Preventing Child Maltreatment: Defining the Problem, Discussing Solutions

8/14/2014

Introduction

Child maltreatment is a pervasive public health issue affecting thousands of children across the United States.

In 2012, more than 1,600 children from newborns to age 17 died from abuse and neglect. The majority of these victims, 68 percent, were 4 years of age or younger. Child fatalities caused by abuse and neglect do not reveal the full extent of the problem. State and local child protective services agencies estimate that 686,000 were victims of maltreatment in 2012.

The consequences of child maltreatment are long term. Children who are victims of maltreatment are more likely to experience poor health status into adulthood including, substance abuse, depression, cardiovascular disease, diabetes, cancer and premature death. 

United States map of Child Maltreatment Victims, 2012

Source: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.(2012). Child maltreatment 2012. Available from http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012.

Defining Child Maltreatment

Child maltreatment includes all types of abuse and neglect of children under age 18 by a parent, caregiver or another person in a custodial role (e.g., clergy, coach, or teacher). Four major types of child maltreatment are physical abuse, neglect, emotional abuse and sexual abuse.  These types of child maltreatment are not mutually exclusive and often occur in combination.

  • Physical abuse is the intentional use of physical force against a child, such as hitting, kicking, chocking, stabbing, shaking, burning, or other actions that result in, or have the potential to result in physical injury.
  • Neglect is the failure to meet a child’s basic needs, including housing, food, clothing, education and access to medical care. The definition of child neglect varies among states, agencies, professional groups and disciplines, and is considered the most frequently unreported type of child maltreatment.  Generally child neglect can be defined as “the failure to provide for a child’s basic physical, emotional or educational needs or to protect a child from harm or potential harm.” 
    • Physical neglect is the failure to provide food, shelter or appropriate supervision.
    • Medical neglect has been defined by many states as failing to provide needed medical or mental health care to a child.
    • Educational neglect involves the failure of a parent or caregiver to educate a child or provide special educational needs.
    • Emotional neglect is the inattention to a child’s emotional needs or failure to provide psychological care.
  • Emotional abuse refers to actions and behaviors that harm a child’s sense of self-worth or emotional well-being.
  • Sexual abuse involves engaging a child in sexual acts including fondling, rape and exposing a child to other sexual activities. This type of abuse is the most under-reported type of child maltreatment. Actual rates of sexual abuse against children are likely higher than officially reported rates.

Neglect is the most common type of maltreatment perpetrated against children, accounting for 78 percent of all reports of child maltreatment.  In some states, child neglect accounts for more than 90 percent of all child maltreatment cases. 

Pie chart of different types of child maltreatment

Source: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.(2012). Child maltreatment 2012. Available from http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012.

United States map of Percent of Child Maltreatment Victims Who Where Neglected, 2012

Source: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.(2012). Child maltreatment 2012. Available from http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012.

Child maltreatment is a complex social issue and research on prevention explores a wide range of social and economic interventions. Unhealthy relationships between caregiver and child and high levels of parental or caregiver stress, among many other things, may contribute to higher rates of child maltreatment. States have adopted strategies that aim to prevent child neglect and abuse before it occurs, such as connecting new parents to community support opportunities, achieving greater access to high quality child care, and coordinating funding. This policy primer reviews state legislative policy options to prevent child maltreatment.

Connecting New Families to Community Support Opportunities

The first few years of life are vital for a child’s brain development. Stress and lack of medical care during these important years can have negative long-term consequences on a child’s physical and mental health that extend into adulthood. High rates of abuse, neglect and medical neglect in the early years of a child’s life indicate that more can be done to develop systems and strategies to support new and expecting families. During these first years, children are more likely to be isolated from social and community networks, and are more vulnerable to parental or caregiver abuse and neglect. Policymakers have adopted many different strategies to connect new families with health care services and other social support programs.

Bar chart of Child Maltreatment Victims, by Age

Source: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.(2012). Child maltreatment 2012. Available from http://www.acf.hhs.gov/programs/cb/resource/child-maltreatment-2012.

