Preventing Child Abuse and Neglect with Parent Training: Evidence and Opportunities
Researchers have identified four common co-occurring parental risk factors—substance abuse, mental illness, domestic violence, and child conduct problems—that lead to child maltreatment. The extent to which maltreatment prevention programs must directly address these risk factors to improve responsiveness to parenting programs or can directly focus on improving parenting skills, says Richard Barth, remains uncertain.
Barth begins by describing how each of the four parental issues is related to child maltreatment. He then examines a variety of parent education interventions aimed at preventing child abuse. He cautions that many of the interventions have not been carefully evaluated and those that have been have shown little effect on child maltreatment or its risk factors.
Although some argue that parent education cannot succeed unless family problems are also addressed, much evidence suggests that first helping parents to be more effective with their children can address mental health needs and improve the chances of substance abuse recovery. Barth recommends increased public support for research trials to compare the effectiveness of programs focused on parenting education and those aiming to reduce related risk factors.
Child welfare services and evidence-based parent training, says Barth, are in a period of transformation. Evidence-based methods are rapidly emerging from a development phase that has primarily involved local and highly controlled studies into more national implementation and greater engagement with the child welfare system. The next step is effectiveness trials.
Citing the importance and success of multifaceted campaigns in public health policy, Barth discusses a multifaceted parenting campaign that has demonstrated substantial promise in several large trials. The goal of the Triple P-Positive Parenting Program is to help parents deal with the full gamut of children’s health and behavioral issues. The campaign includes five levels of intervention, each featuring a different means of delivery and intensity of service. More broadly, Barth suggests that the evidence-based Triple P approach offers a general framework that could be used to guide the future evolution of parenting programs. [End Page 95]
Improved parenting is the most important goal of child abuse prevention. Parents maltreat their children for many reasons and combinations of reasons. In the past three decades, researchers have identified four common co-occurring issues—parental substance abuse, parental mental illness, domestic violence, and child conduct problems— that are related to parenting and that lead to child maltreatment. Understanding and responding to these issues is fundamental to designing effective parenting education programs that can help prevent abuse and neglect. One key decision facing those who design such programs is whether (and the extent to which) a parenting program should directly address these related problems or whether efforts to improve parenting should focus primarily or solely on improving parenting skills, with the expectation that the negative effects of these other problems on parenting may recede if parenting programs are effective.
A fifth risk factor for child abuse is family poverty. Every national incidence study of child abuse and neglect has shown that poor families are disproportionately involved with child welfare services. Parenting education, however, is not designed to reduce poverty, and that risk factor will not be further discussed below. See the article in this volume by Fred Wulczyn for a discussion of family poverty and child maltreatment.
What Parental Behaviors May Lead to Child Abuse and Neglect?
A description of the prevalence of the co-occurring risk factors among parents who abuse and neglect their children sets the stage for a discussion of parenting education elements that may mitigate the untoward effects of these co-occurring problems.
Substance abuse by a child’s parent or guardian is commonly considered to be responsible for a substantial proportion of child maltreatment reported to the child welfare services.1 Studies examining the prevalence of substance abuse among caregivers who have maltreated their children have found rates ranging from 19 percent2 to 79 percent or higher.3 One widely quoted estimate of the prevalence of substance abuse among caregivers involved in child welfare is 40 to 80 percent.4 An epidemiological study published in the American Journal of Public Health in 1994 found 40 percent of parents who had physically abused their child and 56 percent who had neglected their child met lifetime criteria for an alcohol or drug disorder.5
Substance abuse has its greatest impact on neglect. In the 1994 study noted above, respondents with a drug or alcohol problem were 4.2 times as likely as those without such a problem to have neglected their children. In another study conducted during the 1990s, child welfare workers were asked to identify adults in their caseloads with either suspected or known alcohol or illicit drug abuse problems.6 In 29 percent of the cases, a family member abused alcohol; in 18 percent, at least one adult abused illicit drugs. These findings approximate those of the more recent National Survey of Child and Adolescent Well-Being (NSCAW) that 20 percent of children in an investigation for abuse and neglect had a mother who, by either the child welfare worker’s or mother’s account, was involved with drugs or alcohol; that figure rises to 42 percent for children who are placed into foster care.7 These studies have clearly established a positive relationship between a caregiver’s substance abuse and child maltreatment among children in out-of-home care and among children in the [End Page 96] general population. Among children whose abuse was so serious that they entered foster care, the rate of substance abuse was about three times higher.8 Thus, substance abuse by parents of victims of child abuse may not be as common in the general child welfare services-involved population as often believed, but substance abuse appears to be a significant contributor to maltreatment.
The mechanism by which substance abuse is responsible for child maltreatment is not as evident (outside of the direct relationship created by the mandated reporting of children who have been tested to have been born drug-exposed). Stephen Magura and Alexandre Laudet argue that in-utero exposure to cocaine and other drugs can lead to congenital deficits that may make a child more difficult to care for and, therefore, more prone to being maltreated.9 Parenting skills can also suffer among substance-abusing parents, who may be insufficiently responsive to their infants.10 Caregivers who abuse substances also may place a higher priority on their drug use than on caring for their children, which can lead them to neglect their children’s needs for such things as food, clothing, hygiene, and medical care. Findings from the NSCAW indicate that substance abuse was much more highly associated with “neglect, failure to provide basic necessities” than with “neglect, failure to supervise” or any type of abuse.11 Finally, violence may be more likely to erupt in homes where stimulant drugs and alcohol are used.12 The interplay between substance abuse and child maltreatment within family dynamics and across children’s developmental periods is gradually becoming clearer. Dana Smith and several colleagues showed that prenatal maternal alcohol and substance abuse and postnatal paternal alcohol and substance abuse are most highly associated with child maltreatment.13 Mothers most often maltreat infants or very young children; fathers involved with alcohol and other substances are more likely to maltreat non-infants. These findings can help in developing parent education programs aimed at preventing child abuse.
