eJournals Psychologie in Erziehung und Unterricht 59/4

Psychologie in Erziehung und Unterricht
3
0342-183X
Ernst Reinhardt Verlag, GmbH & Co. KG München
101
2012
594

Early Childhood Prevention in the United States

101
2012
Elizabeth A. Steed
Child abuse and neglect is an international issue that continues to affect too many Young children. This paper provides an overview of prevention of child abuse and neglect in the United States. Key challenges related to the prevention of child maltreatment in the United States are discussed, such as high caseloads and a lack of a national prevention approach. The federal agency providing prevention and intervention in the United States continues to use social workers as Intervention agents who may lack training to provide effective prevention and intervention techniques and focuses services on only the most at-risk families. Four alternative types of United States prevention and intervention programs are described, including parent education, home visitation, community programs, and respite and crisis care programs. Specific evidence-based programs, such as Parent-Child Interaction Therapy and SafeCare are briefly reviewed. The paper also explores comparisons of prevention efforts in the United States to those undertaken in Germany. Finally, recommendations are provided for future efforts to decrease the incidence of child maltreatment globally.
3_059_2012_004_0247
Psychologie in Erziehung und Unterricht, 2012, 59, 247 - 255 DOI 10.2378/ peu2012.art19d © Ernst Reinhardt Verlag München Basel n Übersichtsartikel Early Childhood Prevention in the United States Elizabeth A. Steed Georgia State University Summary: Child abuse and neglect is an international issue that continues to affect too many young children. This paper provides an overview of prevention of child abuse and neglect in the United States. Key challenges related to the prevention of child maltreatment in the United States are discussed, such as high caseloads and a lack of a national prevention approach. The federal agency providing prevention and intervention in the United States continues to use social workers as intervention agents who may lack training to provide effective prevention and intervention techniques and focuses services on only the most at-risk families. Four alternative types of United States prevention and intervention programs are described, including parent education, home visitation, community programs, and respite and crisis care programs. Specific evidence-based programs, such as Parent-Child Interaction Therapy and SafeCare are briefly reviewed. The paper also explores comparisons of prevention efforts in the United States to those undertaken in Germany. Finally, recommendations are provided for future efforts to decrease the incidence of child maltreatment globally. Child abuse and neglect is a major international issue. Approximately 3,500 children die each year from maltreatment in the industrialized world (UNICEF, 2003). Two children die from abuse and neglect every week in Germany and 27 children die each week in the United States (UNICEF, 2003). In the United States, it is the second leading cause of death for young children. Approximately 905,000 children experience abuse or neglect in the United States each year (DHHS, 2010). The youngest children are most at risk for abuse or neglect, with one third of cases including children under four; infants under 1 are the most likely victims (DHHS, 2010). Many of these young children will suffer the effects of maltreatment into adulthood with poor physical health, social and emotional difficulties, cognitive impairment, and behavioral problems (Wang & Holton, 2007; Wiggins, Fenichel, & Mann, 2007). Abuse in early childhood is also associated with longterm depression and increased risk of substance abuse and criminal activity (Widom & White, 1997). The effects of child maltreatment extend to all of society with increased criminal behavior and decreased productivity (Stagner & Lansing, 2009). Given these substantial long-term consequences it is a primary obligation of communities and political agencies to reduce risks for child abuse and neglect. There are many well-known risk factors for and causes of child maltreatment, such as poverty, family violence, substance abuse, and a lack of knowledge about parenting and child development (Okun, Parker, & Levendosky, 1994). Many of these risk factors are difficult or expensive to change while others can be easily addressed and reduced by suitable programs. In fact, respective research on risk factors and/ or causes of child maltreatment as well as evidence from evaluation research has clearly informed and helped to improve approaches to early prevention in terms of their research-based framework and effectiveness. This paper will provide an overview of prevention in the United States, review current prevention and intervention programs, com- 248 Elizabeth A. Steed pare these to prevention efforts in Germany, and provide recommendations to improve early childhood prevention and intervention globally. Overview of Prevention and Intervention in the United States In the United States, Child Protective Services (CPS) is responsible for screening and providing services to the majority of children that are at risk for abuse and neglect in each state. Federal laws such as