Early Childhood Home Visiting

Early childhood home visiting programs help new parents gain knowledge of basic parenting skills by matching new families with trained providers, such as nurses, social workers or parent educators. These prevention-focused programs are voluntary, and are offered to new families as a connection to social and medical supports throughout pregnancy or the first few years of life. Certain home visiting models have proved to be effective in reducing child maltreatment. Communities that have implemented the Nurse Family Partnership, for example, have seen on average a 48 percent reduction in child abuse and neglect, and a 56 percent reduction in emergency room visits for accidents and poisoning. Healthy Families America is another example of a Home Visiting Program that emphasizes reducing child maltreatment.

Evidence-Based Home Visiting

The Nurse Family Partnership is the most extensively evaluated early home visiting program and has consistently been found to be an effective intervention for preventing child maltreatment. In this program, first-time moms who choose to participate are connected with a nurse from the time of pregnancy until the child turns 2 years old. Nurses conduct ongoing home visits to help support a healthy pregnancy, teach new moms techniques to foster health and positive interactions with her baby, and assist new families in continuing their education or finding work.

State legislatures have been supporting home visiting programs for more than a decade. Recently, in 2013, Hawaii enacted a law to establish a statewide hospital-based home visiting program to provide universal screening of newborns’ families to identify risk factors for poor health, child abuse and child neglect. High-risk families are referred to the statewide home visiting program, and can choose to participate in the program. Other states, such as Arkansas and Texas, require home visiting programs to be evidence-based, and to track outcome measurements to monitor program effectiveness. In these two states, the legislature plays a direct role in monitoring and modifying home visiting program standards. For a full list of Home Visiting legislation passed between 2008 and 2014 please visit NCSL’s Home Visiting Webpage.

State Legislative Options for Early Childhood Home Visiting

  • Explore opportunities to use and leverage current state, federal and local funding to  support early childhood home visiting programs. In Washington state, for example, the Legislature established the Home Visitation Services Account in 2010 to align and leverage public funding with matching private funding to increase the number of families served.
  • Examine how agencies and programs coordinate home visiting services throughout the state, and consider ways to minimize home visiting program duplication or fragmentation. Connecticut’s Early Childhood Education Cabinet appointed a home visitation committee with the goal of linking home visiting with other state priorities and to study best practices.
  • Ensure the state is investing in research-based home visiting models that demonstrate effectiveness and have accountability measures in place.

Health Literacy for New Families

Health literacy can be thought of as a person’s ability to obtain, process and understand basic information and services in order to make appropriate health decisions.  It is estimated that almost 36 percent of American adults are “health illiterate.” Low health literacy among new parents creates barriers to obtaining important health and safety information during a child’s life.  A 2009 study published in the Journal of the American Academy of Pediatrics found that more than 28 percent of parents had only basic health literacy or less than basic health literacy.  Incorporating simple, easy-to-understand child maltreatment prevention information into prenatal and pediatric care visits may decrease health literacy demands on parents, and help new families understand easy ways to prevent child abuse and neglect.

Supporting Greater Access to Positive Parenting Support

Triple P, or the Positive Parenting Program, is an evidence-based intervention that offers parents simple strategies to manage their children’s behaviors. By incorporating simple messages to encourage parents to create nurturing environments for children and support nonviolent parenting skills, Triple P aims to build healthy, positive relationships between parent and child. This program uses a combination of tools, such as parent local media outlets, consultation with trainers and public seminars, to spread information about positive parenting skills. Learn more about Triple P.

According to the Centers for Disease Control and Prevention, at least 20 states have implemented activities to address health literacy. Many of these activities involve collaborations between state and local governments, academic institutions and non-profit organizations. In addition to these state activities, some legislatures have addressed the issue of health literacy in state law. Maryland law requires the Office of Minority Health and Health Disparities to work collaboratively with universities, public health and social work programs, and allied health to create courses that focus on cultural competency, sensitivity and health literacy. In 2006, the Washington Legislature created the governor’s interagency coordinating council on health disparities, which is required to create a statewide policy to address social determinants of health, including increasing health literacy.