Parental Mental Illness
Relatively little has been written about the effect of serious and persistent parental mental illness on child abuse, although many studies show that substantial proportions of mentally ill mothers are living away from their children.14 Much of the discussion about the effect of maternal mental illness on child abuse focuses on the poverty and homelessness of mothers who are mentally ill, as well as on the behavior problems of their children—all issues that are correlated with involvement with child welfare services.15 Jennifer Culhane and her colleagues followed a five-year birth cohort among women who had ever been homeless and found an elevated rate of involvement with child welfare services and a nearly seven-times-higher rate of having children placed into foster care.16 More direct evidence on the relationship between maternal mental illness and child abuse in the general population, however, is strikingly scarce, especially given the 23 percent rate of self-reported major depression in the previous twelve months among mothers involved with child welfare services, as shown in NSCAW.17
The relationship between maternal depression and parenting has been better explored and offers guidance regarding the design of parent education programs to prevent child abuse and neglect. Penny Jameson and several colleagues show that depressed mothers have difficulty maintaining interactions with their children and that toddlers tend to match the negative behavior rates of [End Page 97] their depressed mothers (but not of their non-depressed mothers).18 Along similar lines, Casey Hoffman, Keith Crnic, and Jason Baker have shown that maternal depression interferes with parenting and is linked with the development of emotional regulation and behavior problems in children—thus making subsequent parenting even more difficult.19 Sang Kahng and several colleagues tested the relationship between changes in psychiatric symptoms and changes in parenting and concluded that as symptoms of mental illness lessened, a mother’s parental stress decreased and her nurturance increased. Contextual factors—on the positive side, more education and social support; on the negative side, a history of substance abuse and increased daily stress—predict both symptoms and parenting.20 Taking these contextual factors into account helps to weaken the relationship between psychiatric symptoms and poor parenting. Nicole Shay and John Knutson concur that maternal depression is a risk factor for child abuse and neglect, though they find that it is not so much depression as the irritability that accompanies depression that causes mothers to be physically abusive.21
Considerable evidence has also accumulated over many years that as parenting improves, symptoms of maternal depression may lift.22 Long-term analyses of maternal depression and child problem behavior show that completing parent management training is effective, overall, in improving parenting and reducing conduct problems. Significantly, mothers who improve their parenting skills over a period of a year also show significant reductions in depression during that same interval. And the lifting of depression contributes significantly to improved parenting and child conduct over the next eighteen months.
Many families involved with child welfare services must also cope with domestic violence. According to the NSCAW, the lifetime and past-year self-reported rates of intimate partner violence against mothers were 44.8 percent and 29.0 percent, respectively.23 Caregiver major depression was also strongly associated with violence against women. In a pair of analyses based on NSCAW, Cecilia Casaneueva and colleagues showed that about one-third of parents with low parenting skills had experienced domestic violence.24 Such violence was also associated with harsher parenting: children over the age of eighteen months were more likely to be spanked if their parents were facing domestic violence.25 But parents who had once experienced domestic violence, but had been able to put it behind them, did not show elevated rates of impaired or violent parenting.26 The parenting of women currently suffering interpersonal partner violence is significantly worse than that of women who have faced it in the past, suggesting that the context of the violence is creating the problems in parenting and child conduct problems and that its cessation may be a more important contributor to child outcomes than parent instruction. [End Page 98]
Child Behavior Problems
Many studies have shown that children who are involved with child welfare services have high rates of behavioral problems. Indeed, during the 1970s, child welfare services were specifically targeted at two types of children—those without extraordinary behavior problems who needed protection from parental abuse and those with extraordinary behavior problems whose parents often needed the assistance of treatment or placement services.27 Although the Adoption Assistance and Child Welfare Act of 1980 and subsequent child welfare legislation made federal funding for child welfare services contingent on parental incapacity or abuse, many children continue to enter care because of behavior problems. (They are often reclassified as abused or neglected or abandoned to meet the requirements of funding).28 Whatever the reason for their involvement with child welfare services —whether difficult child behavior or some measure of parental incapacity—the share of children involved with these services who have behavior problems is substantial. NSCAW indicates that, at least according to parental reports using the Child Behavior Checklist, 42 percent of children between the ages of three and fourteen score high enough to warrant clinical treatment for their problem behaviors.29 The high rates of behavior problems reported by parents of these children may, however, exaggerate the actual rates. Anna Lau and several colleagues show that physically abusive parents rate the “externalizing” misbehavior (that is, delinquent or aggressive behavior) of their children far more negatively than do independent raters—a difference that does not exist for non-abusive parents.30 This pattern is consistent with a commonly noted sign of physical abuse—the description by the parent of the child as “bad.” Indeed, according to a study by Michael Hurlburt and several colleagues, “The tendency to overreact to child misbehavior, and to overstate behavior problems, may represent a key dispositional risk factor that predicts child physical abuse.”31
Barbara Burns and several colleagues found that only a small proportion of children with behavior problems receives treatment and, in all likelihood, a still smaller proportion receives evidence-based services.32 Therefore, because parents believe that their children’s behavior is poor and few practitioners are providing evidence-based methods to help them, the risk of abuse is elevated.
