Child Maltreatment Prevention Priorities at the ... - SAGE Journals

10.1177/1077559505274674 Whitaker CHILD MALTREATMENT et al. / CHILD MALTREATMENT / AUGUST 2005 PREVENTION PRIORITIES

Child Maltreatment Prevention Priorities at the Centers for Disease Control and Prevention Daniel J. Whitaker John R. Lutzker Gene A. Shelley Centers for Disease Control and Prevention

The Division of Violence Prevention at Centers for Disease Control and Prevention’s (CDC) National Center for Injury Prevention and Control has had a long-standing interest in the prevention of child maltreatment. The nation’s public health agency, CDC, seeks to focus the public health perspective on the problem of child maltreatment and to promote science-based practice in the field. Since 1999, CDC has developed research priorities to address the prevention of child maltreatment. Described here is a brief rationale for applying a public health approach to child maltreatment and a discussion of the priority-setting process, priorities in each of four areas of the public health model, and some of CDC’s current child maltreatment prevention activities. Keywords: Centers for Disease Control and Prevention; child maltreatment research agenda; expert panel

Child maltreatment is a far-reaching problem in

the United States that demands a response from the public health system. In the Department of Health and Human Services’ (DHHS) Healthy People 2,010 objectives (Objective 15-33, Maltreatment and maltreatment fatalities of children), this problem and its sequelae are identified as public health priorities. The Centers for Disease Control Prevention’s (CDC) National Center for Injury Prevention and Control (“Injury Center”) has developed a research agenda that includes priorities for the prevention of child maltreatment. This article presents a rationale for a

CHILD MALTREATMENT, Vol. 10, No. 3, August 2005 245-259 DOI: 10.1177/1077559505274674 © 2005 Sage Publications

public health approach to child maltreatment prevention, describes the priority setting process, and highlights some of the prevention priorities and activities at CDC. RATIONALE FOR A PUBLIC HEALTH APPROACH TO CHILD MALTREATMENT

Child maltreatment became widely recognized in 1962 when Kempe, Silverman, Steele, Droegemueller, and Silver published “The Battered Child Syndrome.” Even with this broad exposure of the problem, the Child Abuse Treatment and Prevention Act (1974) did not come into law until 12 years later in 1974. The response to child maltreatment has primarily been addressed through social service agencies (public, private, community-based, and faith-based) and justice agencies through formal reporting laws in all states and an expanded child welfare system serving at-risk families. Because of the scope of child maltreatment and because it is associated with a range of negative health outcomes (see Crittenden, 1998; Trickett & Putnam, 1998), the public health system should respond accordingly (Djeddah, Facchin, Ranzato, & Romer, 2000; Hammond, 2003; Merrick & Browne, 1999). Authors’ Note: We would like to thank the individuals who participated in the creation of the research priorities outlined in this article. We thank Linda Dahlberg for her conceptual and editorial contribution and Sue Ann Swenson for editorial assistance. Correspondence regarding this work can be directed to any of the authors by postal mail at Centers for Disease Control and Prevention, 4770 Buford Highway NE, Mailstop K-60, Atlanta, GA 30341; emails: [email protected], [email protected], or GShelley@ cdc.gov. 245

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Whitaker et al. / CHILD MALTREATMENT PREVENTION PRIORITIES

The public health model offers a framework to address public health problems in a coordinated manner (Hammond, 2003). Generally, the public health model includes four major activities that inform one another: (a) surveillance to determine the magnitude of the problem, (b) etiologic research to identify risk and protective factors, (c) development and empirical testing of prevention strategies and interventions, and (d) broad dissemination of empirically supported prevention strategies and interventions. The public health model is scientifically based and action oriented; all four activities utilize scientific methodology, with each having the ultimate goal of informing efforts to improve health outcomes. That is, surveillance activities and etiologic research are conducted with an eye toward developing interventions; intervention development and evaluation are conducted with an eye toward disseminating empirically supported intervention and prevention strategies. As an action-oriented model that seeks to affect health outcomes broadly, the public health model relies on a vast and multidisciplinary infrastructure to bring evidenced-based prevention and intervention strategies to the public. The infrastructure includes a range of organizations: governmental, community, professional, voluntary, and academic (CDC, 1999a). Necessarily, the public health model is the modus operandi of CDC, but the model is surely not the exclusive domain of CDC. That is, though CDC is one of the lead federal public health agencies, many other agencies are engaged in activities that constitute the public health approach (e.g., National Institutes of Health support more basic research; Administration for Children and Families support services and the collection of some surveillance data). This is necessary because of the scope of public health problems, such as child maltreatment, and the need to address such problems on a broad scale. A great deal of child maltreatment research during the past 30 years has been generated focusing on risk and protective factors for identifying child maltreatment perpetration and victimization (Black, Heyman, & Slep, 2001a, 2001b; Schumacher, Slep, & Heyman, 2001); the negative sequelae of child maltreatment (Crittenden, 1998; Trickett & Putnam, 1998); intervention strategies for at-risk families, such as including home visitation (Olds et al., 1998); and behavioral parent training (Eyberg, 1988; Forehand & McMahon, 1981; Lutzker, Frame, & Rice, 1982; Sanders, 1999; Webster-Stratton, 1994). However, there has been a lack of coordination between service providers, researchers, and advocates in the prevention of child maltreatment (Daro & Donnelly, 2002).

Much research has not been effectively translated into prevention strategies for efficient use by service providers. Likewise, evaluations of existing programs and services delivered directly by service providers are rare (DePanfilis & Zuravin, 2002; Duggan, McFarlane, et al., 2004), and it is not always clear that those practices are based on empirical evidence. One of the goals of the public health model is to strengthen the link between research and practice. Finally, the public health model puts an emphasis squarely on primary prevention or strategies that seek to prevent problems before they occur. Many of the most notable major public health achievements in the 20th century (see CDC, 1999a) have been primary prevention efforts. This is most apparent for diseases, such as smallpox, polio, and measles, for which a vaccine has been developed resulting in the elimination or near elimination of that disease. But several behaviorally based health conditions have been drastically reduced from broad intervention efforts of the public health system. For example, smoking was widely identified as a public health threat in 1964, and, since then, efforts to reduce the incidence and prevalence of smoking using medical, behavioral, policy, and legal interventions have resulted in a steady decline in the smoking prevalence (CDC, 1999b). Turnock (1997) estimates that there were 42 million fewer smokers in 1996 than would have been expected given smoking trends in 1965. Primary prevention of child maltreatment is a focal point on which many child maltreatment experts agree needs greater attention (Becker et al., 1995; Donnelly, 1999; Lutzker, 1998; Melton, 2002; Wolfe, 1991). Relatively few resources have been devoted to intervening with families in which maltreatment has not occurred so as to prevent it. Such prevention is the pinnacle of the public health approach. With the public health model in mind, a process for setting priorities regarding child maltreatment activities was begun at CDC. PRIORITY-SETTING PROCESS

Prior to 1999, the majority of the work in CDC Injury Center’s Division of Violence Prevention (DVP) focused on the prevention of intimate partner violence, sexual violence, youth violence, and suicide. However, in 1999 and 2000, Congress added specific language in its appropriations, allocating additional funding support for expansion of CDC’s work toward preventing child maltreatment. This proved to be a primary impetus for developing child maltreatment priorities. CHILD MALTREATMENT / AUGUST 2005


Child Maltreatment Experts Meeting, October 1999

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Development of the NCIPC Research Agenda (broad subject areas, including child maltreatment

Congressional appropriation of $2 million (guided by recommendations from the October 1999 meeting of child maltreatment experts) CDC funds first child maltreatment projects

NCIPC research agenda approved

The “Think Tank” meeting of Child Maltreatment experts, October 2001 (to incorporate finalized research agenda)

Publication of NCIPC Research Agenda

Additional congressional appropriations of $3 million CDC funds additional child maltreatment projects

FIGURE 1: Process of Developing Child Maltreatment Prevention Priorities at CDC NOTE: CDC = Centers for Disease Control Prevention; NCIPC = National Center for Injury Prevention and Control.

