Treatment of parents who abuse their children: A literature review and implications for professionals

This article contains a review of the current treatment approaches to child abuse in terms of the following models: psychopathological, sociological, social-situational, family systems and social learning. The psychopathological model of child abuse emphasizes direct services. The services provided may consist of individual, group and lay treatment, volunteer companions, and self-help groups. The sociological model's approach to intervention emphasizes the need for wide-ranging changes in social values and structures. The socio-situational model's approach to treatment is based upon the assumption that the cause of child abuse lies not in the individual, but in the social situation, which may, in turn, be maintaining abusive patterns of behavior. The family systems approach to treatment resembles that of the socio-situational model in that it too emphasizes changing the family's pattern of interaction and behaviors. Finally, the social learning approach to treatment involves the identification of behavioral goals, specific techniques for achieving these goals, and the use of social reinforcers to facilitate this process. Data indicate that parents who abuse their children face multiple social and psychological difficulties. It has been suggested that the reason why treatment programs have not prodoced significant results in treating parents who abuse their children is that they focus on only one of the factors that operate to produce child abuse, i.e., lack of child management skills, marital dissatisfaction, or vocation or interpersonal skills dissatisfaction. It is logical that a treatment approach to abuse must view the problem as multi-determined and services should be structured in such a manner. Thus, the comprehensive treatment program should consist of the following; (1) Child Management Program; (2) Marital Enrichment Program; (3) Vocational Skills Enrichment Program; (4) Interpersonal Skills Enrichment Program. Programs to accomplish the acquisition of requisite skills in each of the four areas of emphasis are chosen from the technology of applied behavioral analysis. Each of the four program components is reviewed along with the rationale for a comprehensive program delivered through a behavioral group work approach. The article concludes with a discussion of the implementation and evaluation of the program.     

Child strengths and placement stability among racial/ethnic minority youth in the child welfare system

While all children deserve a stable living environment, national data illustrate that many states struggle to achieve placement stability for youth in the child welfare system as a significant number of children in foster care continue to experience multiple placements while in state custody. Prior research has not considered the impact of youth protective factors or strengths on the frequency of placement changes that youth experience while in the child welfare system. This study examined the association between strengths measured at multiple levels (i.e., individual, family, and community) and placement stability among 4022 minority youth (aged 10–18) using administrative and clinical data from the Illinois child welfare system. Negative binomial regressions at the family level revealed that youth with at least one loving and supportive family member experienced 16% fewer placement changes than youth without family strengths. At the community level, youth attending schools that work to create an environment that meets its students’ needs experienced 13% fewer placement changes than youth without educational supports. These findings can inform the quality of treatment and services provided to minority youth in the child welfare system.     

Why are suspected cases of child maltreatment referred by educators so often unsubstantiated?

School professionals have a unique vantage point for identifying child maltreatment and they are a frequent source of referral to child protective services. Disturbingly, past studies have found that maltreatment concerns reported by educators go unsubstantiated by child protective services at much higher rates than suspected maltreatment reported by other professionals. This study explores whether there are systematic differences in the characteristics of cases reported by educators as compared to other professionals and examines whether such variation might account for differences in investigation outcome. Analyses were based on 7,725 cases of suspected maltreatment referred by professionals to child protective services from the Canadian Incidence Study of Reported Child Abuse and Neglect – 2003 a national database on the characteristics of children and families investigated by child protective services. School professionals were responsible for 35.8% of professional referrals. Reports by educators were much more likely to be unsubstantiated (45.3%) than those by other professionals (28.4%) in subsequent child protective investigation. Cases reported by educators were found to contain significantly more child risk factors (e.g., child emotional and behavioural problems) and fewer caregiver and family risk factors (e.g., caregiver mental health problem, single parent family) than cases reported by other professionals. Even controlling for these differences, educator-reported concerns were still 1.84, 95% CI [1.41, 2.40] times as likely to be unsubstantiated as reports from other professionals. Contrary to the notion that educators are mostly reporting non-severe cases, suspected/substantiated cases reported by school professionals were more likely to be judged as chronic and more likely to involve families with a previous child protection history. Results are concerning for the capacity of the education and child protection systems to work together to meet their shared goal of promoting healthy child development. Additional research is needed on the way in which child risks and problems influence child protective service, particularly in the context of chronic abuse and neglect and lack of availability of child and family mental health interventions. Potential problems with credibility of school professionals as reporters of child maltreatment concerns also warrant further investigation.     