Have Parenting Programs to Prevent Child Abuse Addressed the Major Parental Risk Factors?
Many interventions target parents who have been found to be abusive. Fewer explicitly aim at preventing child maltreatment, although prevention is certainly a secondary objective of many early intervention efforts such as the Nurse-Family Partnership. Almost all parent education programs are directed at helping parents to develop more appropriate expectations of their children, to learn how to treat them with empathy and nurturance, and to use positive discipline instead of corporal punishment. Some more comprehensive efforts also address the risks posed by parental social and behavioral problems discussed above. The programs suggested, below, are offered because they tender innovative approaches. It should be noted, however, that Joanne Klevens and Daniel Whittaker conclude that many child abuse prevention programs that address a broad range of risk factors have not been carefully evaluated and that those that have been evaluated have generally been found to have little effect on child maltreatment or its risk factors.33 [End Page 99]
Substance abuse services for adults rarely include parenting skills. A few initiatives have been developed to help parents in out-patient methadone programs. A more common, and costly, strategy, used both in the United States and abroad, is to treat both women and their dependent children in residential treatment centers. I discuss below some substance abuse programs that show promise in teaching women how to be better mothers. Few, however, have had rigorous evaluations.
The Focus on Families (FOF) field experiment emphasized relapse prevention for mothers in methadone treatment. FOF included thirty-three sessions of parenting skills education, as well as home-based case management services lasting about nine months.34 Compared with mothers in the control group, mothers receiving the program, especially those motivated enough to initiate and follow through with at least sixteen sessions, were able to learn effective parenting skills. The experiment included no explicit evaluation of child abuse prevention.
Because children who test positive for prenatal drug exposure must, by federal law, be referred to child welfare services, they are a group of special interest to those examining child abuse prevention. The Arkansas Center for Addictions Research, Education, and Services (CARES) provides comprehensive residential substance abuse prevention and treatment services to low-income pregnant women, mothers, and their children. The center provides various services for the mother and her dependent children, but the main service is parenting classes. Within these classes the mothers discuss child development, appropriate parental roles, and role reversal (which occurs because parents do not play their proper role during their addiction). They also learn what behaviors are appropriate to expect of their children and how to practice positive discipline.35 Nicola Conners and her colleagues found that women who participated in CARES not only made gains in employment and mental health but also decreased risky behaviors and substance abuse.36 The longer the women stayed in the program, the more they improved. Although parents came to have more realistic expectations of their child and to understand role reversal, however, they continued to see corporal punishment as a necessary parental tool. Analysts did not evaluate the effect of the program on subsequent child maltreatment.
The Coalition on Addiction, Pregnancy, and Parenting (CAPP) provides services to substance-abusing women and their children in the Boston area. During the women’s stay at the residential treatment center, they are required to participate in a parenting skills group, a child development group, and a mothers’ support group. The parenting skills group, based on Stephan Bavolek’s Nurturing Program for Parents of Children: Birth to Five Years Old, addresses inappropriate expectations of children, lack of empathy, corporal punishment, and role reversal, all [End Page 100] considered correlates of abuse and neglect. When participants rated their progress, almost all reported improved parenting skills but, again, the program included no formative evaluation of effects on child abuse.
Parental Mental Illness
The lack of data on the link between parental mental illness and child abuse is matched by the paucity of research on interventions that simultaneously address mental health problems and parenting concerns. Aside from work by David DeGarmo and his colleagues showing that parent education can reduce depression, I was able to find no recently published peer-review work on interventions that address parental mental illness with the aim of preventing child abuse.37
The Thresholds Mothers’ Project (TMP), developed in 1976, was the nation’s first program for mothers with psychiatric illnesses that also offered services to children, who could live with their mothers in supportive housing or independent apartments.38 The program builds on a classic psychosocial rehabilitation base, which is a best practice for mentally ill adults according to the Substance Abuse and Mental Health Services Administration. Care managers help mothers meet their basic needs, stabilize living arrangements, and address psychiatric symptoms. They also help mothers enroll children in appropriate educational programs, including a therapeutic nursery and after-school care. A 2005 report by Patricia Hanrahan and several colleagues found that at intake, forty-three children were living with their mothers; after one year, 77 percent of children whose mothers remained in the program were still living with their mothers. All the children had been enrolled in school and had their well-child visits. The study lacked a comparison group to provide evidence of the program’s effect on child abuse prevention during that year or thereafter.
Mental health problems often co-occur with substance abuse and exposure to traumatic events like domestic violence. Nancy Van-DeMark and several colleagues report on the Children’s Subset Study of the Women, Co-Occurring Disorders, and Violence Study, an intervention that addresses the needs of mothers with co-occurring problems of domestic violence, substance abuse, and mental illness.39 The report was based on a quasi-experimental evaluation—one that compared the outcomes of participants who did and did not receive treatment, though participants were not assigned randomly to the treatment and no-treatment groups. The study found that mothers reported that their children, aged five to ten, showed considerable improvement in emotional and behavioral functioning. Given the influence that a mother’s perception of her child’s behavior may have on child maltreatment, the finding is significant and promising for preventing child abuse, although the evaluation made no direct test of a preventive effect.
