6


Interventions and Service
Delivery Systems

Since the 1993 National Research Council (NRC) report was issued (NRC, 1993), significant advances have occurred in the development and dissemination of model programs for treating and preventing various forms of child abuse and neglect (Daro and Benedetti, 2014). In addition to the public child protection and child welfare systems found in all communities, a variety of treatment programs targeting victims and perpetrators of child abuse and neglect are offered through various mental health and social service agencies. Many communities also have access to primary and secondary prevention services designed to reduce the risk for child abuse or neglect for families experiencing difficulties. Among this growing array of service options, an increasing number of interventions have strong evidence of efficacy with at least a portion of their target populations. Many others are aggressively building their evidence base and now operate with increased awareness of the need for and the value of robust evaluative data.

The current evidence base also suggests that the availability of these services is uneven across communities and populations, leaving many of the most vulnerable children and families without adequate services. Even when identified, children who are victims of child abuse or neglect may not receive the therapeutic services needed to address their serious developmental and behavioral problems. Families at significant risk of child abuse or neglect as a result of mental health issues, domestic violence, or substance abuse are among those least likely to be adequately served by the current array of preventive and family support services. And when services are offered, their quality and potential impacts vary greatly (Paxson and Haskins, 2009). On balance, however, much progress has been made in the ability



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6 Interventions and Service Delivery Systems S ince the 1993 National Research Council (NRC) report was issued (NRC, 1993), significant advances have occurred in the development and dissemination of model programs for treating and preventing vari- ous forms of child abuse and neglect (Daro and Benedetti, 2014). In addi- tion to the public child protection and child welfare systems found in all communities, a variety of treatment programs targeting victims and perpe- trators of child abuse and neglect are offered through various mental health and social service agencies. Many communities also have access to primary and secondary prevention services designed to reduce the risk for child abuse or neglect for families experiencing difficulties. Among this growing array of service options, an increasing number of interventions have strong evidence of efficacy with at least a portion of their target populations. Many others are aggressively building their evidence base and now operate with increased awareness of the need for and the value of robust evaluative data. The current evidence base also suggests that the availability of these services is uneven across communities and populations, leaving many of the most vulnerable children and families without adequate services. Even when identified, children who are victims of child abuse or neglect may not receive the therapeutic services needed to address their serious developmen- tal and behavioral problems. Families at significant risk of child abuse or neglect as a result of mental health issues, domestic violence, or substance abuse are among those least likely to be adequately served by the current array of preventive and family support services. And when services are of- fered, their quality and potential impacts vary greatly (Paxson and Haskins, 2009). On balance, however, much progress has been made in the ability 245

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246 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH to successfully identify, engage, and assist a growing proportion of children and families that have experienced or are at risk for child abuse and neglect. The purpose of this chapter is to describe those program models and intervention strategies with the strongest evidence of success, identify ap- proaches that have been found lacking, and highlight the importance of building an integrated system of care to enhance the capacity to success- fully prevent child abuse and neglect and treat victims. In developing this conceptual framework, the committee intentionally considered the collec- tive challenges facing all relevant interventions instead of segmenting the discussion into the traditional silos of treatment and prevention services. Also highlighted are the common challenges faced with all interventions in attempting to enhance their assessment, implementation, replication, and sustainability. The child abuse and neglect interventions reviewed here are aimed in part at improving the capacity of parents and caretakers to cease certain harmful behaviors or to adopt behaviors commonly accepted as contribut- ing to healthy child development. The behaviors targeted include those that are illegal and wrong, as well as those for which evidence demonstrates a link to negative or positive impacts on a child’s development or safety. Parental capacity and behaviors can be altered either directly by providing services to individual caretakers to improve their knowledge and skills, or indirectly by creating a context in which doing the “right thing” is easier, such as by reducing stress and increasing support within the immediate family and local community. The child welfare system, as described in Chapter 5, provides a neces- sary public policy and service response but is insufficient to address the immediate and long-term consequences of child abuse and neglect or give families the support they need to prevent these outcomes. This chapter focuses on why it is important to develop, implement, assess, and sustain an array of strong interventions that address the consequences of child abuse and neglect (treatment) and offer promising pathways to improve parental capacity to support optimal child development by reducing risks and strengthening protective factors (prevention). The committee recognizes the wider range of interventions that address myriad issues associated with an elevated risk for child abuse and neglect, such as substance abuse treat- ment programs, domestic violence interventions, depression treatments, income support programs, child care, and community violence prevention programs. The discussion here, however, is limited to strategies whose core objectives include reducing child abuse and neglect, improving parental capacity, and ameliorating the consequences of child abuse and neglect. The first two sections of the chapter identify an array of service strat- egies and program models that have demonstrated success in achieving their targeted outcomes, as well as those efforts that have failed to fulfill

