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Chapter 8 Interventions to Prevent Child Maltreatment Deborah A. Daro and Karen P. McCurdy 8.1. INTRODUCTION The term child maltreatment has been used by advocates and policy makers to describe a set of individual behaviors toward children as well as a set of social conditions (Daro, 1989; Helfer, Kempe, & Krugman, 1997). Parental behaviors considered as abusive or neglectful include, among others, the willful or intentional physical beating of a child; the failure to provide for a child’s basic emotional and physical needs; overt emotional abuse of a child through continuous belittling, inappropri- ate control, or extreme inconsistency; and the sexual mistreatment of a child or use of a child for sexual pleasure. Social norms and public policies that condone and, sometimes, promote corporal punishment or high levels of violence and sexually explicit language in the media as well as child poverty, inadequate housing, failing educational systems, and limited access to preventive health care also represent, in the eyes of some, society’s collective maltreatment of its children (Garbarino, 1997; Straus, 1994). Given this diversity in perspectives, it is understandable that the ﬁ eld has struggled with deﬁ ning the problem’s scope, consequences, and appropriate interventions.

Setting aside the issue of social conditions and inadequate welfare and support systems, the number of children directly abused or neglected is substantial. One of the earliest and most rigorous studies on the annual incidence of maltreatment estimated that in 1968 between 2 and 4 million families either failed to act or used physical force with the intent of hurting, injuring, or killing their children (Gil, 1970). Since that time, repeated household surveys and national incidence studies consistently document a problem of substantial proportion and one that affects children of all ages and socioeconomic groups (Finkelhor, Ormrod, Turner, & Hamby, 2005; Gelles & Straus, 1988; Sedlak & Broadhurst, 1996). Indeed, state and local child protective services (CPS) agencies investigated or assessed an estimated 1,800,000 referrals alleging child abuse or neglect in 2002. These referrals included more than 3 million children and, of those, approximately 869,000 (12.3 per 1,000) 137 138 D.A. Daro and K.P. McCurdy were determined to be victims of maltreatment (U.S. Department of Health and Human Services [HHS], 2004).

The consequences of maltreatment vary, depending on a child’s age; the dura- tion and severity of the abuse; the co-occurrence of other forms of maltreatment; and other conditions known to be harmful to a child’s immediate well-being and subsequent development, such as domestic violence, substance abuse, and paren- tal mental health (Chalk, Gibbons, & Scarupa, 2002). Maltreatment’s immediate physical effects range from relatively minor trauma (e.g., bruises, cuts) to serious and permanent injuries such as broken bones; intracranial and intraocular brain hemorrhages; and changes in the part of the brain linked to memory, emotions, and basic drives (Conway, 1998; Kempe, Silverman, Steele, Droememuller, & Silver, 1962; Perry, 2001). Medical neglect can result in minor developmental delays and common childhood illnesses going undiagnosed or untreated. Over time, these conditions can result in permanent physical impairment (e.g., hearing loss) or more profound delays in a child’s cognitive and social development (Gaudin, 1999).

In addition, studies have documented direct affects of maltreatment on a young victim’s cognitive development, including language deﬁ cits, reduced cogni- tive functioning, and attention deﬁ cit disorders (Kendall-Tackett & Eckenrode, 1996). Although it is unclear if such disorders are a direct result of maltreatment or a consequence of other economic or social deprivations, maltreatment victims often do poorly in school, leading to high drop-out rates and limited long-term economic self-sufﬁ ciency (Courtney, Terao, & Bost, 2004; HHS, 2003).

And victims of all forms of maltreatment often present with adult histories of physical and mental health disorders, including depression, hopelessness, and low self-esteem (Egeland & Stroufe, 1981; Jungmeen & Cicchetti, 2003; Kendall- Tackett, 2003; Lamphear, 1985). Such victims can develop antisocial behavior and physical aggression and struggle to establish and maintain trusting and supportive relationships throughout their lives (Morrison, Frank, Holland, & Kates, 1999; Widom & Maxﬁ eld, 2001).

Over the years, child maltreatment researchers and practitioners have explic- itly recognized that most maltreatment results from a complex web of factors found within a person’s personality, family history, and community context (Garbarino, 1977; Bronfenbrenner, 1979; Belsky, 1980). Ecological theory, with its acknowledg- ment that individual, familial, community, and societal factors interact to increase or decrease the likelihood of child maltreatment, now represents the most com- monly accepted theory of maltreatment (Cicchetti & Rizley, 1981). Unfortunately, most prevention programs have the capacity to address only a fraction of these causal factors, a reality that can complicate efforts to assess a program’s effective- ness. No single intervention will successfully remediate the consequences of all types of maltreatment, nor will it spare all children from initial or repeated abuse or neglect. Selecting the appropriate intervention is largely in the hands of practi- tioners and those allocating scarce public and private resources. The purpose of this chapter is to outline the continuum of choices available to these decision makers in a way that makes the best use of what we have learned. 8.2. BRIEF HISTORY OF PREVENTION Over the past 30 years, efforts to prevent child maltreatment have moved through three stages: public recognition of the problem, experimentation with a wide range of prevention programs addressing one or more factors believed to increase Interventions to Prevent Child Maltreatment 139 a child’s risk for maltreatment, and the evolution of systems designed to better integrate these diverse efforts (Cohn, 1987; Daro & Cohn-Donnelly, 2002a).

