National Academies Press: OpenBook

Understanding Child Abuse and Neglect (1993)

Chapter: 5 PREVENTION

« Previous: 4 ETIOLOGY OF CHILD MALTREATMENT
Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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5
Prevention

In the field of child maltreatment, the goals of preventive interventions are to reduce risk factors associated with child abuse and neglect, to improve the outcomes of individuals or families exposed to such risk factors, and to enhance compensatory or protective factors that could mitigate or buffer the child from the effects of victimization.

Overview

Building on the discussion in Chapter 4, the panel reviewed research on child maltreatment prevention within a framework that considers individual and family behaviors within a broader context, including the consideration of community, society, and developmental factors. This ecological, developmental model emphasizes the importance of interactive processes in the development of behaviors that lead to child abuse and neglect. In the past, the literature has been dominated by an orientation that emphasizes perceived weaknesses or problem behaviors that require correction and ignores protective factors that may influence outcomes. In recent years, some researchers have begun to examine variables that foster healthy relationships or reduce risk for child maltreatment (Cicchetti and Rizley, 1981; Rosenberg, 1987). The developmental perspective of the panel encourages consideration of significant research areas from the field of child development, such as attachment, autonomy and social relationships, peer competency, parental styles, and so forth, in the evaluation of preventive efforts for child

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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maltreatment. The interaction between risk and protective factors is the approach that the panel believes holds much promise for future prevention research.

The panel examined evidence of what appear to be promising prevention programs, such as home visitation, parental education, and child sexual abuse prevention curriculums. We also examined research on interventions not designed specifically for child maltreatment prevention but that may reduce such behavior by improving the welfare of families that are characterized by multiple problems or by reducing the use of violence in general. The research is organized by the system that is targeted—the individual, the family, the exosystem, or the macrosystem—as outlined in earlier chapters. The framework adopted by the panel in our review of these programs highlights the areas of strength and weakness in current knowledge about prevention strategies. Table 5.1 summarizes the broad range of major prevention programs by developmental period identified in 1988. Many of these interventions are discussed in this chapter. The availability of such programs, in terms of their accessibility by diverse populations, is not certain.

As noted in Chapter 4, a variety of interactive models has been proposed in recent years to describe different systems that influence the causes and consequences of child maltreatment. The interactive models seem particularly useful to guide prevention efforts because they suggest that intervention should take place on every level of the system and they offer a range of interventions that are sensitive to diverse cultural values affecting family life and parental practices. This approach assumes that the transactions between these levels of risk—for example, living in an at-risk neighborhood and in a family at high stress—are major influences on the occurrence of maltreatment rather than the presence of single risk factors. Therefore, the reduction of multiple vulnerabilities and the development of compensatory behaviors are emerging goals of child maltreatment prevention.

Although many advocates of the prevention of child abuse and neglect have encouraged the need for a continuum of services (Helfer, 1982), research on maltreatment prevention efforts has generally focused on a single type of maltreatment (physical or sexual abuse, neglect, or emotional maltreatment); a single intervention (such as family preservation programs or maternal-child health programs); or a single risk factor (poverty, alcohol, or harsh parenting). The approach of the panel in preparing a research agenda for the prevention of child maltreatment seeks to encourage the development of interactive research analyses by focusing on the processes by which multiple risk factors coexist in the family system and the family environment.

Our approach differs from that of the traditional public health model for prevention, which considers primary, secondary, and tertiary levels of pre-

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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TABLE 5.1 Types of Child Abuse and Neglect Prevention Programs

Type of Program

Perinatal

Toddler and Preschool Years

Elementary School Years

Junior and Senior High School Years

Before Birth

Infancy

PROGRAMS CURRENTLY AVAILABLE

         

Home visitor

         

Professional who visits

X

X

X

   

Lay visitors

X

X

X

   

Extended postpartum contact and rooming-in

 

X

     

Central-location parent education and counseling

X

X

X

   

"Total push" programs, which involve services (e.g., home visitor, parental education)

X

X

X

   

Respite nursery or day care

 

X

X

   

Child-targeted sex abuse prevention programs

   

X

X

X

Latch-key demonstration and education for children in self-care after school

     

X

 

Programs for pregnant and parenting teenagers

       

X

Telephone hotlines or "warm lines" for parents and children

 

X

X

X

X

Media campaigns

 

X

X

X

X

(table continued on next page)

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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TABLE 5.1 (continued)

Type of Program

Perinatal

Toddler and Preschool Years

Elementary School Years

Junior and Senior High School Years

Before Birth

Infancy

PROGRAMS NOT AVAILABLE (NA) OR INSUFFICIENTLY AVAILABLE (IA)

         

Father or stepfather-targeted abuse prevention

NA

NA

NA

NA

NA

Pedophile or perpetrator-targeted sex abuse prevention

   

IA

IA

IA

Education and counseling for parents of older children

     

IA

NA

After-school day care for school-age children; i.e., so-called latchkey child care

     

IA

 

SOURCE: Mueller and Higgins (1988:32).

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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vention. Although the public health model might be useful in the child maltreatment prevention field, we have not adopted it for the following reasons. First, although most child maltreatment prevention programs (with the exception of child sexual abuse programs) fall into the category of secondary prevention, the programs vary significantly by the type of maltreatment and interactional processes that are the focus of the program, the context of the prevention effort, the nature of the risk assessment process, and the developmental stage of the child. Second, adapting the public health model to child maltreatment research is difficult because many prevention programs are hybrids in terms of this framework. For example, treatment interventions often represent tertiary prevention programs for families that have been reported to child welfare authorities, but such interventions may also offer counseling for the child to mitigate the damaging consequences of maltreatment and to prevent maladaptive behaviors that could influence future parenting styles. Such interventions thus serve as a source of secondary intervention for the child who may become a future parent.

In this chapter, we will review research on prevention programs highlighting theoretical frameworks (where they exist) that guide the development of such programs, illustrating programs that have been evaluated in the professional literature, reviewing the state of current knowledge about the role of prevention in child maltreatment research, and identifying gaps as well as promising opportunities in constructing a research agenda for this area. This review focuses on promising prevention strategies that incorporate multiple factors that are believed to be most likely to be successful in reducing child maltreatment.

Most preventive interventions focus on one particular system within the panel's framework of analysis, as outlined in Chapter 4. Examples include programs designed to improve the parental skills and cognitive knowledge of high risk mothers (individual system); interventions designed to establish good interactions between parents and children, particularly infants (family microsystem); curriculum-based efforts that seek to develop skills for parenting, conflict resolution, and sexual abuse prevention in school-age populations, ranging from elementary to college students (exosystem); and legislative efforts or public campaigns designed to reform child welfare programs or the use of violence in the media and children's programming (macrosystem). Programs for sexual offenders (discussed in Chapter 7), including incarceration and various forms of treatment services, seek to prevent the reoccurrence of abusive behaviors, but systematic evaluations of these programs are rare. Although various advocacy organizations have urged that systemic change become part of the child maltreatment prevention movement, research on system-based factors has been limited.

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Risk Factors and Preventive Interventions

Risk factors are elements that predispose an individual to a dysfunction, although being at risk does not mean that the dysfunction is inevitable. Risk factors can be environmental or individual (including biological) or reflect an interaction between the individual and the environment. Many prevention efforts seek to modify particular risk factors in order to reduce an individual's vulnerability to the disorder (Felner et al., 1991).

As noted in Chapter 4, the etiology of child maltreatment is not yet well understood, but the existing state of knowledge about risk and protective factors can guide the development of future prevention research (Cicchetti et al., 1988; Kazdin, 1989; Willis et al., 1992). Examinations of single risk factors thought to play significant roles in pathways to child maltreatment (such as poverty, substance abuse, and childhood history of abuse) need to move toward studies of the interactions of multiple factors in a situational and developmental context. The transition from single causes to multiple interactions complicates the design of prevention research, and many prevention programs are characterized by an absence of theory demonstrating the etiological factors that the program seeks to change.

To be effective, prevention research needs to establish a clear link between a reduction in selected risk factors and an ultimate decrease in abuse. Until recently, the primary or even sole focus in designing preventive interventions was the identification and modification of problematic or damaging parental practices associated with child maltreatment, such as excessive physical discipline, failure to provide children with basic necessities and care, and mismatches between a parent's expectations and a child's ability (Daro, 1992).

As noted by Daro (1992), this singular focus on parental roles was altered with the recognition of the prevalence of sexual abuse in the late 1970s. Research on victims of sexual abuse suggested that risk factors with respect to perpetrator characteristics, victim characteristics, and sociodemographic variables are far more heterogeneous than physical abuse or neglect victims (Melton, 1992). As a result, prevention advocates had limited information for formulating effective prevention strategies targeted to potential perpetrators or communities in response to sexual abuse.

In the area of sexual abuse, prevention advocates focused on ways to strengthen potential victims to reduce the occurrence of child sexual abuse (Finkelhor, 1984). These efforts, generally identified as part of child assault prevention—or child safety education—provide classroom-based instruction for children of all ages on how to protect themselves from sexual assault and ways to deal with the experience of actual or potential abuse. The primary focus of the school-based programs is to strengthen a child's

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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ability to resist assault, although these programs often include information sessions for parents and school personnel.

