Early Childhood Intervention Programs: opportunities and challenges for preventing child maltreatment.
Due to the destructive impact of child maltreatment child maltreatment '…intentional harm or threat of harm to a child by someone acting in the role of a caretaker, for even a short time…Categories Physical abuse, sexual abuse, emotional abuse, neglect…', the last being most common. and limited available funding to address its consequences, the value of preventive measures is evident. Early Childhood Intervention Early Childhood Intervention is a support system for children with developmental delays and/or disabilities and their families.
If a child experiences a developmental delay, this can compound over time. Programs (ECIPs) provide excellent opportunities to prevent and identify cases of child maltreatment, among other varied objectives. These programs are typically targeted at high-risk families with children under age 5 and address risk factors across various levels of intervention (child, parent, immediate context, and broader context). A sample of ECIPs within home, school, clinic, and community settings were selected for description in this paper if they include services that address common child maltreatment risk factors, demonstrated reductions in risk factors through outcome research, and provide valuable lessons for preventing child maltreatment. Challenges to preventing child maltreatment through ECIPs are discussed, including unreliable identification of high-risk families, lack of involvement of low-income and minority parents, and barriers to effective dissemination dissemination Medtalk The spread of a pernicious process–eg, CA, acute infection Oncology Metastasis, see there and implementation of programs. Recommendations for future research and improving child maltreatment prevention through ECIPs are provided.
The disturbing prevalence of child abuse and neglect in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. has sparked a great deal of research and mobilization mobilization
Organization of a nation's armed forces for active military service in time of war or other national emergency. It includes recruiting and training, building military bases and training camps, and procuring and distributing weapons, ammunition, uniforms, over the past few decades. Yet despite the growing awareness and recognition of this societal problem, hundreds of thousands of children continue to be maltreated every year. The U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS (2006a) reported 872,000 substantiated cases of child maltreatment in 2004 alone, at a rate of 11.9 per 1,000 children. Many estimates indicate that approximately 20% of children will be sexually abused before becoming adults (Davis & Gidyez, 2000). Even more tragic are the severe cases of abuse and neglect that lead to child fatalities. In 2004, it was estimated that 1,490 children died as a result of child maltreatment, with the majority of deaths attributed solely to neglect (U.S. Department of Health & Human Services, 2006a).
Aside from the serious physical consequences of child maltreatment, several emotional and behavioral consequences for children have been noted in the literature. These consequences vary according to according to
1. As stated or indicated by; on the authority of: according to historians.
2. In keeping with: according to instructions.
3. differences in the severity, duration, and frequency of maltreatment maltreatment Social medicine Any of a number of types of unreasonable interactions with another adult. See Child maltreatment, Cf Child abuse. , as well as differences in the child (e.g., temperament temperament, in music, the altering of certain intervals from their acoustically correct values to provide a system of tuning whereby music can move from key to key without unacceptably impure sonorities. , coping skills, developmental stage) and his or her environment (e.g., family income, social support, neighborhood characteristics; Hecht & Hansen, 2001). In general, children who have been maltreated are likely to develop insecure in·se·cure
1. Lacking emotional stability; not well-adjusted.
2. Lacking self-confidence; plagued by anxiety.
in attachments with caregivers, which often lead to interpersonal difficulties, aggressive behavior, and low self-esteem. They may also have impaired emotion regulation capabilities and exhibit internalizing problems, such as depression, anxiety, and self-harm behaviors (Hecht & Hansen, 2001; Saywitz, Mannarino, Berliner, & Cohen cohen
(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. , 2000; Tyler, 2002). The consequences of child maltreatment have a broader impact on society as well. Economic analyses have estimated the direct (e.g., hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.
2. the term of confinement in a hospital. , treatment, law enforcement) and indirect (e.g., special education, foster care, juvenile delinquency juvenile delinquency, legal term for behavior of children and adolescents that in adults would be judged criminal under law. In the United States, definitions and age limits of juveniles vary, the maximum age being set at 14 years in some states and as high as 21 , unemployment) costs of child maltreatment to be over $94 billion per year (Fromm, 2001; U.S. Department of Health & Human Services, 2004b).
Considering the destructive impact of child maltreatment on individuals and society as a whole, as well as the limited funding available to address its consequences, the value of preventive measures is becoming increasingly apparent. The benefits of prevention efforts can be seen at both individual and societal levels. Prevention programs can save millions of dollars through reductions in health care costs, child welfare services costs, out-of-home care costs, law enforcement costs, judicial system costs, and unemployment costs to society. Moreover, long-term benefits of child abuse prevention include improved mental and physical health, educational achievement, employment prospects, social functioning social functioning,
n the ability of the individual to interact in the normal or usual way in society; can be used as a measure of quality of care. , and family stress (Karoly et al., 2001; U.S. Department of Health & Human Services, 2004b).
Though greatly varied in nature, Early Childhood Intervention Programs (ECIPs) are excellent resources for preventing child maltreatment. In this paper, the term "Early Childhood Intervention Program" refers exclusively to programs designed to promote healthy development and prevent negative outcomes for at-risk children. These programs have become increasingly prevalent since the 1960s, which marked the beginning of the modern era in early childhood intervention (Meisels & Shonkoff, 1990). Though their roots stem from a variety of fields (e.g., mental health, social work, education) and the programs themselves are diverse in context, purpose, and intervention strategies, ECIPs share the common goal of "translat[ing] ever-growing knowledge about the process of human development into the formation of the best kind of environment in which a child can grow" (Meisels & Shonkoff, 1990, p. 27). These programs also share the idea that intervention should occur early in life, before more significant problems are likely to develop. Because child maltreatment is most common in children under 5 years of age, ECIPs are in an ideal position to prevent maltreatment before it occurs (Graham-Bermann, 2002; U.S. Department of Health & Human Services, 2006a). These programs have the unique ability to address multiple problems at multiple levels and across multiple settings, increasing the likelihood that child maltreatment can be prevented (Daro, 2000; Karoly et al., 2001; U.S. Department of Health & Human Services, 2006a).
The purpose of this paper is to identify common risk factors for child maltreatment (i.e., physical abuse, sexual abuse, and neglect) from the available literature and review a sample of ECIPs that address specific risk factors. In particular, the unique opportunities available within ECIPs for preventing child maltreatment will be discussed, as well as challenges that often arise in ECIPs and strategies for addressing them. The paper will begin with a review of risk factors, organized according to Belsky's (1993) developmental-ecological framework. This is followed by a description of ECIPs and their potential for reducing the risk of child abuse and neglect. A selection of ECIPs implemented within home, school, clinic, and community settings are then reviewed. Programs were chosen for review if they include services that address common child maltreatment risk factors, demonstrated reductions in these risk factors through outcome research, and provide valuable lessons for preventing child maltreatment. Barriers to preventing child maltreatment through ECIPs are discussed as well as limitations of current research. Finally, recommendations are provided for future research and for improving child maltreatment prevention through ECIPs.
Overview of Child Maltreatment Risk Factors
It has been widely accepted that there is no single cause of child maltreatment (Belsky, 1993; Daro, 2000; Daro & Harding, 1999; Hecht & Hansen, 2001). A variety of risk factors exist in a range of contexts, producing "many pathways to child abuse and neglect" (Belsky, 1993, p. 413). Each of these characteristics alone may increase the risk of maltreatment, but they often co-occur and increase risk in a cumulative manner (Hecht & Hansen, 2001). It is likely that most families will experience one or more of these risk factors at some point, while not all families will experience abuse or neglect (Daro, 2000). For this reason, it has proven extremely difficult to identify either potential victims or potential perpetrators of abuse and neglect (Daro, 1994; Hecht & Hansen, 2001). However, as research continues to uncover information about common risk factors, prevention programs can be designed and modified to address multiple risk factors within a single program.
A review of common child maltreatment risk factors is necessary before discussing the ability of ECIPs to address these factors. Belsky (1993) outlined a developmental-ecological framework to organize the various risk factors across multiple levels of analysis, based on the work of Bronfenbrenner and forming the basis for the work of Cicchetti and others (Bronfenbrenner, 1979; Cicchetti & Toth, 2000; Hecht & Hansen, 2001). According to this framework, child maltreatment risk factors can be conceptualized in terms of parent factors, child factors, factors in the immediate interactional context, and those existing in the broader environmental context. Factors within each level are continuously influencing and interacting with factors in other levels in a transactional manner (Belsky, 1993; Cicchetti & Toth, 2000). Several of these risk factors are discussed below, within a developmental-ecological framework.
While they are not directly predictive of child maltreatment, factors related to a parent's mental health, personality, and personal history have all been linked to child abuse potential. A parent with mental health problems may have less emotional and psychological resources available to invest in meeting their child's needs. Studies have shown that abusive parents frequently have low self-esteem, lack of impulse control impulse control Psychology The degree to which a person can control the desire for immediate gratification or other; IC may be the single most important indicator of a person's future adaptation in terms of number of friends, school performance and future , and impaired empathy empathy
Ability to imagine oneself in another's place and understand the other's feelings, desires, ideas, and actions. The empathic actor or singer is one who genuinely feels the part he or she is performing. for others (Belsky, 1993). In one study of maltreating families, 84% of the parents were diagnosed with a DSM-III mental disorder mental disorder
Any illness with a psychological origin, manifested either in symptoms of emotional distress or in abnormal behaviour. Most mental disorders can be broadly classified as either psychoses or neuroses (see neurosis; psychosis). Psychoses (e.g. by a licensed mental health professional (Taylor et al., 1991). In particular, a significant relationship has been found between maternal depression and child abuse (Hecht & Hansen, 2001; Sheppard, 1997). Abusive parents also tend to attribute hostile intent The threat of imminent use of force by a foreign force, terrorist(s), or organization against the United States and US national interests, US forces and, in certain circumstances, US nationals, their property, US commercial assets, and other designated non-US forces, foreign nationals, to their children's behaviors and perceive childrearing as more difficult than non-abusive parents (Hecht & Hansen, 2001). They often perceive themselves as having little control and display high levels of negative reactivity (Belsky, 1993).
