Introduction
This chapter presents a basic overview of the empirical status of methods designed to assess and treat child physical abuse (CPA) and its consequences in children and adolescents. Relevant evidence-based treatments (EBT) will be described, which offer empirical evaluations of specific practices. We focus on information that could help the health care professional (HCP) to better understand and support intervention efforts with these cases. Because many children with a history of CPA or their caregivers do not spontaneously report abusive experiences or any resulting consequences, including trauma symptoms, HCPs may be in the best position to identify these children and to offer suggestions about possible interventions. Thus, it is important for HCPs to be aware of the various forms and characteristics of CPA, to be prepared to evaluate abused children and suspected caregivers in the health care setting, and to serve as knowledgeable referral sources to EBTs that deal with this problem. To facilitate this understanding, we cover the following topics: definitions and prevalence, characteristics and consequences, screening and assessment, service referral and access, intervention and treatment, and prevention. A summary is provided of the implications of this research for practice and research as well as topics for further exploration.
Child Physical Abuse and the Continuum of Force
Definitions
The nature and extent of CPA has been described using various definitions. The National Incidence Study (NIS-3) defined CPA as present when a child younger than 18 years of age has experienced an injury (harm standard) or risk of an injury (endangerment standard) as a result of having been hit with a hand or other object or having been kicked, shaken, thrown, burned, stabbed, or choked by a parent or parent-surrogate. In contrast, the definitions used in the National Child Abuse and Neglect Data Study (NCANDS) were based on separate state definitions, but the item used to capture physical abuse information reflected the “number of victims of physical acts that caused or could have caused physical injury.” For purposes of clarification, this review includes literature on a related topic, namely, corporal punishment (CP), which includes “the use of physical force with the intention of causing a child pain, but not injury, for the purposes of correction or control of the child’s behavior.”
As highlighted by these few definitions, what constitutes CPA varies by local standards and official definitions, the context in which abusive behavior is being examined, and the level of empirical rigor used in crafting a definition. Thus, CPA may reflect a range of behaviors that differ in behavioral topography, frequency, severity, and temporal stability, not to mention informant source. In light of the breadth of this topic and the many forms and definitions of abuse, it is important to keep in mind that there is a continuum of physical force that includes the more serious, substantiated cases of physical abuse (CPA), as well as other acts that might be viewed as general forms of child physical maltreatment (CPM), and the use of CP or physical discipline.
Prevalence/Scope
CPA continues to reflect a significant physical and mental health concern in this country. Based on reports from the states to the Department of Health and Human Services in 2005, physical abuse accounted for 16.6% of all reports, which is second only to reports of neglect (62.8%). The National Survey of Child and Adolescent Well-Being (NSCAW) is a study of children and adolescents who came to the attention of the child welfare system for suspected abuse or neglect. Based on the recently released NIS-4 survey using data from 2005–2006, an estimated 323,000 children met the harm standard and an estimated 476,000 children met the endangerment standard for child physical abuse. These numbers represent 23% and 29% reductions in the rates reported for physical abuse cases relative to the rates reported in the prior NIS survey for cases meeting the harm and endangerment standards, respectively. Among all abuse reports, physical abuse accounted for the majority of reports (58%). As these figures suggest, the physical abuse of children still remains all too common.
Understandably, estimated rates of prevalence and incidence are influenced by the specificity of the definition used to identify cases of CPA, given the absence of a clear consensus definition. Unlike the use of medical or mental health diagnoses, the determination of child abuse reflects a social judgment process that seeks to integrate several social-demographic details (e.g., risk factors, safety issues) with the child’s physical/medical status and severity of injury. In many cases, it is difficult to determine when an incident involving physical force by a caregiver represents actual CPA or extreme parent-to-child discipline (e.g., beating vs. spanking/slapping), which often blurs the distinctions among abusive, subabusive, or nonabusive behavior. Reporting rates are also subject to variation in the interpretation of county or state definitions, as well as other case (e.g., prior history of agency involvement), caseworker (e.g., caseload, history of experience, training), and/or social service system factors (e.g., degree of supervision/monitoring, population size), among other variables.
Health and other officials recognize that cultural and personal attitudes about the use of CP play a substantial role in shaping one’s views about identifying and reporting CPA, among other influences. Although few positive developmental outcomes, if any, have been found associated with the use of CP, , most individuals view various forms of CP, such as spanking, as appropriate and effective methods of correction. In fact, 62% of Americans in general, and 61% of American parents in particular, view spanking as a favorable form of discipline. In addition, more than 90% of parents in various countries frequently hit toddlers.
Although CP is not tantamount to child abuse, the line between abusive and proper discipline often remains obscure. As noted by Straus, about two thirds of all cases of CPA begin as CP, which escalates into abusive behavior. Thus, the task of determining when a specific parental behavior or set of behaviors qualifies as CPA and deserves to be reported is complex and multidetermined and requires a concerted effort to understand the broader continuum of physical force. These and other judgments about the various forms of physical discipline in which caregivers engage are among the reasons for different rates of substantiation across states in the United States.
HCPs clearly recognize that children’s exposure to excessive or harmful punishment or ineffective physical discipline takes numerous forms and often defies easy identification or a simple or precise definition. After all, these experiences are frequently not reported by the family, even when physical signs or symptoms are evident. Also, many children or parents offer alternative descriptions when asked about the nature and contributors to a child’s physical symptoms or pain. Thus, the classification of punishment as abuse can be difficult, especially given the serious consequences for parents and children when CPA is confirmed.
Chapter 2 , “Epidemiology of Physical Abuse,” outlines factors in children, parents, family, and environment that increase the likelihood of abuse. By identifying the individual features that increase the risk for CPA, past and current abuse can be more easily addressed, and future abuse is more likely to be prevented.
Characteristics and Consequences
In addition to its health and medical effects, another important area for HCPs to consider is the range of clinical consequences that may be experienced by physically victimized children. Although CP appears to have few beneficiary effects, the literature reveals a variety of associations between CP and impaired or disrupted development. Children and adolescents who have experienced CP or CPA often develop externalizing or internalizing problems that can promote other behavior problems. Many of these behavioral and emotional problems surface by late childhood and adolescence, although some may be apparent earlier.
