Key points

Prevention of child abuse needs to be explained and understood within a broad context of child well-being. A child’s experiences do not occur in a vacuum but rather within the context of family, community, and society. Risk factors for maltreatment such as parental depression, substance abuse, or lack of social support may lead to other adverse outcomes in addition to maltreatment. Likewise, interventions to prevent maltreatment may have other positive effects on children and families, including improved development, improved maternal health, enhanced parent-child communication, decreased use of public assistance, and decreased involvement in the criminal justice system. For these reasons, many organizations and experts, including the American Academy of Pediatrics (AAP), The Centers for Disease Control and Prevention (CDC), and the Harvard Center on the Developing Child directly link child maltreatment prevention to strengthening families, improving developmental outcomes, and promotion of child and family safety, stability, and nurturance.

The role of pediatric health care providers in child maltreatment prevention

Pediatricians and other health care providers can play several important roles in the prevention of child maltreatment. As part of routine patient care, pediatricians can provide anticipatory guidance, screen for maltreatment risk factors, and refer parents and families to effective community-based programs. These efforts can be integrated into routine care without increasing visit length if parents complete screening questionnaires before the visit and listings of community resources are readily available. On a broader level, pediatricians can advocate at the local, state, and national level for policies and programs that support families and children. Each of these roles are discussed in this article. A summary is provided in Box 1 .

The role of pediatric health care providers in child maltreatment prevention

Pediatricians and other health care providers can play several important roles in the prevention of child maltreatment. As part of routine patient care, pediatricians can provide anticipatory guidance, screen for maltreatment risk factors, and refer parents and families to effective community-based programs. These efforts can be integrated into routine care without increasing visit length if parents complete screening questionnaires before the visit and listings of community resources are readily available. On a broader level, pediatricians can advocate at the local, state, and national level for policies and programs that support families and children. Each of these roles are discussed in this article. A summary is provided in Box 1 .

Screening for maltreatment risk factors and identification of families at risk

From an ecological perspective, interactions among and between child, parent, family, and community/society may all increase the likelihood of maltreatment. Any characteristic that makes a child difficult to care for, including physical, emotional, behavioral, or developmental disabilities, may increase risk. Parents with mental health problems, limited social support, limited knowledge of normal child development, low sense of parenting competence, or harsh, inattentive, or inconsistent parenting may be at higher risk of abusing or neglecting their children. Families experiencing intimate partner violence or who have nonbiologically related adults in the home may also be at increased risk. Several community and societal factors such as violent neighborhoods, and inadequate social welfare programs such as food and housing assistance, may increase stress on families and increase the likelihood of maltreatment. Table 1 summarizes major maltreatment risk factors.

Several protective factors should also be noted. Social support is an important protective factor; families with higher levels of social support have lower rates of physical abuse and greater use of discipline strategies other than corporal punishment. Self-efficacy, an individual’s belief in his or her ability to succeed, is another characteristic that can limit the adverse effects of risk factors. Some parents are very adept at identifying and securing helpful resources and services such as home nursing for a sick child, or a child care center that serves children with developmental disabilities. Parents’ sense of competence in child rearing may enable them to better cope with the challenges of raising children. Children with high intelligence, self-esteem, and/or self-efficacy, are involved with extracurricular activities or religious institutions, or who have a supportive adult involved in their lives may be less likely to suffer negative sequelae from maltreatment.

A child health professional who is familiar with the risk factors of child maltreatment can work with families to identify and address these risks. Because many high-risk parents have limited health care access and do not seek out supportive services, they may have more contact with their child’s primary care provider than any other professional. Child health professionals are therefore uniquely suited to identify and address the risk for child maltreatment.

As with any screening program, screening for child maltreatment risk factors should be focused on problems for which effective treatment is available, such as parental depression and substance abuse. Universal screening (ie, screening all families in a primary care practice) is recommended because it eliminates the stigma of screening selected families and reduces the likelihood of missing families at risk. Several questionnaires that screen for child maltreatment risk factors have been developed and validated. Though brief, most identify only a single risk factor.

