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Public Health Child Maltreatment
by
Joanne Martin

Introduction

Child maltreatment encompasses all forms of child abuse and neglect. Child maltreatment has long-term devastating consequences, and it is preventable. Children die of abuse and neglect at a rate of 2.33 per 100,000 children. Shaken baby syndrome results in blindness, motor and cognitive impairment, and death. Chronic abuse and neglect during infancy and young childhood interferes with brain formation and function Child maltreatment increases the risk of chronic diseases during adulthood. Child maltreatment is a form of violence. Public health starts with the assumption that violent behavior and related adverse consequences can be prevented. The public health approach moves from problem to solution by (1) systematically gathering data on what is known about the scope and consequences of child maltreatment; (2) determining the causes of child maltreatment and what increases and decreases risk factors for abusive and neglectful behavior; (3) discovering ways to prevent child maltreatment by designing, implementing, and evaluating interventions; and (4) disseminating promising and proven interventions to prevent child maltreatment in diverse communities. Violence is the intentional use of force or power and includes threats, intimidation, and neglect. The World Health Organization categorizes violence as self-directed, interpersonal, and collective. Interpersonal violence includes community violence and family violence. Community violence includes youth violence, gangs, sexual violence, and violence in settings such as schools and workplaces. Family violence includes child abuse, intimate partner violence, and elder abuse. Violence is complex and best understood within an ecological framework. First proposed by Urie Bronfenbrenner, the ecological model illuminates the interactions among individual characteristics, social relationships, community context, and societal factors. Public health interventions include primary prevention (before child maltreatment occurs), secondary prevention (immediate response to child maltreatment), and tertiary prevention (reducing long-term consequences resulting from child maltreatment). Approaches to prevent child maltreatment include interventions that are universal, selected, and indicated. Universal interventions are designed for the general public regardless of level of risk. Selected interventions are directed toward persons who are at increased risk of abusing or neglecting children. Indicated interventions are for persons who already have experienced child maltreatment.

General Overviews

Many resources relating to violence and violence prevention are available on the Internet. However, three websites stand out as being authoritative, comprehensive, and up-to-date: Centers for Disease Control and Prevention, World Health Organization, and Centre for Public Health, Liverpool John Moores University. Accessing these websites is recommended as a first step for persons who are interested in child maltreatment as well as the broad topic of violence prevention. Chalk and King 1998 provides in-depth information about family violence and child protection policy and practice. Haskins, et al. 2007 makes recommendations to improve child protection services. Landy and Menna 2006 is a comprehensive resource for working with multi-risk families. Berlin, et al. 2005 puts child maltreatment in the context of early child and caregiver relationships. Jordan and Sketchley 2009 provides a public health framework for preventing child maltreatment, focusing on children from birth to age three.

  • Berlin, Lisa J., Y. Ziv, L. Amaya-Jackson, and M. Greenberg, eds. 2005. Enhancing early attachments: Theory, research, intervention, and policy. New York: Guilford.

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    Puts child abuse and neglect in the broader context of early attachment and the importance of early child and caregiver relationships. Provides underlying rationale and principles for specific effective interventions and how programs fit within health, social service, and early education systems. Good resource for graduate education.

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  • Centers for Disease Control and Prevention. Global Violence Prevention.

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    Well-designed, user-friendly extensive resource for all types of violence prevention information. Links allow the user to download many reports and articles, including World Health Organization reports.

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    • Centre for Public Health, Liverpool John Moores University. Violence Prevention Evidence Base and Resources.

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      Online database provides access to abstracts from published studies that measure effectiveness of interventions to prevent violence. The studies meet selection criteria and standards, with those highly rated identified by stars. Each abstract is coded by region, country, and type of violence (e.g., child, youth, intimate partner).

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      • Chalk, Rosemary, and Patricia King, eds. 1998. Violence in families: Assessing prevention and treatment programs. Washington, DC: National Academy Press.

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        Synthesis of research evidence to support recommendation for family violence interventions. Focuses on a critical review of 114 evaluation studies conducted between 1980 and 1996. Many tables will help readers categorize and make sense of a plethora of published studies.

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      • Haskins, Ron, Fred Wulczyn, and Mary Bruce Webb, eds. 2007. Child protection: Using research to improve policy and practice. Washington, DC: Brookings Institution.

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        Reports findings from the National Survey of Child and Adolescent Well-Being, a longitudinal study of children referred to child protective services. Provides information to challenge unfounded assumptions and makes recommendations to improve the practice of child protection.

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      • Jordan, Brigid, and Robyn Sketchley. 2009. A stitch in time saves nine: Preventing and responding to the abuse and neglect of infants. Child Abuse Prevention 30:1–26.

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        This excellent article summarizes the application of the public health approach and identifies primary, secondary, and tertiary interventions for child maltreatment. The section on out-of-home care addresses the dilemmas of the infant’s need for a secure attachment while working toward reunification with the parents. Other practice issues are identified, including infant mental health services.

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      • Landy, Sarah, and Rosanne Menna, eds. 2006. Early intervention with multi-risk families: An integrative approach. Baltimore: Brookes.

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        A comprehensive resource for scholars and practitioners interested in promoting the development of children living in families with multiple stressors. Challenges clinicians to avoid relying on favored approaches. Would be good for training clinicians and as a reference for practicing clinicians.

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      • World Health Organization. World report on violence and health Geneva, Switzerland: World Health Organization, 2002.

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        Provides a comprehensive global review of all types of violence. Clearly articulates the public health approach to prevention as it relates to violence. Resources include multiple links to general and specific types of violence-related websites.