Though the research is inconclusive INCONCLUSIVE. What does not put an end to a thing. Inconclusive presumptions are those which may be overcome by opposing proof; for example, the law presumes that he who possesses personal property is the owner of it, but evidence is allowed to contradict this presumption, and show who is , a history of childhood maltreatment has frequently been linked to increased abuse potential (Belsky, 1993; Hecht & Hansen, 2001). Rates of intergenerational in·ter·gen·er·a·tion·al
Being or occurring between generations: "These social-insurance programs are intergenerational and all transmission of abuse have been estimated to range from 7 to 70 percent, providing little conclusive evidence CONCLUSIVE EVIDENCE. That which cannot be contradicted by any other evidence,; for example, a record, unless impeached for fraud, is conclusive evidence between the parties. 3 Bouv. Inst. n. 3061-62. of this phenomenon (Belsky, 1993). It has been suggested that abusive behaviors may be learned from parents, that adults who were abused as children may be hyperreactive to stressful situations, and that these individuals may not have developed appropriate coping and problem-solving skills (Belsky, 1993). Additionally, there is significant evidence that parental alcohol and drug use are related to family violence. Fluctuations in child maltreatment rates have been coupled with fluctuations in rates of substance abuse in the general population (National Clearinghouse on Child Abuse and Neglect Information [NCCAN NCCAN National Clearinghouse on Child Abuse and Neglect ], 1996). In 1995, it was estimated that 675,000 children are maltreated each year by substance-abusing caretakers.
Several characteristics of children have been associated with increased risk of child maltreatment, particularly factors that are innate to the child. Prenatal prenatal /pre·na·tal/ (-na´tal) preceding birth.
Preceding birth. Also called antenatal.
preceding birth. drug use by mothers can lead to low birth weight, prematurity, and developmental disabilities, each of which are child characteristics that have been shown to increase maltreatment risk (Cicchetti & Toth, 2000; Solomons, 1979). Child age has also been identified as a risk factor for maltreatment, with younger children being at higher risk (Cicchetti & Toth, 2000; Graham-Bermann, 2002; U.S. Department of Health & Human Services, 2006a). In fact, over 80% of child fatalities due to child maltreatment in 2004 were children under 4 years of age, with infant boys having the highest rates of fatalities (U.S. Department of Health & Human Services, 2006a). Furthermore, child behavior problems appear to be a significant child risk factor for maltreatment (Belsky, 1993; Urquiza & McNeil, 1996). Children exhibiting noncompliant, disruptive, impulsive im·pul·sive
1. Inclined or tending to act on impulse rather than thought.
2. Motivated by or resulting from impulse.
im·pul , and aggressive behaviors are at higher risk for physical abuse than their well-behaved counterparts.
Certain child characteristics have been found to increase the risk of sexual abuse in particular, such as low self-esteem, lack of social support, and inadequate knowledge of personal safety skills (Daro, 1994; Daro & Donnelly, 2002). Several studies have found that passive children with low self-esteem tend to be chosen as victims of sexual abuse (e.g., Daro, 1994). These children are often less likely to respond assertively as·ser·tive
Inclined to bold or confident assertion; aggressively self-assured.
as·sertive·ly adv. to adults and may value the positive attention they are receiving from the perpetrator A term commonly used by law enforcement officers to designate a person who actually commits a crime. . In addition, children who are more isolated tend to be at higher risk for sexual abuse, because they are less likely to disclose the abuse to others (Daro, 1994; Daro & Donnelly, 2002). Finally, children with little knowledge of personal safety skills (e.g., good vs. bad touches, inappropriate sexual behavior sexual behavior A person's sexual practices–ie, whether he/she engages in heterosexual or homosexual activity. See Sex life, Sexual life. ) are often easier targets for sexual exploitation (Daro & Donnelly, 2002). While the intention here is clearly not to blame the victim, it is important that child factors be examined as possible targets of intervention to prevent child maltreatment before it occurs.
Immediate Interactional Context
Beyond personal characteristics of children and parents, several risk factors can be identified within the child's immediate interactional context. There is little doubt that problematic parenting practices increase the risk of child maltreatment. Lack of parenting skills and knowledge of child development have been associated with child maltreatment risk, with high-risk parents exhibiting inappropriate expectations of their children and frequently using ineffective child management techniques (Daro & Donnelly, 2002; Hecht & Hansen, 2001). In particular, physical punishment of children to elicit e·lic·it
tr.v. e·lic·it·ed, e·lic·it·ing, e·lic·its
a. To bring or draw out (something latent); educe.
b. To arrive at (a truth, for example) by logic.
2. compliance (i.e., corporal punishment corporal punishment, physical chastisement of an offender. At one extreme it includes the death penalty (see capital punishment), but the term usually refers to punishments like flogging, mutilation, and branding. Until c. ), such as spanking spanking Pediatrics Corporal punishment, usually of children, in which the buttocks, are pummeled, swatted, or otherwise struck. See Corporal punishment Sexology Slapping, usually of the buttocks as a part of sexuoerotic activity. Cf Sadomasochism. and slapping, has been shown to increase the risk of physical abuse (Straus, 2001). Studies have shown that mothers who are violent toward their children are much more likely to approve of corporal punishment (Holden, Coleman, & Schmidt, 1995; Murphy, 1997). In general, abusive parents often exhibit negative parent-child relationships, including interacting with their children in negative ways, providing less support to their children than nonabusive parents, and interacting with their children less often than nonabusive parents (Urquiza & McNeil, 1996). Belsky (1993) suggests that neglectful ne·glect·ful
Characterized by neglect; heedless: neglectful of their responsibilities. See Synonyms at negligent.
ne·glect parents tend to be unresponsive unresponsive Neurology adjective Referring to a total lack of response to neurologic stimuli to their children, while physically abusive parents are controlling, punitive, and rigid in their parenting strategies.
Marital discord Discord
See also Confusion.
demon of discord. [Occultism: Jobes, 93]
discord, apple of
caused conflict among goddesses; Trojan War ultimate result. [Gk. Myth. and partner violence are significant risk factors as well, given that they negatively impact parenting skills, increase the level of stress in the home, and lead to feelings of isolation, all of which increase the risk of child maltreatment (Hecht & Hansen, 2001; Prevent Child Abuse America [PCAA], 2006; Thompson, 1995; Thompson, Flood, & Goodvin, 2006). Moreover, partner violence and child maltreatment often co-occur and children may be injured in·jure
tr.v. in·jured, in·jur·ing, in·jures
1. To cause physical harm to; hurt.
2. To cause damage to; impair.
3. intentionally or accidentally during a violent incident (Graham-Bermann, 2002; NCCAN, 1996). For example, studies have consistently found rates of overlap between child physical abuse and domestic violence above 20% (Graham-Bermann, 2002). In addition to the physical risk involved, children who are exposed to domestic violence often suffer significant psychological trauma Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event. When that trauma leads to Post Traumatic Stress Disorder, damage can be measured in physical changes inside the brain and to brain chemistry, which affect the person's (Graham-Bermann, 2002; Hecht & Hansen, 2001; NCCAN, 1996).
Poverty has long been shown to be a significant environmental risk factor for child maltreatment (Daro & Donnelly, 2002; Dupper & Poertner, 1997; Evans, 2004; Garbarino & Kostelny, 1994; Hecht & Hansen, 2001). It has been linked to every form of child maltreatment and past studies of incidence rates have found that families with incomes under $15,000 were 22 times more likely to have a child who is maltreated than families with higher incomes (NCCAN, 1996). However, this relationship may be mediated me·di·ate
v. me·di·at·ed, me·di·at·ing, me·di·ates
1. To resolve or settle (differences) by working with all the conflicting parties: by other risk factors that are present in low-income households, such as substandard substandard,
adj below an acceptable level of performance. housing quality (e.g., structural defects, inadequate heat) and lack of access to healthy food (Evans, 2004; Hecht & Hansen, 2001). Stress has also been shown to mediate MEDIATE, POWERS. Those incident to primary powers, given by a principal to his agent. For example, the general authority given to collect, receive and pay debts due by or to the principal is a primary power. the relationship between poverty and child maltreatment, with significantly higher levels of parental stress found in low-income families (Evans, 2004; Hecht & Hansen, 2001). In addition, increased rates of substance abuse and mental health problems can be found in families living in poverty, as well as low levels of social support (Baydar, Reid, & Webster-Stratton, 2003; Evans, 2004; NCCAN, 1996).
Characteristics of neighborhoods and communities can increase the risk of child maltreatment as well. High risk neighborhoods are defined by a lack of positive neighboring neigh·bor
1. One who lives near or next to another.
2. A person, place, or thing adjacent to or located near another.
3. A fellow human.
4. Used as a form of familiar address.
v. , high population turnover, more stressful daily interactions between families, and low social cohesion cohesion: see adhesion and cohesion.
