CHILD ABUSE AND NEGLECT PREVENTION STRATEGIE

Home Visiting

As noted, the provision of home-based interventions at the time a woman becomes pregnant or gives birth is one of the most widely disseminated child abuse and neglect prevention strategies (Daro, 2010). Although findings remain inconsistent across program models, target populations, and outcome domains, the approach continues to demonstrate impacts on the frequency of child abuse and neglect and harsh punishment (Chaffin et al., 2012a; DuMont et al., 2010; Lowell et al., 2011; Olds et al., 2010; Silovsky et al., 2011), parental capacity and positive parenting practices (Connell et al., 2008; Dishion et al., 2008; DuMont et al., 2010; LeCroy and Krysik, 2011; Nievar et al., 2011; Roggman et al., 2009; Zigler et al., 2008), and healthy child development (DuMont et al., 2010; Lowell et al., 2011; Olds et al., 2007; Shaw et al., 2009). Likewise, home visiting programs that engage families with older children (aged 5-11) have demonstrated an ability to reduce depressive symptoms, parental stress, and life stress and enhance parental competence and social support (DePanfilis and Dubowitz, 2005).

Findings of a 15-year follow-up study of families enrolled in the Nurse Family Partnership’s randomized clinical trials support that program’s long-term positive impacts on both parents (Eckenrode et al., 2010) and children (Kitzman et al., 2010; Olds, 2010). In contrast to control families, mothers who received the program were involved in fewer substantiated reports for maltreatment, abuse, and neglect, and children were less likely to report running away or to have had contact with the juvenile justice system. These and similar gains were most concentrated among families with the fewest material and emotional resources at the time they enrolled in the program.

As noted earlier, confidence in home visiting as an effective way to address child abuse and neglect, as well as other poor child developmental and behavioral outcomes, contributed to the inclusion of the Maternal, Infant and Early Childhood Home Visitation Program in the ACA. As of this writing, 12 home visiting models that serve young children have met the criteria for identification as an evidence-based model appropriate for this initiative in that one or more rigorous evaluations have documented impacts in one of eight core outcome domains (child health; child development and school readiness; family economic self-sufficiency; linkages and referrals to other services; maternal health; positive parenting practices; reduction in child abuse and neglect; or reduction in juvenile delinquency, family violence, or crime) (Avellar et al., 2012). However, only 3 of the 12 approved models have had a measurable and significant impact in reducing either child abuse or neglect reports or the incidence of harsh parenting.

While home visiting programs continue to build an evidence base around a wide range of outcomes, preventing child abuse and neglect as measured by a reduction in initial or subsequent abuse and neglect reports remains an area in which consistent findings are lacking. Also, as promising models are taken to scale, sustaining their impacts is proving problematic. For example, a broad replication of the Nurse Family Partnership in Pennsylvania resulted in no significant differences in visits to hospital emergency departments for serious injuries between families enrolled in the program and a comparison group (Matone et al., 2012). Other studies also have raised concern about the extent to which home visiting services are able to prevent the recurrence of physical abuse or neglect (MacMillan et al., 2005) or alter the developmental consequences of abuse or neglect (Chaffin, 2004; Cicchetti and Toth, 2005).

For the past several years, a number of states and local communities have explored ways of extending support to a greater proportion of newborns and their parents. In contrast to targeted approaches that limit services to parents identified as high risk, these more universal initiatives are built on a public health model aimed at altering the context in which parents raise their children. Specifically, these initiatives offer comprehensive assessments and a limited number of service contacts to all parents or all first-time parents living within a specific geographic area (e.g., neighborhood, city, county) (Daro and Dodge, 2010). Assessments of the impacts of this approach have found that families are receptive to offers of such assistance and are able to access additional services in a more timely and appropriate manner (Dodge et al., 2013; Urban Institute, 2012).

At least one randomized study of this approach, conducted in Durham County, North Carolina, found that families with access to an initial nurse home visit at the time their child was born were less likely to use hospital emergency room services; less likely to present with anxiety; and more likely to exhibit positive parenting behaviors, to have strong community connections, and to participate in higher-quality out-of-home care (Dodge et al., 2013). Additional research is required to fully understand the implementation challenges associated with such universal strategies and their ultimate impacts on parental behaviors and child outcomes.

