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6
Preventing Child Maltreatment
Key Points Raised by Individual Speakers
Universal prevention efforts, especially when focused on new par-
ents, provide evidence of altering parental behaviors and improving
outcomes. These positive impacts from early intervention programs
are inconsistent across models and populations.
Home visits targeted at mothers with depression can reduce child mal-
treatment and the transmissions of those behaviors across generations.
Brief, focused interventions can substantially reduce child maltreat-
ment recurrence rates compared with more typical and higher dose
parenting programs.
A variety of child maltreatment evidence-based prevention models
are now available for dissemination, implementation, and evaluation
in community settings.
Because child maltreatment has many causes, different types of ef-
forts are made to prevent it. Speakers at the workshop session on preven-
tion discussed primary interventions for all families, secondary
interventions for targeted families (e.g., those that experience mental
health disorders or substance use problems), and tertiary interventions to
prevent recurrence of child maltreatment and chronic neglect. In all three
of these areas, many programs are becoming more focused and targeted
on specific behaviors. This trend holds out promise that interventions
could be briefer, more structured, and more responsive to outcomes, said
several speakers.
55
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56 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE
UNIVERSAL PREVENTIVE INTERVENTIONS
Universal prevention programs that target entire populations have
evolved in recent decades, said Deborah Daro, Chapin Hall Senior Re-
search Fellow at the University of Chicago. Beginning in the 1960s, re-
searchers moved from simply trying to raise awareness to developing a
large number of programs. As their understanding evolved, the focus of
programs narrowed to early developmental stages, with a growing em-
phasis on home-based interventions to maximize impact when children
are young. In the past few years, universal prevention programs have
emphasized infrastructure and community development, the strengthen-
ing of existing programs, and a shift toward evidence-based models.
Shaken Baby Syndrome1
A good example of recent trends in intervention efforts is the variety
of programs developed to prevent shaken baby syndrome, said Daro.
Public awareness and community engagement have been cornerstones of
efforts in this area. In addition, recent efforts have concentrated aware-
ness programs on very specific behaviors.
Daro listed several well-known programs, including the Central
Massachusetts Shaken Baby Syndrome Campaign, a web-based commu-
nity engagement program, and a hospital-based initiative at Pennsylvania
State University’s Hershey Medical Center. One common pathway used
by these programs is universal education for new parents on coping skills
and parenting practices, often including print or video media. In addition,
the programs encourage parents to share what they have learned with oth-
ers who care for their infants, thus expanding the reach of the curriculum.
Daro particularly emphasized the role of parents as spokespersons
for these programs. Two-way communication between parents and
broader networks, she said, is a major factor in the education of parents
and can play a huge role in disseminating positive parenting skills and
approaches. It also is important to educate professionals and first re-
sponders, who see families when children are very young. In this way,
public and professional education work in concert to improve outcomes.
1
In 2009, the American Academy of Pediatrics issued a policy statement recommend-
ing that the term abusive head trauma be used instead of shaken baby syndrome to reflect
that an injury to the head and brain may be caused by a variety of mechanisms, including
shaking and blunt impact (Christian et al., 2009).
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PREVENTING CHILD MALTREATMENT
Some randomized trials have shown an increase in parental aware-
ness and the use of alternative strategies. In an upstate New York study,
treatment communities had a 53 percent reduction in head trauma from
substantiated abuse, comparing pre- and postintervention rates over a 6-
year historical control period followed by 5.5 intervention years (Dias et
al., 2005). No decrease was recorded in Pennsylvania—where this treat-
ment was not provided—during this time period. Anecdotal evidence,
Daro said, also points to greater awareness among parents and to an in-
creased comfort level discussing parenting techniques and skills. The
behaviors documented by such evidence “sit at the core of good public
health initiatives,” said Daro. “Why do we stop smoking? Why do we
use seatbelts? It is because individuals are willing to tell other individu-
als to change their behavior. . . . Person-to-person change is a way to
generate normative change in a much quicker way than if you rely solely
on a formal intervention.”