The child assault prevention approach has been supplemented in recent years by an emphasis on violence prevention programs, designed to equip students to develop nonviolent methods of conflict resolution in peer relations. Although the generalizability of these programs to the field of child maltreatment has not been systematically assessed, they are included in this review because such programs represent a promising direction for future research. This belief is based on the following assumptions: maltreating families are often characterized by a syndrome of multiple problems (including violence), the use of violence against children may be linked to other types of violent behavior, and efforts to reduce the use of violence in resolving individual conflicts may lead to a reduction of child maltreatment.

Summary

Most studies of prevention of risks for maltreatment have sought to isolate the relative significance of risk factors within the family, including poverty, social isolation, age and education of the mother, unrealistic parental expectations, and prior history of child maltreatment. In designing preventive interventions, researchers have given very little attention to interactions among multiple variables in the determination of risk status for subsequent child maltreatment. Efforts to target a single risk factor are not likely to be as effective in preventing maltreatment as programs based on an ecological developmental model, particularly one focused directly on the family.

The Family Microsystem

We begin with a review of parenting education programs because they represent the bulk of existing prevention efforts. The panel believes that exciting research developments exist at other levels of the framework used in this analysis, which convey new insights into the value of a multiple-level approach. These are discussed later in the chapter.

Parental practices in families with young children are a major focus of research on prevention strategies for child maltreatment. Young children spend most of their time in familial settings—even with the increase in maternal employment and the use of child care services, families still provide the bulk of child care (Baydar and Brooks-Gunn, 1991; Hayes et al., 1990). For most abuse and neglect, or the punitive or rejecting parental behavior associated with abuse and neglect, cases of young children are less likely to come to the attention of service providers than are cases of older children and youth, since infants and preschoolers are not in any universal

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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societal institution such as the school system. In the early years, the only time that virtually all children came into contact with a service organization is at birth. Although the majority of children in the United States receive immunizations within the first year of life, not all children have repeated contact with a regular health care provider.

From a prevention perspective, targeting young children and families is critical. The transition to parenthood is a period in which marital conflict, depression, and social isolation can occur, in addition to the inevitable realignment of roles inside and outside the home (Belsky, 1991; Cowan and Cowan, 1988; Deutsch et al., 1988; Egeland and Erickson, 1991; Entwhisle and Doering, 1981; Ruble et al., 1990). Parents may be particularly responsive to interventions during this life transition, given their experience of simultaneous changes, their often limited knowledge about parenting, and their desire to be effective parents. Not surprisingly, then, the majority of primary prevention programs for child abuse and neglect focus on this transition, beginning either prenatally or just after the child's birth and continuing through part or all of the first year of life or even through the second and third years.

Pathways to Parental Practices

Prevention strategies have built on individual, familial, and community-level risk and protective factors that contribute directly to both parental practices and to child well-being. This research foundation has provided the basis for identifying families that are at risk for parental practices associated with child abuse and neglect. Generally, groups have been targeted for prevention efforts by either individual or familial risk factors. In some cases, communities (or hospitals) with a high incidence of families with biological or other individual risk factors are chosen as the site of a prevention effort, with further targeting of at-risk individuals within these already high-risk communities. Increasingly, communities are becoming the target of early intervention programs, as the importance of offering comprehensive, coordinated services is recognized (Schorr, 1988).

The dimensions of prevention services focusing on families with young children vary by delivery setting (home, school, community center, clinic), primary target (family, parent, child), timing of onset (prenatal, infant, toddler, school-age, adolescent), intensity (amount of programming per week), scope and length of program, uniformity of services to client, number of services offered, training of service provider, and curriculum content. While many prevention programs focusing on parental practices have been developed and implemented over the past decades, only a handful have been evaluated in the scientific literature, often measuring outcomes such as the acquisition of cognitive or behavioral skills and observational studies of

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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parent-child interactions. Very few parenting programs have been evaluated in terms of their effects on child maltreatment.

Incidents of child maltreatment may be difficult to identify in the aftermath of preventive interventions (unless such incidents are reported to government authorities). Therefore, improvements in intermediate or surrogate measures are often viewed as indicators of reduced risk status. But here again, uncertainty remains as to whether such measures are correct proxies for child abuse and whether a parent's improved knowledge of childrearing skills is a sufficient measure of effectiveness given the multiple pathways that may result in child maltreatment.

While many child maltreatment prevention programs have the reduction of abuse and neglect as a goal, most programs focus on intermediate or surrogate outcomes, such as parenting behavior, childrearing attitudes, maternal mental health, maternal problem-solving and use of health and social services, subsequent fertility, maternal employment, job training, and school completion (Benasich et al., 1992; Clewell et al., 1989; Olds, 1990). As research reviewed in Chapter 4 indicates, certain types of parenting styles or indicators of maternal well-being are associated with abuse and neglect, suggesting that home visiting and center-based programs with a parental focus can help prevent child abuse and neglect. Indeed, almost all programs aimed at enhancing child competence employ parent-oriented strategies.1

As we discuss in Chapter 4 and Chapter 6, we still know very little about pathways for the development of maltreating behaviors in parents, and the sequelae of physical and sexual abuse, parental rejection, parental emotional unavailability, and parental neglect are poorly understood. Important developmental challenges that occur in early childhood have been a focus for prevention because of the recognition of parents' (or more generally, the caregiver's) role in facilitating child well-being. Models of risk and vulnerability as well as family systems and ecological models speak to various factors that promote or restrain development (Bronfenbrenner, 1989; Garmezy and Rutter, 1983; Hinde and Stevensen-Hinde, 1988; Reiss, 1981; Werner and Smith, 1982).

Prevention Programs for Families with Young Children

Four major types of prevention strategies have been developed for families with young children (defined as the prenatal period through age 8) who are at risk of significant social or health problems: (1) comprehensive programs, often including home visitor services that vary widely in both scope and content, (2) center-based programs that include a family support component, parent information services, and early childhood education services, (3) community-based organizations, including voluntary and grass roots services,

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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and (4) hospital-based interventions. Most of these programs have focused on multiple risk factors, and the evaluations of program outcomes focus primarily on child health measures. Only a few have been evaluated in terms of their impact on child maltreatment.

Comprehensive Home Visitation Programs

The majority of home visiting models or short-term, neonatal nursery-based interventions have been developed for children at biological risk of a host of poor outcomes, but they were not developed specifically for child abuse and neglect (Bennett, 1987; Brooks-Gunn, 1990). Home visiting programs initially focused almost exclusively on low-birthweight and preterm children, providing services only in the home environment. A notable exception is the Infant Health and Development Program, which combined home visiting and center-based programming for low-birthweight, premature infants and toddlers and their parents (Brooks-Gunn et al., 1992; Infant Health and Development, 1990; Ramey et al., 1992). Programs for children exposed to drugs in utero are being initiated across the country, but the majority of prior prevention programs in the field of substance abuse have not been guided by empirical data (Kumpfer, 1989).

Home visiting programs designed to provide universal services for all new mothers were popular earlier in this century and continue in many European countries. In the United States, a resurgence of interest in home visitation occurred in the last decade, and the audience for such programs has expanded from children solely at biological risk (from low-birthweight or pre-term births) to children who are at risk because of poverty or child maltreatment. Approaches based on a variety of models that have been initiated and evaluated in the last 10 years include a parent education model (Dunst et al., 1989), a public health model (Olds et al., 1986a,b, 1988), a social support model (Barnard et al., 1988), a mental health model (Greenspan et al., 1987), a parenting education and problem-solving model (Wasik, 1984), and an interactional attachment model (Egeland and Erickson, 1991, in press). Overlaps among these models exist (for example, the public health model includes social support and parenting as program components).

Olds (1990) has reviewed a number of home-based programs. Generally, home visitation programs start during a woman's pregnancy and continue through the first or second years of her child's life (a few begin postnatally). Many home visitors come to the mother's home weekly, others less than once or twice a month. Almost all programs focus on the mother, rather than on other caregivers such as the father or the grandmother.

Programs are likely to focus on environmentally at-risk parents: those who are poor, are young, are single, and have low education. These factors

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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often co-occur in families, making it unlikely that programs have been offered only to one group of poor mothers (the one exception are programs specifically targeting teenage mothers) (Clewell et al., 1989; Klerman, 1991). In a few instances, at-risk communities are being targeted, as in the Hawaii Healthy Start initiative (Fuddy, 1992).

The training and experience of home visitors vary across programs—the public health models use public health nurses, whereas other models employ social workers, early childhood educators, and, in some cases, paraprofessionals.

Home visitors often expand the participant's knowledge about available services and the participant's ability to obtain these services. Home visitors also refer their families for social, educational, welfare, and health services, but such referrals are often not documented even though they may make a large impact on families. For example, Olds (1986a,b) reports that mothers who received home visiting completed more education than those in a control group. Brooks-Gunn and colleagues (in press, b) report that mothers with more educational experience who received home visiting were more likely to receive Medicaid-reimbursed health insurance and Aid to Families With Dependent Children than similarly educated mothers who did not receive home visiting services (presumably these mothers were eligible for these service but were unaware of their eligibility).