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      Causes and Consequences

      The Centers for Disease Control and Prevention’s Adverse Childhood Experiences (ACE) Study found a strong dose-related relationship between exposure to abuse and household dysfunction during childhood and risk factors for major causes of death in adulthood. MacMillan, et al. 2001 links child abuse with psychiatric disorders. This is in addition to the devastating impact on child development. Kendall-Tackett 2002 identifies the pathways that explain the link between child abuse and health problems in adulthood. Holt, et al. 2008 reports that the overlap between intimate partner violence and child abuse is 45 to 70 percent. Factors that predispose parents to abuse their children are identified in Wolfe 1985. Children who are abused or witness violence are more likely to be victims of violence as an adult, as seen in Renner and Slack 2006. Recognizing the importance of this issue, Behrman 1999 devotes an entire journal issue to domestic violence and children.

      • Behrman, Richard E., ed. 1999. Special issue: Domestic violence and children. Future of Children 9.3.

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        This issue includes ten articles written by leading experts in the fields of law, public health, and social work. Future of Children publications are available online as full reports or executive summaries.

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      • Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE) Study.

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        This extensive website makes available over forty ACE study publications that link adverse childhood experiences to a wide range of health outcomes, organized by chronic disease, health-risk behaviors, mental health, reproductive health, and intimate partner violence.

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        • Holt, Stephanie, Helen Buckley, and Sadhbh Whelan. 2008. The impact of exposure to domestic violence on children and young people: A review of the literature. Child Abuse and Neglect 32:797–810.

          DOI: 10.1016/j.chiabu.2008.02.004Save Citation »Export Citation »E-mail Citation »

          Provides a good review of the literature (1995–2006) and links exposure to domestic violence and forms of child abuse. It also includes the role of protective factors.

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        • Kendall-Tackett, Kathleen. 2002. The health effects of childhood abuse: Four pathways by which abuse can influence health. Child Abuse and Neglect 26:715–729.

          DOI: 10.1016/S0145-2134(02)00343-5Save Citation »Export Citation »E-mail Citation »

          Behavioral, social, cognitive, and emotional pathways are identified as the links between child abuse and health problems in adult survivors. Specific research-supported examples are given within each pathway to illustrate the connection to health and the overlap with the other pathways.

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        • MacMillan, Harriet L., Jan E. Fleming, David L. Streiner, Elizabeth Lin, Michael H. Boyle, Ellen Jamieson, Eric K. Duku, Christine A. Walsh, Maria Y.-Y. Wong, and William R. Beardslee. 2001. Childhood abuse and lifetime psychopathology in a community sample. American Journal of Psychiatry 158:1878–1883.

          DOI: 10.1176/appi.ajp.158.11.1878Save Citation »Export Citation »E-mail Citation »

          Focuses specifically on the link between childhood physical abuse and psychiatric disorders and finds a stronger association for women compared to men.

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        • Renner, Lynette M., and Kristen Shook Slack. 2006. Intimate partner violence and child maltreatment: Understanding intra- and intergenerational connections. Child Abuse and Neglect 30:599–617.

          DOI: 10.1016/j.chiabu.2005.12.005Save Citation »Export Citation »E-mail Citation »

          Challenges the notion that parents who were abused or neglected as children are more likely to maltreat their own children. In fact, they were more likely to be victimized as adults. This sheds light on the association between intimate partner violence and child maltreatment.

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        • Wolfe, David A. 1985. Child-abusive parents: An empirical review and analysis. Psychological Bulletin 97.3: 462–482.

          DOI: 10.1037/0033-2909.97.3.462Save Citation »Export Citation »E-mail Citation »

          This article examines conceptual models that attempt to explain which parents are likely to abuse their children, and then reviews comparative studies to identify predisposing factors. The results can be used to refine prevention efforts.

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        Prevention

        Public health interventions include primary prevention (before child maltreatment occurs), secondary prevention (immediate response to child maltreatment), and tertiary prevention (reducing long-term consequences resulting from child maltreatment). Approaches to prevent child maltreatment include interventions that are universal, selected, and indicated. Universal interventions are designed for the general public regardless of level of risk. Selected interventions are directed toward persons who are at increased risk of abusing or neglecting children. Indicated interventions are for persons who already have experienced child maltreatment. Not all interventions are effective in preventing child maltreatment or reducing risk factors. Rigorous evaluation is essential to determine what interventions are effective, with whom, and under what circumstances. Outcomes need to be measured consistently using reliable, valid tools. Independent comparative reviews are an invaluable resource to sort out what does and does not work. Home visitation aptly illustrates these points.

        Comparative Reviews

        Systematic reviews are important sources of less biased information and compare different approaches against the same criteria. Randomized trials that include outcomes for all participants provide the strongest evidence. Lee, et al. 2008 provides cost-benefit analyses of programs and shows which programs improve outcomes and the extent to which benefits outweigh program costs. MacLeod and Nelson 2000 is a meta-analytic review with effect sizes for each program. MacMillan, et al. 2009 identifies interventions with sufficient evidence of effectiveness. Mikon and Butchart 2009 rates the quality of twenty-six systematic reviews. As new information becomes available, critical reviews by government agencies, government-sponsored entities, and nongovernmental organizations are published and made available on websites. Examples are the Task Force on Community Preventive Services 2005, the Center for the Study and Prevention of Violence’s Blueprints for Violence Prevention, and MacMillan 2000. Paxson and Haskins 2009 includes thoughtful commentary by recognized experts.

