Tertiary Child Maltreatment Prevention Strategies: Not Only Last but Also Least Effective of the Three Traditional Approaches – Carly Foster

Introduction
Child maltreatment has been recognized in numerous publications as a global public health problem that needs immediate attention and intervention. Currently, the U.S. Child Abuse Prevention and Treatment Act recognizes four major types of child maltreatment: physical abuse, neglect, sexual abuse, and emotional abuse. In 2006, U.S. state and local Child Protective Services (CPS) cited that more than 900,000 children were victims of abuse in an investigated 3.6 million reports of children being abused or neglected (1). Agencies such as the World Health Organization and the U.S. Centers for Disease Control and Prevention argue that children who have experienced abuse and neglect are at an increased risk of negative health outcomes such as higher rates of alcoholism, drug abuse, depression, smoking, multiple sexual partners, suicide, and chronic disease (2, 3). Organizations agree that these health outcomes are in addition to the immediate physical and emotional effects of maltreatment. Public health prevention programs are absolutely essential to eradicating this global crisis. Unfortunately, many of the current public health prevention programs have originated from treatment programs. Considered to be prevention, the treatment programs are designed to alter the behavior of the abuser and protect the child from future abuse (4).
There are three types of child maltreatment programs currently recognized: primary, secondary, and tertiary prevention. Primary prevention strategies promote dissemination of information regarding positive parenting techniques, child development, risk factors for child maltreatment, and resources across communities and society. Secondary prevention strategies target individuals who are determined to be at “high-risk” for child maltreatment. Those at “high risk” for abuse may have predictive factors for child maltreatment such as history of abuse, drug or alcohol use, young age, and low levels of education. Tertiary prevention, closely related to treatment programs, strive to end further abuse and target the individual abuser. Minimal evidence exists to demonstrate effectiveness of this strategy and most professionals involved with families of abuse stress the importance of primary and secondary strategies if child maltreatment is ever to be eradicated (4).
Prevention of Abuse “After the Fact” May be too Late
Due to the complicated nature of predicting and identifying root causes of abuse, tertiary prevention programs may not address the many factors that may contribute to abuse. Many researchers agree that the perpetration of abuse results from complex interactions among characteristics of parents, children, cultures, and environmental influences (5). In a Developmental Psychology argument, Belsky attributes child maltreatment to three contexts – the developmental, immediate interactional, and environmental contexts of maltreatment. The “developmental context” examines the roles of parent and child characteristics in child maltreatment. When focusing on parent-child interaction and its processes associated with abuse, the “immediate interactional context” is analyzed. Lastly, the “broader context" discusses effects of the community, cultural, and evolutionary processes on child maltreatment (6). The volume of factors contributing to abuse limit prevention programs that target individual perpetrators of abuse. When developing a prevention program for groups of people who have committed child maltreatment, it is extremely difficult to reach the individual level and address specific needs. Next steps would include developing methods to identify the root causes of abuse for each individual perpetrator of child maltreatment in order to effectively prevent the behavior.
In addition to the multiple factors contributing to child maltreatment, tertiary prevention strategies tend to be punitive in nature and do not address social, economic, or psychological factors affecting the perpetrator of abuse. Response to child abuse and neglect involves identification of maltreatment and referral of victims and perpetrators for associated health care, social, and legal services; treatment of medical and psychological effects; and the reporting of abuse and neglect to the appropriate investigatory authorities in order ensure appropriate protection for the child. In addition to the child receiving protective services, the perpetrator may have to undergo such activities as parent support groups, parent education, home visitations, mental health, and other social support and therapeutic services (7). Despite efforts to affect behavior changes and prevent future abuse, studies show that one-third or more of the parents receiving intense support maltreated their children while in treatment. Many researchers suspect that over one-half of the families served are likely to mistreat their children following tertiary prevention strategies (8).
Some argue that the stress of treatment and prevention programs in addition to the existing array of factors may contribute to continued maltreatment of children. In addition, it may be difficult for parents and caregivers to focus on the treatment and prevention program when the root causes of child maltreatment have not been addressed (8). Other researchers argue that parental risk factors for child maltreatment, such as mental health problems and substance abuse may exacerbate the difficulty of establishing a trusting and open dialogue with parents (9).