The most scientifically rigorous program evaluation of a comprehensive prevention program documented in the literature is the Prenatal/Early Infancy Project conducted by Olds and associates (1980, 1982, 1984, 1986a,b, 1990, 1992). One significant feature of this secondary prevention program is the use of nurse home visitation services for expectant mothers and their families in Elmira, a rural section of upstate New York. Elmira County was part of the standard metropolitan statistical area rated the worst in the United States in 1980 in terms of economic conditions (Boyer and Savageau, 1981), and it had the highest rates of reported and verified case of child abuse and neglect in New York State from the early 1970s through the mid-1980s (Olds, 1992). Of 400 women registered for the study, 90 percent were white, and all of the major findings reported by Olds apply only to this group (Olds, 1992). The Prenatal/Early Infancy Project is characterized by the use of professionally trained nurses as home visitors as well as a rigorous evaluation methodology that includes random assignment of subjects to four treatment groups.2 The project evaluated prenatal, birth, and postnatal outcome variables, including length of gestation, infant birthweight, quality of maternal interactions with the child, disciplinary behaviors, child maltreatment reports, and postnatal emergency room visits. The major finding of the project was that nurse home visitation services significantly reduced the number of subsequent child maltreatment reports, compared with the control population. The reduction was especially significant among fami-

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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lies judged to be at high risk for child maltreatment. The program is now being tested in an urban center in Memphis, Tennessee, with a sample of 1,100 low-income black families to study the generalizability of the findings (Olds, 1992).

The relatively small sample sizes in these studies generally do not provide enough statistical power to assess differences in child abuse and neglect among treatments (Olds, 1990). Although few home visitation programs report actual rates of child abuse and neglect (see review by Olds, 1990), evaluations have assessed risk factors for child maltreatment such as unstable relationships, social isolation, maternal education, personal adjustment and mental health of parents, limited childrearing skills, lack of knowledge about child development, unrealistic expectations and attributions, the quality of the relationship between parent and child, and harsh or punitive parenting.

One frequently cited study compared reported (state-verified) cases of child abuse and neglect over the first two years of the child's life for a subgroup of the Elmira Project mother—those who were poor, unmarried teenagers—with a comparable control group (Olds et al., 1986a,b): the rate was 19 percent in the control group and 4 percent in the nurse visitation group. Two other smaller programs conducted over a decade ago in Denver, Colorado, and Greensboro, North Carolina, also reported on verified cases of child abuse and neglect and found no treatment effects (Gray et al., 1979; Seigel et al., 1980), although they did not divide their sample into subgroups, as did Olds and his colleagues. However, in the Denver program, like the Elmira Prenatal Early Infancy Project, mothers in the home visitation group had more visits to the hospital for serious injuries (a possible marker for abuse and neglect). In the Elmira project, parental practices, as observed in the homes, were less punitive and restrictive in the young mothers who had received the home visitation services. Similar (but modest) effects were seen the Greensboro program.

In his review of 12 well-designed randomized trials of home visiting, Olds (1990) suggests that the most successful programs could be characterized as follows: first, they were designed on comprehensive models, including a focus on maternal, social, behavioral, and psychological factors; second, the schedule included frequent visits and the visitor engaged in positive interactions with the mother, which are believed to have facilitated a relationship between the family and home visitor; and third, the programs targeted at-risk families. He concluded that social support during the prenatal months by itself will not alter birthweight outcomes, and that prenatal visits, by themselves, will not alter maternal and child well-being if not followed by postnatal visits. However, few trials (the Elmira project is the exception) have included different treatments or different home visiting patterns (i.e., pregnancy, post-pregnancy, neither, both) in order to test these premises directly.

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Another recent home visitation program that has received significant attention is the Healthy Start program sponsored by the Maternal and Child Health Branch of the Hawaii State Department of Health. The Hawaii program seeks to target families at the time of birth that are at high risk for future incidents of child maltreatment and provides intervention to foster healthy child development and family self-sufficiency. Home visitors visit families weekly, based on their level of need, with the schedule of visits lasting about a year, diminishing to monthly and finally four visits per year until the child reaches age five. To date, only limited evaluations have been conducted to examine the effectiveness of the Hawaii Healthy Start program by comparing child maltreatment reports for families enrolled in the program with those of other high-risk or state populations.3 Initial results suggest that abuse rates are substantially lower among high-risk families served by the program than among high-risk families who do not receive services. Abuse rates among families identified as low risk are also lower than the state average (Fuddy, 1992).

Center-based Programs

In contrast to the home visitation programs discussed above, which directly target families reported for or at risk of child maltreatment, a number of family-oriented programs have been developed to improve the general welfare of children whose families are characterized by multiple problems, including child abuse and neglect. These programs often require that family members (usually the mother) attend special classes or counseling sessions in a center that offers a wide range of resources. Family support programs may be effective in reducing the prevalence of child maltreatment by addressing multiple risk factors associated with abuse and neglect, including disabilities, poverty, family violence, and poor health. However, the comparative effectiveness of general family support programs and center-based programs that target families based on psychosocial factors associated with poverty, child abuse, punitive parenting, and child failure, such as stressful life events, maternal depression, and low social support, has not been evaluated.

Some center-based programs, which usually start in the first or second year of life, have resulted in cognitive and school improvements for children who have severe developmental delays (e.g., cerebral palsy, Down's syndrome) (Meisels and Shonkoff, 1990; Shonkoff and Hauser-Cram, 1987; Shonkoff et al., 1992). Child development centers, which also provide early center-based intervention, reported sustained effects as well (Bridgemen et al., 1981).

A majority of center-based programs for groups at familial environmental risk focus on poor children. A review of the results from 11 separate

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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(primarily preschool) programs indicates that most children in these programs demonstrated the efficacy of early education immediately following the treatment (Lazar et al., 1982), including significant reduction in grade failure in the middle of elementary school (Ramey, 1991; Wasik et al., 1990). The majority of children from disadvantaged families are served by federal initiatives such as the Parent-Child Development Centers (PCDC) and, for older children, Head Start. Some programs target teenage mothers who, in general, are also poor (Chase-Lansdale et al., in press; Clewell et al., 1989; Klerman, 1991). Programs designed for teenage mothers and for poor mothers include large proportions of single mothers, mothers on welfare, and minority families (Chase-Lansdale and Brooks-Gunn, in press; Duncan, 1991; Huston, 1991).

Community-based Programs

A wide range of community-based programs target poor communities, including national or state programs such as Healthy Start, Fair Start, Head Start, Healthy Beginnings, and the Children's Initiative. These forms of community intervention programs seek to improve health care and social services for families at risk of a range of social and health problems (including low birthweight, teenage pregnancy, as well as child abuse and neglect). Such programs avoid the risks of labeling families and can be integrated into ongoing community services (beyond the demonstration stage) if they are seen as benefiting the entire community. Neighborhood or community-level interventions allow for an examination of differential effects of programs for various groups of families or families with a particular pattern of risk factors (see the Elmira Prenatal/Early Infancy Project, targeted toward families at risk of child health problems, and the Infant Health and Development Program, targeted for low birthweight and premature infants and their parents, as examples; Olds et al., 1986a,b, 1988; Brooks-Gunn et al., 1992, in press a,b). But, apart from the Olds studies of the Elmira project, few community intervention programs have examined the impact of their services on child abuse and neglect.

Community-level interventions are often expensive. Most family-oriented community programs have sought to minimize costs and maximize benefits by targeting poor neighborhoods, in which the majority of parents have at least one known familial risk factor (i.e., poor, single, on welfare, teenage mother, substance abuse).

Several community programs that have followed preschool children report significant effects persisting into the high school years. Reduction in juvenile delinquency and increases in high school graduation have been reported (Zigler, 1992). These few, small studies suggest that community programs for young children may have long-term effects on factors associ-

Suggested Citation:"5 PREVENTION." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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ated with educational and job success and, by inference, spillover effects on the poverty status of the next generation (Brooks-Gunn et al., 1992).

Although few programs have tested the premise that early childhood interventions may have a differential impact and may be particularly effective for the most at-risk families, two studies have supported this finding. The Infant Health and Development Program found that the intervention was most effective for mothers with low compared with high educational attainment; this was true for both African-American and white families (Brooks-Gunn et al., 1992). An analysis of Head Start attendees in three sites nationwide suggests larger effects for African-American than for white families (Lee et al., 1988). This finding may be associated with the fact that poor African-American families are much more likely to live in poor neighborhoods, to be comprised of a single parent, to have been poor longer, and to be more poor than poor white families (Liaw and Brooks-Gunn, in press).

While benefits clearly accrue to poor children, what about the mothers? And do such benefits lead to a reduction in the frequency or severity of child maltreatment? Not all center-based programs for young children report their effects on maternal or familial outcomes, or their effect on reported cases of child abuse and neglect, even though all pay lip service to the relevance of their programs for families. In a recent review of 12 center-based programs begun in the first three years of life for poor families, 7 of the 12 looked at maternal employment as an outcome, and 6 found increased employment for mothers in the intervention group. Of the 12 programs, 5 have reports on parent-child interaction via observation. All but one found that parents in the intervention group had better interaction skills (i.e, positive and supportive interaction, less criticism) than mothers in the control group. The home environments of mothers in such early intervention programs also provided more stimulating learning experiences in all of the studies that looked at the home (Benasich et al., 1992). Mothers also scored higher in warmth and acceptance as a function of early intervention in these studies.

For all three maternal outcome measures just reviewed, similar findings are reported in the one center-based program for children at biological risk—the Infant Health and Development Program (Spiker et al., in press; Bradley et al., in press). Whether these maternal effects are sustained into the elementary school years is not known (Woodhead, 1988; Zigler, 1992). Also, these programs do not report on child maltreatment—a major limitation.

