Child Physical Abuse: A Pathway toComprehensive Prevention

Heather J. Risser and Edessa David

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2Mental Health Promotion Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Universal Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Primary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Secondary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Tertiary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Individual and Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Community Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Societal Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Societal Level Implementation on the Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Quaternary Prevention Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Individual Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Family Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18System-Level Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Disparities in CPA, Service Involvement, and Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Effectiveness of Prevention Programming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Key Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Cross-References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

H. J. Risser (*) · E. DavidFeinberg School of Medicine, Northwestern University, Chicago, IL, USAe-mail: heather.risser@northwestern.edu; edessa.david@northwestern.edu

© The Author(s) 2020R. Geffner et al. (eds.), Handbook of Interpersonal Violence Across the Lifespan,https://doi.org/10.1007/978-3-319-62122-7_252-1

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Abstract

This chapter provides an overview of the risk and protective factors associatedwith child physical abuse and a list of evidence-based interventions designed totarget these factors and protect children from experiencing CPA. Universal,primary, secondary, tertiary, and quaternary prevention CPA interventions, suchas home visiting programs and parent training models, are described in detail.They are broken down and organized by the levels of the socio-ecological modelthrough which they operate, in order to affect change within the entire system(individual, family, community, societal levels). The chapter concludes with adiscussion of the racial disparities and disproportionality of children of colorwithin the child welfare system in the United States, specifically as it relates tochild physical abuse cases.

Keywords

Child physical abuse prevention · Primary prevention · Secondary prevention ·Tertiary prevention · Quaternary prevention · Child abuse

Introduction

Child physical abuse (CPA) is a pervasive public health concern, with as many as25% of all adults worldwide reporting having been physically abused as children(World Health Organization [WHO] n.d.). The estimated economic burden of childmaltreatment based on substantiated incident cases in 2015 was $428 billion annu-ally (Peterson et al. 2018). Furthermore, the lifetime per victim cost of nonfatal andfatal child maltreatment was $830,928 and $16.6 million, respectively (Peterson etal. 2018).

As Cross and Risser explain elsewhere in this handbook, child protective services(CPS) is not able to independently meet the needs of children experiencing abuse.CPS must leverage other systems to adequately protect children. One way toaccomplish this is to invest in a comprehensive, public health approach to CPAprevention (Durrant et al. 2009; Risser et al. 2019). A promising approach toconceptualizing comprehensive prevention is to combine Bronfrenbrenner’s ecolog-ical model with a vertical stepped care model of prevention (e.g., Glassgow et al.2018) (Fig. 1). Thus, all layers of the social ecology can benefit from all levels ofprevention. While different taxonomies of prevention are beyond the scope of thischapter, there is a benefit to using aspects of multiple taxonomies to specifyprevention targets and activities.

We propose that a comprehensive model of CPA prevention must contain ele-ments of health promotion and universal prevention in addition to primary, second-ary, tertiary, and quaternary prevention (Risser et al. 2019). Health promotionempowers people to achieve optimal physical and mental health by increasing accessto high-quality information, services, and supports. Universal prevention provides

2 H. J. Risser and E. David

CPA prevention information, services, and supports to an entire population, regard-less of the presence of any risk factors for CPA. Primary prevention strategies aim toprevent CPA risk factors and promote protective factors that inhibit CPA. Secondary,or selective, prevention strategies aim to reduce the probability of abuse amongparents who have risk factors of CPA. Tertiary, or targeted, prevention strategies aimto reduce the recurrence of CPA, reduce injury, and prevent additional CPA infamilies in which it has already occurred. Quaternary prevention strategies aim toprevent iatrogenic effects of CPA interventions such as out-of-home placements.

Mental Health Promotion Strategies

Child health promotion strategies seek to optimize the healthy development ofchildren and adolescents and prevent the burden of disease throughout the lifecourse. From a population health perspective, these different strategies are mosteffective when coordinated and implemented together, to intervene at multiple pointsof the socio-ecological system: targeting behavior change not only among childrenand their parents but also at the institutional, community, and policy level (Korin2016). Mental health promotion strategies could include traditional health promotionstrategies that impact mental health (e.g., sleep and nutrition) as well as specificmental health promotion strategies like social emotional learning and supports, bekind campaigns, and emotion regulation strategies like mindfulness. Some examples

Fig. 1 Ecological Stepped Care Approach to Prevention

Child Physical Abuse: A Pathway to Comprehensive Prevention 3

of general health promotion strategies include media communications, such ascommercials or public advertisements, health education and family support pro-grams, changes in school policies regarding physical education and nutrition, com-munity capacity building, and structural changes to the environment to facilitatehealthy behaviors and mental health. While a full discussion of health promotionstrategies to prevent CPA is beyond this chapter, it is important for parents and policymakers to understand that the importance of what to do to promote positive parentingbehavior in addition to preventing ineffective and unsafe behavior that could lead toCPA.

Universal Prevention Strategies

Universal prevention strategies provide CPA prevention information, services, andsupports at the population level, regardless of the presence of any risk factors forCPA. Some existing universal CPA prevention strategies at the individual and familylevel include anticipatory guidance provided at well-child pediatric primary carevisits, parenting education, and family support programs. Existing strategies atthe community level include community capacity building and structural changesto the built environment, school programming fostering anti-bullying, and socialemotional development. Some existing strategies at the societal level include high-quality childcare and the public health system infrastructure.

Individual and Family Level

Anticipatory guidance is proactive counseling provided to the parent(s) by a child’sprimary care physician at every well-child visit. Anticipatory guidance providesinformation about physical, emotional, psychological, and developmental changesrelevant to the child’s age to promote healthy development. Pediatricians provideeducation regarding a variety of developmental milestones relevant to the child’ssituation (e.g., Dosman and Andrews 2012). The American Academy of Pediatricshas created a system of anticipatory guidance called Bright Futures that includes theschedule for distributing content that is recommended for each pediatric visit basedon the child’s age (American Academy of Pediatrics n.d.). There is also someevidence to suggest that a brief intervention in primary care to promote nonphysicaldiscipline strategies could reduce positive attitudes toward physical punishment(Chavis et al. 2013).