The services provided during a child abuse and/or neglect case investigation and the barriers that exist to service provision

More than one million cases of child abuse and neglect come to attention of child protection agencies each year. During the course of investigating these cases, social workers are charged with protecting the child while assessing whether or not abuse or neglect has actually occurred. Child welfare philosophy also dictates that at the same time the investigation is being conducted, the social worker strives to maintain the family intact, if at all possible. One way to address this dual responsibility of protecting the child while working towards family stability is through the provision of services during the investigation. The purpose of this paper is to identify the services that are provided during the course of a child abuse and/or neglect case investigation. The paper also identifies the barriers that exist both within an agency and within the external community that discourage the provision of services to children and families. The findings of this research show that in the majority of cases services are not provided during the investigation. In those case investigations where services are provided, a much broader range of services are considered for provision than are actually delivered. The research also found that placement is the most frequently provided service; however, only one-third of those children in placement receive any clinical services while in placement. Finally, this study found that the greatest barrier to service provision is a lack of evidence necessary to intervene in the home situation.     

Predictors of treatment outcome in sexually abused children

PROBLEM: This study evaluated the impact of child and family characteristics on treatment outcome of sexually abused children. METHOD: Forty-nine recently sexually abused 7- to 14-year-old children were randomly assigned to either abuse-focused cognitive behavioral therapy or nondirective supportive therapy, and assessed pre- and post-treatment using several standardized instruments. These included five measures of psychological symptomatology and four measures of child and family characteristics hypothesized to mediate treatment response. Correlational and multiple regression analyses were utilized to evaluate the impact of the following mediating factors on treatment outcome: Children's abuse-related attributions and perceptions; family cohesion and adaptability; parental support of the child; and parental emotional reaction to the child's abuse. RESULTS: Children's abuse-related attributions and perceptions and parental support of the child were strong predictors of treatment outcome in this population. CONCLUSIONS: Therapeutic attention to children's sexual abuse-related attributions and to enhancing parental support may be important factors in optimizing treatment outcome in 8- to 14-year-old sexually abused children.     

Neglected fathers: Limitations in diagnostic and treatment resources for violent men

In its examination of violent activity within the family, current literature assumes a “pecking order” exists: Larger and stronger family members attack those who are smaller and weaker. Adult males are usually studied as primary maltreaters of spouses, while females are considered mainly responsible for physically abusive behavior with children. Use of this perspective has led to neglect of male abusers, who injure half of the mistreated children in the United States. Through assessment of 66 studies of child abuse published during a 5-year period, this paper documents the lack of attention abusive fathers have received. Twenty-eight of these studies included only mothers, while two dealt exclusively with fathers. Most of the 36 remaining two-parent studies did not discuss sex differences. No diagnostic categories consistently differentiated male from female abusers. No study discussed specialized treatment needs of women and men. This survey suggests that the therapeutic field considers the child's mother the primary responsible parent, even though she may not be the perpetrator of violence in the family. As a result, inadequate treatment resources have been made available to maltreating fathers. The survey points to the need for much more comprehensive research comparing male and female maltreaters.     

