Abstract
Due to the destructive impact of child maltreatment and limited
available funding to address its consequences, the value of preventive
measures is evident. Early Childhood Intervention Programs (ECIPs)
provide excellent opportunities to prevent and identify cases of child
maltreatment, among other varied objectives. These programs are
typically targeted at high-risk families with children under age 5 and
address risk factors across various levels of intervention (child,
parent, immediate context, and broader context). A sample of ECIPs
within home, school, clinic, and community settings were selected for
description in this paper if they include services that address common
child maltreatment risk factors, demonstrated reductions in risk factors
through outcome research, and provide valuable lessons for preventing
child maltreatment. Challenges to preventing child maltreatment through
ECIPs are discussed, including unreliable identification of high-risk
families, lack of involvement of low-income and minority parents, and
barriers to effective dissemination and implementation of programs.
Recommendations for future research and improving child maltreatment
prevention through ECIPs are provided.
**********
The disturbing prevalence of child abuse and neglect in the United
States has sparked a great deal of research and mobilization over the
past few decades. Yet despite the growing awareness and recognition of
this societal problem, hundreds of thousands of children continue to be
maltreated every year. The U.S. Department of Health and Human Services
(2006a) reported 872,000 substantiated cases of child maltreatment in
2004 alone, at a rate of 11.9 per 1,000 children. Many estimates
indicate that approximately 20% of children will be sexually abused
before becoming adults (Davis & Gidyez, 2000). Even more tragic are
the severe cases of abuse and neglect that lead to child fatalities. In
2004, it was estimated that 1,490 children died as a result of child
maltreatment, with the majority of deaths attributed solely to neglect
(U.S. Department of Health & Human Services, 2006a).
Aside from the serious physical consequences of child maltreatment,
several emotional and behavioral consequences for children have been
noted in the literature. These consequences vary according to
differences in the severity, duration, and frequency of maltreatment, as
well as differences in the child (e.g., temperament, coping skills,
developmental stage) and his or her environment (e.g., family income,
social support, neighborhood characteristics; Hecht & Hansen, 2001).
In general, children who have been maltreated are likely to develop
insecure attachments with caregivers, which often lead to interpersonal
difficulties, aggressive behavior, and low self-esteem. They may also
have impaired emotion regulation capabilities and exhibit internalizing
problems, such as depression, anxiety, and self-harm behaviors (Hecht
& Hansen, 2001; Saywitz, Mannarino, Berliner, & Cohen, 2000;
Tyler, 2002). The consequences of child maltreatment have a broader
impact on society as well. Economic analyses have estimated the direct
(e.g., hospitalization, treatment, law enforcement) and indirect (e.g.,
special education, foster care, juvenile delinquency, unemployment)
costs of child maltreatment to be over $94 billion per year (Fromm,
2001; U.S. Department of Health & Human Services, 2004b).
Considering the destructive impact of child maltreatment on
individuals and society as a whole, as well as the limited funding
available to address its consequences, the value of preventive measures
is becoming increasingly apparent. The benefits of prevention efforts
can be seen at both individual and societal levels. Prevention programs
can save millions of dollars through reductions in health care costs,
child welfare services costs, out-of-home care costs, law enforcement
costs, judicial system costs, and unemployment costs to society.
Moreover, long-term benefits of child abuse prevention include improved
mental and physical health, educational achievement, employment
prospects, social functioning, and family stress (Karoly et al., 2001;
U.S. Department of Health & Human Services, 2004b).
Though greatly varied in nature, Early Childhood Intervention
Programs (ECIPs) are excellent resources for preventing child
maltreatment. In this paper, the term "Early Childhood Intervention
Program" refers exclusively to programs designed to promote healthy
development and prevent negative outcomes for at-risk children. These
programs have become increasingly prevalent since the 1960s, which
marked the beginning of the modern era in early childhood intervention
(Meisels & Shonkoff, 1990). Though their roots stem from a variety
of fields (e.g., mental health, social work, education) and the programs
themselves are diverse in context, purpose, and intervention strategies,
ECIPs share the common goal of "translat[ing] ever-growing
knowledge about the process of human development into the formation of
the best kind of environment in which a child can grow" (Meisels
& Shonkoff, 1990, p. 27). These programs also share the idea that
intervention should occur early in life, before more significant
problems are likely to develop. Because child maltreatment is most
common in children under 5 years of age, ECIPs are in an ideal position
to prevent maltreatment before it occurs (Graham-Bermann, 2002; U.S.
Department of Health & Human Services, 2006a). These programs have
the unique ability to address multiple problems at multiple levels and
across multiple settings, increasing the likelihood that child
maltreatment can be prevented (Daro, 2000; Karoly et al., 2001; U.S.
Department of Health & Human Services, 2006a).
The purpose of this paper is to identify common risk factors for
child maltreatment (i.e., physical abuse, sexual abuse, and neglect)
from the available literature and review a sample of ECIPs that address
specific risk factors. In particular, the unique opportunities available
within ECIPs for preventing child maltreatment will be discussed, as
well as challenges that often arise in ECIPs and strategies for
addressing them. The paper will begin with a review of risk factors,
organized according to Belsky's (1993) developmental-ecological
framework. This is followed by a description of ECIPs and their
potential for reducing the risk of child abuse and neglect. A selection
of ECIPs implemented within home, school, clinic, and community settings
are then reviewed. Programs were chosen for review if they include
services that address common child maltreatment risk factors,
demonstrated reductions in these risk factors through outcome research,
and provide valuable lessons for preventing child maltreatment. Barriers
to preventing child maltreatment through ECIPs are discussed as well as
limitations of current research. Finally, recommendations are provided
for future research and for improving child maltreatment prevention
through ECIPs.
Overview of Child Maltreatment Risk Factors
Developmental-Ecological Framework
It has been widely accepted that there is no single cause of child
maltreatment (Belsky, 1993; Daro, 2000; Daro & Harding, 1999; Hecht
& Hansen, 2001). A variety of risk factors exist in a range of
contexts, producing "many pathways to child abuse and neglect"
(Belsky, 1993, p. 413). Each of these characteristics alone may increase
the risk of maltreatment, but they often co-occur and increase risk in a
cumulative manner (Hecht & Hansen, 2001). It is likely that most
families will experience one or more of these risk factors at some
point, while not all families will experience abuse or neglect (Daro,
2000). For this reason, it has proven extremely difficult to identify
either potential victims or potential perpetrators of abuse and neglect
(Daro, 1994; Hecht & Hansen, 2001). However, as research continues
to uncover information about common risk factors, prevention programs
can be designed and modified to address multiple risk factors within a
single program.
A review of common child maltreatment risk factors is necessary
before discussing the ability of ECIPs to address these factors. Belsky
(1993) outlined a developmental-ecological framework to organize the
various risk factors across multiple levels of analysis, based on the
work of Bronfenbrenner and forming the basis for the work of Cicchetti
and others (Bronfenbrenner, 1979; Cicchetti & Toth, 2000; Hecht
& Hansen, 2001). According to this framework, child maltreatment
risk factors can be conceptualized in terms of parent factors, child
factors, factors in the immediate interactional context, and those
existing in the broader environmental context. Factors within each level
are continuously influencing and interacting with factors in other
levels in a transactional manner (Belsky, 1993; Cicchetti & Toth,
2000). Several of these risk factors are discussed below, within a
developmental-ecological framework.
Parent Factors
While they are not directly predictive of child maltreatment,
factors related to a parent's mental health, personality, and
personal history have all been linked to child abuse potential. A parent
with mental health problems may have less emotional and psychological
resources available to invest in meeting their child's needs.
Studies have shown that abusive parents frequently have low self-esteem,
lack of impulse control, and impaired empathy for others (Belsky, 1993).
In one study of maltreating families, 84% of the parents were diagnosed
with a DSM-III mental disorder by a licensed mental health professional
(Taylor et al., 1991). In particular, a significant relationship has
been found between maternal depression and child abuse (Hecht &
Hansen, 2001; Sheppard, 1997). Abusive parents also tend to attribute
hostile intent to their children's behaviors and perceive
childrearing as more difficult than non-abusive parents (Hecht &
Hansen, 2001). They often perceive themselves as having little control
and display high levels of negative reactivity (Belsky, 1993).
Though the research is inconclusive, a history of childhood
maltreatment has frequently been linked to increased abuse potential
(Belsky, 1993; Hecht & Hansen, 2001). Rates of intergenerational
transmission of abuse have been estimated to range from 7 to 70 percent,
providing little conclusive evidence of this phenomenon (Belsky, 1993).
It has been suggested that abusive behaviors may be learned from
parents, that adults who were abused as children may be hyperreactive to
stressful situations, and that these individuals may not have developed
appropriate coping and problem-solving skills (Belsky, 1993).
Additionally, there is significant evidence that parental alcohol and
drug use are related to family violence. Fluctuations in child
maltreatment rates have been coupled with fluctuations in rates of
substance abuse in the general population (National Clearinghouse on
Child Abuse and Neglect Information [NCCAN], 1996). In 1995, it was
estimated that 675,000 children are maltreated each year by
substance-abusing caretakers.
Child Factors
Several characteristics of children have been associated with
increased risk of child maltreatment, particularly factors that are
innate to the child. Prenatal drug use by mothers can lead to low birth
weight, prematurity, and developmental disabilities, each of which are
child characteristics that have been shown to increase maltreatment risk
(Cicchetti & Toth, 2000; Solomons, 1979). Child age has also been
identified as a risk factor for maltreatment, with younger children
being at higher risk (Cicchetti & Toth, 2000; Graham-Bermann, 2002;
U.S. Department of Health & Human Services, 2006a). In fact, over
80% of child fatalities due to child maltreatment in 2004 were children
under 4 years of age, with infant boys having the highest rates of
fatalities (U.S. Department of Health & Human Services, 2006a).
Furthermore, child behavior problems appear to be a significant child
risk factor for maltreatment (Belsky, 1993; Urquiza & McNeil, 1996).
Children exhibiting noncompliant, disruptive, impulsive, and aggressive
behaviors are at higher risk for physical abuse than their well-behaved
counterparts.