Another group of community-based organizations includes the grassroots volunteer groups such as La Leche League, midwifery programs, and local Visiting Nurse Associations. These programs, often have been in existence longer than the more comprehensive community maternal-child services dis-

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cussed above, and they appear to play useful roles in decreasing infant mortality and morbidity. Grassroots organizations may exercise some role in preventing child abuse and neglect as well, since they routinely work with high-risk or stressed families, but the scientific literature regarding their operation and outcomes is too limited at present to allow for systematic evaluations regarding their impact on child maltreatment.

In the past decade, a number of community-based interventions have been developed to address the problem of domestic violence (Ohlin and Tonry, 1989; Stark and Flitcraft, 1991). These programs include a range of services, including law enforcement and judicial programs designed to protect women who are victims of physical or sexual assaults by their husbands, as well as battered women's shelters that offer housing, financial, and counseling services to victims of domestic violence and their children. Domestic violence treatment programs may offer some promise in preventing child maltreatment as well. However, the scientific literature regarding the impacts of domestic violence treatment programs on the children who witness spousal assaults, or who may be subject to violence themselves, is too limited at this stage to provide a basis for inferences by the panel.

Hospital-based Interventions

Many hospital centers, clinics, and health professional groups have sought to provide opportunities for parent-child interactions in the neonatal period, recognizing that the quality of parent-infant attachment and bonding in the immediate postpartum period has significant implications for child development (Egeland and Erickson, 1991). Examples include the policy of encouraging mothers to room-in with newborns and the using educational videos for both mothers and fathers at major hospital centers (Holden et al., 1992). The objectives of these services are to heighten parental awareness of the significance and implications of neonatal cues and to identify and correct faulty parental expectations and perceptions of infant behaviors.

Early proponents of hospital mother/child rooming-in policies investigated its effects on subsequent child maltreatment. In two separate studies, O'Connor et al. (1980 and 1982) randomly assigned first-time mothers to rooming-in and no rooming-in conditions to evaluate the impact of this arrangement on subsequent rates of child maltreatment. The 1980 study showed some positive effect of rooming in by the time the child was 17 months in the families that received rooming in, but the 1982 study was more equivocal since prenatal assessments of the risk status of the mother for child maltreatment affected rooming-in assignments (Hollis et al., 1992). Studies by Gray (1983) also examined child maltreatment outcomes with respect to groups that differed in the amounts and timing of maternal-child contact in the neonatal period. Initial evaluations, based on self-reports,

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suggested no significant differences across the four participating groups, although high rates of subject attrition may have biased the outcome evaluation (Holden et al., 1992).

In addition to early and extended contact strategies, researchers have acknowledged the need to emphasize the capabilities and limitations of newborns for parents, enhance parent-child interactions, and thus address factors that may lead to child maltreatment. A large number of investigations have indicated that programs that encourage parents to practice eliciting responses from their newborns have positive effects on parent-child interactions several weeks to several months postnatally (Holden et al., 1992). However, the effectiveness of this intervention does not depend solely on the cognitive information or demonstrations; motivational factors are particularly significant (Belsky, 1985). Although quite promising, no investigation to date has evaluated the effects of newborn demonstration projects on subsequent rates of child maltreatment (Holden et al., 1992).

Drotar (1992) notes that medical intervention that identifies and corrects physical and nutritional deprivation in infants and young children is not sufficient to prevent the chronic psychological and physical deficits associated with child neglect. A crucial element in successful prevention programs is the development of active and persistent contacts between the caseworker and the parent, emphasizing the parent's role and ability to improve their child's condition, to create a sense of optimism regarding the child's future, to negotiate directly areas of conflict or confusion regarding the standards of adequate care that should be implemented by the parent, to maintain support and advocacy for the parent, and to develop a social system that can maintain the parent once the intervention effort is completed.

Summary

Almost all early intervention programs target the parent (Benasich et al., 1992; Clarke-Stewart and Fein, 1983). Strategies include helping the parent, usually the mother, improve her interactions and teaching skills with her child, providing the mother with problem-solving skills, raising the mother's self-esteem and emotional functioning, and increasing maternal knowledge about child development. Promising design features for parent enhancement efforts with diverse populations include supporting parents in their childrearing responsibilities prior to or as close to the birth of the first child as possible, linking parental enhancement services to a child's specific developmental level, providing opportunities for parents to model the interactions or discipline methods promoted through the interventions, recognizing cultural differences in family and parental styles, and providing referrals for social supports and needed assistance to ensure the safety of the child beyond the immediate intervention period (Daro, 1992).

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Although some well-designed, randomized control, clinical trials exist, many early intervention services lack a theoretical framework and their mission is not always well defined (for example, are home visitation programs ''rescue missions" or "crisis management services" for troubled families, or are they efforts to change parental attitudes and behavior?). While some interventions demonstrate that knowledge about child development can be transferred to parents in a relatively brief period of time (i.e., 6 to 12 weeks), a time commitment of six to twelve months or more is often needed to change attitudes and strengthen parenting and personnel skills (Daro, 1992). Short-term, low-intensity programs (such as hospital-based neonatal interventions) are not sufficient, by themselves, to alter long-term parent-child relationships to reduce the incidence of child maltreatment. Prevention programs need to focus directly on families most at risk for maltreatment, to accommodate families with differing needs and experiences, and to adapt to changing family situations.

The Exosystem

In the panel's framework of analysis, the third level of prevention programs includes interventions within the various state, institutional, school, workplace, and other community systems that influence family functioning. The large majority of existing programs in the exosystem focus on prevention of physical and sexual abuse.

Child maltreatment prevention programs are usually found in the schools: they are primarily child sexual abuse prevention programs designed for children in elementary and high schools. In addition to major efforts in child sexual abuse prevention, two other efforts were reviewed by the panel that may have implications for the prevention of child abuse and neglect. These are the violence prevention programs in the schools designed to educate children, primarily adolescents, about conflict resolution skills, and community-based antipoverty programs, some of which involve vocational or educational assistance. Although such programs may be important in helping improve the welfare of many families, they have not been systematically evaluated in terms of their outcomes for child abuse and neglect.

The Role of the States and Child Abuse
Prevention Challenge Grants

Recognizing the costs of the consequences of child abuse and neglect, the Congress established a program for Child Abuse Prevention Challenge Grants as part of the Comprehensive Crime Control Act of 1984 (P.L. 98-473). The purpose of the legislation was to provide incentives and a source of funding for the states that would be dedicated to preventing child abuse

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and neglect as well as treating its consequences (General Accounting Office, 1991).

The Challenge Grants Program, funded at $5 million per year, is the only federal funding program dedicated solely to prevention of child abuse and neglect. Additional sources of federal funds can be used to support prevention activities (such as block grants to states included in title XX (Social Services) and title IV-B (Child Welfare Services) of the Social Security Act, but these programs do not require reports from the states on how the funds were spent (General Accounting Office, 1991). States also often draw on other funding sources from a broad range of programs, including day care, teenage parenting, parent education, family counseling, and respite care, in supporting their applications for Challenge Grant funds, but many of these applications are often disallowed after scrutiny by federal officials. As a result, records of the scope and nature of federal and state prevention program efforts in the area of child maltreatment are limited.

The Challenge Grants were designed to assist the states in developing trust funds to endow state programs specifically for the purpose of prevention. Four categories of prevention activities were defined in the program legislation: (1) education and public information seminars, (2) education for professionals, (3) dissemination of information to the public, and (4) development of community prevention programs. According to the General Accounting Office (1991), the states have reported spending 70 percent of their challenge grant funds on the last category alone.

Although community prevention activities constitute the major area of programmatic efforts within the states, no research evaluations have been conducted to study the outcomes of the program activity.

School-Based Sexual Abuse Prevention Programs

Current preventive interventions rest on several core assumptions that influence many programs and materials designed to help children prevent or escape sexual abuse: many children do not know what sexual abuse is, that sexual touch need not be tolerated, that adults want to know about children who experience sexual touches by older persons, and that disclosure of sexual abuse will help stop it (Conte and Fogarty, 1990; Kolko, 1988; Tharinger et al., 1988). Most prevention materials also incorporate several key concepts outlined by Conte et al. (1986): children own their own bodies and can control access to their bodies; the touch continuum recognizes that there are different kinds of touches (e.g., safe and unsafe); secrets about touching can and should be told; and children have a range of supportive individuals whom they can tell about touching problems. Some programs encourage children to trust their own feelings so that when a situation feels

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uncomfortable or strange they should "go and tell." Others encourage and teach children how to say "no."

Sexual abuse prevention programs have a wide variation in the range of materials presented, the length of the program, the vocabulary that describes the concepts, the location of the program (home or school), the format of presentation (e.g., video, instruction by adult trainers, printed matter), the degree to which the child interacts with the material (e.g., reads a book or role plays the skills), and the occupation of the trainer (Reppucci and Herman, 1991). Programs generally consist of short presentations, although some curricula involve more than 30 short sessions (Committee for Children, 1983).

The tendency to avoid explicit discussions of sexual behavior in the schools has emphasized protective, rather than sexual, themes in the curricula (Finkelhor, 1986), stressing concepts such as good and bad touches and discussions of bullies or relatives who forcefully try to kiss a child (Reppucci and Herman, 1991). The development of sexual abuse prevention programs for children under the age of 10 has been controversial because of criticisms about the appropriateness of teaching young children concepts and actions for understanding and repelling sexual abuse, the absence of consideration of children's developmental capacities in the design and implementation of such programs, the fairness of focusing prevention programs exclusively on potential victims rather than perpetrators, and uncertainties about long-term or unanticipated consequences of such programs on sexual and intimate behaviors (Conte, 1992; Leventhal, 1987; Melton, 1992; Reppucci and Herman, 1991).

