Feature

In 2006, child welfare authorities investigated suspected maltreatment of 6 million American children, three-quarters of them under age 4. In today's rocky economy, that number is likely growing, say researchers.

"When parents are out of work or stressed, some react in patterns of aggression, or turn to substance abuse," says Preston A. Britner, PhD, a psychologist and professor at the University of Connecticut.

But a new report from APA and the Centers for Disease Control and Prevention could prevent an uptick in child abuse. At the request of the CDC, APA's Violence Prevention Office convened seven experts on maltreatment, including Britner, to identify the best science on prevention and recommend how best to help families protect their children from abuse and neglect.

Their advice? Offer evidence-based programs that promote positive parenting practices through the nation's 1,100 federally funded community health centers. In 2007, these centers served 16 million Americans, mostly low-income parents and uninsured and socially isolated minority families at high risk for child abuse and neglect.

Research shows that well-designed evidence-based parenting programs can strengthen family relationships, reduce harsh discipline practices that are often precursors to maltreatment, and lower future rates of child maltreatment, says working group chair Karen Saywitz, PhD, of the University of California, Los Angeles School of Medicine.

The time couldn't be better for the report's release, she adds, since President Barack Obama's stimulus package included $155 million to create 126 new community health centers and set aside $338 million to expand services at existing ones.

Members of the APA group hope their report, "Effective Strategies to Support Positive Parenting in Community Health Centers," will convince lawmakers to invest in maltreatment prevention because prevention is good economic policy. Intervening early with high-quality interventions for vulnerable families, Saywitz says, prevents problems from escalating into abuse, and is more cost-effective than remediation later.

"The frustration of my daily life of interacting with various child welfare agencies is that they spend only 1 percent of their budgets on prevention," adds Britner. "That's a losing formula."

Positive, not punitive

To start, the Public Interest Government Relations Office is working with Sen. Daniel Imoye's (D-Hawaii) office on a bill to urge Congress to fund evidence-based preventive positive parenting programs through demonstrations at community health centers for families from diverse backgrounds. The centers would screen for mental health problems and refer parents for mental health services if they are at risk for abusing their children. The centers would also provide home visits to train parents on positive parenting skills.

The report also emphasizes the need for a multidisciplinary, one-stop shop approach. Preventing child maltreatment requires constant collaboration between medical and mental health professionals on a family-centered approach, says Saywitz. Such an integrated approach will allow the community health centers to identify parents who could benefit from the parent-training programs during all well- and sick-child visits, routine medical visits and screenings for substance abuse, depression, and neglect and abuse, even during obstetrical and gynecological checkups. Research suggests that such a wide-net approach works better than singling out potential abusers or high-risk parents, says Saywitz.

"When we wait until families come to the attention of police or child welfare for suspicion of abuse, referrals to parenting programs will be seen as punitive and stigmatizing, rather than helpful, and dropout rates can be as high as 80 percent," says Saywitz.

The programs would teach parents how to listen actively, and help their children identify and cope with their emotions, and to use "time-outs," rather than harsh discipline known to be a risk factor for physical abuse. Research shows that the most effective intervention programs teach parents how to have positive interactions with their children, to be consistent, and replace negative commands and criticism with developmentally sensitive consequences, praise and enthusiasm for good behavior. Parents would practice their new skills with their own children during training sessions.

By tapping into community health centers, an existing system and network, the programs have room to grow, says Julia M. da Silva, director of APA's Violence Prevention Office. Programs proven to work are likely to get picked up by others in the system with similar needs, she notes.

Better research, better programs

The demonstration projects will also give psychologists an opportunity to further study how best to prevent child neglect and abuse, says Britner.

"We already have a good sense of the elements that should be there," says Britner. "At the same time, we would need to tailor these to specific communities, to see what would fit where."

For instance, some approaches will ultimately work better for physical abuse, some for neglect. Others will succeed in urban areas, while others are better suited for rural areas, he and Saywitz say. But to keep tabs on such trends, and to adapt standardized programs to the needs of individual communities, more psychologists and other mental health professionals need to work in these centers—ideally, one in each center—and evaluate the interventions, says Saywitz.

"We want someone at the site who is going to keep up on the prevention literature, on the child maltreatment literature, and adapting these programs," she says.

With more funding, Britner and Saywitz hope community health centers will eventually be hubs for training of health-care providers and mental health professionals in child-maltreatment prevention, an area in critical need of more experts.

To learn more about the report, attend the session "Behavioral Health Contributions to Child Maltreatment Prevention in Primary Care," on Aug. 8, 11 a.m.–12:50 p.m., during APA's Annual Convention in Toronto. The session will provide an overview of child maltreatment research and the challenges to integrating positive parenting into primary-care settings. Visit the Web site for a copy of the report.

Members of the Working Group on Child Maltreatment Prevention in Community Health Centers

Karen Saywitz, PhD, chair
Preston A. Britner, PhD
Jessica Henderson Daniel, PhD
Howard Dubowitz, MD
John R. Lutzker, PhD
Neena Malik, PhD
Joseph Stone, PhD