Shaken babies make up a small percentage of the overall child abuse
problem, Daro continued, but focusing on the behavior has merit given
its fatal consequences in many cases and the high costs associated with
head trauma. In addition, it is a problem for which there are clear and
demonstrated ways to lessen its frequency.
Ecological Theory and Community Prevention
Ecological theory provides a useful structure for child abuse work,
Daro said. “Child maltreatment has lots of causes,” she explained, “and
we need lots of ways to address it.” But social service systems tend to be
narrowly targeted, which is not very hospitable to ecological theory.
Much work happens independently without regard for other areas, and
success is measured on an individual level rather than a population level.
“The idea of doing community prevention,” Daro continued, “is in part
driven by trying to be more explicitly in tune with ecological theory.”
Community programs existed since the turn of the last century, serv-
ing as a critical intervention during the Progressive Era. More recently,
investments in place-based strategies surfaced again in the 1960s as part
of the War on Poverty. Today’s community programs to address child
maltreatment target high-risk communities and incorporate various inter-
ventions, and each program has very different levels of research and
evaluation. Some look at the effects of the entire initiative, while others
focus only on one or two components.
Common pathways used by these community programs fall into sev-
eral categories. Expanding services and providing more resources is a
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58 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE
constant goal, whether through better use of existing resources or adding
elements to a program. Many programs also work to change the relation-
ship between provider and participant, Daro said, which is known as
“practice reform.” This strategy sets clear standards for interaction and
describes common messages and specific behaviors for anyone working
with families. For example, she noted that Triple P (Positive Parenting
Program) has a specific training program where they train every provider
in the community in order to put out a common definition about the rela-
tionship of parent and child.2
Some programs also use agency reform initiatives that are working
to change institutional culture. This strategy may focus on creating a sys-
temic response to child abuse, bringing agencies together to act in concert.
Finally, some programs focus on normative change. “They want
people to be different,” Daro observed. “They want to change the values
around mutual reciprocity or appropriate caregiving, and they go to the
families themselves.” This style of broad-scale outreach, she said, at-
tempts to change the way parents view their responsibilities, both inde-
pendently and collectively.
Some research on community initiatives has found measurable re-
ductions in child abuse reports, substantiated cases, hospital emergency
room use, and out-of-home placements at the population level, though
other initiatives have not demonstrated measurable population-level
change. “It is not uniform, but there is certainly some evidence that under
certain circumstances the strategy can work.”
Research also shows changes in parent self-reporting that suggest
fewer adverse parenting practices and other normative changes. The tar-
get communities have seen better engagement and more mobilization of
community resources. “People are doing more. They can generate greater
interest. They get more people involved,” Daro said.
Continuing Challenges
Implementing these programs and generating positive outcomes con-
tinues to face steep challenges. Generating new social networks can be
difficult, Daro pointed out, as opposed to enriching ones that already ex-
ist. Some families are very isolated when they enter the program and
have a difficult time building connections.
Another issue is considering which neighborhoods can support
community-level initiatives. Less stressed communities, Daro said, gen-
2
Additional discussion of the Triple P model can be found in Appendix D.
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PREVENTING CHILD MALTREATMENT
erally can implement programs faster, and programs that are quicker to
implement have better outcomes. The community also has an impact on
the program operations, which has to factor into the decision-making
process.
Many programs fail because they do not have an intentional and stra-
tegic framework to guide decision making, said Daro. “These are com-
plex initiatives. There are a million balls in the air.” Programs with three
or four distinct components, she said, inevitably have to let some things
go, and someone must make decisions about how to prioritize and allo-
cate resources to keep the operation from being too scattered and there-
fore ineffective.
Community intervention programs also require large investments,
Daro pointed out, which means that consideration must be given to how
they can remain sustainable and consistent. Creating measurable change
takes time, and a program must be built with that constraint in mind.
