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Emerging Practices in the Prevention of Child Abuse and Neglect

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You are in section: Table of Contents Advisory Group Members Acknowledgments 1 - Introduction 2 - Maltreatment Incidence, Impact… 3 - Featured Programs from the First… 4 - Future Directions References Appendix A - Emerging Practices in… Appendix B

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Maltreatment Incidence, Impact, and Existing Models of Prevention

Nature and Scope of Child Maltreatment in the United States

Abuse and neglect of children occurs in families from all walks of life, and across all socioeconomic, religious, and ethnic groups. There is no single, identifiable cause of child maltreatment; rather, it occurs as a result of an interaction of multiple forces impacting the family. While certain factors related to parents, children, families, and the environment are commonly associated with a greater incidence of child maltreatment, the presence of these factors alone is not sufficient for abusive situations to develop. Stated differently, the presence of known risk factors does not always lead to family violence, and factors that may cause violence in one family may not result in violence in another family (DePanfilis & Salus, 1992).

There are four main types of child maltreatment: physical abuse, child neglect, sexual abuse, and emotional abuse. Physical abuse is the infliction of physical injury by various methods, even if the perpetrator does not intend harm. Child neglect is the failure to provide for the child's basic needs and can be physical, educational, or emotional. Sexual abuse is the involvement of a child in any kind of sexual act, including prostitution or pornography; many believe this is the most underreported type of abuse. Emotional abuse is an act or omission that has caused or could cause, serious behavioral, cognitive, emotional, or mental disorders. These types of maltreatment often occur together within a family, though they can appear alone as well.

How Many Children Are Maltreated Or At Risk Of Maltreatment?

In 2000, nearly 2 million reports of alleged child abuse or neglect were investigated by child protective services agencies, representing more than 2.7 million children who were alleged victims of maltreatment and who were referred for investigation (U.S. Department of Health and Human Services, 2002). Of these children, approximately 879,000 were found to be victims of maltreatment, meaning that sufficient evidence was found to substantiate or indicate the report of child maltreatment.

This reflects a national rate of approximately 12.2 children per 1,000 children younger than 18 years of age in the general population who were found to be substantiated or indicated victims of maltreatment. This estimate represents an annual rate of abuse among children under 18. However, an individual child's likelihood of being abused over the course of his or her childhood may be higher. A study that analyzed local data on abuse rates of children in Cuyahoga County, Ohio, estimated that nearly 17 percent of children born between 1998 and 2000 could be expected to have substantiated reports of maltreatment before reaching age 8, though the largest occurrence for any given year of age (birth to age one) was less than 5 percent (Sabol, Polousky, & Billing, 2002).

Nearly two-thirds of child victims (62.8%) suffered neglect, including medical neglect, while nearly one-fifth (19.3%) suffered physical abuse and approximately 10 percent suffered sexual abuse. The risk of maltreatment is highest for children under 4 years of age. Moreover, children with a prior history of victimization were more than three times as likely to experience recurrence compared with children without a prior history.

Recent Trends In Observed Rates Of Maltreatment

The 2000 Annual Report from the National Child Abuse and Neglect Data System (NCANDS) indicates that national child abuse incidence rates increased in each year from 1990-1993, and decreased in each year through 1999. The rate of victimization was 13.4 per 1,000 children in 1990. The rate peaked at 15.3 children per 1,000 in 1993, then decreased to 11.8 per 1,000 in 1999, while increasing slightly to 12.2 children per 1,000 in 2000. Meanwhile, the National Incidence Studies (NIS) found that rates of child maltreatment under the Harm Standard increased 149 percent from the time the first NIS study (NIS-1) was conducted in 1980 to the time the latest NIS study (NIS-3) was conducted in 1993.

Factors most commonly attributed to the increase in observed rates are: a greater public awareness of the reporting system through media and education; reporting system changes, such as a centralized intake, more effective intake assessments, use of standardized screening tools, and newly implemented data systems; increased rates of substance abuse; and changing standards and definitions of what constitutes abuse, both over time and across professions (Tzeng, Jackson, & Karlson, 1991; Wang & Daro, 1997).

Factors Influencing Risks To Children

While there are varying schools of thought on the origins of maltreatment, most theories of child maltreatment recognize that the root causes can be organized into a framework of four principal systems: 1) the child, 2) the family, 3) the community, and 4) the society. Though children are not responsible for the abuse inflicted upon them, certain child characteristics have been found to increase the risk or potential for maltreatment. Children with disabilities or mental retardation, for example, are significantly more likely to be abused (Crosse, Kaye, & Ratnofsky, 1993; Schilling & Schinke, 1984). Evidence also suggests that age and gender are predictive of maltreatment risk. Younger children are more likely to be neglected, while the risk for sexual abuse increases with age (Mraovick & Wilson, 1999). Female children and adolescents are significantly more likely than males to suffer sexual abuse.

Important characteristics of the family are linked with child maltreatment. Families in which there is substance abuse are more likely to experience abuse or are at a higher risk of abuse (Ammerman et al., 1999; Besinger et al., 1999; U.S. Department of Health and Human Services, 1993). But, identifying families in which substance abuse is present can be difficult. The Child Welfare League of America (2001) recently found that substance abuse is present in 40-80 percent of families in which children are abuse victims. Recent studies also have established a link between having a history of childhood abuse and becoming a victimizer later in life, including Clarke et al. (1999), confirming some of the earliest work in the field. Dilillo, Tremblay, and Peterson (2000) found that childhood sexual abuse increased the risk of perpetrating physical abuse on children as adults. Domestic violence and lack of parenting or communication skills also increase the risks of maltreatment to children.