Cognitive/Learning and Attributions
CPA affects how children understand relationships, often creating maladaptive attribution patterns. Girls who have been abused attribute less power to themselves than to parents, and women who were abused as children attribute less power to themselves than to children. Often, victims of CPA develop distorted social cognition schemas, which lead them to accept violence in future relationships.
As shown by recent neurophysiological research, abused children process information relating to emotion differently than normal children. They are more attentive to visual and auditory anger cues and potential threats, which places them at a greater risk for anxiety than nonabused children. They are also more likely to display depressive symptoms.
CPA has been found to produce detrimental effects upon adaptive functioning. Even in children who face multiple adversities (e.g., low socioeconomic status, minority status), those who experienced CPA show a greater degree of maladaptive functioning than their nonabused counterparts. Given that some of the parents who abuse their children were victims of physical abuse during their childhood, one of the most damaging consequences of CPA is the increased likelihood that such victims will later abuse their own children. ,
Behavior and Mental Health Problems
Quite possibly, the most common consequences of CPA that arise during childhood and adolescence involve externalizing (aggression or antisocial behavior) and, to a lesser extent, internalizing problems (depression or anxiety). Such dysfunctional behavior patterns can, at times, reflect serious antisocial or dangerous behaviors, such as firesetting behavior. In terms of the externalizing patterns, the victims of CPA are more likely to display aggressive or antisocial behavior, develop oppositional defiant disorder, or abuse drugs and/or alcohol. Physical abuse can also worsen behavior problems, possibly by elevating the emotional and behavioral difficulties that often lay at the root of maladaptive behavior. For example, juvenile firesetters who have experienced CPA tend to display more severe behavior problems than their nonabused counterparts, and children with a history of CPA may be more likely to start drinking earlier and to use alcohol to cope rather than for pleasure or social reasons. Externalizing behavior problems related to CPA can occur as early as the late toddlerhood years.
As for internalizing disorders, the most frequently documented consequence of CPA exposure is depression. , Other research suggests that experiencing CPA leads to increased risks of suicidality, suicide attempts, and general mental health problems.
Social/Interpersonal Competence and Relationship Skills
Individuals with a history of CPA tend to have more difficulties with interpersonal relationships than nonabused individuals. CPA increases the greater risk for violent or aggressive behavior in relationships and impaired interpersonal functioning. Maltreated children may be less communicative, less warm, and more conflicted in their interpersonal relationships than nonabused children, and they experience more conflict with peers and partners. Victims of CPA do not always become the aggressor; sometimes people who experienced CPA are more willing to accept violence in their future relationships than nonabused people. Essentially, the people who experienced CPA are at a greater risk for continuing the vicious cycle of abuse, either as a perpetrator or a victim, which also affects the lives of their families.
Posttraumatic Stress Disorder
Some physically abused children may experience posttraumatic stress disorder (PTSD) as a result of exposure to a specific traumatic event or series of events. PTSD consists of five core components. The child must experience a traumatic event that qualifies as a serious traumatic stressor, possibly one that was either objectively or subjectively related to threats to life or physical integrity. , The three core symptom clusters of PTSD are reexperiencing (e.g ., symptoms include upsetting feelings when memories or reminders of the traumatic event recur) , avoidance/numbing, and hyperarousal . In order to meet full PTSD criteria, children must have at least one reexperiencing symptom (e.g., recurrent and distressing memories or thoughts of the event, physiological reactivity to trauma reminders), three avoidance symptoms (e.g., efforts to avoid thoughts, feelings, or talking about the traumatic event; avoiding activities, places, people, or situations that serve as trauma reminders), and two hyperarousal symptoms (e.g., difficulty falling or staying asleep, irritability, or temper outbursts). Finally, these symptoms must be present for at least a month and must cause functional impairment in social, school, family, health, or another important area of daily living. Even if a child has only a few PTSD symptoms, the case may warrant a referral for further evaluation if the symptoms are of sufficient severity to cause functional impairment.
Health/Medical
In a large telephone interview study of adult women, the poorest health was found among women with a history of both sexual and physical abuse in childhood (e.g., severe depression, physical symptoms, joint pain, nausea/vomiting, fair/poor health, lower functionality). Those with either form of abuse also had modest levels of these problems.
Summary
CPA produces an environment that is stressful to the child, which increases the likelihood of internalizing and externalizing behavior problems. Thus, when HCPs recognize internalizing or externalizing behavior problems, specifically aggressive or antisocial behavior or depression, they should consider inquiring about the child’s exposure to CP — and possibly CPA. Furthermore, it is important to recognize that CPA often occurs with exposure to another type of adverse situation, such as psychological, sexual, or substance abuse. HCPs should then consider the breadth of factors and consequences related to CPA and harsh physical discipline, since such experiences can have severe physical, psychological, and cognitive effects on these children and their families. Reporting and intervening in cases of physical abuse can help the child and the surrounding family members. By understanding some of the risk factors, consequences, and related problems and disorders associated with CPA, HCPs will be in a better position to recognize and aid the victims of physical abuse and to help to prevent future abuse.
Screening and Assessment/Evaluation
Interview Probes for Exploring Exposure to Physical Discipline and Child Physical Abuse
There is clearly no standard protocol, procedure, or set of questions for learning about a child’s potential history of child abuse. Instead, one can only attempt to establish interview conditions that are conducive to the conduct of an accurate and comfortable interview and to ask simple, clear, and nonleading questions that seek helpful information. Setting the stage for a productive conversation like this requires an understanding of the child’s developmental history and family circumstances, sensitivity to the topic, and patience in responding to the child’s or parent’s answers. Another important condition involves establishing the purpose and limits of confidentiality for an interview so that the informant is aware of how the information will be used.
Due to the context in which physical discipline often occurs, it is helpful to ask open-ended questions and to normalize the use of punishment and various forms of discipline. Key initial questions could solicit information about the child’s exposure to punishment (e.g., how often punished, what happens), including physical punishment (e.g., spanking, slapping, grabbing, pushing) and most extreme or serious kinds of punishment or discipline used with the child. In some cases, it may then be important to ask if a child is worried about parental loss of control and the possibility of being physically hurt.
