The concept of prevention is central to addressing child maltreatment. The World Report on Violence and Health describes the visible and invisible nature of violence, challenging the notion of inevitability and recognizing the contributions of various systems. Religious, philosophical, legal, and communal systems have advanced strategies to prevent child maltreatment. Prevention, in many fields, is often oversimplified, misunderstood, and seen as a programmatic component to be added if and when critical support services have been realized. Acknowledging child maltreatment as preventable, it is critical that evidence-based frameworks ground efforts designed to stop maltreatment. Research addressing multisector, multidimensional, multicomponent strategies to address victimization and perpetration has evolved and the need for prevention research identifying specific approaches to prevent child maltreatment has been recognized. Yet although more research is always desirable, available evidence offers a model for prevention programs to address child maltreatment.
The Science of Prevention
Models that describe the problem of maltreatment provide useful data and support an understanding of the magnitude, trends, victims, perpetrators, and circumstances associated with events. Models that address causation recognize violence as a complex event resulting from effects and interactions among a range of social, psychological, and biological factors. The causal models help define and describe the component causes that accumulate over time and can be targeted at multiple stages. However, neither the descriptive or causal models provide guidance about developing effective prevention programs.
When considering prevention program planning there are three factors to be considered:
1. When: When in the chain of related events are we attempting to effect change?
2. What: What is the desired result or outcome of the prevention strategy?
3. Who: To whom will the prevention efforts be directed?
All three of these concepts are unique and critical to successful prevention programming.
When to Intervene?
Common conceptualizations group prevention programs into three categories based on when, in the chain of events, the planned program is to intervene (in this context intervention describes any prevention or service-related activity). These categories are as follows:
Primary Prevention. Approaches that take place before maltreatment occurs, to prevent initial perpetration or victimization.
Secondary Prevention. Approaches that take place in response to violence that has already occurred and focuses on immediate response such as prehospital care, emergency services, or treatment.
Tertiary Prevention. Approaches that occur after maltreatment has occurred and are intended to deal with the long-term consequences of that maltreatment.
Child maltreatment prevention programs can be directed at preconception, immediately following birth, and during child rearing and can represent primary, secondary, or tertiary prevention strategies. Historically many interventions take place after maltreatment has occurred and are designed to reduce or ameliorate the negative effects of maltreatment. Prevention strategies designed to address and prevent maltreatment before it occurs are growing and the empirical basis for these programs is strengthening. Because the concept of prevention encompasses a wide range of activities the categorization of prevention solely by when an intervention occurs is not useful.
What Is the Focus?
To prevent maltreatment, it is important to understand the circumstances and factors influencing its occurrence. Many different theoretical models attempt to describe the root causes of maltreatment, such as biological models, psychological models, cultural models, and grassroots or advocacy-based models. Each of these contributes to an understanding of maltreatment and helps build programs that sustain protective factors and reduce modifiable risk factors. The application of an ecological approach to prevention is universally recognized as key to successful prevention. A range and variety of ecological models exist, and all offer a framework for understanding the complex interplay of individual, relationship, social, political, cultural, and environmental factors that influence an outcome. The model adopted within the field of public health describes the associated levels as individual, interpersonal relationship, community, and society. The critical point in understanding the value of any ecological model is that the models relate to and define the desired outcome rather than the setting where the prevention efforts take place. Thus, individual-level strategies influence and effect change in individual characteristics while community-level strategies influence change in characteristics of the defined community.
Individual-level strategies are designed to affect the knowledge, attitudes, or behaviors and practices of children, parents, professionals, providers, and so on. Interventions for individual-level influences are often designed to target social and cognitive skills and behavior and include approaches such as counseling, therapy, skill building, and educational training sessions. For example, efforts to prevent shaken baby syndrome (SBS) typically focus primarily on individuals. Dias and his colleagues found that training individual nurses to provide information to individual parents could effectively prevent SBS.