Factors related to the community and the larger society also are linked with child maltreatment. Poverty, for example, has been linked with maltreatment, particularly neglect, in each of the national incidence studies (Sedlak & Broadhurst, 1996), and has been associated with child neglect by Black (2000) and found to be a strong predictor of substantiated child maltreatment by Lee and Goerge (1999). Bishop and Leadbeater (1999) found that abusive mothers reported fewer friends in their social support networks, less contact with friends, and lower ratings of quality support received from friends. Violence and unemployment are other community-level variables that have been found to be associated with child maltreatment. Perhaps the least understood and studied level of child maltreatment is that of societal factors. Ecological theories postulate that factors such as the narrow legal definitions of child maltreatment, the social acceptance of violence (as evidenced by video games, television and films, and music lyrics), and political or religious views that value noninterference in families above all may be associated with child maltreatment (Tzeng, Jackson & Karlson, 1991).

Researchers, practitioners, and policy makers are now increasingly thinking about protective factors within children and families that can reduce risks, build family capacity, and foster resilience. In 1987, case studies of three victims of child maltreatment began to shed light on the dynamics of survival in high-risk settings. Resilience in maltreated children was found to be related to personal characteristics that included a child's ability to: recognize danger and adapt, distance oneself from intense feelings, create relationships that are crucial for support, and project oneself into a time and place in the future in which the perpetrator is no longer present (Mrazek & Mrazek, 1987).

Since then, researchers have continued to explore why certain children with risk factors become victims and other children with the same factors do not. What are the factors that appear to protect children from the risks of maltreatment? In a recent overview by the Family Support Network, factors that may protect children from maltreatment include child factors, parent and family factors, social and environmental factors. Child factors that may protect children include good health, an above-average intelligence, hobbies or interests, good peer relationships, an easy temperament, a positive disposition, an active coping style, positive self-esteem, good social skills, an internal locus of control, and a balance between seeking help and autonomy.

Parent and family protective factors that may protect children include secure attachment with children, parental reconciliation with their own childhood history of abuse, supportive family environment including those with two-parent households, household rules and monitoring of the child, extended family support, stable relationship with parents, family expectations of pro-social behavior, and high parental education. Social and environmental risk factors that may protect children include middle to high socioeconomic status, access to health care and social services, consistent parental employment, adequate housing, family participation in a religious faith, good schools, and supportive adults outside the family who serve as role models or mentors (Family Support Network, 2002). Some recent studies have found that families with two married parents encounter more stable home environments, fewer years in poverty, and diminished material hardship (Lerman, 2002).

Consequences and Costs of Child Maltreatment

The impact of child maltreatment is profound and enormous. A single incident affects the victim not only today, but quite often tomorrow and beyond as well. That incident also reverberates through families and across institutions—including medical and mental health resources, law enforcement and judicial systems, public social services, and nonprofit helping agencies—as they respond to the incident and support the victim in the aftermath.

Abuse And Neglect Of Children Can Have A Long-Lasting Legacy

Maltreatment has immediate physical effects on children that include broken bones, physical disability, mutilation, and sensory impairment; maltreatment ended in death for approximately 1,200 children in 2000. Child maltreatment is known to have considerable long-term psychological and behavioral effects on survivors that include mental retardation and intellectual and social deficiencies, as well as an increased risk for difficulty in school, delinquency, and violent criminal behavior.

According to social science researcher Cathy Spatz Widom, being abused or neglected as a child increased the likelihood of being arrested as a juvenile by 53 percent, as an adult by 38 percent, and for a violent crime by 38 percent (Widom, 1992). More recent studies have found that victims of abuse or neglect are over-represented among high-risk, male juvenile parolees (Wiebush, McNulty, & Le, 2000), as well as among both adult male and female offenders incarcerated in State prisons (Harlow, 1999). Results of these studies are essentially consistent with a number of other studies of the same general hypothesis that established empirical links between maltreatment and later deviant or criminal behavior (Alfaro, 1981; Kelly, Thornberry, & Smith, 1997; McCord, 1983). It is well known that children who suffer abuse or neglect are also more likely, as adults, to abuse children themselves.

Child maltreatment also has a tremendous impact on law enforcement and the judicial and correctional systems, which incur extraordinary costs for the investigation, prosecution, and confinement of perpetrators accused and convicted of child abuse and neglect. In a national survey of criminal justice practitioners, 91 percent of responding prosecutors and 82 percent of public defenders said that child and spouse maltreatment contribute to workload problems in their offices. Four out of five judges (79%) noted that child abuse cases contribute to workload problems, while 85 percent noted that domestic violence cases do so. Meanwhile, the majority of administrators of correctional facilities suggested that offenders in such cases contribute to jail crowding problems (National Institute of Justice, 1995).

Local social services agencies, which provide child protective services, foster care and other out-of-home placements, along with family preservation, rehabilitation, and treatment programs, are also engaged in the aftermath of child abuse and neglect. Families with victims suffering long-term injuries or trauma may rely on Medicaid, income maintenance programs such as Temporary Assistance to Needy Families (TANF) and food stamps, and services provided through State and local departments of mental health. Nonprofit entities also may be engaged, including child fatality review teams and children's trust fund organizations (National Research Council, 1998).

