Cbrfd~buse& N&w, Vol. IS. Sup. I, pp. 99-106, Printed in the U.S.A. All r&h:5 resewed.
0145-2134/91 $3.00 i .Oo Copyright 0 1991 Pergamon Press plc
WHAT WE HAVE LEARNED WHAT WE SHOULD
ABOUT P~VENTION: DO ABOUT IT
ANNE: H. COHN DONNELLY Director, National Committee for Prevention of Child Abuse, Chicago
DURING THE LAST DECADE, child abuse efforts throughout the world have increasingly focused on prevention, and those efforts have grown more sophisticated. During this time much has been tried and learned, and some has been accomplished. This paper will review what has transpired and what challenges lie ahead for the next decade.
Even before the 198Os, the focus of prevention efforts-really the very first in the fieldwere on the underlying causes of abuse. The understanding was that child abuse is a very complex problem with a variety of underlying causes; and for preventive strategies to be effective, the goals of prevention needed to include: increase future parents’ knowledge of child deveIopment and the demands of parenting; enhance parent-child bonding, emotional ties and communication; increase parents’ skills in coping with the stresses of caring for children, including special needs children; increase parents’ knowledge about home and child management; reduce the burden of child care; reduce family isolation and increase peer support; increase access to social and health services for all family members; reduce the long-term consequences of poor parenting (Cohn, 1988). No one approach to prevention was perceived as the “cure,“’ and certainly no one approach was seen as relevant for all forms of abuse and neglect. Included in notions of a comprehensive approach to prevention were: 0 support programs for new parents: l education for parents; * child care oppo~unities; l programs for abused children and young adults; o life skills training for children and young adults; l self-help groups and other neighborhood supports; l family support services; Reprint requests may be addressed to Anne I-I. Cohn Donnelly, D.P.H., Director National Committee for Prevention of Child Abuse, 332 S. Michi~n Ave., Suite 1600, Chicago, 1L 60604. 99
100 l l
Anne H. Cohn Donnelly
community organization activities; public education of child abuse prevention (Cohn, 1988).
Even in those early years of the prevention movement, it was recognized that it was not possible to just identify potential abusers, because of accuracy considerations, and thus prevention efforts needed to address whole population groups (Cohn, 1988). Prevention Eforts During the 1980s During the 1980s prevention efforts multiplied rapidly. With the recognition that a variety of one-on-one prevention services tailored to different population groups were important, came the recognition that so too were efforts to change the environment in which we were trying to prevent abuse (e.g., with changes in legislation, policy, social conditions, public pa~icipation, and values). And so efforts during the decade were divided among services, advocacy, public education, and public involvement. Supplementing these efforts were various kinds of research and demonstration projects, which contributed to the advancement of our knowledge about how to prevent abuse. In reviewing activities in each of these areas, the wealth of effort for the last 10 years is most apparent. Services. All approaches to prevention seem to ultimately include some kind of one-on-one service for individuais or families. The most common prevention services have been various kinds of educational and support programs for parents. Home health visitor-type programs, using either professional, paraprofessional, or lay persons have been popular and have been shown to be effective (Daro, 198S), as have parenting groups, based either in hospitals or through various community settings, including schools. These programs have largely been developed by community groups with an emphasis on the use of volunteers. Some programs emphasize providing parents with support (someone to talk to) and places to turn for help, while others stress parenting skills and the dissemination of child development information; and of course, many programs attempt to do both. Special population groups, such as teenage mothers or first-time parents, have frequently been the targets of these programs. Various kinds of crisis or support services for parents-ranging from helplines and hotlines to drop-in centers and support groups, such as Parents Anonymous-have been established in communities. Based on the notion that parents need a place to reach out to for help when the big and little pressures of life build up to the point where abuse may happen, these crisis services have been directed at both parents who have not yet abused and those who have. These services have largely been volunteer and community-based. The early 80s saw the birth of a preventive strategy directed at the potential victim rather than the potential perpetrator. Prevention education for children (also known as assault prevention, sexual abuse prevention, life skills development) initially focused on teaching children how to say no in the face of threatened abuse and to go and tell someone. As experience with this type of programing grew during the decade and questions about how to ensure effectiveness were asked, programs increasingly moved beyond the simple “no, go, tell” messages to focus on development of self-esteem, conflict resolution skills, adult-child and peer-peer relations as tools in self-protection. The long-term emotional, developmental, and behavioral impacts of abuse on the victim were documented in the early years of child abuse work (Elmer & Gregg, 1967). Therapeutic care for victims, long recognized as a long-term strategy for breaking the cycle of abuse, has been that prevention strategy slowest to develop. Perhaps because of the cost, communities have not moved ahead with this prevention strategy as they have with others. Notable exceptions include the development of survivors’ groups across the country-essentially for victims but typically years after the victimization, and the efforts of Parents Anonymous to develop