Certain child characteristics have been found to increase the risk
of sexual abuse in particular, such as low self-esteem, lack of social
support, and inadequate knowledge of personal safety skills (Daro, 1994;
Daro & Donnelly, 2002). Several studies have found that passive
children with low self-esteem tend to be chosen as victims of sexual
abuse (e.g., Daro, 1994). These children are often less likely to
respond assertively to adults and may value the positive attention they
are receiving from the perpetrator. In addition, children who are more
isolated tend to be at higher risk for sexual abuse, because they are
less likely to disclose the abuse to others (Daro, 1994; Daro &
Donnelly, 2002). Finally, children with little knowledge of personal
safety skills (e.g., good vs. bad touches, inappropriate sexual
behavior) are often easier targets for sexual exploitation (Daro &
Donnelly, 2002). While the intention here is clearly not to blame the
victim, it is important that child factors be examined as possible
targets of intervention to prevent child maltreatment before it occurs.
Immediate Interactional Context
Beyond personal characteristics of children and parents, several
risk factors can be identified within the child's immediate
interactional context. There is little doubt that problematic parenting
practices increase the risk of child maltreatment. Lack of parenting
skills and knowledge of child development have been associated with
child maltreatment risk, with high-risk parents exhibiting inappropriate
expectations of their children and frequently using ineffective child
management techniques (Daro & Donnelly, 2002; Hecht & Hansen,
2001). In particular, physical punishment of children to elicit
compliance (i.e., corporal punishment), such as spanking and slapping,
has been shown to increase the risk of physical abuse (Straus, 2001).
Studies have shown that mothers who are violent toward their children
are much more likely to approve of corporal punishment (Holden, Coleman,
& Schmidt, 1995; Murphy, 1997). In general, abusive parents often
exhibit negative parent-child relationships, including interacting with
their children in negative ways, providing less support to their
children than nonabusive parents, and interacting with their children
less often than nonabusive parents (Urquiza & McNeil, 1996). Belsky
(1993) suggests that neglectful parents tend to be unresponsive to their
children, while physically abusive parents are controlling, punitive,
and rigid in their parenting strategies.
Marital discord and partner violence are significant risk factors
as well, given that they negatively impact parenting skills, increase
the level of stress in the home, and lead to feelings of isolation, all
of which increase the risk of child maltreatment (Hecht & Hansen,
2001; Prevent Child Abuse America [PCAA], 2006; Thompson, 1995;
Thompson, Flood, & Goodvin, 2006). Moreover, partner violence and
child maltreatment often co-occur and children may be injured
intentionally or accidentally during a violent incident (Graham-Bermann,
2002; NCCAN, 1996). For example, studies have consistently found rates
of overlap between child physical abuse and domestic violence above 20%
(Graham-Bermann, 2002). In addition to the physical risk involved,
children who are exposed to domestic violence often suffer significant
psychological trauma (Graham-Bermann, 2002; Hecht & Hansen, 2001;
NCCAN, 1996).
Broader Context
Poverty has long been shown to be a significant environmental risk
factor for child maltreatment (Daro & Donnelly, 2002; Dupper &
Poertner, 1997; Evans, 2004; Garbarino & Kostelny, 1994; Hecht &
Hansen, 2001). It has been linked to every form of child maltreatment
and past studies of incidence rates have found that families with
incomes under $15,000 were 22 times more likely to have a child who is
maltreated than families with higher incomes (NCCAN, 1996). However,
this relationship may be mediated by other risk factors that are present
in low-income households, such as substandard housing quality (e.g.,
structural defects, inadequate heat) and lack of access to healthy food
(Evans, 2004; Hecht & Hansen, 2001). Stress has also been shown to
mediate the relationship between poverty and child maltreatment, with
significantly higher levels of parental stress found in low-income
families (Evans, 2004; Hecht & Hansen, 2001). In addition, increased
rates of substance abuse and mental health problems can be found in
families living in poverty, as well as low levels of social support
(Baydar, Reid, & Webster-Stratton, 2003; Evans, 2004; NCCAN, 1996).
Characteristics of neighborhoods and communities can increase the
risk of child maltreatment as well. High risk neighborhoods are defined
by a lack of positive neighboring, high population turnover, more
stressful daily interactions between families, and low social cohesion
or integration (Belsky, 1993; Daro & Donnelly, 2002; Garbarino &
Kostelny, 1994). The fear induced by living in high crime environments
can lead parents to be more restrictive and punitive in their parenting
in order to protect their child from the frightening prospects
surrounding them (Garbarino & Kostelny, 1994). There is abundant
evidence that social isolation can increase the risk of child
maltreatment as well (Lovell & Hawkins, 1988; Lovell & Richey,
1997; Norbeck, Dejoseph, & Smith, 1996; Richey, Lovell, & Reid,
1991). One study found that 95% of families who were labeled
"severely abusive" did not have any continuous relationships
with individuals outside of the family (Thompson, 1995). The literature
suggests that insular mothers, or mothers who report high rates of
unsolicited and coercive social interactions rather than solicited
positive interchanges, tend to show inconsistency in their own responses
to their children (Dumas & Wahler, 1983). Because these mothers
appear to have little impact within their social communities, they may
also lack the necessary social skills to impact their home environment.
Insular mothers are more likely to extend coercive exchanges with their
children and to have difficulty implementing effective parenting
strategies (e.g., Time Out, point system; Wahler, 1980; Wahler, Hughey,
& Gordon, 1981). It appears to be the case that parents who face
significant stressors and lack a support network may see their options
as more limited and are more likely to resort to hostile and violent
behavior (PCAA, 2006).
Finally, lack of societal awareness about child maltreatment and
general acceptance of violence have contributed to consistently high
rates of abuse and neglect in the United States (Belsky, 1993; Greven,
1990; Straus, 2001). Violence is commonly accepted and condoned in this
country, as evidenced by television shows, movies, music, news programs,
and court rulings. This society is characterized by negative attitudes
toward children as well as acceptance of corporal punishment as a form
of discipline. While its use in schools has significantly declined,
corporal punishment by parents is legal in every state and parents
continue to support the use of corporal punishment in the home, at least
as a 'last resort' (Straus, 2001). As Belsky (1993) asserts,
"The fact of the matter is that in cultures in which physical
punishment is rare, child abuse is quite unusual" (p. 423).
Early Childhood Intervention Programs
ECIPs and Preventing Child Maltreatment
Child maltreatment risk factors, such as those discussed
previously, often co-occur within families. Due to the limited
predictive utility of any single risk factor and the common
co-occurrence of several risk factors, it may be insufficient to address
each risk factor in isolation. According to Daro (2000), "Child
maltreatment arises from both the individual contribution of many causal
factors and the combined impacts of these factors on parents'
abilities to care for their children" (p. 164). Programs that
address multiple risk factors across various levels of analysis appear
to be the most effective in preventing child maltreatment (Daro &
Donnelly, 2002; Evans, 2004; Hecht & Hansen, 2001; NCCAN, 1996).
Program effectiveness also appears to increase with earlier
intervention, from toddlers and preschoolers to as early as prenatal
intervention (Daro & Donnelly, 2002; NCCAN, 1996). Children under
age 5 are disproportionately more likely to witness or experience family
violence than older children (Graham-Bermann, 2002; U.S. Department of
Health & Human Services, 2006a). In fact, the victimization rate was
highest among children under age 3 in 2004 at a rate of 16.1 per 1,000
children (U.S. Department of Health & Human Services, 2006a). This
supports the need for early intervention, particularly with high-risk
families. Targeting mothers as early as pregnancy provides the
opportunity to establish a strong foundation in the home before the
child is born and additional stressors arise (Daro, 2000).
For these reasons, ECIPs provide excellent opportunities to prevent
and identify cases of child maltreatment. These programs are typically
targeted at high-risk populations, including families living in poverty,
children with disabilities, substance abusing parents, families with
histories of violence, and young parents with little knowledge of
parenting or child development (Baydar et al., 2003; Meisels &
Shonkoff, 1990; Peddle, Wang, Diaz, & Reid, 2002; U.S. Department of
Health & Human Services, 2006d). ECIPs have the potential to address
multiple risk factors for child maltreatment in a population of very
young children and pregnant mothers. These programs can address child
maltreatment through promotion of healthy families, prevention of
maltreatment in high-risk families, and early intervention for children
who have been identified as maltreated (National Public Health
Partnership, 2003). While early identification of child maltreatment is
critical, it is undoubtedly more beneficial and cost effective to
prevent child maltreatment before it occurs. For this reason, the
remainder of this paper will specifically focus on ECIPs that attempt to
prevent child maltreatment at the promotion and prevention levels.
Overview of ECIPs
A brief explanation and overview of ECIPs is necessary before
proceeding to specific examples of programs. The term "Early
Childhood Intervention Program" does not refer to a specific
program, but rather refers to a broad class of programs that vary widely
in several areas. Two broad types of ECIPs are generally discussed in
the literature: (a) programs designed to prevent negative outcomes for
children by targeting at-risk children and families, and (b) programs
targeting children with confirmed physical and developmental
disabilities. This paper focuses exclusively on the former. Such ECIPs
may differ in the setting, target of intervention, interveners involved,
inclusion criteria, as well as overall purpose of the program. Common
settings for early intervention services are the home, schools and child
care centers, health care and mental health clinics, and community
settings (Daro & Donnelly, 2002; Peddle et al., 2002; Thompson,
1995). Many ECIPs span a variety of settings, although most programs are
primarily focused on one specific context. While characteristics and
skills of parents and children are the most common targets of ECIPs
(Daro & Donnelly, 2002; Nelson, Laurendeau, & Chamberland, 2001;
PCAA, 2006), other targets may include the parent-child relationship
(Aos, Lieb, Mayfield, Miller, & Pennucci, 2004; Bell & Eyberg,
2002; Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996),
teachers (Daro, 1994; Daro & Donnelly, 2002), peer groups (Daro
& Donnelly, 2002; Thompson, 1995; Thompson et al., 2006), families
(Dupper & Poertner, 1997; Shaw, Dishion, Supplee, Gardner, &
Arnds, 2006), and entire communities (Daro & Donnelly, 2002; Nelson
et al., 2001).
Individuals providing services through ECIPs may include nurses,
mental health professionals, paraprofessionals, social workers,
teachers, law enforcement officers, and graduate students, among others.
ECIPs vary in their assessment process and inclusion criteria as well.