Child-parent psychotherapy, which focuses on relationship enhancement, appears effective in reducing the behavioral problems and traumatic symptoms of children living with domestic violence. Such psychotherapy has also been shown to reduce the mother’s posttraumatic stress disorder (PTSD) avoidance symptoms and to allow the mother to discuss with her child the violence that occurred.40 The effect on future child abuse and neglect remains unexamined.
Child Conduct Problems
A growing number of evidence-based parent training programs help parents of children at [End Page 101] risk of behavior problems, with emerging behavior problems, or with significant conduct problems. These programs are not designed specifically for parents who have abused their children but rather to help parents deal with their children’s problem behavior. Several have included families involved with child maltreatment or at high risk of maltreatment, but hardly any have included families who were the subject of child abuse and neglect reports.41 The Incredible Years (IY) is considered to be one of the most effective interventions for reducing child conduct problems.42 Jamila Reid, Carolyn Webster-Stratton, and Nazli Baydar examined IY, randomly assigning children to the IY program or to a control group that received usual Head Start services.43 Children with significant conduct problems and children of mothers whose parenting was highly critical—arguably those dyads most at risk for child maltreatment—benefited most from IY.
Although on-the-point research is lacking about the child maltreatment risk for parents of children with aggressive behavior who themselves come from families with delinquent behavior, a strong association seems plausible. Laurie Brotman and her colleagues examined IY’s effects on families with preschoolers predisposed to antisocial behaviors, as indicated by having a relative with a delinquent history, to determine whether the intervention helped reduce the child’s aggression and helped teach the parents effective parenting.44 IY reduced children’s physical aggression and parents’ harsh parenting and increased parents’ responsive parenting and their stimulation of their child’s learning. Parent ratings of child aggression were unchanged, however—a concern regarding its efficacy in preventing child abuse among this very high-risk group. Parent-Child Interaction Therapy (PCIT) uses observation and direct audio feedback to the parent via headset to build parental competence in interacting with children whose behaviors are difficult and disruptive. It teaches parents to give their children positive attention and how to manage their problem behavior. Throughout the intervention the therapist instructs the parents and helps them to use new skills effectively in the clinic so they can transfer them to the home.45 In the most compelling study of the effectiveness of PCIT in preventing physical abuse, Mark Chaffin and his colleagues showed that they could significantly improve parenting competence and lower the rates of repeated reports and re-investigations for child abuse and neglect in Oklahoma.46 Success was greatest when therapists had strong ongoing coaching and supervision and when parents were not exposed to multiple interventions and were allowed, instead, to focus on learning how to use positive parenting and discipline methods.
Other Parenting Programs Aimed at Preventing Abuse and Neglect
Other parenting programs that are effective in reducing child abuse are cognitive behavioral therapy, parent-child interaction therapy, and child behavioral management programs.47 Some, but not all, home visitation programs, which have historically been used to help disadvantaged mothers, show evidence of success in preventing child abuse. Because these programs require reporters to visit the home, however, child abuse is reported more often in home visitation programs than in control groups that do not receive in-home services.48 Finally, multifaceted interventions that incorporate specific safety training (for example, related to sleep safety practices) and general parent training appear to be effective in reducing unintentional child [End Page 102] injury.49 Although unintentional injury is not the same as child maltreatment, procedures that increase child safety are also likely to decrease neglect charges that stem from failure to supervise. Another approach that shows promise in both three- and nine-month versions is Family Connections, which works with families who have been referred to child welfare services but have not yet progressed into the formal system. It addresses caregiver issues (parents and custodial grandparents) and incorporates in-home parent training as well as coordinating care with other service providers.50
Are Multifaceted Campaigns That Include Parent Training Programs Effective?
For more than thirty years, public health policy has emphasized the importance of multifaceted campaigns using approaches that range from media efforts to group work to individual counseling to address complex health behavioral problems.51 Beti Thompson and her colleagues conclude, in their wide-ranging review of community interventions, that these campaigns continue to be a compelling approach to changing health behaviors and that the modest but important effects they show at the population level can have large effects on disease.52 Some interventions in the field of parent training—such as Family Connections and others described above—address co-occurring problems, and some new approaches also include multifaceted campaigns.