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INTERVENTIONS AND SERVICE DELIVERY SYSTEMS 247 expectations. Because of variations in legal authority, target population, and scope across the various elements of the child abuse and neglect service continuum, this evidence is presented in two broad groupings: treatment programs designed to reduce reincidence and ameliorate the consequences of child abuse or neglect, and prevention efforts designed to enhance pa- rental capacity, improve child outcomes, and reduce a child’s risk for ex- periencing abuse or neglect. The third section of the chapter examines a set of issues that have limited the replication and efficacy of interventions designed to address child abuse and neglect. Although the issues addressed are not exhaustive, they illustrate the challenges facing both public child welfare systems and the direct services provided to children and families. Improving outcomes for a greater proportion of victims and those at risk of child abuse and neglect will require new research on such issues as cultural relevance, replication fidelity, cost-effectiveness, service delivery reform, and service integration. In addition to offering guidance on how to structure and target specific interventions, such research can guide reforms in public child welfare and other public service delivery systems to improve overall service quality and create an institutional infrastructure capable of sustaining such reforms. The fourth section examines important aspects of building an integrated system of care, including organization culture and interagency networks. The final section presents conclusions. Any intervention or reform strategy, regardless of its target population or primary outcomes, appears to benefit from a set of “core ingredients” (Barth et al., 2012). Although identifying the exact nature of these ingre- dients is a work in progress, they generally include building on a strong theoretical foundation that links intended outcomes to a clearly articulated theory of change, offering the program at a sufficient dosage and duration to make it possible to achieve the intended outcomes, staffing the program with individuals who have the knowledge and competencies to work with participants to achieve the desired outcomes, and operating within a sys- tem of quality assurance to ensure that the program is delivered properly and the desired outcomes are achieved (Chorpita et al., 2005; Duncan et al., 2010; Wulczyn et al., 2010). As noted in the following sections, these characteristics, among others, help distinguish successful efforts from those with less promise. TREATMENT PROGRAMS The greatest change in the development of treatment programs to address child abuse and neglect has been an emphasis on evidence-based practices rather than new theories that might suggest radically different treatment areas. Two primary advances have occurred. The first is the development of therapies that specifically target the impact of trauma or

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248 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH abuse on children. These approaches deal mainly with posttraumatic stress, depression, and anxiety—the primary emotional impacts of abuse. There is a robust literature on interventions addressing these outcomes, but it is not exclusive to child abuse. This research base acknowledges the importance of screening for trauma (including abuse) and validating its occurrence, but encompasses strategies that operate within the traditional framework of mental health interventions. Treatment clinically targets the outcomes or the mental health condition, not the event or cause per se. This focus is consistent with the evidence showing that not all children exposed to child abuse, various forms of trauma, or even terrible lives in general develop mental health disorders. The emphasis also is on modular approaches that address multiple clinical outcomes rather than a single presenting problem. The second main advance in treatment interventions is in approaches to problematic parenting and behavior problems in children. Child abuse and neglect represent extreme forms of problematic parenting, and parent- ing interventions are the most common service recommendation in child welfare. It has long been known that parenting approaches, parental behav- iors, and their interaction with child behaviors are primary determinants of behavioral problems in children. In child abuse and neglect situations, behavioral problems are both a consequence of abuse or neglect and a potential risk factor for triggering physical abuse. It is not only physical or sexual abuse that may produce behavioral problems in children; the inconsistent or coercive parenting that often characterizes neglect is also implicated (Gardner, 1989; Patterson et al., 1990; Stormshak et al., 2000). Neglecting parents may be inattentive, unresponsive, or inconsistent. There- fore, effective parenting interventions are the first-line treatments both for dealing with behavior problems in child victims and for reducing the risk for subsequent child abuse and neglect. The empirical literature is unanimous that behavioral problems are addressed most effectively through interventions that target parents as the primary change agents. In many cases, especially those involving younger children, the interventions are fully parent mediated (Carlson et al., 1989); the children need not be the recipients of individual treatment. This target- ing of parents is particularly apt in the context of child abuse and neglect as compared with the typical nonabusive scenario in which children have behavioral problems. Wolfe and others (Graziano and Diament, 1992; Wolf et al., 1987; Wolfe et al., 1988) demonstrated early on that a behavioral parent training program was effective with abusive parents. However, the idea of applying this well-established approach to child abuse and neglect situations did not fully take hold until Urquiza and McNeil (1996) pub- lished a paper in Child Maltreatment advancing the application of parent- child interaction therapy (PCIT) in these cases (Urquiza and McNeil, 1996) (PCIT is further discussed below). The emphasis on promoting positive