Costs Of Maltreatment To Society Are Extraordinary

Prevent Child Abuse America, a national advocacy organization, recently generated the first national estimates of the annual costs of child abuse and neglect in the United States. That analysis, which includes estimates of the direct or immediate costs of abuse as well as the indirect or long-term costs, suggests that child abuse and neglect costs the nation $258 million each day, or approximately $94 billion each year (Prevent Child Abuse America, 2001).

The direct costs of abuse, which include costs associated with hospitalization, chronic health problems, mental health care, the child welfare system, law enforcement, and the judicial system, were estimated at approximately $24 billion each year. Indirect costs of abuse, which include costs associated with special education, mental health and health care, juvenile delinquency, lost productivity, and adult criminality, were estimated at approximately $70 billion each year. Prevent Child Abuse America cautions that its estimates likely understate the true annual cost since the analysis did not capture the full range of indirect costs, such as cash and food assistance to adults whose difficulties can be directly traced to past maltreatment.

As perhaps the most comprehensive analysis to date in terms of the component costs of maltreatment that it includes, recent estimates by Prevent Child Abuse America dwarf the results of all earlier analyses of the costs of violence in American families. The magnitude of these estimates is startling, and they may begin to exert influence on the manner in which the problem is approached and the direction of future public policy.

What is Prevention and Why Is it Important?

Prevention of child abuse and neglect has taken on many forms since the 1960s when C. Henry Kempe identified the Battered Child Syndrome. Policy makers, legislators, professionals, and concerned citizens have struggled to find effective ways to prevent violence against children. The term "prevention" has several meanings. Prevention can be used to represent activities that promote an action or behavior. The term is also used to represent activities that stop an action or behavior. A dictionary defines prevention as "stopping or keeping from doing or happening; hindering."

Why Does Prevention Matter?

Prevention of socially undesirable and hazardous behaviors cannot only save lives, but also precious resources. While impossible to entirely eradicate certain kinds of behavior that can have tragic human consequences, including the maltreatment of children, human service professionals have been buoyed by improvements over time across numerous major indices that measure the health and well-being of individuals and families. Public education campaigns that increase awareness by delivering steady messages can alter behavior, saving lives and critical resources in the process. The following illustrate a few of the significant recent trends in health-related measures of well-being:

• Alcohol-related traffic deaths have dropped substantially from the early 1980s to 2001, attributable, in part, to national campaigns to elevate public awareness and change behavior such as the "Designated Driver" campaign. Traffic fatalities in alcohol-related accidents declined 13 percent from 20,159 fatalities reported in 1991 (49 percent of total traffic fatalities for the year) to 17,448 reported in 2001 (41 percent of total fatalities); total fatalities per year are down approximately 30 percent since 1982 (National Highway Traffic Safety Administration, 2002). Though fatalities increased slightly from 2000 to 2001, the 20-year trend represents a tremendous savings in prevented injury and avoided loss of life.
• There has been a dramatic reduction in the AIDS incidence among adult, adolescent and mother-to-child, or perinatal, HIV transmission rates. Between 1992 and 1997, perinatally acquired AIDS cases declined 66 percent in the United States. The U.S. Centers for Disease Control and Prevention (CDC) recently estimated a net savings of $38 million in preventing 656 new HIV infections, based on medical care costs alone. Though these figures are encouraging, new adult cases have begun to move upward again among specific subpopulations, a reminder that trends are influenced by factors that can change in the short term (U.S. Centers for Disease Control and Prevention, 1999a).
• Continuing a downward trend in adolescent pregnancy that began in the early 1990s, the CDC reported that the national pregnancy rate for adolescents ages 15-19 declined by 7.8 percent from 1995-1997. There was also an overall decline of 7.5 percent in the abortion rate for adolescents ages 15-19 (U.S. Centers for Disease Control and Prevention, 2000). In addition, all States have applied at some point for the Maternal and Child Health Bureau abstinence education block grant funds and most are using the monies in innovative ways to promote abstinence from sexual activity as the healthiest choice for youth (Devaney et al., 2002).
• Though concerns remain about the relatively steady rate among 18-24 year olds, the CDC reported substantial decreases from 1993 to 2000 in smoking prevalence for all other age groups. The estimated direct and indirect costs associated with smoking exceed $68 billion annually (U.S. Centers for Disease Control and Prevention, 2002).

With sustained advocacy from groups such as Mothers Against Drunk Driving (MADD), the problem of alcohol-related traffic fatalities has become a case study in the critical elements that are necessary to bring about meaningful social change. In addition to sensitizing the public to the hazards of driving under the influence, which has been accomplished by giving a personal face to the human tragedy of alcohol-related traffic accidents, advocacy groups have utilized an array of effective tactics. These include lobbying for lower legal blood-alcohol limits, more severe penalties for offenders, innovative strategies for prevention, stricter standards on advertising of alcohol, and higher excise taxes that are designed to reduce demand for alcohol.

Studies conducted by the Michigan Children's Trust Fund and the Colorado Children's Trust Fund illustrate the potential value of child maltreatment programs that can reduce incidence. In 1992, the Michigan Children's Trust Fund estimated that the cost of responding to child maltreatment in Michigan was $823 million annually, including the estimated costs associated with low-weight births, child fatalities and preventable infant mortality, medical treatment, child protective services, foster care, juvenile and adult criminality, and psychological problems. In contrast, the cost of providing prevention services to all first-time parents in Michigan was estimated at $43 million annually. The study concludes that while the incidence of abuse cannot be reduced to zero, investments in prevention can be cost effective if they result in even modest reductions in abuse events (Caldwell, 1992).

