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Early Childhood Intervention Programs: opportunities and challenges for preventing child maltreatment.

Abstract

Due to the destructive impact of child maltreatment and limited available funding to address its consequences, the value of preventive measures is evident. Early Childhood Intervention 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 and implementation of programs. Recommendations for future research and improving child maltreatment prevention through ECIPs are provided.

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The disturbing prevalence of child abuse and neglect in the United States has sparked a great deal of research and mobilization 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 (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 differences in the severity, duration, and frequency of maltreatment, as well as differences in the child (e.g., temperament, 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 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, 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, treatment, law enforcement) and indirect (e.g., special education, foster care, juvenile delinquency, 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, 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

Developmental-Ecological Framework

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.

Parent Factors

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, and impaired empathy for others (Belsky, 1993). In one study of maltreating families, 84% of the parents were diagnosed with a DSM-III mental disorder 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 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, a history of childhood maltreatment has frequently been linked to increased abuse potential (Belsky, 1993; Hecht & Hansen, 2001). Rates of intergenerational transmission of abuse have been estimated to range from 7 to 70 percent, providing little conclusive evidence 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], 1996). In 1995, it was estimated that 675,000 children are maltreated each year by substance-abusing caretakers.

Child Factors

Several characteristics of children have been associated with increased risk of child maltreatment, particularly factors that are innate to the child. Prenatal 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, 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 to adults and may value the positive attention they are receiving from the perpetrator. 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) 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 compliance (i.e., corporal punishment), such as spanking 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 parents tend to be unresponsive to their children, while physically abusive parents are controlling, punitive, and rigid in their parenting strategies.

Marital discord 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 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 (Graham-Bermann, 2002; Hecht & Hansen, 2001; NCCAN, 1996).

Broader Context

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 by other risk factors that are present in low-income households, such as substandard 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 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, high population turnover, more stressful daily interactions between families, and low social cohesion 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 mothers, or mothers who report high rates of unsolicited and coercive social interactions rather than solicited positive interchanges, tend to show inconsistency 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 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, 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, 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 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.

Home-Based Programs

In the United States, home visitation 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 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 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 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 (CPS) 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 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 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 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 is the Nurse-Family Partnership (NFP), also known as the Nurse Home Visitation Program, established by David Olds in 1977 in Elmira, New York (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 the positive effects of the program. In other words, 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 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, 2004) and may be considered the best current prevention program for child physical abuse and neglect (Chaffin & Friedrich, 2004). The program has now been expanded to over 23 states and serves approximately 10,000 families annually (Child Trends, 2003). It is more expensive than most other programs of its kind, although the cost of the program is typically recovered by the child's fourth birthday (University of Colorado, 2004). Cost-benefit analyses estimate that this program achieves an impressive net benefit of $17,000 to $25,000 per family (Aos et al., 2004; Karoly et al., 2001).

School-Based Programs

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, inappropriate secrets, trusting intuition, 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 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 Child Sexual Abuse 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, 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 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 Center for Substance Abuse Prevention (EBPPC, 2007; University of Colorado, 2004).

Clinic-Based Programs

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) is a parent training program developed by Sheila Eyberg that is based on Constance Hanf's two-stage operant 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 of prosocial behaviors. The second stage of PCIT, Parent Directed Interaction, addresses appropriate discipline strategies and behavior management techniques. According to Bell & Eyberg (2002), this treatment program was based on the influences of developmental theory, attachment theory, 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 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 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 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.

Community-Based Programs

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, 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 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 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 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 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 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 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 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 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. 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 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 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 (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 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 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 investigations, and lack of statistical power from infrequent 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 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 and moderator 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 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, 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 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 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: lecronch@yahoo.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
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Author:Asawa, Lindsay E.; Hansen, David J.; Flood, Mary Fran
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