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INTERVENTIONS AND SERVICE DELIVERY SYSTEMS 249 parent-child relationships to address behavioral problems in abused or neglected children resonated with the child abuse and neglect community because behavioral problems in these cases are the result of abusive or neglectful parenting. In other words, applying a proven parent-mediated intervention would simultaneously address the child’s behavior problems and the deficits in the parent-child relationship. Ideally, enhancing the parent-child relationship promotes more secure attachment and stronger bonding, which in turn not only improves child behavior but also lowers the risk for future abuse or neglect. The focus on parenting interventions is not new; they have always been a primary service for child abuse and neglect cases. What changed was the recognition that parenting practices and child behavior problems are inextricably interrelated and are best addressed through a single parenting- focused intervention, as opposed to sending parents to parent education classes and children to individual therapy when abuse or neglect results in behavior problems. Moreover, the parenting interventions typically offered were didactic classes or peer support, neither of which involve learning and using new skills in difficult parenting interactions. While parenting classes are still common, it is increasingly appreciated that they are unlikely to produce behavior change in abusive or neglectful parents. Evidence for Effectiveness The standard, well-established parent management training or behav- ioral parent training programs have now been applied extensively to child abuse and neglect situations, and in some cases subjected to specific clinical trials. Findings on parent management training suggest robust effects across cultural groups (Lau, 2006; Martinez and Eddy, 2005). PCIT is effective with abusive or neglectful parents (Timmer et al., 2005), as well as with fos- ter parents (Timmer et al., 2006), when children have behavioral problems. For example, the Incredible Years (Herman et al., 2011; Webster-Stratton et al., 2011a,b) has been tested extensively with low-income Head Start families, many of which are at high risk for abuse or neglect or have been involved in the child welfare system. The Parent Management Training Oregon (PMTO) model is one of the earliest and most well-established interventions for behavior problems. It is the basis for two interventions that have been used in child welfare popu- lations. The first, Multi-dimensional Treatment Foster Care (Chamberlain et al., 2008), is a treatment foster care model for severely behaviorally disturbed children that teaches foster parents to deliver the PMTO model with the active consultation and support of a consultant. Under the model, youth can be transitioned to regular foster care or their family home in less than 6 months. The second intervention is Keeping Foster and Kin Parents