Community Level

The Pyramid Model for Promoting Young Children’s Social Emotional Competence(Pyramid Model) is a multitiered framework designed to organize research practicesand interventions that seek to improve young children’s (ages 0–5 years) social,

4 H. J. Risser and E. David

emotional, and behavioral health outcomes (Fox and Hemmeter 2014). The lowestlevel of the pyramid model focuses on universal supports, which includes two keycomponents to support children’s social and emotional skills: (1) high-qualityenvironments (in the classroom and in the home) and (2) nurturing and responsiverelationships. Strategies to achieve these competencies include supporting children’splay, specific praise and encouragement, structured play centers and schedules, andengaging activities with clear rules (Fox and Hemmeter 2014). The two higher tiersof the Pyramid Model focus on increased social emotional supports for children atrisk of challenging behavior (secondary prevention) and individualized intensiveinterventions for children with persistent behavioral challenges (tertiary prevention)(Fox and Hemmeter 2014).

Similarly, the Collaborative for Academic, Social, and Emotional Learning(CASEL) targets classrooms, schools, homes, and communities and provides guidesand resources to support the adoption and implementation of social and emotionallearning (SEL) programs across the schoolwide system. CASEL’s SEL frameworkpromotes competencies for children in the domains of self-awareness, self-manage-ment, responsible decision-making, relationship skills, and social awareness(CASEL 2019). These two programs both provide universal support for childrenacross settings, in order to promote healthy development and prevent risk factors forchild maltreatment and abuse.

Societal Level

An existing universal prevention strategy at the societal level is the US public healthsystem infrastructure. The public health infrastructure includes the US Departmentof Health and Human Services (USDHHS), the principal federal agency tasked withprotecting health and providing human services. Agencies such as the Administra-tion for Children and Families (ACF) and Departments of Public Health operate atboth the federal and the state level. Departments of Public Health also operate onregional levels within states. These agencies provide funding and human services aswell as provide recommendations and policy guidance. Policies such as the Afford-able Care Act represent societal level universal prevention strategies that ensurepeople have access to health care and behavioral health.

Primary Prevention Strategies

Primary prevention strategies aim to reduce CPA risk factors and promote protectivefactors that inhibit CPA. Risk and protective factors can occur on an individual,family, community, or societal level. Risk factors at the individual level includeparental mental health or substance use issues, unrealistic expectations for the child’sdevelopmental level, positive attitudes toward physical discipline, and parentalstress. Protective factors at the individual level include knowledge of child devel-opment and empathetic responding. Risk factors at the family level can include poor

Child Physical Abuse: A Pathway to Comprehensive Prevention 5

parent-child relationship, coercive parenting patterns, difficult child behavior, familydisorganization, social isolation, and family violence. Protective factors at the familylevel can include secure attachment relationships, relationship routines and parent-child synchrony (dyadic interactions characterized as being extended, nonnegative,and connected), financial stability, safe housing, and social support (Harrist et al.1994; Barber et al. 2001). Risk factors at the community level can include commu-nity violence, low neighborhood social cohesion (mistrust) and neighborhooddivestment (lack of resources), and disorder (trash, vandalism). Protective factorsat the community level include community resources for families (social support andsocial networks through schools, churches, and other organizations) and positivesocial norms that support a healthy and safe environment for families and children.Risk factors at the societal level include societal health and social disparities andsocial policies that contribute to disparities and structural (physical, legal, andeconomic) barriers to high-quality services. Protective factors at the societal levelinclude access to health and social services, adequate housing, and economicsupports.

Individual and Family Level

Parent training is one type of intervention format used to target parents’ skills,knowledge, belief in physical/corporal punishment, and self-efficacy, in order topromote positive parenting practices and thereby protect against CPA. Brief trainingswithin the community, pediatrician’s office, or early home visitation by a nurse,social worker, or paraprofessional are common methods for delivering parent train-ing interventions.

The Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV)administered by the federal Health Resources and Services Administration (HRSA)is a national effort that seeks to provide support and services to pregnant women andparents in order to prevent the development of some risk factors such as unrealisticexpectations for child development and promote protective factors such as sensitiveparental responding. MIECHV directly funds states, territories, and tribal entitiesto develop and implement their own programs based on common service deliverymodels, such as Healthy Families America, Nurse-Family Partnership, andSafeCare, all of which are described in further detail below (HRSA 2020).The program supports interventions promoting child health and development byhealth, social services, and child development professionals in the context of homevisiting. It also supports the use of home visiting to teach positive parenting practicesto prevent child abuse and neglect.

In the Nurse-Family Partnership (NFP) program, public health nurses visit young,first time pregnant women and provide them with support, from pregnancy throughtheir child’s second birthday. This program seeks to improve pregnancy outcomes,enhance parenting skills, and support the child’s health and development. Originallydeveloped in the 1970s, it is now one of the most well-developed home visitationprograms in the United States. Multiple randomized control trials (RCTs) and long-

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term follow-up studies have validated its positive effects on child health outcomes(Nurse-Family Partnership n.d.). One evaluation of the NFP revealed a 48% reduc-tion in child abuse, and neglect discovered at a 15-year follow-up among familieswho had received the intervention (Howard and Brooks-Gunn 2009).

Triple P-Positive Parenting Program (Triple P) also started as an individualizedhome visiting program but has since grown to be a population-level, multitieredintervention. It is designed to strengthen families’ protective factors (knowledge,attitudes, and skills) while reducing the risk of child maltreatment by helpingimprove parents’ self-regulatory processes (Sanders et al. 2003). This interventionis unique in that the different tiers of the programs all reach a different populationbased on how intense children’s needs are. Level 1 of Triple-P is a universal media-based information campaign on general parenting issues that seeks to promoteawareness and normalization of participation in parenting programs. Levels 2–3target parents with specific parenting concerns and include parenting seminars andbrief consultations to normalize parenting interventions and offer skills training.Levels 4 and 5 add on to the interventions in previous levels by including training onmore specific, targeted behaviors and parental concerns (it also qualifies as asecondary prevention program) (Sanders et al. 2003). Triple P includes curriculatargeting five different developmental periods, from infancy to adolescence, and canbe implemented in a variety of settings by different types of service providers (Prinzet al. 2009; Sanders et al. 2003). Prinz et al. (2009) randomly assigned 18 counties inthe United States to receive either Triple P or services as usual. Counties with TripleP had significantly lower rates of substantiated cases of child maltreatment, child-out-of-home-placements, and hospitalizations/ER visits for maltreatment injuries inthe treatment counties (Prinz et al. 2009).