groups for children who have been abused. Only a small proportion of mental health and child care groups have developed therapeutic care programs for victims. To the extent funds have been available for such programing, they generally have not come from child protective service-type agencies-which are mandated to “protect” children but ironically not to “treat” them when they have not been well protected. Funds, if any, have come through state-defined victim assistance programs. Advocacy. It is regularly argued that child abuse cannot be prevented unless the environment in which one is trying to prevent child abuse is altered. Parenting classes and other prevention services, it is argued, cannot be totally helpful if messages about the value of violence or tolerance of poverty abound. With this in mind, and recognizing the need for financial resources to put preventive services in place, advocacy efforts have become an important part of any prevention strategy. One of the earliest and to date one of the most successful advocacy efforts has been that of creating special funding mechanisms for child abuse prevention at the state level. Called Children’s Trust Funds and established through state legislation, these special funds gather monies through special check-offs on state income tax returns or through increased fees for marriage licenses or birth certificates. Advocacy efforts have also been directed at certain policies which, if changed, would assist in a reduction of abuse. Introduction of legislation banning the use of corporal punishment in the schools is one good example. Not only does school-based corporal punishment result in actual serious physical harm to a student on occasion, but the use of corporal punishment in general would appear to be counter to efforts to prevent child abuse. Children are sent to school to learn; schools using corporal punishment are teaching children that hitting people is an acceptable method of solving problems and correcting behavior. In 1980, over 40 states allowed the use of corporal punishment in the schools. Changes in laws or at least in school practices were important and became a focus of advocacy efforts during the 1980s; so too did changes in policies and thus laws su~ounding the criminal prosecution of child abuse cases. Too often, it appeared, that as children came forward to testify in the courtroom about alleged abuse, they were reabused because courtroom procedures simply did not treat them like children. Advocacy efforts were also directed at the introduction of new legislation to expand existing programs or create new prevention programs where none existed. Mandating prevention education for children in the schools, parental leave policies, and day care were three of the more visible programs which prevention advocates embraced. Public education. Prevention efforts have always been tied in part to the notion that the public must not only be aware of the child abuse problem, but must also understand what to do about it. To this end, prevention efforts have included activities to provide the public with a broad education about the problem. The primary vehicle used has been public service advertising through TV, radio, and the print media, although other media programing has been used as well, Initially, the focus of efforts was on the existence of the problem in all its forms and the reasons for focusing on prevention (“It shouldn’t hurt to be a child” and “Child abuse hurts us all”). Later, public awareness efforts covered two other messages: how parents under stress could help themselves and how everyone has a role to play in helping parents under stress. Messages included: “When the big and little stresses of life build up and you are just about to lash out at your child, stop. Take time out. Don’t take it out on your kid.” “Children believe what their parents tell them. Watch what you say. Stop using words that hurt. Start using words that help.” “ We all have a role to play in preventing child abuse. If you know of a parent having trouble, reach out and offer some help.”
Anne H. Cohn Donnelly
Public involvement. A central theme in child abuse prevention work has been the need to involve the whole community. Child abuse, it is argued, is too complex a problem, too deeply engrained in the ways our communities are organized and our families are structured, for any one profession or any one sector of society to be in a position to prevent abuse-all sectors need to be involved and do have a role to play. Given this, throu~out the 1980s prevention efforts included a focus on expanding the number of players, on increasing the number of prevention-focused organizations, and on increasing the number of organizations which would take on a prevention focus. Much energy went into creating child abuse prevention coordinating bodies, both at the state and local level, which could bring together all the players in a given geographic area. These organizations typically were created with a membership structure so that truly anyone interested in preventing child abuse could join in some way. But efforts also focused on reaching out to a variety of other types of organizations for whom child abuse was not and never would be the primary mission but for whom child abuse prevention could have importance (e.g., Boys Clubs, the Boy Scouts, and other youth-serving organizations; sororities and fraternities; and corporations and religious institutions). Governmental agencies, as far reaching as the military and the Agriculture Department’s Cooperative Extension and community agencies (such as Head Start), and the YMCA and service organizations (such as Kiwanis), all found ways to get involved.
