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Prevention of physical child abuse: concept, evidence and practice.

Abstract

Given a lack of standardised procedures for preventing child abuse, what can be done in terms of thinking and action about the prevention of physical child abuse in health visiting and community practice? This paper reflects on knowledge gained while undertaking case series research into non-accidental head injury (NAHI), qualitative research with health visitors and mothers and fathers into the feasibility of preventing NAHI, and work as a team member of the Welsh Child Protection Systematic Review Group.

Prevention is an abstract term, with dimensions of an ethical nature, and requires prompt and timely action. To identify when preventive action is required, an understanding is needed of where there is risk, and what benefit or outcome may follow interventions. However, the knowledge in this field is limited, which means that it is wise to be cautious in claiming effectiveness of prevention activity. Nonetheless, if prevention is not seen to be practised, the development of skills and the means to evaluate interventions will not become embedded in the routine care of families with small children, and physical child abuse will not be prevented.

Key words

Prevention, child abuse, risk, intervention, public health

Community Practitioner 2008; 81(6): 18-22.

Introduction

The aim of this paper is to understand the value and limitations of assessing risk for physical child abuse and to consider how to work preventatively.

Preventing child abuse is a public health issue that meets the objectives of changing health and social care practice to a culture of prevention and early intervention. [1] In Every child matters, [2] children's services priorities are prevention, promotion and enhancing life chances. The Department of Health's report on the Victoria Climbie Inquiry [3] emphasises the prevention of abuse and safeguarding children. Such policy, along with legal changes and public awareness, are described as macro-level interventions for prevention, in line with the World Health Organization European Region message to policy makers that preventing injuries is society's responsibility. [4] This is complementary to preventive interventions at the micro level, of informing and educating parents and carers. It is also a shift away from delegating responsibility to individuals, emphasising instead the role of communities, families and professionals in integrating efforts for prevention.

However, the limitations of child abuse prevention as described by Daro and Donnelly [5] suggest there is a danger of over simplifying child abuse, and thus overstating the potential for prevention, so that both the depth and quality of prevention are compromised for maximum breadth. The prevention of physical abuse has not benefited from the same research rigour or theoretical approach as accidental injury, and any practice is within the context of current knowledge on prevention.

Prevention in child abuse

An abstract term

As a concept, prevention is an abstract term. It has a moral and ethical nature, being described as paramount, or that most child abuse is preventable given the will to make major changes to the way society views and protects children. [6] For some, the underlying principle is the right of a child to be treated with the same dignity and care as an adult, as demonstrated by advocating the avoidance of physical punishment.

Prevention also embodies the sense that action should be, or should have been, taken at a time appropriate to avoid a serious outcome in a child's life. Yet inquiries following fatal child abuse acknowledge that all risk in child protection work can never be eliminated. Practitioners can only be judged as to whether they were acting professionally and in good faith. Where this is found lacking, criticism is used to improve services, as in the Victoria Climbie Inquiry, [3] which heavily criticised those who occupy senior positions in the public sector for lack of accountability in failure to protect vulnerable children.

An epidemiological framework

As an abstract term, prevention is open to interpretation by different users. An epidemiological framework is useful in describing these different perspectives. It may be helpful to consider what prevention means within this framework:

* In public health, prevention is the appropriate risk reduction of a future adverse health event. This is primary prevention and is action for populations aimed at reducing the likelihood of new cases. It includes health promotion

* A biomedical perspective sees prevention as observing early signs of what could become a chronic problem and intervening to halt that progress, perhaps by making a referral for assessment of the family. This targets individuals and groups at risk and is also called secondary prevention. It includes the identification of risk factors for early detection, perhaps with screening tools, and modification with prompt intervention

* A social situational model will define the potential for child abuse by knowledge of negative attributes in family circumstances and functioning that may develop into adverse consequences for a child. It may assess mitigating circumstances, thus modifying risks and finding ways of building resilience. This model employs an empowerment and ecological approach. The target is families with recognised potential for abuse in their community and environmental context [7]

* Tertiary prevention involves measures to reduce or eliminate long-term damage and disability. In child protection, this is for children and families where abuse has occurred, minimising suffering and promoting adjustment or recovery through therapy. This extends the field of prevention into the field of rehabilitation and may specifically relate to looked-after children in the care of social services.