Tertiary child prevention strategies have been shown to be most effective when the programs were more intense and prolonged, rather than short-term regimes. Generally a program that lasts longer than 4-6 weeks may be considered a ‘longer’ program (10). This data suggests that the success of the intervention, however, may depend on its ability to engage and retain parents for the entire program. The National Center for Injury Prevention and Control reported thirty to eighty percent of families most at risk for child maltreatment actually complete prevention programs. Even though families may attend programs, studies have shown they do not always adopt changes or maintain their skills. Despite the effectiveness of tertiary prevention programs, they have limited impact if they are unable to reach, engage, and retain prospective participants (11).
The last and perhaps most significant reason why prevention programs after the fact may be too late is demonstrated by Geeraert et al. This meta-analysis of 40 child maltreatment prevention programs suggests abusive parenting may become a fixed pattern of parent-child interaction without intervention (12). The reality is child maltreatment may exist for a long period of time before the authorities and child protective services become involved. This study provides important insight into the complex nature of parent-child relationships. Merrill also suggests that there are certain traits according to Personality Theory that predispose individuals for abuse. He suggests that parents may be categorized into four groups based upon psychological traits – chronically aggressive; rigid and compulsive, lacking warmth and reason; those who demonstrate a high degree of passivity and dependence; and extremely frustrated individuals (13). Not only is the treatment and prevention of further abuse more difficult at the tertiary level, but also may be ineffective if child maltreatment patterns are ingrained behaviors or personality traits of the perpetrator.
Control Theory
Control Theory, as defined by Glasser in 1986 states that all behavior is an attempt to satisfy powerful forces within ourselves. He argues that regardless of our circumstances, all people do, think, and feel is always the best attempt at the time to satisfy the forces within them. This behavior may be ineffective or even destructive to oneself or those around them. Individuals have choices, and he notes that people are typically unaware that they choose much of their misery (14). Expanding on this idea, Flowers explains that family violence may be an attempt to maintain power and control over another or others. He also argues that the use of force is always a choice. He even mentions that abusers would not necessarily become “out of control” when dealing with a police officer or member of society, but may become out of control when dealing with family or children (15). Utilizing Control Theory to explain child maltreatment challenges previous arguments that the causation of abuse is due to psychological, social, or environmental factors. This adds an additional layer to the problem and an additional reason why tertiary prevention programs may not be effective in stopping abuse.
If a parent or caregiver is using child maltreatment as a form of control, intervention and treatment may be extremely difficult. Family violence occurs in the absence of social controls that would normally result in positive behavior and punish acts of violence. Unless the abuser regains control in other aspects of their life such as social, economic, and emotional factors, treatment and prevention efforts may not decrease the incidence of child maltreatment. There are also researchers who argue whether social control is designed to keep violence from occurring or to maintain a certain level of family violence. There are still conflicting norms as to whether the use of violence in families is acceptable; many still feel that a certain amount of violence in families is accepted and even mandated.
What about the Child? The Ecological Model and Tertiary Prevention
Arguably, parental involvement is the most influential factor in determining child outcome. Attentive, stimulating, affectionate, and responsive child rearing may lead to optimal child development. Of the many influences associated with abuse, characteristics of parents are considered to be most important because they mitigate the external influences such as the environment. Thus, parents are often the target of interventions designed to prevent the occurrence of child abuse (17).
Though parental traits and behaviors may be an important aspect of child maltreatment, the Ecological Model considers the entire context of the abuse in order to understand and prevent child maltreatment. The four factors affecting child maltreatment include the parent, the family (including the child), the community, and the culture or society. Each of these levels may affect the child differently. Previous arguments have discussed the parent, the community, and the societal factors of abuse, but the purpose of this argument emphasizes the importance of the child. Tertiary prevention factors focused on the parent may not address the special needs or temperament of the child, nor prevention strategies targeted towards the child.