The most widely disseminated and tested of these campaigns is the Triple P-Positive Parenting Program, a multi-level evidence-based intervention designed to strengthen parenting. Designed in Australia by Matthew Sanders and several colleagues, it has since been used in many countries including the United States.53 Triple P includes five levels of intervention, each building on the same language and concepts but featuring a different means of delivery and intensity of service. Universal Triple P, level 1, is an overall media campaign that informs parents about parenting issues and gets them involved in parenting programs like Triple P. Selected Triple P, level 2, targets one topic, such as toilet training or bedtime, about which parents may either receive direct or phone contact with a trainer or therapist or attend a seminar. Primary Care Triple P, level 3, is directed toward parents who are concerned about their children’s development or behavior. Parents attend four brief programs, each about eighty minutes in length, to learn how to manage their children’s behaviors. Some parents may have either phone or direct contact with a primary care practitioner if needed. Standard Triple P, level 4, is for parents of children with more severe behavioral problems, like conduct disorder or aggression, who want to learn effective parenting skills. These parents attend twelve sessions of about an hour each, with a choice of group or individual sessions. Parents also may have phone contact with a primary care practitioner. Finally Enhanced Triple P, level 5, is for parents who have children with behavioral problems and who have dysfunction within their family. These parents attend about eleven one-hour individual sessions that are specific to their needs. Practitioners may also conduct home visits to ensure that parents are using the skills they are being taught.54
The framework for Triple P, very much like that of other leading American parent training programs, is squarely based on social learning theory. Triple P is based on five principles that are imperative in teaching positive parenting: ensuring a safe and engaging environment, creating a positive [End Page 103] learning environment, using assertive discipline, having realistic expectations, and taking care of oneself as a parent.55 The conceptual underpinning of Triple P is that the parent must be “self-regulatory,” meaning that she believes that she can improve the behavior of her child through her own actions and is confident in making decisions and problem solving to do so.56
Triple P is now undergoing a major trial in South Carolina with a slightly different configuration. Though the principles are the same, some of the levels differ slightly. Selected Triple P, for example, is delivered as a “one-time seminar” to a group. All levels include a specific session for teen children. Group Triple P is similar to level 2 but it targets more specific behavioral and emotional problems and is given to a smaller group. Level 4, Standard Triple P, also includes Group Triple P, a Group Teen Triple P, and Standard Stepping-Stones Triple P. The latter level is for parents who have a developmentally disabled child. Both Group Triple P and Group Teen Triple P are administered to groups of parents. Standard Triple P and Standard Stepping-Stones Triple P are administered individually to parents in a home or clinic setting. Finally, level 5 includes Enhanced Triple P, which is directed to families with several problems, and Pathways Triple P, which is for parents who are at risk for child abuse. Both level 5 programs are administered individually, at home or in a clinic.57
The results of this first major U.S. Triple P trial are quite promising. After training more than 600 primary care practitioners in Triple P, and implementing the universal media strategies in half of eighteen counties randomly assigned to Triple P in South Carolina, Ronald Prinz found that administering Triple P to families in a population of 100,000 children under the age of eight resulted in 340 fewer cases of maltreatment, 240 fewer children being removed from their homes, and 60 fewer injuries from maltreatment requiring medical attention.58 To estimate the potential for more widespread use of the Triple P System of Interventions, the U.S. trial queried 448 service providers who were trained for more than two and a half years in their use of Triple P methods.59 As a group, the service providers reported becoming more effective in delivering parenting consultation based on the Triple P approach. Months of setup work by Triple P staff were typically required to gain access to the service providers and to determine the most appropriate level of training for the providers. As a result of the training process, service providers in the U.S. Triple P trial demonstrated significant improvement in confidence and competence in delivering this evidence-based parenting awareness and training program. After completing training, most service providers reported a high degree of confidence and skill in delivering parent consultations.60
What Makes High-Risk Families Stay Involved in Parent Training Programs?
Although many programs aim to help parents avoid maltreating their children, hardly any are mandatory. For these programs to be effective, parents must be actively involved and want to change. Many studies have tried to find ways to help parents be more motivated to change.
Matthew Nock and Alan Kazdin administered a Participant Enhancement Intervention (PEI) to parents of oppositional, aggressive, antisocial children, giving each parent eight [End Page 104] sessions with a therapist employing PEI, which is designed to “increase parents’ motivation to participate in treatment and to increase attendance and adherence to treatment.”61 On the first, fifth, and seventh sessions the parents devoted about fifteen minutes to discussing their motivation to change and any barriers that were present. The therapist and the parent then worked together to develop a plan that would allow the parent to overcome the barriers and make a positive change. In a randomized control trial, parents who received PEI had greater treatment motivation, attended significantly more treatment sessions, and adhered more closely to treatment, according to both parent and clinician report. Because parents attended most of their sessions, it can be stated that PEI was effective in increasing their motivation.
Guided Self-Help and Parent Aide Models
Minnesota’s Early Childhood Family Education program has provided Minnesotans with support for the transition to parenthood for a third of a century. Its core program element is discussions in local community centers or elementary schools, though written materials are also available. The parent education discussions, available in almost every school district in Minnesota, are attended by about 300,000 parents of children from birth to age four each year. If families are isolated, parent educators bring the program to them. Parents, who meet with each other and with the educators, often indicate that although they enter the program for their children, they stay in it for themselves.62 During each session parents and children have “parent-child time,” structured activities overseen by the parent educator. Though it is the largest and oldest group support parenting program in the country, it has not been rigorously evaluated.