Community Level

Neighborhoods with higher levels of positive social processes (collective efficacy,intergenerational closure, neighborhood social networks) and lower levels of phys-ical and social disorder have been found to have lower rates of child maltreatment(Molnar et al. 2016). Social and cultural norms that condone or are indifferent to actsof violence can also influence individual-level attitudes, beliefs, and behaviorsrelated to child physical abuse. Interventions targeting these modifiable risk factorswithin neighborhoods and communities to prevent the occurrence of child physicalabuse include capacity building and mobilization efforts, as well as social marketingcampaigns.

Strong Communities for Children is one such comprehensive capacity buildingprogram geared toward child protection. The original program was implementedacross neighborhoods in South Carolina, in which entire communities were mobi-lized in a large-scale effort to change social norms and other social processes withinthe community to prevent child abuse and maltreatment. Neighborliness, feelings ofinclusion within the community, collective efficacy, and action were all targeted as

Child Physical Abuse: A Pathway to Comprehensive Prevention 7

community norms of interest. The program’s strategy involved using communityoutreach workers to drive grassroots level action to foster relationships betweenfamilies and institutions in the community, in order to promote the message thatchildren and parents are “noticed and cared for” by others in the community. Theseoutreach workers also generated resources to meet families’ material needs, inaddition to organizing the provision of family activities through existing communityinstitutions. The Strong Communities program yielded positive changes in commu-nity social norms when compared with matched communities over time (Melton2014).

No Hit Zones (NHZ) are a primary prevention strategy that can help change socialnorms that support corporal punishment, which is a key risk factor for childmaltreatment. When an organization adopts NHZ, it amends its policies to explicitlystate that “no forms of hitting will be tolerated, including parents hitting theirchildren” (Gershoff 2020). This policy is rooted in the theory of bystander interven-tion. As such, a key component of the policy includes training organization staffon how to identify a situation in which a parent might hit their child, helping themto feel a responsibility to intervene in such a situation and teaching them theknowledge and skills to intervene effectively (Gershoff 2020). An outcome evalu-ation of a hospital-wide NHZ intervention revealed that 10 months post-implemen-tation, hospital staff felt less support for spanking and felt that their coworkers alsofelt less support for spanking, than they did prior to the intervention (Gershoff et al.2018). The evaluation also revealed that parents’ perception that their children’spediatricians supported spanking decreased post-intervention (Gershoff et al. 2018).Both of these results lend support for NHZ as a means to change attitudes and socialnorms toward physical punishment.

In addition to negative social processes, community violence is another risk factorassociated with high rates of child physical abuse. Community violence preventionprograms, such as Communities That Care (CTC) seek to prevent violencein communities before it begins. CTC was developed by the University of Wash-ington, and similar to Strong Communities, operates at a grassroots level to buildcommunity coalitions and an advisory board to assess the unique risk and protectivefactors for violence within a specific community. After the assessment, CTC trainerswork with community members to develop specific, measurable goals to promoteyouth’s social development, strengthen protective factors, and implement evidence-based programs that target predicted child and adolescent health and behavioralproblems within the community. Results of the program show that when comparedto a matched sample of students, students from CTC communities had fewer healthand behavior problems, including a lower likelihood of initiating delinquent behav-ior and initiating use of alcohol or cigarettes, and lower odds of engaging in violentbehavior within the past year (University of Washington n.d.).

Large-scale social marketing through educational media campaigns can alsochange individual and community-level social norms and behaviors regardingchild physical abuse. One such campaign would be the first level of the aforemen-tioned Triple P program, which is a multimedia campaign that targets all parents, inorder to increase awareness and adoption of positive parenting practices with the

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intent of normalizing such behaviors within the community. It includes a range ofmaterials distributed through various channels, including brochures, posters, news-paper columns, and billboards (Triple n.d.).

Societal Level

Flexible and family-friendly work policies, including livable wages, paid leave, andconsistent scheduling, are all policies that organizations and governments canimplement to provide economic supports to families. A guaranteed annual incomehas been shown to lead to decreases in low levels of education and mental healthproblems, which are two risk factors associated with child abuse and neglect(Fortson et al. 2016). Various studies have shown that paid leave, in the form ofsick days, maternity leave, and vacation, are associated with reductions in childhospitalizations for abusive head trauma and lower rates of parental depression andstress (Fortson et al. 2016). A consistent schedule in turn also allows parents tomanage more consistent childcare services. Parents who work irregular scheduleshave been shown to experience greater work-family conflict and stress (Fortson et al.2016). Head Start programming is another strategy that is implemented on thesocietal level to promote school readiness in children from low-income families.

State legislative policy to reduce or ban corporal punishment (CP) has also beensuggested as a method to change social norms and acceptance of corporal punish-ment as a discipline technique. For example, Sweden has banned CP. Studies haveshown that individuals who reported experiencing spanking, a mild form of CP,during childhood, were 60 times more likely than their counterparts to also reporthaving experienced physical abuse as children (Fréchette et al. 2015). While someStates in the United States have banned the use of corporal punishment in child-serving settings such as schools and juvenile detention facilities, many states havenot. Despite many organizations supporting a complete ban on physical punishment,including the American Academy of Pediatrics, the United States has not banned CPin some child-serving settings or within the home (Fortson et al. 2016).

Secondary Prevention Strategies

Secondary prevention strategies focus on reducing risk within populations thatalready have one or more risk factors associated with physical abuse, such asyoung parental age, parental substance abuse, or parental mental health concerns(Child Welfare Information Gateway [CWIG] n.d.). Home visiting programs similarto those described above are common secondary prevention interventions that targetthe individual and family-level risk factors for child physical abuse. Safe From theStart (SFS) is another federal and state strategy for treating young children who havebeen exposed to violence and preventing additional exposure. SFS is alsoimplemented on a state level. In Illinois, for example, the Illinois Criminal JusticeInformation Authority funds between 9 and 12 sites to provide community-based

Child Physical Abuse: A Pathway to Comprehensive Prevention 9

mental health treatment to children and families exposed to violence, communitysupport, and prevention activities (e.g., Schewe et al. 2013; Risser and Schewe2013).