Many programs have tried to involve parents, often with disappointing results (Berrick, 1988). Parent programs are rarely evaluated (Miller-Perrin and Wurtele, 1988; Reppucci and Haugaard, 1989). For example, in one study, only 39 of 116 parents whose children were participating in prevention programs attended the parent education meetings (Berrick, 1988). Furthermore, participating parents are likely to be better informed and more likely to discuss sexual behavior and sexual abuse issues with their children anyway (Porch and Petretic-Jackson, 1986).

Evaluations of several different programs using a variety of training formats have been conducted extensively (Binder and McNiel, 1987; Conte et al., 1985; Downer, 1984; Garbarino, 1987; Wolfe et al., 1986; Wurtele et al., 1987, 1989). Typical of these results, Kenning et al. (1987), evaluating the effectiveness of Child Assault Prevention (CAP), found a significant difference in posttest scores for first and second graders on a 25-item knowledge questionnaire.

Few programs examine intimate or long-term types of sexual abuse, molestation by parents, or the concept that some "bad" touches can be sexually arousing (Reppucci and Herman, 1991). Curricula that employ

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concrete concepts and an interactive learning experience, including rehearsal and modeling, appear to be most effective, such as the studies conducted by Kraizer and her colleagues that use role-playing techniques focused on stranger abductions (Fryer et al., 1987a,b; Kraizer et al., 1989). Although some sexual abuse prevention programs seek to expose abuse, the effectiveness of the program in achieving this goal needs to be more systematically assessed, since current data do not support this desired program effect.

Some studies have examined the issue of negative effects or unanticipated consequences of sexual abuse prevention programs on sexual behaviors and intimacy. Although there is no evidence of adverse long-term effects from such programs, some investigators have documented postprogram anxiety among a small proportion of children (usually 5 to 10 percent of participants) in the form of nightmares, upset stomachs, or similar symptoms (Daro, 1988; Gilbert et al., 1988; Kleemeier and Webb, 1986; Swan et al., 1985; Wurtele, 1988; Wurtele et al., 1989). Empirical data do not currently support fears that prevention programs will have negative consequences for most children, such as increasing anxiety or creating behavioral problems. One comprehensive multisite study of the impact of sexual abuse prevention programs on preschool children was prepared by the Berkeley Family Welfare Research Group (Daro, 1988; Daro et al., 1987; Gilbert, 1988). The Berkeley evaluation reviewed seven representative curricula for preschool children4 and questioned the developmental readiness of preschoolers to understand the fundamental concepts conveyed in these programs.

Although sexual abuse prevention education programs have generally achieved the goals of teaching prevention knowledge and skill acquisition, it is not clear that these gains will be retained over time or would be useful to a child in an assault situation, especially if the offender was a relative or trusted adult.

Less is known about the efficacy of child sexual abuse prevention programs compared with prevention efforts (such as parental enhancement programs) directed primarily at the physical abuse and neglect of children. There is more disagreement in the child safety field about the key concepts and approaches that should guide the development and implementations of child sexual abuse prevention programs. At this juncture, it seems critical for child sexual assault prevention programs to create more formal and extensive parent and teacher training components. Efforts should be expanded to include extended after-school programs and more in-depth discussion opportunities for certain high-risk groups (e.g., former victims, teenage parents) (Daro, 1992).

Improvements in child sexual abuse prevention programs need to be considered in terms of developing curricula with a more balanced developmental perspective, identifying what skills will make a child less susceptible to sexual abuse in a variety of situations at different age levels, provid-

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ing opportunities for children to rehearse prevention strategies, offering feedback on a child's performance to facilitate a child's depiction of their involvement in abusive as well as unpleasant interactions, and developing longer programs that can be integrated into regular school curricula and practices (Daro, 1992). Skills learned by a child that are appropriate for stranger abduction situations may not be transferable to assaults involving trusted adult figures (Conte, 1989). The use of role playing and in vivo assessment situations is a promising new technique in the formation of effective prevention programs, but such approaches raise important ethical issues that need to be considered carefully before exposing children to them (see discussion in Chapter 9).

Other Community-based Prevention Programs

Preventive interventions focused on various aspects of community life have been proposed as part of an interactive systems approach to reducing child maltreatment. Potential intervention sites are included in the following discussion, although the panel notes that many such approaches have not been evaluated in the professional literature and their impact on child maltreatment remains uncertain.

Antipoverty and Vocational Training Programs

As noted in Chapter 4, poverty has consistently been associated with child maltreatment, particularly child neglect. Programs designed to improve the income of poor families, especially those headed by a single parent, could become a major source of prevention of child neglect. At a time when higher education has become a mandatory requirement for well-paying jobs, programs designed to increase the career options of young parents through educational and vocational training efforts are commonly viewed as part of the preventive spectrum for child maltreatment (Chase-Lansdale and Brooks-Gunn, in press; Huston, 1991).

But antipoverty or vocational training programs are often not sufficient to deal directly with the complex set of psychological, social, and biological factors that increase risk for child neglect. This behavior may be only one expression of other inadequacies in the parent's life, many of which become apparent early in adolescence (Polansky et al., 1972a, 1981, 1992). Others have argued that child neglect behaviors are responses to the experience of poverty, for which the parent is only partially responsible (Pelton, 1989). Furthermore, the change and unpredictability associated with the lifestyles of neglectful families often affect their involvement in programs that require a commitment to a consistent schedule of meetings.

As a result, some "two generation" programs have sought to incorpo-

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rate multiple dimensions of vocation training and parent-child interactions. The distinctive features of the two-generation model includes the goals of: (1) self-sufficiency services designed to improve the parent's education level, vocational skills, and employment status and (2) child development services that may include preventive health care, parent education, day care, and early childhood education. One such program is New Chance, a multisite research and demonstration program designed to improve the life prospects and parental skills of young welfare mothers. These programs, and others created as part of the Family Support Act of 1988 (P.L. 100-485), are designed to deal with many of the risk factors associated with child abuse: job training, education, parenting, health, and child development. New Chance is located at 16 different program sites across the country. At each site, the services and activities include building human capital, enhancing personal development, enhancing child development, and case management and counseling.

Educator and Child Care Staff Training

Day care providers, teachers, principals, and others who have ongoing and long-term contact with children are in a position to identify suspected victims of maltreatment and report them to child protective services. Such interventions can be a source of reduced incidence for the recurrence of child maltreatment and may prevent incidents when the offenders become aware that they can be reported for abusive or neglectful actions. Day care providers, educators, and other youth service personnel require training in the identification of child abuse and neglect, guidance in reporting suspected cases, and methods for supporting maltreatment victims and their families, including referrals to relevant treatment services and peer support groups for victims (Abrahams et al., 1992).

Sensationalized reports of child abuse in school or youth service organizations (such as the Boy Scouts) and day care centers (such as the McMartin case) have stimulated legislative and media efforts to improve the background screening and oversight of employees and volunteers who come into contact with children (Finkelhor et al., 1988). Such efforts have been criticized, however, because administrative oversight is extremely expensive and time-consuming and imposes a significant bureaucratic burden on organizations characterized by high staff turnovers and volunteer members. The benefits to be achieved, in terms of a reduction in child maltreatment, may be quite small given the low rates of reported incidence of child maltreatment that occur within educational or institutional settings.

A much greater opportunity exists in the area of educator programs that can improve the processes by which teachers, school administrators, and school health officials can recognize, report, and monitor reports of child

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maltreatment (Tower, 1992). Such interventions have the opportunity to strengthen the prevention of child maltreatment within the population of children who attend public or private schools. One recent national survey that assessed teacher knowledge, attitudes, and beliefs about child abuse revealed shortcomings in the training and support of teachers with respect to child abuse reporting and prevention (Abrahams et al., 1992). Only 57 percent of the teachers surveyed indicated that their school had written procedures for identifying and reporting suspected child abuse cases; the nature of existing school policies was unclear. Teachers usually report abuse cases to other school personnel, such as the principal, social worker, or nurse, and not directly to child protection agencies. The low percentage of these suspected cases that are eventually reported to child protection agencies may be a cause for special concern (Abrahams et al., 1992).

Violence Prevention in the Schools

Increases in school and community violence, especially in the inner city (Goldstein, 1992) have led many to believe that schools are an ideal location for violence prevention programs (Feindler et al., in press). School-based interventions have several advantages, including accessibility to a broad youth population, mandated attendance, ease in scheduling, and cost effectiveness (Hammond and Yung, 1991).

Despite the interest in violence prevention efforts, most school-based programs have not been evaluated. This review will focus on violence prevention programs that have been evaluated for effectiveness of their goals, recognizing that these programs were not designed to deal specifically with child abuse prevention, but rather the prevention of violence in general or in social or peer relationships. A few promising comprehensive programs, incorporating both school and family settings, are described here because interventions that target multiple levels of systems may be most likely to affect change in the area of child maltreatment.

