Moving child abuse and neglect prevention programs forward: improving program evaluations

This paper focuses on evaluations of programs to prevent child abuse and neglect. It discusses the quality of the evaluations and offers suggestions for improvement to evaluators, program planners, and funders. Thirteen evaluations recommended by experts and published from 1978 through 1988 were reviewed. Using the true experiment as the standard of quality, we found evaluations frequently characterized by careful attention to methodologic detail. Evaluators describe eligibility criteria; half of the studies had control groups or followed progress. However, to learn more about prevention of abuse and neglect the caliber of evaluation research must improve. Evaluators do not define abuse or neglect; they accept reports of abuse. This has the effect of shifting the responsibility to others whose concerns and reporting standards differ. Lack of definition is reflected in a paucity of valid measurements; we could not assess the characteristics of families who benefit most from programs. Evaluators also omit important topics. Although seven evaluations studied health-related variables, no comprehensive analysis of the consequences and costs of medical neglect could be found; very little information on costs and benefits of any kind was available.     

The effect of Alaska's home visitation program for high-risk families on trends in abuse and neglect

OBJECTIVES: At 6 sites serving 21 communities, Alaska implemented Healthy Families Alaska, a home visitation program using paraprofessionals designed to decrease child abuse and neglect. The primary study objective was to compare changes over time in Child Protective Services outcomes by Healthy Families Alaska enrollment status. METHODS: Enrollment status was linked to birth certificates for birth years 1996-2002 which in turn was linked to the Alaska Child Protective Services database for outcome years 1996-2004. All children were followed through the study databases until age 2 years. RESULTS: There were 40,099 children born during 1996-2002 to residents of Healthy Families Alaska communities and 985 were enrolled in the program. Physical abuse referrals among enrolled children decreased from 73 to 42 per 1000 child-years of follow-up from 1996-1998 to 2000-2002 (p=.005); all of this decrease occurred among children who received 20 or more home visitations. This decrease may have been unrelated to program impact as a similar decrease in referral was seen among unenrolled high-risk children. Compared to unenrolled high-risk children, enrolled children had a modest decrease in the proportion with substantiated neglect but no difference in the proportion with neglect referral or physical abuse referral or substantiation. CONCLUSIONS: Little evidence exists that Alaska's home visitation program had a measurable impact on child maltreatment outcomes. PRACTICE IMPLICATIONS: Within Alaskan communities that had a home visitation program targeting families at high risk for child abuse, changes in Child Protective Services outcomes among children less than 2 years of age were followed over time by program enrollment status. Enrollment was associated with a substantial decrease in physical abuse referrals, but a similar decrease was seen among unenrolled high-risk children. No improvement was seen in physical abuse substantiation. A greater number of home visitations was not associated with fewer abuse outcomes. This work supports most of the recent literature, which questions the field effectiveness of home visitation programs. In combination with other studies, the current work may lead decision-makers and funding agencies to re-examine the usefulness of home visitation programs, particularly those using a methodology similar to that implemented in Alaska.     

Dilemmas for international mobilization around child abuse and neglect

The goal of this commentary is to articulate some issues and dilemmas raised by various efforts to mobilize international action around child abuse and neglect (CAN). We will start by proposing a typology of international mobilization strategies, noting that initiatives to promote CAN programming in new settings have tended to emphasize one of three vectors: governments, professionals, or international NGOs. There are pros and cons to each emphasis, which we discuss. We also review the debates around some of the following dilemmas: Should low-income countries be a top priority for CAN mobilization? Are there cultural and institutional capacities that need to be present in a country in order for CAN programs to work or be ethical? Are some CAN programs more likely to be internationally transferable than others and why so? Has the field adequately considered whether non-CAN programming (e.g., family planning) might actually be more effective at preventing maltreatment than CAN programming? Does the field give adequate acknowledgment that policies and practices emanating from high-resourced and Western countries may not always be the best to disseminate? Are we relying too much on a model of program transplantation over a model of local cultivation? Should we aim for modest rather than ambitious accomplishments in international mobilization? How much emphasis should be placed on the priority dissemination of evidence-based programming? We conclude with some suggestions in the service of clarifying these dilemmas and making some of these decisions more evidence based.     

Patterns of reported child abuse and neglect

Confirmed reports of abuse and neglect logged in a large state registry file from 1977 to 1984 are analyzed. Boys tend to sustain more frequent and more serious injuries. Victims of male perpetrators tend to sustain more serious injuries. A modest same-sex perpetrator/victim pattern is revealed for physical abuse; males are more likely to physically abuse boys while females are more likely to physically abuse girls. Among younger victims (aged 12 and younger) boys outnumber girls in all reporting categories except sexual abuse. Among adolescent victims, female victims greatly outnumber male victims in all reporting categories. Similarities between adolescent physical abuse and spouse abuse are noted; males are are the predominant perpetrators and females the predominant victims. As expected, victim age emerged as a strong predictor of severity of physical abuse injury. Several other factors including social isolation, mental health problems, lower income, and unemployment of the father are identified as modest predictors of severity.     

Prediction and prevention of child abuse and neglect

Utilizing an interview, a questionnaire, and observations during labor, delivery, and the postpartum period, a sample of one hundred mothers was identified as at high risk for abnormal parenting practices. These mothers were randomly divided into a “High-Risk Intervene” group (N=50) and a “High-Risk Nonintervene” group (N=50). The “Intervene” group received comprehensive pediatric follow-up by a single physician, a lay health visitor, and/or a public health nurse in the home. The “Non-intervene” group received routine care, although the results of these screening procedures were shared with the physicians and nurses responsible for their ongoing care. Another group of 50 mothers, who delivered during the same time period and who were assessed as low risk in terms of abnormal parenting practices, served as controls. When the children were approximately two years old (mean age 26.8 months), 25 families in each of the three groups were chosen at random for detailed evaluation.     