the Child Abuse and Prevention Act (CAPTA), initially passed in 1974, govern CPS activities and provide funding for prevention and intervention efforts across the country (Waldfogel, 2009). The initial aim of CPS was to prevent the recurrence of maltreatment through reporting laws and protecting children from future harm through monitoring and/ or removal from the home (Stagner & Lansing, 2009). In the most recent reauthorization of CAPTA in 2003, the federal legislation places more emphasis on prevention of maltreatment before it occurs by funding prevention programs. It also established a specific agency within the federal government called the Office on Child Abuse and Neglect (Stagner & Lansing, 2009). While these efforts mirror social pressures to focus more national attention and funding on prevention of child maltreatment, CPS state agencies in the United States continue to demonstrate that they may not be attaining goals of prevention of child abuse and neglect (e. g., Campbell, Cook, LaFleur & Keenan, 2010). There are signs that CPS workers do not intervene at the first signs of neglect, but rather focus on families that demonstrate significant need over families with fewer risk factors (Wilson & Horner, 2005). Of the 702,000 cases of substantiated abuse or neglect in the United States in 2009, 40 % receive no follow up (DHHS, 2010). It is known that CPS workers have high caseloads and limited resources (Wilson & Horner, 2005). So, it makes sense that they may put a higher priority on cases of abuse rather than cases of neglect with fewer risk factors (Waldfogel, 2009). However, we know that acting early in cases of neglect may prevent further neglect or the progression of neglect into abuse (Boyd, 2009). The CAPTA reauthorization of 2003 stipulates that CPS must refer low-risk families for whom they are unable to provide services. However, while they are mandated to do this, states vary considerably in their ability to refer low-risk children and families to communitybased prevention services. Some states such as Minnesota have been able to increase their referral of low-risk families through private funding. In Minnesota, funds from the McKnight Foundation have allowed the state to increase prevention services to an extra 20 percent of families who had been denied services from CPS (Waldfogel, 2009). Most states do not have private funding sources such as this and are just beginning to address the large number of families that need prevention services beyond what CPS can provide. Further findings regarding CPS include a study that demonstrated that families participating in four years of CPS services did not show marked improvements in risk factors such as maternal depression and children’s problem behaviors (Campbell et al., 2010). Other studies have also noted high rates of children rereported for child abuse following post-investigation CPS services (Waldfogel, 2009). One explanation of the low efficacy of CPS may be that they are providing services to families with the most risk factors that may be the most difficult to influence. Another explanation is that CPS professionals have been found to use intervention techniques that are not substantiated by research or to implement curricula incorrectly or insufficiently (Waldfogel, 2009). Further, CPS workers have been charged with disregarding cultural variations in family practices and ignoring family voices about what they need and want from their services (Bolen, McWey & Schlee, 2008; Harder, 2005; Wilson & Horner, 2005). It is important that interventions address specific family issues (e. g., substance abuse, isolation) in the context of parenting and child Early Childhood Prevention in the United States 249 rearing (Guterman, 2006). It is also important that professionals acknowledge and understand the social isolation that many target families experience. Families may harbor distrust of “outsiders” and anyone seen as an authority (Waldfogel, 2009). For this reason, prevention and intervention program personnel need to be well trained on a variety of issues, know how to engage families collaboratively, and understand the cultural context in which they will be operating when serving families. Prevention and Intervention Programs in the United States In addition to the monitoring and intervention services provided by CPS, there are four general categories of prevention provided to families in the United States who are at risk or suspected of child maltreatment. These services include (1) group based parent education and parent support groups, (2) home visitation, (3) community programs, and (4) respite and crisis care programs for families in need (Stagner & Lansing, 2009). We know from the literature that prevention is most effective if it is started at birth or even prenatally, is intensive, includes support for families to address financial and/ or health issues including alcohol and illegal drug abuse, involves home-based services, limits case loads, and provides ongoing training to families (Bakermans-Kranenburg, van IJzendorn & Juffer, 2003; Waldfogel, 2009). There is limited research on most prevention and intervention approaches that are used in practice. However, there is some initial evidence to support that some approaches (e. g., brief cognitive-behavioral) may be more effective than others (Bakermans-Kranenburg