Introduction
The effects of abuse and neglect can be devastating. No one would disagree that to prevent abuse and neglect from ever occurring is far more preferable than to provide treatment to try and mend these broken lives. Prevention efforts can be divided into three categories. Primary prevention refers to those programs or interventions aimed at the general population without targeting a particular high-risk group. Secondary prevention refers to those programs or interventions aimed at a particular segment of the population considered at high risk for a particular condition. Tertiary prevention refers to those programs or interventions aimed at a segment of the population that has proved itself to be at risk because of previous experiences, and is actually an attempt to prevent recurrence or other negative consequences. ,
Why has prevention of child maltreatment been so hard to achieve? One reason is that there is not, and never will be, one program that prevents all abuse and neglect. The problem is multifactorial and will require an armamentarium of programs. Prevention of abusive head trauma requires a much different strategy than preventing childhood sexual abuse. Likewise, preventing sexual abuse of toddlers will require a different approach from preventing abuse of middle school children.
A second consideration is that prevention does not simply deal with children. In order to prevent abuse and neglect, we must understand the abusers and target our intervention directly at them. There is a huge difference between the sociopath who wants to hurt a child and the parent who has no parenting skills and does not know she should not shake her baby. These two abusers require very different prevention strategies.
Another consideration is funding. Prevention is not cheap. In the past more money was available from state and Federal sources. These sources of funding are rapidly shrinking. The private sector has been able to make up for some of the loss in government funding, but in hard economic times, this source also feels the pinch. How can we get state and Federal governments to see the value of prevention? The biggest drawback with prevention is that, in most cases, the rewards are not immediate. There is a time lag between the initiation of an intervention and the resulting change in abuse/neglect statistics. Legislators are reluctant to support bills that put money into efforts that might not come to fruition during their term of office. They want to boast about big results that will bolster their chance at reelection or, at the very least, allow them to retire from office with the reputation of “having made a difference.”
Another problem with prevention is that, until recently, there have not been many programs or interventions with scientific data to back up their effectiveness. Recently this has been recognized as an important aspect of prevention program development, and there are now a number of programs with good data available on their effectiveness. This will greatly aid states in their quest for effective prevention.
The goal of this chapter is to present a practical approach to effective prevention along with a resource guide highlighting specific programs. (See Chapter 64 Supplemental Resources online at www.expertconsult.com .)
Victim Considerations
Several factors must be taken into consideration when choosing a program with the best potential for effectiveness.
Age
The first factor to consider is the age of the patient. The youngest victims of abuse and neglect are unborn fetuses exposed to health hazards. The most classic example of this is fetal alcohol syndrome (FAS). Millions of children in the United States and a round the world continue to be exposed to alcohol in utero despite efforts to educate the public about the dangers of consuming alcohol during pregnancy. Why have these efforts failed? The alcohol industry is adept at creating and maintaining market share with promotions and advertising that normalizes drinking among youth, young women, and minority groups, fostering the belief that there is a “safe” level of alcohol consumption, and that only those women who are “alcoholic” will damage their infants. The medical profession does not help dispel this myth when doctors tell pregnant women not to worry about having a glass of wine once in a while. If a glass of wine once in a while is acceptable, it must be acceptable to drink alcohol. Current recommendations are that no amount or type of alcohol is safe to consume during pregnancy. It is essential that all medical personnel adopt this recommendation to ensure that pregnant woman understand the seriousness of this issue.
After birth, the next most vulnerable time is from immediately after birth through 12 months of age. During this time, infants and their parents are adjusting to major lifestyle shifts. Parents are often sleep deprived and many are poorly prepared for the demands of parenthood. Identifying risk factors for abuse in the newborn nursery is critical. Preterm infants, multiple gestation, and previous sibling involved with child protective services are all risk factors for abuse, as well as young parental age, lack of social support, maternal depression, and history of domestic violence. If risk factors are identified, referral to visiting nurse services or parent support programs is appropriate. Early follow-up with the primary care physician is also important. An all-too-common abusive injury during this time is abusive head trauma (AHT). Anticipatory guidance regarding infant crying should start in the newborn nursery and continue at all well-child check-ups to 6 months of age. Crying is the single most common antecedent event prior to shaking an infant, making anticipatory guidance about crying critically important.
