National Academies Press: OpenBook

Understanding Child Abuse and Neglect (1993)

Chapter: 7 INTERVENTIONS AND TREATMENT

« Previous: 6 CONSEQUENCES OF CHILD ABUSE AND NEGLECT
Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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7
Interventions and Treatment

Examples of intervention in child maltreatment include the investigation of child abuse reports by state child protection agencies, clinical treatment of physical and psychological injuries, family counseling, self-help services, the provision of goods and services such as homemaker or respite care, legal action against the perpetrator, and removal of the child or the offender from the home. This chapter reviews interventions that occur after suspected child maltreatment has been reported to child protection agencies. These treatment interventions are viewed by some as a form of tertiary prevention, for they are often designed not only to remedy whatever harm may have occurred, but also to prevent future occurrences of child maltreatment and to minimize the negative consequences of child maltreatment experiences for children and their families.

Some observers believe that the concept of treatment, in the field of child maltreatment studies, should be restricted to interventions that are therapeutic in nature, thus distinguishing such programs from social and legal efforts to investigate or prosecute reports of child abuse and neglect. However, the panel believes that therapeutic programs should be viewed within a broader social context that includes interventions by social and legal agencies. Access to therapeutic care is often determined by social service or law enforcement personnel, and the availability of medical or psychological services is significantly uneven in different social sectors. As a result, only a small percentage of victims have access to the services that they need (McCurdy and Daro, 1993). Thus, in the panel's view,

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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''treatment" should include the processes by which child maltreatment reports are assessed, investigated, and substantiated.

In this review, treatment approaches are categorized by the systems and developmental levels for which they are designed. Many studies of interventions for victims of child maltreatment distinguish between different types of abuse, particularly sexual abuse. However, victims of child physical abuse, sexual abuse, neglect, and emotional maltreatment often experience similar psychological effects (e.g., fearfulness, aggression, low self-esteem, and depression) (Erickson and Egeland, 1987; Conte and Berliner, 1988). In addition, although treatment programs may be targeted to victims of a specific form of maltreatment, populations served by these programs may include victims of multiple forms of abuse. For example, increased awareness of emotional or psychological maltreatment has suggested that this form of child abuse may be an underlying factor in all forms of child victimization, although few treatment programs focus on it directly.1

Historical, empirical, organizational, and social factors complicate an understanding and analysis of intervention systems for child maltreatment. Multiple agencies have responsibility for determining policies that guide interventions in child abuse and neglect and coordinating human and financial resources to fulfill these objectives. Research that describes or evaluates the methods and mechanisms used to identify or confirm cases of child maltreatment; to assess the severity of child and family dysfunction, personal and social resources, and family strengths; and to match clients to appropriate treatments is minimal.

Although project evaluations that assess the benefits and limitations of treatment evaluations are often required by federal and state sponsors, problematic methodological issues characterize research in this area. Such issues include the following: the research generally does not include controlled experiments, has limited sample size, uses questionable measures to assess performance, and common assessment strategies have not been used across different interventions, making it difficult to know what works for whom. These issues need to be addressed to improve the use of research evaluations in the development of services and programs,

Furthermore, it is difficult to isolate factors specifically associated with child abuse and neglect in programs that often include families with multiple problems. Research on service delivery and accessibility is complicated by ethical, legal, and logistical problems. Researchers in this area have limited resources to collect compatible data, and the results of project evaluations are rarely published in the professional literature. In addition, clinicians who provide treatment services in child abuse and neglect cases may lack time, resources, and skills to develop systematic research evaluations.

Despite these limitations, a few significant outcome evaluations of treatment

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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interventions do exist in the research literature on child maltreatment. In 1987, Cohn and Daro reviewed four major studies of multiple site program evaluations funded by the federal government since 1974.2 These four studies, collectively, represented over $4 million invested in child maltreatment research over a 10-year period, involving 89 different demonstration treatment programs for which the government spent about $40 million and collected data on 3,253 families experiencing abuse and neglect problems (Cohn and Daro, 1987). Although these studies demonstrated how to provide direct services to both adults and children, documented improved client outcomes in individual and family functioning, and indicated reduced propensities for sexual abuse in families, the analysis of these studies provided significant cause for concern, concluding that treatment efforts in general were "not very successful" (p. 440):

Child abuse and neglect continue despite early, thoughtful, and often costly intervention. Treatment programs have been relatively ineffective in initially halting abusive and neglectful behavior or in reducing the future likelihood of maltreatment in the most severe cases of physical abuse, chronic neglect, and emotional maltreatment. One-third or more of the parents served by these intensive demonstration efforts maltreated their children while in treatment, and over one-half of the families served continued to be judged by staff as likely to mistreat their children following termination.

Given this pessimistic assessment of the benefits that have been obtained through federally funded treatment interventions, much effort has been directed toward programs that will improve the treatment of victims or eliminate the potential for child abuse and neglect behavior.3

In this chapter, the panel reviews the strengths and weaknesses of different types of interventions, identifying gaps in knowledge and highlighting areas in which research can lead to the development of improved programs. This review is not comprehensive, but it is intended to reflect the general state of research in this area. The interventions discussed here include those commonly classified as treatment (such as family counseling or self-help services) for both the victim and the perpetrator, the administrative and legal processing of reported child abuse cases, the assessment of families, and foster care placement. In keeping with a process-oriented approach, the panel has included discussions of child protective services, law enforcement, and medical responses to reports of child maltreatment because of their potential to exacerbate or diminish the negative consequences of child maltreatment and influence the provision and effectiveness of treatment.

It should be noted, however, that this review is selective. The fragmentary nature of research on the intervention process and the absence of research reviews and controlled studies inhibited the panel's ability to evalu-

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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ate the strengths and limitations of this field of work. Furthermore, we did not have sufficient time to evaluate the full spectrum of case handling and legal procedures associated with reports of child maltreatment. We have thus focused our attention on those areas in which important theoretical and data collection efforts have been achieved in identifying future research priorities for studies of the intervention processes. A broad range of topics germane to the study of child maltreatment, such as the recidivism records of child molesters, the reliability of child witness testimony, and the relationship of child maltreatment reports to child custody disputes, are not addressed here because the panel did not have a sufficient scientific research record on which to evaluate the quality of the reported findings.

Treatment Efforts At The Individual Level

Treatment of Child Victims

As discussed in Chapter 6, the form of a child's response to maltreatment may be influenced by their age and developmental level. The panel has incorporated a developmental perspective into this review of treatment programs for individuals in order to assess the efficacy of treatment both in reducing the negative effects of maltreatment at different developmental stages and also in improving the victim's functioning during such critical developmental milestones as attachment, peer competency, and parenting styles.

Despite the large literature on the detrimental effects of child maltreatment that Chapter 6 outlines, the majority of treatment programs do not provide services directed at the psychosocial problems of the abused child. Children's involvement in treatment programs has generally occurred in the context of family-based services in which they have received direct programmatic attention4 (Kolko, in press). The multiple therapeutic components of such programs make it difficult to determine the specific contribution of child treatment to outcomes.

Some treatment studies have examined the benefits of day or residential treatment/care programs for very young children, many of which use play or art therapy techniques (Azar and Wolfe, 1989). Studies of physically maltreated youngsters who have participated in specialized day care or residential programs have generally included diverse therapeutic activities for children as well as other parent or family-based services (e.g., counseling, homemaker and family and individual therapy and support groups) (Culp et al., 1987a,b, 1991; Elmer, 1977; Parish et al., 1985; Sankey et al., 1985).