WHAT HAS BEEN ACCOMPLISHED? Having reviewed the range of prevention activities pursued during the last decade, it is important to provide some kind of a report card-what has, in fact, been accomplished? What do all these efforts collectively add up to? Is the public more aware and involved? Are more services in place? Have these activities resulted in any reductions in the amount of child abuse? Public Awareness A tremendous amount of progress has been made with respect to the public’s understanding of and involvement with preventing child abuse (Schulman, Ronca, & Bucuvalas, Inc., 1990). In 1975, an informal study showed that one out of every ten adults was aware of the child abuse problem. By the mid-1980s research documented that nine out of every ten adults not only knew about the child abuse problem, but also understood that there were different types of abuse and that abuse was connected to other social problems such as crime and drugs. By 1990, virtually all adults in the United States were aware of child maltreatment as a major social problem. In addition, the public was demonstrating a new sensitivity to behaviors which can lead to abuse. Ninety percent (90%) of the public report believing that yelling and swearing at children can lead to long-term emotional problems, and 70% believe that physical punishment can lead to physical injury. Further, in contrast to the late 1970s when the majority of adults in the country supported a Supreme Court decision which ruled that corporal punishment should be allowed in schools, by 1990, 60% of the public believe that teachers should not be allowed to use corpora1 punishment; and 92% believe that schools should teach children how to protect themselves from being abused. The public’s concern about child abuse goes even further. Two-thirds say they believe that they could do something to prevent child abuse, e.g., that they do have a role to play. Half the public (50%) say they are very willing to do something to help; and in 1990,25% report having
done something to help prevent abuse. Steps taken most frequently included helping a parent under stress and stopping a friend or relative from yelling or hitting a child.
The numbers of individuals and organizations involved in prevention virtually exploded during the decade. Networks of prevention organizations have evolved, best characterized perhaps by the volunteer-based chapter network of the National Committee for Prevention of Child Abuse. These grassroots type of organizations, which draw representatives from the child abuse and corporate communities as well as the general public now, cover all 50 states, generally with statewide governing bodies and local affiliations through child abuse coalitions in communities throughout their states. In 1980 only 12 chapters existed as did very few community child abuse prevention coalitions. Today, that chapter network represents well over 120,000 involved volunteers. Beyond organizations with child abuse prevention as a primary mission, numerous other organizations with other primary missions have joined the movement. To name a few of these who have decided in the last decade that they could have a significant role to play in prevention and are doing something about it, the Boy Scouts of America, the General Federation of Women’s Clubs, the Kappa Delta and Sigma Delta Tau Sororities, the Kiwanis, the U.S. Cooperative Extension Service, the K Mart Stores, Marvel Comics, Dominos Pizza, Master Card International, the American Amu~ment Machine Association, and the National Basketball Association. It’s a diverse group, reflective of the diverse interests that have found a significant role to play.
P~~~e~tionPolicies Success has certainly been seen with efforts to change the environment by changing policies. In 1980, only one state in the U.S. had a Children’s Trust Fund. By 1985, approximately half the states had adopted legislation creating these special funding mechanisms for child abuse prevention. By 1990, all but one state had established such funds. In 1989, the Funds collectively spent 28 million dollars on prevention- dollars that otherwise would not have been available. In 1980, very few of the funds spent by the U.S. National Center on Child Abuse and Neglect were allocated for prevention. Because of advocacy efforts, by 1990 fully 50% of these funds were to be directed to prevention. New prevention policies have not been limited to new funding. Most states passed new laws during the decade protecting child abuse victims in the courtroom to avoid re-victimization. Over 10 states mandated prevention education in the schools. An additional 12 states banned the use of corporal punishment in the classroom, boning the total to 2 1 states. Even as some states were slow to adopt this important legislation, school districts across the country-even in the seemingly intractable South and Southwest-banned corporal punishment. By 1990, over half the schools in the country no longer allowed corporal punishment. Moreover, federal legislation regarding child care was established.