et al., 2003; Harder, 2005). Parent Education and Support Groups Educational and support groups for parents who are at risk or who have been suspected of child maltreatment seek to enhance protective factors that will reduce the likelihood of recurrence of maltreatment. The focus is usually on improved parent-child interactions and communication and reduction of the child’s problem behaviors (Stagner & Lansing, 2009). Initial research indicates that parent support groups, especially those that are offered through early education programs such as Head Start, show promise in improving parent attitudes, knowledge, and behaviors (Daro & McCurdy, 2007). Other findings support manualized curricula such as Parent-Child Interaction Therapy (PCIT; Hood & Eyberg, 2003) or Incredible Years (Webster-Stratton & Reid, 2010) that have demonstrated evidence of improving parent-child interactions, reducing parent stress, and preventing children’s problem behavior. These curricula are helpful as they provide guidance for professionals to deliver intervention and usually include training for the interventionists who may have received little to no pre-service training in how to deliver familyfocused instruction. These manualized programs, such as Incredible Years involve a behavioral or cognitive-behavioral approach and address specific parenting competencies intended to train and reinforce more positive than punitive parenting practices. Other meta-analytic research has demonstrated that behavioral approaches to improving parents’ sensitivity and responsiveness to their infants are most effective in improving infant attachment for at risk families (Bakermans- Kranenburg et al., 2003; Huxley & Warner, 1993). These interventions use attachment theory as a theoretical basis and range from brief video-based training sessions with parents to intensive individual meetings with families over the first three years of the child’s life (e. g., Wasik, Ramey, Bryant & Sparling, 1990). Other parent education programs based on attachment theory utilize a psychotherapy approach to address parents’ childhood trauma and teach them new ways of parenting. The “angel in the crib” theory behind such programs is that parents relive childhood episodes and emotions when parenting young children. If one’s childhood was characterized by neglect and/ or violence, one is more likely to use inef- 250 Elizabeth A. Steed fective and/ or abusive parenting strategies with one’s own children. A program that uses this conceptual model to address neglect or abuse and instead promote healthy parent-child relationships is Alicia Lieberman’s approach to child-parent psychotherapy (Lieberman & Horn, 2011). Attachment interventions have been found to be effective with children and families with a range of risk factors. They are most effective when they involve a moderate number of sessions and when the focus is on parental sensitivity (Bakermans-Kranenburg et al., 2003). Home Visitation Home visiting services are a promising means of delivering prevention and intervention programs for families at risk or who have a history of maltreatment. In the United States, a paraprofessional or a nurse usually conducts home visitation. Home visitors provide instruction and information to families that are tailored to the family’s unique needs and situation. They also provide some screening of environmental factors in the home that may lead to further services for the family (Stagner & Lansing, 2009). In contrast to CPS services that may provide some in home assessment and intervention following a report of child abuse and neglect, home visitation is meant as preventative and is less investigatory, authoritative, and adversarial (Guterman, 2006). The goals of home visitation are to support and strengthen family bonds, connect families to needed resources, and teach parents about child developmental milestones and health and safety in the home. One home-based prevention model that is particularly well researched in the United States is the SafeCare model. SafeCare is an in-home parent-training model to prevent child maltreatment (Lutzker & Bigelow, 2002). It uses a behavioral, skill-based model with weekly 1 - 2 hour sessions over 18 - 20 weeks that focus on: (1) children’s health, (2) children’s safety, (3) parent-child interactions, and (4) problem solving and counseling skills (Lutzker & Bigelow, 2002). In California, SafeCare interventionists worked with families already involved with child welfare due to a history of child abuse and/ or neglect. After the family members participated in SafeCare, there was a 75 % reduction in the reports of those family members to Child Protective Services (CPS) due to continued child abuse and/ or neglect (Gershater- Molko, Lutzker & Wesch, 2002). SafeCare families also reported to experience less depression and more satisfaction with the services they received than families who received alternative prevention/ intervention services (Gershater-Molko et al., 2002). Further, SafeCare employees were more likely to stay in their job than traditionally trained home visitors, such as social workers (Aarons, Sommerfield, Hecht, Silovsky & Chaffin, 2009). Home visitation is a promising practice for the prevention of child maltreatment. For example, the Nurse-Family Partnership program has shown positive effects for