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

StrategyApproach
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
SOURCE: Modified version of Centers for Disease Control, Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Notes on Table

*Strategy added by Child Welfare Monitor

**Strategy and approach titles modified by Child Welfare Monitor

***Approach added by Child Welfare Monitor

****Approach moved from following strategy by Child Welfare Monitor

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.

Who’s watching the children? Abuse more likely when child is with male caregiver

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Kevin Daniel Jackson, 28, accused of killing his girlfriend’s son: WDIO.com

When a child is found to be seriously or fatally abused, the perpetrator is often found to be a  male caregiver. But a new study using data from pediatric emergency rooms provides powerful evidence of the correlation between caregiver characteristics and the likelihood of abuse.

The new study is the first to compare caregiver features among children with injuries due to abuse to those with accidental injuries. The article was published in the Journal of Pediatrics, and a summary is available online on the Science Daily website. The authors used data on 1615 children under four who were brought to a pediatric emergency department. Overall, 75% of the injuries were classified as accidents, 24% as abuse and 2% as indeterminate.

The differences between the likelihood of abuse versus accident among different groups of caregivers are striking. Abuse was determined to be the cause of injury to only 10% of the children for whom a female was the only caregiver at the time of injury and fully 58% of children who were with a male caregiver when injured. There was a big difference between fathers and boyfriends however; an “alarmingly high” 94% of the children who were alone with the mother’s boyfriend at the time of injury were determined to be abused, as compared to “only” 49% of injured children who were with their fathers at the time of injury.

Analysis of the 83 cases of severe injury (including fatalities) provided even stronger evidence of the connection between male caregivers and abuse. The authors found that “nearly all cases of severe injury in which fathers and boyfriends were present involved abuse, and for fatalities, the fathers and boyfriends were most commonly present as lone caregivers. Mothers were rarely present alone when severe abusive injuries occurred.”

Among female caregivers, one group was more likely associated with injuries and that was babysitters. Fully 34% of the children left alone with babysitters were found to be victims of abuse

The researchers point to several policy implications of their study. First, they highlight the importance of asking who was caring for the child at the time of injury as part of the investigation to determine whether an injury is the result of abuse. Second, they call for abuse-prevention strategies to focus on male caregivers and female babysitters.  (Currently, such programs, like shaken baby education, often focus on mothers.)

But the authors do not mention another policy implication that is equally important. Ensuring that all low-income children have access to high-quality early care and education (ECE) is a logical implication of the study.

As I have written in an earlier post, there are many pathways by which ECE can prevent maltreatment. Free, high quality ECE would provide mothers with an alternative to leaving their children with caregivers who are unsuitable to the task–be it boyfriends, fathers, or babysitters. ECE has other child welfare benefits as well. Staff who are trained as mandatory reporters ensures that more adults will be seeing the child and able to report on any warning signs of maltreatment. Quality ECE programs that involve the parents can also improve child safety by teaching parents about child development, appropriate expectations, and good disciplinary practices. They may also connect parents with needed supports and resources in the community and help them feel less isolated and stressed.

Of course the benefits of ECE extend far beyond child welfare in the narrow sense. We are worried about school readiness for low-income children and we know that much of brain development occurs between the ages of 0 and 3. That’s why quality ECE has been such a priority for the early childhood community. But  child welfare policymakers have not yet caught onto the importance of ECE as a means of preventing child maltreatment.

An excellent issue brief from the Administration on Children and Families recommends improving access to ECE for families that are already involved with child welfare. That is a great proposal, but the child welfare field is beginning to focus on prevention rather than only treatment. We must explore ways to provide access to ECE among children who are at risk of child abuse and neglect. Expanding access to subsidized child care among lower-income families, because income is so highly correlated with child maltreatment, would be a good beginning.

Prevention is the word of the day in child welfare. A key part of prevention is making sure children spend their time with caregivers who will not harm them.

 

 

An Overlooked Approach to Child Maltreatment Prevention

LARCs
Image: Policy Lab

 

April is child abuse prevention month, and many organizations are offering recommendations on how to prevent child maltreatment. Typically these recommendations do not include one approach that may promise the most success–prevention of teenage, unplanned and closely spaced pregnancies.

Sarah Brown, founder of the National Campaign to Prevent Teen and Unplanned Pregnancy (now Power to Decide) gave a lecture in December 2015 that brought home this unfortunate omission. She reported being struck by “the total absence of pregnancy planning, spacing and prevention in virtually all discussions of how to improve overall child and family well being.” As she put it, many groups concentrate on services after the child is born, but “rarely do they mention the time when decisions are made about when with whom and under what circumstances to become pregnant or cause a pregnancy.”

