also an action network facilitated by the W. Haywood Burns Institute, a national consultant on race equity, specific to structural well-being and race equity. The action network consists of a learning, planning, and implementation process to design and test change initiatives across sites. Regular office hours are held for sites to join in informal conversations about specific topics and general conversations with peers and national partners. The national partners also provide technical assistance and resources to the sites as requested, including on race equity, prevention, and co-creation with lived experts.

Over the past 2 years of Thriving Families, it became clear that building authentic and equitable partnerships within Thriving Families sites would require financial investment. As a result, Annie E. Casey Foundation granted $1 million to PCA America to provide grants to Thriving Families sites. The grants could not go to child welfare agencies, but rather, were granted to community-based organizations with a history of engaging Black, Latino, and Indigenous youth and families. A total of ten grantees were selected for funding in the Thriving Families sites of Arizona, New Mexico, Kentucky, Oklahoma, Minnesota, DC, and New York City. The grantees proposed new leadership opportunities for youth, parents, and community members, and committed to building durable structures that will impact how decisions are made now and in the future. Grantees embraced innovations such as learning circles and robust truth and reconciliation processes to identify meaningful changes and provide opportunities for healing and building trust in communities impacted by racial disparities and unnecessary child and family separations.

PCA America also received a grant from W. K. Kellogg Foundation to support primary prevention efforts in Thriving Families, Safer Children sites. Grants totaling $500,000 will be made over a 2-year period to state PCA America chapters in the Thriving Families sites. The grantees will be expected to thoughtfully share power and co-create the transformation in partnership with lived experts and engage authentic voices. A learning collaborative of the grantees will be developed to provide regular learning and networking opportunities among the sites.

In the next section, we provide illustrative examples across round 1 and round 2 Thriving Families sites to highlight the ways in which system transformation is occurring through intentional co-design and the core components of a public health framework.

Thriving Families, Safer Children Case Examples

Colorado

The Colorado Partnership for Thriving Families goal is to prevent child maltreatment and child fatalities in families with children under 5 years of age. Their vision is to create the conditions for children and families to thrive by transforming the safety net systems in Colorado so fewer children and families have contact with the child welfare system. The backbone organization for the Thriving Families work in Colorado is Illuminate Colorado, the PCA America state chapter. The Colorado Partnership has three priorities: systems alignment, community norms, and early touchpoints. Each priority has identified strategies that have been created with local communities and family input (i.e., Family and Caregiver Space). Even prior to the national Thriving Families work, government leaders, nonprofit partners, families, and caregivers in Colorado mobilized to set a clear vision for family engagement which placed race/equity at the forefront of the work. Recognizing the significant investment of time necessary to authentically engage in such an initiative, the Colorado Partnership has developed a strategy to compensate and support those with lived expertise who are helping to create a new child and family well-being system, through the Family and Caregiver Space.

The Colorado Partnership is also working with the state child welfare agency to “Reimagine Child Welfare” and create a blueprint for transformation that is responsive to the history of racism and oppression in the child welfare system. This work requires the development of new partnerships and new ways of operating for what have been historically siloed sectors. In addition, this work is being guided by and co-created with the leadership of caregivers and families who have been affected by the child and family serving systems that are being transformed. These systems are learning new ways to share power with families in the visioning and implementation of a child and family well-being system. As system alignment comes into clear focus, the Colorado Partnership has a desire to work on policy reform as it relates to neglect statues, family economic security, and mandatory reporting in the state.

The Colorado Partnership has invested heavily in identifying and shifting societal norms to reduce stigma around help-seeking behavior and increase family and community informal social connections. With the leadership of social norms experts from Montana State University, the Colorado Partnership conducted a survey of Colorado adults to assess attitudes, behaviors, and social norms associated with help-seeking. The Colorado Partnership has conducted listening sessions to help conceptualize the data from the survey and to determine next steps for creating normative change across Colorado.