Details need to be obtained for all reported incidents of child maltreatment or abuse. Common parameters of such incidents reflect the perpetrator and relationship to child, possible contributors to the incident, the specific acts or behaviors involved, the setting, and any consequences or reactions in the child (e.g., pain, injuries, medical services) and perpetrator (e.g., threats to maintain secrecy). The child’s overall impressions regarding the reasons for the incident may also be relevant to examine. Generally, it is helpful to ask open-ended questions, which solicit more complete details, although there are times when a reluctant or low-functioning informant may benefit from more close-ended questions. Clearly, one implication of such careful questioning is the need to carefully document the child’s or parent’s statements, and the possibility of needing to report the incident to child protective services. Further, it might be necessary to consider what, if any, safety plans are needed immediately based on an approximation of the child’s level of risk.
Some HCPs feel comfortable asking children about exposure to physical abuse or other types of events. Generally, children and parents should be asked these questions separately and privately, mindful of any reporting requirements. A few general questions designed to elicit information about a child’s general exposure to traumatic events might be helpful, such as (1) Has there been any significant change in the child’s life or functioning since the last visit? (2) Did anything unusual happen to the child? (3) Has there been any significant change in the child’s behavioral or emotional functioning? and (4) Has anyone reported or observed any sudden changes in the child’s behavior or mood? These questions could also be directed toward identifying the child’s exposure to specific types of noninterpersonal traumas (e.g., bad accidents, medical illness/procedures, natural disasters), and interpersonal traumas (e.g., physical violence, physical abuse, sexual abuse, domestic violence, traumatic death), and other frightening events (e.g., kidnapping, terrorism, etc.).
When assessing children for the presence of PTSD symptoms, it is important to anchor the symptoms to a specific stressor. If the HCP is interviewing the child, he or she should ask the child whether any of the above experienced events was very upsetting or scary to the child. If the child reports that any of these events were distressing, it is then important to determine which one was most traumatic from the child’s perspective , and then assess the child for the presence of the PTSD symptoms described above. However, interviewing children for PTSD symptoms is a challenging task, particularly asking about avoidance. Children and parents should ideally be asked about the child’s symptoms separately to obtain optimal information, since inclusion of parental report has been shown to improve the rate of accurate diagnosis.
In most practices, time demands will preclude clinicians from conducting personal interviews to assess PTSD symptoms. As described in the next section, self-report instruments are available for inquiring about trauma exposure.
Formal Instruments/Tools
Numerous instruments have been reported to facilitate screening and assessment of CPA. We have identified certain ones that seem applicable to the HCP and the setting in which this activity would be conducted. Some measures examine broad clinical concerns that can co-occur following abuse, such as PTSD, depression, anxiety, and behavioral problems. Consequently, it may be necessary to include other instruments to evaluate a child’s clinical needs or psychosocial status. In some cases, parents identify other clinical concerns that relate to the child’s recent exposure to traumatic events, beyond CPA. What follows are some brief descriptions of potentially relevant instruments that have adequate psychometric properties.
Injury/Re-Abuse (Recidivism) and High-Risk Behaviors
The Traumatic Events Screening Inventory (TESI) can serve as a general screen to identify a child’s recent exposure to various traumatic experiences. The measure includes several primary domains that reflect both interpersonal and noninterpersonal events (e.g., direct exposure to or witnessing of severe accidents, illness, disaster, family or community conflict or violence, sexual molestation). The measure has good psychometrics and is recommended as an interview, especially since it has follow-up probes designed to solicit more details when a given trauma is identified.
Focusing more on possible physical abuse, a treatment provider might prefer to administer a few, brief questions to caregivers or children to determine if the child is exposed to high-risk parental behaviors. The Weekly Report of Abuse Indicators (WRAI) captures a few high-risk parental behaviors to assess risk status and monitor treatment course. , The three items reflect the severity of parental anger (1-5 point scale), any parental use of threats or physical force/discipline, and the severity of any recent family problems (1-3 point scale). Parents are also asked to report whether they thought about using physical force.
The Brief Child Abuse Potential Inventory (B-CAPI) was recently developed to provide an efficient tool for screening parents at risk for CPA or mistreatment of their children. The B-CAPI consists of a 24-item abuse risk scale with a recommended risk cutoff (12) and a 9-item validity scale. Scores on the risk scale relate to future child protective services reports. Thus, this tool may help to inform an HCP’s concerns about parental risk for physical abuse.
HCPs could also request information from official child welfare system records in order to learn more about histories of both caregivers and their children in terms of child welfare involvement and outcome. This could include incidents involving child maltreatment, physical injury, court involvement, and placement stability or disruption. Relevant parameters of these experiences have been coded using the Maltreatment Classification System (MCS) to help identify key incident details (e.g., type, perpetrator, frequency, severity). , Given the often modest to high recidivism rates, such information may be useful in highlighting children at risk for continued involvement in abuse or neglect. , It should be noted that some agencies will be reluctant to share this type of information outside of the environment of a community/hospital multidisciplinary team.
Clinical Problems/Symptoms
The Trauma Symptom Checklist for Children (TSC-C) is one of the few clinical instruments developed to assess children’s and adolescents’ responses to unspecified traumatic events in an array of symptom domains. The scales include posttraumatic stress, anger, anxiety, depression, sexual concerns and preoccupation, and dissociation. The child is asked to indicate how often each item happens to him or her using a four-point scale (0 = never; 1 = sometimes; 2 = lots of times; 3 = almost all the time). One advantage of the TSCC is that it can efficiently assess posttraumatic stress symptoms and other symptoms related to exposure to physical abuse. In particular, the posttraumatic stress scale consists of 10 posttraumatic stress symptoms (e.g., intrusive recollections of traumatic events, sensory reexperiencing and nightmares, dissociative avoidance, fears), and has high good psychometric properties. The TSCC was standardized on a large sample of racially and economically diverse children from urban and suburban settings, and provides norms according to age and gender (T-score mean = 50) as well as clinical cutoff scores.
The nine-item Abbreviated UCLA PTSD Index provides a brief evaluation of the severity of PTSD symptoms. A score of 20 correlates highly with a diagnosis of PTSD, although children with scores of 8 to 10 likely have clinically meaningful symptoms of PTSD that, if accompanied by functional impairment, may also merit clinical referral for further evaluation. The validity of this measure has been demonstrated in school settings following disasters such as the September 11, 2001 terrorist attacks.
