[Archived] Prevention of Child Maltreatment: Commentary on Eckenrode, MacMillan and Wolfe

Introduction

Child maltreatment affects more than one million American and Canadian children annually. That figure, based largely upon reports from child protective services, is widely regarded as seriously under-representing the actual scope of the problem because in population-based surveys about one-third of adults report having been abused as children. Neglect is more prevalent than abuse, but can be a precursor to abuse. Child maltreatment has negative consequences that reach beyond the immediate pain of childhood victimization. Dollar costs to society are great, and there are significant and serious lifetime mental and physical sequelae to victims, such as major depression and cardiovascular disease.¹ John Eckenrode, Harriet MacMillan and David Wolfe have stressed the utility of the developmental-ecological and public-health models in preventing child maltreatment. In doing so, they note the need to identify effective prevention programs that address child maltreatment at multiple levels, including family, schools, the health-care system and the community. More and better surveillance and etiologic data and the establishment of attainable programmatic goals are further concerns of these authors.

Research and Conclusions

Eckenrode stresses the need for well-designed and evaluated prevention efforts. He also stresses the need to utilize universal approaches that include public information campaigns and public advocacy to garner policy change by national and local governing bodies. In terms of individual programs, Eckenrode notes the success of home visitation programs, but reminds us that a focus at that individual family level cannot be as effective as combing home visitation with the community-level suggestions noted above. Such efforts should include schools. Though controversial, school programs aimed at teaching children to avoid potential sexual abuse or abduction, Eckenrode points out, can be included in the array of efforts. Such programs include behavioural rehearsal and modelling, and should include concrete concepts for young children.² MacMillan, however, questions whether or not improved knowledge and skills reduce risks to children. Finally, she recommends that health professionals should play a key role in home assessment and in helping parents identify key risk situations such as excessive crying. Finding cost-effective and efficient mechanisms for such parental support represents challenges for researchers and service-providers.

MacMillan notes that the lack of uniform definitions and ethical issues is a barrier to accomplishing robust research in child maltreatment prevention. As does Eckenrode, MacMillan comments on the components of home visitation programs, particularly the Nurse Visiting Program of Olds and his colleagues. She suggests that there has been little or no research demonstrating that these programs prevent child maltreatment; however, the Guide to Community Preventive Services at the Centers for Disease Control (CDC), after a systematic review, has recently concluded that home visitation programs are effective in preventing child maltreatment. Of the studies that met the review criteria, there was a 40% reduction in child maltreatment; longer duration programs were more effective than shorter; and in shorter programs, professionals may produce better outcomes than paraprofessionals.³ Nonetheless, as MacMillan cautions, not all home visitation programs are created equal and it should be noted that the CDC review was unable to discern procedural differences among home visitation programs.

Wolfe also endorses what he describes as personalized home visitation programs, tailored for given families. He stresses that such programs must focus on practical skills delivered in easy-to-understand formats. Similarly to Eckenrode and MacMillan, Wolfe reminds us that prevention must include community efforts, such as those that have occurred in several countries, including media campaigns aimed at informing the public how to recognize signs of abuse and how to respond to concerns about it. He also recommends consideration of community-level issues such as housing, professional education, better training for professionals in identifying maltreatment, and better screening tools.

Implications for Services

The need for further training of professionals such as caseworkers, health providers, educators and the legal profession is a point well taken by Eckenrode. This is a more complicated issue than meets the eye, because funding limitations for training are far from the only issue preventing more and better training. With caseworkers, there are a host of issues that make improved training difficult, such as the time needed to conduct training and the approaches used in training. There are few empirical data to suggest the best formats for training, the most efficient methods for training and the most propitious durations for training. Further, there are issues of maintenance of learned skills and the quality of skill maintenance (fidelity).⁴ Finally, there are complications regarding priorities for training. For example, perhaps the highest priority for training should be in the valid determination of child risk. Milner and his colleagues⁵ have found that caseworkers cannot reliably judge a child’s future risk. Until there are uniform definitions of child maltreatment and until methods are found to successfully teach caseworkers to more reliably assess risk, training in this area will, of necessity, be less than optimal. Training for other professionals also raises questions, such as whether training medical personnel to detect risk or offer brief parenting tips actually reduces risks for children.

Each author expresses concern at the small number of rigorous evaluations of child maltreatment programs conducted to date. There are numerous reasons for such a dearth, including the difficulty of random assignment with child maltreatment cases, the uncertainty of what measures best capture outcomes of interest, and the difficulty of capturing the qualitative aspects of programs and their role in outcomes. More randomized control designs evaluating child maltreatment programs are surely in order when possible. As well, there is a need for more use of quasi-experimental designs using comparison groups, formative and prospective studies and single-case research designs to learn more about individual behaviour change strategies and how to fine-tune them. Finally, any rigorous evaluation should include a robust cost analysis.⁶

Each author has expressed the need for community-level research. Included in this concern is a need for sensitivity to diverse ethnic and cultural group nuances that may affect assessment, research and service. Implicit in these concerns is a need to study social norms that affect nations and subgroups within those nations regarding parenting practices and child maltreatment. There are two dimensions of social norms worth considering: understanding what is the current set of norms for the target group, and also affecting social norms with respect to changing tolerance of child maltreatment.

Child maltreatment prevention requires coordination of efforts at multiple levels: government, the public, agencies, law enforcement researchers and service-providers. Increased emphasis on and improvements in primary prevention, community-level efforts, outcome and program evaluations and cultural responsiveness will help such efforts.

References

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2. Boyle CF, Lutzker JR. Teaching young children to discriminate abusive from nonabusive situations using multiple exemplars in a modified discrete trial teaching format. Journal of Family Violence. In press.
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