Preventing child abuse and neglect: It’s time for a broader approach

April is Child Abuse Prevention Month, the blue pinwheels are on view around the country, and the obligatory emails and tweets are urging people to recognize the month with Facebook frames and Zoom backgrounds. And in the past year or so, prevention has become the word of the day in child welfare. This year, the House of Representatives has passed the Stronger CAPTA Act, which would raise the authorization for prevention services to match that of treatment services. CAPTA provides funds to state child welfare agencies for child abuse prevention, investigation and treatment programs. However when it comes to prevention, child welfare agencies are only a small part of the answer. Preventing child maltreatment requires the involvement of many other sectors of the government and society. It is important for prevention advocates to understand this and to work with other child advocates to support these programs.

In searching for guidance in how to view child abuse and neglect prevention, I came across an excellent 2016 publication from the Centers for Disease Control (CDC). Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities provides “a select list of strategies ….based upon what we know about risk and protective factors as well as empirical evidence on whether they have been shown to affect child abuse and neglect.” The CDC cites a number of risk factors researchers have found to be associated with the perpetration of child abuse or neglect, including young parental age, single parenthood, large number of dependent children, low parental income, parental substance abuse, parental mental health issues, parental history of abuse or neglect, social isolation, family disorganization, parenting stress, intimate partner violence, poor parent-child relationships, community violence, and concentrated neighborhood disadvantage. In addition, children who are younger and have special needs are more at risk of suffering maltreatment. Protective factors include supportive family environments and social networks, and probably other factors like parental employment, adequate housing, and access to health and social services.

Considering risk and protective factors leads to a broader conception of child abuse prevention than the one promoted by federal, state and local child welfare agencies. The CDC report lays out five strategies, all of which contain approaches that have demonstrated success in preventing child maltreatment. I have added a new strategy to CDC’s list and made some other smaller changes which are explained in notes. My modified list of strategies and approaches is summarized in the table below.

Preventing Child Abuse and Neglect

Strategy	Approach
Strengthen economic supports to families	-Strengthening household financial security -Family-friendly work policies
Encourage pregnancy planning, spacing and prevention*	-Increased availability of long acting contraceptives -Public engagement and education campaigns
Change social norms to support parents and positive parenting	-Public engagement and education campaigns -Legislative approaches to reduce corporal punishment
Provide quality care and education early in life	-Preschool enrichment with family engagement -Improved quality through licensing and accreditation
Provide parenting support to at-risk parents**	-Early childhood home visitation -Other parenting skills and relationship interventions -Enhanced case management plus peer engagement*** -Enhanced primary care to address maltreatment risks****
Intervene in maltreating families to lessen harms and prevent future risk	-Behavioral parent training programs -Treatment to lessen harms of abuse and neglect exposure -Treatment to prevent problem behavior and violence

As the CDC points out, the strategies address different levels, from the individual to the societal. The first four operate on the community or societal level and the CDC hypothesizes that they are most likely to have a “broad public health impact on child abuse and neglect.” The last two strategies operate on the family and individual level and would have a narrower impact focusing on targeted populations.

Strengthen Economic Support to Families: Low parental income is one of the major risk factors for child maltreatment, as documented by multiple studies cited by the CDC. Economic insecurity leads to maltreatment, presumably by making it more difficult to meet children’s needs and provide quality childcare and by increasing parental stress and depression, both risk factors for child abuse and neglect. Approaches to strengthening economic support for families could include both improving economic assistance to low-income families and intervening to support family-friendly work policies like livable wages, paid leave, and flexible and consistent scheduling. The CDC cites studies of several economic support programs for which research has demonstrated a direct effect on child abuse and neglect or associated risk factors. Perhaps the expanded 2021 child tax credit will have such an effect.

Encourage Pregnancy Planning, Spacing and Prevention: The CDC report identified young parental age and large number of dependent children as risk factors for abuse and neglect, but it did not propose a strategy to address those risk factors. But as I have written before, there are strategies to address these risk factors and they should be considered. One approach would be to expand access to long acting removable contraceptives (LARC’s). A statewide campaign to increase availability of LARC’s in Colorado resulted in a halving of the teen birth rate in five years. Another approach would be public information campaigns to inform people of the dangers of early and closely spaced childbearing and the advantages to both parents and children of pregnancy planning and spacing. Research indicate that such campaigns can change people’s health-related behavior, as in the case of smoking cessation and HIV prevention. 