Paramount and foundational to the success of the Thriving Families work in Colorado is the identification of universal early touchpoints for families during pregnancy and the first year of life. This includes a cross-system commitment to establishing, supporting, and connecting a continuum of services for families to improve outcomes for parents and infants. Expanding availability of services starts with each county exploring their unique strengths, needs, and community characteristics and then leveraging their strengths, filling in the gaps, and creating a comprehensive services continuum that is tailored to their specific county. The Colorado Partnership has completed pre-implementation groundwork and generated leveraged investments that have identified Family Connects, as a promising approach to supporting family and child well-being and improving the safety of children in the context of a universal system. Family Connects is an evidence-based program that works to connect new caregivers and their infants to community resources and is often delivered universally across populations. In addition to Family Connects and fully realizing the potential of their family resource center network statewide, Colorado has also completed some preliminary exploration on how to use the Colorado Perinatal Continuum of Care Framework as a tool for communities to use in community conversations about the availability of services for the perinatal period.

Finally, the Family & Caregiver Space led an effort to create an equity council to drive the Colorado Partnerships work in anti-racism forward, along with other equity priorities—focusing on structure, trainings, policy, and practices to embed anti-racism and equity into every aspect of the work. The equity council has created a purpose and approach document that informs the Partnership and an equity assessment (built from CSSP’s Race Equity Impact Assessment Tool) is being utilized across multiple spaces to provide initial findings and guide strategy development.

Nebraska

Bring Up Nebraska is a statewide prevention partnership to advocate for local community collaboratives that keep children safe, support strong parents, and help families address life’s challenges before they become a crisis. By bringing together state and local agencies, leaders, and citizens, Bring Up Nebraska is helping to ensure that every community across Nebraska is working to increase the availability of critical supports and services, reduce unnecessary government system involvement, and improve the lives of Nebraska children and families. The Bring Up Nebraska vision for child welfare transformation with the Thriving Families opportunity includes (1) equality in opportunities and outcomes for every child in the State of Nebraska, regardless of race, ethnicity, or economics, and elimination of disproportionality of children, youth, and families involved in the child welfare and justice systems; (2) reshaping the current child welfare system to better support their Community Well Being Model (CWB) by collaborating with other partners and aligning public and private funds, supports, and services; (3) ingraining the CWB model within the state government and local communities so it continues as the operational norm regardless of political or administrative leadership changes over time; (4) parents, youth, and other community members—people with lived experience (PWLE) are more engaged in decision-making and leadership at community and state levels; and (5) state and federal partners support and act on recommendations for practice and policy changes from the communities to reduce involvement in the child welfare system and to expand and enhance well-being in Nebraska.

The Bring Up Nebraska partnership shares a belief that local communities are best positioned to identify and implement solutions that address nuanced needs. As such, Bring Up Nebraska supports 22 formally organized CWB Collaboratives covering 80% of Nebraska’s counties. The Bring Up Nebraska work with Thriving Families is focused on the efforts of five of these community collaboratives where interest and readiness are high and where disparate well-being outcomes and service gaps have been identified.

To advance their work on addressing disproportionality for system-involved youth, Bring Up Nebraska is working with the W. Haywood Burns Institute, an organization committed to creating collaboration, capacity building, and engagement of those with lived expertise to dismantle structural racism and build community well-being. Through this engagement with the W. Haywood Burns Institute, Bring Up Nebraska is providing technical assistance and support to the five community collaboratives in addressing disparities through co-created solutions.

Bring Up Nebraska is advocating for policy changes, including a re-design of the John H. Chafee Foster Care Independence Program (USDHHS, 2012) funding formula to support youth in their transition from foster care; the ability to use Title IV-E dollars for prepetition legal representation; a change to the definitions in the Social Service Block Grant to include young people (ages 19–26); and approved models on the Family First Prevention Services Clearinghouse that help families meet their basic needs. Bring Up Nebraska has also engaged a behavioral design firm, Ideas42, state and local partners, and PWLE to develop greater access to resources for supportive stable housing and alternatives to CPS hotline calls/investigation. In addition, Nebraska is changing their state definition of neglect; better connections between the Community Collaboratives and the CPS hotline; developing new pathways for prevention and working with Evident Change on their structured decision-making.

Los Angeles County, California

Los Angeles County’s Thriving Families team is a movement centering the voice of community and local experts with lived expertise in child welfare and other systems to co-create a new way forward with partners across Los Angeles County. They work from the premise that child welfare and other systems have done harm, and continue to harm, communities—particularly communities of color—throughout Los Angeles. Los Angeles County’s Thriving Families team strives to transform child and family serving systems into ones that support communities and improve child and family well-being.