The process for developing these priorities revolved around the work of two panels of experts and internal work by CDC scientists. In October 1999, DVP convened the first panel of child maltreatment experts, which included service providers from social service and justice agencies, researchers from a range of disciplines, CDC scientists, and representatives from other federal agencies engaged in working in the area of child maltreatment (e.g., Office of Child Abuse and Neglect [OCAN], National Institutes of Health, National Institutes of Justice). Sixty experts attended; 40 others did not attend, but served as ad hoc reviewers. Participants were briefed on DVP’s mission and function and then were assigned to workgroups. Each workgroup developed priorities for their assigned element of the public health model. The full set of recommendations from this meeting is found in Appendix A. In December 2000, CDC’s Injury Center began developing a broad research agenda to address both CHILD MALTREATMENT / AUGUST 2005

unintentional and intentional (i.e., violence related) injuries. Family violence, including child maltreatment, was included in this research agenda. A second panel of 15 child maltreatment experts was convened in October 2001 to integrate recommendations from the first expert panel into CDC Injury Center’s research agenda. Appendix B lists the recommendations judged to be of highest priority by the second expert panel. The process is illustrated in Figure 1, including points at which funds were made available for research. This article highlights some of the prevention priorities resulting from this process, along with CDC’s subsequent efforts to addressing those priorities. For CDC efforts, we indicate which of the final priorities (listed in Appendix B) that each activity addresses. Discussion of the priorities is organized as follows: cross-cutting priorities, surveillance, etiologic and risk factor research, intervention and evaluation, and implementation and dissemination.

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CROSS-CUTTING PRIORITIES

Several priorities recommended by the expert panels are relevant to more than one part of the public health model. One set of issues includes the need for uniform definitions of child maltreatment. A lack of clear definitions for child maltreatment about which there is agreement can hinder efforts to achieve effective surveillance (it would be unclear as to what is being counted), etiologic research (research studies based on different definitions would not be comparable), and intervention development and evaluation (interventions developed based on one definition of maltreatment may not translate to individuals who meet another definition). Consensus on the behaviors that constitute abuse or neglect and validated tools and methods to measure these behaviors will advance child maltreatment prevention. Uniform definitions would make incidence and prevalence rates across localities more comparable, assist in comparing risk and protective factors across studies, and help with the translation of interventions from one area to another. But achieving consensus definitions for child maltreatment will be difficult because of the lack of agreement on what constitutes adequate versus inadequate parenting (Greene & Kilili, 1998). Also, differences in definitions of maltreatment at the state or county level may represent differences in regional norms for acceptable parenting behaviors, which would make the development of uniform definitions across localities even more difficult. Another cross-cutting priority that requires attention is to understand the co-occurrence, shared and independent risk factors, consequences, and prevention strategies for each type of child maltreatment. There may be similarities and differences among the four types of child maltreatment (physical abuse, sexual abuse, psychological abuse, and neglect), but these are not well-studied. For example, separate reviews address risk factors for child sexual abuse (Putnam 2003), physical abuse (Black, Heyman, & Slep, 2001a), psychological abuse (Black, Slep, & Heyman, 2001), and neglect (Gershater-Molko & Lutzker, 2003), but there are relatively few efforts to integrate these findings or to examine how specific risk factors differentially predict one form of child maltreatment versus another. Much more attention has been paid to physical abuse and sexual abuse than to neglect (Behl, Conyngham, & May, 2003), even though neglect accounts for more than 60% of child maltreatment (U.S. DHHS, 2002). There is a need for research to identify common and unique risk factors, consequences, and effective prevention and intervention strategies for each of the four types of child mal-

treatment. Doing so will allow targeted intervention in a more expedient and cost-effective manner and will advance the overall understanding of child maltreatment. Wherever possible, the co-occurrence between child maltreatment and other forms of family violence should be addressed. Although results among studies vary, Appel and Holden (1998) estimated cooccurrence between partner violence and child abuse to be 40%. As recommended by Appel and Holden (1998) and O’Leary, Slep, & O’Leary (2000), there is a need for more precise estimates to better understand how definitions of abuse, samples under study, and data sources impact co-occurrence. Also, empirically tested theories that account for co-occurrence of child maltreatment and family violence need to be developed. Of most importance, interventions that can affect the precipitating factors and negative consequences of both must be developed. Finally, both expert panels emphasized the need for greater methodological rigor in child maltreatment research. Many studies examining the consequences of child maltreatment have involved crosssectional studies using retrospective reports from victims (Felitti et al., 1998). There is a clear need for longitudinal studies to better understand the development of victimization and perpetration and the shortand long-term consequences of child maltreatment (Widom, Raphael, & DuMont, 2004). Much of the evaluation of empirical interventions has used singlecase research designs with inherent limited external validity. Relatively few methodologically rigorous studies have examined the impact of specific prevention programs on child maltreatment. SURVEILLANCE

Surveillance allows the assessment of the magnitude and impact of a public health problem and how it changes throughout time and can form the basis for the allocation of resources. Through surveillance studies, variations in incidence and prevalence of a problem can be identified by a number of factors (i.e., gender, race, socioeconomic status, geographic location, and relevant risk behaviors). When applied to child maltreatment, improved surveillance will indicate the number of children suffering maltreatment, whether maltreatment is increasing or decreasing over time, the types of maltreatment occurring, specific characteristics of perpetrators and their victims, and the conditions under which maltreatment occurs. Given the value of surveillance in child maltreatment research, the need for a national public health surveillance system emerges as a clear priority. CHILD MALTREATMENT / AUGUST 2005


Data Collection Data collection efforts clearly need expansion and improvement. Currently, there are two primary sources of child maltreatment surveillance in the United States. The National Child Abuse and Neglect Data System (NCANDS), administered by OCAN, is a nationwide database of child maltreatment reports from the various state Child Protective Services (CPS). The National Incidence Study of Child Abuse and Neglect (NIS), issued by the U.S. DHHS, is a periodic survey of professionals whose positions are likely to place them in direct contact with maltreated children (e.g., law enforcement, public schools personnel, and mental health agencies). Each of these data systems collects important information, but each has limitations. In 2002, NCANDS data revealed approximately 3 million reports to CPS, 1.8 million investigations by CPS, and about 896,000 cases of children who had been maltreated or were at risk for maltreatment. Although CPS reports are a critical data source and often considered the “gold standard” for measuring maltreatment, there are problems with its use. One obvious problem is that CPS reports underestimate the true number of child maltreatment cases, because they only include reported cases. Also, CPS reports are not likely to be representative of the child maltreatment cases because of the many factors that influence the reporting and substantiation of cases. Many factors can influence caseworkers’ decisions regarding the reporting and substantiation of child maltreatment, including the interviewer’s profession, beliefs, personal history with regard to abuse, and the gender of victim and perpetrator (Milner, Murphy, Valle, & Tolliver, 1998). Finally, changes in the way in which CPS systems investigate and substantiate cases of child maltreatment will affect child maltreatment rates with time, and, thus, it would be unclear whether those trends represented actual changes in maltreatment or simply changes in CPS procedures (see Finkelhor & Jones, 2004, for discussion of declines in sexual abuse). In contrast to NCANDS, the NIS forms a nationally representative sample by relying on “sentinels”— professionals who have contact with parents and children—to gather information about the number of maltreatment cases. These sentinels represent a range of professions, including CPS workers. Thus, the survey can include children who have been reported to CPS, as well as those who have not been reported. Data from NIS-3, collected in 1993 and 1994, indicate that CPS had investigated only 28% of children meeting the harm definition of maltreatCHILD MALTREATMENT / AUGUST 2005