The California Evidence-Based Clearinghouse for Child Welfare (CEBC) is aresource designed to promote the implementation of EBTs for children and familiesin the child welfare system. The CEBC uses the Scientific Rating Scale to indicatethe extent to which the intervention has evidence supporting its effectiveness.The CEBC assigns a rating to each intervention that it reviews. Lower ratingsindicate a greater level of empirical evidence supporting the intervention’s effec-tiveness. The Scientific Rating Scale ratings range from 1 (well-supported byresearch evidence) to 5 (concerning practice) with a 6th category for interventionsthat are unable to be rated (California Evidence-Based Clearinghouse for ChildWelfare n.d.). The CEBC ratings are as follows: (1) well-supported by researchevidence; (2) supported by research evidence, (3) promising research evidence, (4)evidence fails to demonstrate effect, (5) concerning practice, and (6) not able to berated (NR) on the CEBC Scientific Rating Scale. Psychotherapy models that arerated as 1 on the CEBC ratings can be considered EBTs.

Individual and Family Level

SafeCare is one example of an evidence-based in-home intervention delivered toparents who are either at-risk or have been already been reported to CPS for childmaltreatment. The overall goal of the SafeCare curriculum is to improve parentingskills and reduce future incidents of maltreatment. The curriculum includes threemajor components, addressing (1) the health of the child, (2) home safety, and (3)positive parent-child interactions (parenting skills) (Georgia State University n.d.).This last module specifically targets risk factors related to neglect and physicalabuse. Over 60 studies over the past 30 years support the effectiveness of SafeCare,including a statewide cluster RCT, in which SafeCare’s effectiveness was comparedto usual home-based services (Chaffin et al. 2012). Recidivism outcomes werepromising, for example, families who received the SafeCare intervention had arate of child maltreatment that was approximately 26% lower than families receivingusual services (Chaffin et al. 2012).

The Chicago Parent Program was designed to target the parenting needs ofracially and ethnically diverse families with young children, living in low-incomecommunities (Breitenstein et al. 2020). The 12-session curriculum is based on sociallearning theory and attachment theory. Parents watch video recordings of shortparenting vignettes and practice parenting skills through role plays. CPP staff alsointeract with parents to encourage them to develop strategies for supporting anurturing environment at home. Content specifically related to the reduction ofspanking and physical punishment is included to reduce the risk of CPA and ispresented through discussions that offer alternative strategies for discipline in aculturally competent manner. Two cluster RCTs have shown that the Chicago Parent

10 H. J. Risser and E. David

Program yielded significant improvement in parenting self-efficacy, a decline inphysical punishment, and more consistent discipline (Breitenstein et al. 2020).

Healthy Families America (HFA) (CEBC 2019) is a second home visitingprogram that targets families at-risk for child abuse and neglect due to a history oftrauma, mental health issues, and/or substance abuse issues. It is theoretically rootedin attachment theory, and the principles of trauma-informed care and services in theprogram are initiated either prenatally or at birth, until the child reaches 3–5 years ofage (CEBC 2020). Primary components of HFA include screening and assessmentfor at risk families, home visiting services, and screenings and assessments of parent-child interactions, child development, and maternal depression (US Department ofHealth and Human Services 2018). It has been rated by the CEBC as a level 1intervention for child-well-being and level 4 for prevention of abuse and neglect.

Community Level

Media campaigns targeting people susceptible to acts of child abuse and maltreat-ment are also a type of secondary prevention strategy that can lead to changes inindividual and community level social norms, attitudes, knowledge, and riskybehaviors. The Breaking the Cycle campaign was part of a broad community-levelintervention from the late 1990s implemented in New Zealand, which used televi-sion, radio, print media, phone lines, and other resources to increase parents’awareness and knowledge about child emotional and physical abuse. The campaignused the transtheoretical model stages of change theory in order to influence parentsto engage in non-abusive behavior (Stannard et al. 1998). A survey evaluating theresults of the campaign revealed that up to 44% of the population contemplatedchanging their behavior as a result of the campaign, and up to 16% actually reportedchanging their behavior, which in this case referred to acts of child emotional abuse(Stannard et al. 1998).

Societal Level

Policy level interventions to provide economic supports for children and familieshave the potential to have the most significant impact on lowering the risk for childabuse and neglect. By strengthening household financial security, parents can moreeasily provide for their child’s basic needs and access childcare services. This resultsin improved parent mental health due to decreased stress (Fortson et al. 2016). TheEarned Income Tax Credits (EITC) are federal tax credits refunded to low- andmoderate-income families through their tax returns (IRS 2020). They help reducechild poverty and reward low-income families for employment. The EITC have beenfound to have positive impacts on decreasing infant mortality, increasing healthinsurance coverage, promoting school performance, and reducing parental stress(Fortson et al. 2016). The Supplemental Nutrition Assistance Program (SNAP),colloquially known as “food stamps,” helps low-income families purchase food.

Child Physical Abuse: A Pathway to Comprehensive Prevention 11

As well as helping meet children’s basic nutritional needs, it helps reduce family andchild poverty and the severity of food insecurity. Empirical evidence supports thebenefits of SNAP, one study linking Medicaid children receiving SNAP or othernutrition benefits with fewer reports of child abuse and neglect than families notreceiving the benefits (Fortson et al. 2016).

States can apply grants from the US Housing and Urban Development toward thepurchase of homes in low-poverty neighborhoods, which they can then rent to low-income families at a lower cost. This allows families to relocate to safer, well-resourced communities and save money on rent. The US Department of Housingand Urban Development’s Moving to Opportunity (MTO) experiment in the 1990srevealed that low-income families who received a housing voucher for low-povertyneighborhoods experienced less psychological distress and depression, and theirchildren were more likely to attend college and earn a higher income (Ludwig et al.2012; Fortson et al. 2016).

Subsidized child care is another type of economic support that increase parentalcapacity by aiding parents in choosing higher quality care for their children, thusleading to a higher likelihood for those children to be cared for in a safe, nurturingenvironment (Fortson et al. 2016). The Illinois Action for Children Child CareAssistance Program (CCAP) is one such state program through which qualifyingfamilies can receive financial support for childcare. The IL Action for Children alsooffers an array of programs and services through initiatives such as the Teen ParentProject, Prevention Initiative (for at risk teen mothers and their children), FamilyEngagement Training, and early learning programs for young children.

Tertiary Prevention Strategies

Tertiary, or targeted, prevention strategies aim to prevent additional CPA or reducethe impact of CPA. Existing tertiary strategies include a variety of therapeuticinterventions. Some interventions focus primarily on reducing the impact of CPAby addressing symptoms of trauma and other emotional and behavioral effects on thechild. Some interventions primarily focus on changing parent behavior to preventadditional CPA. Information about the interventions, the populations for which theyare suited, and the effectiveness in improving targeted symptoms and behaviorsare available online from the California Evidence-Based Clearinghouse for ChildWelfare (2020). For interventions and practices specifically designed for childrenwho have experienced trauma, see The National Child Traumatic Stress Network(nctsn.org).