        • Center for the Study and Prevention of Violence, University of Colorado. Blueprints for Violence Prevention.

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          After a review of eight hundred violence prevention programs, eleven were selected as Blueprints Model Programs, and nineteen were designated Blueprints Promising Programs. Selection criteria is rigorous, and standards are high. The website describes each program and includes contact information. It includes a matrix of prevention programs with a table of three hundred programs rated by twelve agencies. This allows the reader to compare the various categories and criteria used to classify programs.

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          • Lee, Stephanie, Steve Aos, and Marna Miller. 2008. Evidence-based programs to prevent children from entering and remaining in the child welfare system: Interim report. Document no. 08-07-3901. Olympia: Washington State Institute for Public Policy.

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            Widely read and referenced controversial report that evaluates the costs and benefits of seventy-four programs. Benefit-to-cost ratios per participant and benefits-minus-costs per participant range widely, with net costs exceeding benefits for some programs.

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          • MacLeod, Jennifer, and Geoffrey Nelson. 2000. Programs for the promotion of family wellness and the prevention of child maltreatment: A meta-analytic review. Child Abuse and Neglect 24.9: 1127–1149.

            DOI: 10.1016/S0145-2134(00)00178-2Save Citation »Export Citation »E-mail Citation »

            Review of fifty-six programs, including proactive interventions to prevent child maltreatment and reactive interventions after child maltreatment occurs. The effect size and constructs measured are included in a helpful chart, with proactive effect sizes greater than reactive effect sizes. Of interest to policymakers and program managers, findings suggest that home visitation should last longer than six months and should include at least twelve home visits.

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          • MacMillan, Harriet L. 2000. Preventive health care, 2000 update: Prevention of child maltreatment. Canadian Medical Association Journal 163.11: 1451–1458.

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            This update of the 1993 report from the Canadian Task Force on Preventive Health Care finds additional evidence to strengthen an earlier recommendation for Nurse-Family Partnership. The review also finds evidence to avoid screening for child maltreatment risk because of high false positive rates and the risk of mislabeling parents as potential child abusers. The use of demographically based eligibility criteria is recommended. Available online.

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          • MacMillan, Harriet L., C. Nadine Wathen, Jane Barlow, David M. Fergusson, John M. Leventhal, and Heather N. Taussig. 2009. Interventions to prevent child maltreatment and associated impairment. Lancet 373:250–266.

            DOI: 10.1016/S0140-6736(08)61708-0Save Citation »Export Citation »E-mail Citation »

            Critical review of multiple interventions with children and caregivers and one community-based program. Identifies interventions with sufficient evidence of effectiveness in preventing child maltreatment. Recommends conducting randomized clinical trials to establish effectiveness in preventing child maltreatment, implementing evidence-based principles, and linking science with policy.

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          • Mikton, Christopher, and Alexander Butchart. 2009. Child maltreatment prevention: A systematic review of reviews. Bulletin of the World Health Organization 87:353–361.

            DOI: 10.2471/BLT.08.057075Save Citation »Export Citation »E-mail Citation »

            A synthesis of systematic and comprehensive reviews of seven types of interventions to prevent child maltreatment. Table 2 displays twenty-six reviews with the number of the publication included and scores the quality of most reviews. Notes that promising interventions are plagued by methodological problems and that few outcome evaluations are from low- or middle-income countries.

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          • Paxson, Christina, and Ron Haskins, eds. 2009. Special issue: Preventing child maltreatment. Future of Children 19.2 (Fall).

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            This issue of the Future of Children is worth reading in its entirety. The issue is devoted to child maltreatment and comprises thoughtful articles by recognized experts, with commentary on home visiting, parent training, efforts to prevent sexual abuse, and the child protection system.

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          • Task Force on Community Preventive Services. 2005. Recommendations to reduce violence through early childhood home visitation, therapeutic foster care, and firearms laws. American Journal of Preventive Medicine 28:6–10.

            DOI: 10.1016/j.amepre.2004.10.001Save Citation »Export Citation »E-mail Citation »

            The address also accesses “A Recommendation to Reduce Rates of Violence among School-Aged Children and Youth by Means of Universal School-Based Violence Prevention Programs,” American Journal of Preventive Medicine 33 (2007): S112–S113. The task force oversees systematic reviews led by scientists from the Centers for Disease Control and Prevention, summarizes review results, and makes recommendations for interventions. The recommendations are published in the American Journal of Preventive Medicine and are available on the Community Guide website. The task force determined that there was sufficient evidence of effectiveness to recommend early childhood home visitation, therapeutic foster care, and universal school-based violence prevention programs.

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          Home Visitation

          Home visiting is viewed by many as the most promising intervention to prevent child maltreatment. Some advocate for universal home visitation, primarily to make participating in home visiting more of a normative experience. Routine home visits by public health nurses after the birth of a baby in European countries and Australia is a model that has been abandoned in the United States. However, the purpose of those home visits was not the prevention of child abuse. Currently, home visiting programs are a secondary prevention, reserved for families with increased risk for child maltreatment, although typically no child abuse or neglect has occurred. Despite broad appeal and support for home visiting, in most cases it has failed to live up to its promise. In randomized trials conducted in the United States, home visiting programs rarely demonstrate evidence of effectiveness on measures of child maltreatment or most other measures. Gonzalez and MacMillan 2008 and Astuto and Allen 2009 identify Nurse-Family Partnership as the exception, because it demonstrates consistent evidence of effectiveness under rigorous evaluation. Behrman 1993 and Behrman 1999 capture the evolution in thinking about the potential of home visiting in two issues of the Future of Children. As noted in Sweet and Appelbaum 2004, evaluation findings vary widely, because the content of home visiting models varies. Johnson 2009 reports state investments in home visiting. The Maternal and Child Health Bureau’s Maternal and Child Health Library is an online resource for publications in the evolving field of home visiting.