The London Secondary School Intervention Project on Violence in Intimate Relationships (Jaffe et al., in press) is a violence prevention program designed for use with adolescents. The goals of this program are to challenge stereotypes about wife abuse and violence as a way to resolve conflict, raising awareness and therefore preventing abusive behavior. The program was implemented in several schools in the form of day or half-day workshops focused on topics related to family violence, often including a video or theatrical presentation. Presentations were followed by classroom discussions, intended to help students process the information and develop school-based plans for preventing violence. The evaluation of this program (Jaffe et al., 1990) consisted of a 48-item questionnaire on wife assault, sex roles, dating violence, and behavior in violence-related situations. Pre- and

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postintervention questionnaires were administered one week before the intervention, one week after the intervention, and in some cases, also six weeks after the intervention. The short-term evaluations suggested significant change in a prosocial direction on some questions, but boys also showed some significant change in the undesired direction regarding excuses for date rape. From one week to six weeks postintervention there was significant change in the undesired direction on six of the questions. The authors suggest that the backlash effect may be from boys who were already involved in abusive relationships.

One popular behavioral change program is Positive Adolescents Choices Training, or PACT, a culturally sensitive program designed for use with African-American middle school students ages 12-15 (Hammond and Yung, 1991). Participants were selected by teachers because of behavior problems, social skills deficits, or a history of being a victim of violence. The goal of PACT was to train the participants in the behavioral components of conflict resolution skills using videotapes and role-playing scenarios in 37-38 sessions, led by two African-American facilitators with 10-12 students in each group. The evaluation of this program was carried out by teachers and blind observers on a small sample of 14 students in treatment and 13 students in the control group. Overall, 75 percent of the intervention group showed improvement on the relevant skills, but only 43 percent of the control group showed skill improvement. School records also suggested less involvement in violent incidents in school by the intervention group than the control group.

These two programs are examples of promising interventions in the area of violence prevention that may have implications for child maltreatment, although they were not designed with the prevention of child maltreatment as a specific objective. In addition to the school-based programs discussed above, several organizations have designed comprehensive multisystem approaches to address the interaction of family and school factors that foster violence. One example of a comprehensive program is the Seattle Project, which focuses on multiple risk factors in the family and school context in an effort to prevent drug abuse and delinquency (Hawkins et al., 1992). A second example of a comprehensive program is the FAST Track program (Bierman et al., in press). This program, which has not yet been evaluated, was designed to help children who show disruptive behavior and poor peer relations both at school and at home. The intervention goals of these multisystem programs are to encourage collaboration among parents, children, and the school to reduce aggressive behavior. This type of multifaceted intervention may have a more pervasive effect on violence in the lives of children than purely school-based programs.

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Summary. The relationship between the use of violence in peer relations and the use of violence against children in family situations is not well understood. Since many families who are reported for child maltreatment are characterized by other forms of violence (including spouse abuse and involvement in criminal assaults), interrupting the cycle of violence in one area of life may have spillover effects on others, but this assumption lacks empirical evidence. It is also possible that intervening in other areas of family dysfunction, such as substance abuse, may help prevent child maltreatment (especially maltreatment that is drug-related), although little research has been conducted to test this hypothesis.

Given the increasing number of youth involved in violence, surprisingly few well-designed, rigorously evaluated, and effective prevention programs exist, and the association between violence prevention programs and child maltreatment is largely unknown. The lack of consistent positive results in the evaluation of school-based violence prevention programs may be due to the relatively narrow scope of the interventions. It may not be possible to intervene in school with a child and expect changes in beliefs, attitudes, and behaviors that may be perpetuated by family and community. School is not the only relevant context for violence, and intervening in one context while leaving others untouched may not be optimally effective.

Although school-based violence prevention programs are a promising development, no firm conclusions can be drawn at this time regarding their effectiveness or generalizability for the prevention of child abuse. These programs do not report on the generalizability of the violence prevention to other contexts or over time, and it is not known if participants will be less likely to be perpetrators of family violence. It is the panel's view that school-based programs will not serve as effective deterrents of physical or sexual violence toward children, peers, and adults, unless they incorporate family and community components such as those described by the ecological developmental model presented in this report.

Clergy and Religious Institutions

Religious institutions are often viewed as an underused resource in preventing and detecting child maltreatment and its effects, but efforts to address child abuse and neglect in religious institutions have not been assessed. Religious institutions have access to enormous numbers of children and families and the means to deliver messages about child maltreatment (Bush, 1991).

Some leaders in the religious community, emphasizing that religious institutions have a mandate to address moral issues and to care for children, have taken action in the area of child protection. A nonprofit organization,

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Covenant to Care, has been established to link representatives of religious institutions with social workers, to sponsor public education forums, and assist pastors, rabbis, and temple leaders in developing sermons on the topic of child maltreatment (Bush, 1991). The experience of religious institutions in handling increasing numbers of disclosures of abuse that may involve their own members also has not been documented systematically.

Media Roles

The media exercised a significant role in setting an initial political agenda for child abuse and neglect when "The Battered Child" article by Henry Kempe and his colleagues (1962), published in a professional journal, was highly publicized in the popular press. Five years later, every state had passed child abuse reporting laws (Nelson, 1984). The U.S. Advisory Board on Child Abuse and Neglect (1990) has stressed the continued impact of media involvement in child maltreatment issues and the importance of including the media in "a concerted community response" to child abuse.

Media representatives can become important participants in public education about prevention in child abuse and neglect. Survey data from the National Committee for Prevention of Child Abuse involving various forms of print and broadcast media suggest that public awareness of child maltreatment has increased dramatically over the past decade.

Media efforts to prevent child maltreatment may benefit from lessons derived from the role of the media in addressing public health issues. For example, expanded media efforts in child abuse and neglect could adapt the methods used to change human behavior and social expectations (and ultimately alcohol-related traffic fatalities) in the national media campaign to promote the concept of the "designated driver" (Winsten, 1992). Research is needed to evaluate the effectiveness of various types of social marketing and advertising campaigns directed toward the prevention of child maltreatment. For example, quasi-experimental field designs and time series analyses, using matched controls, could be developed to identify the differential effects of programs using print or broadcast media for selected community campaigns.

But the limitations of public awareness or educational campaigns also deserve consideration. Such approaches may be effective with subpopulations who are part of the target audience and who are motivated to change health or social behaviors, and who are willing to seek assistance in making such changes. For groups who have low literacy skills or who are socially isolated from media or educational services, however, public awareness campaigns may have little value unless they are specifically targeted to such subpopulations.

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Bystander's Responses

Although child abuse and neglect commonly occurs in the privacy of the home, incidents of child maltreatment occasionally appear in public places such as stores and playgrounds. Witnesses who may be disturbed by cases in which adults punish children too severely usually hesitate to intervene (Oldenburg, 1992). In one random survey, only 17 percent of observers acted to stop someone from hitting a child (National Committee for Prevention of Child Abuse, 1990). Factors that affect the willingness of bystanders to intervene on behalf of children who are inappropriately disciplined by parents or caretakers have not been well studied although uncertainty about appropriate forms of response has been suggested as a significant factor. The vague distinction between acceptable discipline and abuse also may discourage intervention. Social psychology literature on bystander behavior, which seeks to identify situational and individual factors that promote altruistic or prosocial intervention in public, may be useful in future studies of cases of child maltreatment (Davis, 1991; Korbin, 1993).

Summary

Prevention efforts in the exosystem show promise, especially in the design of multisystem approaches that can build on family-school-community approaches. The community mental health approach, and examples of media and community-based interventions designed to reduce smoking and heart disease, represent much promise, but such efforts are only beginning to be developed and evaluated in the area of child maltreatment. Well-designed program evaluations that consider interactive effects of various types of individual, family, and community-based intervention are crucial for developing a knowledge base to guide future efforts. For example, we often do not know if current interventions produce long-term changes in knowledge, skills, and behavior. We also do not know if prevention programs in selected areas of physical or sexual violence involving peers or adults can be generalized to incidents involving child maltreatment by trusted adult figures. Gaining such knowledge will require studies that follow cohorts of sample populations over time, to identify the strength of various program components and the requirements of special populations, such as children who have already experienced abusive behaviors, in designing effective prevention programs.

The Macrosystem

As noted in Chapter 4, the macrosystem consists of fundamental values and cultural norms that affect public, private, and institutional behaviors.

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In selected areas of public health interventions, cultural values are an important element in changing behavior that fosters adverse consequences. Examples that illustrate this point include the rapid change in American values on issues such as smoking, diet, and exercise. As a result, prevention programs increasingly focus on ways to foster social perceptions and cultural changes that would foster the well-being of children. One such approach is encouraging the use of ''time outs" to reduce the use of spanking and other forms of physical punishment in child discipline behaviors.

Several areas in the macrosystem have relevance for research on the prevention of child maltreatment. although these issues are relatively untested in intervention strategies or research evaluations, the panel includes them here because of our belief that they warrant attention in a research agenda for the future.

Corporal Punishment

No research data have suggested that corporal punishment promotes child well-being. Despite the suggestion by several scholars that corporal punishment may be a major risk factor for physical abuse, the idea that spanking puts a parent at risk of going too far and engaging in physical abuse is not mentioned in publications issued by the National Center on Child Abuse and Neglect (the major federal agency). One content analysis by Straus and Yodanis (1994) of 120 books on child abuse found that only 12 percent included an unambiguous recommendation that corporal punishment should not be used.