Several therapeutic interventions have been designed to treat child victimsof physical abuse and their families. Evidence-based treatments (EBTs) have dem-onstrated statistical and clinical significance in reducing symptoms in childrenwho have experienced physical abuse. For reviews of interventions for childhoodsymptoms of trauma, see The National Childhood Traumatic Stress Network(NCTSN) ( n.d.) and Vanderzee et al. (2019).

12 H. J. Risser and E. David

Individual and Family Level

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Trauma focused cogni-tive behavioral therapy (TF-CBT) was designed to treat children aged 3–21 yearswho have a history of trauma exposure (Kliethermes et al. 2017). The goal of TF-CBT is reduce trauma-related symptoms. The program components include psycho-education and skill development such as relaxation skills, affect regulation, cognitivecoping, trauma processing, and in vivo exposures. Treatment can include bothindividual and parent-child sessions. The treatment targets are symptomsof trauma, depression, anxiety, grief, and/or shame related to their traumatic expe-rience. On the CEBC ratings, TF-CBT has been rated level 1 (CEBC 2020).

Parent-Child Interaction Therapy (PCIT). PCIT was designed to treat issues thatinterfere with parent-child relationships in children aged 2–7 years old andtheir parents. Treatment goals include decreasing child externalizing behaviors,increasing child social skills, and improving the parent-child relationship. Treatmentcomponents include skill development and behavior management skills during play-based coaching sessions. Treatment targets include increasing child compliance,increasing parent use of praise, effective commands, and appropriate consequencesfor noncompliance, and decreasing parent use of coercive parenting behaviors.While PCIT has a CEBC rating of 1 for disruptive behavior and parent training fordisruptive behavior, it has not been rated for use of reducing additional CPA.However, a randomized clinical trial demonstrated significantly lower rates of re-report to CPS in the PCIT group (19%), relative to a community-based parentinggroup (49%) (Chaffin et al. 2004).

Child-Parent Psychotherapy (CPP). CPP was designed to treat children aged 0–5years who have been exposed to a traumatic event or events (Lieberman et al. 2005;Reyes et al. 2017). The child is seen with his or her primary caregiver. Goals of theintervention include examining how previous and current experiences, behavior, andcontext impact the parent-child relationship and the child’s development. Treatmenttargets include strengthening the parent-child relationship and ameliorating care-givers’ and children’s maladaptive representations of themselves and each other andpromoting positive interactions and behavior that support the child and the parent-child relationship. CPP has been rated level 2 on the CEBC rating scale (CEBC2020).

Multisystemic Therapy for Child Abuse and Neglect (MST-CAN; Swenson et al.2010). MST-CAN was designed to treat children aged 6–17 years old, and theirfamilies recently reported to child protective services due to the physical abuse and/or neglect. The family may be intact or the child may be placed in foster care. Goalsinclude reducing physical abuse, out-of-home placement, and family reunificationfor children in out-of-home placement, improving noncoercive parenting, andimproving family functioning and social support. Treatment components includeintensive services, 24/7 services for families, parent training, caregiver mental healthand substance abuse, anger management, and family communication training. Treat-ment targets include youth aggression, anxiety and trauma symptoms, substanceabuse, difficulty managing anger, safety risks, difficulties with family problem

Child Physical Abuse: A Pathway to Comprehensive Prevention 13

solving, negative family communication, parental physical and psychologicalaggression, social support, and other dysfunctional behavior. MST-CAN has beenrated level 2 on the CEBC rating scale (CEBC 2020).

Child-Centered Play Therapy (CCPT). Child-centered play therapy (CCPT) wasdesigned to treat children aged 3–10 years who are experiencing social-emotionaland behavioral problems (e.g., Lin and Bratton 2015; VanFleet et al. 2011). The childis seen individually usually for 16–20 sessions. The goal of CCPT is to promotemore positive and integrated self-concept. Components of CCPT include accessingchild’s feelings through play and developing a strong therapeutic relationship,reflection, empathic response and therapeutic limit setting. CCPT targets includeimproved coping, self-reliance, and sense of control. CCPT has been rated level 3 onthe CEBC rating scale (CEBC 2020).

Combined Parent-Child Cognitive Behavioral Therapy (CPC-CBT) (Runyon etal. 2009). CPC-CBT was designed for parents of children aged 3–17 years old inwhich parents use coercive parenting behaviors. Treatment goals include enhancingparent-child relationship, healthy coping, and behavior change. Treatment compo-nents include psychoeducation, motivational interviewing, addressing trauma his-tory, adaptive coping, anger management, relaxation, interpersonal effectiveness,problem solving, affect regulation, behavior management, safety planning, traumaprocessing, and parent training. Treatment targets include decreasing coercive par-enting behavior and child internalizing and externalizing and trauma symptoms.CPC-CBT can be delivered in individual family sessions or group family sessions.In the group sessions, it is recommended to have 4–5 families involved and that mayinclude multiple caregivers and multiple children. All topic areas of CPC-CBT(interventions for abusive behavior, parent training programs that address childabuse, prevention of child abuse and neglect, and child and adolescent traumatreatment) have been rated level 3 on the CEBC rating scale (CEBC 2020).

Alternatives for Families Cognitive-Behavioral Therapy (AF-CBT). AF-CBTwas designed to treat parents of children aged 5–17 years old, who are verbally orphysically aggressive toward their children and children who experience trauma-related symptoms as a result of parent behavior. Treatment goals include improvingparent-child relationships, strengthening effective parenting practices, enhancingchild coping and social skills, increasing safety, reducing coercive and aggressivebehaviors, and decreasing risk of additional child physical abuse. Treatment com-ponents include a multi-informant assessment, motivational interviewing, functionalbehavioral analysis, psychoeducation, affect regulation, parent training, behaviormanagement, cognitive restructuring, trauma processing, social skill development,assertiveness training, problem solving, and effective communication. Materialssuch as handouts, examples, and outcome measures are integrated into the treatment,and clinicians tailor aspects of the treatment to the family’s specific strengths andchallenges. Treatment targets include increasing interpersonal effectiveness,decreasing aggressive and hostile behavior, reducing trauma-related symptoms,increase affect regulation, and use of effective noncoercive parenting behavior.AF-CBT is designed to be delivered in three phases. The child is typically seenindividually for the first and second phases, and the parent and child participate

14 H. J. Risser and E. David

together in the third phase. AF-CBT has been has been assigned a level 3 on theCEBC rating scale (CEBC 2020).