Parenting Education

Improving parents’ capacity to meet the developmental and emotional needs of their children has long been viewed as an effective strategy for preventing child abuse and neglect (Helfer, 1982; Kempe, 1976). Parenting education programs designed to increase knowledge of child development, enhance care, promote positive parent-child interaction and emotional sensitivity, and address child discipline and behavior management are considered a strong theoretical and practical approach to reducing risk and strengthening protective factors (Barth et al., 2005; Johnson et al., 2008). Since parenting education programs can occur in diverse settings, including both home-based and center-based models, and often include additional service components, such as child care services and family support groups, it is difficult to distinguish those impacts that may be attributable to specific parenting education activities (Barth, 2009; Reynolds et al., 2009). Further, the populations utilizing these programs are diverse. While unique challenges are faced by parents and families dealing with difficult circumstances, such as substance abuse, mental illness, poverty, domestic violence, or divorce, and those parenting a child with behavioral or developmental difficulties, these parents would not all be expected to engage in abusive or neglectful behavior in the absence of parenting education services.

An assessment of parenting education models by the California Evidence-Based Clearinghouse for Child Welfare identified several social learning-based educational efforts with robust results supported by repeated randomized controlled trials, including two that are often cited as demonstrating strong potential to reduce the risk for child abuse and Participants in Webster-Stratton’s The Incredible Years, a multifaceted and developmentally based curriculum for parents, teachers, and children delivered in both primary school and early education settings, demonstrated more positive affective responses and a corresponding decrease in the use of harsh discipline, reduced parental depression, and improved self-confidence and better communication and problem solving within the family (Daro and McCurdy, 2007; Gardner et al., 2010; Reid et al., 2001, 2004; Webster-Stratton et al., 2011b). Significant aspects of the model include group-based training in parenting skills; classroom management training for teachers; and peer support groups for parents, children, and teachers.

Triple P, mentioned earlier, is another well-established and well-researched parent management training program. It consists of a series of integrated or scaled interventions “designed to provide a common set of information and parenting practices to parents who face varying degrees of difficulty or challenges in caring for their children. Based on social learning theory, research on child and family behavior therapy, and developmental research on parenting in everyday contexts, each intervention is designed to reduce child behavior problems by teaching healthy parenting practices and how to recognize negative or destructive practices. Parents are taught self-monitoring, self-determination of goals, self-evaluation of performance, and self-selection of change strategies (Daro and Dodge, 2009, p. 75). A geographically randomized study illustrated the effectiveness of Triple P at a population level (Prinz et al., 2009). Triple P was implemented in 18 randomized medium-sized southeastern U.S. counties over a 2-year period, demonstrating a decrease in child abuse and neglect. Additionally, multiple randomized controlled trials of the model in various cultural contexts have found it to have positive impacts on parent-reported child behavior problems, reducing dysfunctional parenting and improving parental competence (Bor et al., 2002; Leung et al., 2003; Martin and Sanders, 2003).

Most recently, those examining parenting education programs have focused on identifying those elements of the programs that appear to have the most consistent impact on participant outcomes (Barth et al., 2012). A meta-analysis conducted by the Centers for Disease Control and Prevention on training programs for parents of children aged 0-7 identified components of programs that have a positive impact on acquiring parenting skills as demonstrated by increased use of effective discipline and nurturing behaviors (CWIG, 2011). The 77 studies selected for the review all assessed parenting programs that incorporate active learning strategies such as completing homework assignments, modeling, or practicing skills. Among the 14 content and program delivery characteristics examined, the factors most frequently associated with positive outcomes were teaching parents emotional communication skills, helping them acquire positive parent-child interaction skills, and giving them opportunities to demonstrate and practice these skills while observed by a service provider (CWIG, 2011; Kaminski et al., 2008). The study also found small program effects on parent behaviors and skills outcomes with those programs having ancillary services. The researchers hypothesized that these ancillary services were a burden for the parents and program staff, and could impede skills development focused on parent-child interactions.

Universal Antiviolence Education Programs

In contrast to efforts designed to alter the behavior of adults who might commit child abuse or neglect, a category of prevention programs that emerged in the 1980s was designed to alter the behavior of potential victims (CWIG, 2011). Initially, such efforts focused exclusively on providing children information on physical and sexual assault; how to avoid risky situations; and if abused, how to respond. Meta-analyses and evaluations of these programs found they were effective in conveying safety information to children and imparting skills to avoid or lower the risk of assault (Berrick and Barth, 1992; Daro, 1994; MacMillan et al., 1994; Rispens et al., 1997). It remains unclear, however, to what extent these programs can alter adult behavior and responsiveness or change institutional culture in ways that reduce the likelihood of children being victimized and if they are, having their case addressed in an appropriate and transparent manner (Daro, 2010).