Shaken Baby Syndrome Prevention. Nurses in maternity hospitals were trained and asked to disseminate information (1-page leaflet and 11-minute video) about violent infant shaking to both parents of newborn infants before the infant’s discharge and to have both parents sign a statement affirming their receipt and understanding of the materials. Dias’s program was implemented in eight counties in New York. Regional incidence of abusive head injuries among infants less than 3 years old was tracked prospectively for 66 months and compared to the regional incidence in the 60 months before the intervention. The rates in New York were compared to incidence rates in Pennsylvania during the same period of time. Rates of SBS in the New York counties decreased by 47%, and no such decreases were seen in Pennsylvania.
Enhanced Parent Child Centers. Enhanced Parent Child Centers are comprehensive childcare center-based early intervention programs for parents and children. Programs providing a stable enriched learning environment for children and parent educational activities that promote parental involvement and positive parent-child interactions have been found to support multiple positive outcomes. Research, following children for 18 years, compared programs implemented in 20 child-parent centers to 5 schools with alternative full-day kindergarten programs and found that the rates of substantiated reports of child maltreatment through both court petitions and child protective services were 52% lower in the treatment condition.
Project SafeCare/Project 12-Ways. Project SafeCare/ Project 12-Ways is a home-based intervention for physical abuse and neglect. The SafeCare model focuses on training parents in specific behavioral skills (i.e., health care, positive parent-child interaction, safety). Project 12-Ways includes additional components (e.g., social support, basic skills, problem solving, stress reduction, money management, self-control training, job finding). Among SafeCare program completers at 36-month follow-up, there were fewer recurrences of maltreatment in families receiving SafeCare than in families receiving family preservation services. Wesch and Lutzker found the results for Project 12-Ways more equivocal, with decreases in severity but not overall rates of child maltreatment between Project 12-Ways and an Illinois Department of Children and Family Services comparison group.
Nurse Family Partnership. Nurse Family Partnership (NFP) is consistently identified as one of the most promising of the home visitation programs. The initial trial indicated that there were fewer cases of child abuse and neglect among NFP-visited families than comparison families at 15-year follow-up. Subsequent trials have involved focused on other measures of child maltreatment and had smaller effects. This program has an infrastructure and processes in place on a national level to promote widespread use.
Interpersonal relationship-level strategies are designed to influence group dynamics or factors that increase or decrease the risk for maltreatment. These prevention strategies are directed at influencing the relationships that exist with peers, partners, family members, and so on. Interpersonal relationships can shape an individual’s behavior and range of experience. Child maltreatment prevention strategies that address the interpersonal relationship level include family support approaches, bystander intervention skill development, and parent or caregiver training.
One example is efforts to develop comprehensive childcare center-based programs for parents and children that actively promote parental involvement and positive parent-child interactions.
Parent Child Interaction Therapy. Parent-child interaction therapy (PCIT) is protocol-driven behavioral intervention for parents and children that involves training on specific parenting skills using live coaching during dyadic parent-child sessions and changes aspects of the child’s behavior and adjustment. Targeted outcomes include improvements in parenting skills, parent-child interactions, and child behavior and adjustment. A randomized trial compared PCIT plus a 6-week motivational enhancement to services as usual and found 19% of parents assigned to PCIT had a subsequent report of physical abuse compared with 49% of parents assigned to the standard community group. There were no significant effects for neglect reports.
Incredible Years. The Incredible Years, a multifaceted, developmentally based curricula for parents, teachers, and children delivered in both primary school and early education settings, has been found to influence positive affective response and a corresponding decrease in the use of harsh discipline, reduced parental depression, improved self-confidence, and better communication and problem solving within the family.
Community-Level and Societal-Level Strategies
Community-level strategies are designed to influence those factors within the community or social environments that influence an individual’s experiences. These strategies are directed to changes in policies, programs, and practices within schools, workplaces (including childcare settings as workplaces), and neighborhoods. The goal of these strategies is to influence organizational or community-level change to impact the climate, systems, and policies in a given setting.
Societal-level strategies may influence factors surrounding maltreatment such as inequality, religious or cultural belief systems, societal norms, and economic or social policies that create or sustain gaps and tensions between groups of people. Interventions for societal-level influences typically involve collaborations by multiple partners to change laws and policies related to maltreatment. Examples of societal efforts to prevent child maltreatment include those that attempt to strengthen cultural or societal supports for parenting.