Attention, Regulation, and Competency (ARC). The ARC framework wasdesigned to treat children and youth aged 2–21 years with complex trauma, partic-ularly attachment-related traumas such as child abuse and neglect (Blaustein andKinniburgh 2018; NCTSN n.d.). The intervention usually involves the parent-childdyad. The goals of the ARC framework include improving parent-child attachment,affect regulation, and children’s resilience and strengths. Treatment componentsinclude psychoeducation, skill development, and behavioral change. Treatmenttargets include increasing predictability and a sense of safety, improving the par-ent-child relationship, and increasing adaptive affect regulation. The ARC frame-work has been rated NR on the CEBC ratings with a high level of child welfarerelevance (CEBC 2020).

Project support is another intervention designed to reduce incidents of childmaltreatment in families reported to CPS for allegations of physical abuse andneglect (Jouriles et al. 2010). The intervention includes two key components. Thefirst is a hands-on, intensive child management skills training designed for mothers,which covers skills such as listening to their child, providing contingent praise, andparticipating in attentive play (Jouriles et al. 2010). This in-home training incorpo-rates didactic teaching and opportunities for practice with feedback, in order toreduce coercive parent-child interactions. The second key component of the programinvolves providing instrumental and emotional support to mothers in order to reducetheir psychological distress. The curriculum is delivered by a therapist in weeklysessions for up to 8 months. In comparison with services as usual delivered by CPScaseworkers, mothers in the project support condition demonstrated greaterdecreases in their perceived inability to manage their children’s behavior anddecreases in self-reported harsh parenting. In addition, only 6% of project supportfamilies had a re-referral to CPS compared to 28% of families in the services as usualbranch (Jouriles et al. 2010).

Community Level

One existing community-level tertiary prevention strategy is wraparound serviceprovision (e.g., Yohannan et al. 2017). Wraparound is a team-based, planning andimplementation process designed for families of children aged 4–17 years old withsevere emotional and behavioral problems. Wraparound was designed for childrenand families that have complex needs, are often involved in several child and family-serving systems such as CPS and juvenile justice, and are either in or at risk of beingplaced in, out-of-home placement (quaternary prevention). The goals of wraparoundare to stabilize crises and develop and implement a care plan and safety/crisis plans.Wraparound components include developing action steps and addressing logisticsrelated to care plan implementation, tracking progress, evaluating success, updatingplan and strategies as needed, maintaining team cohesion, and developing a transi-tion and termination plan. Treatment targets include maintaining children in their

Child Physical Abuse: A Pathway to Comprehensive Prevention 15

homes and communities, improving family function across all life domains, anddecreasing out-of-home placements. Two wraparound topic areas (behavioral man-agement programs for adolescents in child welfare, placement stabilization pro-grams) have been rated as a 3 on the CEBC rating system (CEBC 2020).

Societal Level

Child protective services (CPS) or child welfare services (CWS) are state-levelsystems that are the principal agency responsible for tertiary prevention (see▶ “Child Welfare Systems: Structure, Functions & Best Practices”). CPS has avariety of services designed to prevent additional CPA. However, most of the CPSservices are implemented on the family level. The Child Abuse Prevention andTreatment Act (CAPTA) and the CAPTA Reauthorization Act are examples ofsocietal level policies that establish and maintain the Office on Child Abuse andNeglect and the National Clearinghouse of Information Related to Maltreatment.CAPTA provide States with funding and guidance regarding prevention, assessment,investigation, prosecution, and treatment. CAPTA also funds public, nonprofit, andtribal organizations to conduct demonstration programs. CAPTA also specifies thefederal role in supporting research and data collection regarding the prevalence ofchild abuse, neglect, and CPS involvement.

Societal Level Implementation on the Family Level

Intact services are provided to families in which the child remains in the homedespite a substantiated instance of CPA. Intact services could include a wide varietyof services that could include CPS caseworker case management, EBTs to reduceadditional CPA, and other interventions targeting risk factors for CPA (e.g., parentsubstance abuse treatment). Intensive family preservation services are provided tointact families with a high level of risk and needs. Intensive family preservationservices are provided by a mental health professional and typically involve morefrequent and intensive service delivery. For example, a service array could includeindividual sessions, parent training, and family sessions within the same week. Someprograms provide access to 24/7 professional support.

Family stabilization programs are designed to ensure the safety and well-being ofchildren in families that have been reported to CPS. In this chapter, programsimplemented with families in which children have not yet been placed out of thehome, we discuss them in the tertiary prevention section. For programs implementedwith families in which children are returning from out-of-home placement, wediscuss them in the quaternary prevention section. Some programs can beimplemented as either tertiary or quaternary prevention. One program,Homebuilders®, has been rated as level 2, three programs have been rated as level3, and eight programs have not been able to be rated on the CEBC rating scale(CEBC 2020).

16 H. J. Risser and E. David

Family group decision-making (FGDM) (CEBC 2017b) is one program which istargeted toward children who are abused and/or neglected and their family groups.The program emphasizes the importance of including not only children and theirparents in the program’s treatment model but the entire family group, which consistsof people connected to the child through extended kinship and other relationships.The family group works with a trained coordinator and CPA personnel to developand implement plans to protect the safety, permanency, and well-being of the child. Itis rated as a level 3 by the CEBC, indicating promising research evidence in supportas a family stabilization programs, placement stabilization programs, and programthat reduces racial disparity and disproportionality in child welfare programs (CEBC2020).

Sobriety Treatment and Recovery Teams (START) (CEBC 2017a) is anotherfamily stabilization program, which targets families with at least one child under 6years of age in the child welfare system, and a parent with a reported substance useproblem that places the child at risk. A few of the key components of START includefamilies’ quick entry into START program (program takes only new cases within 30days of CPS referral), family team meetings scheduled at key points in the program,addiction treatment and mental health services for parents, and full-time familymentors who attend home visits with an assigned CPS worker. It is scored at level3 by the CEBC rating scale (CEBC 2020).