Therapeutic day care can address problems with attachment, self-concept, emotional behavior problems, and physical problems in abused and neglected children (Daro, 1988). In a recent study of physically abused

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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children, therapeutic day care resulted in significant pre- and post-test gains (compared with controls) in all tested developmental areas, including fine and gross motor skills, cognitive development, social and emotional functioning, and language development (Culp et al., 1987a,b).

A series of studies focused on samples of preschool physically abused children have found limited improvements in social behavior and peer relations. Although sample sizes were small, these studies are notable for their use of objective and repeated measures, experimental designs, and clearly described intervention procedures (Fantuzzo et al., 1987, 1988).

Case studies and clinical anecdotes offer glimpses of psychodynamic, insight-oriented and behavioral methods employed in individual and group treatments of sexually abused children (Becker et al., 1982; Gagliano, 1987; Gilbert, 1988; Van Leeven, 1988). Clinical literature on the treatment of child sexual abuse tends to emphasize the importance of expression and exploration of feelings, alteration of attributions of responsibility, and reduction of fear and anxiety (Berliner and Wheeler, 1987). To the panel's knowledge there are minimal outcome data on the comparative effectiveness of group and individual treatments for sexually abused children. Treatment interventions for child victims of abuse and neglect draw extensively from approaches for treating other childhood and adolescent problems with similar symptom profiles (Bonner and Walker, 1991). Empirical evaluations of programs that address child or adolescent problems in the areas of depression (Kolko et al., 1988; Lewinsohn et al., 1990), anxiety (Kendall et al., 1992), aggression or antisocial behavior (Kazdin, 1989; Kazdin et al., 1987; Pepler and Rubin, 1991), and social or peer disturbances (Kolko et al., 1990) have reported positive outcomes.5 Replication of this work to determine the effectiveness of these treatment approaches with victims of child abuse and neglect would be extremely helpful.

Empirical evidence indicating a sustained reduction in the sequelae of abuse over time is not available from programs that directly and consistently involve abused or neglected children. Experimental designs and standardized outcome assessments, including adequate follow-ups, have rarely been used to evaluate interventions designed for maltreated children (Bonner and Walker, 1991; Browne and Finkelhor, 1986; Wheeler and Berliner, 1988). Five experimental treatment outcome investigations were funded in 1990 by the National Center for Child Abuse and Neglect to examine individual and group interventions for sexually and physically abused children in clinical settings, but the results of these studies are not yet known. With few exceptions, detailed descriptions of treatment protocols that would facilitate replication are not available.

Therapeutic interventions for child victims of maltreatment are limited in part because the psychological effects of abuse have not been well formulated in terms of theoretical constructs that can provide a basis for inter-

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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vention (Wheeler and Berliner, 1988). Treatment approaches also rarely address the cumulative impact of victimization on children who may have additional experiences of racial or ethnic discrimination.

Treatment of Adult Survivors

The treatment of adult survivors of childhood sexual victimization is a newly emerging field; the first programs appeared in the late 1970s (Forward and Buck, 1978; Giaretto, 1976; Herman and Hirshman, 1977; Meiselman, 1978). Adult survivors are seen in various health centers (for somatic complaints, depression, or anxiety) and clinics for weight reduction, sexually transmitted diseases, and family planning. In contrast, few, if any, treatment programs or studies are available for adult survivors of physical or emotional abuse or child neglect.

Research on the treatment of adult survivors is submerged in the literature on adult psychological disorders such as addiction, eating disorders, borderline personality disorders, and sexual dysfunction (Alpert, 1991). It is difficult to isolate information specifically about the treatment of adult victims of child abuse from other adult patients because many adult survivors of child abuse do not identify themselves as such. However, a small but growing literature is beginning to address the treatment of adults abused as children. Most research focuses on female survivors of sexual abuse, particularly incest, but studies of the treatment of male victims of sexual abuse are expanding (Vander May, 1988).

Although a variety of individual and group approaches have been used in the treatment of adult survivors (including self-support techniques, building affect-regulation skills, cognitive interventions, exploration of desensitization of trauma, and emotional processing) (Briere, 1992), studies of the efficacy of these treatments are minimal. Most empirical research involves consumer evaluations of therapy (Jehu, 1988), changes in measures of mood disturbance (Alexander and Follette, 1987; Jehu, 1988; Roth and Newman, 1991; Roth et al., 1988), social adjustment and interpersonal problems (Alexander and Follette, 1987; Jehu, 1988), self-esteem (Alexander and Follete, 1987; Herman and Schatzow, 1984), sexual dysfunction (Jehu, 1988), guilt and assertiveness (Cole, 1985; Herman and Schatzow, 1984; Tsai and Wagner, 1978), and psychological well-being and overall sexual functioning (Wyatt et al., in press).

Studies have examined predictors associated with positive treatment outcomes in adult survivors. Factors considered in these studies include the existence of a support system (Goodman and Nowack-Schibelli, 1985; Herman and Schatzow, 1984), motivation and expectations (Herman and Schatzow, 1984), education, experience of "lesser" sexual abuse (Follette et al., 1991),

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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and involvement in individual therapy while attending group therapy (Follette et al., 1991; Goodman and Nowack-Scibelli, 1985).

To the panel's knowledge, only one controlled outcome study of the treatment of adult survivors has been conducted (Alexander et al., 1987, 1991; Follette et al., 1991). This study used a randomized design to demonstrate that group therapy was significantly effective relative to a waiting-list control condition for adult survivors of incest and that treatment gains were maintained at a six-month follow-up. Differential benefits of different types of group therapy were also identified, with the more structured format providing more anxiety relief and the less structured interpersonal groups providing more opportunities for interpersonal learning and improved social adjustment (Alexander et al., 1991).

Future research on the treatment of adult survivors should pay particular attention to operationally defining moderating and mediating variables, clearly describing treatment methods, employing a broad range of outcome measures, using control or comparison groups, and administering follow-up assessments (Alpert, 1991). A developmental approach also needs to be integrated in such research, as the value of particular forms of therapy may vary at different stages of recovery (Alpert, 1991).

Treatment for Adult Sex Offenders

The treatment of child molesters is a controversial issue. Treatment programs are frequently offered to adult and adolescent offenders as part of plea bargaining negotiations in criminal prosecutions. The traditional assumption has been that children and society are better protected by offender treatment than by traditional prosecution and incarceration if the treatment service is effective (Finkelhor et al., 1988). However, there is currently considerable debate about whether child molesters can be effectively treated.

The most common approaches to treating child molesters are comprehensive treatment programs aimed at simultaneously treating multiple aspects of deviant sexual behavior. These programs usually incorporate educational approaches, behavior therapy, and relapse prevention (Prentky, 1990). Group therapy, widely used in the treatment of pedophiles, allows patients with similar problems to share experiences, confront their behaviors, and understand motivations that govern sexual acts against children (Langevin, 1983). Its primary purpose is to identify and confront cognitive distortions, rationalizations, excuses for offending, and behaviors that signal potential reoffending (Salter, 1988). However, the lack of controlled studies, the difficulties of comparisons between studies using different and sometimes contradictory techniques, and the lack of replication complicate assessment of the value of group therapy in treating child molesters (Crawford, 1981).

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Relapse prevention, which includes a variety of techniques including stress management training, cognitive restructuring, and victimization therapy (Prentky, 1990), is also a frequent component of offender treatment programs. First developed in the treatment of addictive behaviors, such as substance abuse, relapse prevention was adapted for use with sex offenders to reduce the risk of re-offending (Marques, 1988; Laws, 1989; Pithers, 1990).