Programmatic efforts to prevent child abuse and neglect have followed two distinct paths: interventions targeting reductions in physical abuse and neglect (including emotional neglect and attachment disorders) and interventions target- ing reductions in child sexual abuse (Daro, 1989; Daro & Cohn-Donnelly, 2002b).

Programs in the ﬁ rst group began with an emphasis on parental knowledge or parental behavior as the “cause” of maltreatment, with services designed to address the cause (e.g., parent education workshops). Such programs have evolved in concert with the ecological paradigm to addressing the broader context in which the parent–child relationship develops. It is common for today’s prevention pro- grams to focus on parental-support networks, health care access, and parent–child interaction patterns, in addition to the more traditional emphasis on parental behavior or knowledge. Furthermore, these programs tend to focus on new parents, offering assistance when a child is born or a woman is pregnant (Daro, 2000).

Subsequent prevention services are then added to this universal base in response to the speciﬁ c emerging needs presented by the growing child or the evolving parent–child relationship (Guterman, 2001; Melton & Berry, 1994).

In contrast to efforts to prevent physical abuse or neglect, the target popula- tion for sexual abuse prevention has been potential victims, not potential perpetra- tors. Three factors contributed to this pattern: the social discomfort surrounding sexuality, the difﬁ culty in developing voluntary treatment options for offenders, and the absence of clear risk factors identifying potential perpetrators or victims (Daro, 1994). Strategies within this framework include a number of educational- based efforts, provided on a universal basis, to children on the distinction between good, bad, and questionable touching and the concept of body ownership or the rights of children to control who touches their bodies and where they are touched (Wurtele & Miller-Perrin, 1992). As children mature, these classes cover a broader range of concepts, such as appropriate dating behavior, gender stereotypes, and nonaggressive conﬂ ict resolution strategies (Wolfe, MacPherson, Blount, & Wolfe, 1986). These educational programs also offer children and youth service options or referrals if they have been abused or are involved in an abusive peer relation- ship. Although most of these efforts include some type of orientation or instruc- tion for both the parents and school personnel on how to detect and respond to suspected cases of sexual assault, their primary emphasis is making children less vulnerable.

Several policy and contextual factors have inﬂ uenced the structure and focus of the current pool of child maltreatment prevention services. At the center of this shift is a general dissatisfaction with many therapeutic interventions, particularly with the ability of services to alter the trajectory of families with extensive histories of serious physical abuse and neglect. Extensive reviews of a wide range of treatment modalities ﬁ nd very few with strong, empirical evidence of effectiveness (Saunders, Berliner, & Hanson, 2003). Those interventions that have demonstrated the great- est promise are generally embedded in ecological theories of human development and cognitive learning theories, offer intensive services, and have a strong research base (Henggeler, Melton, Brondino, Scherer, & Hanley, 1997; Kolko, 2002; Lutzker, 2000). In addition, a child’s ﬁ rst 3 years of life has become a major focus among those seeking better outcomes for children in numerous cognitive, emotional, and social domains (Carnegie Task Force on Meeting the Needs of Young Children [CTF], 1994; Shonkoff & Phillips, 2000). Given that the highest prevalence rates for both child maltreatment reports and placement in foster care involve children 140 D.A. Daro and K.P. McCurdy under the age of 1 year (Wulczyn, Barth, Yuan, Jones Harden, & Landsverk, 2005), the importance of early and thoughtful intervention for the birth to 3 population has become even more salient.

Today, the concept of prevention is moving away from the notion of a single- response agency or targeted intervention and more toward a communitywide system of shared responsibility and mutual support. As Melton, Thompson, and Small (2002) noted, achieving child protection becomes a shared, moral respon- sibility “not merely to prevent wrongdoing, but to achieve positive obligations as well” (p. 11). When this moral responsibility is jointly shared by every resident and every agency, a community can begin building the type of reciprocity and mutual support viewed by many as essential to achieving a higher standard of care for chil- dren (Melton & Berry, 1994). Although such systems are far from operational in any community, the goal of altering both the individual and the context provides a programmatic and policy response more reﬂ ective of the ecological theory often cited as the most appropriate in explaining the cause of child maltreatment. 8.3. CHAPTER PREVIEW The purpose of this chapter is to focus on the documented effects of a number of universal and targeted prevention services and, to the extent possible, identify those program features associated with more robust outcomes. In judging the effectiveness of the various interventions we reviewed, we primarily focused on interventions that had evidence of a reduction in child abuse and neglect reports and other child safety outcomes, such as reported injuries and accidents. In addi- tion to these outcomes, we identiﬁ ed programs with documented effects on risk factors that correlate with child maltreatment, including parent characteristics, child characteristics, and the parent–child relationship. We believe that reviewing programs in light of both their distal and proximate outcomes is important as it reﬂ ects the ecological framework that guides most prevention programs and has the greatest utility for moving the ﬁ eld forward.