A similar study commissioned by the Colorado Children's Trust Fund estimated that responding to child maltreatment costs Colorado $402 million annually, whereas home visitation services for high-risk families would cost Colorado just $24 million annually (Gould & O'Brien, 1995).

Existing Framework For Prevention In The Field Of Child Maltreatment

With respect to human services, prevention typically consists of methods or activities that seek to reduce or deter specific or predictable problems, protect the current state of well-being, or promote desired outcomes or behaviors (adapted from Bloom, 1996). Professionals working to prevent child abuse and neglect have "borrowed" from other disciplines, including public health, education, and mental health. Though all these disciplines influence and guide practice, perhaps public health has had the greatest influence in organizing a framework of prevention services. That framework consists of three levels of services: primary prevention programs, which can be directed at the general population (universal); secondary prevention programs, which are targeted to individuals or families in which maltreatment is more likely (high risk); and tertiary prevention programs, targeted toward families in which abuse has already occurred (indicated).

Primary prevention activities can be directed at the general population and attempt to stop the occurrence of maltreatment. All members of the community have access to and may benefit from services directed at the general population. Primary prevention activities with a universal focus seek to raise the awareness of the general public, service providers, and decision-makers about the scope and problems associated with child maltreatment. Universal approaches to primary prevention might include:

• Public service announcements that encourage positive parenting;
• Parent education programs and support groups that focus on child development and age-appropriate expectations and the roles and responsibilities of parenting;
• Family support and family strengthening programs that enhance the ability of families to access existing services, and resources and support interactions among family members; and
• Public awareness campaigns that provide information on how and where to report suspected child abuse and neglect.

Secondary prevention activities with a high-risk focus are offered to populations that may have one or more risk factors associated with child maltreatment, such as poverty, parental substance abuse, young parental age, parental mental health concerns, and parental or child disabilities. Programs may direct services to communities or neighborhoods that have a high incidence of any or all of these risk factors. Approaches to prevention programs that focus on high-risk populations might include:

• Parent education programs located in high schools, for example, that focus on teen parents, or within substance abuse treatment programs for mothers and families with young children;
• Parent support groups that help parents deal with their everyday stresses and meet the challenges and responsibilities of parenting;
• Home visiting programs that provide support and assistance to expecting and new mothers in their homes;
• Respite care for families that have children with special needs; and
• Family resource centers that offer information and referral services to families living in low-income neighborhoods.

Tertiary prevention activities focus on families where maltreatment has already occurred (indicated) and seek to reduce the negative consequences of the maltreatment and to prevent its recurrence. These prevention programs may include services such as:

• Intensive family preservation services with trained mental health counselors that are available to families 24 hours per day for a short period of time (e.g., 6-8 weeks);
• Parent mentor programs with stable, non-abusive families acting as "role models" and providing support to families in crisis;
• Parent support groups that help parents transform negative practices and beliefs into positive parenting behaviors and attitudes; and
• Mental health services for children and families affected by maltreatment to improve family communication and functioning.

Distinctions between primary, secondary, and tertiary prevention, while perhaps useful for some purposes, do not necessarily reflect the way prevention-related services are actually organized and provided on the ground. Rather than sorting prevention initiatives into mutually exclusive categories, prevention is increasingly recognized as a continuum.

Federal Funding of Prevention Activities in the United States

Various sources of funding are available to States and local jurisdictions to finance child abuse and neglect prevention activities. At the Federal level, the Children's Bureau, which is responsible for assisting States in providing services that are designed to protect children and strengthen families, administers 9 State grant programs and 6 discretionary grant programs. Title II of the Child Abuse Prevention and Treatment Act (CAPTA), for example, authorizes the Community-Based Family Resource and Support (CBFRS) program to help develop networks of community-based, prevention-focused family resource and support programs. CBFRS funds are invested by the States in accordance with their own strengths and needs, and supplemented by State funds and other local resources. Some key components of CBFRS-funded programs include statewide prevention networks, home visiting, mutual support, parent education and support, respite care, and public awareness activities. The program also encourages States to maximize and leverage funding through partnerships and collaborations with other prevention-related programs.

Under the Promoting Safe and Stable Families program, capped matching entitlement grants to States are awarded to support four specific activities, including community-based family support services to support and strengthen vulnerable families before abuse or neglect occurs, intensive family preservation activities, time-limited family reunification services, and adoption promotion and support services. States also receive basic grants for developing and implementing child abuse and neglect prevention and treatment programs, while discretionary funds are available to support research and demonstration projects.

Various sources other than the Children's Bureau also support maltreatment prevention activities, including Federal agencies, such as the CDC, the Maternal and Child Health Bureau, and the U.S. Department of Justice; State agencies through earmarked State funds; and foundations and nonprofit organizations. Though this section only provides general information on Federal sources of funds, many State organizations have been very creative at utilizing a variety of public and private funding streams such as the State general fund appropriations, State income tax check-offs, license plates, foundations, and fundraising. Appendix B identifies local contacts for more information regarding various States' efforts.

The following section presents an overview of some of the nation's most well-known prevention programs, many of which are established, multisite programs with lengthy histories of service in communities across the country.

What Kinds of Prevention Programs Currently Exist?

Child maltreatment prevention services operating in communities today generally fall within a typology that includes several major approaches or methodologies: public awareness activities, skill-based curricula for children, parent education programs and support groups, home visitation programs, respite and crisis care programs, and family resource centers. In recent years, programs have been developed and implemented in a wider array of settings including prisons, places of worship, hospitals, and schools.