The tendency of atoms or molecules to coalesce into extended condensed states. This tendency is practically universal. or integration (Belsky, 1993; Daro & Donnelly, 2002; Garbarino & Kostelny, 1994). The fear induced by living in high crime environments can lead parents to be more restrictive and punitive in their parenting in order to protect their child from the frightening prospects surrounding them (Garbarino & Kostelny, 1994). There is abundant evidence that social isolation can increase the risk of child maltreatment as well (Lovell & Hawkins, 1988; Lovell & Richey, 1997; Norbeck, Dejoseph, & Smith, 1996; Richey, Lovell, & Reid, 1991). One study found that 95% of families who were labeled "severely abusive" did not have any continuous relationships with individuals outside of the family (Thompson, 1995). The literature suggests that insular insular /in·su·lar/ (-sdbobr-ler) pertaining to the insula or to an island, as the islands of Langerhans.
Of or being an isolated tissue or island of tissue. mothers, or mothers who report high rates of unsolicited un·so·lic·it·ed
Not looked for or requested; unsought: an unsolicited manuscript; unsolicited opinions.
Adjective and coercive co·er·cive
Characterized by or inclined to coercion.
co·ercive·ly adv. social interactions rather than solicited positive interchanges, tend to show inconsistency in·con·sis·ten·cy
n. pl. in·con·sis·ten·cies
1. The state or quality of being inconsistent.
2. Something inconsistent: many inconsistencies in your proposal. in their own responses to their children (Dumas & Wahler, 1983). Because these mothers appear to have little impact within their social communities, they may also lack the necessary social skills to impact their home environment. Insular mothers are more likely to extend coercive exchanges with their children and to have difficulty implementing effective parenting strategies (e.g., Time Out, point system; Wahler, 1980; Wahler, Hughey, & Gordon, 1981). It appears to be the case that parents who face significant stressors and lack a support network may see their options as more limited and are more likely to resort to hostile and violent behavior (PCAA, 2006).
Finally, lack of societal awareness about child maltreatment and general acceptance of violence have contributed to consistently high rates of abuse and neglect in the United States (Belsky, 1993; Greven, 1990; Straus, 2001). Violence is commonly accepted and condoned in this country, as evidenced by television shows, movies, music, news programs, and court rulings. This society is characterized by negative attitudes toward children as well as acceptance of corporal punishment as a form of discipline. While its use in schools has significantly declined, corporal punishment by parents is legal in every state and parents continue to support the use of corporal punishment in the home, at least as a 'last resort' (Straus, 2001). As Belsky (1993) asserts, "The fact of the matter is that in cultures in which physical punishment is rare, child abuse is quite unusual" (p. 423).
Early Childhood Intervention Programs
ECIPs and Preventing Child Maltreatment
Child maltreatment risk factors, such as those discussed previously, often co-occur within families. Due to the limited predictive utility of any single risk factor and the common co-occurrence of several risk factors, it may be insufficient to address each risk factor in isolation. According to Daro (2000), "Child maltreatment arises from both the individual contribution of many causal factors and the combined impacts of these factors on parents' abilities to care for their children" (p. 164). Programs that address multiple risk factors across various levels of analysis appear to be the most effective in preventing child maltreatment (Daro & Donnelly, 2002; Evans, 2004; Hecht & Hansen, 2001; NCCAN, 1996). Program effectiveness also appears to increase with earlier intervention, from toddlers and preschoolers to as early as prenatal intervention (Daro & Donnelly, 2002; NCCAN, 1996). Children under age 5 are disproportionately more likely to witness or experience family violence than older children (Graham-Bermann, 2002; U.S. Department of Health & Human Services, 2006a). In fact, the victimization victimization Social medicine The abuse of the disenfranchised–eg, those underage, elderly, ♀, mentally retarded, illegal aliens, or other, by coercing them into illegal activities–eg, drug trade, pornography, prostitution. rate was highest among children under age 3 in 2004 at a rate of 16.1 per 1,000 children (U.S. Department of Health & Human Services, 2006a). This supports the need for early intervention ear·ly intervention
n. Abbr. EI
A process of assessment and therapy provided to children, especially those younger than age 6, to facilitate normal cognitive and emotional development and to prevent developmental disability or delay. , particularly with high-risk families. Targeting mothers as early as pregnancy provides the opportunity to establish a strong foundation in the home before the child is born and additional stressors arise (Daro, 2000).
For these reasons, ECIPs provide excellent opportunities to prevent and identify cases of child maltreatment. These programs are typically targeted at high-risk populations, including families living in poverty, children with disabilities, substance abusing parents, families with histories of violence, and young parents with little knowledge of parenting or child development (Baydar et al., 2003; Meisels & Shonkoff, 1990; Peddle, Wang, Diaz, & Reid, 2002; U.S. Department of Health & Human Services, 2006d). ECIPs have the potential to address multiple risk factors for child maltreatment in a population of very young children and pregnant mothers. These programs can address child maltreatment through promotion of healthy families, prevention of maltreatment in high-risk families, and early intervention for children who have been identified as maltreated (National Public Health Partnership, 2003). While early identification of child maltreatment is critical, it is undoubtedly more beneficial and cost effective to prevent child maltreatment before it occurs. For this reason, the remainder of this paper will specifically focus on ECIPs that attempt to prevent child maltreatment at the promotion and prevention levels.
Overview of ECIPs
A brief explanation and overview of ECIPs is necessary before proceeding to specific examples of programs. The term "Early Childhood Intervention Program" does not refer to a specific program, but rather refers to a broad class of programs that vary widely in several areas. Two broad types of ECIPs are generally discussed in the literature: (a) programs designed to prevent negative outcomes for children by targeting at-risk children and families, and (b) programs targeting children with confirmed physical and developmental disabilities. This paper focuses exclusively on the former. Such ECIPs may differ in the setting, target of intervention, interveners involved, inclusion criteria
Inclusion criteria are a set of conditions that must be met in order to participate in a clinical trial. , as well as overall purpose of the program. Common settings for early intervention services are the home, schools and child care centers, health care and mental health clinics, and community settings (Daro & Donnelly, 2002; Peddle et al., 2002; Thompson, 1995). Many ECIPs span a variety of settings, although most programs are primarily focused on one specific context. While characteristics and skills of parents and children are the most common targets of ECIPs (Daro & Donnelly, 2002; Nelson, Laurendeau, & Chamberland, 2001; PCAA, 2006), other targets may include the parent-child relationship (Aos, Lieb, Mayfield, Miller, & Pennucci, 2004; Bell & Eyberg, 2002; Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996), teachers (Daro, 1994; Daro & Donnelly, 2002), peer groups (Daro & Donnelly, 2002; Thompson, 1995; Thompson et al., 2006), families (Dupper & Poertner, 1997; Shaw, Dishion, Supplee, Gardner, & Arnds, 2006), and entire communities (Daro & Donnelly, 2002; Nelson et al., 2001).
Individuals providing services through ECIPs may include nurses, mental health professionals, paraprofessionals, social workers, teachers, law enforcement officers, and graduate students, among others. ECIPs vary in their assessment process and inclusion criteria as well. While some programs recruit participants through human service agencies or self-referrals (Thompson, 1995; Urquiza & McNeil, 1996), others provide universal assessment of all families in a particular region (Breakey & Pratt, 1991; Daro, 2000). Many programs assess for the presence of specific child maltreatment risk factors (Breakey & Pratt, 1991; Duggan et al., 1999; Thompson, 1995) or include only high-risk populations such as teen mothers or children with developmental delays (Meisels & Shonkoff, 1990; Peddle et al., 2002). ECIPs vary greatly in their stated purpose, ranging from programs that promote school readiness and overall development to those that aim to provide health care and prevent child maltreatment. ECIPs of any kind have the unique potential to address multiple risk factors and prevent the abuse and neglect of children, an essential precursor precursor /pre·cur·sor/ (pre´kur-ser) something that precedes. In biological processes, a substance from which another, usually more active or mature, substance is formed. In clinical medicine, a sign or symptom that heralds another. to achieving any other goals a program may have.
Examples of Early Childhood Intervention Programs
In order to demonstrate the ability of ECIPs to prevent child maltreatment, several programs will be discussed that address common maltreatment risk factors. The following review focuses exclusively on programs designed to promote healthy development and prevent negative outcomes for at-risk children. Another broad type of ECIPs target young children with established physical and developmental disabilities (such as early childhood special education programs), although these programs are not the focus of this paper and have been discussed elsewhere (e.g., Baker & Feinfield, 2003; Majnemer, 1998). Rather than providing a comprehensive review of ECIPs, a small sample of programs across various settings was selected for discussion. Programs were selected for discussion if they include services that address common child maltreatment risk factors, demonstrated reductions in these risk factors through outcome research, and provide valuable lessons for preventing child abuse and neglect. These programs are organized into the following categories: home-based, school-based, clinic-based, and community-based.
In the United States, home visitation VISITATION. The act of examining into the affairs of a corporation.
2. The power of visitation is applicable only to ecclesiastical and eleemosynary corporations. 1 Bl. Com. 480; 2 Kid on Corp. 174. programs are the most common ECIPs aimed at preventing child maltreatment (Peddle et al., 2002) and are the only programs to provide clear evidence of child abuse prevention (Nelson et al., 2001). According to Prevent Child Abuse America (2006), home visitation is "the most innovative and holistic prevention program used in approaching the difficulties of educating and supporting the at-risk family" (p. 1). Based on an extensive review of literature, home visitation was recommended by the United States Task Force on Community Preventive Services as an effective strategy for preventing child maltreatment (Hahn et al., 2003). These programs appear to be very cost effective, with net benefit estimates ranging from $6,000 to $25,000 per family (Aos et al., 2004; Nelson et al., 2001; Noor, Caldwell, & Strong, 2003). A cost effectiveness study by Michigan's Children's Trust Fund in 2002 found that a statewide comprehensive home visitation program for first time parents would cost less than 4% of the cost to treat the consequences of child maltreatment (Noor et al., 2003).