Peer support groups also help parents who are involved in child welfare services, but whose abuse cases have not necessarily been substantiated.63 After parents complete court-ordered parenting classes and other assigned programs, they have the option to enroll in an empowerment group consisting of professionals and peers who are or have been involved with child welfare services. Anecdotal evidence indicates that parents in these groups experience positive changes on a range of dimensions. Evidence is also becoming available about Parents Anonymous,© which has recently undergone a long-term single-group evaluation indicating significant reductions in the risks associated with child maltreatment.64 Circle of Parents,© another well-known support group intervention, is beginning to develop an evidentiary base (although the research conducted so far would not yet lift this program into the group generally known as “promising practices”).65
More than 100 home visitation programs provide services to parents at risk for abuse and neglect in twenty-eight states.66 Operated under the oversight of the National Exchange Club Foundation, each site offers a free home visitation program for parents involved with child welfare services; the goal is to reduce the cycle of abuse. Parents are [End Page 105] referred to the program by child welfare services. Those who choose to participate are linked with a case manager and often a volunteer parent aide who conducts home visits. The aim of both is to build a relationship and become a positive mentor in the parent’s life. During weekly visits the aide targets individual areas of concern as well as parenting skills and also shares information about how to get services, such as housing, health care, and social services, that the parent requires. The program has been shown to be effective in reducing the number of subsequent referrals to child welfare services.67 Like most parent education programs aimed at preventing child abuse and neglect, it has not undergone rigorous evaluation.
The Design of Parent Training Programs
Each of the interventions discussed so far includes a manual that communicates how parent training should be delivered. As such, these interventions are certainly likely to be an advance over the existing ad hoc ways in which many child welfare agencies now develop parent training programs.
Common Elements of Effective Programs
John Piacentini observes that identifying and building on the effective common elements of parent training programs offers considerable advantages.68 Among the common elements that he notes are potential use in multiple clinical and service applications, including the development of benchmarks for assessing quality of care; simplified therapy training efforts focused on key techniques as opposed to individual treatment manuals; and use in developing individualized modular or stepped-care interventions that fit the unique characteristics of the clients rather than the vision of the treatment designer.
A team of British researchers has recently completed a review of parenting education programs that isolates a number of effective components.69 Early intervention, for example, results in better and more durable outcomes for children, though late intervention is better than none and may help parents deal with parenting under stress. Having a strong theory base and having a clearly articulated model of the predicted mechanism of change are also likely to make interventions effective, as is targeting: aiming interventions at specific populations or individuals deemed to be at risk for parenting difficulties. Including explicit strategies to recruit, engage, and retain parents is also a core element of promising parenting programs. Interventions should also have multiple components, such as a variety of referral routes for families and more than one method of delivery. Group work, where the issues involved are suitable to be addressed in a “public” format and where parents can benefit from the social aspect of working in groups of peers, are preferable to individual work, unless the problems are severe or entrenched or parents are not ready or able to work in a group. Individual work should, typically, include an element of home visiting as part of a multi-component service, providing one-to-one, tailored support. Programs that carefully structure and control the services delivered to maintain program integrity appear to be successful, as are interventions delivered by appropriately trained and skilled staff, backed up by good management and support. Interventions of longer duration, with follow-up and booster sessions, are recommended for problems of greater severity or for higher-risk groups. Behavioral interventions that focus on specific parenting skills and practical “take-home tips” for changing more complex parenting behaviors and affecting child behaviors are also considered effective. Finally, interventions [End Page 106] that work in parallel (though not necessarily at the same time) with parents, families, and children are considered best practice.
In the United States, Ann Garland and several colleagues reviewed all the evidence-based treatment programs for disruptive child behavior and identified the common elements, which they confirmed with an expert panel.70 Garland and her team were able to distinguish treatment elements directed to children and those directed to parents and to separate therapeutic content from therapist techniques. Perhaps most significant, they added practice elements such as frequency and intensity of treatment. The five fundamental working alliance and treatment parameters common to effective interventions were: consensually set goals, a minimum of twelve sessions, meeting at least once weekly, building rapport and an effective bond with the therapist, and active participation by the child and parent.
Michael Hurlburt and colleagues derived a list of eight key components of three leading parent education programs—the Incredible Years, Parent-Child Interaction Therapy, and Parent Management Training—with a history of some success with child maltreatment populations.71 What the three programs had in common was that each strengthened positive aspects of parent-child interaction, decreased the use of parent directives and commands, used specific behavioral approaches, included detailed materials to support parent skill building, included homework, monitored changes in parenting practices, required role-playing, and lasted at least twenty-five hours.
Video Feedback to Parents
Other intervention elements that may be important to program design have not been fully evaluated. Researchers, for example, recently subjected parent education programs that use video playback of parent-child interactions to a meta-analysis.72 They found that these programs have a sizable positive effect on parent behavior and a modest but significant effect on children’s behavior—no less for children referred to clinics for conduct problems than for children referred from other sources.
Parents and Children Together
Returning to the effect of parenting practices on maladapted child behavior and the reciprocal influence of children’s behavior on parenting practices, a promising avenue for future research would involve testing concurrent interventions for parents and for children. For example, it might be valuable to pair an evidence-based parent training group with a concurrent child group focused on social skills, social information processing, and interpersonal problem-solving skills. Such child-focused groups alone have been shown to influence significantly both parenting behavior and child behavior in school settings.73 Pairing the child group with the parent group could test to see whether they act synergistically when run concurrently. Making good use of children’s time may also act as yet another incentive for parents to attend and benefit from parent training groups.