In light of the growing attention being given to early intervention services, our review pays special attention to the evidence surrounding programs that target parents of newborns and young children. Our data base involved a detailed review of meta-analyses conducted on speciﬁ c program models (e.g., home visitation pro- grams, child assault prevention efforts) as well as broad categories of programs (e.g., family-support efforts, early intervention programs). These data were augmented by an examination of speciﬁ c evaluation studies conducted on both single-site as well as nationally replicated programs. We also reviewed Web-based summaries of model or exemplary programs as a secondary source for identifying evaluations beyond those typically included in academic, meta-analyses such as Blueprints for Violence Prevention (Center for the Study and Prevention of Violence) and Substance Abuse and Mental Health Services Administration (SAMHSA)’s National Registry for Effective Programs.

Following this presentation, the chapter identiﬁ es the key programmatic and policy recommendations emerging from our review. This section pays particular attention to questions of appropriate target populations, scope, critical outcomes, staff characteristics, and replication methods. In addition, the chapter addresses the key research and evaluation questions central to improving our ability to design, implement, and integrate preventive services. The chapter concludes with Interventions to Prevent Child Maltreatment 141 a set of general recommendations regarding the importance of developing more community-focused interventions. 8.4. INTERVENTIONS AND THEIR EVIDENCE BASE Table 8.1 summarizes the range of interventions we examined and their relative success in achieving measurable reductions on direct indictors of child maltreat- ment as well as proximate indicators of this construct. As noted earlier, this choice reﬂ ects the overall goals of most prevention programs and the theory that changing parental or child attitudes and behaviors will prevent child maltreatment. Maltreat- ment indicators include both reported and substantiated CPS cases of abuse or neglect and proxy measures of abuse and neglect such as emergency room visits and hospitalization for injuries or accidental ingestions (Hahn, Mercy, Bilukha, & Briss, 2005). Related outcomes consist of observational measures of attachment, measures of parental attitudes, knowledge and behavior, and child outcomes such as cognition and social-emotional development.

Whenever possible, we rely on meta-analyses to assess the effectiveness of prevention efforts. It should be noted that differences in meta-analytic techniques can lead to disparate ﬁ ndings. The meta-analyses reviewed here all share two approaches that help increase their comparability: (1) poorly designed studies (e.g., no comparison group) are excluded, and (2) nonpublished studies or government reports are included. In addition, when differences arise, we discuss the procedural differences that may have led to divergent ﬁ ndings. Table 8.1. Summary of Effectiveness of Child Maltreatment Prevention Strategies a Reports of Abuse or Neglect and Proxy Measures b (injuries, accidents, emergency room Type of Prevention Strategy visits) Related Outcomes c Products Soft baby carriers 3 4 Physical environments 3 3 Behavioral interventions Individual/parent level Newsletters and print 3 2 materials Videotapes 3 4 Parent education and support 3 4 Family level Early home visitation 5 5 School level Sexual abuse prevention 4 4 Community level 3 3 Societal level Media campaigns 3 3 a The scale is as follows: 5, effective (supported by two or more well-designed studies or systematic review); 4, promising (supported by one well-designed study, similar to effective intervention, expert consensus of beneﬁ ts); 3, insufﬁ cient evidence (not enough research, insufﬁ cient evidence, mixed evidence); 2, not effective (no effect found in two or more well-designed studies or systematic review); 1, harmful (negative effect found in two or more well-designed studies or systematic review).

b Examples include injuries, accidents, and emergency room visits.c Examples include parental attitudes, knowledge and behaviors, parent–child interactions, and child outcomes. 142 D.A. Daro and K.P. McCurdy 8.4.1. Products Although products are not traditionally a part of child maltreatment prevention strategies, one product, soft baby carriers, represents a promising strategy for enhancing mother–child attachment and maternal sensitivity, two factors believed to protect against maternal neglect (Anisfeld, Cusper, Nozyce, & Cunningham, 1990). A randomized study of soft baby carriers versus infant seats found that the use of soft baby carriers signiﬁ cantly increased maternal responsiveness and secure attachment in infants as compared to the use of infant seats (Anisfeld et al., 1990).

Two related randomized controlled studies support this approach. Hunziker & Barr (1986) found that increased maternal carrying of young infants, whether by arms or soft baby carriers, signiﬁ cantly reduced infant crying and fussiness and increased periods of infant content. Furthermore, Tessier et al. (1998) reported that skin-to-skin contact between treatment mothers and their low birth weight infants signiﬁ cantly increased maternal competence and sensitivity as compared to control mothers receiving traditional hospital services. As a group, the studies report positive effects on both mother and child of strategies that promote early periods of close, physical contact.

8.4.2. Behavioral: Individual Focus 8.4.2.1. Media Videotapes have been successfully used to educate parents around many important child health issues (Glascoe, Oberklaid, Dworkin, & Trimm, 1998). Our search produced only one study of relevance to early child maltreatment prevention efforts. Black and Teti (1997) examined the effect of a culturally sensitive video- tape depicting both successful and unsuccessful strategies for parents to employ when feeding infants. Findings from a randomized study of the video’s impact on ﬁ rst-time African American teen mothers demonstrated that treatment mothers reported signiﬁ cantly more positive parental attitudes and more parent–child inter- action during feedings than control mothers. The treatment mothers also received signiﬁ cantly higher ratings on an observational measure of involvement during a feeding session. As other research corroborates the use of videotapes for stimulat- ing behavioral change for parents of children with conduct disorders (Webster- Stratton, 1994), the research suggests that videotapes are a promising strategy that prevention programs should consider incorporating into their program arsenal.