The LA County team sees co-creation as an integral part of any framework intended to improve outcomes for children, families, and communities. The LA County team defined co-creation as such: communities and individuals with lived expertise leading and developing policies, programming, and making decisions with system partners from the inception of the idea to its implementation and ongoing ownership. The team believes that community members have their own tried and true methods of organizing and creating change and have deep knowledge of what needs to change at a local level. LA County’s team’s overarching strategy is focused solely on supporting communities in advancing local priorities and building a collective movement that institutionalizes authentic community ownership in all sectors making decisions that impact communities. Explicit in their engagement of lived experts, LA County is focused on race equity and ensuring that marginalized voices from across LA County—those people often not involved in decision-making—are key to devising solutions to their challenges and leading efforts.

Members of the LA County Thriving Families, Safer Children team also participate in the national Haywood Burns Institute Action Network. The Action Network convenes multiple site teams on a monthly basis to discuss race equity strategies and their implementation. The Haywood Burns Institute’s framework to advance well-being is used as a foundation for the learning, which is then applied in the sites.

LA County has a track record of multiple sectors partnering to move upstream and prevent families from needing to engage with child welfare and other systems. The Thriving Families, Safer Children effort presented an opportunity to highlight and build upon the collaborative work already underway. The LA County team has broken their work down into multiple phases. Phase 1 included building a partnership among team members representing various sectors and individuals with lived expertise to plan and implement visioning sessions with community members. These agencies, in partnership with the original team members, hosted 30 visioning sessions with over 400 participants across LA County. Participants were all community residents and represented populations such as fathers, individuals with lived expertise in child welfare (parents, youth/alumni, kin caregivers, foster, and adoptive parents), and people involved in a variety of services and programs throughout LA. A summary of the resulting themes from the visioning sessions is currently under development. This summary will be taken back to participants for their review and to identify priorities and how to move forward. The team is currently planning “phase 2” of their engagement and collaboration with communities across LA County.

Virginia

Thriving Families, Safer Children Virginia’s vision is for a true “Team Virginia'' approach, where state agencies, local and regional providers, public and private sector partners, and community leaders come together and identify unique strengths and skill sets, best avenues through which to use those assets, how each can complement the others, to provide services in an organized and non-duplicated fashion, with accountability for Virginia’s children and families. The vision of Team Virginia is to go deeper within selected localities across the state to lift up any and all supports toward the greatest preventative efficacy, addressing the social determinants of health, equity outcomes, and capacity building for leadership at local and state levels. Team Virginia is interested in gaining understanding of effective methods of community engagement in a manner that focuses on community-level initiative, leadership, and locally driven partnerships. The overarching goal of Team Virginia is to minimize crisis, mitigate the need for intervention services, and strengthen family well-being.

The team believes that the greatest potential for achieving well-being for families and communities is ensured through identifying all necessary partners, gathering the partners together, mobilizing the partners at local and state levels to enact identified goals, and soliciting leadership for delegation and decentralization of the work (from state to local/community levels). The national Thriving Families, Safer Children movement provides a platform in which to fully explore reimagining what the child welfare system can and should be. Virginia chose to participate to change the future course of families in Virginia by creating new infrastructures to support family well-being in a way that leverages the inherent strength that exists in communities and the families that live there.

In 2020, the Virginia General Assembly (GA) made a bold commitment to prevent child abuse and neglect. Knowing the fragmentation caused by the intersections of primary, secondary, and tertiary prevention services, the GA directed Virginia Department of Social Services to establish a 5-year child welfare prevention plan. This plan was developed in conjunction with the Department of Behavioral Health, Department of Health, Department of Education, Family and Children’s Trust Fund, Families Forward Virginia, Voices for Virginia’s Children, and the Virginia Poverty Law Center. The plan includes 5 strategic areas: well-being and economic stability, person and family-centered programs, social norms, collaboration, and infrastructure, which will allow Virginia to advance from a reactive child welfare system to a proactive upstream child and family well-being system. Each strategic area had a work group composed of local experts and lived experts which created robust and thorough recommendations for implementation. One such recommendation was to create a central point of contact for families. The national Thriving Families effort was a perfect opportunity for Virginia to examine and shape a strategy that was anchored in this already identified priority.