Family-centered treatment (FCT) (CEBC 2018) is an intensive, homemvisitingprogram that aims to provide families with practical solutions to ensure familystability and functioning, when there is an imminent risk of disruption of the familyunit. This can refer to the removal of the child from the home due to abuse/neglect orthe child’s delinquent behavior or other stressors and circumstances. The programincludes multiple phases, which seek to assess families’ goals and strengths, trainingand coaching the family in new skills, all to achieve a balance and level offunctioning that reduces harm and increases coping and stability within the family.FCT targets families with children 0–17 years of ages involved in agencies related toeither child welfare, mental health, substance abuse, developmental disabilities,juvenile justice, or crossover youth. It is scored at level 3 by the CEBC ratingscale (CEBC 2020).

Family preservation programs “not rated” by the CEBC on their scientific meritsas of yet include Cultural Broker Program, Families First of Michigan, Foster CareRedesign, Functional Family Therapy Child Welfare (FFT-CW), Minority Youth andFamily Initiative for African Americans (MYFI), Minority Youth and Family Initia-tive for American Indian/Alaskan Native Children (MYFI), Mockingbird FamilyModel (MFM), and the Parent Support Outreach Program (PSOP) (CEBC 2020).

Supervised visitation may be court ordered if there is high risk for continued CPA.Supervised visitation typically involves visitation between the child(ren) and thepreviously abusive parent. The child(ren) may be living with the other parent, otherfamily members, or in an out-of-home placement. Supervised visitation can occurwithin a family setting with another family member designated as the supervisor orat a community-based organization with a professional staff member of the organi-zation supervising the visit. In some cases, visits can be supervised by a guardian ad

Child Physical Abuse: A Pathway to Comprehensive Prevention 17

litem, a person appointed by the court to determine what solutions would be in thebest interests of the child.

Out-of-home placements (discussed in Cross and Risser) can also serve to preventfuture CPA by placing the child in a safe living arrangement away from abusiveparents. This strategy is typically used when CPA has led to serious child injury, riskof CPA continues to be very high, or the child has serious health, mental health, orbehavioral needs after experiencing CPA that cannot be managed in the home of thechild’s biological parents.

Termination of parental rights is a term that refers to the legal status of no longerbeing the child(ren)’s parent. The termination of parental rights is reserved forsituations in which risk the child remains high, and it is unlikely that the child willbe able to return to reside with his/her family of origin. In this case, in an effort topromote permanency (see Cross & Risser), CPS may seek to terminate parentalrights so that the child may be eligible for adoption into another permanent family.

Quaternary Prevention Strategies

Quaternary prevention strategies aim to prevent iatrogenic effects of CPA interven-tions such as out-of-home placements. The Family First Prevention Services Act(FFPSA) was signed into law in 2018. The FFPSA was designed to reform thefunding for child welfare by setting parameters around how money through Title IV-E and Title IV-B, of the Social Security Act could be spent. FFPSAwas designed toemphasize prevention and early intervention and reduce out-of-home placements incongregate care. FFPSA was also designed to promote the use of evidence-basedpractices for children and families and improve the well-being of children already infoster care.

Individual Level

Existing individual-level quaternary prevention strategies include many of the indi-vidual-level components of tertiary interventions listed above. The targets of theseinterventions at the quaternary level are often to ameliorate symptoms that childrenmay develop in response to an out-of-home placement or dealing with the grief andloss of a biological parent or family of origin.

Family Level

Existing family-level quaternary prevention strategies include a variety of programsfor family of origin and foster parents.

18 H. J. Risser and E. David

Families of OriginHomebuilders were designed to treat families of children aged 0–18 years old needingintensive services to return from out-of-home placements such as foster care or resi-dential treatment including psychiatric and juvenile justice placements (CEBC 2020).

Foster FamiliesTrainings are designed to provide foster families with knowledge and tools for betterunderstanding and responding to child(ren)’s needs (California Evidence-BasedClearing House for Child Welfare 2020). Some training includes general knowledge,and some have been assigned a CEBC rating that indicates the extent to which itis an EBT. KEEP (Keeping Foster and Kin Parents Supported and Trained; Price etal. 2019) was designed to train foster caregivers of children aged 4–12 years old.The goal of KEEP is to provide foster parents with tools to manage child(ren)’semotional and behavioral problems. Treatment components includepsychoeducation, behavior management training, affect regulation, setting effectivelimits, and stress management and are delivered in a 90-minute, weekly groupsetting. Treatment targets include decrease placement disruptions, increase effectiveparenting strategies, decrease child emotional and behavioral symptoms, anddecrease parent stress. Three of the KEEP interventions (kinship caregiver supportgroups, placement stabilization programs, and resource parent programs) have beenrated as a level 3 on the CEBC rating scale (CEBC 2020). Three adaptations forfoster parents of adolescents, called KEEP SAFE (behavioral management programsfor adolescents in child welfare, resource parent programs, and placement stabiliza-tion programs), have been rated as a level 2 on the CEBC rating scale (CEBC 2020).

System-Level Interventions

Foster care redesign (FCR) was designed for ethnically diverse and minority childrenaged 0–17 years old and their families who are at risk of entering CPS. FCR wasdesigned to address overrepresentation of minority populations in the child welfaresystem. It is an attempt to implement programmatic and organizational changes thatprioritize prevention and diversion services over out-of-home placements (CEBC2020). Components of the redesign include safety management services, in-homefamily-centered services, behavior change, an integrated practice team, and casemanagement. Targets include reducing the number of children entering out-of-homecare and reducing re-referral for child abuse and expedite reunification. FCR has beenrated as NR (not able to be rated) on the CEBC rating scale (CEBC 2020).

Disparities in CPA, Service Involvement, and Service Delivery

Dakil et al. (2011) examined child physical abuse disparities across ethnic groups tobetter understand the high prevalence of minorities within the child protectionsystem. African Americans were found to have the highest rates of reported physical

Child Physical Abuse: A Pathway to Comprehensive Prevention 19

abuse cases, highest rates of substantiated physical abuse, and the highest rateof physical abuse related deaths in the United States, compared to whites, Latinos,Asian/Pacific Islanders, multiracial, and Native American children. Of the reportedcases of physical abuse for each race/ethnicity, African American, Asian/PacificIslander, and multiracial cases were more likely to be substantiated, compared tothose of white children (Dakil et al. 2011). In addition, a greater percentage ofreported physical abuse cases resulted in death within Native Americans, AfricanAmericans, and Asian/Pacific Islanders families. These disparities may indicate aneed for addressing cultural bias and culturally tailored physical abuse preventioninterventions.