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250 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH Supported and Trained, a less intensive version of the model for foster par- ents and kinship caretakers that has been found to be effective in reducing behavior problems and promoting placement stability (Chamberlain et al., 2008). As discussed later in this chapter, another well-established parent management training program—the Positive Parenting Program, commonly known as Triple P (Sanders et al., 2002)—also is increasingly being used in child welfare cases. A number of these parenting interventions have been shown to im- prove child welfare outcomes in addition to improving behavior problems in abused and neglected children. PCIT with a motivational enhancement component significantly reduces referrals to the child welfare system com- pared with services as usual (Chaffin, 2004; Chaffin et al., 2004). In fact, PCIT by itself outperforms PCIT combined with other services (Chaffin, 2004). Alternatives for Families-Cognitive-Behavioral Therapy (AF-CBT) entails parent-child cognitive-behavioral therapy for physically abusive families. It incorporates standard parent management training; coping skills for children and parents; and a process for parents to make amends for the abuse, which reduces behavior problems and violence in both children and parents. Parent-Child CBT (PC-CBT), a similar approach for ­ hysically p abusing families in which the intervention is delivered in child and par- ent groups, also has been shown to improve behavior problems and re- duce future aggression (Runyon et al., 2009). And Triple P delivered as a ­ population-based intervention has been shown to offset increases in child abuse referrals and placement rates (Prinz et al., 2009). Infant mental health interventions have been developed for the very youngest victims of abuse and neglect. These programs are fully parent mediated and focus on enhancing parents’ sensitivity and responsiveness to their children, as well as basic protective parenting. Parents learn to recognize child cues, especially for distress, and to respond in ways that are consistently comforting. Several programs have been tested in clinical trials involving abusive or neglectful situations and been found to be effective in improving parent sensitivity and child adjustment (Bernard et al., 2012; Spieker et al., 2012). SafeCare is a parenting-focused intervention for neglect situations in- volving young children. It is a brief structured home-based program, de- livered by trained professionals or paraprofessionals, consisting of three components: safety proofing the home, teaching parents how to moni- tor and manage child health, and coaching in parenting. The parenting coaching component is not intended for cases in which the children have significant behavioral problems, but teaches basic positive parenting skills. In a recent statewide randomized trial taking the intervention to scale, families receiving SafeCare in addition to the usual array of home-based services had significantly lower rates of rereferral to child protective ser-

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INTERVENTIONS AND SERVICE DELIVERY SYSTEMS 251 vices (Chaffin et al., 2012a). Implemented in a trial with American Indian families, SafeCare not only was effective but also was highly acceptable to these families (Chaffin et al., 2012b). Not infrequently, children show more than one internalizing impact of abuse and neglect, including posttraumatic stress, anxiety, and depres- sion. The literature is robust for the effectiveness of Trauma-Focused CBT (TF-CBT) (Mannarino et al., 2012), a structured intervention for children and caregivers that directly targets the impact of traumatic experiences, including physical and sexual abuse. It reduces not only posttraumatic stress, but also depression and moderate behavior problems when present. The intervention consists of standard CBT elements such as psychoeduca- tion, relaxation and emotion regulation skills, and positive parenting. The trauma-specific CBT component is the trauma narrative, which entails gradual exposure to trauma memories and cognitive processing to correct maladaptive trauma-related beliefs. TF-CBT has been tested extensively with children involved with the child welfare system, including those in foster care placement. It has also been widely disseminated in a variety of public mental health settings through the National Child Traumatic Stress Network. CBT is well established for children with depression or anxiety (Walkup et al., 2008), although research has not specifically addressed whether the proven interventions are equally effective with abused and neglected children. Child and Family Posttraumatic Stress Intervention (Berkowitz, 2011), a brief trauma-focused intervention, has been shown to be effective in pre- venting chronic posttraumatic stress disorder when delivered shortly after a trauma. It consists of assessing trauma impact with feedback to families, providing psychoeducation and normalizing about traumatic stress, and teaching coping skills. Although not yet specifically tested in child abuse or neglect cases, this intervention has been shown to be effective in domestic violence cases and is potentially applicable as an early intervention in cases of child abuse and neglect. There are also well-established interventions for anxiety and depres- sion in children. CBT is the first-line treatment and may be combined with medication in some cases (Walkup et al., 2008). Children are given information about anxiety or depression; are taught relaxation and coping skills; undergo cognitive restructuring designed to change maladaptive and unhelpful thoughts; and in the case of depression, are taught exposure to unrealistic fears and behavioral activation. Parents may or may not be ac- tively involved in this therapy. The literature has not established that these models work specifically with abused and neglected children, but there is no reason to believe that they would not. TF-CBT and many parent management training programs have been found to be equally effective for minority youth and their families among