          • Astuto, Jennifer, and LaRue Allen. 2009. Home visitation and young children: An approach worth investing in?. Social Policy Report 23:3–21.

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            Published by the Society for Research in Child Development at the University of North Carolina at Chapel Hill. Presents major concerns and early 21st-century developments in home visitation as the US government plans a major expansion of home visitation. Debate about the effectiveness of home visitation is acknowledged. Implementation of evidence-based programs is recommended.

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          • Behrman, Richard E., ed. 1993. Special issue: Home visiting. Future of Children 3.3 (Winter).

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            Landmark report that was published as national models of home visiting were being established, spurred by the recommendation for universal home visiting made by the US Advisory Board on Child Abuse and Neglect. This Future of Children issue provides the reader with a sense of the mood and thinking at the time when policymakers and practitioners considered launching home visitation initiatives.

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          • Behrman, Richard E., ed. 1999. Special issue: Home visiting; Recent program evaluations. Future of Children 9.1 (Spring–Summer).

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            Evaluations of the major home visiting programs are presented, including Nurse-Family Partnership, Hawaii’s Healthy Start, Parent as Teachers, Home Instruction Program for Preschool Youngsters, and Healthy Families America. Outcomes for these programs are summarized in tables that are easy to read and make comparisons. In randomized trials, Nurse-Family Partnership is the only program that demonstrates improvement in a variety of measures.

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          • Gonzalez, A., and Harriet L. MacMillan. 2008. Preventing child maltreatment: An evidence-based update. Journal of Postgraduate Medicine 54:280–286.

            DOI: 10.4103/0022-3859.43512Save Citation »Export Citation »E-mail Citation »

            Concise article that identifies three home visiting programs that were effective in preventing child maltreatment based on a randomized clinical trial: Nurse-Family Partnership, Healthy Families New York, and Early Start in New Zealand.

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          • Johnson, Kay. 2009. State-based home visiting: Strengthening programs through state leadership. New York: National Center for Children in Poverty. New York: National Center for Children in Poverty.

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            Describes how states are investing in home visitation programs based on survey responses received from forty-six states.

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          • Maternal and Child Health Bureau. Maternal and Child Health Library.

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            This extensive resource is maintained by Georgetown University. It includes links to websites for model and promising programs and allows the user to search databases of annotated publications and unpublished reports on home visiting and other related topics.

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            • Sweet, Monica A., and Mark I. Appelbaum. 2004. Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development 75.5: 1435–1456.

              DOI: 10.1111/j.1467-8624.2004.00750.xSave Citation »Export Citation »E-mail Citation »

              First meta-analysis of home visiting; includes data from sixty home visiting programs. This article clearly states what is at the core of the mixed findings relating to home visiting. That is, home visiting is a strategy for service delivery, not the service per se. What occurs during the home visit likely accounts for the wide variation in results.

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            Measurement Issues

            Home visiting programs and other interventions purport to prevent child maltreatment, yet measuring this outcome is difficult. Fallon, et al. 2010 notes that when child protective service reports are used, methodological challenges are reported across jurisdictions and most maltreatment is not reported. Recidivism studies in different states—reported in Way, et al. 2001, Lipien and Forthofer 2004, Connell, et al. 2007, and Kohl, et al. 2009—highlight the fact that lack of substantiation does not equate with lack of risk for subsequent maltreatment. Home visiting programs that fail to demonstrate desired outcomes with existing measures search for new measures that will “prove” their program is making a difference. However, measures need to be reliable and valid. DeVoe and Kantor 2002 and Ross and Vandivere 2009 identify existing appropriate measures that researchers and evaluators of home visiting programs can use. Corso and Lutzker 2006 calls for economic analysis of efforts to prevent child maltreatment.

            • Connell, Christian M., Natasha Bergeron, Karol H. Katz, Leon Saunders, and Jacob Kraemer Tebes. 2007. Re-referral to child protective services: The influence of child, family, and case characteristics on risk status. Child Abuse and Neglect 31:573–588.

              DOI: 10.1016/j.chiabu.2006.12.004Save Citation »Export Citation »E-mail Citation »

              Emphasizes that investigation of re-referrals should not be limited to substantiated cases. Cases that were substantiated initially were less likely to have a new allegation. To reduce the risk of re-referral, prevention services should be targeted to families during the first six months after an investigated case is either substantiated or unsubstantiated.

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            • Corso, P. S., and J. R. Lutzker. 2006. The need for economic analysis in research on child maltreatment. Child Abuse and Neglect 30:727–738.

              DOI: 10.1016/j.chiabu.2005.12.006Save Citation »Export Citation »E-mail Citation »

              Bemoaning the fact that few evaluations of child maltreatment prevention programs include an economic analysis, the authors also recognize the challenge of attaching a monetary value on improving parent-child relationships or a child’s quality of life. However, cost-effectiveness of child maltreatment prevention programs is essential for dissemination, and the authors recommend that program evaluators begin by doing a detailed cost analysis of their programs and compare costs to outcomes.

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            • DeVoe, Ellen R., and Glenda Kaufman Kantor. 2002. Measurement issues in child maltreatment and family violence prevention programs. Trauma, Violence, and Abuse 3.1: 15–39.