Public Awareness Activities

Public awareness activities are an important part of an overall approach to address child abuse and neglect. Such activities have the potential to reach diverse community audiences, including parents and prospective parents, children, and community members. In designing prevention education and public information activities, national, State, and local organizations use a variety of media to promote these activities, including:

• Public service announcements
• Press releases
• Posters
• Information kits and brochures
• Television or video documentaries and dramas.

Through these media, communities are able to promote healthy parenting practices, child safety skills, and protocols for reporting suspected maltreatment.

One of the largest child maltreatment public awareness initiatives is focused on the prevention of Shaken Baby Syndrome. A national network of State contacts for Don't Shake the Baby was established to ensure that all professionals involved in the care of children (e.g., teachers, physicians, nurses, home visitors, parent educators) became aware of the dangers associated with shaking infants. In addition to professionals, this campaign targeted parents to alert them to the dangers of shaking their babies and to provide information on positive coping skills when caring for a crying infant. Another initiative designed to capture attention and raise public awareness is STOP IT NOW!, which is a primary prevention media campaign that targets male and female sexual abuse perpetrators and other adults, calling on abusers and potential abusers to stop and seek help. STOP IT NOW! also increases public awareness about the trauma of sexual abuse. People are encouraged to call a toll-free help line for information and referrals regarding child sexual abuse.

Prevent Child Abuse America, formerly the National Committee to Prevent Child Abuse, also directs efforts to increase public awareness of the dangers and signs of child maltreatment. In collaboration with Marvel Comics, Prevent Child Abuse America developed Spider-Man comic books to address child sexual abuse and other child safety issues. In addition, Prevent Child Abuse America distributes an information packet each year to assist community groups in planning Child Abuse Prevention Month activities. Chapters in 37 States and one in the District of Columbia provide ongoing public awareness and other activities to prevent child maltreatment.

State Children's Trust Funds (CTFs) exist in all 50 States and the District of Columbia with the specific goal of preventing child maltreatment. CTFs and their local councils and affiliates coordinate prevention activities throughout each State by promoting and funding a variety of community-based programs, including public awareness campaigns, home visitation programs, skills-based curricula for children, and parent education and support activities. In addition, many CTFs develop and distribute public awareness materials for community groups, schools, and many other professionals working with children. These materials may include posters, bookmarks, magnets, and scripts for public service announcements. Many of the Children's Trust Funds also have been designated as the State lead agencies for the CBFRS program.

Skills-Based Curricula For Children

Many schools and social service organizations in local communities offer skills-based curricula to teach children safety and protection skills. Most of these programs focus efforts on preventing child sexual abuse and teaching children to distinguish appropriate touching from inappropriate touching. Other programs focus on preparing young people to function successfully in society, while still others teach or enhance protective behaviors in children. Curricula may have a parent education component as well to give parents and other caregivers the knowledge and skills necessary to recognize and discuss sexual abuse with their children. Curricula may use various methods to teach children skills, including:

• Workshops and school lessons
• Puppet shows and role-playing activities
• Films and videos
• Workbooks, storybooks, and comics.

Examples of skill-based curricula include programs such as Talk About Touching, Safe Child, Good Touch/Bad Touch, Kids on the Block, and Illusion Theater.

Parent Education Programs and Parent Support Groups

Perhaps the most prominent prevention activity is parent education. Typically, these programs focus on decreasing parenting practices and behaviors associated with child abuse and neglect. Though parent education programs may serve the general community, many are directed at populations determined to be at risk for child maltreatment. These programs address issues such as:

• Developing and practicing positive discipline techniques
• Learning age-appropriate child development skills and milestones
• Promoting positive play and interaction between parents and children
• Locating and accessing community services and supports.

Parent education programs are designed and structured differently, usually depending on the curriculum used and the target audience. Programs may be short-term, offering classes once weekly for 6-12 weeks, or programs may be more intensive, offering services more than once weekly for up to a year. Well-known parent education programs include Parents as Teachers, National Parent Aide Network, Meld, Effective Parenting Information for Children (EPIC), Parents and Children Together (P.A.C.T.), and the Nurturing Program.

• The Parents as Teachers program targets parents with children from birth to 5 years old and focuses on child development; recommends activities that encourage language development, intellectual growth, and social and motor skills; and strengthens the parent-child relationship. This program has 4 components, including personal home visits, group meetings, developmental screenings, and connection to community resources.
• The National Parent Aide Network, a component of the National Exchange Club Foundation, is a national network of professionally trained individuals who become friends and role models to parents and teach them how to be responsible and bond with their children. Parent aides provide support, encouragement, and genuine and caring friendships; focus on the good qualities of the parents; serve as an outside social control to stop abuse immediately; and address special needs of the family by referring them to community agencies when necessary.
• Meld offers educational and support services for parents to help them set goals and make decisions for their education, work, and family life that increase their self-confidence, self-sufficiency, and ability to manage a family successfully, and to reduce family isolation that can lead to abuse and neglect.
• Effective Parenting Information for Children (EPIC) provides a series of workshops to train parents and teachers to assist children in developing life skills and civic values leading to responsible adulthood and parenting.
• Parents and Children Together (P.A.C.T.) is a program in which parents and children participate in playtime, build family skills, and connect emotionally. P.A.C.T. also encourages parents to focus on child development and communication.
• The Nurturing Program is a family-based program that involves both parents and children in activities, focusing on building a positive regard for self and others. There are 15 Nurturing Programs that are focused on specific populations (e.g., Parents and Children Birth to 5 Years, Parents and Children 4 to 12 Years, Hispanic Parents and Children Birth to 5 Years, and Families in Substance Abuse Recovery). Programs are home based or group based and range from 1½ to 3 hours per week for 9-45 weeks.