Services Just as public involvement has exploded in the last decade, so too have the numbers of prevention services which are available-this during a period when most social and health services saw cutbacks and closings (Daro, Abrahams, & Casey, 1990). At the beginning of the decade, elementary schools in the country simply did not offer prevention education for children. Today 6 1% of all elementary schools report offering some kind of prevention education; 12% of all schools added this kind of education in the last two years alone.
Anne H. Cohn Donnelly
Data throughout the decade for other services is not available, but information dating from 1986 still tells an exciting story: Prenatal parenting education is offered by 14% more hospitals, bringing the total to 94%; 10% more are offering postnatal parenting education, bringing the total to 55%; and 10% more are offering parent support groups (the most time-consuming and costly of these services) bringing the total to 29% of all hospitals offering this service. Amount ofAbuse Ultimately, to assess the impact of our efforts, we would like to be able to look at select proxy measures for the amount of abuse, since there is no one reliable direct measure. Beyond measures of how much we have done (e.g., how many services have been put into place), it is important to know whether or not what we have done has resulted in changes in parental behavior, which in turn would be reflected by less abuse. The news is mixed. Measures of parenting practices give us encouraging info~ation (Schulman et al., 1990). For example, since 1988 alone, 15% fewer parents report yelling and swearing at their children, and 13% fewer parents report using hitting as a form of discipline. Not only do these changes mirror the messages of national media campaigns of the past several years, which suggests the tremendous impact such campaigns can have, but these changes also provide tremendous hope for the longer term for preventing much of the child abuse problem. It would appear that some proportion of parents can be reached through prevention progumming. In contrast to this good news, however, are data which look at reports of serious abuse and fatalities (Daro & Mitchel, 1990). Child abuse fatalities appear to be on the rise (by 23% in the last two years) as do reports of serious abuse (up 10% in the last year alone, in contrast to increases of 2-3% during each of the previous 4-5 years). The numbers, we know, are not precise. Arguments are often made that the change in numbers only reflect better or different methods of counting. However, in-depth discussion with CPS workers and administrators lend support for these increases. CPS workers say that they do believe they are seeing more serious cases and more fatalities. They say that the uninte~pted and worsening problems of the underclass, the lack of services for families on the fringe, and most significantly, substance abuse explain these increases. Drugs, more so than any one single factor, seem to be wreaking havoc with the lives of certain parents and, in turn, those of their children. And the increased numbers of cases have had other impacts as well. Since CPS funding has in no way kept pace with caseload sizes (reports are up 50% over 5 years; funding is only up 2-3%), CPS has increasingly been unable to help those families who are reported, and the abuse in those families simply continues and too often worsens. In summa~, we have made much progress-people and programs are in place; certain parental behaviors are changing-but prevention efforts to date seem not to have touched certain families, certain population groups, creating significant challenges for the next ten years.
FOR THE NEXT DECADE
Given where our efforts have been and what progress (albeit modest) has been made, it is essential to determine where our efforts would best be placed during the next ten years. Given a commitment to preventing abuse before it occurs, it would appear that we need to continue to do more of the same and at the same time develop more new and different approaches.
Doing More of the Same Having analyzed just how much has been going on in the prevention area and what the potential impacts have been, it seems clear that we need to do a lot more of what we have been doing:
While the public is aware ofthe problem and wants to do something about it and while there has been a decline in the numbers of parents who yell and swear at and hit their children, many people are still not involved, and many parents still hit and yell at their children. Public education efforts must continue and must be intensified. A goal should be at least to double the number of people who say they are helping to prevent child abuse so that more than half of the adults in the United States are in fact involved. And we should work to cut in half the number of parents who now say they hit (49%) and yell at (60%) their children (S~hu~man et ai., 1990). l While many groups are involved in the prevention of child abuse, the numbers who are not are far greater. For every religious group actively involved, there are truly countless others which are not. The same is true for service organi~tions and sports groups and corporations. Even doubling the number of different groups and different types of groups involved in preventing child abuse would not create enough of the critical mass needed to get the job done. . While advocacy efforts have had some success, there is a long way to go before corporal punishment is not used in any child-serving institutions, when all parents have access to quality child care and work policies such as parental leave which enhance not hinder the parenting job, and even when funding for prevention is both stable and ample. Advocacy efforts, at both the national and state level, need to multiply significantly if we are truly to alter the environment in which we are trying to prevent child abuse. * And while good progress has been made in putting prevention services in place, too many parents and children and families remain unserved even by the few services we have been focusing on. Only 30% of the hospitals in the country where babies are born now offer parenting support programs for new parents and close to 40% of the elementary schools in the country do not yet offer prevention education. Whole populations must be served if we are to prevent abuse-all hospitals and all schools, among other community agencies, must make primary prevention services available.