There is no lack of research on the connection between pregnancy timing and child maltreatment. There is a strong association between child maltreatment and the mother’s age at the birth of the child. California researchers Emily Putnam-Hornstein and Barbara Needell found that babies born to mothers who were under 20 were twice as likely to be reported to child protective services (CPS) by the child’s fifth birthday as those born to mothers 30 or older. Among children referred to CPS by age five, almost 18 percent were born to a teenage mother and 50 percent were born to a mother younger than 25. Among children with no CPS contact, only 8 percent were teen births and 30 percent were born to a mother under 25.

There is also strong evidence that family size and child spacing are correlated with child maltreatment. Putnam-Hornstein and Needell found that children who fell third or higher in the birth order were more than twice as likely to be the subject of a report as first children. Moreover, a large study published in 2013 found that women who gave birth to another child within 24 months of the previous child were 80 percent more likely to have a substantiated CPS report.

And research suggest that the interaction between birth order and maternal age  creates the highest risk for a child maltreatment fatality. A study using linked birth and death certificates for all births in the U.S. between 1983 and 1991 found that the most important risk factors for infant homicide were a second or subsequent infant born to a mother less than 17 years old. These infants had 11 times the risk of being killed compared with a first infant born to a mother 25 years old or older. A second or subsequent infant born to 17 to 19-year-old mother had nine times the homicide risk of the first infant born to the older mother.

And setting the research aside for a moment, anyone who has worked for or with CPS, or in foster care, knows the prevalence of larger families with closely-spaced children in the system, often with a mother that started childbearing as a teen. The same pattern has been observed among families that experience a child fatality.1 

It is truly unfortunate that the number of children in families that are involved in child welfare is not among the data required to be reported to the federal government by states. It is highly plausible that if these data were collected we would see a big difference.

If it is not the lack of research, why do supporters of child maltreatment prevention fail to include family planning and contraception in their suggestions? In part, Sarah Brown says of child advocates in general, it may be that they simply don’t think of it. But in large part, says Brown, it is because they fear getting in trouble and becoming mired in controversy about abortion or sex outside marriage. In addition to the issues raised by Brown, it is likely that others avoid this topic because of the shameful legacy of past attempts to control the population of minority groups.

But people who care about the future of African American children should not allow this racist history to prevent thinking clearly about what is best going forward. There are few if any policies that could be more helpful to the future of black children and the elimination of racial disproportionality in foster care placement than ensuring that black women have access to the most effective methods of contraception so that they can determine their own futures.

Family planning and contraception need to be included in the discussion about child maltreatment prevention. We have made great progress in teen pregnancy prevention. The teen birth rate has fallen dramatically from 59.9 per thousand in 1990 to 24.2 per thousand in 2014. While research suggests that reality TV shows and the last economic recession contributed to the decline in teenage pregnancy,  better information about preventing pregnancy and the availability of more effective methods have doubtless contributed to the drastic decline.

The Colorado Family Planning Initiative, initiated with the help of a private funder, improved access to highly effective methods of contraception by training public health providers, supporting family planning clinics and removing the barriers to obtaining Long Acting Reversible Contraceptives (LARC’s). As a result of this initiative, the state’s teen birth and abortion rates were cut in half in just five years, with big financial savings to the state. Because younger mothers are so much more likely to abuse or neglect their children, this initiative should yield lower maltreatment rates now and into the future.

Upstream USA, a nonprofit organization, hopes to expand the Colorado program nationwide, starting with Delaware. Delaware’s Contraceptive Access Now (CAN) is a partnership between Upstream and the State of Delaware to decrease the incidence of unintended pregnancy. CAN works to ensure that all women get same-day access to all methods of birth control, free or at a nominal cost. They are also working to eliminate administrative and reimbursement barriers so that women can access LARC’s immediately after giving birth, taking advantage of a crucial opportunity to provide this critically important service.

Imagine if these initiatives could be expanded nationwide, combined with a public information campaign to explain the benefits of planning, spacing and timing pregnancy for both children and their parents.

Few child welfare experts have noted the link between family planning and child welfare. One of the few is Judge Patricia Martin of Illinois, a member of the Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF). Martin included teen pregnancy prevention, especially in high-poverty neighborhoods and among youth in foster care, as one of the recommendations in her dissenting report.

Family planning experts also rarely if ever mention the potential of their programs to reduce child maltreatment. The more immediate benefits of increased opportunities for women and reduction in taxpayer funding for cash assistance and other services are more than enough to justify spending on helping women plan their childbearing.

The link between child abuse prevention and family planning is clear. I hope that the word will spread and that child welfare advocates and family planning advocates can work together for increased resources to help young people plan their childbearing based on their readiness to be parents.