In contrast to videotapes, prevention programs are more likely to include print materials as part of their effort to educate parents about normative child develop- ment, activities to promote learning, and the physical needs of infants. Insufﬁ cient evidence exists to support this strategy. Although early studies suggested some posi- tive effects, lack of comparison groups, single point in time measures, sole reliance on parental reports, and low response rates characterized much of this research (Cudabak, et al., 1985; Riley, Meinhardt, Nelson, Salisbury, & Winnett, 1991). A more rigorous study using comparison groups reported little effects on parental attitudes (Laurendeau, Gagnon, Desjardins, Perreault, & Kischuk, 1991).

8.4.2.2. Parent Education and Support Groups Educational and support services delivered to parents in the context of center-based programs or in group settings have been used in a variety of ways to address the risk factors associated with child abuse and neglect. At least one national survey estimates Interventions to Prevent Child Maltreatment 143 that more than 100,000 groups of parents meet every year in the United States to attend parent education classes, to provide mutual support to other parents, and to advocate for better services or public policy options (Carter, 1995).

Although the primary focus of these interventions is often on the parent, virtually all of the most frequently replicated models include opportunities for structured parent–child interactions and many incorporate parallel interventions for children. This multicomponent approach is particularly true when the program is offered to families through public education systems, early education programs such as Head Start, or day-care centers. Common features of these group-based efforts include weekly discussions for 8–14 weeks with parents around speciﬁ c parenting topics (e.g., discipline, cognitive development, communications); group- based sessions with the children that provide parents with an opportunity to discuss issues or share feelings; parent–child interaction sessions to model the skills being presented to parents; and regular opportunities for all participants to share meals and important family celebrations, such as birthdays and graduations. In addi- tion, speciﬁ c instructions to children might also be incorporated into the regular classroom curriculum, further reinforcing the concepts. Because of the important role educators and day-care providers play in reinforcing and modeling positive adult–child interactions, these models also include speciﬁ c teacher or staff train- ing components on the program’s goals and behavior expectations. In almost all instances, these models draw on the family-support philosophy, which emphasizes the enhancement of protective factors in addition to the reduction of negative behaviors (Dunst, 1995).

Solid empirical evidence supporting the method’s efﬁ cacy in reducing mal- treatment risk is limited but growing (Baker, Piotrkowski, & Brooks-Gunn, 1999; Carter & Harvey, 1996; Chalk & King, 1998; Daro & Cohn-Donnelly, 2002b; Wolfe, 1994). Repeated randomized trials of the Incredible Years, a multifaceted, developmentally based curricula for parents, teachers, and children delivered in both primary school and early education settings, found that participants demon- strated more positive affective response and a corresponding decrease in the use of harsh discipline, reduced parental depression and improved self-conﬁ dence, and better communication and problem solving within the family (Webster- Stratton, 1998; Webster-Stratton, Reid, & Hammond, 2001). Signiﬁ cant aspects of the model include group-based parenting skills training; classroom management training for teachers; and peer support groups for parents, children, and teachers.

A meta-analysis of a broad range of family support services provided to families with children of all ages conducted by Abt Associates, found that these types of group-based parenting education and support produced larger effects than home visitation services in affecting children’s cognitive outcomes and social emotional development (Layzer, Goodson, Bernstein, & Price, 2001).

In contrast to these relatively short-term interventions, other prevention efforts using a group format provide services for multiple years. For example, MELD (formerly the Minnesota Early Learning Design) is a 2-year curriculum in which groups of 10–20 mothers of newborns meet weekly to discuss various parenting and personal issues, such as health care, child development, child guidance, family man- agement, and personal growth. Core techniques include large-group presentations, small-group discussions, modeling, and socialization before and after the meetings.

Evaluations of this strategy have found the following service features central to achieving positive outcomes: group facilitation by parents who have experienced life situations similar to those of group members, long-term service availability 144 D.A. Daro and K.P. McCurdy (e.g., 2 or more years), persistent focus on parent strengths, emphasis on making decisions that produce long-term solutions to problems rather than achieving a “quick-ﬁ x,” and a commitment to ongoing staff training and supervision (Hoelting, Sandell, Letourneau, Smerlinder, & Stranik, 1996).

The success of these efforts, however, is far from universal (Layzer et al., 2001).

Many high-risk families ﬁ nd it difﬁ cult to sustain involvement in structured group programs due to logistical barriers, such as poor transportation, adjusting to a ﬁ xed schedule, and limited access to child care (Daro, 1993). Also, group-based services can be difﬁ cult to tailor to the individual needs of all participants. If the issue being addressed is general, with broad application across populations, such as how to access a given service or how to anticipate a speciﬁ c parenting challenge, this inability to personalize the service is less salient. However, if parents face complex problems, the inability to provide personal guidance can reduce program effective- ness (Daro & Cohn-Donnelly, 2002b).

8.4.2.3. Child Assault Prevention Programs In contrast to efforts designed to alter the behaviors of those who might commit maltreatment, a category of programs emerged in the early 1980s designed to alter the behavior of potential victims. Often referred to as child assault preven- tion or safety education programs, these efforts present children with speciﬁ c information on the topic of physical abuse and sexual assault, how to avoid risk situations, and, if abused, how to respond. A key feature of these programs is their universal service-delivery systems, often being integrated into school curricula or into primary-support opportunities for children (e.g., Boy Scouts, youth groups, recreation programs). Although certain concerns have been raised regarding the appropriateness of these efforts (Gilbert, 1988; Reppucci & Haugaard, 1989), the strategy continues to be widely available in many school districts and to have increas- ingly adopted a more general focus on assisting children in avoiding a broad range of abusive behaviors, including peer aggression and violence prevention.