In addition to the disproportionate representation of minority children in the childprotection system, disparities also exist in the types of CPS interventions which areprovided and accessed by families. In Dakil et al.’s (2011) study, Latinx had muchlower odds of being offered family preservation, adoption, foster care, and employ-ment/educational services compared to Whites. African Americans, however, hadhigher odds of being offered educational/employment services, but lower odds ofmental health and substance abuse services. There are multiple hypotheses that havebeen proposed as to why certain ethnic groups are more likely to receive certaintypes of services, including factors related to the family’s cultural preferences andcaseworker biases in reporting and assessment (Dakil et al. 2011). It is also importantto note that while families of color might be offered or referred to certain servicesmore often than whites, they may not necessarily be receiving the services due toissues of accessibility and availability within the communities that they live (CWIG2016). A study investigating the availability and proximity of child welfare servicesin predominantly Black and Latinx communities in three Texas cities revealed thatdespite the overrepresentation of minorities in the state welfare system, there waseither no nearby services or no/lengthy public transportation to access neededservices in 25% of the combined cities (Dorch et al. 2010). A lack of access tochild welfare and parent education services has the potential to negatively impactfamilies’ case plans and influence their subsequent interactions with CPS, in waysthat would only serve to increase the disparities in the system and reduce thelikelihood of family reunification (CWIG 2016).

Effectiveness of Prevention Programming

While universal and primary prevention can have a significant impact on reducingCPA and a large return on investment, universal and primary prevention strategiessuffer from a lack of rigorous empirical research and are often accompanied withsignificant implementation challenges. For programs that demonstrate null effects, itcan be difficult to determine if the intervention is not effective or if there wereproblems with implementation or aspects of the evaluation design and protocol.For example, a statewide implementation of the Hawaii Healthy Start Program(HSP) assessed the intervention’s impact on preventing child abuse and neglectover a 3-year period (Duggan et al. 2004). HSP involves two phases: (1) screening

20 H. J. Risser and E. David

and assessment to identify families at-risk for child maltreatment and (2) homevisiting of families by trained paraprofessionals. The program model involveseducating parents, modeling problem-solving skills, and providing instrumentalsupport to help parents access services to support their family. Despite being thecentral purpose of the intervention, study results showed that HSP had very littleprogram impact in regard to preventing child abuse and promoting nonviolentdiscipline, with HSP and control groups presenting similarly across most measuresof abuse and neglect. Potential explanations to explain this result pointed to the factthat the needs of the families, many of whom had multiple, complex risks for abusewere not able to be addressed by the level of training of the paraprofessional(Duggan et al. 2004). Furthermore, paraprofessionals rarely referred parents toneeded services in the community, suggesting an issue in program implementation(Duggan et al. 2004).

Key Points

• A comprehensive public health approach to prevent child physical abuse (CPA)incorporates universal, primary, secondary, tertiary, and quaternary preventionstrategies that intervene at multiple levels of the social ecology.

• Mental health promotion strategies function to prevent CPA by supporting chil-dren’s positive health behaviors, socio-emotional learning, and overall well-being.

• Universal prevention strategies operate at the population level to prevent CPAregardless of the presence of risk factors.

• Examples of universal prevention strategies include anticipatory guidance, pro-moting children’s socio-emotional learning, and public health systeminfrastructure.

• Primary prevention strategies reduce risk factors and promote protective factorsagainst CPA.

• Examples of primary prevention strategies include parent training and homevisiting programs, capacity building programs for neighborhoods, and family-friendly work policies.

• Secondary prevention strategies target populations that already have one or morerisk factors for CPA.

• Secondary prevention interventions include home visiting programs, community-level campaigns to change high-risk behavior, financial and housing security, andsubsidized childcare.

• Tertiary, or targeted, prevention strategies include therapeutic interventions thataddress symptoms of trauma or other effects of CPA on the child, or changeparent behavior to prevent the recurrence of CPA.

• Examples of tertiary prevention strategies include evidence-based treatment,wraparound and family stabilization services, and child protective serviceinfrastructure.

Child Physical Abuse: A Pathway to Comprehensive Prevention 21

• Quaternary prevention strategies aim to prevent iatrogenic effects of CPA inter-ventions, such as out-of-home placements.

• Examples of quaternary prevention strategies include evidence-based treatment,trauma-informed services, Family First Prevention Services Act, and CPSredesign.

• There is a disproportionate representation of children of color within the childprotection system. There are gaps in the types of CPS interventions which areprovided to and accessed by families of color. We need to be cognizant ofeliminating bias that contribute to harmful practices.

• Universal and primary prevention interventions can suffer from implementationchallenges that make it difficult to determine a program’s true effectiveness.

Summary and Conclusions

The United States has established a comprehensive array of health promotion andCPA prevention resources, services, and policies. It has allocated funding to imple-ment policies and provide services and resources (e.g., Fortson et al. 2016; U.S.Department of Health and Human Services 2016; Rudolph et al. 2018). The UnitedStates and its citizens are committed to CPA prevention. However, CPA continues tobe a major public health concern. There are at least four ways that we could moreeffectively prevent CPA. First, we can fully align system-level policies and infra-structure with children’s needs for a safe and stable upbringing (Risser et al. 2019).While we discussed multiple policies and infrastructure that support children andfamilies and are designed to prevent CPA, there are countless other opportunities tomore effectively prevent CPA. Second, we can ensure ubiquitous access to effectiveCAN prevention resources and services for all families. This includes access to high-quality, evidence-based services and financial support to facilitate healthy familyfunction (Risser et al. 2019). Third, by promoting earlier health promotion andstrength-based prevention services, perhaps we can reduce any stigma that mayprevent caregivers from seeking support and accessing services. Removing thestigma associated with child welfare services as something to remediate parentingcould pave the way for child welfare to more proactively partner with families. Thisway we can support families in feeling entitled to services and empowered toadvocate for them. Fourth, by investing in rigorous program evaluation of preven-tion implementation and programming, we can build evidence for earlier moreubiquitous services that can benefit all of society and prevent CPA before it occurs.

Cross-References

▶Abusive Head Trauma▶Child Welfare Systems: Structure, Functions & Best Practices▶Corporal Punishment: Finding Effective Interventions▶Corporal Punishment: From Ancient History to Global Progress

22 H. J. Risser and E. David

▶ Parents who Physically Abuse: Current Status & Future Directions▶The Impact of Neighborhood-based Interventions on Reducing ChildMaltreatment

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