Finally, Daro addressed the importance of timing and focus when de-
livering services. “We lack a science of execution,” she said. When par-
ents are “absolutely at wit’s end,” they need something to help them
through that difficult period. “We don’t know how to get that something
to the parent at the point at which they need it, and that is what we are
really struggling with.”
Future Opportunities to Strengthen Universal
Prevention Programs
The outcomes of programs could be strengthened through an inten-
tional focus on the contexts of intervention programs and individual fam-
ilies, Daro said. Additional research also will be necessary on the
sustainability of reform and population-level change.
Assuming that every family is at risk could provide benefits by
providing a universal assessment at a specified point in time, Daro said.
The system also could benefit from a greater understanding of the critical
elements necessary for high-quality interventions and a sense of how
much programs can adapt while retaining those ingredients.
In addition, using technology more effectively could have many ben-
eficial impacts, such as improving supervision, empowering participants
to seek information, and strengthening provider–participant relationships.
Finally, public and private programs need to be integrated more
closely to maximize support for community programs. “There are simply
not enough public dollars to meet the needs of families and children at
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60 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE
risk,” Daro concluded. She emphasized that “people need to be empow-
ered to act on their own to support parents and protect children.”
Discussion
In response to a question about the expense of preventive services,
Daro pointed out that the cost varies widely. “The real trick is linking
families with the level of service they need, not more, not less.” She add-
ed that cost can be minimized by looking to the systems that are already
in place and adapting them as necessary. Another participant pointed to a
lack of economic analysis in childhood abuse and neglect and the need
for precise and targeted cost-benefit and comparative effectiveness anal-
ysis of welfare programs; several panelists agreed with this point.
SECONDARY PREVENTIVE INTERVENTIONS
WITH HIGH-RISK POPULATIONS
Delivery of services through home visits shows promise for decreas-
ing the transmission of child maltreatment across generations, said Frank
Putnam, professor of pediatrics and child psychiatry at the Cincinnati
Children’s Hospital Medical Center and professor of psychiatry at the
University of North Carolina School of Medicine. Home visits are a
common intervention in many countries, but they are more limited in the
United States and tend to attract high-risk families with inadequate re-
sources. At present, Putnam said, about 500,000 families across the
country are participating in home visiting programs.
The Results from Research
In a brief review of research on home visitation, Putnam reported
that only one out of five trials found a substantiated reduction of substan-
tiated abuse, but four out of five showed a reduction in parent-reported
abuse (Astuto and Allen, 2009).3 Putnam pointed out that population
studies see a higher frequency of parent-reported abuse (including sexual
abuse, physical abuse, and shaken baby syndrome) than substantiated
abuse reports, so he thinks it is important not to discount those data.
Home visitation programs also have demonstrated influence on parenting
3
Additional discussion about home visiting programs is included in Appendix D, in-
cluding a summary of evaluations of the effectiveness of home visiting models for pro-
moting child well-being and a discussion of the strength of the available evidence.
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PREVENTING CHILD MALTREATMENT
sensitivity and parenting harshness, two important risk factors for mal-
treatment.
An important factor in understanding research on home visitation is
that these programs often have strong site effects, said Putnam. Some
sites get very good results, while others do not produce the same kinds of
outcomes, which tends to dilute statistical significance (Howard and
Brooks-Gunn, 2009). Putnam added that it will be important to research
why there are often strong site effects and why the same program seems
to produce results in some communities and with some agencies and not
with others.
In the research sample Putnam and his colleagues have been study-
ing of 15,000 families receiving home visits, most of the mothers were
single or unmarried, had on average an 11th-grade education, and had
young children. Many mothers were estranged from their families and
socially isolated, and two-thirds of the mothers in the research sample
had a history of maltreatment (Ammerman et al., 2011).
Reviews and meta-analysis suggest a two to three times greater risk
of maternal depression when mothers have a history of child maltreat-
ment. Maternal depression, in turn, is a risk factor for child abuse and
neglect. This result is a vicious cycle, Putnam pointed out. “If you were
abused, you are more likely to become depressed. And if you become
depressed, you are at a higher risk for maltreatment of your offspring.”