Repeated meta-analyses and other qualitative reviews of evaluations conducted on these programs have determined the method is effective in conveying safety education to children and providing children a set of skills in avoiding or minimiz- ing the risk of assault (Berrick & Barth, 1992; Daro, 1994; MacMillan, MacMillan, Oxford, Grifﬁ th, & MacMillan, 1995; Rispens, Aleman, & Goudena, 1997). Equally important, these programs have offered children who have been victimized the language tools and procedures necessary for accessing help and reducing the risk of subsequent maltreatment (Kolko, Moser, & Hughes, 1989; Hazzard, 1990).

Although the average effect sizes (ES) noted by Berrick and Barth (1992) were modest (ES < 0.20) and limited to knowledge gains, more robust ﬁ ndings emerged from the meta-analysis by Rispens, Aleman, & Goudena (1997). Their review revealed signiﬁ cant and large effect sizes at both the postintervention (ES:

0.71) and follow-up (ES: 0.61) data collection points. Variation in these patterns most likely reﬂ ects differences in the pool of evaluations included in the two reviews. Because Rispens and co-worker’s meta-analysis used studies with more rigorous designs (e.g., control groups, sufﬁ cient data for the computation of effect size, dependent variables that included knowledge of child abuse and acquisition of self-protection skills), greater conﬁ dence can be placed in those ﬁ ndings.

Both the descriptive reviews and meta-analyses of this strategy found that gains are unevenly distributed across concepts and participants. On balance, children have greater difﬁ culty in accepting the idea that abuse can occur at the Interventions to Prevent Child Maltreatment 145 hands of someone they know than at the hands of strangers (Finkelhor & Strapko, 1992). Among younger participants, the more complex concepts such as secrets and dealing with ambiguous feelings often remain misunderstood (Gilbert, Duerr Berrick, LeProhn, & Nyman, 1990), although the most recent meta-analysis found that younger children (i.e., those under the age of 5.5 years) initially beneﬁ ted more than older children from these programs (Rispens et al., 1997) in both knowl- edge and skills. However, this ﬁ nding disappears at follow-up, suggesting younger children have more difﬁ culty retaining knowledge and skills over time.

Some have attributed the 40% decline in reported cases of child sexual abuse between 1992 and 2000 to the widespread implementation of these programs, along with more consistent efforts to screen adults, providing direct intervention with children and aggressive prosecution of offenders (Finkelhor & Jones, 2004).

Although it is impossible to fully understand the extent to which decreased reports reﬂ ect an absolute decrease in the total incidence, the reduction in reports offers possible evidence of the effects of universal efforts to provide most personal educa- tion or to craft a safer environment for children. 8.4.3. Behavioral: Relationship Focus 8.4.3.1 Early Home Visitation Home visitation, a service-delivery strategy that has been around since the late 1800s, has gained some distinction in recent decades (Gomby, Culross & Behrman, 1999).

Many prevention-focused, home visiting programs target parents of newborns or young children. In such early home visitation programs, four common objectives have been identiﬁ ed: to prevent child abuse and neglect, to improve child health, to optimize child functioning and development, and to enhance parental care-giving abilities (McCurdy, 1995). Often, the home visitor seeks to achieve these objectives by offering education regarding infant health and development, modeling posi- tive adult–child interactions, providing social support, and assisting the parent in achieving life outcomes such as further education.

Early home visiting services can vary on a number of program dimensions, including initiation and length of services, provider education and training, target population, and program size. Although such variation can obscure efforts to isolate the “true” effects of early home visitation as a method to prevent child maltreat- ment, meta-analytic techniques can assess the overall effect of home visiting on parents and children and calculate how these effects vary across certain program dimensions.

Three recent meta-analyses of early home visitation programs present similar ﬁ ndings regarding effectiveness—that home visiting programs signiﬁ cantly prevent child abuse and neglect in families with children 3 years old or younger, as mea- sured by CPS reports or by proxy measures of maltreatment, including injuries, accidents, and emergency room visits. The two meta-analyses that investigated other indicators of child and family functioning also report positive and signiﬁ cant effects of home visiting; however, these analyses produce somewhat different estimates of effect size.

Hahn and co-workers’ (2003) examination of 26 home visiting programs reports a 39% reduction in child abuse and neglect by visited parents as compared to the control group, with prevention measured by CPS reports and reported injuries. The results from two other meta-analyses corroborate this ﬁ nding. In their examination of 60 home visiting programs, Sweet and Appelbaum (2004) 146 D.A. Daro and K.P. McCurdy document a signiﬁ cant reduction in potential abuse and neglect as measured by emergency room visits and treated injuries, ingestions, and accidents (ES: 0.239, p < .001). The effect of home visitation on reported or suspected maltreatment was moderate but insigniﬁ cant (ES: 0.318), though failure to ﬁ nd signiﬁ cance may be due to the limited number of effect sizes available for analysis of this outcome (k = 7). Geeraert, Van den Noorgate, Grietens, and Onghena (2004) focused their meta-analysis on 43 programs with an explicit focus on preventing child abuse and neglect for families with children under 3 years of age. Though programs varied in service-delivery strategy, 88% (n = 38) used home visitation as a component of the intervention. This meta-analysis notes a signiﬁ cant, positive overall treatment effect on CPS reports of abuse and neglect and on injury data (ES: 0.26, p < .001).