Child maltreatment as a risk factor for opioid dependence: Comparison of family characteristics and type and severity of child maltreatment with a matched control group

ObjectiveTo examine the prevalence, characteristics and risk factors for child maltreatment among opioid-dependent persons compared to a community sample of similar social disadvantage.MethodThe study employed a case-control design. Cases had a history of opioid pharmacotherapy. Controls were frequency matched to cases with regard to age, sex and unemployment and were restricted to those with a lifetime opioid use of less than five times. The interview covered child maltreatment, family environment, drug use and psychiatric history.ResultsThis study found a high prevalence of child maltreatment among both cases and controls. Despite the elevated prevalence among controls, opioid-dependent males had a higher prevalence of physical and emotional abuse; female cases had a higher prevalence and greater severity of sexual abuse. The prevalence of neglect was similar for both groups. Early parental separation was more prevalent among female cases compared to female controls; otherwise the prevalence of the risk factors was comparable for both groups. The risk factors significantly associated with child maltreatment were also similar for both cases and controls.ConclusionsGiven the documented association between child maltreatment and adult mental disorder, child maltreatment may be an important antecedent of current psychological distress in persons presenting to treatment for opioid dependence. Apart from a possible association between early parental separation and sexual abuse among female cases, the increased prevalence of child maltreatment associated with opioid dependence did not appear to be related to differences in early childhood risk factors considered in this paper. Other risk factors may be more pertinent for those with opioid dependence.Practice implicationsThe high prevalence of child maltreatment among the opioid-dependent sample has implications for the assessment and treatment of clients presenting with opioid dependence. Assessment of child maltreatment history could help inform the development of individual treatment plans to better address those factors contributing to the development and maintenance of opioid dependence. Specifically, management of co-morbid mental disorder associated with child maltreatment could be the focus of relapse prevention programmes and also have a positive influence on treatment retention.     

The development of children with down syndrome: the influence of maternal adaptation,mother-child interaction and early forms of support

In this paper, we present a longitudinal case study involving four dyads with babies with Down syndrome from birth until the age of 7 years – the moment at which the children were observed for the last time before they began compulsory schooling. At each data collection point, the mother was given a semi-directive interview and we filmed a free interaction situation. The objective of our study was to carry out an indepth analysis of the ways in which mothers adapt to the birth of a ‘different baby’, the evolution of their expectations in relation to the child's development, mother–child interaction and early support for both the child and the family, and the way in which these aspects of the overall situation relate to the children's development. The data of our longitudinal study show that there is an interaction between children's development and family characteristics and patterns, particularly mother–child interaction and the way in which the mother deals with the stress factors associated with the fact that she has a disabled child. We found that the four dyads experienced different models of early support, which to some extent reflect what really does happen in Portugal in cases involving children with disabilities, and that the programmes' impact was not identical in every situation. The most successful was the one which best suited the family's wishes, and involved both the mother and later on the kindergarten teacher.     

Fatal child maltreatment: Characteristics of deaths from physical abuse versus neglect

This study examined victim, family, and alleged perpetrator characteristics associated with fatal child maltreatment (FCM) in 685 cases identified by child welfare services in the state of Oklahoma over a 21-year period. Analyses also examined differences in child, family, and alleged perpetrator characteristics of deaths from abuse versus neglect. Case information was drawn from child welfare investigation records for all FCM cases identified by the state Department of Human Services. Fatal neglect accounted for the majority (51%) of deaths. Children were primarily younger than age 5, and parents were most frequently the alleged perpetrators. Moreover, most victims had not been the subject of a child welfare report prior to their death. A greater number of children in the home and previous family involvement with child welfare increased children's likelihood of dying from neglect, rather than physical abuse. In addition, alleged perpetrators of neglect were more likely to be female and biologically related to the victim. These results indicate that there are unique family risk factors for death from neglect (versus physical abuse) that may be important to consider when selecting or developing prevention efforts.     