Although many different approaches to the treatment of sexual offenders have been tried (including group therapy, family systems treatment, chemical interventions, and relapse prevention), scientific data indicating sustained reductions in recidivism are not available (Becker, 1991). Most studies follow offenders only for one year after treatment, and it is not known if treatments are effective in eliminating molestation behavior beyond that period.

Adolescent Sex Offenders

Until recently, adolescent sexual offenders have been neglected in clinical and research literature, and empirically tested models to explain why adolescents commit sexual crimes or develop deviant sexual interest patterns are minimal (Becker, 1991). The components and goals of treatment for adolescent sex offenders are similar to those involved in the treatment of adult sex offenders. In general, the treatment of adolescent sex offenders focuses more on family contexts and less on behavioral and chemical techniques such as aversive conditioning and chemical interventions (Knopp et al., 1986). Preliminary outcome data on the treatment of juvenile sex offenders show positive outcomes (Kavoussi et al., 1987). However, the National Adolescent Perpetrator Network (established in 1983) has called attention to the lack of substantive research in the field and the lack of consensus regarding basic principles of treatment (National Adolescent Perpetrator Network, 1988). Studies that employ standardized measures of treatment outcomes and long-term follow-ups on homogeneous samples are likely to be revealing about the effectiveness of treatment for this population (Kavoussi et al., 1987).

Self-Help Services for Abusive Adults

Self-help support and treatment programs are based on the premise that individuals can benefit from learning about the victimization experiences of others. These programs have attracted popular support in a wide range of health services, including the treatment of alcoholism, weight loss, and rape counseling programs, and they have also been applied in the treatment of both physically and sexually abusive adults. Parents Anonymous, a self-

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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help group for physically abusive parents that started in the early 1970s, currently provides free, confidential group services to approximately 30,000 families each year in 1,200 chapters across the United States. A self-help component has also been integrated into treatment programs for intrafamilial sexual abuse (Giaretto, 1982). Parents United had 135 active chapters in the United States and Canada in 1988, which included self-help groups for the incest offender, the nonoffending spouse, children, and adults molested as children. Other groups similar to Parents Anonymous and Parents United are continually being formed.

Few empirical studies with reliable outcome measures have been used to evaluate the effectiveness of individual self-help programs or to identify the characteristics of individuals who are most likely to benefit from such efforts. A comparison study of self-help groups conducted by Berkeley Planning Associates found that self-help groups and lay therapists were reliable predictors for reduced recidivism (Cohn, 1979). One evaluation of Parents Anonymous, conducted by Behavior Associates, found that physical abuse stopped after one month of attendance and verbal abuse showed a significant decrease after two months of attendance (Ehresman, 1988).

Microsystem Approaches:
Family-Oriented Interventions

Most treatment interventions for physical abuse, child neglect, and emotional abuse seek to change parents or the home environment. Only recently have treatment services begun to incorporate empirical findings that build on ecological, developmental models of child maltreatment and examine the interactions of family members, abusive parents' perceptions of their children, behavioral characteristics that may restrict parenting abilities, and emotional reactions to stressful childrearing situations (Wolfe, 1992:9). Contemporary parent training programs focus on improving cognitive-behavioral skills and usually adapt behavioral methods designed originally to assist non-abusive families with behaviorally disturbed children (Wolfe, 1992:10). Family systems treatments target the psychodynamic interplay in relationships in families. Intensive home-based services and family preservation services directly correspond to ecological, developmental theories of maltreatment and provide services directed at the overall needs of abusive families.

A lack of consensus still exists regarding the effectiveness of a wide range of treatment services for maltreating families (Azar and Wolfe, 1989; Isaacs, 1982). Outcome studies have indicated positive behavioral and attitudinal changes as a result of family or parent treatment, but few studies have examined the effects of such interventions on subsequent reports of child abuse and neglect beyond one year. Definitive conclusions about the

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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generalizability of the findings from studies of family-oriented programs in reducing subsequent maltreatment are difficult to develop because the participants in these programs often present varied types of parental dysfunction.

Research in this area is dominated by single-case studies. Group studies that have been used are often characterized by a lack of random assignment to treatment conditions, small sample sizes, and inappropriate comparison groups (Kaufman, 1991).

Parental Enhancement

Most parental enhancement programs focus on training abusive parents in child management (e.g., effective discipline), childrearing (e.g., infant stimulation), and self-control skills (e.g., anger control). Programs for neglectful parents typically focus on areas such as nutrition, homemaking, and child care. Parental enhancement programs may help some families who experience child management problems when a sexually abusive father is removed from the home. In these cases, child management skills help develop positive child-parent interaction in sexually abusive families.

The efficacy of parent-training approaches for physically abusive parents has been supported by various single-case studies, one study using repeated measures, and group design studies (Azar and Twentyman, 1984; Crimmins et al., 1984; Gilbert, 1976; Jeffrey, 1976; Reid et al., 1981; Szykula and Fleischman, 1985; Wolfe et al., 1981a,b, 1982). Studies of multiple approaches and diverse populations have provided consistent evidence that parents can acquire behavioral skills and use them in interactions with their children, at least in clinical settings (Golub et al., 1987). Some evidence suggests that training has reduced parental distress or symptomatology and, in some instances, improved child functioning (Wolfe et al., 1988) and reduced the likelihood of child placement (Szykula and Fleischman, 1985). Efforts to expand the scope of parental enhancement programs have fostered attention to parents' cognitive-attributional and affective repertoires (see Azar and Siegel, 1990). Therapeutic directions highlight the need to incorporate diverse skills and to evaluate the effectiveness of individual approaches (see Azar and Wolfe, 1989).

Project 12-Ways is an intervention program for high-risk abusive and neglectful parents based on an ecobehavioral approach—that is, an approach that includes attention to environmental as well as individual and family factors. Following an in-depth assessment, parents participate in customized programs including the use of groups, behavioral methods, and parental aides to offer specialized services including parent-child relations, home safety, nutrition and health maintenance, assertiveness training, job placement and vocational skills training, stress reduction training, alcoholism

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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treatment, and financial planning (Lutzker, 1984). Positive findings from single-subject case reports, reports of clients attaining treatment goals in the majority of cases, and lower recidivism rates for program clients compared with controls for a five-year period of program evaluation support this approach to family treatment (Lutzker, 1984; Luztker and Rice, 1987). However, no comparison data were collected, and client assignment to Project 12-Ways was not random. Evidence also suggests that treatment gains are not maintained when compared with a comparison group (Wesch and Lutzker, 1991).

At present, few definitive studies demonstrate the efficacy of parent training in reducing re-abuse. Evaluations of the clinical impact of intervention on subsequent re-abuse (recidivism) rates and child and family functioning are needed (Kolko, in press). The severity of family dysfunction evident in some cases of abuse or neglect may also limit the applicability of parent-training methods.

Family Systems Treatment

Family systems treatment, commonly used in the treatment of intrafamilal sexual abuse, seeks to change the psychosocial interactions among family members. Clinical descriptions of family therapy combined with individual and group therapy suggest its potential usefulness for families who are highly dysfunctional, although controlled evaluations of family therapy in child sexual abuse have not been conducted (Alexander, 1990; Bentovim and Van Elburg, 1987; Giaretto, 1976, 1978; Ribordy, 1990; Sgroi, 1982; Walker et al., 1988). Some programs have indicated a recidivism rate as low as 3 percent (Anderson and Shafer, 1979).