Many studies suggest that characteristics of the child do not increase the likelihood of child maltreatment. On the other hand, studies have shown that children who have special needs such as physical or mental disabilities, difficult temperaments, and mental health problems are more likely neglected. Regardless of whether child characteristics increase the likelihood of child maltreatment, the Ecological Model highlights the interaction between parents and children as considerations for abuse. A parent with high levels of stress interacting with a child with a difficult temperament may increase the probability of child maltreatment. Additionally, child characteristics may indirectly affect the parenting strategies used and the child-parent relationship. If a tertiary prevention strategy does not incorporate child characteristics, the program may be ineffective in preventing child maltreatment (18).
Following reported cases of abuse, parents are often referred to Child Protective Services (CPS) in order to undergo varying levels of therapy and treatment. Children often undergo therapy to address any feelings associated with the abuse and prevent them from being an abuser in a future family setting. What about the child’s role in preventing the abuse? Tertiary prevention programs do not empower children to prevent the abuse and obtain help when they are subjected to abuse. Without consideration for the child, tertiary prevention programs may not be successful in ending future abuse.
Conclusion
Minimal evidence exists to demonstrate effectiveness of tertiary prevention of child maltreatment and future research needs to focus on primary and secondary prevention efforts. Arguments against the tertiary prevention strategies include: the target population has already perpetrated the abuse, the Control Theory suggests an additional factor to address, and the child is left out of most tertiary prevention strategies. In order to fully understand and prevent child maltreatment, multi-faceted and multi-agency approaches need to be researched and validated. It is important for public health professionals to develop strategies based on the most current research.
Prevent Child Maltreatment Before it Starts:
Implement Parent Training Programs for all New Parents

There are three types of child maltreatment programs currently recognized: primary, secondary, and tertiary prevention. Primary prevention strategies promote dissemination of information regarding positive parenting techniques, child development, risk factors for child maltreatment, and resources across communities and society. Secondary prevention strategies target individuals who are determined to be at “high-risk” for child maltreatment. Those at “high risk” for abuse may have predictive factors for child maltreatment such as history of abuse, drug or alcohol use, young age, and low levels of education. Tertiary prevention techniques, closely related to treatment programs, strive to end further abuse and target the individual abuser. Primary prevention of maltreatment in the form of parent training should be implemented for all new parents, regardless of risk factors (4). This achievement would require an overhaul of the pre and post-natal care system, but may benefit children in the long term.
The Approach
Similar to Project 12-ways of the Behavior Analysis & Therapy Program of the Rehabilitation Institute at Southern Illinois University, this intervention would offer a range of services to families. The primary focus of Project 12-ways is to teach children and their parents the skills necessary to get along without abuse and neglect. This initiative emphasizes that family problems may be eased by teaching parents effective child-rearing skills. By incorporating the principles of Project 12-ways into the proposed national public health intervention, all new parents would receive parent training as a part of their pre and post-natal care. If finances were not a barrier to this intervention, home visitation may also be an important aspect of the parent training experience. By sending clinicians, social workers, or case managers to the families’ homes, the program would be able to identify risk factors for child maltreatment and assess the progress the families have made in accordance with the parent training.
Prevent Child Maltreatment Before it Begins
In a meta-analysis of 23 parent training programs, Lundahl et. al reported moderate but significant positive gains in all outcome constructs, such as attitudes linked to abuse and emotional adjustment. This study argues parent training is effective in reducing the risk of physical abuse, emotional abuse, and neglect. Following parent training, parents were more likely to develop child-friendly beliefs and attitudes and understand children’s developmental capabilities, emotions, and intentions. Parent training programs challenged the notion that corporal punishment is an effective long-term discipline strategy. Parent training also served to enhance the emotional well-being and stability of the parent, a major risk factor attributed to child maltreatment. When parents interacted with children following parent training, they were more likely to use warmth and democratic reasoning rather than coercion or force (5).
By conducting parent training for all expecting parents, the program trainers may be able to identify risk factors present in the parents. For instance, they may be able to assess the stress and anxiety levels of the parents, their employment status, and emotional attitudes towards child abuse. Early identification of these indicators is an important reason why primary prevention may be most effective. In tertiary prevention, or treatment, the root causes of child maltreatment have not been addressed, whereas primary prevention would enable parents to address risk factors for child maltreatment prior to the child’s birth or early in the child’s development (8). Similarly, the parental training programs may identify mental health problems and substance abuse, which are thought to contribute to child maltreatment and prevent open dialogue with healthcare providers (9).