Addressing Hew Challenges Just doing more of what we have been doing is not going to get the prevention job done. Substance abuse, poverty, societal violence have powerful effects on parents and parenting practices. Current prevention strategies are not enough to suppress them. Nor are current prevention strategies enough to overcome the ill effects the current state of children’s protective services in our country have on families. Prevention efforts of the next decade must move well beyond where we are today: l
Prevention solutions to substance abuse as it impacts parenting are needed. Can we teach crack cocaine-addicted parents to parent? Can we stop substance-abusing parents from using substances so that they can parent? Is the only answer to take the children away? Are there other social supports we can look at? These are the questions. In the next decade we need to find and implement the answers. Prevention solutions for parents living in the underclass are needed. The cycle of poverty with its family disintegration and chronic violence counteracts current prevention strategies; we need to do a better job of determining what will work and put those things (be they jobs or housing or support programs) into place.
Anne H. Cohn Donnelly
The amount of violence children and families are exposed to must be lessened. It is simply not OK for a high school graduate in our country to see 40,000 murders on TV before graduating from high school; it is not OK for children in our country to be bombarded daily with rock music heavily laced with messages of violence. The violence we are exposed to through the media alone in this country overrides and erases the prevention messages we are trying to put forward. It is time to lessen our exposure to such violence even if the only way to do so is to lessen the amount of time we allow ourselves to be exposed to it. Times have changed a lot for children’s protective service agencies in this country. Once the agency to whom families were referred for help when problems of child abuse were apparent (and from whom help was provided), children’s protective services today largely serve only an investigative function. With increased numbers of reports and no increases in funding have come increased caseload sizes and, most regrettably, fewer and fewer services for families. Once families at risk for abuse were helped by CPS; today, even in the most serious of confirmed child abuse cases, help may not be offered. The result-abuse continues. As long as protective service agencies are not offering help to families, efforts to prevent child abuse will be stymied. During the next decade we must work to restore to children’s protective service agencies their original function of helping families, largely by ensuring they receive the increased funding required. The challenges we face are many. And, underlying them all is the need for all of our solutions, all of our prevention strategies, to carry cultural relevance. Singular solutions will not work in one community after another or for one population group after another in this country. We are an extremely heterogenous society, and our child abuse prevention solutions must be tailored to each of the different groups to whom they are directed. It is only in this way that in the long term we can really guarantee that it simply won’t hurt to be a child.
REFERENCES Cohn, A. (1988). An approach to preventing child abuse. Chicago, IL: National Committee for Prevention of Child Abuse. Daro, D ( 1988). Intervening wxithnewparents: An efictive way to preventchild abuse. Chicago, IL: National Committee for Prevention of Child Abuse. Daro, D. (In press). Prevention programs. In K. Howells & C. Hollin (Eds.), Clinical approaches to sex q’fkders and their victims. London: Wiley. Daro. D.. Abrahams. N., & Casey, K. (1990).Redltcing child abuse 20% by 1990: Preiiminarj~ ussessment. Chicago. IL: National Committee for Prevention of Child Abuse. Daro. D., & Mitchel. L. ( 1990). Current trends in child abuse reporting undfutulities: The reslrlts q/‘the 1989 annzlal 50 state slrmmur~: Chicago, IL: National Committee for Prevention of Child Abuse and Neglect. Elmer. E., & Gregg. G. S. (1967). Developmental characteristics of abused children. Pediatrics, 40, 596-602. Schulman, Ronca, & Bucuvalas, Inc. (1990). Public attittldes and actions regarding child abuse and its prevention. New York: Author.