While some programs recruit participants through human service agencies
or self-referrals (Thompson, 1995; Urquiza & McNeil, 1996), others
provide universal assessment of all families in a particular region
(Breakey & Pratt, 1991; Daro, 2000). Many programs assess for the
presence of specific child maltreatment risk factors (Breakey &
Pratt, 1991; Duggan et al., 1999; Thompson, 1995) or include only
high-risk populations such as teen mothers or children with
developmental delays (Meisels & Shonkoff, 1990; Peddle et al.,
2002). ECIPs vary greatly in their stated purpose, ranging from programs
that promote school readiness and overall development to those that aim
to provide health care and prevent child maltreatment. ECIPs of any kind
have the unique potential to address multiple risk factors and prevent
the abuse and neglect of children, an essential precursor to achieving
any other goals a program may have.
Examples of Early Childhood Intervention Programs
In order to demonstrate the ability of ECIPs to prevent child
maltreatment, several programs will be discussed that address common
maltreatment risk factors. The following review focuses exclusively on
programs designed to promote healthy development and prevent negative
outcomes for at-risk children. Another broad type of ECIPs target young
children with established physical and developmental disabilities (such
as early childhood special education programs), although these programs
are not the focus of this paper and have been discussed elsewhere (e.g.,
Baker & Feinfield, 2003; Majnemer, 1998). Rather than providing a
comprehensive review of ECIPs, a small sample of programs across various
settings was selected for discussion. Programs were selected for
discussion if they include services that address common child
maltreatment risk factors, demonstrated reductions in these risk factors
through outcome research, and provide valuable lessons for preventing
child abuse and neglect. These programs are organized into the following
categories: home-based, school-based, clinic-based, and community-based.
Home-Based Programs
In the United States, home visitation programs are the most common
ECIPs aimed at preventing child maltreatment (Peddle et al., 2002) and
are the only programs to provide clear evidence of child abuse
prevention (Nelson et al., 2001). According to Prevent Child Abuse
America (2006), home visitation is "the most innovative and
holistic prevention program used in approaching the difficulties of
educating and supporting the at-risk family" (p. 1). Based on an
extensive review of literature, home visitation was recommended by the
United States Task Force on Community Preventive Services as an
effective strategy for preventing child maltreatment (Hahn et al.,
2003). These programs appear to be very cost effective, with net benefit
estimates ranging from $6,000 to $25,000 per family (Aos et al., 2004;
Nelson et al., 2001; Noor, Caldwell, & Strong, 2003). A cost
effectiveness study by Michigan's Children's Trust Fund in
2002 found that a statewide comprehensive home visitation program for
first time parents would cost less than 4% of the cost to treat the
consequences of child maltreatment (Noor et al., 2003).
Home visitation typically involves regular contact between a family
and a home visitor and can address a variety of issues, including
parenting skills, education about child development, the parent-child
relationship, mental health issues, economic problems, education and
employment, adequate health care, and lack of social support. The
advantages of home visitation in preventing child maltreatment lie in
the unique opportunities to assess the child's safety, increase
generalization of skills through learning in the natural environment,
use flexible approaches, increase participation through bringing
services directly to the family, and provide much-needed support to high
risk families (Daro & Donnelly, 2002; PCAA, 2006; Thompson, 1995).
Home-based programs also eliminate common barriers to receiving
services, such as lack of motivation, lack of health insurance, and lack
of transportation (Thompson, 1995). Evidence from these programs
suggests that significant lasting effects on parental behavior have been
achieved (Daro, 2000; Daro & Donnelly, 2002; Duggan et al., 1999;
Karoly et al., 2001; PCAA, 2006; Thompson, 1995). Examples of home
visitation programs include the Parents as Teachers Program (Wagner
& Clayton, 1999; Winter, 1999), Project 12 Ways (Aos et al., 1999;
Lutzker, Frame, & Rice, 1982), Prenatal to Three Initiative (Perez,
Newman, Bruton, & Peifer, 2003), Family Check-Up (Shaw et al.,
2006), Family Connections (DePanfilis & Dubowitz, 2005) and the
Early Head Start Program (Aos et al., 1999; U.S. Department of Health
& Human Services, 2003, 2006b, 2006c). Additional well-known home
visitation programs are described below.
The first statewide home visitation program in the United States
with the primary goal of preventing child maltreatment was Hawaii's
Healthy Start Program (Breakey & Pratt, 1991; Duggan et al., 1999).
A 3-year demonstration project of this program including 234 families
began in 1985 in Leeward, Oahu, an impoverished community with high
rates of abuse and neglect (Breakey & Pratt, 1991; Duggan et al.,
1999). The goals of the Healthy Start Program are to promote positive
parenting skills, improve family functioning, promote child development,
and prevent child maltreatment (Breakey & Pratt, 1991). These goals
are addressed through home visitation by highly trained
paraprofessionals with limited caseloads who provide education,
counseling, and support for families until the child reaches 5 years old
(Breakey & Pratt, 1991; Duggan et al., 1999). In addition, families
are offered child care services, referrals to other agencies, health
care assistance, and social activities outside the home. High risk
families are identified through a review of hospital admissions data for
15 common risk factors for child maltreatment (e.g., unemployment, lack
of education, history of substance abuse, mental health problems) as
well as an interview and completion of standardized measures (Breakey
& Pratt, 1991; Duggan et al., 1999).
A follow-up evaluation of the 3-year demonstration project found
statistically significant reductions in family stress based on the
Family Stress Checklist and no evidence of child abuse in any of the
families involved, leading to statewide expansion of the program
(Breakey & Pratt, 1991; Duggan et al., 1999; Thompson, 1995).
Subsequent randomized controlled trials have revealed significant
differences between families involved in the Healthy Start Program in
comparison to control groups. For example, a randomized controlled trial
of this program that followed 212 families for one year demonstrated
3.3% confirmed reports of child maltreatment among program participants
in comparison to 6.8% among the control group (Duggan et al., 1999).
These results were both statistically and clinically significant.
Another randomized controlled trial conducted in 1994 included 684
families and utilized structured interviews, in-home observations,
developmental assessments, record reviews, and Child Protective Services
(CPS) reports as outcome data (Duggan et al., 1999). This evaluation
revealed significantly lower rates of partner violence, reduced
parenting stress, and greater use of nonviolent discipline strategies
(Breakey & Pratt, 1991; Duggan et al., 1999; Thompson, 1995). Though
this study found statistically significant differences in neglect and
psychological aggression between groups, there was not a significant
difference in physical abuse or confirmed CPS reports. Despite its
effectiveness, the Healthy Start Program faced several challenges
including average attrition rates of 50% after a year, low rates of
home-visiting, substantial differences across participating agencies,
and reliance on CPS reports as outcome data (Duggan et al., 1999). These
problems may have contributed to the findings of a recent randomized
trial with 643 families which found that the program did not prevent
child abuse or promote the use of nonviolent discipline compared to a
control group (Duggan et al., 2004). However, these challenges are
currently being explored and addressed and the program will undoubtedly
continue to evolve accordingly.
Based on the Healthy Start model and its success in Hawaii, the
National Committee to Prevent Child Abuse (now known as Prevent Child
Abuse America) launched Healthy Families America in 1992 (Duggan et al.,
1999). Like Hawaii's Healthy Start Program, this program was
designed to reduce rates of child maltreatment through providing
voluntary support to new parents and promoting positive parenting (Daro,
2000; Daro & Harding, 1999; Martin, 1999). Healthy Families America
targets all first-time or new parents in a community, assessing for
level-of-risk for child maltreatment and inviting high-risk families to
participate in home visitation until the child reaches 5 years of age
(Daro, 2000; Martin, 1999). To ensure flexibility in program
implementation, Healthy Families America requires that its programs
adhere to 12 critical elements rather than follow a specific model
(Daro, 2000). Home visitation in this program addresses child
development, parent-child interaction, social support, and
problem-solving skills, as well as connecting families to community
resources (e.g., medical provider, child care, job training, housing
assistance, mental health treatment; Daro & Harding, 1999; Martin,
1999).
Results from 29 evaluations of this program across the country
indicate significantly low rates of child maltreatment, positive health
outcomes (e.g., fewer birth complications, fewer low birth weight
babies, up-to-date immunizations), decreased child abuse potential and
parenting stress, and improvements in education and employment compared
to control groups (Daro & Donnelly, 2002; Daro & Harding, 1999).
For example, one site in Virginia was unable to substantiate a single
case of child abuse or neglect among 145 families over a 21-month period
(Daro & Harding, 1999). However, it should be noted that many of
these evaluations were quasi-experimental rather than randomized trials
and there is a great need for better controlled research examining this
program. Since its inception, Healthy Families America has been
implemented across 40 states in over 400 communities to nearly 40,000
parents across the nation (Martin, 1999; Peddle et al., 2002). This
program's success has been an inspiration to many others, although
cost-benefit analyses indicate the program may not be achieving the net
benefit expected, with one estimate in 2003 indicating a net benefit of
-$1,263 per child (Aos et al., 2004). This could be attributed to
significant (20-30%) attrition rates, lack of improvement and sometimes
even a decrease in social support, as well as limited impact on child
development (Daro & Harding, 1999). If nothing else, these findings
suggests that further research is necessary to determine the
"active ingredients" of the program, the best ways to address
social support and child development, and more efficient implementation
procedures.
Another home-based ECIP is the Nurse-Family Partnership (NFP), also
known as the Nurse Home Visitation Program, established by David Olds in
1977 in Elmira, New York (Child Trends, 2003; Karoly et al., 2001; Olds,
1999; Olds et al., 1986). The goals of this program are to improve child
health and development, improve economic self-sufficiency, and improve
pregnancy outcomes (Olds, 1999). Trained nurses with limited caseloads
conduct home visits with young low-income mothers during their pregnancy
and throughout the first two years of their child's life. Home
visitors provide parent education, link families to community resources,
and attempt to strengthen social support networks (Child Trends, 2003;
Olds, 1999). Results of the initial demonstration project of 400
families indicated abuse and neglect rates of 4% for program
participants and 19% for control group families (Olds et al., 1986).
Reductions were also seen in emergency room visits and statistically
significant improvements were found in parent-child interaction, health
care utilization, and employment rates (Olds et al., 1986; Thompson,
1995).