              DOI: 10.1177/15248380020031002Save Citation »Export Citation »E-mail Citation »

              Excellent resource for reliable, valid tools that can be used for screening, assessment, or outcome measures. Guidelines for selecting the appropriate tools are provided and would be helpful to evaluators and program managers. The appendix includes the source and cost for each measure.

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            • Fallon, Barbara, Nico Trocme, John Fluke, Bruce MacLaurin, Lil Tonmyr, and Ying-Ying Yuan. 2010. Methodological challenges in measuring child maltreatment. Child Abuse and Neglect 34:70–79.

              DOI: 10.1016/j.chiabu.2009.08.008Save Citation »Export Citation »E-mail Citation »

              This article acknowledges that 50 to 80 percent of victims of child maltreatment are not known to child protection services. Different definitions and inconsistencies defy attempts to create a uniform system of data. Authors compare three major child maltreatment surveillance methods used in the United States and Canada. Researchers and policy analysts can use this information to better interpret the datasets.

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            • Kohl, Patricia L., Melissa Jonson-Reid, and Brett Drake. 2009. Time to leave substantiation behind: Findings from a national probability study. Child Maltreatment 14.1: 17–26.

              DOI: 10.1177/1077559508326030Save Citation »Export Citation »E-mail Citation »

              Analysis of data from the National Survey of Child and Adolescent Well-Being revealed that the risk of recidivism was the same whether the index investigation resulted in a substantiated case or an unsubstantiated case. Researchers and evaluators should include both unsubstantiated and substantiated reports in measuring program outcomes.

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            • Lipien, Lodi, and Melinda S. Forthofer. 2004. An event history analysis of recurrent child maltreatment reports in Florida. Child Abuse and Neglect 28:947–966.

              DOI: 10.1016/j.chiabu.2004.03.011Save Citation »Export Citation »E-mail Citation »

              Initial reports of child maltreatment in 1998–1999 were analyzed. Over one-quarter had a maltreatment recurrence within two years. Risk of recurrence was greatest in the first four months after the initial incident and more likely for young and white children when the first report was substantiation of neglect. Judgment of the case worker contributes to the lack of uniformity within and across states.

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            • Ross, Timothy, and Sharon Vandivere. 2009. Indicators for child maltreatment prevention programs. Washington, DC: Child Trends.

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              This report recommends indicators to use in program evaluation and research, preferably with random control trials. The importance of comparisons with a control group is critical because measures are expected to change over time with or without the intervention. Therefore, program outcomes can be overstated and misleading. Program managers and evaluators will find charts in this guide especially useful in selecting reliable, valid measures.

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            • Way, Ineke, Sulki Chung, Melissa Jonson-Reid, and Brett Drake. 2001. Maltreatment perpetrators: A 54-month analysis of recidivism. Child Abuse and Neglect 25:1093–1108.

              DOI: 10.1016/S0145-2134(01)00258-7Save Citation »Export Citation »E-mail Citation »

              Between 10 and 15 percent of unsubstantiated perpetrators were substantiated when they were re-reported. Children left in their care are at risk of recurring or new maltreatment. Program managers could use this information to monitor the recidivism in their states and provide appropriate intervention to prevent subsequent maltreatment.

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            Universal Interventions

            Universal interventions to prevent child maltreatment are ones that strive to reach all families, not just families at increased risk. Prinz, et al. 2009 and Sanders 2008 describe Triple P, an approach that is in a class by itself, because it incorporates multilevel evidence-based interventions and employs a population-based public health approach to prevention. Klevens and Leeb 2010 notes that child maltreatment fatalities are concentrated on infants with abusive head trauma. Chiesa and Duhaime 2009 discusses the mechanisms and diagnosis and states that two-thirds of the survivors have some neurological impairment, often with a poor prognosis. Therefore, the effective interventions reported in Dias, et al. 2005 and Barr, et al. 2009 strive to prevent shaken baby syndrome by reaching all parents of newborns before hospital discharge. Primary pediatric care also has the potential to reach nearly all young children. Dubowitz, et al. 2009 describes an effective enhancement to routine pediatric care that could be implemented broadly.

            • Barr, Ronald G., Frederick P. Rivara, Marilyn Barr, Peter Cummings, James Taylor, Liliana J. Lengua, and Emily Meredith-Benitz. 2009. Effectiveness of educational materials designed to change knowledge and behaviors regarding crying and shaken-baby syndrome in mothers of newborns: A randomized, controlled trial. Pediatrics 123:972–980.

              DOI: 10.1542/peds.2008-0908Save Citation »Export Citation »E-mail Citation »

              Mothers who participated in the Purple Crying intervention group demonstrated increased knowledge about shaken baby syndrome and shared information about walking away if frustrated and the dangers of shaking. However, behavioral responses to crying and sharing information about infant crying was similar to the mothers in the control group. This approach could be implemented by home visitors working in child abuse prevention programs.

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            • Chiesa, Antonia, and Ann-Christine Duhaime. 2009. Abusive head trauma. Pediatric Clinics of North America 56:317–331.

              DOI: 10.1016/j.pcl.2009.02.001Save Citation »Export Citation »E-mail Citation »

              Challenges related to establishing the incidence are compounded by definitional issues and difficulty making the diagnosis. Use of a multidisciplinary team, careful history taking, and appropriate use of radiography and skeletal surveys are discussed. Management and outcomes for survivors are addressed. Prevention strategies include neonatal education programs, and further research is warranted. Long-term follow-up is called for to evaluate child abuse prevention efforts.