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252 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH the samples included in clinical trials. For example, equivalent outcomes for TF-CBT have been observed for African Americans (Scheeringa et al., 2010). A school-based group version of TF-CBT (Cognitive-Behavioral Inter­ ention for Trauma in Schools [CBITS]) was initially tested and found v effective in the highly diverse Los Angeles school district, where a major- ity of children are immigrants (Jaycox et al., 2002). Culturally adapted versions of CBITS for Latinos and American Indians have been developed (Chaffin et al., 2012b; Workgroup on Adapting Latino Services, 2008). Another trauma-focused intervention (Resilient Peer Treatment) has been identified as probably efficacious for abused African American youth. Several interventions for anxiety have shown some efficacy with ethnic m ­ inority youth (Huey and Polo, 2008). Group cognitive-behavioral therapy (GCBT) has been identified as possibly efficacious for African American and L ­ atino youth (see Huey and Polo, 2008). In addition, anxiety management training and CBT have been identified as possibly efficacious for African American youth. For conduct problems, a variety of approaches show some degree of efficacy; specific approaches tend to differ for African American and Hispanic/Latino youth. Consistent efficacy has been found for Multi­ systemic Therapy (MST) and Coping Power with African American youth, and for Brief Strategic Family Therapy (BSFT) with Latino youth. In addi- tion, MST has been effective with Native Hawaiian youth (Rowland et al., 2005), and in a small randomized controlled trial, The Incredible Years was found to be effective for maladjusted Chinese American youth (Lau et al., 2011). While these interventions have not been tested specifically with abused and neglected youth, there is no reason to believe they would not be effective with this population. In 2013 a comparative effectiveness review of parenting interventions, trauma-focused treatments, and enhanced foster care approaches that ad- dress child abuse and neglect was conducted under the auspices of the Agency for Healthcare Research and Quality (Forman-Hoffman et al., 2013). While the authors note the support for a number of promising treat- ment strategies, the review found that methodological gaps in the evidence limit the ability to compare results across studies adequately. The Bottom Line There are two big success stories in interventions for children affected by abuse and neglect. The first is TF-CBT. Tested extensively, it has been found effective for children and families from diverse backgrounds and circumstances and has been adapted specifically for foster children and chil- dren in residential care (Mannarino et al., 2012). TF-CBT has been widely disseminated throughout the United States, and there are well-established training models for the program.

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INTERVENTIONS AND SERVICE DELIVERY SYSTEMS 253 The second big success story is the application of well-established par- ent management training programs to child welfare populations. Many of these programs have been found not only to improve behavior problems caused by child abuse and neglect but also to impact child welfare outcomes such as reabuse and rereferral. The most pressing remaining questions relate to how these interven- tions can be taken to scale in the mental health and service settings where abused and neglected children receive their care. These questions about implementation and sustainability are not specific to interventions in child abuse and neglect. Questions specific to child welfare relate more to service planning and to how many of what types of interventions should be readily available or ordered for families in the child welfare system. The current approach is to order a single, limited intervention for each problem, which often results in a long list of services that families must complete as part of their child welfare case plan (Society for Prevention Research, 2004). As demonstrated by Chaffin and colleagues (2004), a single evidence-based intervention may actually be more effective for both child and system outcomes than multiple services designed to address the many different problems families may have. Finding: Significant advances have been achieved in the development of therapies that specifically target the impact of trauma or abuse on chil- dren. These advances include the extensive testing of TF-CBT models that have been shown to be effective. Finding: The application of well-established parent management train- ing programs with proven success to children and families involved in the child welfare system has been highly successful with regard to improved outcomes across behavioral problems caused by child abuse and neglect, as well as a reduced need for further involvement in the child welfare system across metrics such as reabuse and rereferral. Finding: More research is needed to explore how better to deploy effec- tive treatment intervention programs in the mental health and service settings where abused and neglected children receive care. Questions to be addressed relate to the types and breadth of services to provide for children and families, as well as how to sustain the impact of effective programs over the long term. PREVENTION STRATEGIES Over the past 50 years, child abuse and neglect prevention strategies evolved to draw on what was known about the scope of the problem at the