His study has found that depression and social support strongly affect the
relationship between a childhood history of maternal trauma and in-
creased parenting stress. In particular, a Beck Depression Inventory of
800 mothers over the course of 9 months had 44 percent scoring in a
clinical range split into three groups: one group that scored high and then
improved, one that remained chronically depressed, and one that first
scored low and then became depressed. In the literature, Putnam said, the
rate of maternal depression in home visiting populations is 30 percent,
and the majority of those mothers do not get treatment (Ammerman et
al., 2011).
Dealing with Depression
A number of strategies have been put forth for addressing maternal
depression in home visitations. Current standard practice involves
screening the mother for referral to community services. Another model
involves having the home visitors screen the mother and provide a refer-
ral to a mental health partner. This technique, Putnam said, was success-
ful in Ohio, with two-thirds of mothers who screened positive accepting
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62 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE
a referral. Embedding a program within the home visiting model is a
third approach. A fourth, which has been used in Louisiana, has the
home visitor screen and then provide the counseling directly, supervised
by a mental health professional.
In-Home Cognitive Behavioral Therapy (IH-CBT) is an intervention
Putnam developed with Robert Ammerman (Ammerman et al., 2011).
“Because there are so many different home visiting programs,” Putnam
said, “we designed this to be as generic and nonprogram-model-specific
as possible. In development for 8 years, the program is standardized to
15 sessions plus a booster session, delivered by a social worker with at
least a master’s-level education who is supervised by doctoral-level psy-
chologists or psychiatrists.”
In multiple trials, the researchers saw a positive impact of the em-
bedded program for treating depression. In addition, the program in-
creased their perceived social support. However, their social networks
did not expand significantly, which means they were getting more bene-
fit from the same network.
The studies showed almost an 80 percent reduction in depression
among mothers who completed all 15 sessions, and 60 percent reduction
for those who received treatment but did not go through the full program.
Two-thirds of those who had no treatment remained depressed
(Ammerman et al., 2011).
A 3-month follow-up showed continued improvement in the treat-
ment population. These trials compare well with randomized controlled
trials in clinical settings, as well as with medication trials, Putnam ob-
served. Other studies, he added, show that depressed subjects with a his-
tory of maltreatment respond poorly to medication but well to cognitive
behavioral therapy.
Future Opportunities with Home Visiting Systems
Home visiting systems provide an opportunity for repeated screening
and delivery of services that mothers will accept, Putnam concluded.
Mothers learn to trust the home visitors; no-show estimates are lower
than for clinic-based services; and the programs can follow families for
multiple years. “Delivering those services in the home reduces a lot of
barriers. Most of these moms don’t have cars. They don’t have transpor-
tation. They have child care problems. They are poor.” Home visitation
programs also provide an opportunity to address other risk factors such
as maternal PTSD, substance abuse, and domestic violence.
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PREVENTING CHILD MALTREATMENT
Discussion
In response to a question about education for providers and home
visitors, Putnam pointed out that a number of curricula are being devel-
oped, particularly in the area of social work. But education on child mal-
treatment is not embedded in medicine or in most of psychology. “There
are many areas where we need to disseminate this,” he said.
Daro expanded on that statement, suggesting that another challenge
for workers is learning to strategize with colleagues in different disci-
plines. The culture does not necessarily support incoming workers with
new skills, she said, and they may get dragged into old ways of doing
things regardless of what they learned previously.
PREVENTION OF RECURRENCES AND
ADVERSE OUTCOMES
Tertiary services are generally not voluntary, said Mark Chaffin, pro-
fessor of pediatrics at the University of Oklahoma. They focus on fami-
lies with recurring instances of maltreatment and emphasize effect size
more than reach or penetration. “The consumer of these services, in an
economic sense and in many other senses, is actually the system,” Chaffin
said. “It is the child welfare system or the courts.” These entities typical-
ly select and prescribe these services, but they rarely have done so in a
well-informed or assessment-driven manner.