Parent Education on Focused Issues
Parent education need not be comprehensive to be helpful in preventing child abuse. A focused program to reduce abusive head trauma, for example, has shown that providing vivid information and requesting a commitment from parents to refrain from shaking babies can substantially reduce child maltreatment—even when no other effort is made to address substance abuse, poverty, or the use of positive parenting principles.74 [End Page 107]
Adaptations for Racial, Ethnic, and Cultural Groups
For the most part these evidence-supported interventions seem robust across cultures although researchers have conducted few definitive evaluations. Three reviews, bridging somewhat different topics and using different methods for comparing the efficacy across groups, have all concluded that minority children and families appear to benefit as much as or more than other groups from evidence-based interventions like those proposed here.75 At the same time, because the success of a program depends importantly on participants’ remaining engaged until they complete the program, as well as the fidelity with which the program is delivered, cultural adaptations that increase the likelihood of optimal delivery and receipt of these programs to practitioners, parents, and children would seem well warranted.76
New Directions for Parent Training and Child Welfare Services
Overall, child welfare services and evidence-based parent training are in a period of transformation. Evidence-based methods are rapidly emerging from a development phase that has primarily involved local and highly controlled studies, into more national implementation and greater engagement with child welfare services. At the same time, the field of child welfare services is showing new awareness of the importance of evidence-based methods. Journals are publishing special issues on the topic, the Administration for Children and Families (ACF) launched a major round of funding in 2004 to promote testing of evidence-based methods, several states (for example, Maryland, Washington, and California) are developing statewide initiatives, and this past year ACF created five regional resource centers on implementation to expedite the dissemination of best practices. Although these efforts are not focused on child abuse prevention per se, the infrastructure to create prevention programs, based on the campaign model, is emerging.
The next major step is to implement effectiveness trials. The programs are mature enough and have enough experience with similar populations of high-risk families caring for children at home,77 as well as foster families,78 to justify immediate testing. Child welfare agencies have demonstrated that they can be the setting for randomized clinical trials. They can build on experience with the Social Security Act Title IV-E waivers, which allow dollars that ordinarily go to out-of-home care to go instead for cost-effective in-home services, and on experience with recent trials funded by ACF, the Centers for Disease Control and Prevention (CDC), and the National Institute of Mental Health. Such trials will help researchers better understand implementation constraints and will clarify which families are most likely to benefit from parent training programs.
Providing effective and evidence-based parent services is the fulcrum of fairness in the American approach to child welfare services delivery. Investing federal and state funds in trials to test interventions for [End Page 108] improving parent training and providing the necessary support to deliver those that succeed offers the opportunity for uncomplicated policymaking.
Should Parenting Programs Have a Multi-Problem Focus or a Parenting-Only Focus?
The evidence that parent education cannot succeed unless other family problems are also addressed is anecdotal and weak—at least as much evidence suggests that first helping parents to be more effective with their children can help address mental health needs and help improve the chances of substance abuse recovery. The work of David DeGarmo, Gerald Patterson, and Marion Forgatch shows convincingly that learning how to improve parenting reduces mental health problems.79 Marjukka Pajulo and her colleagues have argued that strengthening mothers’ positive connections to their children is likely to reduce their dependency on illicit substances as the rewards of successful parenting build neural pathways that compete with the desire for drugs.80
A CDC review of parent training programs found that parents who are given hands-on practice using new skills under the watchful eye of a professional acquire the skills more effectively. The review also found that teaching parents how to communicate their emotions effectively improves their parenting skills.81 The CDC review also showed that having multiple components—for example, addressing parents’ relationship with each other in the context of parent training—does not enhance a program’s effectiveness but rather is likely to decrease it. This finding replicates Mark Chaffin’s work with abusive parents in Oklahoma, which also found that addressing multiple problems at once was less effective than focusing solely on parenting.82 Another study found that parent training in the form of Multi-Systemic Therapy (MST), which includes parent education plus work with significant community partners, was as effective as MST plus wrap-around services.83 The study concluded that targeted, evidence-based treatment may be more effective than system-level intervention alone for improving clinical symptoms among youth with serious emotional disorders served in community-based settings. These findings show that such sources of family adversity as marital conflict and depression can be alleviated in two different ways: by directly treating partner social support and depression through direct interventions aimed at parenting problems and by improving parenting skills.
That insight suggests that rather than deciding who gets mental health interventions to reduce depression based on parents’ entry characteristics, it may be more cost-effective to offer an initial standard parent training program. Practitioners can track how successfully parents progress through the program and continue to monitor other family risk variables, such as continuing marital conflict, depression, and stress, that may interfere with treatment success. Only when program managers see no improvement in child behavior or in measures of the parental or family distress that interferes with the parenting program should they add interventions targeting the specific risk factors of ongoing concern.
Toward a Framework for Delivery of Parent Training to Prevent Child Abuse
For some time, the idea of universal parent training programs to prevent abuse and neglect has generated interest but not much traction among social scientists. Perhaps the [End Page 109] direction was wrong and instead of conceptualizing the question as whether parent training should be universally delivered or even universally available, the proper question is whether there should be a universal approach to parent training. The promising Triple P work in South Carolina, based on decades of development, argues the need to strongly consider such a redirection of the limited parent training resources now available for preventing and responding to child behavior problems and child abuse. Today, access to high-quality parent training programs is limited, and few organizations have the capacity to develop such programs on their own.84 The multi-level approach pioneered by Triple P offers the fundamental elements that are critical to implementing evidence-based materials with fidelity. The core program is carefully structured and controlled to maintain program integrity; it is staffed with sufficient trained personnel to provide supervision; it is equipped with media and marketing materials to spread the program; and it costs less than $50 per child (2008 dollars), making it reasonably affordable.85 To be sure, the Triple P trial in South Carolina was not without problems. Certain providers or systems were unable to add effective parenting support to the menu of services they provided because of clashes with their own mission—sometimes, too, because of barriers to reimbursement for parenting services. Among providers interested in the training and able to deliver parenting support services, many had only limited time available for training because of other demands on agency personnel. Any significant progress in expanding parent training programs on the Triple P model will require a full policy, fiscal, and regulatory review to ensure feasibility.