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            • Dias, Mark S., Kim Smith, Kathy de Guehery, Paula Mazur, Veetai Li, and Michele L. Shaffer. 2005. Preventing abusive head trauma among infants and young children: A hospital-based, parent education program. Pediatrics 115.4: e470–e477.

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              All hospitals in an eight-county region of New York State participated for five years. Seventy percent of parents of newborns signed a commitment statement, reviewed a brochure, and watched a short video about shaken baby syndrome. Abusive head injuries decreased by 47 percent compared to the prior six-year control period.

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            • Dubowitz, Howard, Susan Feigelman, Wendy Lane, and Jeongeun Kim. 2009. Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) model. Pediatrics 123:858–864.

              DOI: 10.1542/peds.2008-1376Save Citation »Export Citation »E-mail Citation »

              Families with children from birth to five years were randomly assigned to model care or standard care. Model care included residents who received special training, a parent screening questionnaire, and a social worker. Residents addressed identified risk factors. Families in the model care had significantly fewer substantiated or unsubstantiated child protective service reports, better compliance with health care, and fewer instances of physical assault.

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            • Klevens, Joanne, and Rebecca T. Leeb. 2010. Child maltreatment fatalities in children under 5: Findings from the National Violence Death Reporting System. Child Abuse and Neglect 34:262–266.

              DOI: 10.1016/j.chiabu.2009.07.005Save Citation »Export Citation »E-mail Citation »

              This article makes the case for a universal approach to reach new parents and prevent shaken baby syndrome or abusive head trauma. Homicide is the fifth leading cause of death for children under five. Over 40 percent of the deaths were attributed to child maltreatment, and over half of those were under one year old. Two-thirds of child maltreatment fatalities to children under five are due to abusive head trauma.

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            • Prinz, Ronald J., Matthew R. Sanders, Cheri J. Shapiro, Daniel J. Whitaker, and John R. Lutzker. 2009. Population-based prevention of child maltreatment: The U.S. Triple P system population trial. Prevention Science 10:1–12.

              DOI: 10.1007/s11121-009-0123-3Save Citation »Export Citation »E-mail Citation »

              County and population rates in eighteen South Carolina counties were measured after two years. Compared with the control counties, Triple P counties had significant reductions in the rates of substantiated child maltreatment, foster home placements, and hospitalizations or emergency room visits for child maltreatment injuries. Large to very large effect sizes under real-world conditions should be of great interest to policymakers and community leaders.

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            • Sanders, M. R. 2008. Triple P: Positive Parenting Program as a public health approach to strengthening parenting. Journal of Family Psychology 22.3: 506–517.

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              Triple P is a multilevel system of parenting intervention that provides evidence-based interventions within a single comprehensive community-wide program: media parent information campaigns and four levels of varying intensity and duration delivered as part of routine well-child health care or by mental health specialists who work with parents about child behavior problems or with parents at risk of child maltreatment.

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            • Triple P—Positive Parenting Program.

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              Triple P is an effective population-based intervention that started in Australia and is now being implemented in the United States, New Zealand, United Kingdom, and countries in Europe and Asia. This website describes Triple P, provides information about training, and is a resource for the scientific evidence to support the components of Triple P. Users can access Triple P initiatives in countries of interest.

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              Selected Interventions

              Home visiting programs are implemented to prevent maltreatment of infants and young children. Home visiting should be viewed as a mechanism for service delivery, but the effectiveness of the different models of home visiting varies depending on what service is being delivered. Not all home visiting programs aim to prevent child maltreatment, but of those that do the results often are less than successful. This section reviews major home visiting models for which there is some evidence of effectiveness. In rigorous randomized trials, Nurse-Family Partnership has by far the most impressive track record of consistent positive outcomes that persist over time, as covered in Olds, et al. 1997 and Eckenrode, et al. 2000. Healthy Families America is the most widely implemented model of home visiting. Evaluations have been mixed, as discussed in Harding, et al. 2007, and generally disappointing when subjected to randomized trials. Healthy Families New York is the exception, as discussed in DuMont, et al. 2008. Bugental, et al. 2002 incorporates an evidenced-based intervention into the basic Healthy Families America and finds an impressive reduction in physical abuse. Project SafeCare, as reported in Gershater-Molko, et al. 2003, is another promising evidence-based intervention that could enhance home visiting programs. Both Healthy Families America and Early Start in New Zealand are adaptations based on Hawaii’s Healthy Start. Duggan, et al. 2004a and Duggen, et al. 2004b did not find evidence of effectiveness when Hawaii’s Healthy Start was evaluated in a randomized trial. However, unlike Healthy Families America, Fergusson, et al. 2005 demonstrated significant positive differences when Early Start in New Zealand was evaluated in a randomized trial.

              • Bugental, Daphne Blunt, Patricia Crane Ellerson, Bonnie Rainey, Anna Kokotovic, and Nathan O’Hara. 2002. A cognitive approach to child abuse prevention. Journal of Family Psychology 16.3: 243–258.

                DOI: 10.1037/0893-3200.16.3.243Save Citation »Export Citation »E-mail Citation »

                High-risk families were randomly assigned to Healthy Families, or Healthy Families plus cognitive retraining, or a control group. After one year the percentage of mothers reporting physical abuse was 26 percent in the control group, 23 percent in the unenhanced Healthy Families group, and 4 percent in the Healthy Families plus cognitive retraining group. Incorporating evidence-based practice into Healthy Families America could improve outcomes.

