Randomized trial of a statewide home visiting program: impact in preventing child abuse and neglect

OBJECTIVES: To assess the impact of home visiting in preventing child abuse and neglect in the first 3 years of life in families identified as at-risk of child abuse through population-based screening at the child's birth. METHODS: This experimental study focused on Hawaii Healthy Start Program (HSP) sites operated by three community-based agencies. From 11/94 to 12/95, 643 families were enrolled and randomly assigned to intervention and control groups. Child abuse and neglect were measured by observed and self-reported parenting behaviors, all hospitalizations for trauma and for conditions where hospitalization might have been avoided with adequate preventive care, maternal relinquishment of her role as primary caregiver, and substantiated CPS reports. Data were collected through annual maternal interviews (88% follow-up each year of all families with baseline interviews); observation of the home environment; and review of CPS, HSP, and pediatric medical records. RESULTS: HSP records rarely noted home visitor concern about possible abuse. The HSP and control groups were similar on most measures of maltreatment. HSP group mothers were less likely to use common corporal/verbal punishment (AOR=.59, p=.01) but this was attributable to one agency's reduction in threatening to spank the child. HSP group mothers reported less neglectful behavior (AOR=.72, .02), related to a trend toward decreased maternal preoccupation with problems and to improved access to medical care for intervention families at one agency. CONCLUSIONS: The program did not prevent child abuse or promote use of nonviolent discipline; it had a modest impact in preventing neglect. Possible targets for improved effectiveness include the program's implementation system and model.     

The diagnostic utility of sexual behavior problems in diagnosing sexual abuse in a forensic child abuse evaluation clinic

OBJECTIVE: This study examined the utility of sexual behavior problems as a diagnostic indicator of sexual abuse. The hypothesis was that sexual behavior problems are multiply determined and consequently are variably related to sexual abuse in a clinical sample. METHOD: A sample of 247 children evaluated for sexual abuse at a multidisciplinary forensic child abuse evaluation clinic were included. Results from the Child Behavior Checklist (CBCL) and the Child Sexual Behavior Inventory (CSBI) were analyzed and compared to the results of a structured abuse assessment performed independent of these scores. RESULTS: The forensic team assessment found evidence of sexual abuse in 25% of cases, and no evidence in 61%. Children in this sample exhibited an elevated level of both sexual and nonsexual behavior problems. However, considerable variability was noted in sexual behavior problem scores. Thus, in this study a high score or a low score had no relationship to the diagnosis of sexual abuse. Indeed, nonsexually abused children were just as likely to have high CSBI scores as sexually abused children. CONCLUSIONS: This study found no significant relationship between a diagnosis of sexual abuse and the presence or absence of sexual behavior problems in a sample of children referred for sexual abuse evaluation. The finding suggests that community professionals should use caution in relying on sexual behavior problems as a diagnostic indicator of abuse.     

Fatal child abuse in Georgia: the epidemiology of severe physical child abuse

Decisions about the occurrence of child abuse are increasingly difficult to make because concepts of what qualifies as reportable child abuse may be broadening. We examined this question by comparing 51 fatal child abuse cases occurring in Georgia between July 1975 and December 1979 to non-fatal cases and to the Georgia population. Overall rates of fatal child abuse were higher for male perpetrators compared with female and black perpetrators compared with white. However, the latter finding varied with economic and geographic status. The highest child abuse fatality rates were found in poor, rural, white families (3.3/100,000 children) and in poor, urban, black families (2.4/100,000 children). Risk factors for fatal abuse included early childhood (RR 6:1), parental teenage childbearing (RR 4:1), and low socioeconomic status. These characteristics were similar to those of the severe child abuse cases noted in the early child abuse literature. Non-fatal cases did not clearly share these risk factors. Severe abuse, here represented by fatal cases, is a distinct subset of reported child abuse, but characteristics associated with it are frequently attributed to all reportable child abuse. Medical personnel should be aware that they cannot rely on the presence or absence of these characteristics in screening for risk of reportable child abuse. Child abuse research should use restricted, stated case definitions. When intervention and prevention programs are being organized, they should not generalize research findings to all forms of child abuse.     