Stability of retrospective self-reports of child abuse and neglect before and after therapy for child abuse issues

OBJECTIVE: This study is a follow-up to a previously reported outcome study evaluating the efficacy of an emotionally focused therapy for adult survivors of childhood abuse. The present purpose was to evaluate the stability of self-reports of child maltreatment in the context of reduced psychopathology after therapy. The Childhood Trauma Questionnaire (CTQ; Bernstein et al., 1994) was used to measure the extent of child abuse and neglect. METHOD: The CTQ and measures of symptomatology, abuse resolution, and self-esteem were administered at pretreatment to 44 clients and after 6 months of therapy to 33 therapy completers. Post-treatment interviews also assessed changes in clients' perceptions of self and abusive and neglectful others. Analyses examined change on dependent measures, in interviews, and on the CTQ, as well as the test-retest and alpha reliabilities of CTQ factor scales, and the relationship of CTQ factor scales with pretreatment measures of distress. RESULTS: Analyses revealed significant reductions in psychopathology on all dependent measures and reduced self-blame, negatively biased memories, avoidance, and minimization of the abuse after therapy. Reports of abuse and physical neglect on the CTQ remained stable from pre- to post-therapy. All CTQ dimensions demonstrated good internal consistency and convergent validity with trauma-specific measures of distress. CONCLUSIONS: The stability of the CTQ in the context of significantly reduced psychopathology contributes to evidence supporting the accuracy of retrospective self-reports of childhood abuse.     

Child abuse and neglect in military and civilian families

Patterns and correlates of child maltreatment were investigated both within the military and between military and civilian families. The results revealed that certain patterns and correlates emerged within the military that were significant. For example, loss of control and lack of tolerance were two major reasons given for abuse by military perpetrators . Also the stresses of family discord, new baby and continuous child care along with relocation and isolation played important roles in the occurrence of abuse within the military. When comparisons were made between military and civilian families, some differences were discovered but many more similarities were found. As an example, the analysis revealed that the stress of broken family was a more important correlate of abuse in civilian than in military cases of abuse. For all the other kinds of stresses (e.g., family discord and isolation), however, one was no more important for military than for civilian perpetrators . Although the patterns and correlates of child abuse and neglect may not be unique to the military, this does not minimize the importance of the problem in the armed forces. Programs of treatment and prevention must be developed and implemented to fit the needs and life styles of military families.     

American Indian law on child abuse and neglect

A wide variety of American Indian tribal codes on child abuse and neglect are currently in effect. They range from anachronistic codes that were promulgated about fifty years ago and have never been revised to recently enacted codes that are innovative and incorporate the best practices in the field of protective services. The efforts, now underway, to collect and analyze Indian tribal codes on child abuse and neglect is supportive of the national interest to improve Indian child welfare services. The knowledge gained will be helpful to Indian tribes as they assess their own codes and will provide a new body of information on the laws in the U.S. on child abuse and neglect. In the past few years, increased national support in the United States has been focused on the protection of the best interest of Indian children with specific resources provided for the support of local Indian children and family programs operated by Indian tribal governments. Many Indian tribes are using these resources to develop and revise their child welfare codes, including those elements pertaining to child abuse and neglect. The momentum under way in the United States to improve Indian child welfare services can be expected to continue to include developments in Indian tribal codes on child abuse and neglect.     

An alternative to foster care for victims of child abuse/neglect: a university-based program

Two central forces dominated the conception and development of the Parents and Children Together (PACT) project: the need for provision of an in-home alternative to foster care for abuse and/or neglect families and the prevention of further abuse and/or neglect in the family. Wayne State University in Detroit is the site for Parents and Children Together (PACT) project, a contractual service of the Michigan Department of Social Services (DSS). Graduate students provide in-home services to referred families who, due to child abuse or neglect, would otherwise have their child(ren) removed from the home. This family-based work is a one-year cooperative education experience for students interested in professions in the human services. This report discusses the PACT project as a grant operated through the university, the specification of course work associated, and the attraction of students to graduate study with "hands-on" experience. All of these program attributes, as well as the resource of the project for research, make it an important effort for the university. Further, the university has an additional meaningful role with community residents. Beyond university and student opportunities, the DSS and its clients benefit by having broad-based expertise brought into homes on a weekly basis. Annual success rates of keeping children out of foster care are cited along with cost effectiveness. The university's role in levels of prevention in a highly coordinated community effort is indicated.     

Children hospitalized with child abuse and neglect: a case-control study

A case-control study of 45 hospitalized abused children was conducted to reassess the risk factors for child abuse when confounding by social class was minimized. Cases were matched for age, sex, family structure, and social class with children admitted to hospital for an acute illness. Abused children were more likely to have younger parents, fewer siblings, and to have been separated from their mothers during the first year of life. Their parents were more likely to have been abused as children and to have a poor relationship with the child's other parent. The families of abused children had encountered more stressful life events in the preceding 12 months. Other previously recognized "risk factors" were not shown to have a statistically significant association with child abuse. Because child abuse is more prevalent in lower socioeconomic families, the association with many of these factors has been accepted as implying a causal relationship. Matching procedures which attempted to eliminate confounding by social class and family structure cast doubts on some previously held beliefs about the risk factors for child abuse.