Home visitation typically involves regular contact between a family and a home visitor and can address a variety of issues, including parenting skills, education about child development, the parent-child relationship, mental health issues, economic problems, education and employment, adequate health care, and lack of social support. The advantages of home visitation in preventing child maltreatment lie in the unique opportunities to assess the child's safety, increase generalization gen·er·al·i·za·tion
1. The act or an instance of generalizing.
2. A principle, a statement, or an idea having general application. of skills through learning in the natural environment, use flexible approaches, increase participation through bringing services directly to the family, and provide much-needed support to high risk families (Daro & Donnelly, 2002; PCAA, 2006; Thompson, 1995). Home-based programs also eliminate common barriers to receiving services, such as lack of motivation, lack of health insurance, and lack of transportation (Thompson, 1995). Evidence from these programs suggests that significant lasting effects on parental behavior have been achieved (Daro, 2000; Daro & Donnelly, 2002; Duggan et al., 1999; Karoly et al., 2001; PCAA, 2006; Thompson, 1995). Examples of home visitation programs include the Parents as Teachers Program (Wagner & Clayton, 1999; Winter, 1999), Project 12 Ways (Aos et al., 1999; Lutzker, Frame, & Rice, 1982), Prenatal to Three Initiative (Perez, Newman, Bruton, & Peifer, 2003), Family Check-Up (Shaw et al., 2006), Family Connections (DePanfilis & Dubowitz, 2005) and the Early Head Start Program (Aos et al., 1999; U.S. Department of Health & Human Services, 2003, 2006b, 2006c). Additional well-known home visitation programs are described below.
The first statewide home visitation program in the United States with the primary goal of preventing child maltreatment was Hawaii's Healthy Start Program (Breakey & Pratt, 1991; Duggan et al., 1999). A 3-year demonstration project of this program including 234 families began in 1985 in Leeward, Oahu, an impoverished community with high rates of abuse and neglect (Breakey & Pratt, 1991; Duggan et al., 1999). The goals of the Healthy Start Program are to promote positive parenting skills, improve family functioning, promote child development, and prevent child maltreatment (Breakey & Pratt, 1991). These goals are addressed through home visitation by highly trained paraprofessionals with limited caseloads who provide education, counseling, and support for families until the child reaches 5 years old (Breakey & Pratt, 1991; Duggan et al., 1999). In addition, families are offered child care services, referrals to other agencies, health care assistance, and social activities outside the home. High risk families are identified through a review of hospital admissions data for 15 common risk factors for child maltreatment (e.g., unemployment, lack of education, history of substance abuse, mental health problems) as well as an interview and completion of standardized measures (Breakey & Pratt, 1991; Duggan et al., 1999).
A follow-up evaluation of the 3-year demonstration project found statistically significant reductions in family stress based on the Family Stress Checklist and no evidence of child abuse in any of the families involved, leading to statewide expansion of the program (Breakey & Pratt, 1991; Duggan et al., 1999; Thompson, 1995). Subsequent randomized ran·dom·ize
tr.v. ran·dom·ized, ran·dom·iz·ing, ran·dom·iz·es
To make random in arrangement, especially in order to control the variables in an experiment. controlled trials have revealed significant differences between families involved in the Healthy Start Program in comparison to control groups. For example, a randomized controlled trial A randomized controlled trial (RCT) is a scientific procedure most commonly used in testing medicines or medical procedures. RCTs are considered the most reliable form of scientific evidence because it eliminates all forms of spurious causality. of this program that followed 212 families for one year demonstrated 3.3% confirmed reports of child maltreatment among program participants in comparison to 6.8% among the control group (Duggan et al., 1999). These results were both statistically and clinically significant. Another randomized controlled trial conducted in 1994 included 684 families and utilized structured interviews, in-home observations, developmental assessments, record reviews, and Child Protective Services child protective services Sociology A state or county agency that addresses issues of child abuse and neglect (CPS (1) (Characters Per Second) The measurement of the speed of a serial printer or the speed of a data transfer between hardware devices or over a communications channel. CPS is equivalent to bytes per second. ) reports as outcome data (Duggan et al., 1999). This evaluation revealed significantly lower rates of partner violence, reduced parenting stress, and greater use of nonviolent discipline strategies (Breakey & Pratt, 1991; Duggan et al., 1999; Thompson, 1995). Though this study found statistically significant differences in neglect and psychological aggression between groups, there was not a significant difference in physical abuse or confirmed CPS reports. Despite its effectiveness, the Healthy Start Program faced several challenges including average attrition Attrition
The reduction in staff and employees in a company through normal means, such as retirement and resignation. This is natural in any business and industry.
Notes: rates of 50% after a year, low rates of home-visiting, substantial differences across participating agencies, and reliance on CPS reports as outcome data (Duggan et al., 1999). These problems may have contributed to the findings of a recent randomized trial with 643 families which found that the program did not prevent child abuse or promote the use of nonviolent discipline compared to a control group (Duggan et al., 2004). However, these challenges are currently being explored and addressed and the program will undoubtedly continue to evolve accordingly.
Based on the Healthy Start model and its success in Hawaii, the National Committee to Prevent Child Abuse (now known as Prevent Child Abuse America) launched Healthy Families America in 1992 (Duggan et al., 1999). Like Hawaii's Healthy Start Program, this program was designed to reduce rates of child maltreatment through providing voluntary support to new parents and promoting positive parenting (Daro, 2000; Daro & Harding, 1999; Martin, 1999). Healthy Families America targets all first-time or new parents in a community, assessing for level-of-risk for child maltreatment and inviting high-risk families to participate in home visitation until the child reaches 5 years of age (Daro, 2000; Martin, 1999). To ensure flexibility in program implementation, Healthy Families America requires that its programs adhere to adhere to
verb 1. follow, keep, maintain, respect, observe, be true, fulfil, obey, heed, keep to, abide by, be loyal, mind, be constant, be faithful
2. 12 critical elements rather than follow a specific model (Daro, 2000). Home visitation in this program addresses child development, parent-child interaction, social support, and problem-solving skills, as well as connecting families to community resources (e.g., medical provider, child care, job training, housing assistance, mental health treatment; Daro & Harding, 1999; Martin, 1999).
Results from 29 evaluations of this program across the country indicate significantly low rates of child maltreatment, positive health outcomes (e.g., fewer birth complications, fewer low birth weight babies, up-to-date immunizations), decreased child abuse potential and parenting stress, and improvements in education and employment compared to control groups (Daro & Donnelly, 2002; Daro & Harding, 1999). For example, one site in Virginia was unable to substantiate To establish the existence or truth of a particular fact through the use of competent evidence; to verify.
For example, an Eyewitness might be called by a party to a lawsuit to substantiate that party's testimony. a single case of child abuse or neglect among 145 families over a 21-month period (Daro & Harding, 1999). However, it should be noted that many of these evaluations were quasi-experimental rather than randomized trials and there is a great need for better controlled research examining this program. Since its inception, Healthy Families America has been implemented across 40 states in over 400 communities to nearly 40,000 parents across the nation (Martin, 1999; Peddle et al., 2002). This program's success has been an inspiration to many others, although cost-benefit analyses indicate the program may not be achieving the net benefit expected, with one estimate in 2003 indicating a net benefit of -$1,263 per child (Aos et al., 2004). This could be attributed to significant (20-30%) attrition rates, lack of improvement and sometimes even a decrease in social support, as well as limited impact on child development (Daro & Harding, 1999). If nothing else, these findings suggests that further research is necessary to determine the "active ingredients" of the program, the best ways to address social support and child development, and more efficient implementation procedures.
Another home-based ECIP ECIP European Community Investment Partners
ECIP Early Childhood Intervention Program
ECIP Erasure Code Internet Protocol
ECIP Energy Conservation Improvement Program
ECIP European Compliance Inspection Program
ECIP Energy Conversion Investment Program is the Nurse-Family Partnership (NFP NFP Not for Profit
NFP Natural Family Planning (contraception)
NFP National Focal Point
NFP National Financial Partners Corp.
NFP Nurse Family Partnership (Denver, CO) ), also known as the Nurse Home Visitation Program, established by David Olds in 1977 in Elmira, New York Elmira is a city in Chemung County, New York, USA. It is the principal city of the 'Elmira, New York Metropolitan Statistical Area' which encompasses Chemung County, New York. The population was 30,940 at the 2000 census. It is the county seat of Chemung County. (Child Trends, 2003; Karoly et al., 2001; Olds, 1999; Olds et al., 1986). The goals of this program are to improve child health and development, improve economic self-sufficiency, and improve pregnancy outcomes (Olds, 1999). Trained nurses with limited caseloads conduct home visits with young low-income mothers during their pregnancy and throughout the first two years of their child's life. Home visitors provide parent education, link families to community resources, and attempt to strengthen social support networks (Child Trends, 2003; Olds, 1999). Results of the initial demonstration project of 400 families indicated abuse and neglect rates of 4% for program participants and 19% for control group families (Olds et al., 1986). Reductions were also seen in emergency room visits and statistically significant improvements were found in parent-child interaction, health care utilization, and employment rates (Olds et al., 1986; Thompson, 1995).