first-time lowincome mothers and their children across multiple sites (Olds et al., 1986). Other programs, such as Parents as Teachers and Home Instruction for Parents of Preschool Children (HIPPY) have used highly trained and credentialed specialists such as nurses or psychologists to successfully improve child health and safety, increase parental sensitivity, and decrease harsh parenting practices like spanking (Sweet & Appelbaum, 2004). A recent U. S. Center for Disease Control meta-analysis showed that up to 60 % of cases of child abuse and neglect could be prevented if families had access to a home visitation program (Guterman, 2006). Community-Based Programs Another type of prevention program in the United States includes services located in families’ neighborhoods to address risk factors that influence child maltreatment by connecting parents to the appropriate resources and programs they need (Stagner & Lansing, 2009). For example, families with limited or no access Early Childhood Prevention in the United States 251 to affordable childcare are referred to free or subsidized childcare in their community. Studies of national subsidized childcare, such as Head Start, suggest that childcare services can help reduce maltreatment for very young children who are the most at risk of child abuse and neglect (Waldfogel, 2009). Childcare services can also provide role models for families and important developmental experiences for young children who would be at risk for potential developmental delays if they stayed in their home environment. Other community-based services include providing families with reliable transportation, facilitating social support networks, and establishing family resource centers in the community (Stagner & Lansing, 2009). These universal programs that all families may access can be combined with other prevention and intervention efforts for families at risk for or who have a history of child maltreatment. This can decrease the stigmatization associated with families’ participation in prevention or intervention programs that are specific to child abuse and neglect (Guterman, 2006). Respite or Crisis Care Finally, services may include respite (temporary childcare) or crisis care for a child who has been maltreated. Different types of respite care services are offered in the United States such as in home childcare, out of home care in childcare centers or foster care homes, and summer or after-school programs. These programs are typically provided by state or local disability organizations like the Easter Seals or privately funded/ for profit companies. Increasingly, vouchers are provided to families in need through Medicaid waivers or other federally supported family support programs to pay for respite service. Medicaid waivers are monies from federal and/ or state funds that qualifying families may use to pay for approved services, such as respite care. Each state has a different policy regarding how Medicaid waivers may be utilized. Crisis respite care was first developed in the United States in the 1970s. The programs were called “crisis nurseries” and were for very young children 0 - 5 whose families were in crisis and had no other safe child care options available. Crisis respite programs will now accept children of any age and continue to be open day and night for emergencies. Respite is the most frequently requested service of parents and other caregivers of young children (Jackson, 2001). However, it is often unused by families in need due to accessibility, affordability, or limited respite providers. In one study of respite use, 75 % of families met respite eligibility requirements and had respite needs, but only 8 % reported using respite care (Rupp, Davies, Newcomb, Iams, Becker, Mulpuru, Ressler, Romig & Miller, 2005 - 2006). This indicates that there are likely many barriers to accessing needed respite services, especially for families that are most in need. Use of respite services is associated with decreases in caregivers’ stress and feelings of isolation (Jackson, 2001). If families at risk for abuse and neglect could access respite services as needed, this may prevent child maltreatment. Comparing Prevention in the United States and Germany While the United States has made progress in its prevention efforts to combat child abuse and neglect, its rates of child abuse are much higher than those in Europe, including Germany (UNICEF, 2003). One reason is likely that Germany has national health and social services upon which a prevention effort may be layered. Germany is also one of the countries in the world that has passed a national law prohibiting violence against children (UNICEF, 2003). No such law has been passed in the United States. Further, Germany’s 13th Children and Youth Report of the Federal Government published in 2009 set various goals for children’s health and development, including the prevention of child abuse and neglect (National Centre on Early Prevention, 2009). While the United States has federal legislation regarding prevention of child maltreatment, it has not produced 252 Elizabeth A. Steed such a collaborative task force and resulting recommendations and goals as those in Germany. As part of its national efforts towards prevention, Germany has established the National Centre on Early Prevention that receives funding to carry