Functional Impairment
HCPs may find it helpful to use the 13-item Columbia Impairment Scale (CIS) with parents or children to capture the child’s overall impairment in four areas of functioning (i.e., family, peers, work, school). Items are rated on five-point Likert-scales (“no problem” = 0; “big problem” = 4), with a range of 0 to 52. The measure has good internal consistency, reliability, and validity in clinic samples.
Environmental Context
Concerns about the presence of negative and absence of positive parenting activities might warrant administration of the Alabama Parenting Questionnaire (APQ). The APQ evaluates six dimensions of parenting practices and activities (i.e., involvement, positive parenting, poor monitoring/supervision, inconsistent discipline, corporal punishment, other discipline practices) that may help to identify common responses to various child behaviors. This scale has good psychometric properties.
The Parent-Child Conflict Tactics Scales (CTSPC) provides a more focused and comprehensive assessment of mild to serious forms of parental verbal, psychological, and physical discipline (non-violent discipline, physical assault) during child conflicts. Some of the items in this tool represent parental actions that may cause severe forms of physical abuse (e.g., using a knife or gun). The scales possess excellent reliability and good validity with children and parents. ,
The Family Environment Scale (FES-A) includes three subscales (e.g., cohesion, expressiveness, conflict) that reflect a general family relationships index. The scale has been used with several clinic samples of varying ethnic backgrounds with good results in terms of reliability, stability over time, and predictive validity. The conflict and cohesion subscales are particularly useful in evaluating the environment in which harsh or coercive parent–child interactions emerge.
For families with adolescents, the 20-item Conflict Behavior Questionnaire (CBQ) can be used to evaluate parent–child hostility and discord, given that negative communication is a common correlate of CPA. Scores can be interpreted using a normative cutoff. The CBQ has high reliability, internal consistency, and treatment sensitivity.
Services or Intervention Experience
To learn about a family’s recent involvement in treatment or other services, the Service Assessment for Children and Adolescents (SACA) can be administered to parents to evaluate the extent of a child’s recent service use in several major domains (e.g., overnight, outpatient, school), as well as some service-related parameters (e.g., usefulness) and obstacles (e.g., agency policies) that might affect the child’s current status. It might be important to learn what concurrent services are being received (e.g., medication, care management) or whether families might benefit from more intensive services (crisis intervention, placement) after an evaluation.
Summary
Since HCPs often see cases involving suspected CPA, this section offers brief recommendations to facilitate recognition and evaluation of these children. It is important, however, to realize that they may not always report such cases to the authorities or be fully aware of reporting requirements. Consequently, there may be potential benefit to providing both education and support to HCPs as a way of reducing any barriers to recognizing and reporting physical abuse.
Service Referral, Access, and Use
In advance of describing the nature and impact of various interventions or treatment approaches, it is important to highlight the issue of service referral, access, and use or involvement given persistent problems with engagement, compliance, and dropout among abusive families. , A fundamental concern is the fact that many families fail to receive needed mental health services, since many victims of CPA are not referred for treatment. One reason for limited service referral is the variability in the timeliness with which caseworkers’ risk assessments are completed by accepted deadlines. In addition, this study found that caseworkers’ risk assessment reports for a subset of cases did not appear related to the results of a battery of clinical assessment measures collected by independent research assistants, which suggests that the client’s mental health needs might not have been clearly identified as a basis for referral.
The relatively low rates of service use among CPA victims and their families are well documented. An administrative record review study found that between 40% and 60% of all cases in which maltreatment was substantiated appeared to receive no subsequent services. A survey of practitioners found that CPA victims received only 7 of a total of 23 sessions of services that were conducted to reduce the negative consequences of this experience. In terms of other services, fewer than half of a small sample of physically abused children had received a medical evaluation related to CPA, although the majority had received wellness care. Half of these cases were heard in family court and fewer than half were receiving mental health services. Children were more likely to receive services if the maltreating caregiver was not in the home. Caregivers were more likely to receive services if they acknowledged the abuse. Similar results were reported based on a chart review for a sample of CPA victims in Sweden, in which about half of these children had received services prior to the abuse, but one fourth of the charts had no mention of the CPA and only 6 of 126 had received individual therapy. Interestingly, formal intervention by the department of social services prior to the abuse was related to receiving interventions by the department up to 4 years later.
One study of families referred to CPS following an incident of child physical or sexual abuse examined the treatment experiences of the sample upon intake and at a second assessment following an initial service about 6 months later. Based on standardized clinical assessments conducted with child victims and their caregivers, several findings were reported, including: (1) 30% of the caregivers and children had a past history of psychiatric hospitalization, and (2) at the follow-up assessment, children and their caregivers reported high rates of family (47%, 39%) and parent counseling (33%, 48%), but lower rates for child treatment (17%, 19%), respectively. Four variables predicted higher overall family service use at intake: white race, low child anxiety, parental distress, and parental abuse history as a child. Such findings highlight the low rate of service involvement of this sample and a few of the background characteristics that may increase service referral.
One of the few national studies of children referred to child welfare services for allegations or abuse or neglect reported a population estimate of service use. Nearly one half of youths ages 2 to 14 years with a completed child welfare investigation had clinically significant behavioral or emotional problems. These youths were much more likely to receive mental health services in the prior 12 months, but only one fourth of such youths received any specialty mental health care. One implication of these findings is the need for more routine screening and treatment referral of youth with recent child welfare referral, especially those with clinical need. Active HCP referral may be particularly necessary given that many parents who think about getting professional counseling for their children do not follow through on their considerations. In fact, only 20% of juvenile crime victims actually received services. In addition, parental help-seeking was influenced by outside advice, suggesting the potential benefit of HCP input or recommendations for mental health consultation.
Even when families are referred and get involved, participation rates are variable. For example, one program evaluation report documented a 38% no-show rate at home, a 66% no-show rate in the clinic, and a 36% dropout rate among 45 families. A similar dropout rate (44%) has been reported in a study of specialty family treatment. Further, participation in child treatment is not always associated with clinical benefit. In this study of 68 children referred to community agency providers after a report of child physical or sexual abuse, child treatment was received by 19% and 50% of the children by 1- and 2-year follow-up, respectively. Initial child treatment was not associated with significant gains in child outcomes; child improvement in abuse-related outcomes was associated with having PTSD and lower adjustment at intake. Initial child treatment was also unrelated to re-abuse or out-of-home placement documented by 2-year follow-up. Other reports indicate mixed benefits following child treatment.