Reliance on corporal punishment by American parents has been identified by some researchers as an important risk factor for physical abuse (Gelles and Straus, 1988; Gil, 1970; Kadushin and Martin, 1981; Straus and Kaufman Kantor, 1994; Straus and Yodanis, 1994; Zigler and Hall, 1989). But corporal punishment is usually not dealt with in programs to prevent physical abuse, possibly a result of the absence of experimental evidence showing that reduction of corporal punishment reduces the risk of physical abuse as well as the existence of cultural norms in American society that support the use of corporal punishment (Greven, 1991).

The U.S. Advisory Board on Child Abuse and Neglect (1991) has recommended that the use of corporal punishment should be eliminated in all activities and facilities which receive federal financial support. However, corporal punishment is almost universally regarded by the general public as legally and morally correct and "sometimes necessary" (Straus and Kaufman Kantor, 1994). It is almost a counterintuitive reversal of thinking about parental practices for parents to conclude that corporal punishment should not be practiced. Consequently, unless an explicit "no hitting of children" element is included in prevention programs (including parent education,

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pediatric and educator guidelines, media public service announcements, and entertainment programming), parents will continue to use corporal punishment. Research is needed on whether the inclusion of a no-hitting element in such programs reduces physical abuse.

Use of Criminal Sanctions

The use of criminal sanctions is an important aspect of prevention of child abuse because of the popular belief that strict legal standards and punitive measures will reduce the incidence of child maltreatment. In the area of sexual abuse, some offenders are so incapable of change that they must be incapacitated by incarceration. Nevertheless, the use of criminal penalties to deter offenders and the development of judicial and administrative procedures to remove children from abusing parents may be counterproductive in many cases, particularly in situations involving parental offenders and mild to moderate forms of child abuse or neglect. We currently lack evidence that criminal penalties deter child abuse or neglect, and reliance on criminal penalties offers few resources to improve the abilities of parents in dealing with their children.

In considering the effectiveness of criminal sanctions in the area of child maltreatment, it is important to recognize the multiproblem character of abusive and neglectful families. Many of these families are already involved with the legal system because of other behaviors, including substance abuse, juvenile delinquency, and other crimes. Assessment of the impact of criminal sanctions solely in the area of child maltreatment is quite challenging, since the perpetrators may be removed from the home in a variety of other ways involving the court system.

Conclusions

Despite its limitations, the current base of evaluative research offers preliminary guidelines for shaping programs and systems. The panel's primary conclusion from this review is that comprehensive and intensive programs that incorporate a theoretical framework, identifying critical pathways to child maltreatment, offer the greatest potential for future programmatic efforts. Many community-based intervention programs have demonstrated some impact on knowledge and attitudes, but their impact on abusive behavior toward children remains uncertain. While such programs may offer many advantages, little evidence currently exists that such interventions directly reduce child maltreatment.

New theoretical models that incorporate ecological and developmental perspectives have complicated the development of prevention research, but these models hold much promise, for they suggest multiple opportunities

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for prevention. Prevention research needs to be guided by rigorous evaluation that can provide knowledge about the importance of different combinations of risk and protective factors, the developmental pathways of various forms of maltreatment, and the importance of replacing or supplementing risk behaviors with compensatory skills. As our knowledge of the etiology of child maltreatment improves, prevention interventions can adapt new theoretical frameworks that will highlight promising interactions and theoretical insights.

Evaluations of home visitation programs, school-based programs for the prevention of sexual abuse and violence, and community-based child maltreatment prevention programs are quite limited. The majority of these evaluations are not controlled experiments, many are compromised by serious methodological problems, and many promising preventive interventions do not systematically examine program outcomes for child maltreatment (Azar, 1988; Daro, 1992; Howing et al., 1989). Children and families who are most at risk for child maltreatment may not participate in prevention interventions, and those who do may not be sufficiently motivated to change or will have difficulty in implementing skills such as "anger management" techniques in their social context, especially if they live in neighborhoods characterized as violent. To this end, a greater understanding is needed regarding how high-risk individuals and families view formal support systems and how members of both formal and informal systems can best work together to provide a consistent and comprehensive network of prevention services for communities at risk of multiple problems, including child maltreatment. Expanded research also is needed on those high-risk individuals and families who successfully engage in prevention programs. More descriptive information is needed to determine the staff characteristics, outreach efforts, and service delivery methods most successful in reaching families at high risk for maltreatment. Once these factors are identified, their impacts on client retention and client outcomes need to be formally tested through well-designed program evaluations.

Research Recommendations

Research on child maltreatment prevention programs should be based on knowledge of the processes by which specific risk and protective factors lead to child maltreatment. As noted in Chapter 4, we do not yet know if the etiologies of the various forms of child maltreatment are similar or different. In the face of uncertainty, a diverse range of approaches to prevention research should be encouraged to explore promising initiatives.

Recommendation 5-1: Research on home visiting programs focused on the prenatal, postnatal, and toddler periods has great potential for

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enhancing family functioning and parental skills and reducing the prevalence of child maltreatment.

The panel recommends that home visiting programs continue to be developed provided that they incorporate appropriate evaluation components. Such evaluations should include rigorous scientific measurements, appropriate measures of child abuse and neglect, and clarification of the theoretical assumptions that shaped the home visitation efforts. We currently lack knowledge about what programs work, for whom they work, and whether they influence child abuse and neglect directly (via a reduction in child abuse and neglect) or indirectly (via changes in parental skills and parental characteristics such as depression, problem solving, fertility, or employment). Both short-term and long-term benefits of programs need to be evaluated. Either a randomized clinical trial or an effective pretest/posttest design must be used. Budgets for home visiting programs must be adequate to carry out such evaluations. Individuals with expertise in evaluation must be included in the program team. The panel makes the same recommendations for other early intervention service programs.

The panel recommends that research on multiple models of home visiting and other early intervention services be funded, since no single model of home visiting has yet been shown to be the most effective. Similarly, no single time period, length of programming, or intensity of program has been identified as the most effective (although the literature suggests that the prenatal and postnatal periods are central, few programs have started home visiting service later; other research suggests that home visiting has to occur somewhat regularly to be effective). The panel recommends that home visiting programs consider varying the time of onset and length of such programs. Programs could offer two or more different sets of service and evaluate the effectiveness of programs of varying lengths, following the scientific practices established in clinical trials.

Other types of prevention programs often find that positive results are best maintained by offering either long-term, continuous services or, after a program ends, a short-term refresher or booster. Such an approach should be considered for home visiting programs.

Home visiting programs typically offer a number of services. Little is known about the mix of services that are necessary to enhance parenting and reduce child abuse and neglect (although the current findings suggest that comprehensive services are most effective). Programs need to be initiated that vary on the type and number of services included; the efforts must be evaluated. Several approaches might be adopted, including direct comparisons of different arms of clinical trials, or from analyses of what program services individual families are actually receiving.

Even when effective, home visiting programs often are unable to give

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much insight as to how the program was implemented or why the program was effective. The panel recommends that evaluations of home visiting programs include descriptions of what goes on in visits, curriculum with clearly identified objectives (the completion of which may be observed by the home visitor), and direct observation of home visitors in action.

Most home visiting programs have generally not been large enough to determine for whom the intervention is effective. Studies with sufficiently large and diverse samples to allow for subgroup analyses are strongly recommended. Of particular concern are mothers with a history of maltreatment of siblings, mothers of varying ages, and mothers with specific health habits (smoking, alcohol use, etc.).

Home visiting programs should also strive to involve immediate and extended family members who may have caretaking responsibilities for the child, including fathers, stepfathers, boyfriends, grandparents, and other relatives.

Finally, evaluations of home visiting programs should examine results that link short-term outcomes for child maltreatment with other measures, such as maladaptive parenting.

Recommendation 5-2: Research on child sexual abuse prevention needs to incorporate knowledge about appropriate risk factors as well as the relationship between cognitive and behavioral skills, particularly in situations involving known or trusted adults. Sexual abuse prevention research also needs to integrate knowledge of factors that support or impede disclosure of abuse in the natural setting, including factors that influence adult recognition of sexual abuse or situations at risk for child abuse.

With a few notable exceptions, research on prevention of sexual abuse has been rare. Very little is known about the psychometric properties (e.g., validity, stability, reliability) of most measures employed in research on prevention. Key research questions include the following:

To what extent do children's responses about the prevention of sexual abuse correspond to what they actually would do in the natural environment?

What level of cognitive performance on prevention measures is associated with meaningful changes in the ability of children to modify their own abuse?

Are there significant differences between children who have been abused and those at risk for abuse on their performance on prevention measures?

The natural histories of children who have participated in sexual abuse

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prevention programs also deserve attention. No records exist to determine the exact number or characteristics of children who have been exposed to sexual abuse prevention programs in the elementary schools, yet these children are in a unique position to inform us about preventive interventions. For example, some children may have been able to use prevention knowledge and skills to successfully prevent, avoid, or escape abuse; other children may have been unsuccessful in their efforts; some children may have been abused in situations or in ways that make prevention impossible; and many children may have reactions to or ideas about preventive intervention that could improve the delivery of these programs. The field has generally ignored the criticisms, support, and ideas of children who are actual consumers of child abuse prevention programs, although a recent national survey of more than 1,400 children (age 10 through 16) conducted by Finkelhor may provide new insights about the experiences of children who participate in victimization prevention programs (Finkelhor, 1993).