Follow-up studies of the participant families indicated significantly lower rates of criminal behavior and lower welfare participation compared to control groups (Karoly et al., 2001). A 15-year follow-up study of the initial NFP demonstration project including 324 mother-child pairs (81% of the original sample) demonstrated 79% fewer verified reports of child abuse and neglect compared to a control group (Eckenrode et al., 2000). However, this study also indicated that the program was ineffective at reducing domestic violence rates. As research has demonstrated that child physical abuse is significantly more likely to occur in families experiencing domestic violence, it is not surprising that the follow-up study also found that severe forms of partner violence (more than 28 incidents over 15 years) actually appeared to negate ne·gate
tr.v. ne·gat·ed, ne·gat·ing, ne·gates
1. To make ineffective or invalid; nullify.
2. To rule out; deny. See Synonyms at deny.
3. the positive effects of the program. In other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"
put differently , the program was unable to prevent child maltreatment in families who also experienced severe levels of partner violence. This troubling finding was addressed by Boris and colleagues (2006) through their augmentation AUGMENTATION, old English law. The name of a court erected by Henry VIII., which was invested with the power of determining suits and controversies relating to monasteries and abbey lands. of the NFP program to include mental health consultants who target maternal depression, barriers to positive parenting, substance abuse, and family violence. In order to effectively prevent child maltreatment, ECIPs must initiate such changes to reduce partner violence in families. Despite this limitation, the Nurse-Family Partnership has been identified as a model evidence-based prevention program by Blueprints for Violence Prevention (Evidence-Based Prevention Programs Committee [EBPPC]; University of Colorado University of Colorado may refer to:
Schools and child care centers are ideal settings for child maltreatment prevention efforts, because they provide access to the general population, more families can be reached through fewer resources, and maltreatment is often disclosed to teachers and other school personnel. Though many of these programs were designed for school-age children, similar approaches can and have been used with preschool children. Sexual abuse prevention programs in particular have utilized the school-based approach, with over 85% of school districts in the United States offering sexual abuse prevention programs in the year 2000 alone (Davis & Gidyez, 2000). For example, all children enrolled in California public schools participated in sexual abuse prevention programs between 1984 and 1988, with a cost of $7.19 per child compared to the cost of $5,000 to $8,000 for sexual abuse treatment (Daro, 1994). These programs emphasize education and empowerment of children to resist sexual abuse, although parents and school personnel are often incorporated as well (Daro, 1994; Daro & Donnelly, 2002). Common topics of these programs include good and bad touches, body ownership, assertiveness training assertiveness training Psychiatry A procedure in which subjects are taught appropriate interpersonal responses involving frank, honest, and direct expression of their feelings, both positive and negative , inappropriate secrets, trusting intuition intuition, in philosophy, way of knowing directly; immediate apprehension. The Greeks understood intuition to be the grasp of universal principles by the intelligence (nous), as distinguished from the fleeting impressions of the senses. , reducing blame, and utilizing support systems.
In general, research has found these programs to be effective in increasing children's knowledge of sexual abuse (e.g., good and bad touches, inappropriate secrets) and how to respond to abusive situations (Daro & Donnelly, 2002; Davis & Gidyez, 2000). A meta-analysis of 30 school-based sexual abuse prevention programs in 1992 found a mean effect size of .90, suggesting a significant gain in children's knowledge following program participation (Daro & Donnelly, 2002; Davis & Gidyez, 2000). A meta-analysis by Davis and Gidyez (2000) that included children between 3 and 13 years of age found higher effect sizes in programs that involved behavioral skills training, puppet puppet, human or animal figure, generally of a small size and performing on a miniature stage, manipulated by an unseen operator who usually speaks the dialogue. shows, and a greater number of sessions. This study also demonstrated higher effect sizes with the youngest children (3 to 5 years), indicating that ECIPs have the potential to implement effective sexual abuse prevention techniques with preschoolers. On average, the authors reported an effect size of 1.07 for prevention-related knowledge and skills across 27 sexual abuse prevention programs. While few studies have examined actual reductions in abuse rates, they have shown increased numbers of disclosures of sexual abuse due to prevention programs (Daro & Donnelly, 2002). This alone may be a powerful incentive to continue implementing sexual abuse prevention programs in schools and child care centers.
Examples of school-based sexual abuse prevention programs designed for use with preschool-age children include the Grossmont College Grossmont College is a community college located in El Cajon, California (county of San Diego). Grossmont College and Cuyamaca College make up the Grossmont-Cuyamaca Community College District (GCCCD) with a single Governing Board and a Chancellor, currently Dr. Omero Suarez. Child Sexual Abuse Child sexual abuse is an umbrella term describing criminal and civil offenses in which an adult engages in sexual activity with a minor or exploits a minor for the purpose of sexual gratification. Prevention Program (Daro, 1994; Ratto & Bogat, 1990) and the Behavioral Skills Training Program (Daro, 1994; Wurtele, Kast, Miller-Perrin, & Kondrick, 1989). The Grossmont College program includes teacher-training, parent-education, and child -education. Children are taught skills through the use of activities, role plays, puppet shows, picture books, and other age-appropriate strategies (Ratto & Bogat, 1990). The Behavioral Skills Training Program focused on the idea that certain behaviors are not acceptable, regardless of how they feel. This program was evaluated through a randomized controlled trial of 100 children in Head Start preschool classrooms (Wurtele et al., 1989). Compared to children who received training in evaluating touches based on how they feel, a statistically significant finding revealed that children in the Behavioral Skills Training Program were better able to correctly identify inappropriate touches at post-treatment and follow-up assessments. This study suggests that pre-school children may benefit from the use of behavioral skills training components.
In addition to sexual abuse prevention programs, schools and child care centers have provided the setting for ECIPs that address various maltreatment risk factors. Two such programs are the School-Linked Family Resource Centers and the Head Start Program. Family Resource Centers were developed to promote safe home environments, educational achievement, and strong communities. Dupper and Poertner (1997) state, "The school provides a logical organizational setting for providing access to high-risk families and children and has the potential of becoming a 'community hub' ... and a 'welcome light'" (p. 416). These centers provide a variety of services, including mental health services health services Managed care The benefits covered under a health contract , job development, child care, health services, education, and housing (Dupper & Poertner, 1997). An exemplary system of Family Resource Centers can be found in the state of Kentucky, where 134 centers were established before 1993. These centers target low-income families with young children and are required to provide full-time preschool for 2- and 3-year-olds, after school services http://commons.wikimedia.org/wiki/Image:Schools_Collection_May_2007_2.JPGSchool Services are a business unit of the National Library of New Zealand (Te Puna Mātauranga o Aotearoa). They provide curriculum and advisory services to support New Zealand schools. for 4-to 12-year-olds, home-visiting, parent education, training for day care providers, monitoring of child development, and health services for families (Dupper & Poertner, 1997).
Another school-based ECIP that addresses child-maltreatment risk-factors, the Head Start Program, is a federally funded comprehensive child development program for low-income families with 3-to 5-year-old children (U.S. Department of Health & Human Services, 2004a, 2006d). It was launched by the U.S. Department of Health and Human Services in 1965 to increase school readiness in children from high-risk families. These programs provide an array of services, including parent and child education, dental, medical, nutritional, and mental health services (U.S. Department of Health & Human Services, 2004a). In 2005, a total of 906,993 children were enrolled in Head Start programs in 19,800 centers across the country (U.S. Department of Health & Human Services, 2006d). In addition to addressing general maltreatment risk factors (e.g., poverty, social support, mental health problems, parenting skills, low birth weight), Head Start programs are ideal contexts for implementing specialized child maltreatment prevention programs (Baydar et al., 2003). The Incredible Years Parent Training Program has been implemented as a universal school-based prevention program offered to all Head Start parents. Through this program, parents learn child-directed skills (e.g., praise, description, reflection), effective discipline techniques (e.g., ignoring, Time-Out procedure), coping skills, and strategies to promote children's social skills through weekly 2-hour sessions (Baydar et al., 2003). Numerous randomized controlled trials have shown statistically significant reductions in child behavior problems, improvements in parent-child relationships, reductions in harsh parenting, and improvements in prosocial behaviors. By providing dinners, child care, flexible hours, and make-up sessions, reasonable success was achieved at retaining low-income participants (74% attended 50% of sessions; Baydar et al., 2003). This program has also been identified as a model evidence-based prevention program by Blueprints for Violence Prevention and the SAMHSA SAMHSA Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention The Center for Substance Abuse Prevention (CSAP) is an agency of the United States government under the Department of Health and Human Services (DHHS) and the Substance Abuse and Mental Health Services Administration (SAMHSA). (EBPPC, 2007; University of Colorado, 2004).
The clinic setting offers several advantages for ECIPs, including a controlled environment, essential resources, availability of close supervision, and the credibility of a professional atmosphere. Through this environment, families can be seen individually or as part of a group in order to address child maltreatment risk factors. This setting has proven particularly valuable for teaching parenting skills and improving the parent-child relationship. Telleen, Herzog, and Kilbane (1989) describe a clinic-based Family Support Program that addresses parenting stress, social support, parenting skills, the parent-child relationship, and knowledge of developmental norms. Family Support Programs such as this one are typically provided in group formats and often include parent education components, self-help discussion groups, and parent-child activities. However, limited outcome research has been conducted for clinic-based Family Support Programs and more research is necessary to establish their effectiveness at preventing child maltreatment.