Partnerships. In Vermont, community partnerships serve to encourage multiple entities to work together to protect children and support families. 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 woman and young children. Since implementing these partnerships, the state has experienced service expansion and a significant reduction in the rates of reported child abuse and neglect as well as improvements in other indicators of child well-being.
Positive Parenting Program. The Positive Parenting Program (Triple-P) is a multilevel parenting program for addressing child behavior and emotional problems. Research supports the program’s efficacy in addressing maladaptive attributions, CAP and STAXI scores, and other child maltreatment risk factors. An ongoing Centers for Disease Control and Prevention project is examining the program’s effectiveness in impacting child maltreatment. Triple P combines individual-level with community-level components that include universal and selected approaches.
An ecological approach supports a comprehensive prevention program that not only addresses an individual’s risk factors, but also the norms, beliefs, and social and economic systems that create and support the conditions for the occurrence of violence.
Who Is It For?
Prevention strategies are often developed based upon the group for whom the intervention is intended. Using this type of differentiation, child maltreatment prevention interventions can again be divided into three categories:
Universal Strategies. Approaches aimed at groups or the general population regardless of individual risk for perpetration or victimization are called universal strategies. Groups can be defined geographically (e.g., entire school or school district) or by characteristics (e.g., ethnicity, age, gender). In preventing child maltreatment these strategies often include parent training that is available to all families.
Selected Strategies. Approaches aimed at those who, based on some known risk factor, are at heightened risk for maltreatment perpetration or victimization are referred to as selected strategies. These strategies include home visitation for high-risk families including those with young single mothers, those with a parent who is a substance abuser or has a mental illness, those that have a history of domestic violence, and so on.
Indicated Interventions. Approaches aimed at those who have already perpetrated violence or have been victimized are called indicated interventions. These include intensive family preservation services or other strategies to intervene after maltreatment occurs.
The evidence that prevention works suggest it is necessary to address any complex issue through broad and multifaceted, comprehensive approaches. These approaches require the skills and involvement from many varied disciplines and areas of expertise. Thus, there are four other key characteristics of effective prevention programming; each is described briefly here.
Data for Decision Making. Data-informed, evidence-based approaches are central to effective prevention program planning and implementation. Data should be used to define the problem, track and monitor trends in the population of interest over time, and produce findings that can be used to apply for resources, focus or refocus the prevention program, and track the success of various efforts over time.
Partnerships/Alliances. Effective prevention programs often utilize a community-oriented approach with the goal of making the responsibility to prevent violence that of the entire community (women, men, and youth), recognizing the importance of community led action that engages more than those impacted by or directly supporting services to those impacted by violence.
Cultural Competency. It is essential that core activities such as collecting and analyzing data, designing and implementing programs, and determining what works be conducted within the context of the unique aspects of various populations and communities.
Guidance from the population is important in the design, implementation, and evaluation of a prevention program. Also, simply translating materials for a given intervention into a different language does not constitute a culturally appropriate or relevant strategy as it does not address the different ways communities talk and think about violence.
Evaluation and Feedback. Data gathered from the experiences of practitioners working with various groups and through community assessments, stakeholder interviews, and focus groups may be useful for designing prevention programs that increase program acceptability among the intended audience. In addition, information gathered during program implementation can be used to document successful and unsuccessful implementation, demonstrate program accomplishments, and identify areas needing improvement. Promising programs and curricula should undergo rigorous evaluation before they are widely disseminated.
Preventing child maltreatment requires a complex set of mutually reinforcing strategies. In 2006, the World Health Organization, in conjunction with the International Society for Prevention of Child Abuse and Neglect, released Preventing Child Maltreatment: A Guide for Taking Action and Generating Evidence. Designed to assist countries in preventing child maltreatment, the guide provides technical advice for professionals working in governments, research institutes, and nongovernmental organizations on how to implement and evaluate prevention programs.