In addition to parent education programs, parent support groups also work to strengthen families and prevent child maltreatment. Two well-known programs include:

• Parents Anonymous^® Inc., founded in 1969, leads an international network of accredited organizations that implement community-based, weekly, free-of-charge Parents Anonymous^® Groups for parents and other caregivers. In Parents Anonymous^® Groups, co-led by parent group leaders and group facilitators, parents find a caring, mutually supportive environment where they can learn new parenting strategies and create long-lasting, positive changes in their families. Their children participate in complementary Parents Anonymous^® Children's Programs that promote positive social and emotional development.
• Circle of Parents, a collaboration of Prevent Child Abuse America and the National Family Support Roundtable, provides parent self-help support groups to anyone in a parenting role. These groups offer parents a place to discuss the challenges of raising kids and to exchange ideas. Funded through a grant from the Children's Bureau, Office on Child Abuse and Neglect, this is an effort to expand and enhance parent self-help support groups across the country. Most established groups have a free program for children as well. The groups provide a place where anyone in a parenting role can discuss the successes and challenges of raising children, find and share support, and learn new parenting skills.

Home Visitation Programs

Home visitation programs have existed in the United States since the late 19^th century. As a strategy for preventing child maltreatment, home visitation came to the forefront of the national agenda in 1991 when the U.S. Advisory Board on Child Abuse and Neglect recommended universal implementation of home visitation programs. Rather than a specific program or activity, home visitation is a strategy for service delivery. Many organizations and agencies in fields as varied as education, maternal and child health, and health and human services use home visitation programs to strengthen and support families.

Home visitation programs offer a variety of family-focused services to pregnant mothers and families with new babies and young children. Activities offered through home visitation programs may include structured visits in the family's home, informal visits, and telephone calls that focus on topics such as:

• Positive parenting practices and nonviolent discipline techniques

• Child development

• Availability and accessibility of social services
• Establishment of social supports and networks
• Advocacy for the parent, child, and family
• Maternal and child health issues
• Prevention of accidental childhood injuries through the development of safe home environments.

As the popularity of home visitation programs has increased, so too has the number and diversity of organizations offering these services. Both large and small organizations are establishing programs and providing community-based services to a wide-ranging population. For example:

• Nurse Family Partnership, originally established as the Prenatal/Early Infancy Project at experimental sites in Elmira, New York, and Memphis, Tennessee, provides services to first-time mothers from the early stages of pregnancy through the child's first two years of life. Nurses provide home visits in accordance with a structured schedule, focusing on maternal health, parental role and life course, family and friends, and community services. The program, which is now available in numerous states, targets critical pregnancy outcomes, the prevention of child abuse and neglect, and subsequent unintended pregnancies.
• Healthy Families America (HFA), a national initiative launched in 1992 by Prevent Child Abuse America and modeled after Hawaii's Healthy Start, links expectant and new mothers to trained staff who provide home visits and referrals to community services. HFA currently has home visitation programs in over 420 communities in the United States and Canada.
• Early Head Start, an outgrowth of Head Start established in 1994 specifically for low-income families with infants and toddlers and pregnant women, promotes healthy prenatal outcomes, enhances the development of very young children, and promotes healthy family functioning. The community-based program provides parent education, comprehensive health and mental health services, and home visits.
• Home Instruction Program for Preschool Youngsters (HIPPY) is an educational enrichment program that builds on the natural bond between a parent and child. The home visitation model helps parents prepare their preschool-aged children for successful, early school experiences and strengthens the bond between schools, families, and communities.
• Parent Child Home Program (PCHP) is a home visitation program serving families challenged by the many obstacles to educational success, including poverty, low levels of education, and language difficulties. In play sessions with parents and children, the home visitor demonstrates various parenting techniques. An emphasis is placed on parent-child interaction and the development of verbal and language skills necessary to succeed in school.
• Hawaii's Healthy Start Program is a multisite program in Hawaii that screens, identifies, and provides services to families at risk for child abuse and neglect. Most participants are enrolled after the birth of a child; however, approximately 10 percent of participants enroll during the prenatal period.
• Project 12-Ways takes a comprehensive approach to prevention that uses an ecobehavioral model to teach parents new skills and knowledge regarding basic parenting, child development, and safety, while providing support to address some of the underlying problems affecting families. At intake, each family's individual needs are assessed and goals identified. Project counselors recommend services and meet with each family once or twice per week, monitoring the family's progress. Started in 1979 in Illinois, the model has since been replicated in California and is now a statewide model in Oklahoma.

Respite and Crisis Care Programs

Respite care services provide short-term care to children who have disabilities or chronic or terminal illnesses, who are in danger of abuse or neglect, or who have experienced abuse or neglect. For caregivers in stressful situations (they may be parents, foster or adoptive parents, or other relatives or guardians), respite care services provide temporary relief from the ongoing responsibilities of caring for children in the home. Crisis care is a unique form of respite. It is provided to children, with or without a disability, when the family is in crisis. Crisis care services may be referred to as crisis respite, emergency respite, crisis nursery, crisis stabilization, or shelter care (ARCH National Resource Center, 1998).