While these latter two studies also report signiﬁ cant effects of home visitation on child and family functioning, the effect size varies. Sweet and Appelbaum (2004) note that home visitation produced signiﬁ cant but relatively small effects on the mother’s behavior, attitudes, and educational attainment (ES: ≤0.18). In contrast, Geeraert et al. (2004) ﬁ nd stronger effects on indicators of child and parent func- tioning, ranging from 0.23 to 0.38. In assessing why these ﬁ ndings diverge, it seems likely that the authors’ program selection processes partially contributed to these differences. Sweet and Appelbaum examine a greater number of programs (60 vs.

43), which potentially increases the accuracy of the overall effect size estimates.

However, Geeraert and colleagues include 18 post-2000 evaluations not covered by Sweet and Appelbaum. These newer evaluations assess a broader array of child- and family-functioning indicators.

Two meta-analyses reported contradictory ﬁ ndings regarding the provider edu- cation and training on overall effectiveness. Hahn et al. (2003) discerned greater effects on child maltreatment indicators by professional visitors (nurse and mental- health workers) as compared to paraprofessional visitors, though paraprofessional visitors who provided visits for 2 or more years achieve consistent and positive effects. Sweet and Appelbaum (2004) found stronger effects on child abuse poten- tial when paraprofessionals delivered the services as compared to professionals and nonprofessionals.

No other common program dimensions are investigated by all three meta- analyses. Overall, the studies note that the timing of service initiation, multiple- vs.

single-component program structure (Hahn et al., 2003), actual service length, child age at service initiation (Sweet & Appelbaum, 2004), and year of study pub- lication (Geeraert et al., 2004) did not signiﬁ cantly inﬂ uence the effect of home visitation services. Sweet and Appelbaum (2004) report that the receipt of more visits corresponded to greater effect sizes in child cognition, but not in measures of potential child abuse, parental behavior, or maternal education.

In terms of targeting services to speciﬁ c types of parents, Sweet and Appelbaum (2004) note differential effects; however, little consistency exists across the observed outcomes. For example, programs focusing on low-income parents yielded greater effects on potential child abuse but weaker impacts on parental behavior. A fourth meta-analysis of early home visitation programs by Guterman (1999) also addresses this issue of target population. Guterman’s analyses suggest greater effects on CPS reports and other maltreatment proxies by 12 home visiting programs with population-based enrollment (i.e., services targeted to families with demographic markers such as single parenthood) as compared to 7 screening-based home visit- ing programs (i.e., services targeted to families based on risk-assessment scores).

Tests of signiﬁ cance were not presented. Interventions to Prevent Child Maltreatment 147 8.4.3.2 Characteristics of Effective Family Support Programs In this section, we review two recent meta-analyses that assess a variety of prevention-oriented, family-support programs with the explicit goal of exploring the effect of assorted program and study elements on treatment effectiveness. The ﬁ rst meta-analysis, by MacLeod and Nelson (2000), examines a range of family- support programs they characterize as proactive (i.e., interventions targeted to all parents or to high-risk, nonabusive parents, with service delivery beginning either before the child’s birth or in the ﬁ rst few years of life) or reactive (i.e., programs serving families with conﬁ rmed instances of maltreatment). Our analysis is limited to ﬁ ndings drawn from the analysis of 34 proactive family-support pro- grams. The second meta-analysis, by Bakersman-Kraneburg, van Ijzendoorn, and Juffer (2003), examines 88 programs designed to increase maternal sensitivity and secure attachments.

MacLeod and Nelson (2000) report that multicomponent programs produced the largest total effect sizes in all outcome areas (ES: 0.58), followed by home visit- ing programs (ES: 0.41) and parent-support groups (ES: 0.38) while media inter- ventions exerted only small effects (ES: 0.13). Follow-up effects were signiﬁ cantly higher than end of treatment effects for those studies that included a follow-up component.

Next, their multivariate analyses identiﬁ ed several moderator variables associ- ated with differential effects of home visiting programs. For child maltreatment outcomes, service length and intensity had a curvilinear pattern with outcomes.

Moderate amounts of home visiting (i.e., 25–30 months with 13–32 home visits), resulted in the greatest effects on the prevention of substantiated cases of child maltreatment and accidents and injuries. However, the reverse was true for parent behavior outcomes where moderate amounts of visits (13–50) led to signiﬁ cantly lower effects on parental behavior than fewer (≤12) or more home visits (>50).

Some unexpected ﬁ ndings emerged. MacLeod and Nelson report that home visiting programs that also sought to provide social support were less successful at reducing maltreatment than home visitation programs without this component.

Similarly, the parent–child environment was less likely to be changed when the home visiting program provided concrete supports (e.g., money, clothing). These results may suggest that too broad a program focus dilutes program effectiveness.