Several screening tools identify multiple maltreatment risk factors. The SPARK (Structured Problem Analysis of Raising Kids) questionnaire identifies factors that may increase the risk of child maltreatment, such as child health, development, and behavior; parenting approach; social contacts and informal support; and family and community environment. The 3-step model starts with detection of problems and concerns, followed by an assessment of the extent and impact of problems and the parents’ perception of need for support. The final step involves making decisions about next steps. The questions are intended to be administered as part of a structured interview, which takes, on average, 29 minutes to complete. Providers are taught how to administer the SPARK in a half-day training session. A recent study has shown that the included risk factors were strongly predictive of child protective services (CPS) reports. However, no data have been published on the effects of SPARK in reducing child maltreatment.

Another model that incorporates a multi–risk-factor screening questionnaire is SEEK (A Safe Environment for Every Kid). The Parent Screening Questionnaire (PSQ), a component of SEEK, is a single-page document that asks about multiple maltreatment risk factors, including parental depression, substance abuse, social support, intimate partner violence (IPV), major parental stress, and food insecurity. To reduce the stigma associated with asking sensitive questions, an introductory paragraph adopts an empathetic tone and notes that parenting can be challenging for anyone. It also notes that the survey is given to all parents bringing their children for a check-up.

The SEEK model includes several other components in addition to the PSQ. Because many pediatricians may not have had training in addressing complicated issues such as IPV and parental substance abuse, training and skill building are incorporated. Motivational interviewing techniques are introduced as a means of enhancing parents’ readiness to change. These techniques have proved to be effective for many types of behavior change, and pediatricians can become skilled with training and practice. With support from the Doris Duke Foundation, these training modules are now available on-line at https://theinstitute.umaryland.edu/SEEK/ . The SEEK Web site also includes algorithms for further assessment and parent handouts that address each risk factor. The SEEK model ideally includes a clinical social worker or mental health professional to assist with family assessments and referrals, either in person or by phone. Alternatively, pediatricians who have been trained to briefly assess and initially address identified problems may implement the SEEK model with the help of office staff to facilitate referrals.

The effectiveness of SEEK has been studied extensively. Two studies have demonstrated the SEEK model’s effectiveness in reducing child maltreatment. One study was conducted in a pediatric resident continuity clinic based in an urban inner-city community. The other was conducted at 18 mostly suburban private primary care practices. SEEK has been endorsed as a promising practice by the federal Agency for Healthcare Research and Quality (AHRQ) Health Care Innovations Exchange, and some materials are included in the Bright Futures guidelines for anticipatory guidance. An economic analysis of SEEK demonstrated that the program would save money by reducing the need for medical and mental health expenses. Of particular importance to the busy pediatrician, practices that implemented the SEEK model did not increase the average time spent with patients.

Prevention programs rooted in models of anticipatory guidance

Several programs use anticipatory guidance to help parents effectively manage situations that might increase the risk of maltreatment. Two programs have specifically focused on the stress associated with infant crying and preventing abusive head trauma (shaken baby syndrome). Dias and colleagues developed a hospital-based postpartum intervention that taught parents the dangers of shaking babies. Equally important, it taught parents how to manage the stress that they might feel when their infant cries inconsolably. After receiving the educational materials, parents were asked to sign a commitment statement stating that they would not shake their baby and that they would teach other caregivers not to shake. An ecological study comparing change in rates of abusive head trauma in the Buffalo, New York area, where the intervention was implemented with rate changes in neighboring Pennsylvania during the same time period, showed a 47% decrease in the rate of abusive head trauma in the intervention community, but no change in rates in the control communities. Unfortunately, a case-control study of a similar intervention implemented in Utah did not show significant reductions in abusive head trauma.