Among the many potential alternatives to increasing service access and use, one novel alternative involves discussing key obstacles to EBT access by a trained professional. This protocol involved the administration of a 29-item checklist of potential barriers, which was then discussed with parents to provide useful information and suggestions to enhance parental expectations of benefit following exposure to an EBT. Results indicated that parents demonstrated an increase in knowledge about and rapport during a medical evaluation, and showed an increase in satisfaction with the routine after the protocol. This application based on a brief interaction between professional and parent highlights one viable approach to enhancing diffusion and use of EBTs in community settings.
Intervention and Treatment
There are a number of alternative interventions and treatment approaches to serving the needs of physically abused children and their families, in part because of demographic and clinical heterogeneity of this client population. These approaches emphasize different clients (e.g., parent/family vs. child centered), targets (e.g., child management, anger management), content or methods (parenting skills vs. peer social support), or modalities (cognitive-behavioral therapy [CBT] vs. family therapy). The following section provides a brief overview of selected intervention approaches and studies whose outcomes bear treatment implications. Where available, outcome evidence will be reported. For further information, several online sources can be consulted.
One exceptional source of relevant information about treatment and services is the National Child Traumatic Stress Network (NCTSN), a national network of over 60 sites that provide community treatment and services across the United States, which was established by the Substance Abuse and Mental Health Services Administration (SAMHSA) in 2001 to improve the standard of care for traumatized children, adolescents, and their families. The NCTSN maintains a website with downloadable and printable information about abuse and neglect, as well as PTSD, which can be given to parents and children in the practitioner’s office. The website includes some new materials related to CPA, including a “Q&A” interview designed to address common concerns about physical abuse, some handouts relevant for professionals or caregivers interested in services, and other related information on trauma in children. A full set of resources for specialized mental health referrals across the United States is available from this resource. To access the NCTSN website, go to www.NCTSNet.org .
Child-Focused Intervention
Children involved in physical abuse might benefit from participation in services, even though the amount of attention paid to descriptions or evaluations of child treatments is limited. , Generally, child intervention is one element of a more broad-based family or parent-directed intervention.
Intensive day and residential treatment programs, primarily for maltreated preschoolers, have offered access to different developmentally appropriate and therapeutic activities (e.g., recreation, learning, play) and modalities (e.g., child play groups, family counseling) with trained staff who work closely with each group. , Clinical reports based on this work document improvements in several developmental skill areas. For example, a program in Australia consisting of a therapeutic preschool and home visitation found improved intellectual functioning and receptive language at discharge 1 year later.
A more intensive, group-based treatment program was aimed at encouraging supportive peer relationships and identification of personal feelings, along with play, speech, and physical therapy. The program incorporated other family services (e.g., family and individual therapy, support group counseling, parent education, crisis line). Relative to a control group, treated children saw themselves as having higher cognitive competence, peer acceptance, and maternal acceptance, and they received higher developmental quotients on standardized measures. Teacher ratings supported these improvements. Still, most children scored below the “normal” range in most areas. Day or residential treatment programs that combine skills training and experiential methods might be most useful in targeting the diverse social-psychological problems of the more seriously dysfunctional child victim and family.
A second approach reflects the application of specific behavioral and social learning procedures directed toward improving peer relations and social adjustment of young child victims by arranging play-buddy sessions in which withdrawn maltreated children were exposed to social initiation techniques demonstrated by trained peer confederates, called resilient peer treatment (RPT). Studies have shown that RPT is more effective than adult initiations in improving children’s social adjustment and peer initiations, , and is more beneficial for withdrawn, than aggressive, children. Maintenance effects 2 months fter RPT have also been documented. This intervention may be especially relevant for children who demonstrate clear social or interpersonal deficits.
A preliminary report was made of a cognitive-behavioral group conducted over a 16-week period with six physically abused children, four of whom completed the group. The program emphasized content in three primary domains (i.e., trauma-specific work, anger management, social skills training). Outcome assessment based on child reports revealed improvements for some but not all group participants (anger reactions, posttraumatic symptoms), with parent reports indicating some increase in emotional and behavioral problems after treatment. Advantages to group work include the ability to draw upon shared group experiences and problems, although it is not always easy to find suitable group members at a given time.
Parent-Focused Intervention
Perhaps the most common intervention strategies for CPA involve training parents in positive and nonviolent child management practices. , Training is often directed toward helping parents learn to monitor their child’s behavior, to issue clear and effective instructions, to use attention and ignoring at the right time, to say positive things or deliver positive consequences (reinforcement), to apply time-out and response cost as alternatives to physical discipline, and to establish and maintain home-based behavioral programs. Interventions that include training in these parenting principles have reported improved parental repertoires and parent–child outcomes (e.g., more prosocial interaction, conflict resolution) that have often been maintained at follow-up. For example, one approach that integrated individualized parent training in various child management procedures with parent–child stimulation training reported improvements in both parent (e.g., child abuse potential, parental depression) and child (e.g., behavior problems) targets, although there was less improvement in family interaction.
Interventions for parents have broadened beyond the focus on child management by targeting parents’ cognitive-behavioral repertoires to deal with a variety of clinical problems. Several CBT procedures have been directed toward changing parental dysfunction related to the use of distorted beliefs or attributions, limited problem-solving skills, and heightened anger reactivity, each of which can contribute to parental aggression. These procedures help parents become aware of their negative self-statements and to generate prosocial alternatives to these statements, promote realistic developmental expectations, encourage the use of coping self-statements and relaxation skills, or interact using appropriate communication and problem-solving skills. , The addition of cognitive restructuring and problem-solving to other stress management methods has been associated with reduced child assault and anger arousal and higher empathy in parents, as well as fewer complaints concerning child behavior problems. , Their clinical merit notwithstanding, some of these studies were uncontrolled reports and none of these studies reported follow-up or abuse recidivism data.
Providing parental education and support is another general approach that has been used with at-risk parents and their young children. For example, one program incorporated several procedures in a community-based center (e.g., respite, support groups, training in discipline and developmental expectations, parent and child sessions), which was associated with clinical improvements on some measures (parental depression and stress) but not others (social support, child misbehavior). Controlled studies need to document the efficacy of this intervention approach with abusive families. A related program that provides exposure to a parenting curriculum (Systematic Training for Effective Parenting [STEP]) has also demonstrated a significant increase in positive perceptions of their children and a reduction in child abuse potential, relative to a control group.