Maternal sensitivity and attachment security have been linked to neglectful and abusive behavior (Egeland & Erickson, 1993), and the meta-analysis by Bakersman- Kraneburg et al. (2003) highlights some program and participant characteristics that promote these proximate outcomes. In this analysis, 88 programs targeting families with children younger than 54 months of age are examined. The pro- grams covered a range of intervention strategies (from viewing videos to receiving home visits), target populations (from clinical to low-risk parents), and provider credentials (ranging from no provider to professional provider). All evaluations relied on observational measures of sensitivity or attachment to assess effectiveness.

Overall, the meta-analysis found moderate program effects on maternal sensitivity (ES: 0.44, p < .001) and positive though small effects on attachment security (ES:

0.19, p < .05).

For the 81 interventions assessing maternal sensitivity, several program, par- ticipant, and study attributes inﬂ uenced effectiveness. First, a program focus on maternal sensitivity was more effective that other objectives, such as increasing maternal support, altering parental cognitive representations, or some combina- 148 D.A. Daro and K.P. McCurdy tion of these three foci. Other program characteristics—such as the use of videos or video feedback, service length of less than 16 sessions, service initiation after the child reached 6 months, and the inclusion of fathers in the intervention—produced signiﬁ cantly stronger effects. For multiproblem families, nonprofessional providers were more effective than professional providers.

In terms of participant characteristics, these programs were more effective with clinical than with nonclinical samples. No differences emerged by low socioeco- nomic status, teen parenthood, premature birth, or multiproblem status. Finally, study characteristics inﬂ uenced effect size because randomized studies yielded a lower, though still moderate, effect size (ES: 0.33) than nonrandomized studies (ES:

0.61), and studies with low attrition rates reported stronger effects.

Of the 29 programs assessing parent–child attachment, a focus on maternal sensitivity produced stronger effects than any other program foci. In contrast to the ﬁ ndings with maternal sensitivity, the use of videos was found to weaken the program’s effect on attachment patterns. Service length, age of child, provider credentials, and randomization procedures did not moderate effect size.

8.4.4. Behavioral: Community or Societal Focus 8.4.4.1. Community Partnerships Community partnerships often serve to encourage multiple entities (e.g., child protection agencies, social service agencies, community organizations, and community residents) to work together to protect children and support families (Annie E. Casey Foundation, 2003; CWS Stakeholders Group, 2003; Farrow, 1997; Waldfoqel, 1998). Other partnerships focus more explicitly on building resident involvement in community protection or galvanizing within local communities a greater emphasis on achieving mutual reciprocity between individual residents (Dodge et al., 2004; Melton et al., 2002).

Measuring the collective effects of a community partnership on child maltreat- ment requires both individual-level and community-level data. To date, insufﬁ cient evidence exists to evaluate the effect of such partnerships on CPS system perfor- mance or on community norms. However, ﬁ ndings from at least one community- based strategy are encouraging. In Vermont, regional partnerships, under the direction of the state’s Team for Children, Families and Individuals, have greatly expanded the availability of family-support services for all pregnant women and young children. Since implementing these partnerships, the state has experienced service expansion and a signiﬁ cant reduction in the rates of reported child abuse and neglect as well as improvements in other indicators of child well-being (Center for the Study of Social Policy [CSSP] 2001; Hogan, 2001).

8.4.4.2. Public Awareness Effort Using public awareness campaigns to mobilize the public has long been regarded as a vital component of a comprehensive child maltreatment prevention strategy (Cohn Donnelly, 1997). The values and attitudes that a people hold about children and how to raise them, the behaviors they engage in as parents toward their own and other children, and the degree to which they support or fail to support certain public policies all help explain the existence of child abuse and its increase or decrease over time. To inﬂ uence societal beliefs about parenting, public-awareness Interventions to Prevent Child Maltreatment 149 campaigns attempt to reach out to large numbers of individuals in a consistent manner using everyday communication media (e.g., television, radio, newspapers and magazines, billboards, the Internet).

Studies of awareness levels suggest that public service campaigns have effec- tively educated the public as to the existence of child maltreatment and its potential effects on victims. In the mid-1970s, only 10% of the general public reported an awareness of child abuse (Cohn Donnelly, 1997). This percent grew to over 90% by the early 1980s (Daro & Gelles, 1992). These later surveys also demonstrated that the general public had a more sophisticated understanding of the different types of child maltreatment, its individual and societal causes, and the need to take action to prevent its occurrence (Daro & Gelles, 1992).

In achieving the more ambitious goal of changing parental attitudes and behav- iors, the evidence to date is mixed. In conjunction with the Advertising Council, Prevent Child Abuse America conducted a nationwide series of educational cam- paigns using TV, print, radio, and billboard public service announcements with editorial assistance from the media (e.g., Op-Ed pieces, columns in “Dear Abby”) targeted sequentially at physical abuse/hitting, verbal abuse/yelling, and emotional neglect/ignoring. The combined campaigns garnered between $20 and $60 million a year worth of exposure in donated time and space.

The effect from the ﬁ rst two of these three waves suggests some success. Since 1988, parents participating in annual public opinion polls have reported a steady reduction in the use of both corporal punishment and verbal forms of aggression in disciplining their children (Daro & Gelles, 1992). However, these same studies ﬁ nd that the proportion of parents who report hitting their child with an object or injur- ing their child in the course of “normal discipline” have remained constant. Each year, roughly 10% of parents will hit their children with a belt or other implement and 1% admit to bruising or physically injuring their child (Daro & Gelles, 1992).