A more detailed description is warranted for the well-known evidence-based practice, Parent-Child Interaction Therapy (Eyberg, 1988). Parent-Child Interaction Therapy (PCIT PCIT Parent Child Interaction Therapy ) is a parent training program developed by Sheila Eyberg that is based on Constance Hanf's two-stage operant operant /op·er·ant/ (op´er-ant) in psychology, any response that is not elicited by specific external stimuli but that recurs at a given rate in a particular set of circumstances.
adj. model (Bell & Eyberg, 2002; Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996). The goal of the first stage of PCIT, Child Directed Interaction, is to develop a positive relationship between the parent and child through positive reinforcement positive reinforcement,
n a technique used to encourage a desirable behavior. Also called
positive feedback, in which the patient or subject receives encouraging and favorable communication from another person. of prosocial behaviors. The second stage of PCIT, Parent Directed Interaction, addresses appropriate discipline strategies and behavior management behavior management Psychology Any nonpharmacologic maneuver–eg contingency reinforcement–that is intended to correct behavioral problems in a child with a mental disorder–eg, ADHD. See Attention-deficit-hyperactivity syndrome. techniques. According to Bell & Eyberg (2002), this treatment program was based on the influences of developmental theory, attachment theory Attachment theory is a psychological theory that provides a descriptive and explanatory framework for discussion of affectionate relationships between human beings. Most of attachment theory as we know it today is derived from the work of John Bowlby and stresses the attitudes and , and social learning theory, with a strong emphasis on play. Treatment typically involves weekly 1-hour sessions, lasting for an average of 13 sessions. It often consists of didactic di·dac·tic
Of or relating to medical teaching by lectures or textbooks as distinguished from clinical demonstration with patients. training, modeling, practicing, live coaching, and homework assignments (Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996). PCIT was designed as an early intervention for families with young children, between the ages of 2 and 7 years (Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996).
PCIT has been applied to a broad range of child and family problems, including child conduct problems, externalizing and internalizing problems, inattention in·at·ten·tion
Lack of attention, notice, or regard.
Noun 1. inattention - lack of attention
basic cognitive process - cognitive processes involved in obtaining and storing knowledge and hyperactivity, family disruption, developmental problems, and child abuse and neglect (Hembree-Kigin & McNeil, 1995). Outcome studies have demonstrated significant improvements in child-noncompliance, disruptive behavior, parenting stress, child self-esteem, and internalizing problems (e.g., depression, anxiety). This progress has been shown to generalize generalize /gen·er·al·ize/ (-iz)
1. to spread throughout the body, as when local disease becomes systemic.
2. to form a general principle; to reason inductively. to the home as well as school settings and is maintained at follow-up evaluations (Bell & Eyberg, 2002; Hembree-Kigin & McNeil, 1995; Urquiza & McNeil, 1996). PCIT has been increasingly applied to abusive and potentially abusive families with very promising results (Urquiza & McNeil, 1996). For example, a randomized controlled trial of 110 physically abusive parents demonstrated at a follow-up of 850 days that 49% of parents in the control group had a re-report of physical abuse, while this was the case for only 19% of parents in the group that received PCIT (Chaffin et al., 2004). In fact, PCIT has been identified for dissemination as an evidence-based practice for abused children and their families (Chaffin & Friedrich, 2004). This treatment is effective because it addresses several maltreatment risk factors when children are very young, including parenting stress, lack of parenting skills, negative parent-child relationship, lack of developmental information, and child behavior problems. There are certainly limitations with this approach, including difficulty implementing it in non-clinic settings, significant requirements for participation that are often unrealistic for high-risk families, and difficulty generalizing from the clinic to the home. However, as a child maltreatment prevention strategy, this treatment has been highly effective and has demonstrated a net benefit of $3,427 per child (Aos et al., 2004), making it greatly worth the time and resources.
Public education and awareness at the broader community level may be the most effective way to implement widespread change and foster child-abuse prevention. Neighborhood-based programs have received increasing amounts of attention in recent years, although they are still an under-utilized resource in the area of child-abuse prevention (Garbarino & Kostelny, 1994). An example of this type of program is the Neighborhood Parent Support Network Project, developed in 1988 in Winnipeg and described in more detail elsewhere (e.g., Fuchs, Lugtig, & Guberman, 2000; Garbarino & Kostelny, 1994). The media is also a valuable tool for mobilizing community prevention efforts. Public education through the media has addressed parenting behaviors, aided in changing attitudes and values related to parenting, and created awareness of the problem of child maltreatment (Daro & Donnelly, 2002). In addition, prevention programs are likely to be more widely accepted when they are recognizable through television, newspapers, and the radio. Prevent Child Abuse America (PCAA) has been a leading force in the United States in community-based prevention efforts since the 1970s (Daro & Donnelly, 2002; PCAA, 2006). Through the use of television, radio, print, and billboards, PCAA has increased public awareness of physical abuse, verbal abuse verbal abuse Psychology A form of emotional abuse consisting of the use of abusive and demeaning language with a spouse, child, or elder, often by a caregiver or other person in a position of power. See Child abuse, Emotional abuse, Spousal abuse. , and emotional neglect. As a result of these media campaigns, annual public opinion polls have found steady declines in reported rates of verbal aggression and corporal punishment (e.g., spanking) as discipline techniques since 1988 (Daro & Donnelly, 2002). PCAA supports a variety of primary, secondary, and tertiary prevention tertiary prevention Medtalk Treatment that alters the course of clinical disease--eg, with CABG or PCTA. See Percutaneous transluminal coronary angioplasty Psychiatry Measures to reduce impairment or disability following a disorder–eg, through rehabilitation. programs targeted at pregnant mothers and families with young children, although their contribution to community-level prevention efforts may be their most notable accomplishment (PCAA, 2006).
Due to difficulties with treatment resistance and program attrition in families at risk for child maltreatment, Turner and Sanders (2006) claim that "the reduction of abuse potential of parents must be tackled within an ecological or systems-contextual framework within a comprehensive multilevel model of parenting and family support available at a population-level" (p. 178). As a result, they developed a multilevel parenting and family support program at the University of Queensland The University of Queensland (UQ) is the longest-established university in the state of Queensland, Australia, a member of Australia's Group of Eight, and the Sandstone Universities. It is also a founding member of the international Universitas 21 organisation. in Australia, known as the Triple P--Positive Parenting Program. This program was developed based on social learning theory as well as psychological and public health research for families with children from birth to age 16 (Sanders, 1999; Sanders, Markie-Dadds, & Turner, 2003). The goals of the program are to promote safe and nurturing environments, build positive relationships between parents and children, increase emotional and social support, and normalize normalize
to convert a set of data by, for example, converting them to logarithms or reciprocals so that their previous non-normal distribution is converted to a normal one. parent education, thereby reducing the risk of child maltreatment. Several risk factors are targeted, including parenting stress, social support, parent-child relationships, parenting skills, marital discord, and knowledge of child development.
Triple P incorporates interventions at five different levels, ranging from individualized in·di·vid·u·al·ize
tr.v. in·di·vid·u·al·ized, in·di·vid·u·al·iz·ing, in·di·vid·u·al·iz·es
1. To give individuality to.
2. To consider or treat individually; particularize.
3. treatment to manualized group interventions and public seminars. Services are provided in medical settings, mental health offices, schools, workplaces, community organizations, over the telephone, and through the mass media. At the population level, Triple P has implemented a universal media information campaign targeting all parents. This campaign has been led by health care professionals and trained volunteers and has involved radio, newspapers, magazines, videos, brochures, and television (Sanders et al., 2003; Turner & Sanders, 2006). For example, a 13-episode television series providing parent education was presented in New Zealand New Zealand (zē`lənd), island country (2005 est. pop. 4,035,000), 104,454 sq mi (270,534 sq km), in the S Pacific Ocean, over 1,000 mi (1,600 km) SE of Australia. The capital is Wellington; the largest city and leading port is Auckland. in 1995, attracting approximately 20 to 35% of the viewing audience (Sanders et al., 2003). Both print media and radio were used to advertise the show and parenting fact sheets were made available to viewers. Each episode included a 5- to 7-minute segment promoting the implementation of Triple P in the home. A group of 56 parents of preschool children were randomly assigned to view the television show or to receive no intervention (Sanders, Montgomery, & Brechman-Toussaint, 2000). Participants viewed all episodes on videotape videotape
Magnetic tape used to record visual images and sound, or the recording itself. There are two types of videotape recorders, the transverse (or quad) and the helical. before the show was released to the public. The results of this evaluation revealed a statistically significant increase in parent confidence, decrease in child disruptive behaviors, decrease in dysfunctional dys·func·tion also dis·func·tion
Abnormal or impaired functioning, especially of a bodily system or social group.
dys·func parenting practices, and overall satisfaction with the program in viewers compared to the control group (Sanders et al., 2003; Sanders et al., 2000). Although parents viewed the show under highly controlled conditions, these results provide support for the use of population-based strategies for preventing child maltreatment. The various Triple P interventions have been disseminated to over 16,000 professionals in 14 countries to date (Sanders et al., 2003; Turner & Sanders, 2006).
Summary of Programs
A wide variety of Early Childhood Intervention Programs have been discussed, including home-based, school-based, clinic-based, and community-based programs. These example programs are summarized in Table 1. These programs span a variety of academic disciplines, from mental health and social work to education and health care. They tend to vary in their goals, participants, and components, but all share the common potential to prevent child maltreatment. Table 2 summarizes specific risk factors addressed by each program reviewed in this paper. As demonstrated in the table, a few important risk factors are rarely addressed in ECIPs. Substance abuse by parents, parental history of abuse, and partner violence are significant risk factors that appear to be neglected in many of these programs. Perhaps incorporating interventions to address these factors would improve child maltreatment prevention.