More recently, the focus of these universal education programs has expanded to encompass issues of bullying and aggressive behavior, particularly among elementary and middle school students. While the immediate goal of these interventions is to reduce levels of bullying and aggressive behavior among children and youth, accomplishing this goal might potentially contribute to a reduction in these behaviors in adulthood, thereby reducing levels of child abuse. A 2006 Cochrane review of school-based violence prevention programs targeting children identified as being or at risk of being aggressive found that aggressive behavior was significantly reduced in the intervention groups compared with the control groups in 34 trials with data on this outcome, and that positive impacts were maintained in the seven studies reporting 12-month follow-up data (Mytton et al., 2006).

These programs also may impact the response of bystanders to bullying behavior. A randomized controlled trial of a whole-school intervention provided universally to students by teachers found that the program moderated the developmental trend of increasing peer-reported victimization, self-reported aggression, and aggressive bystanding compared with schools randomly assigned to the control group. The program also moderated a decline in empathy and an increase in the percentage of children victimized compared with the other intervention conditions (Fonagy et al., 2009). Likewise, an observational study of playground interactions in schools randomly assigned to a bullying prevention program found declines in bullying and argumentative behavior, increases in agreeable interactions, and a trend toward reduced destructive bystander behaviors (Frey et al., 2005). Children in the intervention group reported enhanced bystander responsibility, greater perceived adult responsiveness, and less acceptance of bullying/aggression (Frey et al., 2005). While not well researched, the observed impacts on children’s response to acts of peer aggression and their increased willingness to speak up and support the victim may have implications for subsequent reductions in various forms of child abuse and neglect. Adolescents and young adults who become increasingly comfortable with the concept of actively resisting aggression toward their peers may be more likely to support normative standards by which such behavior toward children is less tolerated and individuals feel more empowered to seek ways to stop it.

Public Education and Awareness

A consistent feature of child abuse and neglect prevention programming has been the development of public awareness campaigns. Initially, these efforts focused on raising awareness of the problem and enhancing the public’s understanding of behaviors that constitute abuse and neglect and their impact on child well-being (Daro and Cohn-Donnelly, 2002). In recent years, broadly targeted prevention campaigns have been used to alter specific parental behaviors. For example, the U.S. Public Health Service, in partnership with the American Academy of Pediatrics (AAP) and the Association of SIDS and Infant Mortality Programs, launched its “Back to Sleep” campaign in 1994 to educate parents and caretakers about the importance of placing infants on their back to sleep so as to reduce the rate of sudden infant death syndrome (SIDS). Campaign strategies included media coverage; the availability of a nationwide toll-free information and referral hotline; the production of television, radio, and print ads; and the distribution of informational brochures to new parents. As of 2002, the National Center for Health Statistics reported a 50 percent drop in SIDS deaths and a decrease in stomach sleeping from 70 percent to 15 percent. Although the evidence linking the campaign to changes in these population-level indicators is exploratory, the data are suggestive of how public education might be used to change normative practices (Mitchell et al., 2007).

One of the most thoroughly examined public education and awareness campaigns addressing child abuse has been the effort to prevent shaken baby syndrome, now termed abusive head trauma. In an evaluation of a 1992 federal campaign to educate the public about the dangers of this practice (“Never Shake a Baby”), one-third of those providing feedback on the campaign indicated that they had no prior knowledge of the potential danger of shaking an infant (Showers, 2001).

Moving beyond basic awareness, Dias and colleagues (2005) developed a universal education program on shaken baby syndrome, which they implemented in an eight-county region in western New York. The program provided information on shaking to parents of all newborns prior to the infants’ discharge from the hospital. During the 6 years before the program, 40 cases of substantiated abusive head injuries were identified in the targeted New York counties—an average of 8.2 cases per year, or 41.5 cases per 100,000 live births. During the 5.5-year period of the intervention, 21 cases of substantiated abusive head injury were identified—3.8 cases per year (a 53 percent reduction), or 22.2 cases per 100,000 live births (a 47 percent reduction). In the Pennsylvania comparison communities, there was no change in the number of such cases observed during the same two time periods (Dias et al., 2005).

Another promising public education and awareness program, The Period of PURPLE Crying, focuses on helping parents understand and cope with the stresses of normal infant crying. The program was tested through four different types of delivery systems: maternity services, pediatric offices, prenatal classes, and nurse home visitor programs. More than 4,200 parents participated in the program. A randomized controlled trial of the program found that it succeeded in enhancing mothers’ knowledge about infant crying. Women who participated in the program were more likely to differentiate “inconsolable crying” from other types of crying that signaled hunger, discomfort, or pain in an infant (Barr et al., 2009).

While these findings are encouraging, others implementing these types of broadly targeted efforts have not achieved comparable results. The extent to which these programs can result in sustained population-level change in parenting behaviors remains unclear.