In addition, related studies of the use of mass media to identify developmental delays found little effect on parental knowledge or attitudes (Kurtz, 1982; Kurtz, Devaney, Strain, & Sandler, 1982). 8.5. POLICY AND PRACTICE IMPLICATIONS Program evaluations and meta-analytic studies of child abuse prevention programs present a fairly positive picture. Most important, our review found evidence that early home visitation strategies are effective at reducing the likelihood that chil- dren will be reported as victims of child abuse and neglect or that they will need treatment for physical injuries or accidents. When the pool of relevant indicators are extended to include proximal indicators of a reduction in abuse potential or an increase in core protective factors, a number of additional strategies surface as promising. Products designed to improve parental sensitivity such as soft baby carriers, interventions to enhance parental knowledge through videotapes and support groups, and strategies to protect children through child assault prevention programs show positive results. Among this second group of strategies, it is impor- tant to note that the reduction in risk behaviors or attitudes by the participants may enhance family functioning, yet have little effect on aggregate rates of physical abuse and neglect. Because some argue that program effectiveness can be proven only by reductions in child maltreatment rates (Chafﬁ n, 2004), the ﬁ eld itself needs to achieve consensus on acceptable indicators of prevention. 150 D.A. Daro and K.P. McCurdy Although our review also sought to identify the service components most likely to result in meaningful change, our efforts in this regard met with limited success. In attempting to answer whether prevention programs should begin before the child’s birth, provide multiple services, rely on professional providers, last for 2 or more years, or target speciﬁ c families, we were stymied by the lack of rigor- ous research and deﬁ nitional clarity available to address these questions. The bulk of evidence suggests, however, that the deﬁ nition and measurement of the target outcome is a critical factor in determining which service component leads to change. For example, strategies that seem to work in preventing maltreatment reports are not necessarily ones that work to enhance child functioning In addition to these issues, our review suggests another source of analytic con- fusion. Many home visitation and parent education program assessed in our review embrace multiple strategies, yet are typically classiﬁ ed as single-component models.

Similarly, many programs identiﬁ ed as “paraprofessional” consist of providers with academic degrees in addition to nonprofessional providers. Given the growing trend among prevention services to offer multiple components and hire diverse staff, such classiﬁ cations may become less salient in the future. 8.6. RESEARCH IMPLICATIONS Our review suggests several areas in which additional research is needed if preven- tion efforts are to maximize their potential. First, greater clarity is needed regarding the most accurate and appropriate way to measure prevention of child maltreat- ment. If maltreatment reports continue to be viewed as the ultimate and most accurate indictor of prevention effectiveness, greater consistency is needed in how such reports are documented, including more careful identiﬁ cation and tracking of the type of maltreatment involved (e.g., physical abuse, neglect, sexual abuse, multiple forms of abuse), the actual perpetrator (e.g., parent or other adult), and the relative severity of the mistreatment.

Second, longitudinal research studies are needed that track the extent to which initial progress on various proximate outcomes is both sustained over time and sufﬁ ciently robust to reduce subsequent reports of maltreatment or involvement with child protective services. To the extent prevention programs embrace the public health model and ecological theories of maltreatment, targeted outcomes for such interventions will include a dual focus on both risk and protective factors.

Understanding how changes in these factors reduce subsequent abusive or neglect- ful behavior is essential both in building better theory in the ﬁ eld of maltreatment and in enhancing program and policy effectiveness and efﬁ cacy.

While independent, rigorous program evaluations can provide evidence of a model’s efﬁ cacy, developing and taking interventions to scale demand the articula- tion of speciﬁ c quality standards and the capacity to monitor program adherence to these standards. Effective programs will be ones that operate under a framework in which information is continuously collected and fed back into the decision-making process. Strengthening our knowledge base and understanding of prevention pro- gramming requires more consistent and rigorous attention to such issues as the characteristics of the target population, the rate at which programs successfully enroll and retain their population, the content of the services provided families, and, the nature of the participant–provider relationship. Interventions to Prevent Child Maltreatment 151 8.7. CONCLUSIONS Despite the emphasis prevention advocates place on altering community context and building a collective sense of responsibility for child protection (Melton & Berry, 1994), most child maltreatment prevention efforts remain focused on chang- ing individual attitudes and behaviors. Efforts to reduce child abuse and neglect rates largely target individual characteristics such as parenting skills or knowledge and the parent–child relationship. When such efforts are carefully implemented, risk can be reduced and positive outcomes achieved; however, effects on aggregate rates of maltreatment may be small.

For many of the most at-risk families, however, access to these types of services remains limited (Daro, 1993). And when at-risk families reside in high-risk com- munities marked by violence, poor social infrastructure, and limited economic opportunities, the odds of successfully protecting a child from harm are greatly reduced. Overcoming these obstacles will require prevention programs to become more community focused in their programming imagery. As noted earlier, calls for this type of integration between individual and contextual reforms is longstanding.

Although preliminary efforts in the area of community capacity building are under way, they have not yet produced signiﬁ cant ﬁ ndings with respect to abuse reduction or the development of more robust levels of social capital (Wandersman & Florin, 2003; Dodge et al., 2004).

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