Revealing the existence of child abuse in the context of marital breakdown and custody and access disputes

OBJECTIVE: Child abuse in the context of legal and de facto marital breakdown has received little attention internationally. Many believe it does not exist in this context and regard it as just a "gambit in the divorce wars." Recently, however, family courts in a number of countries have become concerned over the management of child abuse allegations in custody and access cases, known more commonly now as residence and contact cases. This article presents a unique research study, which investigated how the Family Court of Australia dealt with such cases. The study, covering all forms of child abuse, sought to discover who were the families bringing these problems to family courts, what precisely the abuse was and how the courts dealt with it. METHOD: The study reviewed court records of some 200 families where child abuse allegations had been made in custody and access disputes in jurisdictions in two states, observed court proceedings and interviewed court and related services' staff. RESULTS: The findings showed that these cases had become a core component of the court's workload without any public or professional awareness of this change, that the abuse was real, that it was severe and serious, and that the courts and child protection services did not provide appropriate services to the families. CONCLUSION: A new specialized intervention system was developed based on the research and it is now being trialed and evaluated. The new intervention system contains features derived from the research findings that may be suitable internationally for implementation.     

Abuse in the investigation and treatment of intrafamilial child sexual abuse

This paper examines the effects of current practice in the investigation and treatment of documented incest abusers on the offenders and families involved. Fifteen offenders attending the Utah Parents United group completed a questionnaire on the sequence of events in the investigation and prosecution of their cases and the concomitant results of the investigation on their job status, living and financial situations, family and social relationships, and media reporting of the abuse. Results indicate that there is great variability in the investigation and prosecution of incest cases and the public announcement of abuse convictions. The consequences of the abuse investigation are devastating for offender and his family in terms of job loss; need for public assistance; family disbandonment through removal of the offender, victim, or both from the family, marital separation, and foster care for nonabused siblings; changes of residence, and the public announcement of the abuse in the media. Results also show that offenders receive little, if any, social support from family or friends. Changes in the current approach to the investigation and prosecution of incest offenders are proposed and include the following: (1) banning the publication of convictions for child abuse; (2) streamlining the legal process so that it is consistent from case to case; and (3) developing diversion programs as alternatives to prison for offenders. Suggested are self-help, court-ordered therapeutic programs, such as Parents United, that are designed for the treatment of families involved in child sexual abuse and incest. The desired outcomes of such a diversion program are low offender recidivism, avoidance of the offender's family being placed on welfare, less reliance on foster care placement for the offender's children, involvement of the offender's family in moving toward reunion when feasible, and the use of existing half-way houses in lieu of incarceration when necessary.     

Sexual abuse: A sociological perspective

How have contemporary social changes affected the problem of child sexual abuse? The rapid rise of this problem to public attention in the United States is in part due to the mobilization around the problem by the women's movement and the child welfare movement there. But factors shown by research to be associated with the problem—social isolation and patriarchal authority—are so widespread as to suggest that this is a problem of international proportions, as well. The rising divorce rate in the U.S. and worldwide, would appear to put more children at risk at the same time that it has also made it easier for children and their mothers to escape from the most oppressive and intolerable family situations. The sexual revolution and the erosion of external controls on sexual behavior have also in all likelihood aggravated the problem, too. Sexual abuse needs to be seen as a problem distinct from physical child abuse—characterized by the preponderance of offenders who are males. This suggests searching for the sources of the problem in male sexual socialization rather than in problems of inadequate and disaffected parenting.     

Understanding practitioners' characteristics and perspectives prior to the dissemination of an evidence-based intervention

OBJECTIVES: To describe the characteristics and repertoires of community practitioners serving families involved in child physical abuse that may inform training and treatment dissemination efforts. The aims are to: (a) describe the background characteristics of these clinicians; (b) document their most common intervention techniques; (c) examine clinicians' attitudes toward manualized treatment; and (d) understand the organizational climate of community agencies. METHOD: Practitioners from nine different agencies who have worked with cases in which there was child physical abuse (n=77) completed focus group discussions and three self-report questionnaires. Qualitative and quantitative analyses were conducted in tandem. RESULTS: Practitioners reported that they most often focused on family issues and employed family therapy techniques. Although treatment manuals were important, it was difficult to determine how practitioners used or would use these materials with families. An almost equal number of concerns and benefits were raised regarding using manuals in treatment. There was moderate agreement in how practitioners perceived their work environments. Age and attainment of a graduate degree were positively related to greater caring and job satisfaction, respectively, while length of time at a given agency was positively related to greater reports of emotional exhaustion on a measure of organizational climate. CONCLUSIONS: Given the promising benefits of evidence-based treatments for child abuse, it is important that researchers begin to form partnerships with community agencies that will lead to the dissemination and evaluation of effective treatment strategies.     