Three models of child abuse consultations: A qualitative study of inpatient child abuse consultation notes

Child abuse pediatricians have multiple roles in caring for abused children, including prevention, diagnosis, treatment, and, when needed, expert legal opinion. The child physical abuse consultation differs from the traditional medical consultation in that it has medical, investigative and legal audiences, all of whom have different information needs. How child abuse pediatricians approach their cases and how they document their initial inpatient consultations that will be used by such a diverse audience is currently unexplored. We used content analysis to examine 37 child physical abuse consultation notes from a national sample of child abuse pediatricians in order to understand physicians’ approaches to these consultations. Three commonly used models of child physical abuse consultation were identified in the data that we named the base model, the investigative model, and the family-dynamic model. While model types overlap, each is distinguished by key features including the approach used to gather information, the information recorded, and the language used in documentation. The base model most closely mirrors the traditional medical approach; the investigative model concentrates on triangulation of sources of information; and, the family-dynamic model concentrates on physician perceptions of family relationships. The three models of consultations for child physical abuse mirror the areas of child abuse pediatrics: diagnostic, forensic and therapeutic. These models are considered in relationship to best practice from other medical specialties with forensic components.     

Preschool child development: implications for investigation of child abuse allegations

Allegations of mistreatment by adults made by children of preschool age are often dismissed as fictitious with the suggestion that children of this age are prone to fantasy and unable to discriminate fact from fiction. This paper is intended to familiarize those with a general concern about child abuse with the research and theories in child development. Specifically, it reviews those aspects of normal child development which have direct relevance to the question of the veracity of reports made by children ages 2 to 5 years. Examination of the research on children's thought and language, memory and learning, fears, fantasy, and play, as well as the research on the influence of television on children of this age, led to the conclusion that preschoolers base their play on the reality of their experience.     

Can we measure success in preventing child abuse? Issues in policy, programming and research

Can we measure success in preventing child abuse? As the field of child abuse and neglect prevention matures intellectually and as more and more agencies require evaluative research to substantiate claims of programmatic success, this issue is emerging with ever growing vigor. This paper reviews efforts to set prevention goals in the United States, e.g., by the federal government's Surgeon General's Report on Health Promotion and Disease Prevention and by the National Committee for the Prevention of Child Abuse. For such goal setting to be defensible and socially productive, it must be linked to a research base. This research base is growing and maturing. The home health visitor concept, in particular, has received clear and powerful support as a preventive strategy. However, many issues remain concerning other strategies. Of equal or greater importance are the many difficulties we face in documenting base rates of maltreatment with which to assess the impact of preventive interventions. Questions remain about the adequacy of infant mortality data, child injury rates, and the validity of officially reported cases of child maltreatment. The paper reviews the data available to clarify and resolve these issues, and outlines a strategy for assessing success of efforts to reduce severity and incidence of child abuse in the United States. These efforts are presented in the context of a series of principles regarding child abuse prevention, e.g., the difference between prevention linked to broad social and economic reforms versus preventive programming targeted at ameliorating the lives of high-risk families in the absence of broad socioeconomic change.     

Behavioral/emotional indicators of sexual abuse in child psychiatric inpatients: A controlled comparison with physical abuse

Several behavioral and emotional indicators of child sexual abuse were compared for both sexually (n = 29) and physically abused (n = 52) children from a sample of 103 hospitalized psychiatric patients. The measures included (1) scores from a factor-analyzed sexual abuse symptom checklist covering home/community behavior that was rated by parents during a clinical interview and (2) frequency counts of psychological symptoms exhibited by the children during a 3-week period of hospitalization. Results of a 2 (sexual abuse status) X 2 (physical abuse status) X 2 (gender) Multivariate Analysis of Variance indicated that sexually abused children exhibited greater sexual behavior, fear/mistrust/anxiety, and withdrawal at home, and greater sexual behavior, fear/anxiety, and sadness in the hospital than nonabused children. In contrast, there were no significant differences between physically abused and nonabused children, and no significant interactions. Few significant correlations were found between symptoms exhibited at home and in the hospital.     