Securing the foundation for prevention

In public health, epidemiological studies regarding the prevention of accidents and wider public health issues have been criticised in terms of the usefulness of their scientific background in prevention. As an alternative, debates in this field address the value of using conceptual models to guide practice, such as the Haddon Matrix of aetiologic factors for injury being used to identify potential preventive strategies for developing interventions. [8] This model is of potential risk, and protective factors and/or strategies for prevention, that are related in columns and rows to interactions among the key components and players in an event. It is claimed that this model can be extended to other public health matters. Perhaps in this way, a database of observed interacting elements leading to physical child abuse might be employed to develop a prevention framework for community practice.

Evidence-based practice

Basing interventions on how injuries occur, and developing strategies for intervention in the way described above, is in part reflected in Macdonald's description of the means to effectiveness of prevention in child protection work, using evidence-based practice. [9] Macdonald proposes:

* Using evaluative tools for assessing evidence on child abuse, such as systematic reviews

* Looking at the interplay of causal factors on the basis of the evidence

* Looking for evidence for effective preventive and therapeutic measures

* Incorporating this into professional child protection work.

It is important to know the current state of knowledge about child protection, so that practice is credible, stands up to challenges, and offers the populations worked with the best practice. However, this body of child protection knowledge has to be looked at in a critical way, finding both the strengths and the weaknesses of what has been written, and considering the gaps in evidence.

The disadvantage of this evidence-based approach is that information can be weak, there are errors and there are reviews that jump to conclusions. There is a vast amount of practice for which evidence has not been established. This does not mean practice for which there is no evidence is wrong, but that the evidence does not exist in a formal way.

In reality, for practitioners in child protection, is it reasonable to consider how much value there is in this type of evidence. A study in primary care showed that nurses and GPs rarely accessed or used explicit evidence from research directly, but relied on 'mindlines', which were collectively-reinforced internalised, tacit guidelines. [10] The sources of evidence were brief readings, their own and colleagues' experiences, interactions with each other and with patients, for example. In practice, this is socially-constructed knowledge, dependent on networks to convey evidence. It values the importance of tacit or informal knowledge, compared with an over-rationalist model of prescriptive guidelines, which tend to come from the most formalised type of evidence-based care. These two extremes are not incompatible, as there is no reason for one to exclude the other, but rather should be viewed as a spectrum of evidence.

Munro [11] describes social workers' knowledge as being on a continuum from analytic to intuitive, the tacit knowledge accrued suggesting practitioners look for shared ground rather than polarised views. Case examples of decision-making in child protection are given encompassing formal knowledge, practice wisdom, emotional wisdom and reasoning skills for understanding human actions.

The strengths of tacit knowledge are that this is the way people make sense of the world. It is speedy, it uses a lifetime of background knowledge and claims to identify observable behaviour that influenced judgement. The weaknesses are that the knowledge is implied--so not fully articulated--and cannot be shared publicly. Only low-level theories with a small range of applications are generated.

The strengths of analytic reasoning in child protection work are that they can be applied to the content and process of practice from empirical studies, but need to be kept up to date. In giving more credibility to one approach rather than another, it has to be remembered that the nature of child abuse makes it difficult to research (see Box 1). In addition, many child protection studies have methodological limitations, lacking clear findings and replication. [12] Behavioural interventions for the treatment of physical child abuse are the most developed area of research, and prevention is the least developed, more so in the UK than in the US.

Decision-making in prevention

Decision-making on which intervention to chose in prevention is also systematically applied in the Haddon Matrix. Borrowing from the field of policy analysis, key values such as effectiveness, equity, cost and stigmatisation are used to judge the relative merits of alternative intervention strategies.

Munro [11] compares an actuarial or algorithmic model of decision-making, using instruments, with an analysis of decision-making based on intuition, and notes the capacity for errors in clinical judgement. She sees that instruments are low in accuracy and do not have much impact in practice. In the antenatal and postnatal periods, research has shown that specificity for predicting child maltreatment is poor, even with a sensitive instrument. [13] At best, instruments play a small part in the judgement of probability of harm, and only at one moment in time.

Most families want to provide the best care for their children and for those that are the exception, it may be difficult to know why they do not or cannot provide good care. Yet, without an understanding of cause, of what is lacking, prevention cannot be addressed, nor outcomes assessed.

The Victoria Climbie Inquiry [3] found it was not possible to separate the protection of children from wider support to families, and that the best protection for a child is achieved by the timely intervention of family support services. Developing insight into the deficits of care usually requires investigation, assessment and the development of a working relationship with the parents or carers, with the aim of achieving change in the care of a child. That is, turning around a negative situation into a more hopeful one. The employment of an asset model of health promotion, rather than a deficit model alone, may greatly enhance the outcome through identifying what works well in a particular population. [14] What triggers preventive actions will vary according to the knowledge and experience of the observer as to the child's risk for abuse, and the model for prevention adopted.