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ment. The methods used in the NIS also represent an undercount of child maltreatment cases because NIS only includes children who come to the attention of professionals, and those who do not are not included (U.S. DHHS, 1996). The NCANDS and NIS are two critical information sources for child maltreatment surveillance, but additional sources are needed for a fuller understanding of the problem of child maltreatment. Data sources—trauma registries, child fatality reviews, hospital discharges, emergency department records—and other databases such as those maintained by the Special Supplemental Nutrition Program for Women, Infants, and Children may help paint a fuller picture of the scope of child maltreatment. Uniform Definitions for Child Maltreatment The need for uniform definitions of child maltreatment is another challenge to improved surveillance. As noted above, a lack of uniform definitions may lead to varying estimates in different geographical areas. For example, the NCANDS data are constructed from reports by states, and, although states’ reports are mapped onto common definitional schemes (U.S. DHHS, 2003), the number and types of cases reported by each state may reflect different definitions of child maltreatment (which in turn may represent different local norms for acceptable parenting behavior). This may result in variation in child maltreatment rates between states that has nothing to do with the actual occurrence of child maltreatment, making comparisons of child maltreatment rates among states difficult to interpret. Another problem is the difficulty in determining what behaviors constitute maltreatment. The NIS data system applies two behavioral standards for child maltreatment. A harm standard requires demonstrable harm to the child, whereas an endangerment standard includes harmed children, as well as children who are at risk or whose abuse has been substantiated by a CPS worker. Consensus is needed around the use of these definitions in surveillance to compare child maltreatment rates across states or throughout time. Current CDC Activities The CDC is engaged in several activities designed to improve child maltreatment surveillance. The CDC funds five states (Minnesota, Michigan, Massachusetts, Rhode Island, and California) to develop child maltreatment surveillance systems in hospitals and emergency departments, compare alternative surveillance approaches for fatal and nonfatal child maltreatment, and test potential surveillance methods for measuring violence at all ages. Results from

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these projects will help determine the usefulness of various data sources for child maltreatment surveillance (Priority 4). Using Consumer Product Safety Commission data from the National Electronic Injury Surveillance System, CDC is also examining the suitability of obtaining additional information about victims of violence who are treated in U.S. hospital emergency departments. The CDC is working in collaborative efforts to build consensus definitions for child maltreatment, analyze child fatality review legislation (see Webster, Schnitzer, Jenny, Ewigman, & Alario, 2003, for review of child fatality review) to develop uniform procedural guidelines and operational definitions, and develop a National Violent Death Reporting System to obtain more detailed information about all violent deaths in the United States. Each of these activities will advance child maltreatment surveillance efforts and may be used in concert with the ongoing efforts of NCANDS and NIS to gain a fuller picture of the problem of child maltreatment (Priority 4). ETIOLOGIC AND RISK FACTOR RESEARCH

Priority areas for risk factor research center around three broad categories: · · ·

strengthening methodology in child maltreatment etiologic research, increasing understanding about child maltreatment risk and protective factors, and increasing understanding of the consequences of child maltreatment.

Strengthening methodology for research on the etiology of child maltreatment includes developing uniform definitions for child maltreatment, improving data collection methods, refining theoretical models, developing measurement tools to assess the constructs of those models, and conducting studies that use more robust study designs. The lack of uniform definitions and valid measures for each of the four types of child maltreatment causes unique problems for etiologic research, particularly in the integration of research findings across studies. This is true for studies that focus on a single type of maltreatment and for those that examine etiology across different types of abuse. For example, in etiologic studies, the operational definitions of physical abuse may range from parent reports of discipline behaviors to the presence of substantiated cases of abuse via CPS reports. Because of biases in CPS reporting and substantiation (Milner et al., 1998), the findings from studies that operationalize child physical abuse differently may not be comparable.

Improvements in data collection methods are also needed. Currently, there are few, if any, validated measures of child maltreatment. The most commonly used tools are measures of harsh discipline (e.g., the Conflict Tactics Scale), the Child Abuse Potential Inventory (Milner, 1994), and official CPS records. Additionally, very little is known about the impact of different data collection methods on a caregiver’s willingness to disclose harsh punishment or abuse. Do parents respond more honestly to sensitive questions about parenting behaviors in a computer-assisted interview than in a personal interview? Does the sex or race or the interviewer affect parents’ responses to sensitive questions? The prevalence of cross-sectional rather than longitudinal study designs is another methodological weakness in current child maltreatment research (Widom et al., 2004). Longitudinal studies, although more difficult and expensive, are needed for more confident inference about causal ordering of risk factors and for closer examination of the timing, duration, and natural course of child maltreatment. The Longitudinal Studies of Child Abuse and Neglect, funded in response to the National Research Council’s (1993) call for more methodologically rigorous designs, represent a considerable improvement instead of many prior risk-factor studies. More theoretically based research is needed to understand the causal role of currently identified risk and protective factors for child maltreatment perpetration and victimization. Theoretical models for different forms of child maltreatment need refining to explain which factors influence specific forms of child maltreatment. Currently, separate theoretical models explain different types of child maltreatment such as physical abuse (Azar, 1991; Wolfe, 1987), neglect (Gaudin, 1993), and sexual abuse (Finkelhor, 1984; Marshall & Barbaree, 1990; Ward & Siegert, 2002), but work is needed to integrate models within and across child maltreatment types to account for common and unique risk and protective factors (Azar, Povilaitis, Lauretti, & Pouquette, 1998; Ward & Siegert, 2002). Several specific risk factors require greater examination: characteristics of perpetrators of the various forms of child maltreatment; attitudinal influences of child maltreatment; child-related factors, such as crying or low birth weight; and the relationship between family violence and child maltreatment. Negative Effects of Child Maltreatment There is a sizeable literature documenting a relationship between the types of child maltreatment and a variety of negative consequences, including biologiCHILD MALTREATMENT / AUGUST 2005


cal, psychological, and social deficits (for reviews, see Crittenden, 1998; Kendall-Tackett, Williams, & Finkelhor, 2001). However, the process by which maltreatment leads to negative outcomes, including the causal role of maltreatment, is not fully understood. This is primarily because of the lack of well-developed theory and methodologically rigorous studies examining factors related to child maltreatment. Many studies have employed cross-sectional designs in comparing the health states of individuals who report child maltreatment with those who do not (Felitti et al., 1998). Such studies are valuable points of departure, but longitudinal studies involve the temporal sequence of events allowing stronger causal inference. More longitudinal studies are needed to better examine the processes by which maltreatment leads to negative outcomes. Theoretical work is needed to identify how different types of maltreatment lead to specific negative outcomes, along with the corresponding hypothesis-testing empirical work. CDC Child Maltreatment Risk Factor Projects The CDC cofunds one project from the NIH-led Federal Child Neglect Research Consortium. The project is a multisite, longitudinal examination of 560 adolescent mothers and 180 adult mothers and their children recruited from prenatal clinics and health providers. The goals are to examine the meaning and measurement of neglect by analyzing the results from five sources and measures of parenting; develop and test the accuracy of a screening tool to predict neglectful parenting among teenage mothers based on variables identified prior to the birth of the child; assess consequences of different types of neglect on childhood intelligence, attachment, temperament, problem and prosocial behaviors, and language development; and test and refine a conceptual model to explain the developmental associations among parenting characteristics, parenting behaviors and attitudes, external factors, and child outcomes (Priorities 9, 11). The CDC is also conducting two literature reviews on child sexual abuse. One focuses on negative outcomes associated with child sexual abuse; the other focuses on risk and protective factors for child sexual abuse perpetration. The goals of these projects are to summarize what is known about consequences and perpetration, disseminate those findings to researchers and practitioners, and use the literature to develop prevention strategies for child sexual abuse (Priorities 9, 11). Additional work in etiology is conducted through involvement in analytic projects of existing data sets. For example, CDC collaborates on data analyses for CHILD MALTREATMENT / AUGUST 2005