In a meta-analysis by Geeraert et al, of 40 child maltreatment prevention programs, he suggests abusive parenting may become a fixed pattern of parent-child interaction without intervention (12). If parental training was practiced, parents and children may be more likely to develop positive interactions and relationships, rather than abusive patterns. Parent education programs improve parenting competence, effectively address risk factors for child maltreatment, and may result in fewer incidents of child maltreatment. Moreover, family visits may be an important factor to ensure that child maltreatment does not become a fixed interaction between parents and children (9). Primary prevention strategies encourage fixed patterns of positive parent-child interaction and may be more effective than tertiary prevention strategies.
Control Theory and Primary Prevention Strategies
If a parent or caregiver is using child maltreatment as a form of control, intervention and treatment may be extremely difficult. Primary prevention strategies may enhance social controls, resulting in positive behavior and reducing acts of violence. Parent training programs may assist parents to gain control in other aspects of their life such as social, economic, and emotional factors. Early identification of risk factors for child maltreatment may intensify the parent training, incorporating anger management and classes on self-control. Primary prevention strategies may also address the concern that many parents still believe that the use of violence in families is acceptable or mandated. Primary prevention and parent education may provide alternate strategies for parenting and an opportunity for parents to learn the long-term effects of child maltreatment (15).
The parent education classes would also require a component of child development and behaviors. This segment may reinforce the argument that, by understanding child development, the parents may have a better sense of what actions constitute “normal” childhood behaviors. This strategy may enable parents to relinquish their need for power if they are aware of the aspects of child development over which they do not have control.
The Ecological Model: When Primary Prevention Strategies Acknowledge the Child
Arguably, parental involvement is the most influential factor in determining child outcome. Primary prevention strategies promote attentive, stimulating, affectionate, and responsive child rearing, which may lead to optimal child development. Of the many influences associated with abuse, characteristics of parents are considered to be most important because they mitigate the external influences such as the environment. Thus, parents are often the target of interventions designed to prevent the occurrence of child abuse (17).
Primary prevention strategies address the special needs or temperament of the child. Studies have shown that children who have special needs such as physical or mental disabilities, difficult temperaments, and mental health problems are more likely neglected (18). The proposed parent training program would incorporate principles from the Triple P – Positive Parenting Program in Australia. The Triple P-Positive Parenting Program is comprised of five levels of intervention, which customizes the program with increasing intensity based on the necessities of the families. Level 1 aims to increase community awareness of available parenting resources and to increase parents' receptivity to participating in the Triple-P Positive Parenting. Levels 2-5 incorporate specific concerns of the child into the education. Level 2 of the program offers targeted interventions for specific concerns such as a child's developmental or behavioral difficulties. Level 3 of the Triple P-Parenting Program targets families with a child who possesses mild to moderate behavioral difficulties. The fourth level of the program offers intensive training in positive parenting skills to parents with children who possess more severe behavioral difficulties. Level 5 of the program is geared towards families with children who exhibit persistent behavioral problems and experience additional external risk factors such as parental depression or martial difficulties. This intensive program is specific to meet the families’ needs and the training includes: parenting skills training; mood and stress management training; and, partner support training (9).
Primary prevention strategies may also empower children to prevent the abuse and obtain help when they are subjected to abuse. Without consideration for the child, prevention programs may not be successful in stopping abuse before it starts. The Self Esteem and Assertiveness and Stress Reduction components in Project 12-ways are a great model for empowering the children. These programs aim to educate children about asserting their feelings and reducing stress, each important life skills.
Conclusion
Although labor intensive and a tremendous financial commitment, primary prevention strategies, such as parent training and home visitation may be the most effective methods to eliminate child maltreatment. Secondary prevention strategies target individuals who are at “high-risk” for child maltreatment, but studies have shown that there may be many false positives and false negatives for individuals at risk for committing child maltreatment. Tertiary prevention strategies are implemented following the abuse and may not be effective in reducing child maltreatment. Thus, a strategy of ending child maltreatment may be to stop it before it starts.
References

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