In 2021, Virginia received a grant to move the child welfare prevention plan forward. The Thriving Families Virginia Team secured an agreement to establish Family Resource Centers (FRC) in localities across the Commonwealth. The project will also capitalize on creating a FRC network that will partner with Trauma Informed Communities Network in Virginia to include but not limited to other non-traditional community partners. Additionally, Thriving Families Virginia will contract with a state university to lead data collection and facilitate a data and evaluation advisory team including historically Black colleges and universities. Virginia is now a member of the National Family Support Network, where they can learn from other state FRC models, and leverage the knowledge and expertise of successful FRCs nationwide.

The voice of Lived Expertise (LEx) Leaders, including youth, has been foundational throughout Virginia’s prevention work. LEx leaders were involved in the development of Virginia’s prevention plan to prevent child abuse and neglect. Additionally, LEx Leaders were included in the implementation plan whose goal was to develop state level activities for the prevention plan. Also, the Thriving Families Virginia core team has 3 LEx Leaders with a goal to add five more. The project requires chosen communities to have LEx Leaders at the table co-designing. Each FRC may look different; however, a parent advisory board will be required. It is Thriving Families Virginia’s intention that LEx Leaders will represent over half of all individuals on any committee.

Thriving Families Virginia’s team knows that early intervention minimizes the likelihood that families will progress to more secondary and tertiary services. Their approach is strength-based, meeting families where they are, capitalizing on their strengths, building their confidence and capacity to manage challenges, and helping them to access needed resources and services. They are hopeful that by creating FRC hubs throughout their state, they will create a no-wrong door approach to all family strengthening and support services. The Thriving Families Virginia FRC project implementation will be able to use their existing intervention programs as they focus on creating networks of community-based services and aligning resources to support mobilization toward comprehensive community well-being. Providing a continuum of prevention supports to enhance parental capacities, mitigating the need for more intensive intervention.

As the Thriving Families Virginia core team examines the twenty-first century family, there has been an intentional reflection about how family ecosystems are created, maintained, and sustained over a life span. The team believes that by examining and reframing how families present themselves, they will gain a deeper understanding that one family is exactly one family; there cannot be a one-size-fits-all approach to family engagement. With the FRC networks in Virginia, the team is applying the concepts found in the Centers for Medicare and Medicaid Services (CMS) Disparity Impact Statement (Centers for Medicare & Medicaid Services [CMS], 2022), as a practical way to articulate how the project will practice diversity, equity, and inclusion in all aspects of the development and implementation at the state level and the local community level. The CMS Disparity Impact Statement, developed by the CMS Office of Minority Health, helps organizations address disparities in health by identifying areas of greatest need, prioritizing areas of focus, and monitoring progress towards reducing health disparities.

Discussion

For decades, the statutory child welfare system has been the single point of entry for children and families experiencing need. Current child welfare data suggests that 61% of substantiated cases are a result of child neglect (USDHHS, 2021), arguably a population of families who could benefit from concrete and economic supports (e.g., housing vouchers, tax credits, cash transfers) to avoid child welfare entry. Research shows that not only are outcomes associated with child welfare involvement poor (Merkel-Holguin et al., 2022), but that child welfare intervention disproportionately affects communities of color (Kim et al., 2018). Numerous calls for system reform have been made yet few efforts have resulted in re-design of the child welfare system. Aligned with a public health approach, the Thriving Families, Safer Children movement is seeking transformation of child welfare systems by engaging those with lived expertise in the co-design of a system of care and support that addresses the social and structural determinants of health.

The Thriving Families site examples provided in this article are illustrative of the work of Thriving Families sites across the country and highlight the ways in which sites are aligning with the core components of a public health framework to create prevention systems.

What to focus on?