Risk

What is a risk factor?

A risk factor is a characteristic exclusive to one group. However, studies on risks for specific types of abuse have not been done with a control group to ascertain the relationship between apparent risk and a real child protection event. Such studies that do exist use different methods or selected groups, such as young mothers, which makes comparison difficult. There is little quantitative research on the predictive strengths of individual risks. It can only be concluded that risk factors form the context in which abuse might occur.

What are the risks for abuse?

In child abuse, multiple risk and protective factors are involved. It is the interplay between them that leads to abuse in some cases and not others. [9] Known risk factors for both injury and abuse include low literacy, social isolation and lack of supportive networks. Since children vary in their vulnerability, a judgement about risk will also consider resilience factors, perhaps appreciating the role of peer group and community, and making observations of secure attachment and positive parenting, which lessen risk. The aim in prevention is a reduction of negative and an increase of positive factors. [15]

In looking for the characteristics of those who cause non-accidental head injury (NAHI), as one form of physical abuse, Coles and Kemp [16] reviewed the case records of 90 cases of subdural haemorrhage, of which 65 were due to NAHI, particularly from shaking. Table 1 shows the negative social characteristics associated with the NAHI. Yet, 31% of the 65 cases appeared to have none of these associations. This is an example of a prevention paradox, where large numbers with the condition to be prevented appear to have no risk factors. [17] It adds to the argument for a population approach to prevention, [18] although the reality is that individuals and families are more often the target. In addition, the factors are not exclusive to one form of abuse, but are also risks for accidents and other abuse. The Canadian Task Force review on prevention of child maltreatment [19] identified evidence to target, for intensive home visiting programmes, first-time mothers with one or more of the following characteristics--young age, single status and low socioeconomic status. This type of catch-all framework seems to be the best that can be defined at present. A simple checklist does not reveal the complexities of interactions between key players, the environment and the broader context of, for example, poverty, illness and stress, which is known to impact adversely on resilience and coping. [20]

Strengthening the risk profile

Although precise prediction has limitations, in practice it can be strengthened through applying theoretical knowledge. For example, the above table showed that violence in the relationship and/or on criminal convictions affected 40% of NAHI cases and this association was found in other literature. A theoretical view is that violence and shaking, as part of NAHI, includes the need to maintain control as the trigger to violent action, not that the person was violent by nature. The experience of Crittenden [21] is that perpetrators are lacking in the interpersonal strategies for reducing danger in interfamilial situations, and achieving comfort for themselves and others. It may be helpful to look for these characteristics as much as violence alone.

As to the factor of a history of child abuse, Fang and Corso [22] describe the cycle of violence where victims of child abuse in turn become abusers. Knowing that a parent has been abused may prompt investigation as to how serious this was in terms of victimisation, and the likelihood of perpetration of violence. By linking these two factors it may become clearer that preventive interventions are needed. Munro [11] claims that the best prediction of future behaviour in child abuse is past behaviour. Research shows this is the case in physical abuse, [23] and also that prevention of subsequent abuse is less effective than primary prevention. [24]

Another example of looking at interrelated factors to assess risk is the family with a drug-abusing parent or partner. Drug abuse has strong associations with socioeconomic deprivation and other factors affecting parenting capacity, [25] and it is the seriousness of the drug abuse that signifies the likelihood of it interfering with parenting. Serious drug abuse includes the most complex cases involving a chaotic lifestyle. As a risk factor, drug abuse needs to be viewed in the context of parenting capacity. For prevention, an intervention by alerting agencies supporting the drug abuser, to the vulnerability of a child in the situation, and following up the outcome, is one option.

From this, it can be seen that checklists can be used to identify factors that then need describing in terms of the interplay between factors, the mitigating circumstances and the alleviating factors, to help in prediction, rather than numbers alone. It is not simply a case of the higher the number of risks the more likely abuse is to happen. Further, a checklist needs to be questioned as to how it might be incomplete from your own experience or reading.

The ethical dilemma of identifying false positives in screening has lead Canadian national policy to state that the harm associated with wrongly identifying or targeting potential child abusers from screening programmes, is seen to outweigh the possible good. Screening for physical abuse and neglect is not recommended. [19] In this review of the evidence of effectiveness in the prevention of child maltreatment, home visiting by nurses among first-time disadvantaged mothers in the perinatal period through to infancy is said to provide good evidence to continue recommending it, and other reviews support this. [26, 27] At present, there is good evidence to say that structured early home visiting by professionally-trained persons can prevent child maltreatment in high-risk families. Parenting education, integrated with on-going evaluation and community support programmes to promote and maintain healthy development, is the best way forward (see Box 2).