Once the sedentary infant becomes a “mobile unit,” around 10 to 13 months, new dangers await. Mobile children can now get into things and climb on things. Children who are given inadequate supervision are likely to have falls, ingestions, and other injuries, such as burns and lacerations. Toddlers are naturally active and parents who lack coping skills and patience may find themselves frustrated and exasperated by these active children. Parents may inflict injury in an effort to discipline their children and control their activities.
After children become school age, they are no longer only under the supervision of their parents. They now spend a growing portion of their day under the watchful eyes of other caregivers. With more and more children in daycare, this shift in supervisory roles has occurred at younger ages. Parents are confronted with the task of not only protecting their children from the inherent dangers in their own homes, but also from those outside the home. They must ensure that those they entrust with their children are in fact trustworthy. Those parents with poor parenting skills and poor social supports might be more likely to make poor choices in daycare providers and babysitters.
This is also the age when children need to be educated about personal safety. “Good touch-bad touch” is a confusing lesson because “not all bad touches feel bad.” Rather, teaching children that they can touch their own private places but no one else should touch the child’s private places—and, likewise, that they should not touch anyone else’s—can be a helpful lesson. Despite our best efforts to reassure children that they will never get in trouble for telling, children are reluctant to disclose abuse.
The preadolescent presents new challenges for abuse prevention as children exercise their need for independence while lacking insight and mature judgment. Peer pressure and risk-taking behaviors begin and increase into adolescence. Prevention in this group is most effective when done in a peer setting. This may be in school with peer mentors or in group activities with peers. It is important to consider the preadolescent both as a potential victim as well as a potential perpetrator. Prevention aimed at both these aspects of abuse would be most useful in this age group. For prevention to be effective, the preadolescent must “buy in” to the message. They must identify the message as relevant to their experience.
Adolescents pose the challenge of “knowing everything” and believing that adults do not understand them or know what they are going through. The more effective prevention messages are likely to be delivered in relevant language and delivered by their peer group. Sharing real-life events and their repercussions is much more likely to be remembered by the adolescent than a discussion of the hypothetical repercussions of certain actions. Adolescents are much less likely to accept information based on “faith.” They need to see and feel the wounds to believe it is real.
Developmental Level
In addition to age, developmental level is important to consider in prevention programs. Children who are developmentally disabled are thought to be at greater risk for abuse. , They also pose extra challenges to those entrusted with their care, including parents, teachers, and child care providers. These children are much more likely to trust adults and older children. They lack insight into the actions of others and often believe what they are told. Their disability may also limit their ability to report particular events or to escape frightening situations.
Estimates of the prevalence of sexual abuse among developmentally disabled children range from 25% to 83%. Some estimate that the lifelong risk of abuse among the developmentally disabled is 90%. This is in contrast to the prevalence rates of 30% to 40% of girls and 13% of boys experiencing sexual abuse during childhood overall.
There appears to be no clear correlation between level of disability and prevalence for abuse. However, there does appear to be some evidence suggesting that those individuals with mild mental disability are at increased risk of abuse. This may be due to their higher rates of integration into society and their desire to be accepted by their nondisabled peers. Research suggests that about 80% of victims with mental disabilities were abused more then once and that 92% to 99% of the victims knew their abusers. Also, the vast majority of abuse events occurred in the victim’s place of residence.
A number of factors make this population of children more at risk for abuse. First is their dependence on others for assistance in activities including activities of daily living. A caregiver may engage in activities that are inappropriate but not recognized as such by the disabled child. These activities can recur on a daily basis and may become the “norm” for the abused child. Also, children and adolescents with mental disabilities often lack friends and, in an attempt to be accepted, may allow themselves to be taken advantage of by other children, adolescents, and/or adults. They are more likely to regard the exploitation as love or friendship without understanding the true intent of their abusers. Another very important factor that contributes to the abuse of the developmentally disabled child/adolescent is the lack of sex education. , Parents and teachers often consider them asexual and thus dismiss the need for sex education. Often the realization that their disabled child or student has sexual feelings comes too late, after pregnancy or a sexually transmitted infection has occurred. Although the mentally disabled adolescent might go through puberty at a slightly later time (depending on the cause of the disability), they all go through puberty eventually and experience the hormonal changes inherent in that process. It is important to provide education about physical development, puberty, sexuality, sexual responsibility, and safety. A child with Down syndrome will definitely need sex education. However, a mainstreamed sixth-grade classroom may not be the appropriate environment for that sex education to occur. It is important to provide the education on a level that the child can understand and incorporate into his or her life.