Change social norms to support positive parenting. As the CDC points out, norms about how we discipline our children are especially important to child abuse prevention. An analysis of 50 years of research found that spanking leads to more defiance, and increased antisocial behavior, aggression, mental health problems and cognitive difficulties. A recent study found that the percentage of parents who reported spanking a child in the previous year dropped from 50 percent in 1993 to 35 percent in 2017. Yet corporal punishment remains popular in some communities. While corporal punishment is not necessarily child abuse, it can lead to physical abuse when the parent loses control or goes too far. The CDC recommends both public education campaigns and legislative strategies to reduce the use of corporal punishment. The report cites successful public education campaigns regarding other parenting behaviors, such as emotional abuse. It also cites international studies indicating that bans on corporal punishment were successful at decreasing overall rates of corporal punishment.

Provide quality care and education early in life. Early care and education (ECE) is a particularly appealing child maltreatment prevention strategy because there are so many pathways by which it can operate to reduce child maltreatment. Quality ECE  reduces parental stress, exposes the child to mandatory reporters, and reduces the time spent in an abusive or neglectful home or with an unrelated adult–often the perpetrator of severe or fatal child abuse. ECE approaches with a family engagement component may prevent maltreatment by training parents in positive discipline approaches. Approaches to providing ECE could include expanding government support to programs that combine childcare with educational enrichment and parent involvement and improving standards to increase quality. Studies suggest that childcare programs that include parent involvement are effective in preventing child maltreatment. A 15-year follow up of Child Parent Centers found that children who participated for one to two years had a 52 percent reduction in substantiated child abuse and neglect.

Provide parenting support to at-risk parents. Intervening directly with a targeted population of parents to address risk factors for child maltreatment is perhaps the most popular approach to child maltreatment prevention because it has a clear connection with child maltreatment and often falls under the jurisdiction of child welfare agencies. Such approaches include home visiting programs as well as interventions based in doctor’s offices, preschools, school or mental health clinics. These programs vary in their models and the risk factors they address. Many of these programs focus parent education and training, based upon the assumption that poor parenting skills and ineffective discipline practices can lead to maltreatment. Some interventions focus on the parent-child relationship since poor parent-child relationships are a risk factor for child maltreatment. Many of the home visiting programs include a case management component to help parents set goals for their own lives and access needed services, thus addressing risk factors like substance abuse, mental illness, and parental stress. Home visiting interventions like Nurse Family Partnership, SafeCare and Child First and parent training programs like Incredible Years and Triple P have been found to have small to moderate effects on maltreatment and related risk factors. Another approach is to use the pediatrician’s office to identify families at risk of abuse or neglect, address these risk factors at regular visits, and provide information and referrals. Both SEEK and Healthy Steps are examples of this approach that have had some promising results but needs more evaluation. A new generation of programs, as yet unproven, is connecting at risk families with both a case manager and a family engagement specialist who provides peer support. Examples of that approach include the intensive tier of Allegheny County PA’s Hello Baby program and the Detroit Prevention Project.

Intervene in maltreating families to lessen harms and prevent future risk. In this category, CDC places therapeutic programs that seek to limit the damage caused by prior maltreatment. Such programs are often known as tertiary prevention and aim at preventing further abuse and neglect or healing victims so that they do not proceed to abuse the next generation. The CDC divides these programs into three approaches. One approach is “behavioral parent training programs,” like Parent Child Interaction Therapy. Also included in this approach are SafeCare and Incredible Years, which are also in the secondary prevention category. Another approach is treatment for children and families to lessen the harms caused by abuse or neglect, such as Trauma-Focused Cognitive Behavioral Therapy. And the final approach suggested is treatment to prevent problem behavior and later involvement in violence, which includes programs such as Multisystemic Therapy. All of these programs have shown some impact on maltreatment or associated risk factors.

Of the six strategies discussed above, only the last two generally fall under jurisdiction of child welfare agencies–and and even those are often delivered by public health or behavioral health agencies or pediatricians’ offices. But the other four strategies are often not mentioned in discussions of child maltreatment prevention simply because the latter is considered to be the province of child welfare agencies. It is not surprising that the responsibility for preventing child maltreatment is often attributed to the agencies responsible for identifying and treating it. But as described above, the range of risk and protective factors is much larger than what child welfare agencies have the capacity or mandate to address. CDC suggests that public health agencies are well-suited to take the lead in developing community-wide prevention strategies that bring in the other systems that need to be involved.

It took a public health agency to articulate the broad scope of risk factors that lead to child abuse and neglect and the need for a broad spectrum of approaches to address it. Let us hope that public health agencies on the national, state and local levels can take the lead in pushing for a full spectrum of strategies that deserves the name of child maltreatment prevention.