Professional Practice Reforms

In addition to the provision of direct services to new parents, increased consideration is being given to how best to use existing service delivery systems that regularly interact with families to address the potential for abuse and neglect. For example, the medical field has long sought ways to better address healthy child development and child abuse and neglect within clinical settings. Historically, health professionals have faced barriers to using the traditional checkup appointment to carry out this responsibility. Doctors are often uncomfortable discussing sensitive issues, and they frequently lack the training to instigate such conversations and the ability to recognize key warning signs (Benedetti, 2012). Additionally, adequate and comprehensive screening tools have not been made available to all primary care providers (Benedetti, 2012; Dubowitz et al., 2009). The Healthy Steps program, an evidence-based model that places child development specialists within selected pediatric practices, was initially created in 1994 to address this issue. Today, Healthy Steps is available in 17 states and has demonstrated consistent impacts on child health, child development and school readiness, and positive parenting practices (Benedetti, 2012; Caughy et al., 2003; Minkovitz et al., 2003, 2007).

More recently, the Safe Environment for Every Kid (SEEK) program was created to help health professionals address risk factors for child abuse and neglect through a training course, the introduction of a Parent Screening Questionnaire, and the addition of an in-house social worker team to work with families. Two studies were recently conducted to test existing SEEK programs: one to determine outcomes for children and families and one to measure effects on the health professionals participating in the intervention (Benedetti, 2012; Dubowitz et al., 2009). The first was a randomized trial conducted between 2002 and 2005 in resident clinics in Baltimore, Maryland. Families enrolled in the SEEK treatment group showed significantly lower rates of abuse and neglect across all measures compared with controls (Dubowitz et al., 2009). The second study, conducted 2 years later, investigated whether the program changed doctors’ attitudes, behaviors, and competence in addressing child abuse and neglect among their patients (Dubowitz et al., 2011). Eighteen private practice primary care clinics participated in a cluster randomized controlled trial. The pediatricians in the SEEK group showed significant improvement in their abilities to address substance use, intimate partner violence, depression, and stress, and they reported higher levels of comfort and perceived competence in doing so (Dubowitz et al., 2011).

Community Prevention

A focus on the community as an appropriate prevention target is supported by findings of public health surveillance efforts and research on the effects of neighborhood contexts (Coulton et al., 1997; Pinderhughes et al., 2001; Zimmerman and Mercy, 2010). Research using population- and community-level data underscores the pressing need to design, target, and promote preventive service programs in jurisdictions exhibiting the greatest need (Putnam-Hornstein et al., 2011; Wulczyn, 2009). Accordingly, a number of strategies have emerged that focus on ways to better coordinate and integrate services provided through multiple domains and to alter the context in which parents rear their children (Daro and Dodge, 2009). The goal of such efforts is to move from simply assessing the prevention impacts on program participants to achieving population-level change by creating safe and nurturing environments for all children, as well as communities in which parents are supported through both formal services and normative values that foster mutual reciprocity. Although such initiatives are not fully operational in any community, the goal of altering both individuals and the context in which they live potentially provides a potent programmatic and policy response (Daro et al., 2009).

In a recent review of five multicomponent community initiatives, Daro and Dodge (2009) conclude that the implementation of multifaceted interventions that combine direct service reforms with attempts to alter residents’ access to and use of both formal and informal supports are promising but largely unproven. Based on comparisons of administrative data, at least some of the models they reviewed had successfully reduced reported rates of child abuse and injury to young children at the county or community level (Dodge et al., 2004, Prinz et al., 2009), and repeated population-based surveys revealed that the models had altered adverse parent-child interactions, reduced parental stress, and improved parental efficacy (Daro et al., 2008). When focusing on community building, several models demonstrated a capacity to mobilize volunteers and engage diverse sectors within the community, such as first responders, the faith community, local businesses, and civic groups, in preventing child abuse (Daro et al., 2008; Melton et al., 2008). At present, however, little information is available on how these attitudes and willingness to support one’s neighbors will translate into a measurable or sustained reduction in child abuse and neglect and enhanced parental support (CDC Essentials for Children, available at http://www.cdc.gov/ViolencePrevention/childmaltreatment/essentials/index.html [accessed March 7, 2014].

Designing and implementing a high-quality multifaceted community prevention initiative is costly. The models examined by Daro and Dodge (2009), each of which focused on only a single county or community within a county, cost approximately $1-$1.5 million annually to implement and evaluate. Moving forward, policy makers need to consider the trade-offs of investing in diffuse strategies designed to alter community context versus expanding the availability of services for known high-risk individuals. For the research community, a potential area of inquiry may lie in examining key mediators of either individual- or population-level outcomes and identifying less costly ways to create these mediators within prevention efforts.