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the Northwestern Juvenile Project, a longitudinal study of a random sample of 1,832 adolescents who were newly detained in the Cook County Juvenile Temporary Detention Center in Illinois between 1995 and 1998 (see Teplin, Abram, McClelland, Dulcan, & Mericle, 2002, for description). CDC scientists are examining the concordance between selfreported and court-reported cases of child maltreatment (Priority 5). INTERVENTION AND EVALUATION

In line with the public health approach, CDC’s main focus for child maltreatment is primary prevention, which is preventing new cases of child maltreatment where maltreatment has not occurred. Primary prevention can be contrasted to secondary prevention, which focuses on preventing reabuse, and tertiary prevention, which involves ameliorating the negative consequences of maltreatment. Primary prevention of child maltreatment is important for a number of reasons. Because child maltreatment is a complex behavior influenced by many factors, it may be easier to intervene to prevent abuse or neglect from developing than to intervene to change behaviors that are already well-established. It also allows intervention where there are warning signs of abuse. For example, the use of harsh physical discipline is relatively common and can be a precursor to abuse (Straus & Stewart, 1999). Intervening before physical punishment escalates into abuse may be more effective and more efficient, and parents may be more willing to engage in interventions where there is no stigma from CPS involvement. Primary prevention efforts could thus be marketed universally—that is, for every parent—to further reduce the stigma associated with “parent training.” The message could be that every parent can benefit from parent skills training, not just “bad” parents. This is analogous to universally encouraged strategies, such as vaccines, car seats, and breastfeeding, which are promoted as beneficial to all parents. Currently, many families involved with CPS may resist intervention, not because of a lack of concern for their children, but because of the potential embarrassment of receiving CPS services, the invasive nature of CPS involvement, and fear of further legal action. One of the overarching recommendations by experts from the 2001 meeting was that parenting should serve as the overarching focus of child maltreatment prevention and intervention research. Behavioral skill–based parent training programs offer great promise for preventing child maltreatment. A number of these programs have shown positive behav-

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ioral changes in parents and children (Eyberg, 1988; Forehand & McMahon, 1981; Lutzker, Frame, & Rice, 1982; Sanders, 1999; Webster-Stratton, 1994). Many programs have demonstrated a positive impact on high-risk parents and children, including parents indicated for abuse or neglect (Gershater-Molko, Lutzker, & Wesch, 2002; Lutzker & Rice, 1987). In 2003, CDC reported that home visitation programs, which include parent training, reduced the occurrence of child maltreatment by approximately 40% (Hahn et al., 2003). Recent research, however, suggests that home visitation may not represent the panacea once hoped for to prevent child maltreatment (Duggan, Fuddy, et al., 2004; Duggan, McFarlane, et al, 2004), and further study is clearly in order (see Chaffin, 2004). Home visitation programs are being broadly implemented, however, and, thus, there is an urgent need to bring empirical data to bear on the effectiveness of such programs (Chaffin, 2004). Despite the need for more work, skill-based, empirically supported parent training programs offer a very promising approach for the prevention of child maltreatment. Recommendations for field-based interventions and prevention activities for child maltreatment reflect the need for the development and evaluation of curricula that can be used in “real-world” settings and not in settings constructed or supported by researchers and research funds. Typically, new intervention models are developed and tested in a setting that ensures that the intervention is fully tested. In such efficacy trials, interventionists are carefully trained to implement a curriculum; fidelity is measured and maximized to ensure that the intervention is being implemented as intended; and steps are taken to maximize implementation, participation, and intervention uptake. Such trials address the important question of whether an intervention can work, but not questions of effectiveness in real-world settings. (Will an intervention work where interventionists may not be fully trained? What if the curriculum is not delivered exactly as planned? What effect will result if parents do not attend all of the sessions?) Few studies have examined how curricula that have shown a positive impact in a research setting perform when disseminated to and implemented by existing service providers. Thus, there is a need to examine how empirically supported curricula perform when broadly disseminated to different settings that are not supported by research infrastructure. Indeed, some of these very questions have been raised about the broad implementation of home visitation programs (Chaffin, 2004). The process of moving from efficacy to effectiveness trials to dissemination work is a criti-

cal part of successful public health. (Note that questions have been raised about the efficacy— effectiveness paradigm for moving interventions to real-world implementation by Glasgow, Lichtenstein, and Marcus, 2003.) There is also a need to tailor programs to various cultural or racial and ethnic groups, ensuring the materials, format delivery, and language of certain intervention components are appropriate. Research is needed to determine the best way to tailor and implement programs for different populations while retaining the core substance of an intervention (i.e., the aspects of an intervention that most accounts for behavior change) so that its effectiveness is maintained. Most interventions for child maltreatment are multicomponent and involve multiple behavior change techniques (e.g., Lutzker & Bigelow, 2002), but the critical components of most interventions are not well-understood. Studies evaluating specific components of interventions can produce evidence of what may be necessary and sufficient components of multiple component programs. This will allow for more successful tailoring in that those doing the tailoring will not remove the crucial components that contribute most to behavior change. Additionally, separate intervention components may be effective for different forms of child maltreatment. For example, a neglectful parent may respond to intervention components designed to make the living environment safer and cleaner, whereas a physically abusive parent may respond to intervention components designed to teach positive behavior management skills. Current CDC Intervention and Evaluation Projects The CDC is currently involved in several projects that address gaps in child maltreatment intervention and prevention research. One such effort is a collaboration with the University of Oklahoma Health Sciences Center to (a) implement and evaluate an empirically supported curriculum, Project SafeCare (Lutzker & Bigelow, 2002), statewide in Oklahoma, and (b) pilot the use of Project SafeCare as a primary prevention intervention for at-risk families. The Project SafeCare curriculum (Lutzker & Bigelow, 2002) includes three service protocols (home safety, child health, and planned activities training) that were developed and validated by content experts and through several single-case research studies (e.g., Bigelow & Lutzker, 1998). In a small study, Project SafeCare reduced recidivism of child maltreatment by about 50% during a 2-year period relative to a comparison group of families who received family preservation services (Gershater-Molko et al., 2002). CHILD MALTREATMENT / AUGUST 2005