Follow-up studies of the participant families indicated
significantly lower rates of criminal behavior and lower welfare
participation compared to control groups (Karoly et al., 2001). A
15-year follow-up study of the initial NFP demonstration project
including 324 mother-child pairs (81% of the original sample)
demonstrated 79% fewer verified reports of child abuse and neglect
compared to a control group (Eckenrode et al., 2000). However, this
study also indicated that the program was ineffective at reducing
domestic violence rates. As research has demonstrated that child
physical abuse is significantly more likely to occur in families
experiencing domestic violence, it is not surprising that the follow-up
study also found that severe forms of partner violence (more than 28
incidents over 15 years) actually appeared to negate the positive
effects of the program. In other words, the program was unable to
prevent child maltreatment in families who also experienced severe
levels of partner violence. This troubling finding was addressed by
Boris and colleagues (2006) through their augmentation of the NFP
program to include mental health consultants who target maternal
depression, barriers to positive parenting, substance abuse, and family
violence. In order to effectively prevent child maltreatment, ECIPs must
initiate such changes to reduce partner violence in families. Despite
this limitation, the Nurse-Family Partnership has been identified as a
model evidence-based prevention program by Blueprints for Violence
Prevention (Evidence-Based Prevention Programs Committee [EBPPC];
University of Colorado, 2004) and may be considered the best current
prevention program for child physical abuse and neglect (Chaffin &
Friedrich, 2004). The program has now been expanded to over 23 states
and serves approximately 10,000 families annually (Child Trends, 2003).
It is more expensive than most other programs of its kind, although the
cost of the program is typically recovered by the child's fourth
birthday (University of Colorado, 2004). Cost-benefit analyses estimate
that this program achieves an impressive net benefit of $17,000 to
$25,000 per family (Aos et al., 2004; Karoly et al., 2001).
School-Based Programs
Schools and child care centers are ideal settings for child
maltreatment prevention efforts, because they provide access to the
general population, more families can be reached through fewer
resources, and maltreatment is often disclosed to teachers and other
school personnel. Though many of these programs were designed for
school-age children, similar approaches can and have been used with
preschool children. Sexual abuse prevention programs in particular have
utilized the school-based approach, with over 85% of school districts in
the United States offering sexual abuse prevention programs in the year
2000 alone (Davis & Gidyez, 2000). For example, all children
enrolled in California public schools participated in sexual abuse
prevention programs between 1984 and 1988, with a cost of $7.19 per
child compared to the cost of $5,000 to $8,000 for sexual abuse
treatment (Daro, 1994). These programs emphasize education and
empowerment of children to resist sexual abuse, although parents and
school personnel are often incorporated as well (Daro, 1994; Daro &
Donnelly, 2002). Common topics of these programs include good and bad
touches, body ownership, assertiveness training, inappropriate secrets,
trusting intuition, reducing blame, and utilizing support systems.
In general, research has found these programs to be effective in
increasing children's knowledge of sexual abuse (e.g., good and bad
touches, inappropriate secrets) and how to respond to abusive situations
(Daro & Donnelly, 2002; Davis & Gidyez, 2000). A meta-analysis
of 30 school-based sexual abuse prevention programs in 1992 found a mean
effect size of .90, suggesting a significant gain in children's
knowledge following program participation (Daro & Donnelly, 2002;
Davis & Gidyez, 2000). A meta-analysis by Davis and Gidyez (2000)
that included children between 3 and 13 years of age found higher effect
sizes in programs that involved behavioral skills training, puppet
shows, and a greater number of sessions. This study also demonstrated
higher effect sizes with the youngest children (3 to 5 years),
indicating that ECIPs have the potential to implement effective sexual
abuse prevention techniques with preschoolers. On average, the authors
reported an effect size of 1.07 for prevention-related knowledge and
skills across 27 sexual abuse prevention programs. While few studies
have examined actual reductions in abuse rates, they have shown
increased numbers of disclosures of sexual abuse due to prevention
programs (Daro & Donnelly, 2002). This alone may be a powerful
incentive to continue implementing sexual abuse prevention programs in
schools and child care centers.
Examples of school-based sexual abuse prevention programs designed
for use with preschool-age children include the Grossmont College Child
Sexual Abuse Prevention Program (Daro, 1994; Ratto & Bogat, 1990)
and the Behavioral Skills Training Program (Daro, 1994; Wurtele, Kast,
Miller-Perrin, & Kondrick, 1989). The Grossmont College program
includes teacher-training, parent-education, and child -education.
Children are taught skills through the use of activities, role plays,
puppet shows, picture books, and other age-appropriate strategies (Ratto
& Bogat, 1990). The Behavioral Skills Training Program focused on
the idea that certain behaviors are not acceptable, regardless of how
they feel. This program was evaluated through a randomized controlled
trial of 100 children in Head Start preschool classrooms (Wurtele et
al., 1989). Compared to children who received training in evaluating
touches based on how they feel, a statistically significant finding
revealed that children in the Behavioral Skills Training Program were
better able to correctly identify inappropriate touches at
post-treatment and follow-up assessments. This study suggests that
pre-school children may benefit from the use of behavioral skills
training components.
In addition to sexual abuse prevention programs, schools and child
care centers have provided the setting for ECIPs that address various
maltreatment risk factors. Two such programs are the School-Linked
Family Resource Centers and the Head Start Program. Family Resource
Centers were developed to promote safe home environments, educational
achievement, and strong communities. Dupper and Poertner (1997) state,
"The school provides a logical organizational setting for providing
access to high-risk families and children and has the potential of
becoming a 'community hub' ... and a 'welcome
light'" (p. 416). These centers provide a variety of services,
including mental health services, job development, child care, health
services, education, and housing (Dupper & Poertner, 1997). An
exemplary system of Family Resource Centers can be found in the state of
Kentucky, where 134 centers were established before 1993. These centers
target low-income families with young children and are required to
provide full-time preschool for 2- and 3-year-olds, after school
services for 4-to 12-year-olds, home-visiting, parent education,
training for day care providers, monitoring of child development, and
health services for families (Dupper & Poertner, 1997).
Another school-based ECIP that addresses child-maltreatment
risk-factors, the Head Start Program, is a federally funded
comprehensive child development program for low-income families with
3-to 5-year-old children (U.S. Department of Health & Human
Services, 2004a, 2006d). It was launched by the U.S. Department of
Health and Human Services in 1965 to increase school readiness in
children from high-risk families. These programs provide an array of
services, including parent and child education, dental, medical,
nutritional, and mental health services (U.S. Department of Health &
Human Services, 2004a). In 2005, a total of 906,993 children were
enrolled in Head Start programs in 19,800 centers across the country
(U.S. Department of Health & Human Services, 2006d). In addition to
addressing general maltreatment risk factors (e.g., poverty, social
support, mental health problems, parenting skills, low birth weight),
Head Start programs are ideal contexts for implementing specialized
child maltreatment prevention programs (Baydar et al., 2003). The
Incredible Years Parent Training Program has been implemented as a
universal school-based prevention program offered to all Head Start
parents. Through this program, parents learn child-directed skills
(e.g., praise, description, reflection), effective discipline techniques
(e.g., ignoring, Time-Out procedure), coping skills, and strategies to
promote children's social skills through weekly 2-hour sessions
(Baydar et al., 2003). Numerous randomized controlled trials have shown
statistically significant reductions in child behavior problems,
improvements in parent-child relationships, reductions in harsh
parenting, and improvements in prosocial behaviors. By providing
dinners, child care, flexible hours, and make-up sessions, reasonable
success was achieved at retaining low-income participants (74% attended
50% of sessions; Baydar et al., 2003). This program has also been
identified as a model evidence-based prevention program by Blueprints
for Violence Prevention and the SAMHSA Center for Substance Abuse
Prevention (EBPPC, 2007; University of Colorado, 2004).
Clinic-Based Programs
The clinic setting offers several advantages for ECIPs, including a
controlled environment, essential resources, availability of close
supervision, and the credibility of a professional atmosphere. Through
this environment, families can be seen individually or as part of a
group in order to address child maltreatment risk factors. This setting
has proven particularly valuable for teaching parenting skills and
improving the parent-child relationship. Telleen, Herzog, and Kilbane
(1989) describe a clinic-based Family Support Program that addresses
parenting stress, social support, parenting skills, the parent-child
relationship, and knowledge of developmental norms. Family Support
Programs such as this one are typically provided in group formats and
often include parent education components, self-help discussion groups,
and parent-child activities. However, limited outcome research has been
conducted for clinic-based Family Support Programs and more research is
necessary to establish their effectiveness at preventing child
maltreatment.
A more detailed description is warranted for the well-known
evidence-based practice, Parent-Child Interaction Therapy (Eyberg,
1988). Parent-Child Interaction Therapy (PCIT) is a parent training
program developed by Sheila Eyberg that is based on Constance
Hanf's two-stage operant model (Bell & Eyberg, 2002;
Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996). The goal
of the first stage of PCIT, Child Directed Interaction, is to develop a
positive relationship between the parent and child through positive
reinforcement of prosocial behaviors. The second stage of PCIT, Parent
Directed Interaction, addresses appropriate discipline strategies and
behavior management techniques. According to Bell & Eyberg (2002),
this treatment program was based on the influences of developmental
theory, attachment theory, and social learning theory, with a strong
emphasis on play. Treatment typically involves weekly 1-hour sessions,
lasting for an average of 13 sessions. It often consists of didactic
training, modeling, practicing, live coaching, and homework assignments
(Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996). PCIT was
designed as an early intervention for families with young children,
between the ages of 2 and 7 years (Hembree-Kigin & McNeil, 1995;
Urquiza & McNeil, 1996).
PCIT has been applied to a broad range of child and family
problems, including child conduct problems, externalizing and
internalizing problems, inattention and hyperactivity, family
disruption, developmental problems, and child abuse and neglect
(Hembree-Kigin & McNeil, 1995). Outcome studies have demonstrated
significant improvements in child-noncompliance, disruptive behavior,
parenting stress, child self-esteem, and internalizing problems (e.g.,
depression, anxiety). This progress has been shown to generalize to the
home as well as school settings and is maintained at follow-up
evaluations (Bell & Eyberg, 2002; Hembree-Kigin & McNeil, 1995;
Urquiza & McNeil, 1996). PCIT has been increasingly applied to
abusive and potentially abusive families with very promising results
(Urquiza & McNeil, 1996). For example, a randomized controlled trial
of 110 physically abusive parents demonstrated at a follow-up of 850
days that 49% of parents in the control group had a re-report of
physical abuse, while this was the case for only 19% of parents in the
group that received PCIT (Chaffin et al., 2004). In fact, PCIT has been
identified for dissemination as an evidence-based practice for abused
children and their families (Chaffin & Friedrich, 2004). This
treatment is effective because it addresses several maltreatment risk
factors when children are very young, including parenting stress, lack
of parenting skills, negative parent-child relationship, lack of
developmental information, and child behavior problems. There are
certainly limitations with this approach, including difficulty
implementing it in non-clinic settings, significant requirements for
participation that are often unrealistic for high-risk families, and
difficulty generalizing from the clinic to the home. However, as a child
maltreatment prevention strategy, this treatment has been highly
effective and has demonstrated a net benefit of $3,427 per child (Aos et
al., 2004), making it greatly worth the time and resources.