Location of Abuse
When considering the choice of abuse prevention program, it is important to consider the location where the targeted abuse might occur. Abuse can occur in the home, at school, at day care, or in the community. Community locations include parks, churches, meeting of children’s organizations, and at public buildings such as libraries. It is impossible for parents to have direct supervision of their child in all of these locations at all times. Effective prevention programs should consider all these locations and assess the risk of abuse for each. The risk will vary from community to community. What is assessed to be a high-risk situation in one community may be far down the list in another.
One example of location dictating prevention programs is the tragedy of the Catholic Church and its priest abusers. After many substantiated accusations came to light, the Catholic Church acknowledged a need to provide intervention. Most Catholic organizations now use a curriculum aimed at providing the students with skills and knowledge that will help them avoid victimization.
In response to the persistent occurrence of neglect and abuse among young infants, visiting nurse programs were started in an attempt to provide education and parenting training to new parents in their homes. These programs allow parents to gain training in the environment where they will be using the training: in their homes with their infants.
Another example of the importance of considering location in prevention interventions is the residential care facility. Since developmentally disabled individuals face increased risk of abuse, and knowing that the majority of abuse occurs in their place of residence, it is important to have interventions in place in residential facilities. Meticulous screening of employees, frequent peer review activities, video surveillance, and educational in-services on caring for and nurturing children with developmental disabilities can be helpful in ensuring a safe environment for these children.
Schools are important settings when considering child abuse prevention. There are more and more reports of bullying and sexual harassment of students by other students. Curricula are available that can be incorporated into the school academic cycle to provide students with skills and knowledge to avoid being victimized as well as to prevent them from becoming victimizers.
A final example of the importance of location of abuse is the Internet. While the Internet is an amazing resource for students and young people, it has become a venue for sexual predators. Teaching young users the dangers of the Internet and how to avoid exploitation is important. Prevention tools are now available aimed at electronic abuse.
Perpetrator Considerations
People who unintentionally abuse children are particularly helped by prevention programs. They often abuse or neglect children because they do not know how to safely care for or discipline their children. There is no intent to injure although injury can occur. They are often horrified to learn that their action led to injury of their child and are quite remorseful. Education and training can often solve their problems and prevent future abuse.
Abusive head trauma is a good example in which some perpetrators might not consciously intend to injure their infants. The intent is often to quiet the infant or administer discipline for an undesired behavior. John Caffey noted in his 1972 article, “On the Theory and Practice of Shaking Infants,” “The most common motive for repeated whiplash-shaking of infants and young children is to correct minor misbehavior. Such shakings are generally considered innocuous by both parents and physicians.” Parents, especially first-time parents, are often ill equipped to deal with the demands of a crying infant. In their efforts to comfort their child they become frustrated and angry when the infant does not respond. If they allow themselves to reach the “breaking point” of frustration, they can find themselves grabbing the infant and vigorously shaking. Again Caffey describes this as “… instinctive, almost reflex, violent actions by angry adults in the commission of willful assault. …” He goes on to say that these same adults would never think of hitting their young infants but think nothing of administering a “good shake.” Educational programs aimed at teaching parents the dangers of shaking have been shown to decrease occurrence of shaken baby syndrome.
Parents who had poor parenting themselves are at higher risk for perpetuating abuse. C. Henry Kempe wrote in 1962, “It would appear that one of the most important factors to be found in families where parental assault occurs is ‘to do unto others as you have been done by.’ ” Choosing a prevention program that provides parenting skills and nurturing skills to high-risk parents would help break the cycle of violence.
Another group of unintentional abusers are those with mental health issues. A good example of this group is the new mother suffering from postpartum depression. When an injury occurs, she might not be capable of understanding what she is doing, even if her actions are deliberate. Depression can be so severe that mothers of newborns lose perspective on their actions and feel no emotional connection to their infants. The best intervention in this case is early recognition of postpartum depression and immediate treatment.
When child abuse is done intentionally, prevention becomes much more difficult. Intentional abusers are a much more diverse group, and different issues are involved when people abuse children physically, sexually, or emotionally, or when people knowingly neglect children.
Sexual Abusers
Finkelhor has proposed a model consisting of four preconditions that lead to sexual abuse. Understanding these preconditions allows the targeting of interventions toward specific factors that have the potential to prevent sexual abuse. The four preconditions are (1) motivation to sexually abuse, (2) suppression of internal inhibitors, (3) lack of external inhibitors, and (4) lack of resistance by the child victim. The abuser must feel that sexually relating to the child will satisfy some emotional need and he must feel sexually aroused by the child. Sometimes there is a lack of alternative sources of sexual gratification, leaving the child as the only option.