Treating abused children: Some clinical and research aspects of work carried out by the national advisory centre of the National Society for the Prevention of Cruelty to Children in the United Kingdom

A study of the initial phase of intensive work with families indicated that whilst outreach techniques had dramatically reduced physical injury there was long-term distortion in the child's relationship with mother (parent) less amenable to change. The most recent phase of work has concentrated on direct treatment for the abused child, using a multidisciplinary team that includes a play specialist and child psychotherapist in addition to the social workers involved. Out of a total number of 66 children seen between April 1977 and December 1979 it was alarming to find that almost all were emotionally disturbed; even if the abuse did not reoccur they remained with considerable problems. The study highlights the degree of emotional disturbance suffered by these abused children and how they can be helped by focusing on their particular treatment needs. It is important to assess all children in the family situation and not to miss the quiet, depressed, withdrawn child who might not have been the subject of the initial referral. In some instances the needs of the child may outweigh those of the family and the focus of treatment must be on the child.     

Gray cases of child abuse: Investigating factors associated with uncertainty

Research in child abuse pediatrics has advanced clinicians’ abilities to discriminate abusive from accidental injuries. Less attention, however, has been paid to cases with uncertain diagnoses. These uncertain cases – the “gray” cases between decisions of abuse and not abuse – represent a meaningful challenge in the practice of child abuse pediatricians. In this study, we describe a series of gray cases, representing 17% of 134 consecutive children who were hospitalized at a single pediatric hospital and referred to a child abuse pediatrician for concerns of possible abuse. Gray cases were defined by scores of 3, 4, or 5 on a 7-point clinical judgment scale of the likelihood of abuse. We evaluated details of the case presentation, including incident history, patient medical and developmental histories, family social histories, medical studies, and injuries from the medical record and sought to identify unique and shared characteristics compared with abuse and accidental cases. Overall, the gray cases had incident histories that were ambiguous, medical and social histories that were more similar to abuse cases, and injuries that were similar to accidental injuries. Thus, the lack of clarity in these cases was not attributable to any single element of the incident, history, or injury. Gray cases represent a clinical challenge in child abuse pediatrics and deserve continued attention in research.     

Convergent validity of the preliminary Spanish version of the Child Abuse Potential Inventory: depression and marital adjustment]

This paper studies the "convergent validity" of the preliminary spanish version of the Child Abuse Potential (CAP) Inventory. In relation to the ecological-systemic model of child maltreatment, this inventory evaluates individual, family, and social factors which facilitate the occurrence of physical child abuse. Depression and marital adjustment were measured in three groups of mothers: one group of mother-perpetrators of physical child abuse (n = 20), another group of mothers with a rate superior to cut-off (percentile = 95) in the CAP Inventory (n = 15), and a group of mothers with low punctuation (under percentile 25) in the CAP Inventory (n = 15). The two last groups (High CAP and Low CAP) come from a larger sample of 829 subjects which are a demographically representative sample of the population of País Vasco (in Spain). Because of variations in the detection of social services, the physically abused group is formed by the most extreme and severe cases. The three groups of mothers were matched as to socio-economic family status, education, civil status, age of the mother, sex of the child, number of children. It was expected that in these variables, depression and marital adjustment, the group with physical abuse would resemble the High CAP group and that both groups would be significantly different from the Low CAP group. Results partially confirm these hypothesis, supporting the possibilities of developing a Spanish version of the CAP Inventory for detection of physical child abuse.     