State Legislative Options for Enhancing Health Literacy

  • Consider integrating child maltreatment prevention education into existing health care visit screening standards, such as prenatal care visits for new parents, or preventive care well-child screenings for children. For example, Oklahoma’s Medicaid Care Management Department pairs nurses known as “Health Coaches” with certain new moms or young children with the goal of improving health literacy and health status.
  • Support community education and outreach programs that inform parents about child maltreatment prevention information and resources.
  • Encourage hospitals and clinics to incorporate optional specialized services that offer parenting and child behavior classes or information.
  • Support cultural competence continuing education credits for health care providers. In 2012, Maryland House Bill 679 required the Office of  Minority Health and Health Disparities to work collaboratively with universities, public health and social work programs, and allied health to create courses focusing on cultural competency and sensitivity

Community Health Workers

Community health workers (CHWs) are members of a community who work with a local health care system to assist people in receiving necessary health care and other social services. Their role in a community is dynamic: They help connect people with services, and they also inform health care providers and administrators about the health and social needs of the people in their community. CHWs help members of the community provide social support, offer culturally appropriate health education and information, and help advocate for individuals within the health or social services system.

Community health workers are also referred to as: community health advisers, promotores/promotoras de salud, or lay health workers. They work for pay or as volunteers and tailor their work to meet local community needs. CHW rely on a variety of funding sources including community health centers, grants from private funders, and, in some states, Medicaid.

In terms of preventing child maltreatment, CHWs may play important roles to help new parents adopt healthy behaviors and access positive parenting resources within a community. The Massachusetts’ CHW Advisory Council found that CHWs prioritize four main goals including: client advocacy, health education, outreach and health system navigation

By using existing programs, states may be able to encourage CHWs to expand their goals to include educating new families about child maltreatment prevention strategies, and help parents navigate complicated health and social systems.

Tapping Community Resources to Reduce Child Maltreatment

The Durham Family Initiative began in 2002, when a group of government agency directors in Durham, N.C., signed a memorandum of agreement to implement a community system of care to encourage healthy parent-child relationships. Under this agreement, community services were integrated for the purpose of promoting child well-being and preventing child maltreatment. Community service providers work with families to develop a plan that incorporates formal and informal services, such as parent training or faith-based support groups, to improve family well-being. The purpose of this plan and the community liaison is to ensure that a family has access to the services, resources and support that will help facilitate positive child-parent relationships and a nurturing family environment. The Durham Family Initiative has resulted in a 57 percent reduction of child maltreatment in Durham County. Learn more about the program

Many states have passed legislation to increase the use of community health workers within the primary care system, and a few states encourage the use of CHW for activities that may help prevent child maltreatment. In 2011, for example, Oregon passed House Bill 3650, which directed the Oregon Health Authority to develop training requirements and curriculum standards for nontraditional health workers, such as community health workers. This curriculum requires training in: health promotion and best practices, the social determinants of health, health literacy issues, and warning signs for substance abuse and mental health problems. The social connections and medical guidance offered by CHW may help reduce stress from parenting and offer new families connections to health and social service options in a community.

State Legislative Options to Optimize the Use of Community Health Workers

  • Establish and fund CHW programs to support safe, stable and nurturing family environments. Several states have adopted legislation that defines or recognizes community health workers, establishes standards or credentials or assesses training and certification needs.
  • Support incorporating child maltreatment prevention education into existing state community health worker training curriculum. Arizona’s Health Start, for example, uses community health workers to provide education to pregnant women and new families to improve health outcomes, increase child safety or to make referrals to other services.

Achieving Greater Access to High Quality Child Care

For many years, state and federal governments have been involved with licensing and regulating child care centers, and creating subsidies for low-income families who need child care. Data from the U.S. Census Bureau’s American Community Survey emphasizes the importance of child care options for families of young children. Between 2005 and 2009, 62.3 percent of children under the age of 6 were living with a single working parent or two working parents, indicating that the majority of young American children have working parents and need access to nonfamilial care.