The literature clearly demonstrates that programs that address multiple risk factors across various levels of intervention (child, parent, immediate context, and broader context) achieve the most dramatic and enduring results. It is evident in Table 2 that the ECIPs discussed previously have strived to achieve this goal. Individual attitudes and practices can be changed through one-on-one interaction, although this approach may not address the broader societal influences. Community-based programs have the potential to achieve the most widespread impact on child maltreatment rates, although progress is slow and costly (Daro & Donnelly, 2002; PCAA, 2006). However, as Belsky (1993) asserts, "It is doubtful that maltreatment can be eliminated so long as parents rear their offspring in a society in which violence is rampant, corporal punishment is condoned as a child-rearing technique, and parenthood itself is construed in terms of ownership" (p. 423). A combination of ECIPs targeting individual as well as broader contextual factors is necessary to prevent child abuse and neglect on a larger scale.
Challenges to Preventing Child Maltreatment in ECIPs
Common Barriers in ECIPs
While ECIPs possess great potential for reducing child maltreatment risk in high-risk populations, several barriers to achieving these results have been identified in the literature.
When programs are expanded and disseminated, the quality and scope of services may be sacrificed and the original concept may be distorted (Breakey & Pratt, 1991; Duggan et al., 1999). Examples of this can be seen in home visitation programs. Although research supports more frequent and higher numbers of home visits, several studies have revealed that families are receiving approximately half of the home visits they are scheduled to receive (Sharp, Ispa, & Thornburg, 2003). This may be related to large caseloads, program attrition, difficulty contacting the family, and characteristics of the visitor-family relationship. Programs such as Healthy Start and Healthy Families America have addressed these barriers through adjusting the frequency of visits based on the family's needs and limiting caseload case·load
The number of cases handled in a given period, as by an attorney or by a clinic or social services agency.
Noun size according to the intensity of services required (Breakey & Pratt, 1991; Daro, 2000). To address difficult visitor-family relationships, home visitors receive extensive training in working with at-risk families and ongoing supervision and support from supervisors (Breakey & Pratt, 1991; Daro, 2000). In addition, programs may be more likely to struggle with expansion efforts when rigid replication rules are followed. Healthy Families America addressed this problem by designing a flexible framework composed of twelve critical elements that programs are required to follow, rather than requiring programs to follow a strict detailed format (Daro, 2000).
Another challenge faced by ECIPs is identifying those families most in need of services. Many programs use a structured assessment process, through which risk factors are assessed and high-risk families are identified (Daro, 2000; Daro & Donnelly, 2002; Duggan et al., 1999). However, risk factors within a family change over time and families who are not high-risk during pregnancy may be high-risk when the child enters elementary school elementary school: see school. . In addition, we know that child maltreatment cannot be reliably predicted and several factors across various levels of analysis may interact to increase the risk of abuse. It follows that there is no reliable method of identifying high-risk families at this time. To address this problem, some programs have implemented a universal assessment process (i.e., assessing all parents within a target area) and/or offered services to all families within a community (Baydar et al., 2003; Daro, 2000; Daro & Harding, 1999). This solution increases the likelihood of identifying high-risk families and reduces the stigma stigma: see pistil.
mark of Cain
God’s mark on Cain, a sign of his shame for fratricide. [O. T.: Genesis 4:15]
scarlet letter that may be associated with participating in ECIPs. More research is needed to improve the identification of high-risk families. Due to the limitations of this process, resources may be better utilized through community-level prevention efforts that aim to reduce the risk of child maltreatment in the general population.
Involving low-income and minority parents has been a challenge in many ECIPs (Dupper & Poertner, 1997). Low-income families often experience reproachful re·proach·ful
Expressing reproach or blame.
re·proach and condescending interactions with service providers, in addition to the frequent threat of intrusion by outsiders (e.g., Child Protective Services) and general lack of respect from others. Another common barrier is cultural differences, which tend to breed mistrust as well. Programs such as Head Start (U.S. Department of Health & Human Services, 2004a) and Family Resource Centers (Dupper & Poertner, 1997) have attempted to address these problems through inviting participant families to serve on councils and committees, hiring participants as staff members, incorporating cultural elements and translators in the programs, and involving participants in designing the programs themselves. Other programs such as the Incredible Years Parent Training Program have provided transportation, meals, flexible meeting times, make-up sessions, and childcare for families participating in the program to increase participation rates (Baydar et al., 2003).
Limitations in Research
In general, large-scale ECIPs have shown limited commitment to research and program evaluation Program evaluation is a formalized approach to studying and assessing projects, policies and program and determining if they 'work'. Program evaluation is used in government and the private sector and it's taught in numerous universities. (Reynolds & Temple, 1998). A lack of controlled outcome research is evident for many large-scale programs, particularly in the case of community-based programs. Though it is difficult to document the changes made by community and population-level programs, there is a need for innovative research techniques to study these outcomes (Garbarino & Kostelny, 1994). Smaller-scale randomized controlled trials of demonstration projects are necessary and useful, but more effectiveness research is required. In other words, "Although studies of model programs suggest how effective early intervention can be, policy makers are most interested in knowing how effective large-scale, public service programs are" (Reynolds & Temple, 1998, p. 231).
Other important limitations in ECIP research lie in the research methodologies that are utilized. Because there is a tendency of regression toward the mean Regression toward the mean
The tendency that a random variable will ultimately have a value closer to its mean value. for extreme scores, high-risk families are likely to show improvement over time, regardless of the intervention received (Duggan et al., 1999). For this reason, it is imperative that well-designed randomized controlled trials be conducted to determine which outcomes are related to the intervention itself (Chaffin, 2005; Duggan et al., 1999). According to Chaffin (2005), results of randomized controlled trials indicate that "the majority of perinatal perinatal /peri·na·tal/ (-na´t'l) relating to the period shortly before and after birth; from the twentieth to twenty-ninth week of gestation to one to four weeks after birth.
adj. home visiting prevention programs do not prevent child abuse" (p. 241). This finding may be distressing for some, but is based on well-controlled research and should not be dismissed. It is important to determine which programs are effective at achieving their goals and which programs are "an inefficient use of taxpayer money" (Aos et al., 2004, p. 8).
Chaffin (2005) argues that programs with the self-identified goal of preventing child maltreatment should be evaluated according to this outcome. The trouble then lies in determining the best way to measure the outcome variable (i.e., identify maltreated children). While many studies include "proxy" variables (e.g., children's knowledge about body safety) or risk-factors as the outcome variables, it is preferable to directly measure child maltreatment as the outcome (Chaffin, 2005; Davis & Gidyez, 2000). However, several obstacles exist when attempting to accurately measure child maltreatment. Substantiated reports are probably the best indicators available at this time, although they are limited by lack of evidence, failure to report, flawed flaw 1
1. An imperfection, often concealed, that impairs soundness: a flaw in the crystal that caused it to shatter. See Synonyms at blemish.
2. investigations, and lack of statistical power from infrequent in·fre·quent
1. Not occurring regularly; occasional or rare: an infrequent guest.
2. reporting (Chaffin, 2005; Daro, 2000; U.S. Department of Health & Human Services, 2006a). Another option is to use all child maltreatment reports, both substantiated and unsubstantiated, as the outcome variable. This would increase the numbers of maltreatment cases, although failure to report would remain an obstacle. In addition, reports are often made based on limited evidence and sometimes arbitrary observations. Chaffin (2005) concludes, "The solution to the maltreatment measurement problem is not turning to questionable inferential in·fer·en·tial
1. Of, relating to, or involving inference.
2. Derived or capable of being derived by inference.
in or proxy measures, but rather to collect multi-method data on the direct outcome of interest" (p. 245).
Recommendations and Future Directions for ECIPs
It is evident that ECIPs have great potential to reduce the risk of child maltreatment through addressing risk factors within individual parents and children, their immediate context, and the broader social context surrounding them. At the individual level, ECIPs can address parent factors such as mental health issues, parenting stress, and negative attributions, as well as child factors such as behavior problems, developmental delays, low self-esteem, and knowledge of personal safety skills (Bell & Eyberg, 2002; Daro, 2000; Daro & Donnelly, 2002; Thompson, 1995; Turner & Sanders, 2006; Urquiza & McNeil, 1996). Within the immediate interactional context, ECIPs may target parent-child relationships, parenting skills, and partner violence (Baydar et al., 2003; Bell & Eyberg, 2002; Daro, 2000; Daro & Donnelly, 2002; Turner & Sanders, 2006; Urquiza & McNeil, 1996). At the community level, ECIPs have the ability to address several broader contextual factors such as poverty, social support, community safety, and societal beliefs and attitudes (Dupper & Poertner, 1997; Garbarino & Kostelny, 1994; PCAA, 2006; Turner & Sanders, 2006). As demonstrated in the previous discussion, ECIPs differ greatly in the factors they address and their effectiveness in addressing them. Because it is unclear which risk factors are the most critical to address through ECIPs, it is important that multiple risk factors continue to be addressed simultaneously to maximize the potential of ECIPs to prevent child maltreatment.
Despite their great potential, several challenges and limitations of ECIPs have been noted. It is important that these challenges be addressed through future research and modifications in current programs. It is also crucial that ECIPs incorporate research findings on maltreatment risk factors in order to increase their effectiveness at preventing child abuse and neglect (Aos et al., 2004; Daro, 1994, 2000; Nelson et al., 2001; Thompson, 1995). The literature has provided several helpful recommendations for ECIPs in the areas of research, reaching the target population, retaining service providers, and increasing family involvement. Many of these recommendations are general suggestions aimed at improving ECIPs, which will further improve their effectiveness at preventing child maltreatment.