Home-Based Services and Family Preservation Services

Home-based services and family preservation services address the overall needs of families, include both children and parents, and focus directly on contextual factors, such as poverty, single parenthood, and marital discord, that increase stress, weaken families, and elicit aggressive behavior (Kolko, in press). These programs target functional relationships among diverse individual, family, and systemic problems by combining traditional social work with various therapeutic counselling approaches.

The use of home-based services has been advocated in response to the multiple problems found among abusive and neglectful families, difficulties in providing services in a traditional format, and interests in reducing the number of children placed in foster care. The breadth of potential family dysfunction has encouraged hands-on approaches that address risk factors at

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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multiple levels of the family system, such as financial problems, disruption, social isolation, and behavioral deviance (Frankel, 1988).

Applications of the home-based approach in child maltreatment have become increasingly popular in recent years. Studies of home-based services have found that a multisystemic approach using multiple treatment modalities resulted in greater improvements in parent-child relationships and child behavior problems than simple parent training in child management skills (Brunk et al., 1987; Nichol et al., 1988). However, the generalizability of these findings is limited by methodological problems, including the absence of clear targets for certain conditions (Nichol et al., 1988), follow-up information (Brunk et al., 1987; Nichol et al., 1988), and minimal treatment conditions (Brunk et al., 1987).

Home-based approaches have demonstrated particular effectiveness with neglectful families (Daro, 1988). The crisis conditions of some neglectful families, including poverty at the time of the report of neglect, have sometimes been described as the most recent manifestation of a deeply troubled history of the offending parent (Polansky et al., 1975, 1981). Treatment of neglectful behavior sometimes requires not only resolution of the immediate stressful conditions, but also intensive, long (perhaps more than 12 months), and often expensive interventions to alter the parent's fundamental concepts of self, relationships with others, and beliefs about one's ability to affect the circumstances of life.

Family preservation programs are designed to prevent the placement of children outside the home while ensuring their safety. Family preservation services are often characterized by their intensity (20-30 hours per week), short duration (often 6 weeks), and their flexibility in providing a range of therapeutic and support services tailored to the needs of families in crisis. Family preservation programs are often designed to address multiple goals, including the protection of children, strengthening family bonds, providing stability in crisis situations, increasing family skills and competencies, fostering family use of formal and informal helping resources, and preventing unnecessary out-of-home placement of children (Tracy et al., 1991).

The Homebuilders program (Kinney et al., 1977), established in the State of Washington in the 1970s, is the most widely disseminated and replicated family preservation program (Kammerman and Kahn, 1989; Meyers, 1991; Smith, 1991). The Homebuilders model is notable for its individualized interventions, program intensity, flexible schedule, small caseloads, goal orientation, time limited services, and program evaluation efforts (Whittaker et al., 1990). Individual programs vary by such factors as method of operation (drawing on public agency staff or private contracts), level of training, availability of staff, and availability of funds to purchase goods or services for families (Kammerman and Kahn, 1989). The majority of children remain at home following service termination or at follow-up.6

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Most of the evaluative research on family preservation programs reports success on a limited number of measures, such as preventing the placement of children and short-term improvement in family functioning (Bath and Haapala, 1993). However, the effectiveness of family preservation services remains unclear because most evaluative studies have suffered from methodological problems such as small samples, little reliability with respect to validity of measures, and nonexperimental designs (Kinney et al., 1977; Paschal and Schwahn, 1986; Rossi, 1992; Wells and Beigel, 1991). Research on family preservation services is also complicated by variations in definitions of outcome, the target population, and the quality of services (Wells and Biegel, 1991).7

Recent empirical studies have rigorously examined multiple outcomes of treatment and used experimental and quasi-experimental designs (Feldman, 1991; Mitchell et al, 1988; Nelson, 1990, 1991; Pecora et al., 1991; Schwartz et al., 1991; Yuan and Struckman-Johnson, 1991; Yuan et al., 1991). These studies have revealed equivocal findings about the effectiveness of family preservation programs, including high placement avoidance rates in control groups (Feldman, 1991; Mitchell et al., 1988; Yuan et al., 1991), little difference at follow-up between control and treatment conditions (Mitchell et al., 1988; Yuan et al., 1990), and the fading of treatment effects over time (Feldman, 1991).

In a recent review of family preservation research, Rossi (1991) observes that ''one of the major problems with existing evaluations is that they treat children and their families as if their problems were all the same (p. 61, cited in Bath and Haapala, 1993). It is likely that mixing clients of different ages, problem types, referral sources, and service domains has weakened the findings of studies. One recent study evaluated outcomes of family preservation services in different subpopulations of a relatively large sample within one service domain. Significant differences were found between families experiencing different types of maltreatment: fewer physically abused children were placed than those in the neglect and combined groups (Bath and Haapala, 1993).

Despite equivocal evidence of long-term effectiveness, family preservation services are currently believed to be a cost-effective alternative to the institutionalization or foster care placements for many children. If a child is not placed in foster care as a result of successful family-based services, the projected state savings in foster placement and administrative costs alone are estimated to be $27,000 (Daro, 1988).8 Child welfare and social service agencies are often legislatively required to provide permanent homes or use the least restrictive settings for children and encourage the use of family preservation programs.

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Family Income and Supplemental Benefits

The relationship of poverty to child maltreatment, specifically child neglect, is thought to be significant (see Chapter 4). Several government programs designed to alleviate or mitigate the effects of poverty on children are often part of a comprehensive set of services for low-income, maltreating families. Such programs include Social Security supplemental income programs, Aid to Families with Dependent Children (AFDC), Women with Infants and Children food supplement program (WIC), Head Start, rentsubsidy programs, and school lunch programs, among others.

Gil (1970) has stated that almost 60 percent of families reported for incidents of abuse and neglect received aid from public assistance agencies during or prior to the study year. However, while national and local child welfare programs designed to improve the well-being of all poor families may provide food, shelter, and other necessary resources, for children in households characterized by neglect or abuse, the relationship between income support, material assistance, and the subsequent reduction of maltreatment has not been systematically addressed.

Community Exosystem Interventions

Family-oriented interventions often exist within a context of a broad range of diverse services provided by community agencies. Medical personnel diagnose and treat physical conditions associated with child maltreatment. Child protection services personnel investigate suspected cases of child maltreatment, select and refer families for treatment services, and decide whether to allow a child to remain in the home. Child welfare services authorities provide financial and social services to families who may be in distress. Courts of law and law enforcement personnel intervene when questions are raised about the safety of the child or the community. Understanding these responses to child maltreatment is important in understanding the experiences of children and families following reports of maltreatment. Yet little is known about the efficacy of these community-based interventions.

A few treatment programs have been developed at the community level to provide services to families, such as counseling and educational services for the parents, supervised day care, and specialized referrals for community services, including mental health care, housing, and substance addiction treatment (Zuravin and Taylor, 1987). Although such neighborhood-focused programs may assist children who are victims of abuse or neglect, program evaluations usually do not consider outcomes in terms of maltreatment subpopulations.

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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Medical Treatment of Child Abuse

Health professionals in private practice, community health clinics, and hospitals are often the first point of contact for abused children and their families when serious physical injuries are sustained. Medical examinations of abused children enable physicians to identify physical conditions requiring medical treatment (including sexually transmitted disease and pregnancy), collect forensic evidence, document abuse histories, and refer abusive families to other services. Psychosocial examinations can document the nature, severity, and chronicity of behaviors exhibited by the abused child. Nurses and hospital social workers also play an influential role in managing or detecting child abuse cases in medical settings.