The tension in many prevention programs over the objectives of encouraging children to disclose abuse or helping children prevent future abuse has not been completely resolved. Although a set of clinical ideas (e.g., coercion, secrecy, manipulation) is thought to explain children's failures to disclose abuse, little systematic study has been undertaken to examine the victimization and disclosure processes. Children may disclose ongoing abuse for a variety of reasons—they grown increasingly fearful, they see the offender beginning to groom a younger sibling, someone asks them about abuse—but the disclosure process is poorly understood. Research on the disclosure process in the natural environment of the child and evaluations of programs to increase disclosures of abuse might improve the development of new prevention and disclosure programs.

The role of parents and other adults in the prevention of sexual abuse has also been a matter of current debate. Critics have suggested that existing programs place too great a burden on children for the prevention of their own abuse, and that more effort should be directed toward learning how parents and other adults can become effective in preventing sexual abuse of children. Others in the prevention movement are suspicious of parents and have sought to introduce prevention programs in schools and elsewhere without prior parent permission. Few data exist to inform these concerns.

Although parents with their own abuse histories may be less likely to recognize child abuse incidents or situations, no data has confirmed a parent's abuse history as a child risk factor for sexual abuse. Factors such as the relationship between the adult and offender, the level of stress, attributional style, and a host of other factors may influence the ability of adults to identify and respond protectively to children around sexual abuse. Yet even when adults are well informed, it is not clear how much sexual

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abuse can be prevented by adult actions (e.g., how much sexual abuse takes place out of sight of protective adults, what factors prevent disclosure to adults).

The identification of risk factors for sexual abuse is obviously useful in targeting prevention efforts toward those children in greatest need. Much of the research on risk factors for sexual abuse has been carried out with either clinical samples of sexually abused children or with college student samples, both of which have provided insufficient effort to determine whether certain factors (e.g., psychological characteristics of a child, social-environmental variables) increase a child's risk for sexual abuse. For example, clinical reports suggest that offenders do not abuse all children with whom they come in contact. Some children are selected over others, but it is not clear on what basis some children are selected and others are not. It is not currently known whether selection factors involve characteristics of the child, the offender, the environment in which the child is found, or other currently unknown factors. Research identifying such factors and the interplay among them may have clear implications for prevention interventions.

Recommendation 5-3: Research evaluations are needed to identify the extent to which community-based prevention and intervention programs (such as school-based violence or domestic violence prevention programs, Head Start, etc.) focused on families at risk of multiple problems may affect the likelihood of child maltreatment. Research is also needed on these programs to identify methodological elements (such as designs that successfully engage the participation of at-risk communities) that could be incorporated into child maltreatment prevention programs.

If exposure to a greater number of risk factors increases the risk for violence and child abuse, then community-based prevention and intervention programs need to target multiple childhood risk factors in both the family and school domain as well as within the broader social context of the child (e.g., peers, neighborhood, etc.). School-based programs are often limited because the child returns to the environment that contains many of the risk factors associated with violent behavior. Prevention and intervention programs targeted toward one or a few risk factors are not likely to have an impact on violent behavior and child abuse. Our recommendation is that prevention and intervention programs need to be comprehensive and intensive.

In addition to recommending comprehensive and intensive programs that address multiple risk factors associated with violence and abuse, we recommend research evaluations of long-term interventions that involve home-school collaborations, supplemented by booster sessions at developmentally appropriate points in time.

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Recommendation 5-4: Evaluations of school-based programs designed to prevent violence and to improve parental skills are needed to identify the subpopulations most likely to benefit from such interventions and to examine the impact of school-based programs on the abusive behaviors of young parents.

Such evaluations should give particular consideration to the specific characteristics of participants who participate in school-based programs, including gender as well as social and cultural characteristics. School-based programs need to be designed for specific characteristics, risk factors, and the social context of the participants in order to determine who most benefits from selected programs. Major prevention programs need to include a long-term follow-up as part of their evaluation. The evaluations of the school-based violence prevention programs described in this chapter were short term and basically assessed whether the intended skills and knowledge were acquired by the participant. None of the program evaluations included long-term assessments of outcomes.

Specifically, we recommend that:

(a)

Evaluations of programs examine the characteristics of individuals who benefit from the programs. Most programs are evaluated by comparing the overall mean of the treatment and control groups. We recommend that the range of outcomes within the treatment group be examined in relation to specific characteristics of the participant. Thus, in addition to asking "Does the program work?," we suggest that investigators ask "For whom does the program work and under what circumstances?"

(b)

Programs need to be designed to take into account salient characteristics (e.g., gender) and risk factors of the participants. Perhaps the most important characteristic is the child's developmental level. Few of the programs we reviewed seem to take into account the participants' developmental level. For example, prevention programs for adolescents would need to be different from programs for preteens. Adolescence is a period marked by a number of developmental issues, such as greater autonomy and shifting allegiance toward peers, emerging sexuality, and forming intimate relationships with members of the opposite sex, which need to be considered in developing prevention and intervention programs. The assumption of most existing programs seems to be that they are appropriate for all individuals—which does not seem to be the case.

Whenever possible, the development of prevention and intervention programs should be guided by theory (and appropriate models) and replicated in different schools. Recognizing the current limitations of our understanding of the etiology of complex phenomena like child abuse, program devel-

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opers should describe the processes that they believe lead to child abuse and neglect. One challenge facing prevention researchers is deciding which combinations of risk and protective factors, and which combinations of interactive systems, have the greatest potential to both influence outcomes and be effectively modified through intervention.

Recommendation 5-5: Research should be conducted on values and attitudes within the general public that contribute to, or could help discourage, child maltreatment. The role of the media in reinforcing or questioning cultural norms in areas important to child maltreatment, such as corporal punishment, deserves particular attention.

Important lessons can be learned from the role of the media in fostering healthy or unhealthy behaviors involving the use of alcohol, smoking, drug use, and condoms or safe sex practices. Research is needed that can identify significant pathways in addressing key factors and behaviors that affect child maltreatment, such as parental styles, the use of corporal punishment, alternatives to the use of violence in conflict resolution, and young children's relationships with strangers and abusive caretakers. Rather than focusing solely on the sensational aspects of abusive cases, the media can play an important role in raising questions about the values that should be fostered in family relationships and the protection of children.

Research is needed on whether specific advice to avoid corporal punishment and specific discussion of alternatives contribute to the effectiveness of prevention programs (see Appendix B, Supplemental Views). This includes home visitation programs, early childhood intervention programs, and violence prevention programs for schoolchildren. In connection with the latter, it should be noted that schoolchildren are much more likely to be victims of violence, such as slapping and hitting with objects, by parents than by peers. If school-based programs can teach children to voluntarily use time out to avoid violence, research is needed on whether the same can be done for parents.

There is also a need for empirical research to determine the degrees to which criminal sanctions deter child abuse and the degree to which removal of children protects them from abuse, especially in cases of mild to moderate maltreatment. Research involving case-control designs, which investigate the effect on families and children of mediation versus the use of criminal sanctions in cases of spouse abuse (Sherman, 1992) shows that field experiments can be done within an ethically acceptable framework. Since the relative effectiveness of punitive compared with helping approaches could be different for physical abuse, sexual abuse, and neglect, each of these types of abuse may be analyzed distinctly.

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Notes

1. Sustained effects of early intervention programs are partly, but not primarily, due to alternations in cognitive functioning; for example, differences in intelligence and verbal ability test scores between children who did or did not receive early intervention services tend to dissipate by the middle of elementary school (Lazar et al., 1982; Brooks-Gunn, 1990; Zigler, 1992). Later reductions in school failure and juvenile delinquency are hypothesized to be based on changes in parental commitment to and encouragement of their young children as well as familial functioning more generally (Zigler, 1992), as Bronfenbrenner predicted almost 15 years ago (1979).

2. The four treatment groups are: (1) a control group that did not receive services but participated in the collection of evaluation data; (2) a minimal intervention group that received transportation assistance to attend medical appointments; (3) a group that received extensive nurse home visitors prenatally and transportation services; and (4) a group that received extensive nurse home visitors both prenatally and postnatally as well as transportation assistance. The nurses provided parent education, made efforts to enhance family and other informal social supports, and initiated linkages with professional helpers in the community (Olds et al., 1986a).

3. The National Center on Child Abuse and Neglect awarded a major evaluation study for the Hawaii Healthy Start program to the National Committee for Prevention of Child Abuse in late 1993. The evaluation is expected to be completed in 1994.

4. These curricula included Child Assault Prevention, Children's Self-Help, Talking About Touching, Touch Safety, Child Abuse Prevention Intervention and Education, the Youth Safety Awareness Project, and SAFE—Stop Abuse Through Family Education.

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Understanding Child Abuse and Neglect Get This Book
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The tragedy of child abuse and neglect is in the forefront of public attention. Yet, without a conceptual framework, research in this area has been highly fragmented. Understanding the broad dimensions of this crisis has suffered as a result.

This new volume provides a comprehensive, integrated, child-oriented research agenda for the nation. The committee presents an overview of three major areas:

oDefinitions and scope--exploring standardized classifications, analysis of incidence and prevalence trends, and more.

oEtiology, consequences, treatment, and prevention--analyzing relationships between cause and effect, reviewing prevention research with a unique systems approach, looking at short- and long-term consequences of abuse, and evaluating interventions.

oInfrastructure and ethics--including a review of current research efforts, ways to strengthen human resources and research tools, and guidance on sensitive ethical and legal issues.

This volume will be useful to organizations involved in research, social service agencies, child advocacy groups, and researchers.

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