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              • Duggan, Anne, Loretta Fuddy, Lori Burrell, Susan M. Higman, Elizabeth McFarlane, Amy Windham, and Calvin Sia. 2004a. Randomized trial of a statewide home visiting program to prevent child abuse: Impact in reducing parental risk factors. Child Abuse and Neglect 28:625–645.

                DOI: 10.1016/j.chiabu.2003.08.008Save Citation »Export Citation »E-mail Citation »

                This randomized trial of Hawaii’s Healthy Start Program included 643 families with increased risk for child maltreatment. Overall, Healthy Start had no significant effect on any risk factor or the mother’s desire to address risks. Record review documents limited fidelity to the model, and home visitors often failed to identify risks or refer mothers to community resources.

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              • Duggan, Anne, Elizabeth McFarlane, Loretta Fuddy, Lori Burrell, Susan M. Higman, Amy Windhan, and Calvin Sia. 2004b. Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse and Neglect 28:597–622.

                DOI: 10.1016/j.chiabu.2003.08.007Save Citation »Export Citation »E-mail Citation »

                This randomized trial of Hawaii’s Healthy Start Program, the precursor of Healthy Families America and Early Start in New Zealand, found there were no differences in measures of neglect or child abuse except for reduction in corporal punishment at one of the agencies. Record review indicates that home visitors were unaware of abuse that was occurring.

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              • DuMont, Kimberly, Susan Mitchell-Herzfeld, Rose Greene, Eunju Lee, Ann Lowenfels, Monica Rodriguez, and Vajeera Dorabawila. 2008. Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse and Neglect 32:295–315.

                DOI: 10.1016/j.chiabu.2007.07.007Save Citation »Export Citation »E-mail Citation »

                Families at risk of child maltreatment were randomly assigned to Healthy Families New York or a control group. When children were age two, mothers in Healthy Families were less likely to commit serious abuse, but incidents were rare for both groups. There were no differences overall in substantiated child protective service reports at year one or year two.

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              • Eckenrode, John, Barbara Ganzel, Charles R. Henderson, Elliott Smith, David L. Olds, Jane Powers, Robert Cole, Harriett Kitzman, and Kimberly Sidora. 2000. Preventing child abuse and neglect with a program of nurse home visitation. Journal of the American Medical Association 284.11: 1385–1391.

                DOI: 10.1001/jama.284.11.1385Save Citation »Export Citation »E-mail Citation »

                In a randomized control trial, families who received nurse home-visiting during pregnancy and infancy had significantly fewer maltreatment reports with the mother as the perpetrator over a fifteen-year period. Child maltreatment was not significantly reduced for mothers who reported more than twenty-eight incidents of domestic violence (21 percent of the sample). Effective interventions for families experiencing domestic violence need to be incorporated.

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              • Fergusson, David, John Horwood, Elizabeth Ridder, and Hildegard Grant. 2005. Early Start evaluation report. Christchurch, New Zealand: Early Start Project.

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                This three-year evaluation randomly assigned 443 families to Early Start or a control group. Early Start families were significantly less likely to have a child physically abused by a parent or hospitalized for accidents, injuries, or poisoning. Mothers were more likely to have positive and nonpunitive parenting attitudes. Participation in early education and child health care services was increased. Home safety approached significance.

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              • Gershater-Molko, Ronit M., John R. Lutzker, and David Wesch. 2003. Project SafeCare: Improving health, safety, and parenting skills in families reported for and at-risk for child maltreatment. Journal of Family Violence 18.6: 377–386.

                DOI: 10.1023/A:1026219920902Save Citation »Export Citation »E-mail Citation »

                Project SafeCare has been extensively tested, and significant improvements have been noted in child health care, home safety, and parent-child interactions. This article describes the interventions and how training and coaching establishes fidelity. SafeCare is included in several ongoing randomized trials of home visitation.

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              • Harding, Kathryn, Joseph Galano, Joanne Martin, Lee Huntington, and Cynthia J. Schellenbach. 2007. Healthy Families America effectiveness: A comprehensive review of outcomes. Journal of Prevention and Intervention in the Community 34.1–2: 149–179.

                DOI: 10.1300/J005v34n01_08Save Citation »Export Citation »E-mail Citation »

                This review of thirty-three evaluations of Healthy Families programs across multiple states finds mixed results. Most randomized clinical trials show no evidence of effectiveness in preventing child maltreatment. The most positive results are improved parenting. This article is essential reading for state leaders and program managers who are attempting to disseminate a model of home visiting statewide.

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              • Olds, David L., John Eckenrode, Charles R. Henderson, Harriet Kitzman, Jane Powers, Robert Cole, Kimberly Sidora, Pamela Morris, Lisa M. Pettitt, and Dennis Luckey. 1997. Long-term effects of home visitation on maternal life course and child abuse and neglect: Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association 278:637–643.

                DOI: 10.1001/jama.278.8.637Save Citation »Export Citation »E-mail Citation »

                This classic randomized trial reported multiple favorable outcomes for mothers who were visited by nurses during pregnancy and infancy. Mothers who were unmarried and of lower socioeconomic status also were less likely to be impaired by use of alcohol and other drugs or to be arrested. Findings support focusing services on low-resource mothers and beginning home visiting prenatally and continuing for two years after birth.