When family caregivers are not able to take a break from constantly providing care and supervision for their children, stress builds. This elevated stress can lead to increased incidences of abuse, divorce, and out-of-home placement of the dependent family member. Respite services are provided in a variety of settings, within or outside of the family home. Services are generally short term (ranging from a few hours to a few weeks), and are provided on either a planned or an emergency basis. Both respite and crisis care services can be provided by other family members, friends, neighbors, community recreation programs, child or dependent care providers or centers, home health aides, family resource centers, community human service providers and respite or crisis care agencies. In addition to care and supervision, many respite and crisis care providers also offer a variety of support services to families, including referrals to other programs, counseling, case management, meals, transportation, social activities, lodging, medications, personal care, and assistance with activities of daily living (ARCH National Resource Center, 1998).

Family Resource Centers

Family resource centers are sometimes called family support centers, family centers, parent-child resource centers, family resource schools, or parent education centers. Each family resource center works with community members to develop specific services that meet the needs of the people who use the center and the community that surrounds it. This is accomplished by involving community members in design, implementation, and evaluation. Many centers require that advisory boards oversee the day-to-day operation of the centers, and that more than one-half of the board members be parents.

Family resource centers are located in a variety of community settings and serve diverse populations. Depending upon the resources available in the community, family resource centers may be located in churches, school buildings, hospitals, housing projects, restored buildings, or new structures. Based in the places where families naturally congregate, family resource centers serve as a central support within the community around which families can build their lives, regardless of the challenges they face.

Family resource centers promote both the strengthening of families through formal and informal sources of support and the restoration of a strong sense of community. Services may include parent skill training, drop-in centers, home visiting, job training, substance abuse prevention, violence prevention, services for children with special needs, mental health or family counseling, child care, literacy, respite and crisis care services, assistance with basic economic needs, and housing.

What Do We Know About the Effectiveness of Prevention?

There are three principal areas where research on maltreatment prevention has historically been most concentrated: home visitation programs, parent education programs, and school-based programs for the prevention of child sexual abuse. The following sections summarize what is known about prevention from research and evaluation in these areas.

Home Visitation Programs

Research on the impact of home visitation programs is one area in which there is a relative abundance of evidence, and that evidence, while not universally positive across all evaluations, suggests that home visiting can be an effective approach. David Olds, at the University of Colorado Health Sciences Center, has pioneered high quality, experimental research in the area of home visitation. Through the course of several replications and long-term follow-up studies over a period of 20 years, Dr. Olds has found positive, short-term and long-term outcomes for young, first-time mothers and their children in several areas, including decreased rates of child maltreatment, juvenile delinquency, and maternal criminality; increased economic self sufficiency; and increased social-emotional development (Olds et al., 1997).

The 1999 Future of Children report on home visiting programs also noted that despite some positive findings, many of the programs still struggled in numerous areas. Challenges were raised concerning enrolling, engaging, and retaining families. Similar issues were raised about the use of paraprofessionals versus nurses, staff retention, and the training needed by home visitors. When program benefits were demonstrated, this often only impacted a subset of families, and benefits were rarely seen for all program goals. The following are findings on home visitation from other recent work:

• An evaluation of Family TIES, a program of services for first-time teen mothers during pregnancy, found that teen mothers who received weekly home visits made significantly higher gains in creating a safe and healthy home environment compared with participants who received traditional family support services at a health center. The program had no significant effect on the childbearing philosophies or psychological well-being of participating mothers (Luster et al., 1996).
• An evaluation of the Healthy Start program, part of the Hampton Family Resource Project that provides home-based, parent education and support services to high-risk mothers, found several positive outcomes for families, including reductions in pregnancy risk status, birth complications, and subsequent pregnancies, and increases in childhood immunization rates and the number of adequate/safer home environments. The study also reported a reduced number of confirmed reports of child abuse and neglect (Galano & Huntington, 1996).
• An evaluation of STEEP (Steps Toward Effective, Enjoyable Parenting), an intensive intervention program of home visits and group sessions for high-risk women and their first-born children, found that compared to a control group, program participants demonstrated better understanding of child development, better life management skills, fewer depressive symptoms, and more organized and appropriately stimulating home-environments. The STEEP program also served as a buffer against stress, enabling parents to remain more sensitive to their children's needs even in the face of stressful life circumstances (Egeland & Erickson, 1993; Erickson & Egeland, 1999).

Leventhal suggests nine factors that are necessary for successful home-based services. They include: early intervention, intensive services over a sustained period, development of a therapeutic relationship between the home visitor and parent, careful observation of the home situation, focus on parenting skills, child-centered services focusing on the needs of the child, provision of "concrete" services (e.g., shelter, health care), inclusion of fathers in services, and ongoing review of family needs to determine frequency and intensity of services (Leventhal, 1997).

Parent Education

Some research also has concentrated on the impact of programs that provide education for parents that can reduce risks to children. The record is neither rich nor, on the whole, particularly compelling. However, a few studies have demonstrated positive findings. Many of the existing studies in this area rely on outcomes that do not include actual child maltreatment reports, but focus on short-term gains in knowledge, skills, or abilities. Thus, taken as a whole, little is known about the impact of these programs on child maltreatment in the long term.

