What Do We Know About the Effectiveness of Prevention?

Abuse and Neglect, (2003) U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau, Office on Child Abuse and Neglect. The findings and conclusions presented in this fact sheet do not necessarily represent the official positions or policies of the Children's Bureau's Office on Child Abuse and Neglect.

Introduction

There are three principal areas where research on maltreatment prevention has historically been most concentrated: home visitation programs, parent education programs, and school-based programs for the prevention of child sexual abuse. The following sections summarize what is known about prevention from research and evaluation in these areas.

Home Visitation Programs

Research on the impact of home visitation programs is one area in which there is a relative abundance of evidence, and that evidence, while not universally positive across all evaluations, suggests that home visiting can be an effective approach. David Olds, at the University of Colorado Health Sciences Center, has pioneered high quality, experimental research in the area of home visitation. Through the course of several replications and long-term follow-up studies over a period of 20 years, Dr. Olds has found positive, short-term and long-term outcomes for young, first-time mothers and their children in several areas, including decreased rates of child maltreatment, juvenile delinquency, and maternal criminality; increased economic self sufficiency; and increased social-emotional development (Olds et al., 1997).

The 1999 Future of Children report on home visiting programs also noted that despite some positive findings, many of the programs still struggled in numerous areas. Challenges were raised concerning enrolling, engaging, and retaining families. Similar issues were raised about the use of paraprofessionals versus nurses, staff retention, and the training needed by home visitors. When program benefits were demonstrated, this often only impacted a subset of families, and benefits were rarely seen for all program goals. The following are findings on home visitation from other recent work:

* An evaluation of Family TIES, a program of services for first-time teen mothers during pregnancy, found that teen mothers who received weekly home visits made significantly higher gains in creating a safe and healthy home environment compared with participants who received traditional family support services at a health center. The program had no significant effect on the childbearing philosophies or psychological well-being of participating mothers (Luster et al., 1996).

* An evaluation of the Healthy Start program, part of the Hampton Family Resource Project that provides home-based, parent education and support services to high-risk mothers, found several positive outcomes for families, including reductions in pregnancy risk status, birth complications, and subsequent pregnancies, and increases in childhood immunization rates and the number of adequate/safer home environments. The study also reported a reduced number of confirmed reports of child abuse and neglect (Galano & Huntington, 1996).

* An evaluation of STEEP (Steps Toward Effective, Enjoyable Parenting), an intensive intervention program of home visits and group sessions for high-risk women and their first-born children, found that compared to a control group, program participants demonstrated better understanding of child development, better life management skills, fewer depressive symptoms, and more organized and appropriately stimulating home-environments. The STEEP program also served as a buffer against stress, enabling parents to remain more sensitive to their children's needs even in the face of stressful life circumstances (Egeland & Erickson, 1993; Erickson & Egeland, 1999).

Leventhal suggests nine factors that are necessary for successful home-based services. They include: early intervention, intensive services over a sustained period, development of a therapeutic relationship between the home visitor and parent, careful observation of the home situation, focus on parenting skills, child-centered services focusing on the needs of the child, provision of "concrete" services (e.g., shelter, health care), inclusion of fathers in services, and ongoing review of family needs to determine frequency and intensity of services (Leventhal, 1997).

Parent Education

Some research also has concentrated on the impact of programs that provide education for parents that can reduce risks to children. The record is neither rich nor, on the whole, particularly compelling. However, a few studies have demonstrated positive findings. Many of the existing studies in this area rely on outcomes that do not include actual child maltreatment reports, but focus on short-term gains in knowledge, skills, or abilities. Thus, taken as a whole, little is known about the impact of these programs on child maltreatment in the long term.

From the late 1980s to the early 1990s, the William Penn Foundation funded 14 child abuse prevention demonstration programs in Philadelphia and surrounding suburban areas, and sponsored one of the most comprehensive evaluations of parent education services in the early 1990s. The National Committee for Prevention of Child Abuse conducted the evaluation of this initiative, integrating outcomes from all 14 programs. Data were gathered from 1,078 parents who received services between March 1990 and July 1991 across the 14 sites.

Researchers found that parents' potential for physical child abuse decreased significantly as measured by the Child Abuse Potential Inventory (CAP). Participants exhibiting the highest risk at pretest (i.e., the highest CAP scores) showed the greatest gains at post-test (i.e., the greatest decrease in CAP scores). Total CAP scores, as well as three subscales (distress, rigidity, and unhappiness), decreased significantly. In addition to an observed reduction in child abuse potential, there were observed reductions in the use of corporal punishment and inadequate supervision of their children, while participants demonstrated greater responsiveness to the emotional needs of their children (National Committee for Prevention of Child Abuse, 1992).