Access to high quality and affordable child care can influence caregivers’ ability to support a family, while limiting a child’s exposure to neglect and abuse. Increasing access to high quality child care for all children may reduce the incidence of child neglect, and improve learning and developmental outcomes of children.

Early Head Start

Early Head Start is a federally funded program that offers low income pregnant women and families with children under the age of 3, access to early learning and education in a day care setting and other family support services. Many programs offer home-based services, which include weekly home-visits from trained program staff to promote parent or caregivers’ ability to support the child’s development. Home-based programs also offer twice-monthly group sessions to bring parents and children from many families together to discuss their experiences.

Along with providing high quality child care, research conducted by Columbia University and Mathematic Policy Research found that, compared to control groups, Early Head Start parents were:

  • More emotionally supportive and less detached from their children.
  • Less likely to report having recently spanked their children.
  • Reported to have a greater repertoire of discipline techniques, including more mild and fewer punitive strategies.

These findings indicate that the Early Head Start Program could reduce child neglect and abuse by providing high quality child care for working, low-income parents, and encourage positive parenting techniques among parents.

All 50 states have at least one Early Head Start Program and are funded primarily by the federal government. Not all children who qualify to participate in Early Head Start do so. According to the Children’s Defense Fund, fewer than half of those who are eligible are enrolled in Early Head Start. As of 2012, 10 states use state money to support Early Head Start Programs. Oregon, for example, provides all federally supported EHS programs with state funding to expand the number of children served.

Early Head Start Child Care Partnerships

A new federal initiative, “Early Head Start-Child Care Partnerships,” provides $500 million in new federal grants to new or existing Early Head Start Programs. These grants will support programs to partner with local child care centers and family care providers serving infants and toddlers from low income families.

United States map of Number of Children in a Federally-Funded Early Head Start Program, 2012

Source: U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Office of Head Start, 2012 Program Information Report 2012. Available from http://eclkc.ohs.acf.hhs.gov/hslc/hs.

State Options to Strengthen Early Head Start

Explore the Early Head Start programs in your state or district. Ask the Early Head Start program director the questions you may have, such as:

  • How many children are enrolled in the Early Head Start programs in your district?
  • How long are the waiting lists for Early Head Start programs in your district?
  • Does your state provide supplemental funding for these federally funded programs?
  • What challenges does the program face?
  • What are the primary successes of the program?

To encourage enrollment for those who qualify, consider use existing benefit enrollment systems, such as Medicaid or TANF, to facilitate access to Early Head Start.

Child-Parent Centers

To improve child-parent interactions, foster positive parenting skills, and encourage positive child management strategies, Child-Parent Centers (CPC) are comprehensive educational and family support programs for economically disadvantaged children between age 3 and third grade. These evidence-based  programs offer school- or center-based learning activities that focus on a child’s social and cognitive development, and require consistent parental participation in their child’s education.

Responding to the lack of federal Head Start programs in high poverty neighborhoods, the Chicago Public School Systems developed the Chicago Child-Parent Center program to expand access to quality preschool education to all neighborhoods. To be eligible for participation, families must reside in neighborhoods that receive federal Title I education funds and parents must commit to volunteering at the center every week. Every CPC program includes classroom education with trained teachers, outreach services such as home visits when families enroll and transportation to the center, and parental volunteering at the center for at least one half day per week.  The Chicago CPC uses federal Title I to fund activities.

The Chicago CPC has been shown to decrease children’s exposure to abuse and neglect. Five percent of children who participated in the CPC group experienced child maltreatment, compared to 10.3 percent in the non-CPC control group. Long-term evaluation of this program has also shown other benefits, such as higher reading and math test scores among children who participated in the program.

State Legislative Options for Child-Parent Centers

Many communities have programs or schools that provide preschool education. Consider strengthening these programs by:

  • Encouraging existing preschools in your district or community to adopt a Child-Parent Center model of education.
  • Support preschools that promote evidence-based activities to reduce child abuse and neglect by incorporating parental participation in young children’s education.