From the late 1980s to the early 1990s, the William Penn Foundation funded 14 child abuse prevention demonstration programs in Philadelphia and surrounding suburban areas, and sponsored one of the most comprehensive evaluations of parent education services in the early 1990s. The National Committee for Prevention of Child Abuse conducted the evaluation of this initiative, integrating outcomes from all 14 programs. Data were gathered from 1,078 parents who received services between March 1990 and July 1991 across the 14 sites.

Researchers found that parents' potential for physical child abuse decreased significantly as measured by the Child Abuse Potential Inventory (CAP). Participants exhibiting the highest risk at pretest (i.e., the highest CAP scores) showed the greatest gains at post-test (i.e., the greatest decrease in CAP scores). Total CAP scores, as well as three subscales (distress, rigidity, and unhappiness), decreased significantly. In addition to an observed reduction in child abuse potential, there were observed reductions in the use of corporal punishment and inadequate supervision of their children, while participants demonstrated greater responsiveness to the emotional needs of their children (National Committee for Prevention of Child Abuse, 1992).

More recent evaluations of programs also have focused on families considered to be at risk for child maltreatment. The Bavolek Nurturing Program is a parenting education program that specifically focuses on four parenting constructs, including inappropriate parental expectations, lack of empathy toward the child, belief in corporal punishment, and parent-child role reversal. A secondary analysis using a convenience sample of at-risk rural families found significant improvements from pre- to post-test in each of these four areas, as measured by the Adult-Adolescent Parenting Inventory, with the post-test results consistent with nurturing parenting attitudes. While the results of the study were positive, the researchers acknowledge critical limitations, including the lack of a control group (Cowen, 2001).

Another such program offered 12-week parent education services to teen mothers in an effort to promote healthy, nurturing families. In an analysis of mothers participating in this program, researchers found positive, though not statistically significant, increases in knowledge of child development and attitudes toward parenting and discipline (Britner & Reppucci, 1997). Furthermore, families who participated in the parent education program had significantly fewer substantiated reports of child maltreatment than families who did not participate in the program.

An earlier study focused on a group of high-risk mothers receiving services through an intensive parent education program administered by the National Institute of Mental Health. Mothers with at least one child and who were considered very high risk for child maltreatment were recruited for the program during pregnancy (prior to 26 weeks gestation). The intensive program offered concrete services (e.g., assistance with transportation, assistance returning to school, arranging care for children, reducing bad habits such as smoking and overeating, and financial management), as well as abstract services (e.g., assisting the participant in better understanding others and themselves, and providing someone with whom to talk).

Following participation in the study, mothers reported high rates of satisfaction with the program and improvements in their parenting and life skills (Pharis & Levin, 1991). Both staff and participants reported that positive growth had occurred in 13 areas of the mothers' lives between onset of pregnancy (or entry into the program) and the interview (conducted at least one year after the intervention had begun).

School-based Programs for Prevention of Child Sexual Abuse

Programs for children and parents that are designed to raise awareness about child sexual abuse is another area where there has been a recent and relatively concentrated research focus. Available research suggests that such programs can be successful at imparting information, but there is little evidence to conclude that these programs actually prevent child sexual abuse. A recent study published in 2000 utilized meta-analysis techniques to evaluate existing school-based, child sexual abuse prevention programs. Based on 27 control group studies, the study reported that children who participated in prevention programs performed significantly higher than control group children on outcome measures used in the studies, indicating improvements in knowledge and skills concerning sexual abuse. In the process of developing the sample of studies to include in the analysis, the researchers indicated that they identified no studies that had analyzed the effect of prevention programs on actual rates of abuse (Davis & Gidycz, 2000).

Few studies have attempted to establish a relationship between acquisition of knowledge about child sexual abuse and subsequent behavior change in children. In perhaps the only study of its kind, Finkelhor et al. conducted a national telephone survey of 2,000 children ages 10-16. The researchers found that children who had participated in school-based sexual abuse prevention programs not only demonstrated greater knowledge about sexual abuse, but also reported that these children were more likely to exhibit protective behaviors and utilize protective strategies when threatened or victimized (Finkelhor & Dzuiba-Leatherman, 1995).

In a follow-up study conducted the next year, during which a considerable proportion of the original 2,000-child sample was recontacted, the researchers again found that children who had participated in school-based sexual abuse prevention programs were more likely to use protective strategies (e.g., yelling, running, telling an authority). However, there was no evidence that these children, when threatened with abuse, were any more likely to stop the victimization than children who had not participated in school-based sexual abuse prevention programs (Finkelhor, Asdigian, & Dzuiba-Leatherman, 1995).

Since then, two recent studies have explored the correlation between knowledge gains and behavior change, and actual victimization. In an important recent study of 825 female undergraduates, for example, researchers found that young women who had not participated in a school-based prevention program were nearly twice as likely to have experienced child sexual abuse as young women who had participated in a program (Gibson & Leitenberg, 2000). Also within the last few years, results of a survey of high school students found that students who had participated in a general abuse prevention program were significantly less likely to have reported an incident of physical abuse. There appeared to be no difference between the two groups of students in terms of the incidence of sexual abuse (Ko & Cosden, 2001). Both of these studies, however, utilized small, local samples and relied considerably on self-report data of past experiences. Thus, there are important concerns with the generalizability of the results, as well as the vulnerability of the data to the hazards of memory.

The next section of this report presents profiles of the featured programs in the Effective and Innovative categories following a peer review of the pool of nominations submitted to the Office on Child Abuse and Neglect in 2002 under the Emerging Practices in the Prevention of Child Abuse and Neglect project.

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Updated on February 2, 2010