The Period of Purple Crying program is also focused on the parenting response to infant crying. A video and brochure provide information about infant crying behavior, with advice on how to reduce infant crying and address the associated parenting stress. Two randomized trials demonstrated significant improvement in knowledge about and response to crying. Because the incidence of abusive head trauma is relatively low (approximately 30 cases per 100,000 infants), enrollment of enough families to detect significant differences in rates of abusive head trauma between the intervention and control groups was not feasible. Therefore, the studies were not designed to examine this outcome. The program has expanded from their original sites in Vancouver, British Columbia and Seattle, Washington to many other communities in the United States and Canada. A statewide campaign in North Carolina has incorporated in-hospital postpartum education, community-based education in primary care offices and health departments, and a media campaign. To date, there have been no publications specifically examining whether the intervention leads to a reduction in the rate of abusive head trauma.

The AAP has developed 2 programs for primary prevention of child maltreatment in the clinical setting. Connected Kids: Safe, Strong, Secure is a resiliency-based educational program for parents and providers focused on managing challenging developmental stages, providing effective discipline, and other topics. Although the developers have demonstrated that implementation is feasible, there has not been any evaluation of program effectiveness in reducing maltreatment rates or other benefits. Practicing Safety is another AAP-developed program that helps providers screen for and address maternal depression, and uses anticipatory guidance to help parents cope with challenging developmental stages such as infant crying, colic, and toilet training. It was initially implemented as a Quality Improvement Innovation Network (QuIIN) project to increase attention to and address specific risk factors for child maltreatment. Participants demonstrated changes in practice behavior, but effects on child maltreatment were not examined.

Community-based prevention programs

In addition to providing anticipatory guidance and screening for maltreatment risk factors, pediatricians can also refer families to community-based programs, and encourage them to participate. To do so, however, pediatricians must be aware of which programs are available in their communities. Gathering this information may initially require several hours of pediatrician or office staff time, followed by periodic updates. Community resource information may be available from one’s local or state health department, United Way agency, and/or through an Internet search, supplemented by phone calls and requests for brochures and program information. Identifying and communicating periodically with key contact persons at community-based agencies may also be worthwhile. Brief conversations can be helpful in learning more about the program and in collaboratively addressing the needs of referred families. In addition, families in need of services may be more willing to engage when their pediatrician is familiar with program staff and services.

Pediatricians also must be knowledgable about the quality and effectiveness of the available programs, keeping in mind that many programs have had little or no formal evaluation. Several Web sites focused on evidence-based interventions can help pediatricians acquire this knowledge by summarizing key information. Most provide program descriptions and information on program location(s), targeted populations, research outcomes, and effectiveness ratings. Table 2 lists several useful sites.

Table 2

On-line resources for information on Community-Based Prevention Programs

Resource	Web Site	Information Provided
Department of Health and Human Services, Administration for Children and Families—Home Visiting Evidence of Effectiveness	www.homvee.acf.hhs.gov/Default.aspx	Review of research on home-visiting programs Program descriptions Evidence of effectiveness Findings by outcome domain
California Evidence-Based Clearinghouse for Child Welfare	www.cebc4cw.org	Topic area: Home visiting for prevention of child abuse and neglect Descriptions of specific home-visiting programs Ratings of effectiveness in preventing child maltreatment
Centers for Disease Control and Prevention—Child Maltreatment: Prevention Strategies	www.cdc.gov/violenceprevention/childmaltreatment/prevntion.html	Listing of effective and promising programs Guidelines and planning tools
Promising Practices Network on children, families, and community	http://www.promisingpractices.net/programs_topic_list.asp?topicid=16	Listing and description of proven and promising programs
The Guide to Community Preventive Services: The Community Guide, What Works to Promote Health	http://www.thecommunityguide.org/violence/index.html	Systematic reviews of evidence for early childhood home visitation and other violence-prevention topics

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1. Addressing Child Maltreatment: Helping Those on the Frontlines
2. More than Words
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4. Legal Issues in Child Maltreatment

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