out a multitude of projects across the Federal States (NCEP, 2009). This is in contrast to the United States, where there was a federal mandate for prevention of child abuse, but states were left to provide their own funding and create their own programs (Waldfogel, 2009). This has led to inconsistently implemented prevention projects and a lack of coordination from state to state. Germany’s model of a national center appears to be a more logical approach to providing coordinated and innovative efforts to address prevention projects across the country. Germany has a much broader and wellimplemented safety net for families at risk of child abuse and neglect than families experience in the United States. While rates of child maltreatment are still much lower than those in the United States, rates of child abuse and neglect are increasing in Germany, as are the number of parents losing custody of their children (NCEP, 2009; Sann, 2010). This has led to the development of several pilot projects to address families at risk of child maltreatment. These programs are similar in their focus and delivery as those in the United States, including home visiting programs (delivered by family midwives rather than nurses), parent education programs, childcare, foster care, and crisis support (Sann, 2010; see also Sann, this volume). In some cases a curriculum that is also used in the U. S. is implemented as part of intervention efforts in Germany. For example, the Steps Towards Effective and Enjoyable Parenting (STEEP) curriculum is being implemented as part of the “How Parenting Works” project to counsel atrisk parents in Brandenburg, Germany (NCEP, 2009). In the United States, prevention of child maltreatment is often provided differentially, for families with the most needs and/ or for families who are already suspected of child maltreatment. In Germany, home-visiting systems are well established and provided for all or most families with newborn or very young children (UNICEF, 2003). Family midwives provide support to all parents for the first eight weeks of a baby’s life and are generally trusted sources of information (NCEP, 2009). When midwives are trained to discuss responsive parenting strategies, prevention and intervention related to child abuse and neglect reaches all families in a non-confrontational, cooperative way. One such parenting program, “Nobody falls through the net”, was developed in 2006 and has been implemented in two German states (Eickhorst & Cierpka, 2010; see also this volume). All families receive home visits from trained midwives for their babies’ first 8 weeks and high risk families receive home visits through their babies’ first year (Eickhorst & Cierpka, 2010). Providing prevention in the first few days or weeks of a child’s life and into the first year addresses the timeframe during which children are most vulnerable for child abuse and neglect (UNICEF, 2003). One of the goals in Germany is to connect existing systems of support for families, including the public healthcare system, Youth Welfare Services, midwives, and early childhood intervention (Sann, 2010). It appears that the struggle to share information across systems of health care and child welfare is a universal one, affecting both the United States and Germany. Each system in Germany, as in the United States, has its own legal basis, funding streams, and organizational structures. In the United States, strides have been made to collaborate between healthcare systems and CPS. However, there is currently almost no collaboration between child welfare services such as CPS and early intervention services for children from birth to age 3 in the United States (Stahmer, Sutton, Fox & Leslie, 2008). This is problematic, as many infants and toddlers that are being raised in families suspected of child maltreatment would likely have developmental delays and be eligible for high quality, free and individualized early intervention services. Early Childhood Prevention in the United States 253 Future Directions Future efforts to address prevention and intervention of child abuse and neglect should include coordinated, national efforts to include as many families as possible in research-based, intensive, and family-centered programs. Other issues for the future include the development and adaptation of training materials and approaches that are contextually and culturally appropriate, meet the array of families’ needs, and can be individualized for diverse families (e. g., absent but involved fathers, same sex partnerships, grandparents as primary caregivers). Providing culturally relevant, preventative, individualized, and needs-based intervention approaches moves us away from a one-size-fits-all, reactionary approach and should increase family engagement and the overall effectiveness of prevention of child maltreatment (Waldfogel, 2009). Another issue for the future is an increase and improvement in the research conducted on child abuse and neglect. We currently don’t know enough about the effectiveness of most programs that are utilized to prevent child abuse and neglect (Harder, 2005). One issue is that we need to develop and/ or refine measures of child maltreatment outcomes (Olds, Sadler & Kitzman, 2007). Some measures that are currently used are based on middle class white norms, such as home environment safety