Community-Based Programs
Public education and awareness at the broader community level may
be the most effective way to implement widespread change and foster
child-abuse prevention. Neighborhood-based programs have received
increasing amounts of attention in recent years, although they are still
an under-utilized resource in the area of child-abuse prevention
(Garbarino & Kostelny, 1994). An example of this type of program is
the Neighborhood Parent Support Network Project, developed in 1988 in
Winnipeg and described in more detail elsewhere (e.g., Fuchs, Lugtig,
& Guberman, 2000; Garbarino & Kostelny, 1994). The media is also
a valuable tool for mobilizing community prevention efforts. Public
education through the media has addressed parenting behaviors, aided in
changing attitudes and values related to parenting, and created
awareness of the problem of child maltreatment (Daro & Donnelly,
2002). In addition, prevention programs are likely to be more widely
accepted when they are recognizable through television, newspapers, and
the radio. Prevent Child Abuse America (PCAA) has been a leading force
in the United States in community-based prevention efforts since the
1970s (Daro & Donnelly, 2002; PCAA, 2006). Through the use of
television, radio, print, and billboards, PCAA has increased public
awareness of physical abuse, verbal abuse, and emotional neglect. As a
result of these media campaigns, annual public opinion polls have found
steady declines in reported rates of verbal aggression and corporal
punishment (e.g., spanking) as discipline techniques since 1988 (Daro
& Donnelly, 2002). PCAA supports a variety of primary, secondary,
and tertiary prevention programs targeted at pregnant mothers and
families with young children, although their contribution to
community-level prevention efforts may be their most notable
accomplishment (PCAA, 2006).
Due to difficulties with treatment resistance and program attrition
in families at risk for child maltreatment, Turner and Sanders (2006)
claim that "the reduction of abuse potential of parents must be
tackled within an ecological or systems-contextual framework within a
comprehensive multilevel model of parenting and family support available
at a population-level" (p. 178). As a result, they developed a
multilevel parenting and family support program at the University of
Queensland in Australia, known as the Triple P--Positive Parenting
Program. This program was developed based on social learning theory as
well as psychological and public health research for families with
children from birth to age 16 (Sanders, 1999; Sanders, Markie-Dadds,
& Turner, 2003). The goals of the program are to promote safe and
nurturing environments, build positive relationships between parents and
children, increase emotional and social support, and normalize parent
education, thereby reducing the risk of child maltreatment. Several risk
factors are targeted, including parenting stress, social support,
parent-child relationships, parenting skills, marital discord, and
knowledge of child development.
Triple P incorporates interventions at five different levels,
ranging from individualized treatment to manualized group interventions
and public seminars. Services are provided in medical settings, mental
health offices, schools, workplaces, community organizations, over the
telephone, and through the mass media. At the population level, Triple P
has implemented a universal media information campaign targeting all
parents. This campaign has been led by health care professionals and
trained volunteers and has involved radio, newspapers, magazines,
videos, brochures, and television (Sanders et al., 2003; Turner &
Sanders, 2006). For example, a 13-episode television series providing
parent education was presented in New Zealand in 1995, attracting
approximately 20 to 35% of the viewing audience (Sanders et al., 2003).
Both print media and radio were used to advertise the show and parenting
fact sheets were made available to viewers. Each episode included a 5-
to 7-minute segment promoting the implementation of Triple P in the
home. A group of 56 parents of preschool children were randomly assigned
to view the television show or to receive no intervention (Sanders,
Montgomery, & Brechman-Toussaint, 2000). Participants viewed all
episodes on videotape before the show was released to the public. The
results of this evaluation revealed a statistically significant increase
in parent confidence, decrease in child disruptive behaviors, decrease
in dysfunctional parenting practices, and overall satisfaction with the
program in viewers compared to the control group (Sanders et al., 2003;
Sanders et al., 2000). Although parents viewed the show under highly
controlled conditions, these results provide support for the use of
population-based strategies for preventing child maltreatment. The
various Triple P interventions have been disseminated to over 16,000
professionals in 14 countries to date (Sanders et al., 2003; Turner
& Sanders, 2006).
Summary of Programs
A wide variety of Early Childhood Intervention Programs have been
discussed, including home-based, school-based, clinic-based, and
community-based programs. These example programs are summarized in Table
1. These programs span a variety of academic disciplines, from mental
health and social work to education and health care. They tend to vary
in their goals, participants, and components, but all share the common
potential to prevent child maltreatment. Table 2 summarizes specific
risk factors addressed by each program reviewed in this paper. As
demonstrated in the table, a few important risk factors are rarely
addressed in ECIPs. Substance abuse by parents, parental history of
abuse, and partner violence are significant risk factors that appear to
be neglected in many of these programs. Perhaps incorporating
interventions to address these factors would improve child maltreatment
prevention.
The literature clearly demonstrates that programs that address
multiple risk factors across various levels of intervention (child,
parent, immediate context, and broader context) achieve the most
dramatic and enduring results. It is evident in Table 2 that the ECIPs
discussed previously have strived to achieve this goal. Individual
attitudes and practices can be changed through one-on-one interaction,
although this approach may not address the broader societal influences.
Community-based programs have the potential to achieve the most
widespread impact on child maltreatment rates, although progress is slow
and costly (Daro & Donnelly, 2002; PCAA, 2006). However, as Belsky
(1993) asserts, "It is doubtful that maltreatment can be eliminated
so long as parents rear their offspring in a society in which violence
is rampant, corporal punishment is condoned as a child-rearing
technique, and parenthood itself is construed in terms of
ownership" (p. 423). A combination of ECIPs targeting individual as
well as broader contextual factors is necessary to prevent child abuse
and neglect on a larger scale.
Challenges to Preventing Child Maltreatment in ECIPs
Common Barriers in ECIPs
While ECIPs possess great potential for reducing child maltreatment
risk in high-risk populations, several barriers to achieving these
results have been identified in the literature.
When programs are expanded and disseminated, the quality and scope
of services may be sacrificed and the original concept may be distorted
(Breakey & Pratt, 1991; Duggan et al., 1999). Examples of this can
be seen in home visitation programs. Although research supports more
frequent and higher numbers of home visits, several studies have
revealed that families are receiving approximately half of the home
visits they are scheduled to receive (Sharp, Ispa, & Thornburg,
2003). This may be related to large caseloads, program attrition,
difficulty contacting the family, and characteristics of the
visitor-family relationship. Programs such as Healthy Start and Healthy
Families America have addressed these barriers through adjusting the
frequency of visits based on the family's needs and limiting
caseload size according to the intensity of services required (Breakey
& Pratt, 1991; Daro, 2000). To address difficult visitor-family
relationships, home visitors receive extensive training in working with
at-risk families and ongoing supervision and support from supervisors
(Breakey & Pratt, 1991; Daro, 2000). In addition, programs may be
more likely to struggle with expansion efforts when rigid replication
rules are followed. Healthy Families America addressed this problem by
designing a flexible framework composed of twelve critical elements that
programs are required to follow, rather than requiring programs to
follow a strict detailed format (Daro, 2000).
Another challenge faced by ECIPs is identifying those families most
in need of services. Many programs use a structured assessment process,
through which risk factors are assessed and high-risk families are
identified (Daro, 2000; Daro & Donnelly, 2002; Duggan et al., 1999).
However, risk factors within a family change over time and families who
are not high-risk during pregnancy may be high-risk when the child
enters elementary school. In addition, we know that child maltreatment
cannot be reliably predicted and several factors across various levels
of analysis may interact to increase the risk of abuse. It follows that
there is no reliable method of identifying high-risk families at this
time. To address this problem, some programs have implemented a
universal assessment process (i.e., assessing all parents within a
target area) and/or offered services to all families within a community
(Baydar et al., 2003; Daro, 2000; Daro & Harding, 1999). This
solution increases the likelihood of identifying high-risk families and
reduces the stigma that may be associated with participating in ECIPs.
More research is needed to improve the identification of high-risk
families. Due to the limitations of this process, resources may be
better utilized through community-level prevention efforts that aim to
reduce the risk of child maltreatment in the general population.
Involving low-income and minority parents has been a challenge in
many ECIPs (Dupper & Poertner, 1997). Low-income families often
experience reproachful and condescending interactions with service
providers, in addition to the frequent threat of intrusion by outsiders
(e.g., Child Protective Services) and general lack of respect from
others. Another common barrier is cultural differences, which tend to
breed mistrust as well. Programs such as Head Start (U.S. Department of
Health & Human Services, 2004a) and Family Resource Centers (Dupper
& Poertner, 1997) have attempted to address these problems through
inviting participant families to serve on councils and committees,
hiring participants as staff members, incorporating cultural elements
and translators in the programs, and involving participants in designing
the programs themselves. Other programs such as the Incredible Years
Parent Training Program have provided transportation, meals, flexible
meeting times, make-up sessions, and childcare for families
participating in the program to increase participation rates (Baydar et
al., 2003).
Limitations in Research
In general, large-scale ECIPs have shown limited commitment to
research and program evaluation (Reynolds & Temple, 1998). A lack of
controlled outcome research is evident for many large-scale programs,
particularly in the case of community-based programs. Though it is
difficult to document the changes made by community and population-level
programs, there is a need for innovative research techniques to study
these outcomes (Garbarino & Kostelny, 1994). Smaller-scale
randomized controlled trials of demonstration projects are necessary and
useful, but more effectiveness research is required. In other words,
"Although studies of model programs suggest how effective early
intervention can be, policy makers are most interested in knowing how
effective large-scale, public service programs are" (Reynolds &
Temple, 1998, p. 231).