ICDP approach to awareness-raising about children's rights and preventing violence, child abuse, and neglect

In April 2011, the Committee on the Rights of the Child issued the General Comment No. 13 on the right of the child to freedom from all forms of violence. Its Article 19 declares that "protective measures should, as appropriate, include effective procedures for the establishment of social programs to provide necessary support for the child and for those who have the care of the child." One available social program that focuses on providing support for parents, caregivers and children is the International Child Development Program (ICDP), which is presented in this article. The ICDP is designed to influence and improve the quality of contact and relation between the caregivers, usually parents, and children, through the practical application of the eight themes or guidelines for positive interaction. The Convention on the Rights of the Child is a value-based legal document ratified by most countries in the world. This is a significant achievement and it gives a new basis and legitimization for a more humane treatment of children all over the world. Nevertheless, it is important to understand that there is a big gap between a legal document describing ideal conditions for children at a macro-governmental level and its implementation at the microlevel of families and communities. The ICDP is another expression of the same humanitarian spirit as it is encoded in the convention of children' rights. ICDP can be put in practice in any community to create positive conditions for the fulfillment of fundamental children's rights: the right to be protected from violence and to receive the loving care and guidance from the immediate environment which is required to ensure healthy human development. Introducing children's rights is likely to have a major impact on families (and all levels of authorities) if efforts are also made to activate awareness and deeper bonding to children as persons. Without a deep activation of a more humanized and caring relationship to children, provided by social programs such as ICDP, the advocacy for children's rights may become an empty shell without its basis in human realities.     

Reporting child abuse: pediatricians' experiences with the child protection system

OBJECTIVE: To explore pediatricians' reluctance to adhere to a legal mandate to report suspected child abuse and to compare their perspectives with those described in other jurisdictions in studies informed by different theories and employing diverse methodologies. METHOD: An anonymous survey questionnaire was distributed to all pediatricians with admitting privileges to B.C. Children's Hospital which has a specialized Child Protection Services Unit. Physicians were asked about their own prior reporting experience and the influence of that experience upon future reporting decisions. They were also asked why they think other physicians might be reluctant to report (N = 26). RESULTS: While respondents were generally positive about their experience in filing a report to Child Protective Services, they were less positive about the dearth of feedback they received and they were undecided as to whether there was a positive outcome to their report. Their perceptions of the reasons colleagues might fail to report emphasized dissatisfaction with CPS, concern with loss of relationship with the child's parents, and a desire to avoid court proceedings. CONCLUSIONS: Physicians' noncompliance or at least dissatisfaction with their child abuse reporting mandate is an international problem that can not be addressed by institutional protocols alone. Confusions about the limitations on confidentiality and information sharing might be better addressed through more shared training and opportunities for collaboration than by legal mandates and institutional protocols alone. Organizational theory and exchange theory might inform future research about the conditions under which collaboration is enhanced in the service of protecting children.     

Developmental effects of child abuse: A review

Most research investigating the effects of physical child abuse on children's development has been based on uncontrolled or poorly controlled studies having small samples, no long-term follow-up, and weak instrumentation. These studies, as well as some which have been more carefully designed, have generally suggested seriously detrimental developmental consequences in physical, intellectual, behavioral, and emotional areas. Some recent controlled follow-up studies challenge such a negative picture of abuse. In particular, a study by Elmer, which is probably the most carefully conducted study yet done, found that the harmful effects of abuse dissipated years after the abusive incident and that socioeconomic status (SES) and related factors may be more important than abuse in determining the course of child development. To improve the quality and clarity of future research on developmental effects of child abuse, this paper discusses, in four major areas, problems which plague the research. Definition: The extent, type, and frequency of abuse should be more carefully defined to allow studies to be compared. The types and amounts of social service interventions should also be specified. Generalization: Research should include more middle and upper SES children, more of the mildly and moderately abused, and more neglected children to allow generalization to the total population of maltreated children. Causality: Since developmental deficits may be the cause as well as the effects of abuse and because outside factors such as SES may lead to both the abuse and the deficits, there is a need for large-scale longitudinal studies which can untangle the cause and effect web of abuse by following children from birth and measuring many factors which might affect development (e.g., SES, birth abnormalities, abuse). Statistical Analysis: Future studies should always use statistical analysis and should obtain larger samples and utilize outcome and classification measures with demonstrated reliability and validity to increase statistical power.     