Health professionals are required by law to report cases of suspected abuse to child protection agencies, but the use of discretion in such reports is common. The 1988 National Incidence Survey suggested that only two-thirds of suspected cases are reported by health professionals (NCCAN, 1988).

Little is known about treatments recommended for abused children in medical settings, and even less is known about specific treatment outcomes. Studies suggest, however, that many health professionals may not be sufficiently trained to detect or validate signs of abuse or to deal with the physical, psychological, and legal aspects of evaluating maltreated children, particularly sexually abused children.9 For example, one study showed that many pediatricians were not able to label correctly a diagram of the female genitalia (Ladson et al., 1987).

Examinations of suspected abuse, specifically sexual abuse, sometimes have been described as "revictimizing" children. Sexual examinations sometimes frighten many children and can involve sensations similar to those experienced during victimization. The psychological effects of medical examinations following sexual assault (e.g., the use of the colposcope, which provides light and magnification and allows photographic recording of genital examinations) have not been clarified. The reliability of diagnostic conclusions in physical examinations for sexual abuse has been questioned and is currently the subject of study.

Medical examinations of sexually abused children often include testing for sexually transmitted diseases. Sexual abuse is a potential mode of transmission of infection by the human immunodeficiency virus (HIV) in children, although the incidence of HIV transmission through child sexual abuse is unknown. One recent study attempted to estimate the number of children infected with HIV as a result of pediatric sexual abuse in the United States and Canada (Gellert et al., 1993). This study concluded that sexual abuse resulted in HIV infection in 52 percent of home settings when both biological parents were present and a coinfection rate of HIV and other sexually transmitted diseases of 33 percent (Gellert et al., 1993). Selective testing guidelines have

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been developed for HIV infection based on normative practice among child abuse assessment experts (Gellert et al., 1990), but policies regarding selective testing of sexually abused children have not yet been clarified.

Child Protective Services

Child protective service officials are obligated to respond to cases of suspected child maltreatment. They evaluate the validity of complaints, perform risk assessments of families, monitor cases, and develop and implement family service plans.

Child protection agencies receive and screen initial reports of child abuse and neglect from educators, health personnel, police, members of the public (e.g., neighbors, family friends), relatives (including siblings and parents), and others to determine whether investigation is required. Limited resources often prevent child protection agencies from responding to increasing numbers of reports (see Chapter 3) within the 24 or 48 hours mandated by state child welfare legislation (Child Welfare League of America, 1986). In most locales the system is understaffed, many caseworkers are poorly trained, and high turnover rates are common.10 In New York City in 1991, for example, 77 percent of the workers who investigate child abuse reports resigned, were laid off, or transferred to jobs in other agencies (Dugger, 1992).

Less than half of the reported cases of child abuse and neglect are substantiated (Knudsen, 1988; NCCAN, 1988).11 When a report is substantiated, an agency official selects and refers families to specific treatment services, monitors the treatment process, and decides whether the child can safely remain in the home during treatment. However, one national survey has indicated that more than one-third of confirmed cases of child maltreatment received no therapeutic or supportive services (McCurdy and Daro, 1993).

The processes that determine child protective services responses to maltreated children and their families have not attracted much research attention, although such influences have a profound influence on the treatment process. Evaluations of CPS operations are complicated by the emergency situation in which many investigations occur, as well as variations in definitions of child maltreatment, and the absence of clear objectives, procedures, or standards of evaluation. However, a few studies have made an initial effort to document and characterize the various stages of the CPS process and their effects on children and families (Crittenden, 1992).

Intake and Assessment

Recent efforts to examine risk assessment factors have been initiated (American Public Welfare Association, 1989; NCCAN, 1991, 1992; Tatara,

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1989, 1990), but the factors that influence the treatment of specific cases still need further clarification. There has been little systematic study of factors that influence classification or misclassification of reports. The decision to investigate reports of child maltreatment can be influenced by ambiguous definitions, time restrictions, descriptions of the alleged maltreatment, its presumed seriousness, and even which worker takes the call (Knudsen, 1988)—all of which may have important consequences for certain types of clients and for specific categories of maltreatment. For example, middle-class families are less likely to be defined as dangerous and in need of intervention than lower-class families (Knudsen, 1988). Complaints against ex-spouses known to be involved in custody disputes are likely to be viewed as less dangerous for a child than battering reports made by medical personnel (Knudsen, 1988).

Investigation and Substantiation

Factors that influence the methods used to investigate allegations of maltreatment are poorly understood. State agencies often lack consistent criteria to help workers to make informed judgments in their investigations of reported or suspected child maltreatment. Factors that appear to be correlated with the substantiation of a report include the beliefs or assumptions of child protective services workers, the age of an alleged victim, and reports of multiple or recent incidents (Thoennes and Tjaden, 1990). However, empirical data do not confirm a causal relationship for any single factor, and data describing the life course of cases over time are not available.

Case Management and Referrals

Research on the nature and effectiveness of referral decisions involving maltreating families is difficult, and we know little about the operation of the referral system and follow-up services; the character of cases that are likely to receive services; the nature, intensity, and length of the services provided; and outcomes resulting from intervention services for different types of child maltreatment. Many factors can affect referral decisions, including availability of services, costs to clients and sponsors, ease of access, client attitudes, perceived need, and organizational relations (Knudsen, 1988). Recent clinical reports of child abuse cases suggest that many cases are closed immediately after services have been initiated and, in some instances, even prior to actual service delivery.12

The confidential nature of reports and investigations, the lack of systematic record-keeping and compatible data, and political sensitivity inhibit the observation and analysis of decisions made by child protective services

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workers (Knudsen, 1988). Improvements in knowledge about factors that foster or inhibit service referrals may increase the potential for flexible responses and tailoring of interventions for individual families. Some methods that bear empirical evaluation have been proposed to enhance this outcome, including the use of multiple informants, semistructured interview measures, interdisciplinary evaluation teams, and statistically derived assessment profiles that could translate into service plans (Baglow, 1990).

Child Welfare Services
Foster Care

The number of children placed in foster care during the past decade has increased dramatically. In 1990, the U.S. House of Representatives Select Committee on Children, Youth, and Families (1990) estimated that nearly 500,000 children were in out-of-home placements and that by 1995 the population of children in out-of-home care may be more than 840,000 children. The decision to allow a maltreated child to remain with family members or relatives during treatment is a critical and controversial aspect of the case management process. Children can be removed from the home for a variety of reasons, including physical illness or incapacity of the child's caregiver, mental illness of the parent (often the mother), child personality or emotional problems, severe neglect or abuse, criminal involvement of the parent, or family problems, such as substance abuse, and homelessness (Aber, 1980; Jenkins and Sauber, 1966; Runyan and Gould, 1985; Runyan et al., 1982; Weinberger and Smith, 1970; Widom, 1991). In some cases temporary foster care (sometimes called "respite care") is provided to protect the child and to provide a period for family members to improve the conditions that resulted in the child's removal from the home. Some children placed in foster care, particularly in urban areas, reside with relatives who subsequently receive foster care support payments, a procedure known as "kinship care." A child's permanent removal from the home and legal termination of parental rights may be sought by child welfare officials when family or parental characteristics associated with abusive or neglectful behavior show no signs of improvement. Foster care is often viewed as a temporary solution to an emergency situation and the average length of time in foster care has been decreasing in recent years: the median amount of time in foster care remains 1.5 years (Pelton, 1989). However, five years has been shown as the average length of time spent by children in foster care in some cities (Fanshel, 1981; Wiltse and Gambrill, 1973). One study of 772 foster children in San Francisco suggested that two-thirds of the children were expected to remain in foster care until their maturity (Wiltse and Gambrill, 1973). In addition to the length of placement, research has

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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indicated that the majority of children who remain in foster care for at least six months experience two or more placements (Knitzer and Allen, 1978; Tatara, 1989).