Other important limitations in ECIP research lie in the research
methodologies that are utilized. Because there is a tendency of
regression toward the mean for extreme scores, high-risk families are
likely to show improvement over time, regardless of the intervention
received (Duggan et al., 1999). For this reason, it is imperative that
well-designed randomized controlled trials be conducted to determine
which outcomes are related to the intervention itself (Chaffin, 2005;
Duggan et al., 1999). According to Chaffin (2005), results of randomized
controlled trials indicate that "the majority of perinatal home
visiting prevention programs do not prevent child abuse" (p. 241).
This finding may be distressing for some, but is based on
well-controlled research and should not be dismissed. It is important to
determine which programs are effective at achieving their goals and
which programs are "an inefficient use of taxpayer money" (Aos
et al., 2004, p. 8).
Chaffin (2005) argues that programs with the self-identified goal
of preventing child maltreatment should be evaluated according to this
outcome. The trouble then lies in determining the best way to measure
the outcome variable (i.e., identify maltreated children). While many
studies include "proxy" variables (e.g., children's
knowledge about body safety) or risk-factors as the outcome variables,
it is preferable to directly measure child maltreatment as the outcome
(Chaffin, 2005; Davis & Gidyez, 2000). However, several obstacles
exist when attempting to accurately measure child maltreatment.
Substantiated reports are probably the best indicators available at this
time, although they are limited by lack of evidence, failure to report,
flawed investigations, and lack of statistical power from infrequent
reporting (Chaffin, 2005; Daro, 2000; U.S. Department of Health &
Human Services, 2006a). Another option is to use all child maltreatment
reports, both substantiated and unsubstantiated, as the outcome
variable. This would increase the numbers of maltreatment cases,
although failure to report would remain an obstacle. In addition,
reports are often made based on limited evidence and sometimes arbitrary
observations. Chaffin (2005) concludes, "The solution to the
maltreatment measurement problem is not turning to questionable
inferential or proxy measures, but rather to collect multi-method data
on the direct outcome of interest" (p. 245).
Recommendations and Future Directions for ECIPs
It is evident that ECIPs have great potential to reduce the risk of
child maltreatment through addressing risk factors within individual
parents and children, their immediate context, and the broader social
context surrounding them. At the individual level, ECIPs can address
parent factors such as mental health issues, parenting stress, and
negative attributions, as well as child factors such as behavior
problems, developmental delays, low self-esteem, and knowledge of
personal safety skills (Bell & Eyberg, 2002; Daro, 2000; Daro &
Donnelly, 2002; Thompson, 1995; Turner & Sanders, 2006; Urquiza
& McNeil, 1996). Within the immediate interactional context, ECIPs
may target parent-child relationships, parenting skills, and partner
violence (Baydar et al., 2003; Bell & Eyberg, 2002; Daro, 2000; Daro
& Donnelly, 2002; Turner & Sanders, 2006; Urquiza & McNeil,
1996). At the community level, ECIPs have the ability to address several
broader contextual factors such as poverty, social support, community
safety, and societal beliefs and attitudes (Dupper & Poertner, 1997;
Garbarino & Kostelny, 1994; PCAA, 2006; Turner & Sanders, 2006).
As demonstrated in the previous discussion, ECIPs differ greatly in the
factors they address and their effectiveness in addressing them. Because
it is unclear which risk factors are the most critical to address
through ECIPs, it is important that multiple risk factors continue to be
addressed simultaneously to maximize the potential of ECIPs to prevent
child maltreatment.
Despite their great potential, several challenges and limitations
of ECIPs have been noted. It is important that these challenges be
addressed through future research and modifications in current programs.
It is also crucial that ECIPs incorporate research findings on
maltreatment risk factors in order to increase their effectiveness at
preventing child abuse and neglect (Aos et al., 2004; Daro, 1994, 2000;
Nelson et al., 2001; Thompson, 1995). The literature has provided
several helpful recommendations for ECIPs in the areas of research,
reaching the target population, retaining service providers, and
increasing family involvement. Many of these recommendations are general
suggestions aimed at improving ECIPs, which will further improve their
effectiveness at preventing child maltreatment.
Improving Research on Effectiveness
1. Conduct cost-benefit analyses as part of the overall program
effectiveness evaluations (e.g., Nurse-Family Partnership, Healthy
Families America, California school-based sexual abuse prevention
programs).
2. Develop better techniques for evaluating large-scale ECIPs
(e.g., Healthy Families America, Healthy Start Program, Triple P).
3. Utilize randomized controlled trials to determine the impact of
ECIPs, rather than relying on quasi-experimental research. Programs that
have conducted randomized controlled trials include, but are not limited
to, the Healthy Start Program, Nurse-Family Partnership, Behavioral
Skills Training Program, Incredible Years Program, and PCIT.
4. Further examine mediator and moderator variables influencing
program effectiveness, such as family involvement, relationship with
home visitor, and parental mental health.
5. Include measures of program integrity to ensure that programs
are implemented as intended, as demonstrated by the Healthy Start
Program.
Enhancing Access to Target Population
1. Offer services to all families in a target community to reduce
stigma and improve the chances of reaching the highest risk families
(e.g., Healthy Start Program, Healthy Families America, PCAA, Triple P).
2. Assess for multiple-risk factors across multiple levels of
analysis to identify high-risk families (e.g., Healthy Start Program,
Healthy Families America).
3. Use media resources to familiarize families with programs and to
change widely held beliefs about parenting (e.g., PCAA, Triple P).
4. Allow for flexibility and individualization when implementing
services across diverse populations that differ greatly in their needs
and strengths (e.g., Healthy Families America).
Retaining Qualified Staff Members
1. Hire staff with appropriate education and experience and provide
ongoing training in relevant topics, such as child development,
attachment, health care, parenting skills, substance abuse, mental
health, problem-solving skills, and family violence.
2. Limit staff caseload size and provide ongoing supervision and
support, particularly in home visitation programs. Examples of programs
that are successfully utilizing these strategies are the Healthy Start
Program and Healthy Families America.
3. Provide incentives to staff when possible, such as salary
increases, tuition reimbursement, flexible hours, and awards and
recognition ceremonies (e.g., Healthy Start Program).
Increasing Involvement of Families
1. Acquire assistance from families in developing local programs
and continuously elicit and utilize feedback from participating families
(e.g., Family Resource Centers).
2. Allow families to serve on councils and committees to increase
their level commitment and motivation (e.g., Head Start Program, Family
Resource Centers).
3. Hire participants as program staff and utilize participants as
teachers when possible (e.g., Family Resource Centers).
4. Acknowledge diversity as a strength and improve cultural
competence of staff through training, role plays, and open discussions
(e.g., Family Resource Centers).
5. Provide incentives to families for participation when possible,
such as free meals, transportation, gift certificates, and free
childcare (e.g., Incredible Years Program).
Enhancing Prevention of Child Maltreatment
While the previous recommendations will improve the ability of
ECIPs to prevent child maltreatment through improving their general
effectiveness, several suggestions can be identified that specifically
relate to prevention of child abuse and neglect:
1. When examining the effectiveness of ECIPs in preventing child
maltreatment, Chaffin (2005) recommends using direct measures of child
maltreatment whenever possible, including substantiated and
unsubstantiated reports to Child Protective Services (e.g., Nurse-Family
Partnership, Healthy Start Program, Healthy Families America).
Particularly with school-based sexual abuse prevention programs, very
little research has been conducted using direct measures of sexual abuse
as the outcome variable (Davis & Gidyez, 2000).
2. Use multiple methods of measuring child maltreatment, such as
self-report of child maltreatment by parents, observational data,
information on out-of-home placements, and child welfare reports
(Chaffin, 2005).
3. Address risk-factors at multiple levels of intervention,
including parent factors, child factors, immediate context, and broader
community context (e.g., Triple P). Along the same lines, provide
interventions across multiple settings, such as home visitation,
school-based programs, treatment in clinic settings, and community-wide
media campaigns and interventions.
4. Incorporate interventions to address substance abuse by parents,
parental history of abuse, and partner violence, all of which are
significant risk factors that appear to be neglected in many ECIPs.
5. Utilize behavioral rehearsal and reinforcement techniques,
particularly when training parents in behavior management techniques and
teaching children skills to prevent sexual abuse (e.g., PCIT, Behavioral
Skills Training Program).
6. Intervene as early as possible (preferably during pregnancy) to
teach parenting skills and educate parents on child development (e.g.,
PCAA).
7. Continue to conduct randomized controlled trials of ECIPs
assessing child maltreatment prevention as an outcome variable and
continuously modify programs to incorporate research findings on child
abuse and neglect risk-factors and effective prevention strategies.
In sum, we have learned a great deal over the past few decades from
research on child maltreatment as well as evaluations of ECIPs. It is
clear that much is left to be done, but the field has progressed toward
its goals of strengthening families and protecting children from abuse
and neglect. Until greater efforts are made on a societal level, ECIPs
will continue to chip away at the overwhelming problems faced by
children. As Edward Zigler (1990) laments, "No amount of
counseling, early childhood curricula, or home visits will take the
place of jobs that provide decent incomes, affordable housing,
appropriate health care, optimal family configurations, or integrated
neighborhoods where children encounter positive role models" (p.
xiii). While home, school, and clinic-based ECIPs can be highly
effective at preventing child maltreatment, it is when these programs
are embedded within a system of community-wide prevention efforts that
pervasive and enduring changes can take place.
References
Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A.
(2004). Benefits and costs of prevention and early intervention programs
for youth. Olympia, WA: Washington State Institute for Public Policy.
Baker, B. L., & Feinfield, K. A. (2003). Early intervention.
Current Opinion in Psychiatry, 16(5), 503-509.
Baydar, N., Reid, M. J., & Webster-Stratton, C. (2003). The
role of mental health factors and program engagement in the
effectiveness of a preventive parenting program for Head Start mothers.
Child Development, 74, 1433-1453.
Bell, S. K., & Eyberg, S. M. (2002). Parent-Child Interaction
Therapy: A dyadic intervention for the treatment of young children with
conduct problems. In L. VandeCreek & T. L. Jackson (Eds.),
Innovations in clinical practice: A source book (Vol. 20) (pp. 57-74).
Sarasota, FL: Professional Resource Press/Professional Resource
Exchange.
Belsky, J. (1993). Etiology of child maltreatment: A
developmental-ecological analysis. Psychological Bulletin, 114, 413-434.
