An Online Wellness Magazine produced by The University of Texas Health Science Center at Houston (UTHealth)

Preventing Child Abuse

Researchers and communities work together to stop the pain before it begins

 Preventing Child Abuse

When we think of child abuse, it’s the after that comes to mind. The call to Child Protective Services. The newspaper article detailing horrific stories of neglect and abuse. The mug shot of the abusive parent.

We can’t help but pay attention to the shocking aftereffects of child abuse — a tragic, societal problem that affected more than 686,000 children in 2012. But for a glimmer of hope, we should pay attention to the before, say experts. A growing body of research shows that the right programs, such as parenting classes and home visitation after childbirth, actually help prevent child abuse.

And there’s more cause for hope: Reported cases of child abuse have been steadily declining. There were an estimated 30,000 fewer victims of child abuse in 2012 than 2008, a trend Christopher Greeley, M.D., associate professor of pediatrics at The University of Texas Health Science Center at Houston (UTHealth) Medical School, attributes to increased research and national efforts to prevent child abuse.

Greeley, who became interested in child abuse prevention after spending years treating broken and battered kids with abuse-related injuries, is cautiously optimistic about the progress he and his colleagues have made. But he says addressing the problem of child abuse won’t be a quick or easy fix. Child abuse prevention requires taking the long view. Researchers may not see the impact of their work for decades.

“Preventing child abuse is complex,” Greeley says. “There’s no one program that will fix the problem. You really, really have to work at it.”

“A complicated web”

Prevention programs must address the “complicated web” of child abuse, Greeley says. That means looking for risk factors, or what Greeley calls “childhood adversities,” to unravel the causes of child abuse. Children, parents and communities all play a role. For example, children who are unwanted or unexpected, or who have complicated medical conditions, colic or behavior problems, are more likely to be abused. Parents who abuse alcohol and/or drugs, have mental illness, a history of abuse as a child or a history of abusing another child, are more likely to be abusers. Where a child grows up is also important: Poverty, unemployment and violence in the community increase the risk of child abuse.

Modern prevention efforts consider all of these factors, instead of blaming one group for child abuse. That’s a significant change from the past.

“Our historic view was, ‘There is something wrong with the kid.’ The kid triggered the parents to behave badly. And we focused on fixing the kid. That was about 100 years ago," Greeley says. "Then about 50 years ago, the blame shifted to the parents. Clearly the kids were innocent and the parents were broken — psychotic, crazy, drunk. We had to find the bad parents and fix them. Now, we have a much more nuanced, complicated view about the causes of child abuse, in which there are many risk factors.”

Supporting and educating parents

In 2009, Greeley joined a team of leading pediatricians and academics from UTHealth, Texas Children’s Hospital and Baylor College of Medicine, to identify and address those risk factors. They reviewed strategies for reducing child abuse rates in Houston and found that implementing a community-wide parent education program had the best likelihood of success. A local nonprofit child advocacy organization, Children at Risk, formed the Center for Parenting and Family Well-Being (CPFWB) in 2012 to follow up on the team’s recommendations.

“We are trying to go through the perceived risks for child abuse, and in a thoughtful, evidence-based way, develop strategies that Texas as a whole can potentially adopt,” Greeley says of the organization’s mission.

Research supports the CPFWB’s emphasis on parent education. Teaching parents about child development and positive parenting practices lowers rates of social, emotional and behavioral disorders in families, behavioral disorders in children, parental stress and anxiety, and child abuse. Parent education also improves school readiness and family relationships.

But most parents don’t attend parenting classes — less than 2 percent of the more than 800,000 parents with children under the age of 18 in Harris County attend parenting classes each year.

“The stigma of going to parenting classes is why many parents don’t attend them,” says Luisa Franzini, Ph.D., a member of the CPFWB’s Academic Advisory Council and professor and director of the Division of Management, Policy and Community Health at UTHealth School of Public Health in Houston. “Parenting classes are seen as only for high-risk families or for someone who is not ‘a good parent.’ But if we can offer parenting information to everyone, then we can prevent the problems, rather than just treat them.”

Positive parenting

To increase participation in parent education, the CPFWB launched a pilot program and trained 66 facilitators from 12 community agencies to offer evidence-based parenting classes in the Houston area. Parent education is available through organizations that regularly interact with families such as schools, places of worship, nonprofits, afterschool programs and childcare centers.

The classes use the Positive Parenting Program (Triple P), an evidence-based, public health parent education program that targets all families, not just families at high risk for child abuse. In previous pilot studies, the program decreased the rates of child abuse, out-of-home placements and hospitalizations from child abuse. Triple P in the Houston area offers varying levels of intensity, depending on the needs of the parents: a 90-minute seminar for parents who need general information about parenting skills; brief individual consultations for parents who need help with a specific behavior, such as how to manage tantrums or bedtime routines; an 8-week group class for parents who are interested in more in-depth information; and for parents who have children with mild to moderate behavioral difficulties. 

“They don’t have to yell”

Deborah Bradford, a child development specialist with more than 40 years of experience, teaches the Triple P curriculum to parents in daycares and schools across the Houston area. She appreciates how the curriculum targets all parents — not just ones from high risk families. Bradford believes a wide range of parents can benefit from the support and education parenting classes provide.

“Parenting classes help parents foster communication with their children as they go through the different stages of development, and they offer vital support,” she says. “It is real relief for parents when they learn that there is no cookie cutter way to be a parent.”

Bradford helps parents develop strategies to handle their children’s behavior problems and developmental stages in a positive way. The lessons are a revelation for some parents.

“Many, for the first time, learn that they don’t have to yell at their kids to get them to respond,” Bradford says. “They find their family relationships improve quickly when they are less stressed as parents and can respond rather than react to events in the household.”

The future of child abuse prevention

“There’s no single ‘silver bullet program’ that will fix the problem of child abuse,” Greeley emphasizes. “The future of child abuse prevention will involve evaluating which mix of programs at what dosage, for what duration, and at which time in a child’s life achieves the greatest impact.”

Post-partum depression is next on the list of childhood adversities targeted by the CPFWB. Mothers with post-partum depression bond less with their babies and may develop major depression, which increases the risk of child abuse and neglect. Greeley and his colleagues are assessing the best screening tools and treatments for post-partum depression by piloting a post-partum depression home visitation program — a collaboration between the UTHealth School of Public Health, UTHealth Medical School, UTHealth School of Nursing and the University of Houston. Home visitation is a proven strategy for preventing child abuse, Greeley says, and is widely used in other countries, even though it is not fully embraced in the United States.

Future CPFWB projects may target domestic partner violence, intimate partner violence or substance abuse. Greeley and his colleagues also have collected data on which zip codes in the Houston area are at high risk for child abuse. They hope to use the data to determine which neighborhoods most need child abuse prevention programs.

There’s still work to be done, Greeley admits. But he is hopeful that child abuse prevention programs are making a difference.

“Our prevention efforts, even if they are small, cast a long shadow,” Greeley says. “Together, they can create a tremendous change.”

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