In the statewide trial of Project SafeCare in Oklahoma, the six geographical service regions for parents referred for CPS services were matched and then randomly assigned to either the Project SafeCare curriculum or services as usual. Providers in the Project SafeCare areas have been trained to implement the curriculum. Outcomes will focus on recidivism data obtained through official CPS records and self-report measures of parental behavior. The statewide trial project also includes an examination of the impact of fidelity monitoring and will examine the cost-effectiveness of implementing the Project SafeCare model. The smaller primary prevention project is a pilot study in which families with specific risk factors for child maltreatment (e.g., partner violence, substance use, mental illness) but who are not yet involved with CPS will be randomly assigned to receive the Project SafeCare curriculum or usual care. As in the statewide trial, CPS involvement and indirect measures of maltreatment are being collected to measure impact (Priority 6, 12). Another project is a population-based trial of Triple P, the Positive Parenting Program (Sanders, 1999). Triple P is a set of tiered interventions that use behavioral techniques to promote positive parenting strategies to reduce negative, coercive parenting strategies. The tiers of interventions of Triple P include universal interventions for common behavior problems among children; brief consultative interventions for more specific behavior problems; more lengthy interventions for more severe behaviors; and Triple P Pathways, an intervention for parents indicated for child maltreatment. In this way, Triple P provides a series of interventions from which families can step from one level of interventions to another, depending on their needs and skills. With universal, selective, and indicated interventions, Triple P is appropriate for all families. In the trial, 18 counties in a southeastern state have been randomized to receive Triple P or to a wait-list control condition. In the intervention counties, a broad range of service providers who work with parents (e.g., social workers, nurses, parent educators, teachers, day care providers) are being trained to implement Triple P. Evaluation of the impact of the intervention will be conducted by examining official child maltreatment records and by an annual random digit dial survey of parenting behaviors. This project represents a broad effort at primary prevention of child maltreatment and includes a cost-effectiveness component (Priority 6). Parenting programs can only be effective if parents are engaged in them, and the difficulties engaging parents in effective parenting programs are welldocumented (e.g., McCurdy & Daro, 2001; Prinz CHILD MALTREATMENT / AUGUST 2005

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et al., 2001). In response to the problem of attrition in parenting programs, CDC funded two projects to examine strategies to promote retention and compliance and reduce attrition, in empirically supported parenting programs. The University of Oklahoma Health Sciences Center and Purdue University are evaluating the impact of strategies, such as motivational interviewing, motivated action plans, and financial incentives, on parents’ attendance and cognitive and emotional engagement in two existing efficacious parenting programs. These projects will also examine compliance, readiness to change, and parent and child outcomes, including child maltreatment as outcomes, and assess the cost-effectiveness of retention strategies (Priority 6, 12). Further work is needed regarding home visitation programs and how to translate those programs such that impact is maintained. The CDC has funded two projects to examine the impact of training criteria for home visitors and fidelity to treatment protocols with regard to producing effects for home visitation programs. These issues are particularly germane given the recent studies of home visitation program that did not replicate the preventive effect on child maltreatment (Duggan, McFarlane, et al., 2004). In fact, a lack of skills for home visitors and program delivery were two of the possible reasons cited by the authors for the failure to find a home visitation effect (Duggan, McFarlane, et al., 2004, pp. 615-616). A project designed to address the co-occurrence of domestic violence and child maltreatment represents another multiagency collaborative effort. In 1998, the Juvenile and Family Court Judges assembled an Advisory Committee to develop policy and practice recommendations for agencies regarding the cooccurrence of domestic violence and child maltreatment. The recommendations were published in a document titled Effective Intervention in Domestic Violence and Child Maltreatment Cases: Guidelines for Policy and Practice, which became known as the Greenbook. The Greenbook project is a multiyear collaboration among eight federal agencies that funds six demonstration sites across the United States to implement selected Greenbook recommendations. The intent of these demonstration sites is to alter the three systems (the court system, the child protective system, and the domestic violence service provider system) that interact with abused women, their children, and their perpetrators so that victims are protected and perpetrators held accountable (Priority 6).

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IMPLEMENTATION AND DISSEMINATION

The CDC’s priorities for the dissemination and implementation of child maltreatment prevention focus on partnerships. As noted, a range of partnerships between governmental agencies, and national and community-based organizations are involved at various points in the public health model. Child maltreatment partnerships need strengthening on two fronts. First, because the current services for cases of child maltreatment occur primarily through social service departments rather than public health departments, stronger partnerships with state and local public health departments (who may or may not be involved in child maltreatment work) may bring a stronger preventive approach to social service agencies. The public health approach has much to offer social service departments, including the testing and implementation of validated intervention protocols and a focus on primary prevention. Second, there is also a need to embrace institutions not typically considered part of the public health system, such as the media, the business community, and faith-based organizations. Such partnerships can improve access to populations otherwise unreachable through traditional partnerships. They also provide different venues from which public health prevention messages can be disseminated. To ensure that empirically supported practices are being implemented, there is a need to assess the knowledge and current practices of social service organizations and determine how service providers are trained to intervene with those at risk or indicated for child maltreatment. Furthermore, technical assistance to enhance that training should be available. Local organizations seeking to implement empirically supported prevention activities may also need technical assistance with program monitoring and evaluation. Empirically tested interventions must be translated into products that can be disseminated. Often, interventions are developed and tested in research studies but are not packaged into curricula or manuals that are useful or acceptable to other service providers (Glasgow et al., 2003). Curricula and manuals should provide information about staff training and background, materials that may be needed, proper settings for an intervention, instructions on how to tailor a curriculum and how to ensure intervention and training fidelity, tips for evaluation activities, and any other information that is needed for implementation. Evidence-based practices (i.e., those with strong empirical support) should be disseminated, and service providers should be encouraged to implement

these practices. Some researchers are hesitant to disseminate practices having limited evidence of efficacy or effectiveness, but the expert panelists recommended the dissemination of both best and promising practices. In actual practice, service providers must deliver programs regardless of the presence of rigorous outcomes evaluations. Thus the research community must do their best to inform service providers about practices that appear promising and of those that are demonstrably ineffective as soon as data become available. The public health system has been effective at disseminating empirically based findings in other areas of health concern (e.g., vaccinations for diseases, smoking prevention messages, cancer screening messages), but lengthy, complex behaviorally based interventions hold unique challenges for dissemination. Still, a balance must be reached between too little and too much caution. Current CDC Implementation and Dissemination Projects The CDC is currently implementing several projects to facilitate the implementation and dissemination of prevention strategies for child maltreatment. To facilitate capacity building, CDC supports the Collaborative Efforts to Prevent Child Sexual Abuse Project for which the purpose is to create statewide prevention collaboratives to promote the development and implementation of child sexual abuse prevention programs that focus on adult or community responsibility. This project uses existing infrastructures to broaden efforts to prevent child sexual abuse. Collaborative Efforts to Prevent Child Sexual Abuse involves partnerships that combine the expertise of child abuse prevention, sexual abuse prevention, and public health agencies or organizations (Priority 6). To facilitate the promotion of effective parenting practices, CDC supports a project focused on understanding cultural differences in parenting norms. The goal of this project is to better understand typical parenting behaviors within different cultures to facilitate the implementation and dissemination of parenting-based child maltreatment prevention strategies to various cultures so that culturally appropriate messages and materials can be developed. The project will identify the cultural norms that may contribute to or support the occurrence of child maltreatment, as well as positive parenting practices. Information is being gathered through literature reviews, focus groups, and interviews with external partners to identify regional, ethnic, and socioeconomic factors that influence cultural norms. Focus groups were conducted with individuals in five racial and ethnic groups (Hispanic, Asian, African American, Native CHILD MALTREATMENT / AUGUST 2005


American, and White) concerning cultural attitudes, beliefs, and behaviors in child-rearing practices (Priority 6, 9). SUMMARY

The public health approach is a useful framework for the prevention of child maltreatment, and CDC is committed to advancing prevention efforts by way of this model. The priorities described above and detailed in the appendices were developed through meetings with child maltreatment experts—development of a broad research agenda for CDC—and through work of CDC scientists. It is important to bear in mind that the priorities for surveillance, etiologic research, intervention and evaluation, and implementation and dissemination apply to the entire community of child maltreatment researchers and practitioners, not only CDC (the panel consisted of members representing virtually all sectors concerned with child maltreatment). This is particularly true for the recommendations made by the initial panel of experts (Appendix A). Successful implementation of any of the panel’s recommendations will require collaborative efforts and coordination between the multiple organizations that address child maltreatment. The public health model adds a framework to conceptualize the various activities being conducted, an action-oriented approach that adds a focus on developing prevention and intervention strategies, and a focus on coordinating between the vast numbers of partners necessary to broadly affect a public health problem by dissemination and implementation of evidence-based strategies. APPENDIX A Recommendations From October 1999 Meeting of Child Maltreatment Experts (Prioritized Within Each Working Group) The Surveillance Workgroup 1. Develop a National Surveillance System for child maltreatment, including both database systems and population surveys. 2. Assume leadership in creating National Uniform Definitions for Child Maltreatment and Recommended Data Elements (both developed in conjunction with experts and other federal agencies). 3. Examine legal, medical, and ethical issues in child maltreatment surveillance. (Convene an ethics panel for this purpose.) 4. Include surveillance on the overlap of intimate partner violence and child maltreatment.