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254 NEW DIRECTIONS IN CHILD ABUSE AND NEGLECT RESEARCH time and beliefs about how best to prevent its initial occurrence. Respond- ing to the diverse causes of child abuse and neglect suggested by ecological theory, prevention strategists emphasized the development of a continuum of separate but integrated interventions designed to provide the array of therapeutic and support services necessary to shore up failing or vulnerable families. Within this framework, each component was equally important to achieving positive outcomes regardless of its target population; its targeted outcomes; and, in some cases, evidence of its effects. At the time of the 1993 NRC report, the concept of prevention had begun to shift from a horizontal to a more vertical structure in which particular emphasis was placed on initiating a strong relationship between parent and child at the moment a woman became pregnant or at the time a child was born (Daro, 2009; Daro and Cohn-Donnelly, 2002). The message changed from providing a plethora of prevention services to placing highest priority on building a network of services that would strengthen the sup- ports available to new parents and link these services in a more intentional and effective manner than had previously been the case. Support for new parents has taken many forms over the past 20 years, with leadership in these programs generally being shared by state health and human service administrators and community-based program advocates. A comprehensive review conducted in 1993 identified 37 major parent sup- port initiatives operating in 25 states; 9 states (Delaware, Florida, Hawaii, Kentucky, Minnesota, Missouri, Rhode Island, Vermont, and West Vir- ginia) offered statewide parent education and support programs, generally through their department of maternal and child health (Bryant, 1993). Key components of these state efforts included parent education, child health and developmental assessments, and health and social service referrals. These state initiatives, coupled with the continued expansion of several national home visiting models, have increased public policy interest in the pivotal role of early home visiting in this emerging system of early interven- tion services. The seminal work of Olds and colleagues showing initial and long-term benefits from regular nurse visiting during pregnancy and a child’s first 2 years of life provided the most robust evidence for the effectiveness of this intervention (Olds et al., 2007). Equally important, however, were the growing number of national home visiting programs being developed and successfully implemented by public agencies and community-based service organizations. Although initially not rigorous in their evaluation methodologies, programs such as Parents as Teachers, Healthy Families America, and the Parent-Child Home Program demonstrated respectable gains in parent-child attachment, access to preventive medical care, parental capacity and functioning, and early identification of developmental delays (Daro, 2011). The call for a major federal investment in home visiting programs was

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INTERVENTIONS AND SERVICE DELIVERY SYSTEMS 255 first voiced by the U.S. Advisory Board on Child Abuse and Neglect (1990), which cited the statewide system operating in Hawaii and the early findings of Olds and colleagues. While the U.S. Advisory Board’s recommendation was well received by child abuse and neglect advocates, substantial federal support for this strategy has only recently been provided. Authorized under the Patient Protection and Affordable Care Act (ACA) of 2010, the Mater- nal, Infant and Early Childhood Home Visiting Program will provide $1.5 billion to states, territories, and tribal entities to expand the availability of home visiting programs and create a system of support for families with children aged 0-8. As of the end of the 2012 federal fiscal year, the federal government had awarded $340 million in formula grants to 56 states and territories and an additional $182 million in competitive grants to selected states and territories that demonstrated the interest and capacity to expand and/or enhance their home visiting programs. A total of $21 million in funding also has been provided to multiple tribal entities for purposes of establishing home visiting programs targeting the unique needs of the Na- tive American population. In terms of direct research support, the legisla- tion provides funding for an interdisciplinary, multicenter research forum to support scientific collaboration and infrastructure building related to home visiting research. Beyond the broad implementation of home visiting programs, those seeking to prevent child abuse and neglect continue to design, implement, and assess a range of initiatives. These initiatives include, among others, parent education services; crisis intervention programs that provide tele- phone numbers for families facing an immediate crisis or seeking parenting advice, as well as crisis nurseries; education for children and adolescents on assault prevention, antibullying behaviors, and nonviolence; efforts to assess new parental concerns and service needs; public education to raise awareness and alter parental behaviors; and initiatives designed to change how health care professionals and others working directly with children recognize and respond to potential child abuse and neglect. In addition to targeting change at the individual level, prevention efforts focus on altering community context and implementing a variety of strategies to create social service networks and social environments more conducive to positive par- enting and healthy child development (Daro and Dodge, 2009). Compared with early home visiting, these efforts, in general, are more diffuse and less governed by national standards or expectations. Evidence for Effectiveness Today, prevention research is guided by a set of rigorous standards addressing research design and quality, such as the criteria for efficacy, effectiveness, and dissemination established by the Society for Prevention

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