Parent–Child and Family-Focused Treatment
Many intervention approaches integrate parent and child components, including interventions that focus upon the family, in recognition of the interaction between various parent and child factors. Therefore, early studies have reported some benefits to family casework (e.g., discussion of individualized family treatment plans, training in behavioral parenting techniques) in reducing coercion in physically abusive families.
Parent-Child Interaction Training (PCIT) has been adapted for use with physical abuse based on its long history of application to the treatment of behavior problems in young children. PCIT addresses issues related to harsh or ineffective parental discipline and heightened behavioral dysfunction in children by providing parents opportunities to develop more positive relationships with their children and to learn appropriate parenting techniques through ongoing coaching efforts during observed interactions. Outcome evidence in a recent study in abused children and their caregivers showed that PCIT was associated with lower official recidivism rates than a condition consisting of both PCIT and supplemental family services or a condition involving routine parenting classes conducted in the community. PCIT is noteworthy for its attention to various stages in the treatment process, ranging from assessment and the training of behavioral play skills to the training of discipline skills and use of booster sessions.
Some approaches promote greater integration of interventions for caregivers and children/adolescents. For example, Alternatives for Families: A Cognitive-Behavioral Therapy (AF-CBT) seeks to reduce caregiver/family risk factors for physically abusive or coercive behavior and ameliorate the consequences of these experiences for children, at both the individual and family-context levels. AF-CBT incorporates individual CBT methods for parents and children with family-system procedures. Each of these elements has been associated with improvements in child behavior problems, caregiver abuse risk/behavior, and family conflict/cohesion, and with low recidivism rates at follow-up. , It is important to note that 20% to 23% of all children and their parents independently reported high levels of physical discipline/force during the early and late phases of treatment, as well as heightened parental anger and family problems, suggesting the importance of targeting parent–child coercion and use of force.
A related CBT-based intervention called Combined Parent-Child Cognitive Behavioral Therapy has integrated individual and group components for parents and their children. The intervention includes elements from several treatments, including trauma-focused CBT, AF-CBT, and other methods, and could be especially useful in cases in which children report at least some symptoms of PTSD. Anecdotal evidence suggests some initial improvements among families who have participated in this program.
Most of the aforementioned treatments are administered in clinic settings, but other interventions have been applied in the home, on an intensive basis, and directed toward multiple family participants. Such ecologically based and family-centered services generally have targeted contextual risk factors associated with abuse, specific skills deficits, and/or personal competencies. For example, intensive family-based reunification services (vs. routine reunification services) have been found to improve reunification rates, , possibly because of the provision of in vivo services and training in CBT skills (e.g., problem-solving, communication). Evidence on family preservation and support programs, however, did not support their effectiveness in preventing future child maltreatment cases.
Additional multicomponent clinical interventions have targeted diverse individual, family, and systemic problems in the home and community. For example, multisystemic therapy (MST) targets problems in the child, parent, family, and social systems (e.g., peer training, child management, family communication) following an individualized family assessment and in accord with a set of treatment principles (e.g., ecologically based, individualized, intensive). An early study found that MST was associated with improved parent–child relationships (parental efforts to control child, child compliance), whereas parent training was more effective in reducing identified social problems.
Other programs conducted in the child’s ecology emphasize the application of individualized skills training methods to problems specific to the family (e.g., child management training, social support, assertion training, job training, home safety/finances training). For example, Project SafeCare incorporates three primary interventions from several originally examined in Project 12-Ways designed to address the common behavioral deficiencies of abusive parents (infant and child health care, home safety, stimulation/bonding, or parent–child interaction). Results from Project SafeCare indicated improvements in parent-identified goals, but mixed evidence in terms of reduced re-abuse rates. The strong emphasis upon careful assessment and then individualized home-based training is a significant strength of this program. Such comprehensive interventions underscore the need to provide multiple services to stabilize the home environment and promote improvements in parent–child relations with abusive families, many of which exhibit considerable family dysfunction.
A more recent intervention, child–parent psychotherapy (CPP), is noteworthy for its unique effort to integrate the treatment of young children exposed to domestic violence and their caregivers. CPP combines several therapeutic elements, including play, developmental guidance, trauma-focused interventions, and concrete assistance to promote children’s well-being and parent’s capacity to both nurture and protect. For example, parents learn how to respond to children’s emotional and developmental needs, and create a safe family environment. Relative to the provision of case management and community referral for individual treatment, CPP was found associated with significantly greater reductions in child’s behavior problems and mother’s general distress. This is one of the few EBTs for traumatized preschoolers and their mothers.
It is worth mentioning that other treatments have been developed to address PTSD or related symptoms in children or adolescents exposed to traumatic events, including sexual or physical abuse, family or community violence, loss and grief, and natural disasters, among others. Perhaps the best known treatment for trauma is trauma-focused cognitive-behavior therapy (TF-CBT). TF-CBT has been most extensively examined in the treatment of CSA, where it has yielded reductions in symptoms of PTSD, depression, and anxiety in several studies, but it bears relevance to an array of other traumatic experiences. The treatment includes several key components designed to address the experience of traumatic reactions (e.g., trauma narrative, psycho-education, relaxation, promotion of child safety and support). A related intervention, cognitive behavioral intervention for trauma in schools (CBITS), has been applied on a group basis in schools and has been found to reduce PTSD symptoms in adolescents exposed to violence. Although the intervention has been developed for exposure to community violence, it might be appropriate for dealing with PTSD following physical abuse.
Summary
What are some of the implications of this review of treatment approaches and outcomes? First, these findings provide additional, albeit qualified, support for the continued development of individual, group, and family treatments involving child victims of physical abuse. Second, it seems necessary to address caregivers’ parenting practices in order to develop a more effective disciplinary repertoire. Third, integrated interventions that can adequately target the broad clinical features of abused children and their parents/families might help to improve positive outcomes. In terms of clinical approaches, most interventions have applied CBT and parenting skills training procedures to specific competencies and clinical problems. This general focus is consistent with the four suggested CBT strategies recommended for the treatment of traumatized children and their parents: exposure to the traumatic event, stress management and coping skills training, exploration and correction of cognitive distortions related to the traumatic event, and interventions with parents. Several potential targets exist for parents (e.g., negative child perceptions, developmentally appropriate expectations, self-control, affect or stress management, positive discipline, social support) and children (e.g., anger identification and control, relaxation, social skills, peer play activities, misattributions, academic competencies, problem-solving).