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The Research Workgroup 1. Develop uniform definitions of child maltreatment because the definitions affect how research is conceived. 2. Develop effective surveillance for research activities in child maltreatment prevention. (Centers for Disease Control and Prevention [CDC] should develop a child maltreatment survey similar to the National Violence Against Women Survey, CDC–National Institute of Justice collaboration and examine databases (national, state, local) that limit reporting bias. 3. Sponsor and conduct research (qualitative and quantitative) that generates empirical evidence with scientific rigor, a hallmark of CDC’s work. 4. Conduct research on perpetrators of child maltreatment (e.g., nonbiological perpetrators, overrepresentation of minorities, age distribution of perpetrators, how to identify perpetrators, and when to intervene). 5. Conduct research on the effects of abuse, age of onset, severity, and types of abuse on children’s outcomes (single types of abuse and multiple types co-occurring). 6. Conduct research involving a cost analysis of child maltreatment (also potentially using managed care systems). 7. Conduct research on effects of sociodemographic factors and children’s outcomes. 8. Triangulate data, using multiple data sources and merging of criminal justice, emergency department, hospital, pathology, and Child Protective Service’s databases. 9. Conduct research on comprehensive strategies (combined individual, family, community, and national) for elimination or prevention of child maltreatment. 10. Implement a National Child Death Review team (as recommended by the U.S. Advisory Board in its 1995 report) and use the information from that for child maltreatment research and surveillance. 11. Conduct research on genetic and biological factors leading to future generations of perpetrators (e.g., in utero exposure to alcohol or drugs). 12. Conduct research on biomechanics of child injuries, as much of what is known about children’s injuries has been extrapolated from literature on adult injuries. 13. Conduct research on the overlap of intimate partner violence and child maltreatment. 14. Conduct research on cultural factors and how they affect child maltreatment issues. 15. Conduct research on the effectiveness of stage-based interventions (such as the trans-theoretical model). 16. Conduct research on cause of child deaths to determine the real cause, which may not be immediately apparent (e.g., poisoning may be because of neglect). 17. Conduct research on barriers to changing attitudes concerning violence and abuse. 18. Conduct research on what constitutes a minimally acceptable environment for healthy child development. (Protective factors in abuse-free environments should be examined to help set criteria for minimal acceptability.)

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19. Conduct research on child factors that contribute to child maltreatment. 20. Conduct research on the effects of health care provider training on surveillance systems in emergency departments. 21. Conduct research using managed care systems to discover which groups have low abuse and why. 22. Conduct research on sexual exploitation of children in media. 23. Conduct research on possible data confounds depending on victim’s relationship with perpetrator. 24. Conduct research on the effect of different methods of information gathering (e.g., gender, race of data gatherers). 25. Conduct research on treatment and intervention strategies. 26. Conduct research on teaching children to be safe. 27. Conduct research on measuring the fidelity of interventions. 28. Conduct research using single-case research designs. The Evaluation Workgroup 1. Establish rigorous standards for evaluation of prevention programs. 2. Play an active part in the identification, evaluation, and provision of technical assistance to communities that want to implement prevention or intervention programs for child maltreatment. 3. Encourage a broad view of child maltreatment, which encompasses not only physical, sexual or psychological abuse, but also exposure to community violence, witnessing intimate partner violence, and child neglect. 4. Emphasize prevention as CDC’s priority. 5. Evaluate both universal and specific programs. 6. Evaluate the impact of child maltreatment on child health (both physical and mental health during childhood and adulthood). 7. Conduct longitudinal research for optimal evaluation. 8. Evaluate different types of parenting programs (e.g., for two-parent families, teenage single mothers, or nonresident fathers). 9. Evaluate curricula for K-12 (with regard to issues concerning violence, healthy relationships, and parenting, depending on the age of the child). 10. Evaluate family support programs (e.g., home visitation). 11. Evaluate different programs for boys and girls who have been abused (gender appropriate interventions). 12. Evaluate community responses to child maltreatment (using a coordinated community response methodology). 13. Evaluate training programs for health care providers (e.g., training on the identification and referral of child maltreatment victims). 14. Evaluate different programs for young children and adolescents (for age-appropriate interventions). 15. Evaluate different violence prevention programs for nonabused children and abused children.

16. Evaluate programs that target the prevention of all four types of child maltreatment. 17. Determine the level of integration of a particular intervention into a system (e.g., staff support for implementation, management support for intervention). 18. Consider cultural diversity issues when evaluating program effectiveness. 19. Evaluate the impact of public service announcements that have been developed for prevention of child maltreatment. 20. Evaluate how cultural factors in a community may affect implementation and acceptance of demonstration projects. 21. Evaluate communities (worldwide) that have a lower rate of child maltreatment to discover what is working well. 22. Evaluate potential risk factors for child maltreatment (e.g., race or ethnicity, maternal depression, intimate partner violence, and poverty). 23. Evaluate interventions in pediatric primary care settings (screening for child maltreatment). 24. Evaluate potential protective factors against child maltreatment (e.g., parental competency, access to services, social support). 25. Evaluate public attitudes and norms regarding child treatment (e.g., corporal punishment). 26. Evaluate spanking as a risk of child maltreatment and then evaluate the effects of promoting a behavioral alternative to spanking. 27. Evaluate a comprehensive prevention program for all violence in communities (including intimate partner violence, youth violence, street violence, suicide, child maltreatment, sibling violence, and elder abuse). 28. Evaluate state policies regarding child maltreatment and how they have affected outcomes of child maltreatment prevention (e.g., funding and definitional issues). 29. Evaluate the mechanism for behavior change from violent to nonviolent. 30. Evaluate the effect of participant attrition on program results. 31. Evaluate efforts at influencing state legislators to change policy (e.g., what shapes the policy-making process concerning child maltreatment funding?). The Implementation and Dissemination Work Group 1. Identify best-practice-and-promising programs quickly for fast dissemination of promising interventions. 2. Support multifaceted community-based interventions with a continuum of services, involving program implementation, education efforts, data collection, evaluation, and information dissemination. 3. Engage new and diverse partners (e.g., business, industry, or other health personnel not usually involved in child maltreatment issues) in dissemination and implementation of program information. 4. Create and maintain a central information site on the Internet to highlight best practices and provide up-toCHILD MALTREATMENT / AUGUST 2005


5. 6.

7. 8. 9. 10.

date information on child maltreatment programs and curricula. Promote nonviolent social norms. Translate research quickly into programs that can easily be put into practice. (Information disseminated should be put in simple, understandable terms of what the intervention is and how to do it.) Form partnerships with media to change attitudes about violence. Support a child maltreatment wellness model and evaluate and fund programs for child and family wellness and health promotion. Provide ongoing monitoring of programs or process for implementation of innovative practices. Provide technical assistance in implementation of programs and interventions.