Child abuse in Malmö 1967–1974

All cases of suspected or verified child abuse (the battered child syndrome) registered at the Department of Paediatrics in Malmö from 1967 through 1974 were surveyed. During this period 52 patients (54 incidents) were observed, the majority in the years 1970 to 1974. In 5 suspected cases the examination, social history and other circumstances excluded physical abuse. The incidence of child abuse in the city of Malmö for the years 1970 to 1974 was estimated at 35 cases per million inhabitants and year. When compared to the incidence reported in an earlier Swedish investigation (Barnmisshandel 1969) the figures suggest a real increase in the rate of child abuse. In comparison with the estimated incidence in USA and Great Britain the Malmö figures appear low, however. The age of the battered children, the family situation and the social characteristics were essentially in agreement with previous reports. Of the inflicted injuries 37 per cent were regarded as serious or very serious. One child died and in another the injuries resulted in permanent damage. Sixteen children had been repeatedly battered. Up to the end of 1974 10 per cent of the children had been rebattered in spite of what had been thought to be adequate measures to prevent further abuse. Forty-three families (6 were excluded for different reasons) were retrospectively analyzed with regard to the domestic and social situation. It was concluded that in 16 of these families it had not been possible to discern that the child was at risk. The investigation emphasizes the need for psychological assessment of battering parents, and suggests that cases of child abuse should be handled by a team of medical and social experts.     

The role conflict of the child protective service worker: investigator-helper

Role conflict stems from the established authoritarian role assigned to child protective service workers in addition to their helping role. Workers must conduct investigations, make a determination as to whether cases are founded or unfounded, confront the parents with those findings then tell the family they are there to help. Few workers are convinced that parents see this type of intervention as helpful.Overcoming these doubts and conflicts is not easy. High worker turnover and burnout can often be attributed to the workers not having been given the opportunity to deal with these conflicts. This paper presents five options which if utilized could lessen role confusion: (1) separating the functions of intake and ongoing services; (2) strengthen training and supervisory support; (3) formation of multidicipline teams; (4) unit staffing of cases; and (5) using police for investigations.     

Family,child and location factors and parents’ reasons for multiple concurrent childcare arrangements in the years before school in Australia

Research suggests that multiple non-parental care arrangements may have adverse effects on young children, yet little is known about their prevalence, factors associated with their use, or parents’ reasons for making these care arrangements. This longitudinal study reports on 677 children and their families recruited from government-regulated child care centers and family child care services in urban and rural New South Wales, Australia. Multiple concurrent care arrangements were relatively common, with one third of children attending at least two child care arrangements per week. Multiple child care was found to be more likely for children who were older, with better health, or with employed mothers, and who were living in rural rather than urban areas. Results suggest that parents’ reasons for using multiple care arrangements were based largely based on preferences that were made in the best interests of the child and on convenience. The deliberate choice by parents to use multiple child care arrangements to benefit their child challenges the assumption in previous literature that mixed care is not the parents’ first choice.     

Family profiles of maltreated children in Singapore: A latent class analysis

Children who enter the child protection system often have complex family problems and have experienced early adverse experiences. Using latent class analysis, this study aimed to identify family classes of child protection cases in Singapore, to ascertain the prevalence of these family classes, and to test the association of family class membership to subsequent recurrence of harm. A sample of 440 cases who entered the Child Protective Service in Singapore was analyzed based on eight familial factors on the household and caregiver levels. A four-class solution was found to demonstrate the best fit: (a) the large household group was intergenerational and majority lived with extended family members, (b) the harsh parenting group showed high levels of parenting problems and the caregiver justifying his abuse/neglect, (c) the high criminality group had high levels of caregiver substance abuse and caregiver arrest and incarceration history, and (d) the low disadvantage group rated low on all the familial factors. A Cox Regression revealed that in comparison to the low disadvantage group, the harsh parenting group was twice as likely to have recurrence of harm. There were also differences across family classes with regard to age at entry into child protection, gender composition and abuse types. The findings and practice implications are discussed.