Boris, N. W., Larrieu, J. A., & Zeanah, P. D. (2006). The
process and promise of mental health augmentation of nurse home-visiting
programs: Data from the Louisiana Nurse-Family Partnership. Infant
Mental Health Journal, 27, 26-40.
Breakey, G., & Pratt, B. (1991, April). Healthy growth for
Hawaii's "Healthy Start": Toward a systematic statewide
approach to the prevention of child abuse and neglect. Zero to Three,
16-22.
Bronfenbrenner, U. (1979). The ecology of human development.
Cambridge: Harvard University Press.
Chaffin, M. (2005). 'Is it time to rethink Healthy
Start/Healthy Families?': Response to letters. Child Abuse &
Neglect, 29(3), 241-249.
Chaffin, M. & Friedrich, B. (2004). Evidence-based treatments
in child abuse and neglect. Children and Youth Services Review, 26,
1097-1113.
Chaffin, M., Silovsky, J. F., Funderburk, B. Valle, L. A., Brestan,
E. V., Balachova, T., Jackson, S., Lensgraf, J., & Bonner, B. L.
(2004). Parent-child interaction therapy with physically abusive
parents: Efficacy for reducing future abuse reports. Journal of
Consulting and Clinical Psychology, 72, 500-510.
Child Trends (2003). Guide to effective programs for children and
youth: Nurse-Family Partnership. Retrieved May 27, 2006, from
http://www.childtrends.org/lifecourse/programs/NurseHomeVisitingProgram.htm.
Cicchetti, D., & Toth, S. L. (2000). Developmental processes in
maltreated children. In D. J. Hansen (Ed.), Motivation and child
maltreatment: Volume 46 of the Nebraska Symposium on Motivation (pp.
85-160). Lincoln, NE: University of Nebraska Press.
Daro, D. A. (1994). Prevention of child sexual abuse. Sexual Abuse
of Children, 4, 198-223.
Daro, D. A. (2000). Child abuse prevention: New directions and
challenges. In D. J. Hansen (Ed.), Motivation and child maltreatment:
Volume 46 of the Nebraska Symposium on Motivation (pp. 161-219).
Lincoln, NE: University of Nebraska Press.
Daro, D. A. & Donnelly, A. C. (2002). Child abuse prevention:
Accomplishments and challenges. In J. E. B. Myers, L. Berliner, J.
Briere, C. T. Hendrix, C. Jenny, & T. A. Reid (Eds.), APSAC handbook
on child maltreatment: Second edition (pp. 431-448). Thousand Oaks, CA:
Sage Publications.
Daro, D., & Harding, K. (1999). Healthy Families America: Using
research in going to scale. The Future of Children, 9(1), 152-176.
Davis, M. K., Gidyez, C. A. (2000). Child sexual abuse prevention
programs: A meta-analysis. Journal of Clinical Child Psychology, 29,
257-265.
DePanfilis, D. & Dubowitz, H. (2005). Family Connections: A
program for preventing child neglect. Child Maltreatment, 10(2),
108-123.
Duggan, A. K., McFarlane, E., Fuddy, L., Burrell, L., Higman, S.
M., Windham, A., & Sia, C. (2004). Randomized trial of a statewide
home visiting program: Impact in preventing child abuse and neglect.
Child Abuse & Neglect, 28, 597-622.
Duggan, A. K., McFarlane, E. C., Windham, A. M., Rohde, C. A.,
Salkever, D. S., Fuddy, L., Rosenberg, L. A., Buchbinder, S. B., &
Sia, C. C. (1999). Evaluation of Hawaii's Healthy Start Program.
The Future of Children, 9(1), 66-88.
Dumas, J. E. & Wahler, R. G. (1983). Predictors of treatment
outcome in parent training: Mother insularity and socioeconomic
disadvantage. Behavioral Assessment, 5, 301-313.
Dupper, D. R., & Poertner, J. (1997). Public schools and the
revitalization of impoverished communities: School-linked, family
resource centers. Social Work, 42, 415-422.
Eckenrode, J., Ganzel, B., Henderson, C. R., Smith, E., Olds, D.
L., Powers, J., et al. (2000). Preventing child abuse and neglect with a
program of nurse home visitation: The limiting effects of domestic
violence. Journal of the American Medical Association, 284, 1385-1391.
Evans, G. W. (2004). The environment of childhood poverty. American
Psychologist, 59, 77-92. Evidence-Based Prevention Programs Committee
(n.d.). Evidence-based prevention programs as determined by three major
review sites. Retrieved March 13, 2007, from
http://www.ebppc.hawaii.edu/Documents/documents.htm
Eyberg, S. M. (1988). Parent-child interaction therapy: Integration
of traditional and behavioral concerns. Child and Family Behavior
Therapy, 10, 33-46.
Fromm, S. (2001). Total estimated cost of child abuse and neglect
in the United States: Statistical evidence. Chicago: Prevent Child Abuse
America.
Fuchs, D., Lugtig, D., & Guberman, I. (June, 2000). The
Neighborhood Parent Support Network Project: Final report. Winnipeg,
Canada: Child & Family Research Group, Faculty of Social Work
University of Manitoba Monograph.
Garbarino, J., & Kostelny, K. (1994). Neighborhood-based
programs. In G. B. Melton & F. D. Barry (Eds.), Protecting children
from abuse and neglect: Foundations for a new national strategy (pp.
304-351). New York: Guilford Press.
Graham-Bermann, S. A. (2002). Child abuse in the context of
domestic violence. In J. E. B. Myers, L. Berliner, J. Briere, C. T.
Hendrix, C. Jenny, & T. A. Reid (Eds.), The APSAC handbook on child
maltreatment (2nd edition) (pp. 21-54). Thousand Oaks, CA: Sage.
Greven, P. (1990). Spare the child: The religious roots of
punishment and the psychological impact of physical abuse. New York:
Vintage Books.
Hahn, R. A., Bilukha, O. O., Crosby, A., Fullilove, M. T.,
Liberman, A., Moscicki, E. K., Snyder, S., Tuma, F., Schofield, A.,
Corso, P. S., & Briss, P. (2003). First reports evaluating the
effectiveness of strategies for preventing violence: Early childhood
home visitation. Morbidity & Mortality Weekly Report, 52(RR-14),
1-20.
Hecht, D. B. & Hansen, D. J. (2001). The environment of child
maltreatment: Contextual factors and the development of psychopathology.
Aggression and Violent Behavior, 6, 433-457.
Hembree-Kigin, T. L., & McNeil, C. B. (1995). Parent-Child
Interaction Therapy. New York: Plenum Press.
Holden, G. W., Coleman, S. M., & Schmidt, K. L. (1995). Why
3-year-old children get spanked: Parent and child determinants as
reported by college-educated mothers. Merrill-Palmer Quarterly, 41,
431-452.
Karoly, L. A., Kilburn, M. R., Bigelow, J. H., Caulkins, J. P.,
Cannon, J. S., & Chiesa, J. R. (2001). Assessing costs and benefits
of early childhood intervention programs: Overview and application to
the Starting Early Starting Smart Program. Seattle, WA: Casey Family
Programs.
Lovell, M. L., & Hawkins, J. D. (1988). An evaluation of a
group intervention to increase the personal social networks of abusive
mothers. Children and Youth Services Review, 10, 175-188.
Lovell, M. L., & Richey, C. A. (1997). The impact of social
support skill training on daily interactions among parents at higher
risk for child maltreatment. Children and Youth Services Review, 19,
221-251.
Lutzker, J. R., Frame, R. E., & Rice, J. M. (1982). Project
12-Ways: An ecobehavioral approach to the treatment and prevention of
child abuse and neglect. Education & Treatment of Children, 5,
141-155.
Majnemer, A. (1998). Benefits of early intervention for children
with developmental disabilities. Seminars in Pediatric Neurology, 5,
62-69.
Martin, J. B. (1999). Appendix A: Healthy Families America. The
Future of Children, 9(1), 177-178.
Meisels, S. J., & Shonkoff, J. P. (1990). Handbook of early
childhood intervention. New York: Cambridge University Press.
Murphy, E. (1997). Attitudes towards and use of physical punishment
by US and UK mothers. Ottawa: National Clearinghouse on Family Violence,
1994.
National Clearinghouse on Child Abuse and Neglect Information
(1996). Cross-site evaluation report: Evaluation of nine comprehensive
community-based child abuse and neglect prevention programs. Retrieved
May 20, 2006, from http://nccanch.acf.hhs.gov/pubs/otherpubs/lessons/intro.cfm
National Public Health Partnership (2003). National mental health
promotion and prevention working party (PPWP). Retrieved July 22, 2006,
from http://www.dhs.vic.gov.au/nphp/workprog/ppwp/index.htm
Nelson, G., Laurendeau, M., & Chamberland, C. (2001). A review
of programs to promote family wellness and prevent the maltreatment of
children. Canadian Journal of Behavioural Science, 22, 1-13.
Noor, I., Caldwell, R. A., & Strong, D. (2003, Winter). The
costs of child abuse vs. child abuse prevention: A decade of
Michigan's experience. National Alliance of Children's Trust
& Prevention Funds, 7-10.
Norbeck, J. S., Dejoseph, J. F., & Smith, R. T. (1996). A
randomized trial of an empirically derived social support intervention
to prevent low birth weight among African American women. Social Science
& Medicine, 43, 947-954.
Olds, D. L. (1999). Appendix C: The Nurse Home Visitation Program.
The Future of Children, 9(1), 190-191.
Olds, D. L., Henderson, C. R., Chamberlin, R., & Tatelbaum, R.
(1986). Preventing child abuse and neglect: A randomized trial of nurse
home visitation. Pediatrics, 78, 65-78.
Peddle, N., Wang, C. T., Diaz, J., & Reid, R. (2002). Current
trends in child abuse prevention and fatalities: The 2000 Fifty State
Survey. Chicago: Prevent Child Abuse America.
Perez, L. M., Newman, M. C., Bruton, N., & Peifer, K. L.
(2003). Infant mental health evaluation process: Evaluating, diagnosing,
and treating infant mental health in community practice. Zero to Three,
55-64.
Prevent Child Abuse America (2006). Fact sheet: An approach to
preventing child abuse. Retrieved May 7, 2006 from
http://member.preventchildabuse.org/site/PageServer?pagename=research_factsheets.