Public child welfare systems are highly regulated, Chaffin observed,
but they lack a mandate to use proven effective or evidence-based treat-
ments. Most services are locally derived and delivered by community-
based agencies that may invent their own model without strong guide-
lines. An informal search of the Child Family Services Reviews, which
evaluate child welfare systems, resulted in no matches for the term “evi-
dence based.”
“Typically, services in this area have been ideology driven, not evi-
dence driven, and that is still the case,” Chaffin said. In the 1980s, the
prevailing attitude was that any treatment would be too late and that pre-
vention was the only viable option. In the following decade, intervention
research focused on sexual abuse and posttraumatic stress (PTS) symp-
toms. This resulted in evidence-based services for PTS in children, but
left many needs unaddressed because fewer than 20 percent of children
in foster care show PTS symptoms. As recently as 2004, a review com-
missioned by the Office for Victims of Crime found only a single inter-
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64 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE
vention mode—for PTS in child victims—as well supported, and rated
no parent-focused or perpetrator models as well supported (Chaffin and
Friedrich, 2004).
Recent Progress
More recently, however, there has been substantial growth in the
number of well-supported models that extend well beyond PTS, Chaffin
said. In 2012, for example, the California Evidence-Based Clearinghouse
for Child Welfare (CEBC), which reviews evidence on interventions for
families in child welfare, rated as well supported four parent training
models, one foster care stabilization model for children, two foster care
stabilization models for adolescents, and four models for children with
internalizing anxiety, depression, or PTS.
Now it is clear, Chaffin continued, that child maltreatment recidi-
vism reduction recurrence rates can be substantially reduced with a brief,
focused intervention, compared with more typical and higher dose par-
enting programs. One trial showed a reduction from more than 50 per-
cent to less than 20 percent measured using an evidence-based treatment.
Researchers have replicated these results in settings outside of laborato-
ries with cases severe enough to face termination of parental rights. The
results also have been extended from physical abuse to neglect and from
more acute cases to chronic or deep-end cases. A recent statewide trial
also showed significant reductions when adding evidence-based modules
to a home-based service system. For every 10 to 15 cases treated, recur-
rence dropped by one within the first year, and greater than one in fol-
lowing years. “These are meaningful reductions that can be achieved.”
The majority of current evidence-based treatments have been bor-
rowed from outside child welfare, Chaffin observed. They were devel-
oped in other contexts and have been adapted and integrated into service
programs for high-risk parents. Many of these evidence-based treatments
also require lower doses and fewer sessions compared with previously
favored interventions. They take a more behavioral approach, emphasiz-
ing adaptive skills, and focus less on verbal exploration of issues. They
also tend to be more structured, which Chaffin said gets a mixed reaction
from implementation staff.
In ideology-based models, providers tended to value comprehensive-
ness over depth, trying to fit as many therapies as possible into a pro-
gram. Evidence-based treatments look different. They focus on fewer
things with greater depth and intensity. Greater quality control is empha-
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PREVENTING CHILD MALTREATMENT
sized. “This has been the shift that has been going on and will probably
continue.”
Future Research and Opportunities
Borrowing and adapting from other intervention sources will contin-
ue into the future, said Chaffin. “We have a long way to go before we
exhaust the possibilities of what we can borrow from other evidence-
based treatment literatures,” he said. Many of these interventions are
more advanced than in child welfare settings and are resilient enough to
be translated across communities, problem areas, populations, and cultures.
An important factor to consider is the envelope of effectiveness for
different therapies and where their usefulness begins to taper off. Identi-
fying the most useful elements within borrowed treatments, and pulling
out those crucial ingredients for use in a child maltreatment setting,
would increase effectiveness. Adaptation requires the complex task of
fitting various strategies to the service system, the context, the policy
environment, and the workforce.