ratings, and do not necessarily apply to high risk and diverse families. Research could be conducted on several measures in order to have stronger evidence of the reliability and validity of their scores. Another issue is that research in the area of child abuse and neglect must include fidelity checks for how the intervention is applied. It is imperative that others may replicate the intervention in other locations and with other families. Finally, we need more random control experimental designs when possible to measure maltreatment outcomes (Waldfogel, 2009). Some long-term, randomized studies, such as the “Less is More” study (Bakermans- Karnenburg et al., 2003) are now emerging and demonstrating the impact of focused, behavioral prevention approaches. One such study includes the 10-year randomized control trial of the SafeCare model in Oklahoma where highrisk families receiving the SafeCare in-home program had 26 % fewer reports of repeated child abuse than families in the comparison group who received standard home visits from Child Protective Services (Chaffin, Hecht, Bard, Silovsky & Beasley, 2012). More studies like this are needed to further document the positive impact of specific prevention programs and provide a model for larger scale implementation. Another recommendation as we move forward in a digital age, is to use technological advances in communication, data entry, and data storage to our advantage when collaborating and sharing information across agencies. It would be optimal for various agencies and professionals (e. g., pediatricians, family midwives, church clergy members, teachers, social workers) to have access to a database to enter and view information about families. This would of course require much oversight to address confidentiality issues. However, a national database, such as the one being utilized in the United States for immunization records, would help professionals share information across agencies about an individual family and address the issue of lost data when families move or change doctors. Finally, our prevention and intervention efforts globally must address the link between child maltreatment and poverty. This is especially the case in the United States where there has been an increase in poverty rates and inequality in recent years. Approximately half of all child abuse and neglect occurs within the 15 percent of families who live below the poverty line (Pelton, 1994). We can provide families with empowering parent education programs and home visiting to support positive childrearing practices. However, when one is overwhelmed by feeling unsafe in one’s home or worried about where food is going to come from, those negative emotions are real. Being 254 Elizabeth A. Steed poor is not a perception. It is real and is accompanied by real emotions that affect families’ abilities to use desired parenting practices and abstain from child maltreatment (Pelton, 1994). If we ignore the influence of poverty and all that accompanies it, we will miss a large context for much of the child maltreatment that occurs. For example, we know that high parental stress from perceived hardship and infrequent employment for families living in poverty may lead to maltreatment (Slack, Holl, Mc- Daniel, Yoo & Bolger, 2004). Further a lack of resources to provide a clean and safe home environment, low parental warmth, use of harsh physical punishment, and a lack of affordable, high quality childcare for working parents can precipitate maltreatment (Slack et al., 2004). These findings regarding the mechanisms that may link poverty and child maltreatment suggest that interagency collaboration will be necessary to address the various social, political, and environmental factors that increase a child’s risk for maltreatment, especially for children who are poor (Hay & Jones, 1994). There is much to do to address families’ complex needs. But, knowing that all children deserve a childhood free of violence, abuse, and neglect keeps all of us moving forward. References Aarons, G. A., Sommerfeld, D. H., Hecht, D. B., Silovsky, J. F., Chaffin, M. J. (2009). The impact of evidencebased practice implementation and fidelity monitoring on staff turnover: Evidence for a protective effect. Journal of Consulting and Clinical Psychology, 77, 270 - 280. Bakermans-Kranenburg, M. J., van IJzendoorn, M. H., Juffer, F. (2003). Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129 (2), 195 - 215. 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Problem behaviours in abused and neglected children grown up: Prevalence and co-occurrence of substance abuse, crime, and violence. Criminal Behaviour & Mental Health, 4, 287 - 310. Wilson, D. & Horner, W. (2005). Chronic child neglect: Needed developments in theory and practice. Families in Society, 86 (4), 471 - 481. Wiggins, C., Fenichel, E. & Mann, T. (2007). Literature review: Developmental problems of maltreated children. Retrieved from http: / / aspe.hhs.gov/ hsp/ 07/ Children- CPS/ litrev/ report.pdf United States Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau (2010). Child Maltreatment 2008. Retrieved from http: / / www.acf.hhs.gov/ programs/ cb/ stats_re search/ index.htm#can. Elizabeth A. Steed, Ph. D. Georgia State University Department of Educational Psychology and Special Education P. O. Box 3979 Atlanta, GA 30302-3979