Ratto, R., & Bogat, G. (1990). An evaluation of a preschool
curriculum to educate children in the prevention of sexual abuse.
Journal of Community Psychology, 18, 289-303.
Reynolds, A. J., & Temple, J. A. (1998). Extended early
childhood intervention and school achievement: Age thirteen findings
from the Chicago Longitudinal Study. Child Development, 69, 231-246.
Richey, C. A., Lovell, M. L., & Reid, K. (1991). Interpersonal
skill training to enhance social support among women at-risk for child
maltreatment. Children and Youth Services Review, 13, 41-59.
Sanders, M. R. (1999). Triple P--Positive Parenting Program:
Towards an empirically validated multilevel parenting and family support
strategy for the prevention of behavior and emotional problems in
children. Clinical Child and Family Psychology Review, 2(2), 71-90.
Sanders, M. R., Markie-Dadds, C., & Turner, K. M. T. (2003).
Theoretical, scientific and clinical foundations of the Triple
P--Positive Parenting Program: A population approach to the promotion of
parenting competence. Retrieved July 19, 2006, from
http://www.triplep-america.com/
Sanders, M. R., Mongomery, D. T., & Brechman-Toussaint, M. L.
(2000). The mass media and child behavior problems: The effect of a
television series on child and parent outcomes. Unpublished manuscript,
University of Queensland at St. Lucia.
Saywitz, K. J., Mannarino, A. P., Berliner, L., & Cohen, J. A.
(2000). Treatment for sexually abused children and adolescents. American
Psychologist, 55, 1040-1049.
Sharp, E. A., Ispa, J. M., & Thornburg, K. R. (2003). Relations
among mother and home visitor personality, relationship quality, and
amount of time spent in home visits. Journal of Community Psychology,
31(6), 591-606.
Shaw, D. S., Dishion, T. J., Supplee, L., Gardner, F., & Arnds,
K. (2006). Randomized trial of a family-centered approach to the
prevention of early conduct problems: 2-year effects of the Family
Check-Up in early childhood. Journal of Consulting and Clinical
Psychology, 74, 1-9.
Sheppard, M. (1997). Double jeopardy: The link between child abuse
and maternal depression in child and family social work. Child &
Family Social Work, 2(2), 91-107.
Solomons, G. (1979). Child abuse and developmental disabilities.
Developmental Medicine & Child Neurology, 21(1), 101-106.
Straus, M. A. (2001). Beating the devil out of them: Corporal
punishment in American families and its ffects on children. New
Brunswick, NJ: Transaction Publishers.
Taylor, C. G., Norman, D. K., Murphy, J. M., Jellenik, M., Quinn,
D., Poitrast, F. G., & Goshko, M. (1991). Diagnosed intellectual and
emotional impairment among parents who seriously mistreat their
children: Prevalence, type, and outcome in a court sample. Child Abuse
& Neglect, 15, 389-401.
Telleen, S., Herzog, A., & Kilbane, T. L. (1989). Impact of a
family support program on mothers' social support and parenting
stress. American Journal of Orthopsychiatry, 59, 410-419.
Thompson, R. A. (1995). Preventing child maltreatment through
social support: A critical analysis. Thousand Oaks, CA: Sage.
Thompson, R. A., Flood, M. F., & Goodvin, R. (2006). Social
support and developmental psychopathology. In D. Cicchetti & D.
Cohen (Eds.), Developmental psychopathology (2nd Ed.): Vol.III. Risk,
disorder, and adaptation. New York: Wiley.
Turner, K. M. T. & Sanders, M. R. (2006). Dissemination of
evidence-based parenting and family support strategies: Learning from
the Triple P--Positive Parenting Program system approach. Aggression and
Violent Behavior, 11, 176-193.
Tyler, K. A. (2002). Social and emotional outcomes of childhood
sexual abuse: A review of recent research. Aggression and Violent
Behavior, 7, 567-589.
University of Colorado, Center for the Study and Prevention of
Violence (2004). Blueprints model programs overview. Retrieved March 13,
2007, from http://www.colorado.edu/cspv/blueprints/model/overview.html
Urquiza, A. J., & McNeil, C. B. (1996). Parent-Child
Interaction Therapy: An intensive dyadic intervention for physically
abusive families. Child Maltreatment, 1, 134-144.
U.S. Department of Health & Human Services, Administration for
Children and Families (2004a). About Head Start. Retrieved May 7, 2006,
from http://www.acf.hhs.gov/programs/hsb/about/index.htm
U.S. Department of Health and Human Services, Administration on
Children, Youth and Families (2004b). Making an economic case for
prevention. Washington, DC: National Clearinghouse on Child Abuse and
Neglect Information.
U.S. Department of Health and Human Services, Administration for
Children and Families (2006a). Child maltreatment 2004. Washington, DC:
U.S. Government Printing Office.
U.S. Department of Health & Human Services, Administration for
Children and Families (2006b). Early Head Start Research and Evaluation
Project (EHSRE). Retrieved February 5, 2006, from
http://www.acf.hhs.gov/programs/opre/ehs/ehs_resrch/
U.S. Department of Health & Human Services, Administration for
Children and Families (2006c). Early Head Start Program Performance
Measures. Retrieved February 5, 2006, from
http://www.acf.hhs.gov/programs/opre/ehs/perf_measures/reports/
U.S. Department of Health & Human Services (2006d). Head Start
Bureau. Retrieved May 20, 2006, from
http://www.acf.hhs.gov/programs/hsb/
Wagner, M. M., & Clayton, S. L. (1999). The Parents as Teachers
Program: Results from two demonstrations. The Future of Children, 9(1),
91-115.
Wahler, R. G. (1980). The insular mother: Her problems in
parent-child treatment. Journal of Applied Behavior Analysis, 13,
207-219.
Wahler, R. G., Hughey, J. B., & Gordon, J. S. (1981). Chronic
patterns of mother-child coercion: Some differences between insular and
noninsular families. Analysis and Intervention in Developmental
Disabilities, 1, 145-156.
Winter, M. M. (1999). Appendix B: Parents as Teachers. The Future
of Children, 9(1).
Wurtele, S., Kast, L., Miller-Perrin, C., & Kondrick, P.
(1989). A comparison of programs for teaching personal safety skills to
preschoolers. Journal of Consulting and Clinical Psychology, 57,
505-511.
Zigler, E. (1990). Foreword. In S. J. Meisels & J. P. Shonkoff
(Eds.), Handbook of early childhood intervention (pp. ix-xiv). New York:
Cambridge University Press.
Lindsay E. Asawa, David J. Hansen, and Mary Fran Flood
University of Nebraska-Lincoln
Correspondence to Lindsay E. Asawa, Dept. of Psychology, University
of Nebraska-Lincoln, 238 Burnett Hall, Lincoln, NE 68588-0308; e-mail:
lecronch@yahoo.com.
Table 1 Summary of Selected Early Childhood Intervention Programs
Setting Program Target(s) Intervener(s)
Home-Based Healthy Start Parents and parent- Paraprofessionals
Program child
relationship
Healthy Families Parents and parent- Paraprofessionals
America child
relationship
Nurse-Family Mothers Nurses
Partnership
School- Family Resource Children, parents, Paraprofessionals,
Based Centers families, groups, mental health
and teachers professionals,
and teachers
Head Start Program Children, parents, Paraprofessionals
and teachers and teachers
Clinic- Parent-Child Parents and Mental health
Based Interaction parent-child professionals
Therapy relationship
Community- Prevent Child Abuse Parents and Wide variety of
Based America families service
providers
Triple P--Positive Parents and Health care
Parenting Program families professionals
and trained
volunteers
Setting Program Inclusion Criteria
Home-Based Healthy Start Universal assessment to identify high
Program risk families
Healthy Families Universal assessment to identify high
America risk families
Nurse-Family Young (<19), low-income, single mothers
Partnership
School- Family Resource Students at the school and their
Based Centers families, as well as members of the
surrounding community
Head Start Program Low-income families with children from
3 to 5 years
Clinic- Parent-Child Families with children between 2 and 7
Based Interaction years who were referred for treatment
Therapy
Community- Prevent Child Abuse General public, pregnant mothers,
Based America families with young children
Triple P--Positive All parents in Australia with children
Parenting Program ages 16 and under
Table 2 Summary of Child Maltreatment Risk Factors Addressed by ECIPs
ECIP Parent Factors Child Factors
Healthy Start Program Parent stress Young children
Parent mental health (Birth to age 5)
Negative attributions Behavior problems
Healthy Families America Parent stress Young children
Parent mental health (Birth to age 5)
Negative attributions Behavior problems
Health/development
Nurse-Family Partnership Parent stress Young children
Parent mental health (Birth to age 2)
Substance abuse Health/development
Negative attributions
Family Resource Centers Parent stress Young children
Parent mental health Health/development
Head Start Program Parent stress Young children
Parent mental health (3 to 5 years)
Negative attributions Health/development
Parent-Child Interaction Parent stress Young children
Therapy Negative attributions (2 to 7 years)
Behavior problems
Developmental
disabilities
Low self-esteem
Prevent Child Abuse Negative attributions Young children
America
Triple P--Positive Parent stress Young children
Parenting Program Negative attributions Behavior problems
ECIP Immediate Context Broader Context
Healthy Start Program Parent-child relationship Poverty
Parenting skills Parent social
Parent knowledge support
Discipline strategies
Healthy Families America Parent-child relationship Poverty
Parenting skills Parent social
Parent knowledge support
Discipline strategies
Nurse-Family Partnership Parent-child relationship Poverty
Parenting skills Parent social
Parent knowledge support
Parent discord/violence
Family Resource Centers Parent knowledge Poverty
Parent social
support
Head Start Program Parent-child relationship Poverty
Parenting skills Parent social
Parent knowledge support
Discipline strategies
Parent-Child Interaction Parent-child relationship Parent social
Therapy Parenting skills support
Parent knowledge
Discipline strategies
Prevent Child Abuse Parent-child relationship Societal acceptance
America Parenting skills of violence
Parent knowledge Societal awareness
Discipline strategies of child
maltreatment
Triple P--Positive Parent-child relationship Parent social
Parenting Program Parenting skills support
Parent knowledge Societal acceptance
Discipline strategies of violence
Partner discord/violence Societal awareness
of child
maltreatment