Overall Comments Made by Reviewers, But Which Were Not Specific to a Particular Subgroup 1. Incorporate the role of social work schools in training issues. There is a need for evaluation of training for social workers in the area of child maltreatment, especially in the co-occurrence of child maltreatment and intimate partner violence. Social workers are a vital contact to maltreated children. It is important that social workers recognize violence prevention issues associated with child maltreatment, especially with regard to its co-occurrence with intimate partner violence. 2. Consider intimate partner violence and child maltreatment concurrently, because they frequently co-occur. 3. Examine the long-term effects of child maltreatment on health risk behaviors, health outcomes, quality of life, social problems, and health care costs. As the nation’s public health agency, CDC should highlight the link between child maltreatment and health issues. 4. Obtain more information on boys as victims and future perpetrators, as there has been a link between victimization and later perpetration. 5. Maximize the efficiency of federal efforts through continued collaboration between the CDC and the Office of Child Abuse and Neglect.

APPENDIX B Proposed Child Maltreatment Prevention Priorities From the 2001 Meeting of Experts (The “Think Tank”) Overarching Recommendations 1. Priorities should address all four types of child maltreatment: physical abuse, sexual abuse, emotional abuse, and neglect. 2. Parenting should serve as the broad theme for prevention and intervention work. 3. To promote the professional development around public health approaches to child maltreatment, a fellowCHILD MALTREATMENT / AUGUST 2005

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ship or some other type of financial support should be offered. Top Priorities 4. Use state surveillance systems to develop and evaluate optimal methods for state-based national surveillance of child maltreatment. 5. For each of the four types of child maltreatment (physical abuse, sexual abuse, emotional abuse, and neglect), ensure that measures are reliable and valid. 6. Develop and test field-based interventions and prevention activities for child maltreatment. 7. Create national standards for Child Fatality Review programs and committees. 8. Commission reviews on what is known by clinicians and policy makers about child maltreatment (especially neglect). 9. Conduct research to examine mechanisms and processes that explain the relationship between risk factors and outcomes (including health outcomes and also include both victimization and perpetration). 10. Develop and market a guidelines document listing best practices for child maltreatment interventions and describing prevention protocols for all types of child maltreatment, with a special focus on neglect. 11. Develop conceptual models that address mechanisms and processes of the origin and perpetuation of child maltreatment for all four types of child maltreatment. 12. Replicate and extend studies of previously developed child maltreatment interventions, attending to moderators, mediators, new clinical techniques, and reduction of obstacles to interventions. 13. Facilitate the implementation of evidence-based models by providing enhanced funding and prestige for providers delivering best practices protocols.

REFERENCES Appel, A. E., & Holden, G. W. (1998). The co-occurrence of spouse and physical child abuse: A review and appraisal. Journal of Family Psychology, 12, 578-599. Azar, S. T. (1991). Models of child abuse: A metatheoretical analysis. Criminal Justice and Behavior, 18, 30-46. Azar, S. T., Povilaitis, T. Y., Lauretti, A. F., & Pouquette, C. L. (1998). The current status of etiological theories in intrafamilial child maltreatment. In J. R. Lutzker (Ed.), Handbook of Child Abuse Research and Treatment (pp. 3-30). New York: Plenum. Becker, J. V., Alpert, J. L., BigFoot, D. S., Bonner, B. L., Geddie, L. F., Henggler, S. W., et al. (1995). Empirical research on child abuse treatment: Report by the Child Abuse and Neglect Treatment Working Group, American Psychological Association. Journal of Clinical Child Psychology, 24, 23-46. Behl, L. E., Conyngham, H. A., & May, P. F. (2003). Trends in child maltreatment literature. Child Abuse & Neglect, 27, 215-229. Bigelow, K. M., & Lutzker, J. R. (1998). Using video to teach planned activities to parents reported for child abuse. Behavior Therapy, 20, 1-14. Black, D. A., Heyman, R. E., & Slep, A. M. S. (2001a). Risk factors for child physical abuse. Aggression & Violent Behavior, 6, 121-188. Black, D. A., Heyman, R. E., & Slep, A. M. S. (2001b). Risk factors for child sexual abuse. Aggression & Violent Behavior, 6, 203-229.

258


Black, D. A., Slep, A. M. S., & Heyman, R. E. (2001). Risk factors for child psychological abuse. Aggression & Violent Behavior, 6, 189201. Centers for Disease Control and Prevention (CDC). (1999a). Achievements in public health, 1900-1999. Changes in the public health system. Morbidity and Mortality Weekly Report, 48, 11411146. Centers for Disease Control and Prevention (CDC). (1999b). Tobacco use, United States, 1900–1999. Morbidity and Mortality Weekly Report, 48, 986-993. Chaffin, M. (2004). Is it time to rethink Healthy Start/Healthy Families? Child Abuse & Neglect, 28, 589-595. Child Abuse Prevention and Treatment Act, P.L. 93-247 (1974). Crittenden, P. M. (1998). Dangerous behavior and dangerous contexts: A 35-year perspective on research on the developmental effects of child physical abuse. In P. K. Trickett & C. J. Schellenbach (Eds.), Violence against children in the family and the community (pp 11-38). Washington, DC: American Psychological Association. Daro, D., & Donnelly, A. C. (2002). Charting the waves of prevention: Two steps forward, one step back. Child Abuse & Neglect, 26, 731-742. DePanfilis, D., & Zuravin, S. J. (2002). The effect of services on the recurrence of child maltreatment. Child Abuse & Neglect, 26, 187205. Djeddah, C., Facchin, P., Ranzato, C., & Romer, C. (2000). Child abuse: Current problems and key public health challenges. Social Science and Medicine, 51, 905-915. Donnelly, A. C. (1999). The practice. Child Abuse & Neglect, 23, 987994. Duggan, A., Fuddy, L., Burrell, L., Higman, S. M., McFarlane, E., Windham, A., et al. (2004). Randomized trial of a statewide home visiting program: Impact in reducing parental risk factors. Child Abuse & Neglect, 28, 623-643. Duggan, A., McFarlane, E., Fuddy, L., Burrell, L., Higman, S.M., Windham, A., et al. (2004). Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse & Neglect, 28, 597-622. Eyberg, S., (1988). Parent-child interaction therapy: Integration of traditional and behavioral concerns. Child and Family Behavior Therapy, 10, 33-46. Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz A. M., Edwards, V., et al. (1998). The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine, 14, 245-258. Finkelhor, D. (1984). Child sexual abuse: New theory and research. New York: Free Press. Finkelhor, D., & Jones, L. M. (2004). Explanations for the decline in child sexual abuse cases. Juvenile Justice Bulletin. Retrieved January 26, 2005, from http://www.ncjrs.org/pdffiles1/ojjdp/199298. pdf Forehand, R., & McMahon, R. (1981). Helping the noncompliant child. New York: Guilford. Gaudin, J. M. (1993). Effective intervention with neglectful families. Criminal Justice & Behavior, 20, 66-89. Gershater-Molko, R. M., Lutzker, J. R., & Sherman, J. A. (2003). Assessing child neglect. Aggression & Violent Behavior, 8, 563-585. Gershater-Molko, R. M., Lutzker, J. R., & Wesch, D. (2002). Using recidivism data to evaluate Project SafeCare: Teaching bonding, safety, and health care skills to parents. Child Maltreatment, 7, 277-285. Glasgow, R. E., Lichtenstein, E., & Marcus, A. C. (2003). Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. American Journal of Public Health, 93, 1261-1267. Greene, B. F., & Kilili, S. (1998). How good does a parent have to be? Issues and examples associated with empirical assessments of parenting adequacy in cases of child abuse and neglect. In J. R. Lutzker (Ed.), Handbook of Child Abuse Research and Treatment (pp. 53-72). New York: Plenum.