More recent evaluations of programs also have focused on families considered to be at risk for child maltreatment. The Bavolek Nurturing Program is a parenting education program that specifically focuses on four parenting constructs, including inappropriate parental expectations, lack of empathy toward the child, belief in corporal punishment, and parent-child role reversal. A secondary analysis using a convenience sample of at-risk rural families found significant improvements from pre- to post-test in each of these four areas, as measured by the Adult-Adolescent Parenting Inventory, with the post-test results consistent with nurturing parenting attitudes. While the results of the study were positive, the researchers acknowledge critical limitations, including the lack of a control group (Cowen, 2001).

Another such program offered 12-week parent education services to teen mothers in an effort to promote healthy, nurturing families. In an analysis of mothers participating in this program, researchers found positive, though not statistically significant, increases in knowledge of child development and attitudes toward parenting and discipline (Britner & Reppucci, 1997). Furthermore, families who participated in the parent education program had significantly fewer substantiated reports of child maltreatment than families who did not participate in the program.

An earlier study focused on a group of high-risk mothers receiving services through an intensive parent education program administered by the National Institute of Mental Health. Mothers with at least one child and who were considered very high risk for child maltreatment were recruited for the program during pregnancy (prior to 26 weeks gestation). The intensive program offered concrete services (e.g., assistance with transportation, assistance returning to school, arranging care for children, reducing bad habits such as smoking and overeating, and financial management), as well as abstract services (e.g., assisting the participant in better understanding others and themselves, and providing someone with whom to talk).

Following participation in the study, mothers reported high rates of satisfaction with the program and improvements in their parenting and life skills (Pharis & Levin, 1991). Both staff and participants reported that positive growth had occurred in 13 areas of the mothers' lives between onset of pregnancy (or entry into the program) and the interview (conducted at least one year after the intervention had begun).

School-Based Programs for Prevention of Child Sexual Abuse
Programs for children and parents that are designed to raise awareness about child sexual abuse is another area where there has been a recent and relatively concentrated research focus. Available research suggests that such programs can be successful at imparting information, but there is little evidence to conclude that these programs actually prevent child sexual abuse. A recent study published in 2000 utilized meta-analysis techniques to evaluate existing school-based, child sexual abuse prevention programs. Based on 27 control group studies, the study reported that children who participated in prevention programs performed significantly higher than control group children on outcome measures used in the studies, indicating improvements in knowledge and skills concerning sexual abuse. In the process of developing the sample of studies to include in the analysis, the researchers indicated that they identified no studies that had analyzed the effect of prevention programs on actual rates of abuse (Davis & Gidycz, 2000).

Few studies have attempted to establish a relationship between acquisition of knowledge about child sexual abuse and subsequent behavior change in children. In perhaps the only study of its kind, Finkelhor et al. conducted a national telephone survey of 2,000 children ages 10-16. The researchers found that children who had participated in school-based sexual abuse prevention programs not only demonstrated greater knowledge about sexual abuse, but also reported that these children were more likely to exhibit protective behaviors and utilize protective strategies when threatened or victimized (Finkelhor & Dzuiba-Leatherman, 1995).

In a follow-up study conducted the next year, during which a considerable proportion of the original 2,000-child sample was recontacted, the researchers again found that children who had participated in school-based sexual abuse prevention programs were more likely to use protective strategies (e.g., yelling, running, telling an authority). However, there was no evidence that these children, when threatened with abuse, were any more likely to stop the victimization than children who had not participated in school-based sexual abuse prevention programs (Finkelhor, Asdigian, & Dzuiba-Leatherman, 1995).

Since then, two recent studies have explored the correlation between knowledge gains and behavior change, and actual victimization. In an important recent study of 825 female undergraduates, for example, researchers found that young women who had not participated in a school-based prevention program were nearly twice as likely to have experienced child sexual abuse as young women who had participated in a program (Gibson & Leitenberg, 2000). Also within the last few years, results of a survey of high school students found that students who had participated in a general abuse prevention program were significantly less likely to have reported an incident of physical abuse. There appeared to be no difference between the two groups of students in terms of the incidence of sexual abuse (Ko & Cosden, 2001). Both of these studies, however, utilized small, local samples and relied considerably on self-report data of past experiences. Thus, there are important concerns with the generalizability of the results, as well as the vulnerability of the data to the hazards of memory.

The full report on the Emerging Practices project, Emerging Practices in the Prevention of Child Abuse and Neglect, can be found on the National Clearinghouse on Child Abuse and Neglect Information Web site:
HTML: nccanch.acf.hhs.gov/topics/prevention/emerging/report/index.cfm
PDF: nccanch.acf.hhs.gov/topics/prevention/emerging/report.pdf

A print copy of the report can be ordered by contacting the Clearinghouse at (800) FYI-3366, (703) 385-3206 (fax), nccanch@calib.com (e-mail).