Fathers: a significant omission of focus

There is, however, one significant lack in many research reviews, and that is a focus on the needs of fathers. Fathers are often excluded when healthcare professionals provide information, but they especially need educating about safe parenting and protecting small children. [28, 29] Giving fathers attention in their own right--with prevention messages, in a positive way and related to their own interests--is more acceptable than much standard information aimed at mothers. A quality standard for practice and methods for including fathers, with a guide for use in maternity care and a 'Dad Pack', have been produced by Father's Direct. [30]

The NSPCC has published a booklet online, Encouraging better behaviour, [31] which gives professionals working with parents advice on how to promote positive discipline as an alternative to physical punishment, and a simple one-page guide to use with parents. Helping mothers and fathers to anticipate and visualise the consequences of detrimental actions helps explain the concept of risk reduction, and to learn that anticipating potential injury can lead to protection. For example, in response to a crying baby, parents--especially fathers--need to be provided with coping strategies. [32-34] This is particularly relevant to shaking and NAHI.

Discussion

Risks are not certainties in prediction of abuse, but are useful as pointers in raising a potential awareness of vulnerability and triggering ways of thinking about prevention, looking into the wider picture in order to see which factors operate synergistically to result in adverse transactional processes between child and carer. Lessening risk by encouraging the protective, supportive roles of professionals, peer groups and the community are positive steps to prevention, providing outcomes that can be documented as achievements. When thinking in terms of prevention, Munro [11] advocates describing in writing the basic cause for concern, using a structured approach. For example, is there a time frame to the concerns in which something might happen? Is this an acute or chronic situation? Record speculations as to whether the problem will continue, or what might be the likely impact of behaviour. Is the danger escalating, or changing due to a change in circumstance, such as imminent release or imprisonment of an abuser? She suggests that a personal presentation of concerns for preventing abuse has more effect in a child protection conference than a written submission alone. Children vary in their vulnerability, and given that multiple risk and protective factors are involved, working with uncertainty is part of working with children at risk, so structuring concerns is helpful.

Conclusion

An effective perspective for assessing risk for abuse avoids the assumption that parents or carers have complete control over their situation. Being open to wider influences and the interplay of different negative characteristics and mitigation through resilience will trigger prevention actions and affect solutions. To record in case notes the strategies used for the purpose of prevention is part of effective practice. A flowchart of problem, intervention and outcome may help lead to visible outcomes and patterns of strategies to show what works or what is not effective. This pooling of knowledge to give a composite picture of the social and environmental risk factors, the illness history and the parenting capacity of a family is a recognisable way to assess the potential for abuse. [35]

More research is needed, and the ecological approach suggested above indicates the potential value in recording prevention activity, pooling local findings informally, developing practice guides, principles and statements to share with other agencies, forming a basis for research and evaluation. This inferential generalisation can be done through presentation at a forum or discussion group, as a brainstorming tool for developing ideas about a range of strategies for intervention.

Querying current practice and stimulating debate using research findings is often a precursor to translating research into practice. It can also lead to projects to evaluate emerging practice changes, and set up a hypothesis for researchers to undertake prospective multi-centred comparative studies and strengthen the knowledge base for the prevention of physical child abuse in community practice. There is no typology to inform the reality of prevention in physical child abuse, and one has to be developed from practice, otherwise there is only the rhetoric and theory for prevention that, without action, is not preventive. How risks are perceived is a subjective process, not random, and influenced by research, theory and wisdom acquired through experience.

References

[1] Wanless D. Securing our future health: taking a long-term view. London: Stationery Office, 2003.

[2] Department for Education and Skills. Every child matters. London: Stationery Office 2004.

[3] Lord Laming. Inquiry into the death of Victoria Climbie. London: Stationery Office, 2003. Available at: www.victoria-climbie-inquiry.org.uk/finreport/ downloadreport.htm (accessed 15 May 2008).

[4] World Health Organization. The solid facts on unintentional injuries and violence in the WHO European Region. Factsheet Euro/11/05 Copenhagen, Bucharest, 12 September 2005.

[5] Daro D, Donnelly AC. Charting the waves of prevention: two steps forward, one step back. Child Abuse and Neglect, 2002; 26: 731-42.

[6] National Commission of Inquiry. Childhood matters: report of the national commission of inquiry in prevention of child abuse. London: HMSO, 1996.

[7] Davies WH, Garwood M. Who are the perpetrators and why do they do it? Shaken baby syndrome. Journal of Aggression, Maltreatment and Trauma, 2001; 5(1): 41-5.