Proponents of foster care point to the potential for serious physical harm that can occur when abused and neglected children remain in a dangerous environment, and the psychological and developmental risks to the child that can occur from uncertain living arrangements. Critics argue that family preservation is an important cultural value, children should not be removed unnecessarily from their homes, the costs of placing a child in foster care are significant, and foster care placement may have detrimental consequences,13 including the potential for abuse while in foster care as well as developmental effects (particularly if young children experience multiple placements). Furthermore, the supply of foster care homes has become increasingly limited, especially in large cities (Kammerman and Kahn, 1989). As a result, community resistance to the forced removal of a child from the home remains high.

Current governmental policies seek to reduce the numbers of children requiring foster care or adoptive placement, to reduce the time lag between temporary and permanent placement of young children, and to reduce multiple placements for children. Although public policy decisions regarding the use of foster care must ultimately reflect value judgments within the community, the lack of solid empirical evidence about the nature of placement experiences and selection criteria hinders decision making in this area (Wald, 1976; Wald et al., 1988).

Criteria Regarding Out-of-Home Placement Decisions

Research on the placement of physically abused and neglected children has yielded diverse and contradictory findings, influenced by differences in methodology and in the variables selected for study (Hunter et al., 1990). Many foster care studies do not distinguish between maltreated and nonmaltreated children, although one recent study indicated that approximately 50 percent of the 199,000 children who entered foster care in 1988 were abused or neglected (Tatara, 1989, 1992).14 Children placed in foster care represent a highly heterogeneous population, characterized by different types of severity of maltreatment and family demographics (Aber, 1980). Placement decisions are often influenced by measures of parental functioning or cooperation (Boehm 1962, 1967), availability of maternal support (Hunter et al., 1990; Phillips et al., 1971), maternal health and caregiver cooperation (Meddin, 1984), the presence or absence of other relatives (Widom, 1991), and in sexual abuse cases, the initial history or statement (Jaudes and Morris, 1990).

Research has shown that placement decisions for abused and neglected

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children are affected by judgments about selected characteristics of families and the children (Aber, 1980; Runyan et al., 1982; Widom, 1991). Two studies have suggested that poor families, in particular, are more likely to have a child removed, even after controlling for the nature of the abuse (Katz et al., 1986; Ross and Katz, 1983).

Treatment for Children in Foster Care

Although children in foster care are known to be at high risk for severe emotional, behavioral, and physical difficulties, comprehensive physical and mental health services are not available for children in foster care (Goerge and Kranz, 1988; Schuerman et al., 1990). Two different studies found that children in foster care were generally underreferred for clinical services (Hochstadt and Harwicke, 1985; Meddin and Hansen, 1985).

Research on services provided to children in foster or kinship care is difficult. Information about children in foster care is often dispersed among biological parents, foster parents, relatives, and caseworkers, and cooperation among agencies providing services is frequently hampered by issues of confidentiality, rigid funding and eligibility requirements, budgetary restrictions, and the specialized nature of professional services that tend to focus on isolated problems (National Commission on Children, 1991). Therapists who provide treatment to children in foster care are often influenced by financial and contractual considerations, interagency relations and history, and the effects of decisions on future referrals (Molin, 1988).

Legal Intervention in Child Maltreatment

A small proportion of child maltreatment cases that are substantiated by child protection agencies can become involved with juvenile courts, family courts, and criminal courts, but no cohesive policy exists to guide the justice system's response to child abuse and neglect cases (Smith et al., 1980). Juvenile courts handle dependency proceedings, including adoption and foster care placements, when evidence exists that a parent is unable to protect and properly care for a child. Child maltreatment cases may be relevant to family courts when one parent seeks action against the other and evidence of abuse (usually sexual abuse) is considered in visitation or family custody decisions. Criminal courts handle charges against adults who have severely harmed or molested a child and can mandate that child abusers receive treatment.

Areas of convergence and conflict between the goals of service providers and the legal system in the treatment of child abuse and neglect have been documented, yet much uncertainty remains. Research on crimi-

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nal prosecution of child abusers suggests that many abusers, sexual molesters in particular, are not deterred by incarceration or threats of retribution (Tjaden and Thoennes, 1992). In some cases, the prosecution of an offender can be an impediment to treatment. For example, a parent's willingness to comply with treatment may be diminished if he or she believes that statements made during therapy will be used to incriminate them or terminate their parental rights (Davidson et al., 1981). Psychological problems that underlie maltreatment are usually not resolved by criminal sanctions because courts and prisons often lack resources to provide adequate treatment to offenders. An unsuccessful prosecution can also reduce the effectiveness of voluntary or court-ordered treatment, encourage noncompliance, and subject the child to further maltreatment (DeFrancis and Lucht, 1974).

Legal interventions in child maltreatment are complicated by many factors, such as the absence of physical evidence, difficulties in obtaining consistent and reliable testimony from children, emotional trauma that might be incurred in forcing a child victim to testify against a parent or other adult who may have harmed him or her, and inconclusive scientific evidence regarding the effectiveness of treatment in halting abusive and neglectful behavior.15 Almost nothing is known about the quality of court experiences for children or adults who are affected by physical abuse, neglect, or emotional maltreatment. However, even though relatively low numbers of sexually abused children involve court proceedings (Goodman et al., 1989; Martin and Hamilton, 1989),16 the legal treatment of child sexual abuse cases has attracted significant research attention (Goodman et al., 1989; Runyan et al., 1988). For example, the Department of Justice has sponsored numerous studies on the experience of the criminal and juvenile justice systems in handling child maltreatment cases, the effects of participation in the justice system on children, and the validity of children's statements and behaviors as indicators of abuse (Whitcomb, 1992).17 Researchers have also examined the effects of preparing a child for the experience of testifying, and methods to support the child through the legal system experience (King et al., 1988). However, systematic evaluations of the largest victim support programs (Court Appointed Special Advocates and the Guardian ad litem programs18) have not been conducted. The impact of guardian ad litems and volunteer Court Appointed Special Advocates on the outcome of court cases and on the children they represent is not known.

The role of the courts in ordering particular forms of treatment to prevent child abuse and neglect, such as the use of Norplant (an implantable contraceptive) for women who have histories of being reported for child maltreatment (Feringa, Iden, and Rosenfield, 1992; Scott, 1992); the use of castration for male sexual offenders; or the placement of newborns in foster

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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care if the mother tests positively for illegal drugs is particularly controversial, given the absence of research evidence supporting these actions as effective treatment or prevention programs.

Social/Macrosystem Interventions

Social and cultural values have influenced the development of interventions in child maltreatment in both professional and public institutions. In many situations, these values are complementary and reinforcing, but conflicts can arise. National policies, professional services, and institutional programs may sometimes be governed by different priorities that reveal inconsistent policies and fundamental value conflicts.

The principal values that strongly influence the current American social context for responding to reported or suspected child maltreatment include child safety and family preservation. The rights of individual privacy, confidentiality, and other liberties that are often constitutionally guaranteed also influence both the provision of social and professional interventions as well as evaluations of their effectiveness.