A major Triple P trial among the families of children aged four to seven in Australia provides further evidence that it could have a broad impact on child abuse and neglect in the United States.86 After phone data-collection interviews, Triple P (including seven levels, rather than the usual five, as needed by families) was administered to the entire population in various Australian communities. Analysis of the trial found that parents who had participated in Triple P (at any level) were more likely to use appropriate parenting methods than parents who received usual care. Triple P was also effective in reducing parental depression. Finally, using Triple P as a “population health intervention” resulted in significantly fewer children with behavioral and emotional problems and reduced parental stress associated with having school-age children.87
Could Triple P, or an American derivative, become the universal approach for all parents across the nation? No research has yet documented that, and good arguments can be made that parenting, and hence parent training, might vary by location and culture. Nonetheless, although it would be premature to endorse Triple P as the national choice, the general framework for Triple P should be used to guide the future evolution of parenting programs. The pyramid of programs would start at the base with an easy-to-access media program using basic concepts and specific vocabulary that describes parent-child interactions and parent interventions. The media program would be complemented by parent groups for families with low-intensity problems, moving to a parent consultation model, and then getting to specific in-home programs (tailored for the ages of the children) conducted in the homes.
Because child abuse prevention so often requires addressing the other family issues that influence parenting, the Triple P [End Page 110] approach would need to be complemented with work done in the homes of families, perhaps over a long period of time.88 The in-home work may need variations that are adapted to address the common co-occurring family risk factors, although the evidence for this is not conclusive. Indeed, there is enough evidence that improved parenting may itself reduce some of the other strains and problems to warrant proceeding with broader testing of uniform parenting methods. Certainly, some children may also need clinical interventions to address the affective or cognitive disorders that keep them from responding to parents and the parent training interventions; the clinical interventions may be facilitated if they use language and concepts consistent with those used in the other levels of the parenting campaign.
Massive evidence now shows that child abuse is associated with higher rates of spending on health care.89 The cost-effectiveness of investing in younger children is now broadly accepted.90 The case for implementing parent training programs to help reduce the high social costs of child abuse and neglect is strong. One of the first policy changes needed is to increase support for research trials on parent training to pinpoint “what works.” In addition to comparing the effectiveness of various parenting education programs, the research trials should contrast programs that focus on parenting education and those that aim to reduce related risk factors.
Child welfare services agencies should be allowed and encouraged, with incentives from all levels of government, to change their parent education practices as they modify their children’s services policies. The domination of federal child welfare services funding by worker training, reimbursement of foster parents, case management for children in foster care, and adoption subsidies (all entitlements under Title IV-E of the Social Security Act) leaves few resources to develop or implement high-quality parent education. Discretionary funds allocated through the Child Abuse Prevention and Treatment Act and through Title IV-B of the Social Security Act should be more targeted on parenting education. Even without reconfiguring or increasing funding, accountability could be better focused on parent training. In its periodic reviews of state child welfare services programs, the U.S. Administration for Children and Families could explicitly address the quality of parent education. Child welfare services agencies could be required to provide data, during their federal reviews, about how many families enter parent training and how long they remain to help develop parent training that engages and educates parents in ways that they find helpful.91
Local agencies, in the meantime, will want to learn more about evidence-based parenting education programs and to develop ways to ensure fidelity in the delivery of such programs to their clients. At some point local child welfare services agencies must also make decisions about whether funds are best spent on higher-cost brand-name interventions like the Incredible Years and Parent-Child Interaction Therapy or on training in the common elements on which those programs are built.
Achieving further progress in parent education to prevent child abuse requires continuing efforts to develop effective interventions. The United Kingdom, for example, established a Parenting Fund that, now in its seventh year, has invested about $15 million in projects each year to develop, set up, and [End Page 111] deliver evidence-based interventions aimed at parent support and education in the voluntary and community sector. The efforts in the United Kingdom are part of a broader endeavor across developed nations, including the United States, to increase the evidence base and sharpen the focus of parenting programs and to develop specific public policies targeting improved parenting beyond the traditional mechanisms of child welfare services and income support programs.92
Without this kind of effort, there is little reason to hope for broad governmental support. Demonstration funding to disseminate promising practices is a precondition for developing these programs. Once successful programs are developed, federal support to expand parent training is more likely. Across the board, in order to better support parents, policy needs to embody an evidence-based model of parenting linked to good outcomes for children. Although parent education can help families suffering from various kinds of distress, a stressful family environment is clearly not the optimal one for learning. For many years, considerable evidence has shown that outside stressors hamper learning and implementing the lessons from parent training programs. Policies that reduce the everyday stresses in the lives of families will also be an important part of effective service delivery. [End Page 112]
Richard P. Barth is a professor and dean at the School of Social Work at the University of Maryland–Baltimore.
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