Options for Coordinated Funding

State governments employ a variety of funding sources to support child welfare systems. A small portion of these funds directly support prevention activities. State and local agencies determine who will receive prevention services, and what types of prevention services will be provided. Therefore, identifying funding amounts that directly support child maltreatment prevention is difficult to discern. This section analyzes federal and state funding streams that are authorized for child maltreatment prevention to get a better idea of how states are supporting prevention activities and offer potential strategies to support prevention activities.

Federal Funding Options

Since 1974, the federal Child Abuse Prevention and Treatment Act (CAPTA) has provided funding to states, tribes, tribal organizations, public agencies and nonprofit organizations to address child abuse and neglect. Title II of CAPTA provides Community Based Grants for the Prevention of Child Abuse or Neglect. These grants are intended to help community agencies support child abuse and neglect prevention activities and emphasize family support or parental participation. Programs supported by these grants include voluntary home visiting, family resource centers, parental mutual support and other positive parenting activities.

Several states also use a portion of the federal Social Services Block Grant (SSBG) to fund activities that aim to prevent child maltreatment. SSBG funds are considered nondedicated federal funds and can be used by states or territories to meet the needs of its residents. Examples of SSBG funded services include day care, case management and health-related services for children. Funds are allocated to all states and territories.

The Affordable Care Act’s Maternal, Infant and Early Childhood Home Visiting grant provided additional federal support for child maltreatment. This federal initiative provided states with $1.5 billion for home visiting between 2010 and 2014 with an option for reauthorization. It also emphasized evidence-based home visiting models, of which 13 models meet federal criteria, with 75 percent of the federal funding directed to such programs.

State Funding Options

State funding support for child maltreatment prevention is supported by a complex and diverse source of funding streams. This section discusses a few ways state legislatures have established direct child maltreatment prevention funding support. For more information about child welfare or child protective services, please visit NCSL’s Human Services Overview webpage.

Several states have funding streams dedicated to child abuse prevention.  In 2011, the Illinois legislature created the Child Abuse Prevention Fund, which is funded by a voluntary contribution option on the Illinois income tax return. Similar to Illinois, Oregon allows tax payers who receive a tax refund the option of contributing a portion of their refund to child abuse and neglect prevention.  The Nebraska Legislature provides a direct appropriation to the Nebraska Child Abuse Prevention Fund.  This fund was established in 1986 by the legislature to identify the needs, problems and solutions of child abuse and neglect in the state.  Each state’s child maltreatment prevention funding picture is different.

State Legislative Options to Coordinate Funding

  • Explore state and local programs that aim to prevent child abuse and prevention.
    • Are these programs using several federal, state and local funding sources to sustain child maltreatment prevention activities?
    • Can your state develop mechanisms to unify or leverage funding sources that aim to prevent child maltreatment?
  • Consider creating state funding mechanisms to support child maltreatment prevention activities. Oklahoma, for example, has established “Child Abuse Prevention” license plates. The application fee for these license plates is deposited into the state’s Child Abuse Prevention Fund to support programs across the state.

Conclusion

State legislatures play important roles in preventing child maltreatment. Identifying unique characteristics of each community’s and state’s child maltreatment activities is an important step to understanding existing strengths and needs in the child maltreatment prevention system.  Legislators can be leaders in efforts to prevent child abuse and neglect.

Additional Resources

NCSL Resources

Other Resources

Acknowledgements

This brief was written by Hollie Hendrikson.

The National Conference of State Legislatures thanks Suzanne Friesen, CDC project officers and others at CDC for their time and commitment to make this publication as thorough as possible.

The author also likes to thank the following NCSL staff who reviewed the brief and made recommendations: Nina Williams-Mbengue, Julie Poppe, Robyn Lipkowitz, Melissa Hansen and Martha King

This publication was made possible by contract number 200-2013-M-57330  from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the author and do not necessarily represent the official views of the CDC.