The conditions under which child, parental, or community rights should supersede all other rights and obligations, and the criteria that should be considered in balancing long-term dangers against immediate threats, are unclear. The safety of the child is usually a paramount interest, but minimal risks to the child may be tolerated to help families remain intact. Various anecdotal reports have illustrated cases in which children were not adequately protected because an offender remained in a caretaking role for the child during treatment or delays in court proceedings. For some children, foster care or removal of the offender from the home is the only way to protect the child from imminent harm, even though the out-of-home placement may result in further psychological or social damage and long-term costs to society. Research defining the best interests of the child is becoming a significant issue in determining the outcomes of assignment of visitation and custodial rights in court decisions.

Conclusions

Medical, psychological, social, and legal interventions in child maltreatment cases are based on assumptions that such interventions can reduce the negative physical, behavioral, and psychological consequences of child abuse and neglect, foster attitudes and behaviors that improve the quality of parent-child interactions and limit or eradicate recurrences of maltreatment. Interventions have been developed in response to public, professional, legal, and budgetary pressures that often have competing and sometimes con-

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tradictory policies and objectives. Some intervention services focus on protecting the child or protecting the community; others focus on providing individual treatment for the child, the offender, or both; others emphasize developing family coping strategies and improving skills in parent-child interactions. Assumptions about the severity of selected risk factors, the adequacy of caretaking behaviors, the impact of abuse, and the steps necessary to prevent abuse or neglect from recurring may vary given the goals and context of the intervention.

Little is known about the character and effects of existing interventions in treating different forms of child maltreatment. No comprehensive inventory of treatment interventions currently exists, and we lack basic descriptive and evaluative information regarding key factors that influence the delivery and outcomes of treatment for victims and offenders at different developmental stages and in different environmental contexts. A coherent base of research information on the effectiveness of treatment is not available at this time to guide the decisions of case workers, probation officers, health professionals, family counselors, and judges.

Investigations of child maltreatment reports often influence the development and availability of other professional services, including medical examinations, counseling, evaluation of risk factors, and substantiation of complaints. Research on various federal, state, and private agency involvement in treatment interventions has not been systematically organized, and information that describes how these groups interact is not readily available.

Although the panel acknowledges the challenges of performing research in this area, future study designs require particular sensitivity to the need for adequate sample sizes, well-characterized and designed samples, and validated and comparable measures. Specific causal relationships between services and outcomes have not been determined through experimental research designs with random assignment of subjects to treatment and control or comparison groups. In contrast, there have been successful applications of randomized clinical trials for other social problems, such as school-age pregnancy (Klerman and Horwitz, 1992) as well as randomized programs involving the response of law enforcement agencies to domestic violence reports (Sherman, 1992). Some researchers have suggested reforms in the data collection processes in clinical and legal decision making in child maltreatment cases so that service plans can be used for research purposes as well (Aber, 1980).

Research Recommendations

Recommendation 7-1: Research on the operation of the child protection system, including an evaluation of the sequential stages by which

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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children receive treatment following reports of maltreatment, is a priority need. The factors that influence different aspects of case handling decisions, factors that improve the delivery of case services, and alternatives to existing arrangements for providing services to children and families in distress need to be described and evaluated.

A research framework that provides standardized classifications and descriptions of child maltreatment investigations, adjudications, and referral decisions should be developed to analyze the operation of the child protection system. This classification system should be employed in a national study designed to facilitate data collection and to clarify the types of agencies involved in the system, the forms of maltreatment that stimulate treatment referrals, the range of interventions available for selected forms of maltreatment, the costs of investigating and responding to reports of child maltreatment, and the outcomes of case reports. Analysis is needed of the interaction among different agencies involved in intervention and treatment and the degree to which decisions made by one agency affect outcomes in others.

Recommendation 7-2: Controlled group outcome studies are needed to develop criteria to assess the effects of treatment interventions for maltreated children. Adequate measures need to be developed to assess outcomes of treatment for victims of abuse and neglect, and methods by which developmental, social, and cultural variations in abuse symptomatology can be integrated into treatment goals and assessment instruments need to clarified. The criteria that promote recovery and treatment modalities appropriate for children depending on their sex, age, social class, cultural background, and type of abuse need to be identified.

Research on the impact of abuse on children of different ages and in different contexts needs to be integrated into effective treatment strategies.19 All treatment programs should include some assessment of important outcomes for the child and other family members. In assessing treatment outcomes, consideration needs to be given to the child's developmental stage, cognitive abilities, and gender. The types of therapies (e.g., individual, group, family) and therapeutic techniques, including goals, intensity, and duration that are effective for groups of victims (e.g., young children, school-age children, adolescents), need to be identified. The criteria selected for treatment outcome studies are particularly important because they shape the emphasis of the intervention. The treatment of children with developmental disabilities, past histories of abuse, and factors associated with maintenance of treatment effects (e.g., concomitant therapy for parents), require special attention because they can all influence treatment outcomes.

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The gap between research information on critical factors and conditions under which treatment is provided also needs to be bridged by identifying individual, social, cultural, and contextual variables that affect the use and outcome of treatment interventions. In implementing this recommendation, closer integration of diverse research and practice traditions needs to be developed to improve the quality of treatment interventions in response to child maltreatment.

Recommendation 7-3: Well-designed outcome evaluations are needed to assess whether intensive family preservation services reduce child maltreatment and foster the well-being of children in the long term.

In addition to examining the role of family preservation programs in preventing foster care and other out-of-home child placement decisions, evaluations of family preservation services need to consider the effects of such programs in encouraging positive parent and child interactions and other factors that affect child and family well-being. Evaluations should examine the methods by which families acquire skills that foster positive family interactions and the factors that reduce crises that lead to the need for services. Such evaluations should also measure the impact of family preservation programs on parent and child functioning, psychological health, and long-term consequences for the child and family that are associated with participation in the program. Comparing families in family preservation services with those in alternative services or those who receive no services could test the efficacy of various models of intensive family preservation services as well as the effect of key service components, such as the intensity and duration of services on outcomes.

The costs of family preservation services, including all services received by families during counseling and after termination, need to be determined. Such research will provide data on the costs of treating families and would furnish a baseline from which to compare the effectiveness of different approaches.

Recommendation 7-4: Studies of foster care that examine the conditions and circumstances under which foster care appears to be beneficial or detrimental to the child are urgently needed.

Special consideration should be given to factors that might be related to outcomes, such as characteristics of the process by which the child was removed from the original home, characteristics of the foster family, and characteristics of the child (including age at placement or adoption). Evaluations of regional studies of children placed in foster care as a result of

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child maltreatment should be conducted to develop a comprehensive physical and mental health needs assessment for this special population. The proposed evaluations should draw on the study of abuse effects to develop a physical and mental health profile that can be used in planning treatment interventions for these children.

Recommendation 7-5: Large-scale evaluation studies of treatments for perpetrators of sexual and physical abuse and neglect (familial as well as extrafamilial), with lengthy follow-up periods and control groups of untreated or less intensively treated offenders, need to be designed to compare different treatment modalities. Because of their relatively low costs, evaluations of self-help and support programs may be particularly beneficial. Early intervention through the treatment of adolescent offenders also deserves special consideration at this time.

A large-scale evaluation to test comparative studies of self-help, support, and other therapeutic techniques should be conducted to describe ways in which such peer- and professional-led groups maintain a healthy or unhealthy change-oriented approach. The length of service and scope of participation in programs warrants research attention. Evaluations should examine factors that promote change in abusive behavior and psychological processes associated with abusive behavior (e.g., attitudes), and should identify participant and organizational characteristics associated with differential effectiveness.

Recommendation 7-6: Effective interventions for neglectful families need to be identified. Large-scale evaluation studies of child neglect should be developed to determine types of interventions that can mitigate chronic neglectful behaviors among offending parents and improve outcomes for children victimized by neglect.

