[Archived] Preventing Child Maltreatment

Introduction

Child maltreatment encompasses four main categories of childhood victimization: physical, sexual, emotional abuse and neglect. Since efforts began in the 1960s to prevent child maltreatment, most of the literature has focused on prevention of physical abuse, neglect and sexual abuse, but much less is known about approaches to reduce emotional abuse. 

Subject

Child maltreatment is a significant public-health problem associated with a broad range of adverse outcomes in several domains: physical, emotional, cognitive and social.¹ The Canadian Incidence Study, a national survey of official reports of child abuse and neglect cases, estimated that the annual incidence rate of investigations carried out in Canada in 1998 was 21.52 investigations per 1,000 children.² It is well documented, however, that official reports seriously underestimate the full extent of child maltreatment. For example, a community-based survey of Ontario residents 15 years of age and older found that past exposure to child physical abuse was 31% among males and 21% among females; the rates for sexual abuse were 4% among males and 13% among females.³

Problems

Increasingly, models used to conceptualize the cause of child maltreatment consider the interplay among individual (child and parent), family and social influences. Much of the effort to date in understanding how to prevent child maltreatment has focused on identifying risk and protective indicators for child sexual abuse and child physical abuse and neglect together. The indicators for the former are quite non-specific – for example, poor child-parent relations – whereas the indicators for physical abuse and neglect are generally those associated with psychosocial disadvantage and situations that lead to increased stress or decreased support.  

Research Context

It is challenging to evaluate approaches to preventing child maltreatment for several reasons: 1) there is no uniform definition for each of the categories of child abuse and neglect; 2) there are legal and ethical barriers to measuring its occurrence; and 3) there has been reluctance to employ the most rigorous methods, such as use of control groups, in evaluating program effectiveness.

Key Research Questions

Developing approaches to measure different types of child maltreatment is central in being able to evaluate prevention efforts in this field.⁴ Other key questions include: 1) how to prevent the four main categories of child abuse and neglect from occurring, recognizing that there is often overlap among them; and 2) when it does occur, what strategies are available for preventing recurrence and the impairment associated with exposure? The latter question, while beyond the scope of this summary, is still important in considering an overall approach to prevention of child maltreatment.

Recent Research Results 

Programs aimed at preventing one or more types of child maltreatment can be classified into two main categories: 1) perinatal and early childhood programs – these generally target prevention of child physical abuse and neglect; and 2) education programs – these typically focus on preventing child sexual abuse among the general population.⁵ In the first category, although various support services have been developed, there is only one specific type of home visitation program for which there is good evidence of effectiveness in preventing child abuse and neglect: the Nurse-Family Partnership (NFP) developed by David Olds and colleagues.⁶ The NFP is a program in which nurses provide in-home visits to socially disadvantaged first-time mothers from pregnancy through the child’s second birthday. The nurses focus on three major goals: 1) improving pregnancy outcomes by assisting women with health-related behaviours; 2) improving children’s health and development by helping parents provide competent care; and 3) assisting parents to become more economically self-sufficient. 

The NFP program has been evaluated in three randomized controlled trials and has been shown to improve maternal, child and family functioning, including prevention of child abuse and neglect as well as associated outcomes such as injuries.^6,7 Of particular note, the NFP program is especially effective in reducing adverse outcomes in children born to mothers with low “psychological resources,” such as limited intellectual functioning.  However, among families with extremely high rates of intimate partner violence (IPV), there was no difference in child maltreatment rates between the home-visited and control groups.⁸ Olds and colleagues are evaluating ways of enhancing the NFP program to make it effective in reducing IPV as well as child maltreatment.

Unfortunately, there has been the assumption that home visitation in general is effective in preventing child maltreatment. However, the research has not demonstrated this to be the case. Many regions have implemented home-visitation programs delivered by paraprofessionals, despite the lack of evidence for the effectiveness of this approach.⁹ Furthermore, a study comparing nurses and paraprofessionals demonstrated that few significant effects were achieved on maternal and child outcomes with paraprofessionals.¹⁰ Although successful paraprofessional programs may be developed in the future, to date the best evidence for preventing child abuse and neglect is the NFP program.

In the second category, educational prevention programs, the evidence is quite consistent: there are several models of sexual-abuse prevention programs that improve knowledge and prevention skills, even among children as young as four or five years old.^5,11 However, no study has yet shown that such programs actually prevent the occurrence of sexual abuse in children. It cannot be assumed that improvement in knowledge or skills translates into reduction of child sexual abuse. In fact, one observational study showed that participation in school-based sexual-abuse prevention programs was not associated with any reduction in victimization.¹² Participation in such programs was associated with an increased disclosure of child sexual abuse, suggesting that such programs may be more useful in detecting previous victimization and in preventing recurrence. Several authors have noted the concern that education programs place the onus on children to avoid sexual abuse. Little is known about ways of preventing persons from committing sexual abuse. 

Conclusions

In the ongoing efforts to prevent child maltreatment, it is important to focus on ways to measure the four main types and to conduct longitudinal research that will allow identification of causal risk factors, as well as protective factors. The good news is that the NFP program has been shown to be effective in preventing child abuse and neglect among socially disadvantaged first-time mothers. It is a highly specific program, however, and it should not be assumed that home-visitation programs, even those with some characteristics of the NFP, will have the same effects. Furthermore, it is not known whether the NFP will be effective in other high-risk populations.

Sexual-abuse education programs do improve young children’s knowledge and skills with regard to avoiding victimization; whether that translates into actual reduction in sexual abuse is unknown. The findings from one study suggest that such programs may encourage disclosures of victimization, but not reduce occurrence. 

Implications

Given the demonstrated effectiveness of the NFP program in three U.S. sites, it is time to evaluate whether this intervention would be equally effective in other countries, like Canada, that have different health and social-service systems. As an intervention targeted to socially disadvantaged mothers, it would not be the only approach necessary, but given its success in the U.S., it would be important to evaluate the NFP program, rather than assuming that other home-visitation models are effective.  In the area of child sexual- abuse prevention, it is important to determine whether education programs prevent exposure. The area of emotional abuse is one in which approaches to intervention need to be considered, recognizing that such abuse overlaps frequently with the other three types. Information about promising community-based strategies to prevent child maltreatment will hopefully come from longitudinal studies, but making a commitment to measure child abuse and neglect is an essential first step. 

Acknowledgement: This work is supported by the CIHR Institutes of Gender and Health; Aging; Human Development, Child and Youth Health; Neuroscience, Mental Health, and Addiction; and Population and Public Health. 

References

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