Hahn, R. A., Bilukha, O. O., Crosby, A., Fullilove, M. T., Liberman, A., Moscicki, E. K., et al., (2003). First reports evaluating the effectiveness of strategies for preventing violence: Early childhood home visitation: Findings from the Task Force on Community Preventative Services. Morbidity and Mortality Weekly Reports, 52(14), 1-9. Hammond, W. R. (2003). Public health and child maltreatment prevention: The role of the Centers for Disease Control and Prevention. Child Maltreatment, 8, 81-83. Kempe, C. H., Silverman, F. N., Steele, B., Droegemueller, W., & Silver, H. R. (1962). The battered child syndrome. Journal of the American Medical Association, 181, 17-24. Kendall-Tackett, K. A., Williams, L. M., & Finkelhor, D. (2001). Impact of sexual abuse on children: A review and synthesis of recent empirical studies. In R. Bull (Ed.), Children and the law: The essential readings. Essential readings in developmental psychology. (pp. 31-76). Malden, MA: Blackwell. Lutzker, J. R. (Ed.). (1998). Handbook of child abuse research and treatment. New York: Plenum. Lutzker, J. R., & Bigelow, K. M. (2002). Reducing child maltreatment: A guidebook for parent services. New York: Guilford. Lutzker, J. R., Frame, R. E., & Rice, J. M. (1982). Project 12-Ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect. Education and Treatment of Children, 5, 141-155. Lutzker, J. R., & Rice, J. M. (1987). Using recidivism data to evaluate Project 12-Ways: An ecobehavioral approach to the treatment and prevention of child abuse and neglect. Journal of Family Violence, 2, 283-290. Marshall, W. L., & Barbaree, H. E. (1990). An integrated theory of the etiology of sexual offending. In W. L. Marshall, D. R. Laws, & H. E. Barbaree (Eds.), Handbook of sexual assault (pp. 257-275). New York: Plenum. McCurdy, K., & Daro, D. (2001). Parent involvement in family support programs: An integrated theory. Family Relations: Journal of Applied Family & Child Studies, 50, 113-121. Melton, G. B. (2002). Chronic neglect of family violence: More than a decade of reports to guide U.S. policy. Child Abuse & Neglect, 26, 569-586. Merrick, J., & Browne, K. D. (1999). Child abuse and neglect: A public health concern. Public Health Review, 27, 279-293. Milner, J. S. (1994). Assessing physical child abuse risk: The Child Abuse Potential Inventory. Clinical Psychology Review, 14, 547– 583. Milner, J. S., Murphy, W. D., Valle, L. A., & Tolliver, R. M. (1998). Assessment issues in child abuse evaluations. In J. R. Lutzker (Ed.), Handbook of child abuse research and treatment (pp. 75-115). New York: Plenum. National Research Council. (1993). Recommendations. In A. J. Reiss, Jr. & J. A. Roth (Eds.), Understanding and preventing violence: Panel on the understanding and control of violent behavior. Washington, DC: National Academy Press. Olds, D., Henderson, C. R., Jr., Cole, R., Eckenrode, J., Kitzman, H., Luckey, D., et al. (1998). Long-term effects of nurse home visitation on children’s criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. Journal of the American Medical Association, 280, 1238-1244. O’Leary, K. D., Slep, A. M. S., & O’Leary, S. G. (2000). Cooccurrence of partner and parent-aggression: Research and treatment implications. Behavior Modification, 31, 631-648. Prinz, R. J., Smith, E. P., Dumas, J. E., Laughlin, J. E., White, D. W., & Barron, R. (2001). Recruitment and retention of participants in prevention trials involving family-based interventions. American Journal of Preventive Medicine, 20(Suppl. 1), 31-37. Putnam, F. (2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry, 42, 269-278. Sanders, M. R. (1999). Triple P—Positive Parenting Program: Towards an empirically validated multilevel parenting and family support strategy for the prevention of behavior and emotional problems in children. Clinical Child and Family Psychology Review, 2, 71-90. CHILD MALTREATMENT / AUGUST 2005


Schumacher, J. A., Slep, A. M. S., & Heyman, R. E. (2001). Risk factors for child neglect. Aggression & Violent Behavior, 6, 231-254. Straus, M. A., & Stewart, J. H. (1999). Corporal punishment by American Parents: National data on prevalence, chronicity, severity, and duration in relation to child and family characteristics. Clinical Child and Family Psychology Review, 2, 55-70. Teplin, L. A., Abram, K. M., McClelland, G. M., Dulcan, M. K., & Mericle, A. A. (2002). Psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry, 59, 1133-1143. Trickett, P. K., & Putnam, F. W. (1998). Developmental consequences of child sexual abuse. In P. K. Trickett & C. J. Schellenbach (Eds.), Violence against children in the family and the community (pp 39-56). Washington, DC: American Psychological Association. Turnock, B. J. (1997). Public Health: What it is and how it works. Gaithersburg, MD: Aspen. U.S. Department of Health and Human Services. (1996). The third National Incidence Study of Child Abuse and Neglect (NIS-3). Washington, DC: U.S. Government Printing Office. U.S. Department of Health and Human Services. (2003). Child maltreatment 2001. Washington, DC: U.S. Government Printing Office. Ward, T., & Siegert, R. (2002). Toward a comprehensive theory of child sexual abuse: A theory knitting perspective. Psychology, Crime, & Law, 9, 319-351. Webster, R. A., Schnitzer, P. G., Jenny, C., Ewigman, B. G., & Alario, A. J. (2003). Child death review: The state of the nation. American Journal of Preventive Medicine, 25, 58-64. Webster-Stratton, C. (1994). Advancing videotape parent training: A comparison study. Journal of Consulting and Clinical Psychology, 62, 583-593. Widom, C. S., Raphael, K. G., & DuMont, K. A. (2004). The case for prospective longitudinal studies in child maltreatment research: Commentary on Dube, Williamson, Thompson, Felitti, and Anda. Child Abuse & Neglect, 28, 715-722. Wolfe, D. A. (1987). Child abuse: Implications for child development and psychopathology. Newbury Park, CA: Sage. Wolfe, D. A. (1991). Preventing physical and emotional abuse of children. New York: Guilford.

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Daniel J. Whitaker received his Ph.D. in social psychology from the University of Georgia. He joined Centers for Disease Control and Prevention in 1997. He is currently a behavioral scientist and team leader in the Division of Violence Prevention at Centers for Disease Control and Prevention. His research interests include the prevention of child maltreatment and intimate partner violence. John R. Lutzker, Ph.D., is appointed as distinguished consultant and chief, Prevention Development and Evaluation Branch, for the Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. He has published more than 100 professional articles and chapters and has presented more than 325 professional papers. He is a fellow of the American Psychological Association (Divisions 25, 33, 37, 53) and is a clinical fellow of the Behavior Therapy and Research Society. He is currently on the editorial boards of the Journal of Family Violence, Journal of Behavior Therapy and Experimental Psychiatry, Child and Family Behavior Therapy, and Behavioral Interventions. He is the author of five books, including Reducing Child Maltreatment: A Guidebook for Parent Services (with Kathryn Bigelow) and is editor of Handbook of Child Abuse Research and Treatment. He is also a recent recipient of the James M. Gaudin Outstanding Research Award from the Georgia Professional Society on the abuse of children and of the Alumni Distinguished Achievement Award from the University of Kansas. Gene A. Shelley, Ph.D., is a behavioral scientist with the Division of Violence Prevention at the Centers for Disease Control and Prevention. She received her B.A. in anthropology from Purdue University and her M.S. and Ph.D. in anthropology from the University of Florida. She has taught cultural and medical anthropology courses at Georgia State University. Her interests and expertise include medical anthropology, research methods (both quantitative and qualitative), social network research, child maltreatment, partner violence, and the interface between ethnicity and attitudes toward violence and abuse.