Improving Research on Effectiveness
1. Conduct cost-benefit analyses as part of the overall program effectiveness evaluations (e.g., Nurse-Family Partnership, Healthy Families America, California school-based sexual abuse prevention programs).
2. Develop better techniques for evaluating large-scale ECIPs (e.g., Healthy Families America, Healthy Start Program, Triple P).
3. Utilize randomized controlled trials to determine the impact of ECIPs, rather than relying on quasi-experimental research. Programs that have conducted randomized controlled trials include, but are not limited to, the Healthy Start Program, Nurse-Family Partnership, Behavioral Skills Training Program, Incredible Years Program, and PCIT.
4. Further examine mediator mediator n. a person who conducts mediation. A mediator is usually a lawyer, or retired judge, but can be a non-attorney specialist in the subject matter (like child custody) who tries to bring people and their disputes to early resolution through a conference. and moderator moderator - A person, or small group of people, who manages a moderated mailing list or Usenet newsgroup. Moderators are responsible for determining which email submissions are passed on to the list or newsgroup. variables influencing program effectiveness, such as family involvement, relationship with home visitor, and parental mental health.
5. Include measures of program integrity to ensure that programs are implemented as intended, as demonstrated by the Healthy Start Program.
Enhancing Access to Target Population
1. Offer services to all families in a target community to reduce stigma and improve the chances of reaching the highest risk families (e.g., Healthy Start Program, Healthy Families America, PCAA, Triple P).
2. Assess for multiple-risk factors across multiple levels of analysis to identify high-risk families (e.g., Healthy Start Program, Healthy Families America).
3. Use media resources to familiarize families with programs and to change widely held beliefs about parenting (e.g., PCAA, Triple P).
4. Allow for flexibility and individualization individualization,
n the process of tailoring remedies or treatments to cure a set of symptoms in an indiv-idual instead of basing treatment on the common features of the disease. when implementing services across diverse populations that differ greatly in their needs and strengths (e.g., Healthy Families America).
Retaining Qualified Staff Members
1. Hire staff with appropriate education and experience and provide ongoing training in relevant topics, such as child development, attachment, health care, parenting skills, substance abuse, mental health, problem-solving skills, and family violence.
2. Limit staff caseload size and provide ongoing supervision and support, particularly in home visitation programs. Examples of programs that are successfully utilizing these strategies are the Healthy Start Program and Healthy Families America.
3. Provide incentives to staff when possible, such as salary increases, tuition reimbursement Reimbursement
Payment made to someone for out-of-pocket expenses has incurred. , flexible hours, and awards and recognition ceremonies (e.g., Healthy Start Program).
Increasing Involvement of Families
1. Acquire assistance from families in developing local programs and continuously elicit and utilize feedback from participating families (e.g., Family Resource Centers).
2. Allow families to serve on councils and committees to increase their level commitment and motivation (e.g., Head Start Program, Family Resource Centers).
3. Hire participants as program staff and utilize participants as teachers when possible (e.g., Family Resource Centers).
4. Acknowledge diversity as a strength and improve cultural competence cultural competence Social medicine The ability to understand, appreciate, and interact with persons from cultures and/or belief systems other than one's own of staff through training, role plays, and open discussions (e.g., Family Resource Centers).
5. Provide incentives to families for participation when possible, such as free meals, transportation, gift certificates, and free childcare (e.g., Incredible Years Program).
Enhancing Prevention of Child Maltreatment
While the previous recommendations will improve the ability of ECIPs to prevent child maltreatment through improving their general effectiveness, several suggestions can be identified that specifically relate to prevention of child abuse and neglect:
1. When examining the effectiveness of ECIPs in preventing child maltreatment, Chaffin (2005) recommends using direct measures of child maltreatment whenever possible, including substantiated and unsubstantiated reports to Child Protective Services (e.g., Nurse-Family Partnership, Healthy Start Program, Healthy Families America). Particularly with school-based sexual abuse prevention programs, very little research has been conducted using direct measures of sexual abuse as the outcome variable (Davis & Gidyez, 2000).
2. Use multiple methods of measuring child maltreatment, such as self-report of child maltreatment by parents, observational data, information on out-of-home placements, and child welfare reports (Chaffin, 2005).
3. Address risk-factors at multiple levels of intervention, including parent factors, child factors, immediate context, and broader community context (e.g., Triple P). Along the same lines, provide interventions across multiple settings, such as home visitation, school-based programs, treatment in clinic settings, and community-wide media campaigns and interventions.
4. Incorporate interventions to address substance abuse by parents, parental history of abuse, and partner violence, all of which are significant risk factors that appear to be neglected in many ECIPs.
5. Utilize behavioral rehearsal and reinforcement techniques, particularly when training parents in behavior management techniques and teaching children skills to prevent sexual abuse (e.g., PCIT, Behavioral Skills Training Program).
6. Intervene as early as possible (preferably during pregnancy) to teach parenting skills and educate parents on child development (e.g., PCAA).
7. Continue to conduct randomized controlled trials of ECIPs assessing child maltreatment prevention as an outcome variable and continuously modify programs to incorporate research findings on child abuse and neglect risk-factors and effective prevention strategies.
In sum, we have learned a great deal over the past few decades from research on child maltreatment as well as evaluations of ECIPs. It is clear that much is left to be done, but the field has progressed toward its goals of strengthening families and protecting children from abuse and neglect. Until greater efforts are made on a societal level, ECIPs will continue to chip away at the overwhelming problems faced by children. As Edward Zigler (1990) laments, "No amount of counseling, early childhood curricula, or home visits will take the place of jobs that provide decent incomes, affordable housing, appropriate health care, optimal family configurations, or integrated neighborhoods where children encounter positive role models" (p. xiii). While home, school, and clinic-based ECIPs can be highly effective at preventing child maltreatment, it is when these programs are embedded Inserted into. See embedded system. within a system of community-wide prevention efforts that pervasive and enduring changes can take place.
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Lindsay E. Asawa, David J. Hansen, and Mary Fran Flood
University of Nebraska-Lincoln
Correspondence to Lindsay E. Asawa, Dept. of Psychology, University of Nebraska-Lincoln, 238 Burnett Hall, Lincoln, NE 68588-0308; e-mail: email@example.com.
Table 1 Summary of Selected Early Childhood Intervention Programs Setting Program Target(s) Intervener(s) Home-Based Healthy Start Parents and parent- Paraprofessionals Program child relationship Healthy Families Parents and parent- Paraprofessionals America child relationship Nurse-Family Mothers Nurses Partnership School- Family Resource Children, parents, Paraprofessionals, Based Centers families, groups, mental health and teachers professionals, and teachers Head Start Program Children, parents, Paraprofessionals and teachers and teachers Clinic- Parent-Child Parents and Mental health Based Interaction parent-child professionals Therapy relationship Community- Prevent Child Abuse Parents and Wide variety of Based America families service providers Triple P--Positive Parents and Health care Parenting Program families professionals and trained volunteers Setting Program Inclusion Criteria Home-Based Healthy Start Universal assessment to identify high Program risk families Healthy Families Universal assessment to identify high America risk families Nurse-Family Young (<19), low-income, single mothers Partnership School- Family Resource Students at the school and their Based Centers families, as well as members of the surrounding community Head Start Program Low-income families with children from 3 to 5 years Clinic- Parent-Child Families with children between 2 and 7 Based Interaction years who were referred for treatment Therapy Community- Prevent Child Abuse General public, pregnant mothers, Based America families with young children Triple P--Positive All parents in Australia with children Parenting Program ages 16 and under Table 2 Summary of Child Maltreatment Risk Factors Addressed by ECIPs ECIP Parent Factors Child Factors Healthy Start Program Parent stress Young children Parent mental health (Birth to age 5) Negative attributions Behavior problems Healthy Families America Parent stress Young children Parent mental health (Birth to age 5) Negative attributions Behavior problems Health/development Nurse-Family Partnership Parent stress Young children Parent mental health (Birth to age 2) Substance abuse Health/development Negative attributions Family Resource Centers Parent stress Young children Parent mental health Health/development Head Start Program Parent stress Young children Parent mental health (3 to 5 years) Negative attributions Health/development Parent-Child Interaction Parent stress Young children Therapy Negative attributions (2 to 7 years) Behavior problems Developmental disabilities Low self-esteem Prevent Child Abuse Negative attributions Young children America Triple P--Positive Parent stress Young children Parenting Program Negative attributions Behavior problems ECIP Immediate Context Broader Context Healthy Start Program Parent-child relationship Poverty Parenting skills Parent social Parent knowledge support Discipline strategies Healthy Families America Parent-child relationship Poverty Parenting skills Parent social Parent knowledge support Discipline strategies Nurse-Family Partnership Parent-child relationship Poverty Parenting skills Parent social Parent knowledge support Parent discord/violence Family Resource Centers Parent knowledge Poverty Parent social support Head Start Program Parent-child relationship Poverty Parenting skills Parent social Parent knowledge support Discipline strategies Parent-Child Interaction Parent-child relationship Parent social Therapy Parenting skills support Parent knowledge Discipline strategies Prevent Child Abuse Parent-child relationship Societal acceptance America Parenting skills of violence Parent knowledge Societal awareness Discipline strategies of child maltreatment Triple P--Positive Parent-child relationship Parent social Parenting Program Parenting skills support Parent knowledge Societal acceptance Discipline strategies of violence Partner discord/violence Societal awareness of child maltreatment