As articulated by Higgins et al. (2022), a public health approach to the prevention of child abuse and neglect must focus on decreasing known risk factors while simultaneously increasing protective factors. All the Thriving Families sites share an understanding and commitment to addressing the social and structural determinants of health inequities such as racism, poverty, and access to supportive resources. This approach is in line with the work of Ellis & Dietz (2017) who call for addressing the social and structural conditions in which trauma and adversity occur. The focus on addressing systems and conditions within states is in stark contrast to historical approaches to child welfare which have been around family and community surveillance. In line with the World Health Organization’s Framework for addressing the structural determinants of health (Solar & Irwin, 2010), Thriving Families sites recognize the need to shift, shape, and alter the social, political, and economic conditions within states through engagement and co-creation with those individuals most impacted by child and family serving systems, to address the drivers of health inequities.

Who to intervene with?

One of the defining features of a public health approach is the focus on population-based strategies that are delivered universally across populations, before the onset of problems. This stands in stark contrast to individually focused treatments that attempt to address problems at the individual level, often after problems occur. In their own way, each of the Thriving Families sites is working towards the creation of a universal system of care and support, outside of the current statutory child welfare system, to support child and family well-being. Currently, many of the sites have, or are creating local councils to help conduct landscape assessments of the community service and policy array. Based upon these localized assessments, sites are working with families and communities to identify service gaps and implement community-based strategies to promote child and family well-being. Again, Thriving Families does not promote any one single program, model, or policy, but instead, recognizes that communities are best positioned to make decisions regarding local strategies, using local data.

When to intervene?

Historically, the approach to addressing child abuse and neglect in the USA has fallen under the purview of the statutory child welfare system across the states. The current child welfare system does not intervene until family struggles and challenges reach a level of risk necessitating intervention. This reactionary approach to child and family well-being has done little to address the drivers of child and family need. In recognition of this shortcoming, the focus across Thriving Families sites is on building a system of care and support for children and families where needs are met early and often, in a non-stigmatizing way, at multiple points across the developmental continuum, and in a way that aligns with the cultural beliefs and values of the community. While intervening early in the life of a family (e.g., prenatal) is critical within a prevention framework, services must be provided for children and families across the developmental continuum.

What works?

There are numerous programs and strategies that have been determined, through rigorous review, to meet a strong evidentiary standard to be considered “evidence-based.” In fact, systems like the California Evidence-Based Clearinghouse for Child Welfare (2020), Blueprints for Healthy Youth Development (2020), and the Title IV-E Prevention Services Clearinghouse (2022) conduct rigorous reviews of scientific literature and utilize stringent review criteria to determine which models and programs are effective at reducing or preventing child abuse and neglect. The Centers for Disease Control and Prevention (CDC) created a technical package for the prevention of child abuse and neglect which consists of a comprehensive review of the scientific literature to determine the strategies holding the most promise for the prevention of child abuse and neglect (Fortson et al., 2016). As noted, prior, the Thriving Families sites are working to identify service gaps and have identified the need for programs and policies that align with the CDC’s technical package, including economic and concrete supports, and Family Resource Centers.

However, there is also a recognition and value being placed on community-driven innovation as key to system change. Many local programs and strategies lack rigorous scientific evaluation but may contribute to measurable improvements in population health. Participatory action research (PAR) methods are being explored across the sites to evaluate these local strategies. As noted by Baum et al., (2006, p. 854), “PAR differs from most other approaches to public health research because it is based on reflection, data collection, and action that aims to improve health and reduce health inequities through involving the people who, in turn, take actions to improve their own health.” Through the utilization of PAR, sites can partner together in new ways with communities to build localized evidence to drive system transformation.

As a movement, Thriving Families is at the initial stages of designing an evaluation framework. This framework must take into account the unique nature of each site, adherence to a set of guiding principles, not a practice model or intervention, and the complimentary yet nuanced focus areas of each site. Flexible, developmental, participatory methods are being explored in building the evaluation framework.

Where to base the delivery of supports and interventions?

As Thriving Families sites work to create child and family well-being systems outside of the child welfare system, one key decision is to determine where community-based services and supports should be housed and delivered. Sites agree that a child and family well-being system should be co-created with lived experts and community leaders and focus on addressing systemic racism and poverty and is the collective responsibility of the community. Health, education, juvenile justice, and child welfare, to name a few, are critical partners to help create systems of care and support that ensure a “no wrong door” approach to addressing community needs. Furthermore, there is a recognition that supports and interventions must be rooted in and delivered by the communities. Many Thriving Families sites are utilizing FRCs as a hub for providing community-based supports and referrals.