Fourth, providing treatment in the natural environment can be beneficial, but successful treatment has also been conducted in clinic settings where safety and comfort can be provided. Setting type must be determined based on both program and parental input, but can be influenced by the varying needs of the population found in different geographic regions such as rural areas. Fifth, there may be times when a family needs different services, such as crisis intervention or concrete or support services (e.g., Homebuilders). Since intervention studies have shown mixed evidence for the maintenance of treatment gains, , an examination of therapeutic methods that promote greater scope and stability of improvements seems warranted (e.g., “check-ups,” service calls). Much work still needs to be done to promote the development, application, and evaluation of psychosocial interventions designed to modify both the sequelae of an abusive experience and the risk of re-abuse.
Prevention
The available literature on primary prevention highlights a number of alternative programs and activities. , Numerous prevention programs have been directed toward reducing a variety of risk factors for abuse (see Chapter 64 , “The Prevention of Child Abuse and Neglect”). Klevens and Whitaker conducted a literature review that identified the types of risk factors that were targeted (e.g., individual, family, community) and whether or not the program was evaluated. One-half of the programs were delivered in the home or community, with some programs conducted in hospitals and schools. One third of the programs targeted three or more risk factors, which were highly diverse (poor early bonding, knowledge of child abuse, lack of child care, harsh discipline, poverty, unemployment). Only one fourth of the programs, however, included a rigorous evaluation. On the positive side, programs targeting certain risk factors did report some reduction in abusive behavior (e.g., low education, unwanted pregnancy, poor bonding, expectations, substance abuse, dysphoria, parenting, stress, isolation). Many worthy risk factors, however, were generally ignored and deserve further attention in prevention programs, such as social norms regarding physical discipline, poverty, partner violence, and the young age of parents. Each of these factors could be addressed, at least to some extent, by anticipatory guidance or other brief encounters within the primary care setting.
One of the more commonly evaluated approaches involves home visitation to new parents. An early version of this approach involved establishing nurse–family partnerships in which visiting nurses provided educational information, support, some counseling, and referral information over a lengthy period. Controlled studies showed beneficial maternal and child outcomes, which have been extended to follow-ups of between 4 and 15 years. Positive outcomes included reduced rates of child maltreatment. Interestingly, use of paraprofessionals was associated with about one half of the benefits obtained using nurses as home visitors. Indeed, several home visiting programs that rely upon paraprofessionals have been conducted. The effects of these programs have been limited to short-term benefits in self-reported clinical problems or abusive behavior, but no significant improvements in reducing official child abuse reports. It also bears mentioning that mixed evidence has sometimes been found using public health nurses.
Parent training programs have also been used to address parental comfort with and competence in parenting skills. Such programs often address parenting skills training and parental coping and may include alternative teaching methods (e.g., seminars) and targets (e.g., stress management). Evidence suggests improvements in attitudes and emotional well-being, but only minimal evidence exists regarding the prevention of child maltreatment. The importance of targeting these types of skills is supported by a recent study in which mothers of 3-year-olds were interviewed about disciplinary situations that elicited their strongest reactions, including a situation in which physical punishment occurred. The predictors of physical punishment were found to be maternal attitudes toward physical punishment, maternal perception of the seriousness and intent of the child’s misbehavior, and maternal anger in response to the child’s misbehavior. Such findings highlight the potential benefit of targeting mother’s cognitive and affective repertoires in reducing the decision to use physical punishment.
What Can Health Care Providers Do?
In terms of specific efforts that can be made in office and hospital practice, the HCP is in a unique position to identify, report, and intervene following incidents involving physically coercive, inappropriate, or abusive parental behavior. A first step toward addressing the problem of physical abuse is to become more familiar with its origins, risks, characteristics, consequences, and treatment in order to better recognize situations in which abuse might be likely. There is a need for better training in background information that emphasizes the signs and symptoms of physical abuse, as well as greater HCP participation in reporting appropriate cases to child protection agencies.
In terms of possible case identification, the HCP is often among the first professionals to learn about such incidents and to have an opportunity to provide medical attention and offer feedback designed to discourage further involvement in such behavior. Participant event monitoring (PEM) is a structured process for asking questions about recent injury events and understanding parental interventions used to address these events that may help HCPs incorporate such a routine in their clinical practice. PEM offers a set of interview probes that can help to prevent further injuries to children through systematic tracking of the events themselves and the responses made to them (e.g., what was the child doing at the time of the injury, rate severity of the injury, what was done to help your child afterwards, rate how much the event was due to the caregiver). HCPs may find this structured approach useful in providing clues about prevention efforts at various levels of injury severity.
One other implication of the results from prevention studies for HCPs in the ability to discourage the use of CP, which has been promoted at the policy level in several countries. , Although the available evidence for a legal ban on CP is mixed, it is certainly feasible for HCPs to ask questions about parenting repertoires and child outcomes when parents begin to discuss either child management frustrations or actual use of physical discipline. Such interactions may provide the context for a discussion of more effective child management techniques and actual training or instructions in the use of a different approach.
Avenues for encouraging service participation are also available to the HCP. Schools are a major gateway for mental health referral of crime victims, so HCPs may be able to partner with school officials or teachers to facilitate access to care. In addition, child advocacy centers (CAC) can provide support to primary care providers, especially given some modest evidence showing increased use of medical examinations, law enforcement involvement, and case substantiation among CAC compared with standard services. CACs offer a multidisciplinary approach to investigation, management, treatment, and prosecution of child abuse cases, and are a helpful resource to the HCP for information and medical collaboration. Other approaches include direct efforts to enhance the capacity of primary care provider practices to adopt and implement novel child abuse prevention programs, such as Practicing Safety. In this report, a combination of organizational change approaches and specialized assessment procedures was used to facilitate practice innovation and implementation of the program. Specific safety tools were found to be integrated into the daily repertoires of the pediatricians, including new patterns of communication with patients. This practice-level intervention might provide pediatric settings with new tools to address the problem of CPA and, more generally, child maltreatment.