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              Indicated Interventions

              Universal interventions aim to prevent child maltreatment from ever happening by reaching all families, without regard for risk status. Selected interventions focus on families at increased risk of child maltreatment and strive to prevent child maltreatment before it has a chance to occur. Indicated interventions are used when child maltreatment has already happened. The goal is to prevent future maltreatment and to ameliorate the negative impact of maltreatment that already occurred. The challenge is twofold. First, Barlow, et al. 2006 reviews parenting programs for the Cochrane Collaboration and finds few interventions with evidence of effectiveness. Second, Gilbert, et al. 2009 notes that mandatory reporting results in only the “tip of the iceberg” being reported, let alone being investigated, substantiated, or served. Chaffin, et al. 2004, Chaffin, et al. 2009, and Hakman, et al. 2009 demonstrate positive results with Parent-Child Interaction Therapy, developed by Sheila Eyberg. Hughes and Gottlieb 2004 reports a randomized trial of the Incredible Years, showing modest improvement with maltreating mothers but not their children. Webster-Stratton and Reid 2010 describes how the Incredible Years program has been updated for families with younger children and adapted for maltreating families.

              • Barlow, J., I. Johnston, D. Kendrick, L. Polnay, and S. Stewart-Brown. 2006. Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database of Systematic Reviews Issue 3. Art. No.: CD005463.

                DOI: 10.1002/14651858.CD005463.pub2Save Citation »Export Citation »E-mail Citation »

                Seven studies of randomized trials were reviewed. Three studies assessed effectiveness of parenting programs on objective measures of abuse. Parent-Child Interaction Therapy found significant differences, and the Incredible Years program demonstrated a few nonsignificant differences in parental behaviors with a small sample size. Reviews by the Cochrane Collaboration sift through multiple published reports and identify approaches with the strongest evidence of effectiveness.

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              • Chaffin, Mark, Jane Silovsky, Beverly Funderburk, Linda Anne Valle, E. V. Brestan, T. Balachova, S. Jackson, J. Lensgraf, and B. L. Bonner. 2004. Parent-Child Interaction Therapy with physically abusive parents: Efficacy for reducing future abuse reports. Journal of Consulting and Clinical Psychology 72.3: 500–510.

                DOI: 10.1037/0022-006X.72.3.500Save Citation »Export Citation »E-mail Citation »

                This study randomized 110 families to Parent-Child Interaction Therapy, enhanced Parent-Child Interaction Therapy, and a standard community-based parenting group. After twenty-eight months, 19 percent of parents in Parent-Child Interaction Therapy had a re-report for physical abuse, compared with 49 percent in the standard community group. Enhanced services did not improve the results. Administrators should use this information to implement evidence-based intervention.

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              • Chaffin, Mark, Linda Anne Valle, Beverly Funderburk, Robin Gurwitch, Jane Silovsky, David Bard, Carol McCoy, and Michelle Kees. 2009. A motivational intervention can improve retention in PCIT for low-motivation child welfare clients. Child Maltreatment 14.4: 356–368.

                DOI: 10.1177/1077559509332263Save Citation »Export Citation »E-mail Citation »

                Adding a motivational intervention improved retention only when combined with Parent-Child Interaction Therapy, with 85 percent retention, compared with 61 percent for standard parent training. Benefits were for parents with low motivation.

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              • Gilbert, Ruth, Alison Kemp, June Thoburn, Peter Sidebotham, Lorraine Radford, Danya Glaser, and Harriet L. MacMillan. 2009. Recognising and responding to child maltreatment. Lancet 373:167–180.

                DOI: 10.1016/S0140-6736(08)61707-9Save Citation »Export Citation »E-mail Citation »

                Officially recognized maltreatment statistics are substantially lower than what is reported in community surveys. Professionals’ fear that reporting could worsen the situation is a contributing factor. Only one-quarter to one-half of reports are investigated. Unsubstantiation can result from lack of sufficient evidence rather than absence of maltreatment. When maltreatment is substantiated, children do not always receive appropriate services or actions.

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              • Hakman, Melissa, Mark Chaffin, Beverly Funderburk, and Jane F. Silovsky. 2009. Change trajectories for parent-child interaction sequences during Parent-Child Interaction Therapy for child physical abuse. Child Abuse and Neglect 33:461–470.

                DOI: 10.1016/j.chiabu.2008.08.003Save Citation »Export Citation »E-mail Citation »

                During Parent-Child Interaction Therapy, the physically abusive parent’s positive responses to his or her child’s appropriate behavior rapidly increased, and his or her negative responses rapidly decreased during the first three sessions and maintained throughout the remaining eight sessions.

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              • Hughes, Jean R., and Laurie N. Gottlieb. 2004. The effects of the Webster-Stratton parenting program on maltreating families: Fostering strengths. Child Abuse and Neglect 28:1081–1097.

                DOI: 10.1016/j.chiabu.2004.02.004Save Citation »Export Citation »E-mail Citation »

                In a randomized trial of the Incredible Years program with twenty-six maltreating mothers of children three to eight years old, mothers demonstrated improvement in some areas, but there were no significant differences in the children. Low attrition is an important outcome; 96 percent attended six or more of the eight sessions.

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              • Webster-Stratton, Carolyn, and M. Jamila Reid. 2010. Adapting the Incredible Years: An evidence-based parenting programme for families involved in the child welfare system. Journal of Children’s Services 5.1: 25–42.

                DOI: 10.5042/jcs.2010.0115Save Citation »Export Citation »E-mail Citation »

                Families in the welfare system often are referred for parenting programs, but few of the programs are evidence based. This article discusses how the Incredible Years has been updated for families with infants, toddlers, preschoolers, and school-age children, and how it has been adapted for the families of maltreated children. This information would be useful for child protective services administrators and providers of parent training programs.

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              LAST MODIFIED: 02/23/2011

              DOI: 10.1093/OBO/9780199756797-0038

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