What brings about change at scale?

Thriving Families sites recognize that sustainable child welfare reform requires an intentional dismantling of systemic and systematic policies and practices that negatively affect communities of color and that solutions regarding system reform must occur in partnership with those who have had intimate experience with child and family serving systems. These are the reasons why each Thriving Families site has a specific emphasis on addressing issues of race equity and engaging individuals with lived expertise at all levels of the Thriving Families movement. As noted by Schelbe & Geiger, (2022),

rather than researchers driving any collaborative efforts to re-design the child welfare system grounded in research, there must be shared leadership where all stakeholders have a voice in setting the agenda and defining problems and process. There is a need for meaningful collaborations to re-design child welfare. Forming these partnerships will be messy and time consuming, but there is a better chance of “getting it right” with everyone involved. (p.4)

Sustaining the Thriving Families, Safer Children Movement

Thriving Families, Safer Children is not the first effort to attempt to transform child welfare. A number of community-based initiatives have been developed since the 1993 advisory board report (Daro & Dodge, 2009); yet, none have been taken to scale in a sustainable way. Thriving Families, Safer Children is unique in their explicit focus on addressing issues of race equity and the drivers of health inequities. Furthermore, Thriving Families is attempting to create a reform movement by engaging local experts with child and family serving systems in multiple states. With great potential for achieving system change, there are at least 3 potential challenges on the horizon for sustaining the Thriving Families movement.

True system transformation will require bold solutions, new ways of operating, and collaborations that have not existed in the past. Setting a long-term vision for Thriving Families requires a balance of audacious optimism and laser focus. If Thriving Families attempts to address all challenges and problems facing children and families, the initiative is at risk of becoming too diffuse to achieve transformative aims. If the focus becomes too narrow, the opportunities for system transformation are constricted and will not bring about the type of change necessary to address systemic problems. Striking a balance between aspirational goals and focus will be key to the success of Thriving Families moving forward.

Thriving Families is not a short-term program or initiative intended to bring about quick change; instead, Thriving Families is a commitment to long-term systems change. Building towards systems change requires buy-in across sectors and sharing of power between systems and communities. This work comes with a high degree of uneasiness as individuals, sectors, organizations, and communities learn a new way to engage and partner with one another. Our self-righting tendency towards homeostasis is one of the key risks for disrupting transformative change. When the work of Thriving Families gets tough, it will be paramount for sites to identify, own, and work against their self-righting tendencies to revert to “business as usual.” The work will progress at the speed of trust between systems and communities, a process that does not often align with budget cycles or rigid strategic planning processes.

Sustaining a transformation of systems will require significant financial investment. This means both identifying new sources of funding but also a process for blending and braiding funding across sectors and organizations. In terms of new sources of funding, there will be a need for philanthropy and governmental entities to understand the need for flexibilities and unique ways of using financial resources. For example, paying individuals with lived expertise to engage in system transformation work is critical for all Thriving Families sites. However, administrative rules regarding funding expenses may interfere with using federal, state, or philanthropic funds for such purposes. Additional issues affecting benefits and taxes for individuals can create barriers to compensating individuals with lived expertise for their time in this effort. In terms of blending and braiding funding, organizations need to get creative with how to utilize current funding to maximize impact for work at the community level. Again, this could require changes to administrative rules and procedures that current block such collaboration from occurring.

Conclusion

Efforts to transform child welfare through the Thriving Families, Safer Children movement are aligned with the core components of a public health framework (Higgins et al., 2022). In this article, we provide examples from 4 Thriving Families sites to demonstrate how system transformation is occurring across the country through authentic community engagement and power sharing to address the social and structural determinants of inequities. The time for such transformation has never been so evident. As noted by Tajima and colleagues (2021, p. 5), “informed by science and all forms of evidence, led by the lived experiences of racially and socially marginalized communities, and with our sights set on eliminating structural and institutional racism, we must advance with urgency toward justice for all children and families.”