Information should be sought about the historical, social, and psychological characteristics of neglectful parents in order to identify key variables that may become the focus of treatment interventions. Strategies for recruiting and retaining neglectful families in treatment programs need to be developed and could benefit from comparative studies of strategies used in modifying other behaviors that are resistant to change, such as drug addiction. Future efforts should explore the relative merits of long-term impacts of infant stimulation programs and other intensive services for neglected children and examine the relative contributions of intervention methods for different factors associated with neglect, such as lack of parental involvement or investment, lack of resources, a misunderstanding of the child's needs, social isolation, and maternal depression.

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Notes

1. An excellent review of research on emotional maltreatment is included in a special issue of Development and Psychopathology, Vol. 3(1), 1991.

2. Study I: Berkeley Planning Associates' evaluation of the 11 joint OCD/SRS demonstration programs in child abuse and neglect conducted between 1974 and 1977 with a client impact sample of over 1,600 families; Study II: Abt Associates' evaluation of 20 demonstration and innovative treatment projects funded by the National Center on Child Abuse and Neglect between 1977 and 1981 with a client impact sample of 488 families; Study III: E.H. White's evaluation of 29 service improvement grants funded by the National Center on Child Abuse and Neglect between 1978 and 1981 with a client impact of 165 families; Study IV: Berkeley Planning Associates' evaluation of 19 clinical demonstration projects funded by the National Center on Child Abuse and Neglect between 1978 and 1982 with a client impact of 1,000 families.

3. The National Center on Child Abuse and Neglect offered nine demonstration grants ($200,000/grant) to investigate this area in 1990, but the results of these studies have not yet been published.

4. Studies that include school-age children primarily as participants in parent training or multisystemic programs are described later in this chapter under family treatments.

5. A critical component of these programs was supplemental parent training (Kazdin et al., 1987; Kazdin, 1989).

6. In the Homebuilders model, 90 percent of 134 children remained in the home during the 16-month follow-up (Kinney et al., 1977).

7. Although researchers generally agree that prevention of external placement is an appropriate indicator of programmatic success, the use of this measure alone poses several problems: (1) it is difficult to compare placement rates over time and across communities because not all children who enter family preservation programs would have been placed; (2) placements are affected by factors that are external to success or failure in treatment, such as the availability of after-care services or institutional placements in a community; (3) improvements in the quality of parent-child relationships are not a documented outcome (Daro, 1988; Wells and Biegel, 1991).

8. This figure assumes that the child would be in foster care a total of 8 years, the average length of stay for the Maryland caseload, and that the family-based services would be provided for a total of 15 months, with intensive intervention during the initial 3 months (Daro, 1988).

9. Current training in child abuse focuses predominantly on physical abuse and typically covers only identification and reporting (Alexander, 1990).

10. In New York City, for example, although workers have an average of 19.5 cases, some workers have up to 30. In most states, caseworkers are required to have only a college degree; only in New Mexico and North Dakota are degrees in social work required (Dugger, 1992).

11. Some researchers have indicated that the substantiated/unsubstantiated dichotomy is overly simplistic and inappropriate for capturing the complexity of the child protection system decision-making process (Giovannoni, 1989).

Since the 1970s the nation has witnessed a steady decline in the percentage of child maltreatment reports that are substantiated as well as an increase in the total number of reports. Although the rising percentage of unsubstantiated reports does not necessarily reflect an ineffective or inefficient reporting system, it increases pressure on resources and emphasizes the need to reexamine present reporting laws and investigatory systems (Eckenrode et al., 1988).

12. The decision to close cases may be in response to the administrative problem of increased caseloads, but one effect of this practice is to remove potentially useful social service agency pressure and monitoring that can motivate parents to participate in treatment. Some

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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evidence suggests that institutional or legal pressures enhance treatment outcomes (Wolfe, 1985).

13. See Chapter 6 for a fuller discussion of the consequences of foster care.

14. It is possible that the proportion may be even higher, since several of the other categories, such as child abandonment), could reasonably be considered as stemming from child maltreatment.

15. Since the 1970s, state legislatures have passed laws to facilitate prosecution of child maltreatment cases. The rules governing the admissibility of evidence have been broadened by the Supreme Court. The types of out-of-court or hearsay statements that can be admitted into court proceedings have been expanded, and several states allow videotaped versions of children's testimony or shielding a child witness from the defendant during their testimony (Reppucci and Aber, 1992). The latter two innovations continue to be controversial because they restrict the defendants' Sixth Amendment right to confront witnesses in criminal trials. Empirical studies have not yet documented the impact of these techniques (Reppucci and Aber, 1992).

16. According to 52 law enforcement agencies responding to a Police Foundation survey, only 39 percent of child sexual abuse cases result in arrest; 42 percent of these cases are not prosecuted because they lack sufficient evidence to meet criminal standards of proof beyond a reasonable doubt or involve children viewed as too young to be credible witnesses (Martin and Hamilton, 1989). In the majority of sexual abuse cases that are prosecuted, children do not actually testify in criminal court. In one study of sexual abuse cases referred for prosecution, approximately 8 percent of child victims testified (Goodman et al., 1989).

17. Negative consequences of testifying in sexual abuse cases appear to be specifically associated with multiple testimonies, the harshness of direct and cross-examination experiences, age, lack of corroborative evidence, and lengthy delays in the criminal prosecution process (Goodman et al., 1989; Runyan et al., 1988). Intimidating atmospheres and fear of the separation from a loved one also have particularly negative effects on children (Goodman et al., 1989). Researchers have not attempted to identify the percentage of children traumatized by testifying, the risk factors for experiencing trauma, or the types of abuse that cause the most trauma to testify about (Reppucci and Aber, 1992).

Assessing the validity of behaviors and statements of suspected victims of child abuse in the absence of definitive physical evidence poses many challenges. The accuracy and reliability of a child's allegations are affected by factors such as the consistency of the account, vocabulary appropriate to the child's developmental level, lack of motivation to fabricate the account, appropriate affect, spontaneity, and consistency with corroborative evidence (Perry and Wrightsman, 1991). Most of research in this area has focused on sexual abuse victims. Young children's interactions with anatomical dolls is one type of behavior commonly evaluated in assessing suspected victims of child sexual abuse. Although anatomical dolls often help children describe what has happened to them and are often used in the assessment of young children, conflicting evidence exists about behavioral differences between the behavior of sexually abused and nonabused children with anatomical dolls (Kendall-Tackett, 1992; Realmuto and Wescoe, 1992).

18. Victim witness programs are available in more than 7,000 communities across the United States (Whitcomb, 1992). Approximately 13,000 trained volunteers serve as Court Appointed Special Advocates in dependency hearings and advise judges and prosecutors about victims' needs and request specific intervention. Guardian ad litems are attorneys appointed by juvenile courts to represent a child's best interests, accompany the child to court proceedings, and obtain necessary social, medical, and mental health services.

19. Existing measures developed to address psychological and other aspects of human functioning are not necessarily associated with abuse impacts (particularly sexual abuse impacts). Researchers may require new assessment instruments that are sensitive to abuse-related symptomatology with reasonable psychometric characteristics in order to evaluate outcomes of intervention studies (Briere, 1992; Elliott and Briere, 1991).

Suggested Citation:"7 INTERVENTIONS AND TREATMENT." National Research Council. 1993. Understanding Child Abuse and Neglect. Washington, DC: The National Academies Press. doi: 10.17226/2117.
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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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