Next the perpetrator must overcome internal inhibitors. Although he knows it is wrong to have sexual contact with the child, he finds a way to block those thoughts. This can be accomplished through the use of substances, such as alcohol or drugs. Perpetrators suffering from some types of mental illness or impulse disorders can more easily overcome internal inhibitors.
External inhibitors are those factors that usually protect the child. When a mother is not present or not emotionally connected to the child, the child is much more vulnerable to abuse. Girls from families that are socially isolated are much more vulnerable to abuse by family members as well as by family acquaintances. The girls have fewer supports and are physically available to potential perpetrators. Parents with poor parenting skills might provide poor supervision of their children, leaving them available to potential perpetrators.
The final precondition, resistance by the child, refers to the child’s ability to defend herself against abuse. Children who are emotionally insecure or deprived of parental love may unknowingly allow inappropriate advances from a perpetrator. Intellectually challenged children are less able to understand that an adult is doing something bad to them and thus might allow the action. Some adults use coercion to force the child to allow the abuse to occur. The Finkelhor model is very useful when considering sexual abuse prevention strategies because an intervention can be directed at any one of the four areas described in the model.
Other Types of Abusers
Child abusers are a diverse group. For example, people with antisocial personality disorder have no consideration of others and act to meet their own aberrant needs. Prevention efforts directed toward changing their behaviors are often met with failure. The best approach with this group is to strengthen external inhibitors and/or equip the child with better avoidance skills. Another type of abuser that belongs in this group is the adult that inflicts injury on a child with the intention of hurting. They use corporal punishment or think nothing of hitting children when they misbehave. Their actions often result in minor injury but can also result in major injury or even death. Another group of intentional abusers are mothers who kill their children as acts of revenge (e.g., to get even with spouses who are “cheating on them”) or as acts of mercy (e.g., killing a disabled child that will have to face a cruel and unfair world).
Although this description of intentional abusers is not all inclusive, it is clear that the characteristics of the abusers vary widely, making intervention to prevent abuse very difficult. Prevention can include efforts to change the behavior of the abuser, to strengthen internal inhibitors, to strengthen external inhibitors, and to equip victims with the ability to escape and evade the perpetrators.
Reactive Child and Adolescent Abusers
Reactive abusers are a special group consisting of children who were victimized and who then become abusive to other children. Some estimates suggest that child perpetrators under age 13 account for 18% of child sexual abuse cases. If one increases the age to under age 18, the percentage of child perpetrators is as high as 40%. Children tend to perpetrate against other children younger than themselves, with the average age of child perpetrators ranging from 6 to 8 years, while their victims’ average age ranges from 4 to 6 years. It is important to realize that not all child perpetrators are victims of sexual abuse, but it is definitely a risk factor. Other risk factors include high rates of familial distress (including domestic violence); sexual perpetration within the family or extended family; child physical abuse; parental arrest and incarceration; and failure to take responsibility for others’ sexual abuse within the family or extended family. In this group of abusers it is important to identify risk factors in the family. Prevention efforts can start with anticipatory guidance around issues such as discipline, substance abuse, and appropriate supervision. Referral to child and family counseling as well as counseling for domestic violence is essential to help break the cycle of abuse.
Prevention Programs with Scientific Data on Outcome
Some prevention programs have good data supporting their effectiveness. There are also a few programs with little outcome data available, but the programs show promise based on program design and target. There are many programs being implemented to prevent abuse, but few have been studied carefully. Fortunately, this trend is changing. More programs are collecting data and analyzing the true effectiveness of the prevention strategies. In the future, it should be easier to identify effective evidence-based prevention programs.
Conclusion
When choosing a prevention program, consider several factors. First, choose the desired outcome (e.g., decrease abusive head trauma). Then identify the target population. In the above example the target population would be parents and caregivers of young infants. Next, decide on the program focus. Is the program a “primary intervention” focused at all parents and caregivers of young infants? Or will a secondary intervention be used, aimed at only high-risk parents and caregivers? Once the desired outcome and target population have been identified, the most effective intervention program can be chosen.
A description of several child abuse and neglect prevention programs can be found online at www.expertconsult.com . (See Chapter 64 Supplemental Resources .)
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