[8] Runyan CW. Back to the future: revisiting Haddon's conceptualization of injury epidemiology and prevention. Epidemiologic Reviews, 2003; 25(1): 60-4.

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[14] Bartley M (Ed.). Capability and resilience: beating the odds 2006. London: University College London, 2006. Available at: www.ucl.ac.uk/capabilityandresilience/ beatingtheoddsbook (accessed 15 May 2008).

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[17] Rose G. The strategy of preventive medicine. Oxford: Oxford University, 1992.

[18] Sanders MR, Cann W, Markie-Dadds C. Why a universal population-level approach to the prevention of child abuse is essential. Child Abuse Review, 2003; 12: 145-54.

[19] MacMillan HL. Preventive health care 2000 update: prevention of child maltreatment. CMAJ, 2000; 163(11): 1451-8.

[20] National Institute for Health and Clinical Excellence. Behaviour change: review on resilience, coping and salutogenic approaches to health. London: National Institute for Health and Clinical Excellence, 2006. Available at: www.nice.org.uk/guidance/index.jsp? action=download&o=34609 (accessed 15 May 2008).

[21] Crittenden P. If I knew then what I know now. In: Browne K, Hanks H, Stratton P, Hamilton C (Eds.). Early prediction and prevention of child abuse. Chichester: Wiley, 2002.

[22] Fang X, Corso PS. Child maltreatment, youth violence, and intimate partner violence. American Journal of Preventive Medicine, 2007; 33(4) 281-90.

[23] Ellaway BA, Payne EH, Rolfe K, Dunstan FD, Kemp AM, Butler I, Sibert JR. Are abused babies protected from further abuse? Archives of Disease in Childhood, 2004; 89: 845-6.

[24] MacMillan HL, Thomas BH, Jamieson E, Walsh CA, Boyle MH, Shannon HS, Gafni A. Effectiveness of home visitation by public health nurses in prevention of the recurrence of child physical abuse and neglect: a randomised controlled trial. The Lancet, 2005; 365(9473): 1786-93.

[25] Advisory Council on the Misuse of Drugs. Hidden harm: responding to the needs of children of problem drug users. London, Home Office 2003.

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[28] Coles L, Collins L. Barriers and facilitators to preventing shaking and head injuries in babies. Community Practitioner, 2007; 80(10): 20-4.

[29] Coles L, Collins L. Protecting babies' heads: preventing shaking and accidental head injuries (unpublished research report). Cardiff: Cardiff University, 2007.

[30] Fathers Direct. Dad pack. London: Fathers Direct, 2007.

[31] NSPCC. Encouraging better behaviour: a practical guide to positive parenting. London: NSPCC, 2002.

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[33] Reijneveld SA, van der Wal MF, Brugman E, Sing RA, Verloove-Vanhorick SP. Infant crying and abuse. The Lancet, 2004; 364: 1340-2.

[34] Coles L. Protecting babies' heads: a teaching toolbox for preventing shaking and head injuries in babies. London: Unite/CPHVA, 2006.

[35] Browne KD, Hamilton CE. Prevention: current and future trends. In: Bannon MJ, Carter YH. Protecting children from abuse and neglect in primary care. Oxford: Oxford University, 2003.

Box 1. Prevention as an intervention needs more knowledge

* Prevention as intervention in child protection does not have a clear definition, and evidence-based practice is undermined by limited research and theory

* Partly due to the nature of child abuse, socially-constructed knowledge of tacit information is more likely to be used in prevention, but this is difficult to share formally

* To act preventatively, the cause of child abuse, of what is not right or lacking in childcare, needs first to be understood

Box 2. Identifying risk and resilience factors helps evaluation

* Risk factors form a context in which child abuse might occur, but they are not certainties and do not occur in all cases

* Describing the interrelatedness of risk factors, and resilience features, is more helpful in constructing an understanding of risk than a list of factors alone

* According to current knowledge, structured early home visiting by trained professionals and community support can prevent child abuse, but in the UK this needs more evaluation

Lisa Coles PhD, BA, RHV, RGN Honorary senior research fellow Wales College of Medicine, Cardiff University
Table 1: Negative characteristics associated with 65 NAHI cases

Violence (domestic or criminal) 40% (26/65)
Mental health problems (including postnatal depression) 26% (17/65)
Criminal record (non-violent) 26% (17/65)
Childhood abuse or in care (either or both) 18% (12/65)
Alcohol abuse or drug abuse (either or both) 18% (12/65)
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Title Annotation:PROFESSIONAL
Author:Coles, Lisa
Publication:Community Practitioner
Geographic Code:4EUUK
Date:Jun 1, 2008
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