Finally, in those cases in which significant physical injury or trauma has occurred, the HCP would be able to promote an initial sympathetic response to the child who has been exposed to traumatic events and who exhibits the symptoms of PTSD. Observations of the child during routine physical examinations and related physical evidence can help to identify traumatic exposure and symptoms, which could be corroborated by parental interview using questions that examine the child’s experiences and the timing of any these events. The HCP can also help to prevent further physical injuries and possible PTSD by suggesting to parents when children appear to be at risk for traumatic exposure or experiences, such as when they are exposed to high-risk situations (e.g., new parents who are overwhelmed, escalating use of coercive caregiver practices, reports of increased frustration or physical force during child management or disciplinary interactions, caregiver use of drugs and alcohol). Certainly, the HCP can offer advice regarding steps that may minimize a child’s exposure to high-risk situations and encourage parents to monitor and promote child safety, both in and out of the home.
Strength of the Evidence
This literature review highlights recent developments in understanding and treating CPA and the somewhat variable level of evidentiary support found in different topic areas. For example, far more rigorous research exists regarding certain risk factors for and consequences of CPA than its treatment or prevention. Numerous prior studies have examined an array of consequences associated with CPA relative to nonabused samples or samples of nonphysically abused children. More recent studies have begun to shed light on neuropsychological, neurophysiological, and neuroanatomical consequences using rigorous methodologies, which elucidate key functional and structural problems related to a history of CPA.
Less research has been conducted examining interviewing and screening methods in primary care and the role of HCPs in the identification and management of such cases. Some work has been devoted to understanding HCPs as expert witnesses or the sources of their judgments regarding decisions to report a case to child protective services. Further, there has been a modest increase in the number of intervention approaches that have been subject to empirical evaluation. The findings of those studies suggest greater optimism regarding the impact of treatment on parental repertoires and parent–child or family interaction. Still, few alternative treatment models or approaches have been compared. We also need to study methods to enhance motivation, disclosure, and processing of the abusive incident, given high rates of parental denial or reluctance to discuss what happened and why. Also, it is not clear whether explicit, direct attention to understanding and processing the child’s abusive experiences (incident) or its consequences is important for either child or parent improvement. Most studies do not include evaluations of both clinical problems and recidivism, with some exceptions. ,
Finally, the evidence base regarding efforts to prevent CPA are to some extent equivocal. Whereas some studies show benefits (e.g., home visits by professional nurses), other evidence suggests either more modest benefits or no benefits in terms of reductions in child maltreatment rates. The limitations of these studies include limited retention or participation rates, complicated or lengthy intervention programs, and restricted assessment measures or outcomes. In particular, many studies to do not include direct measures of child abuse or neglect recidivism. Thus, it is somewhat unclear as to whether prevention requires a comprehensive and intensive approach (e.g., nurse visitation) or a more focused intervention directed toward specific topics (e.g., skills training).
Directions for Future Research
Listed below are a few of the more important topics that merit further empirical examination or evaluation in relation to the HCP’s role in addressing the problem of CPA. Since HCPs may be among the first professionals to identify and assess new cases, studies should carefully evaluate the most efficient and useful methods for interviewing and screening for a history of CPA, and to understand how both parents and victims describe/explain their experiences. Such information could help the HCP serve as an effective sentinel for new incidents and as an effective referral source for services. Models of the origins and maintenance of abusive behavior may also benefit from this work.
Studies of the developmental, health-related, and physical effects of CPA would shed further light on the general medical consequences and long-term effects of CPA. Such information would highlight the greater role that HCPs and medical experts play in the management of this problem, and the possibility that such input might affect the selection of both psychological and educational interventions for certain victims and their families. The presence of long-term continuity in several forms of dysfunction following early CPA provides further support for the potential relevance of medical research.
Many children and their parents are not referred for services or, if they are referred, fail to engage in treatment for an adequate length of time. Studies must begin to more carefully articulate the clinical and nonclinical needs of children exposed to CPA and their families, rather than reporting generally vague or broad statements of mental health dysfunction.
As suggested by Staudt, it would be important to identify specific types of mental health need and to suggest appropriate types of services and treatment experiences likely to address these needs, including informal and nontraditional methods. Clearly, studies are needed that examine different parameters of services, including treatment duration, participants, foci or targets, outcomes, and barriers.
In terms of intervention, it seems necessary to extend existing evidence by comparing alternative EBTs and evaluating their impact on several types of key outcomes, including clinical symptoms/functioning, family stability and support, and abuse recidivism. Little information has been reported regarding predictors of successful service involvement and treatment outcome, including treatment moderators and mediators.
Research needs to determine which background or treatment variables contribute to a significant reduction in a child’s risk for repeated CPA or exposure to coercive physical discipline. Other worthy research targets include comparisons of single vs. multicomponent interventions, since many recent treatments include diverse treatment components. Perhaps more streamlined and focused interventions, such as having HCPs provide brief parenting guidelines and psycho-education about the consequences of abuse could enhance both participation and ultimate outcome. In general, few intervention studies relevant to HCPs and the primary care setting have been conducted in the past decade.
Research should be directed toward evaluating prevention approaches in the context of pediatric primary care. Such approaches might be focused on the use of CP, harsh or coercive treatment of children, and parental misunderstandings of common children’s behavioral and emotional reactions. Primary care providers could also be important links to a more comprehensive public health approach to prevention that integrates other methods, such as home visitation, collaborative care management, Internet-based educational programs, and involvement with local children’s advocacy centers.
Summary
This chapter provides a brief summary of recent empirical research regarding the prevalence and consequences, assessment, treatment, and prevention of CPA and the use of physical discipline relevant to HCPs. HCPs are in a special position to recognize, respond to, and refer children who are exposed to CPA, especially given their involvement with children at their earliest ages. The HCP is often the first adult or professional to learn about children who receive physical punishment, suffer from injuries or pain varying in severity, and/or experience significant traumatic reactions in light of these events, which could be facilitated by their ability to obtain evidence that can support this clinical impression. Being more familiar with the content of this chapter will enable the HCP to more effectively ascertain relevant information about an incident of abuse, offer service recommendations, and provide directive feedback designed to discourage the use of harsh or abusive physical discipline. In promoting more focused assessment and treatment efforts, the basic tools described here might help to initiate a more timely and responsive process of professional support of the physically abused child and his family.
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