Assessing the value of structured protocols for forensic interviews of alleged child abuse victims

OBJECTIVE: To evaluate the effectiveness of a structured interview protocol (NICHD Investigative Interview Protocol) operationalizing universally recommended guidelines for forensic interviews. METHOD: The NICHD Investigative Protocol was designed to maximize the amount of information obtained using recall memory probes, which are likely to elicit more accurate information than recognition memory probes. Forensic investigators were trained to use the NICHD protocol while conducting feedback-monitored simulation interviews. The utility of the protocol was then evaluated by comparing 55 protocol interviews with 50 prior interviews by the same investigators, matched with respect to characteristics likely to affect the richness of the children's accounts. The comparison was based on an analysis of the investigators' utterance types, distribution, and timing, as well as quantitative and qualitative characteristics of the information produced. RESULTS: As predicted, protocol interviews contained more open-ended prompts overall as well as before the first option-posing utterance than non-protocol interviews did. More details were obtained using open-ended invitations and fewer were obtained using focused questions in protocol interviews than in non-protocol interviews, although the total number of details elicited did not differ significantly. In both conditions, older children provided more details than younger children did. CONCLUSION: The findings confirmed that implementation of professionally recommended practices affected the behavior of interviewers in both the pre-substantive and substantive phases of their interviews and enhanced the quality (i.e., likely accuracy) of information elicited from alleged victims.     

Developmental effects of child abuse: recent findings

This paper summarizes the pre-1982 research findings on the developmental effects of child abuse and reviews recent contributions to this area. While some of the recent research continues to demonstrate deleterious developmental consequences of child maltreatment, others are pointing to a complex relationship between child maltreatment and development. Mediating variables such as the child's individual characteristics, environmental resources, and the quality of personal interactions the child is exposed to may interact with negative experiences like maltreatment and may be just as important in predicting outcome than maltreatment alone. Recent research has also been concerned with specifying the possible differential effects of different patterns of maltreatment. This has led to a clearer separation between the effects of abuse and neglect, particularly in language development. Despite the methodological improvements in recent research, there is still the need for longitudinal prospective studies on the developmental effects of child abuse, taking into account possible mediating variables.     

Childhood history of abuse and child abuse screening.

Although a childhood history of abuse is related to parental child abuse, many parents with a history of abuse are not abusive. To determine the effects of a childhood history of abuse on adult child abuse potential, a modified Conflict Tactics Scale (CTS) and the Child Abuse Potential (CAP) Inventory were administered to matched groups of physically abusive mothers with a childhood history of abuse, nonabusive comparison mothers with a childhood history of abuse, and nonabusive comparison mothers without a childhood history of abuse. The modified CTS asked about childhood events and was used to confirm a childhood history of abuse. As expected, the CTS verbal and violence scales were higher for the abusive and nonabusive mothers with a childhood history of abuse. None of the CTS scores were different for the abusive and nonabusive mothers with a childhood history of abuse. In contrast, the CAP abuse scores distinguished between all three study groups. However, on the CAP factor scales, only the rigidity and unhappiness factors discriminated between abusive and nonabusive mothers with a childhood history of abuse. Nonabusive mothers with a childhood history of abuse were less rigid in their child expectations and were happier in their interpersonal relationships than abusive mothers with a childhood history of abuse.     

Child on child sexual abuse: psychological perspectives

OBJECTIVE: This study describes the emotional and behavioral responses of children who have been sexually victimized by juveniles (CC) 17 years of age and younger compared to child victims of adults (CA) 18 years of age and older. METHOD: A total sample of N = 194 children and adolescents participated in the study, with 26% (n = 51) comprising CC and 74% (n = 143) encompassing CA. The mother/caretaker was administered a demographic form, Achenbach's Child Behavior Checklist (CBCL), and the Family Assessment Measure (FAM-P). The child was given the Family Assessment Measure (FAM-C) and the Trauma Symptom Checklist for Children (TSCC). The clinician completed the Parental Reaction to Incest Disclosure Scale (PRIDS). RESULTS: No differences were found between the two groups for the type of sexual abuse, penetration, or the use of force. CC were younger and more likely to be males who were abused in a school setting, home, or a relative's home by a sibling or a non-related male. CC endorsed clinically significant sexual preoccupations and manifested borderline clinically significant symptomatology. CONCLUSIONS: Children victimized by other children manifested elevated levels of emotional and behavioral problems and were not significantly different from those who had been sexually abused by adults.     

Central child abuse registers: The British experience

Multi-disciplinary co-operation, including use of central registers, is now regarded as essential to the management of child abuse, both in the UK and USA. There are significant differences in register operation in the UK and USA, however. This paper describes two research studies of registers in the UK, discusses various issues of register operation and contrasts the UK and USA experience as reflected in research and literature.