Evidence-based case management pathways are another area for de-
velopment, Chaffin suggested. People providing services need a back-
ground in matching those services to clients and families. Today, service
plans tend to be scattershot. Parents often cannot realistically complete
all the tasks laid out in their service plan. Assessment-driven service
models, with fewer targets and greater focus and depth, could be a better
fit, with monitoring for outcomes instead of processes.
Chaffin also suggested that researchers look beyond immediate out-
comes to the developmental, occupational, social, and health conse-
quences of interventions for children in the system. Furthermore, new
scientific insights into the causes of maltreatment behavior can influence
decisions about what interventions to borrow, how to develop new inter-
ventions, how to assemble and tailor the elements of interventions, and
how to anchor interventions in a clinical science approach rather than an
ideological approach.
At the end of his presentation, Chaffin noted that neglect is more sta-
ble and recurrent than other types of maltreatment, which results in a
flood of chronic cases in the child welfare system. In Oklahoma, for ex-
ample, more than 40 percent of cases have been seen four or more times
in the past, typically for chronic neglect. “We are still married to an epi-
sodic and reactive service system. You have to have a report, and that is
when you initiate services.” Looking to other chronic diseases, he sug-
gested, could inform development of a different methodology for dealing
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66 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE
with recurrence. Emerging evidence suggests that evidence-based inter-
ventions may have a cumulative service benefit or at least a retained
probability of positive response even among highly chronic cases, as is
seen in addiction treatment. To explore this possibility, research needs to
look at the trajectory of interaction with service systems across a fami-
ly’s child-rearing years, changing developmental issues and the match
with evidence-based treatments, and the role of monitoring, check-up,
and follow-up. For example, who would do such monitoring and how
could engagement be sustained, Chaffin asked, especially among highly
mobile populations with shifting family compositions?
Discussion
One participant asked about the ingredients of success, which Chaffin
listed as quality control, delivery mechanisms, and program structure. In
that regard, he also spoke about implementing structured programs that
can be delivered by employees with a bachelor’s-level education. “If you
asked me what the number one problem is in public child welfare, I
would say it is a workforce problem,” Chaffin said. “Today you have a
bachelor’s degree in English literature or recreation or landscaping, and 3
weeks from now you are a child welfare worker with a full caseload. I
think it is the exception rather than the rule to find much in the way of
course work.” Matching programs with clients could be handled by deci-
sional algorithms, Chaffin said. Expertise is necessary for developing the
algorithm, but once it exists, someone without a Ph.D. can effectively
match elements to a case. Putnam added that the use of continuous quali-
ty improvement techniques developed in the business community could
have a dramatic effect on child maltreatment programs. In contrast to
randomized controlled trials, continuous quality improvement is nimble,
cheap, and data-driven. It embraces variation as a way of improving a
system and depends on quick feedback to foster continual improvements.
John Landsverk, director of the Child and Adolescent Services Re-
search Center at Rady Children’s Hospital in San Diego, commented on
the lack of data on the cost of prevention services. He noted that child
welfare does not have a unit costing system, unlike medical care, in
which a certain amount can be attached to each type of visit or proce-
dure. This is an important barrier to achieving precision in cost calcula-
tions and cost-benefit analyses. He said that a unit cost approach has
been developed in Britain and is currently being adapted for use in the
United States. Finally, he stated that there are a number of different in-
terventions in particular areas that are ripe for comparative effectiveness
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PREVENTING CHILD MALTREATMENT
research. For example, it may be that one intervention actually delivers a
slightly smaller effect than another but costs much less and therefore has
a better cost-benefit ratio.
Barth brought up the challenge of reengaging families in chronic ne-
glect situations without a child abuse report as a mechanism. He said that
this could be made more difficult because of the expansion of multiple
response programs that do not collect or keep complete information from
child abuse reports. Chaffin said such a system would look more like a
prevention system than an intervention system. However, he added, “We
are still very much at the formative state of beginning to think through
understanding how chronic families interact with systems and what they
benefit from cumulatively or episodically over time. We are just begin-
ning to learn something about chronic neglect cases that would allow us
to think about how we would design a different type of system that is less
episodic and reactive.”
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