CHAPTER
17
Child
Abuse Prevention: Within Our Reach
Other
state agencies, including the Department of Public Health,
the Department of Education, and the quasi-public Children's
Trust Fund, are each involved in the development of family
supports that serve at-risk populations or the general public.
Private sector groups are also providing leadership in developing
innovative and effective approaches. Taken together with
proposals put forth in the State Call To Action,
these can become the foundation upon which a truly statewide,
comprehensive, and coordinated system can be built to strengthen
our state's families and prevent the abuse and neglect of
its children.
Other
State-Based Prevention and Family Support Efforts
Department of Public Health
The
Department of Public Health (DPH), through its Bureau
of Family and Community Health, has a number of prevention
and family support programs providing services for low
income and vulnerable families. The First Link
program provides universal screening of newborns and families
at high risk of adverse health or developmental outcomes.
Referrals to needed services and supports are also provided.
DPH's First Steps program provides home visitation
to pregnant women and families of newborns and young infants
in selected cities and town who have been identified as
at higher risk. The Department's Home Visitation Program
also provides home visitation for new parents under the
age of 20 with a child under the age of 6 months.
The
Early Intervention Program identifies children
who experience or are at risk of developmental delay due
to physical or environmental factors. Through home visits,
parent support groups, referral services, and parent training
and education, these services work to improve developmental
outcomes for children. Currently there are 65 Early Intervention
programs across Massachusetts. Other prevention programs
that help to reduce child neglect include DPH's Healthy
Start Program, which reduces financial barriers to
early, comprehensive and continuous prenatal care for
low income uninsured women, and the WIC program
which provides supplemental nutrition to women, infants
and children.
Department
of Education
The
Department of Education (DOE) is committed to improving
children's success in school through early intervention
efforts directed at families with children from birth
through age four. Its Family Network Program operates
in 41 sites that cover 162 communities. Through local
centers, families can participate in programs to improve
parenting skills and reduce isolation, and enroll their
children in playgroups and other activities. Referral
to other appropriate community supports is also provided.
DOE
also funds the Parent-Child Program in Pittsfield
where home visitation by para-professionals is made available
gratis to at-risk, low-income and low-education level
parents of young children. Families can receive up to
two years of home visitation per week. The focus here
is to model effective parenting. The Pittsfield program,
in operation for twenty years, has documented other important
benefits for participating families, including a lower
student dropout rate and improved student test scores.[262]
Massachusetts
Children's Trust Fund
The
Children's Trust Fund currently funds a number of community
agencies and programs serving families. Programs include
parenting education and support programs, and initiatives
aimed at strengthening the role of fathers. The Trust
Fund also funds Family Centers in 6 Massachusetts
communities. These sites target parents of children up
to age 6, coordinate services, and refer families to appropriate
local providers.
Since
its inception, a major focus of the Trust Fund's work
has been to promote newborn home visitation. Though
the effectiveness of home visitation needs to be further
documented nationally through larger scale evaluation
research, some studies are pointing to improved outcomes
for children and mothers involved.
For
example, evaluation of home visiting services that conform
to the model promoted by Health Families America (HFA)
found that families enrolled in home visitation are
two to three times less likely to maltreat their children
than comparable families who are not enrolled.[263] Prevent
Child Abuse America, home of the Healthy Families America
program, reports results from several states (Oregon,
Florida, Virginia, Arizona and Tennessee) that show improved
immunization rates and better links to medical services
for children whose parents participate in HFA-type
home visiting programs.[264] According to the latest survey
conducted in 2000 by Prevent Child Abuse America, over
40,000 families across the country have received these
home visitation services.
Evaluation
of the Prenatal and Early Childhood Nurse Visitation Programs
developed by Dr. David Olds has shown enduring benefits
among poor, unmarried women. They averaged fewer subsequent
pregnancies, a longer time between the births of their
first and second children, fewer months on welfare, fewer
behavioral problems related to substance abuse, and fewer
arrests.
With
support from Healthy Families Massachusetts - an ad hoc
committee of state agencies and private groups promoting
newborn home visiting - the Children's Trust Fund has
taken the lead in successfully advocating for voluntary
home visitation for all new parents age 20 and under in
Massachusetts. Strong support from legislative leaders
has resulted in an increase from $5 million dollars to
$16.1 million dollars for newborn home visiting within
a five-year period.
Healthy
Families Newborn Home Visiting in Massachusetts is funded
through the Children's Trust Fund and administered in
partnership with the Massachusetts Department of Public
Health. It includes 30 lead agencies statewide that offer
home visitation programs, with additional subcontracted
sites bringing the total to 60 program sites. Since its
inception over 400 home visitors, sometimes referred to
as "family advocates," have provided services to approximately
6,500 families. Caseloads are set at 15, although this
can vary depending on the types of family issues involved.
Parents
20 years and under can participate in the program if they
are first time parents, with a child under one year of
age at the time of enrollment. Services can continue until
the child reaches the age of three. Participation is voluntary
in this primary prevention model.
Ninety
hours of basic training through an established core curriculum
is required of all home visitors. It is offered statewide
on a regular basis along with other standardized trainings.
Currently, an independent evaluation involving Healthy
Families participants is being conducted by Tufts University.
Final evaluation results are still pending.
Prevention
and Family Support in the Private Sector
Since
the late 80s, child and family advocates in Massachusetts
have been working to promote a shift away from crisis-driven
interventions toward a proactive promotion of child and
family well-being. The Special Committee on Family Support,
an ad-hoc group of these advocates, has articulated in its
seminal report, From Crisis to Opportunity, a vision
in which families and their communities play the central
role in organizing programs and allocating resources that
genuinely support families.
In its
surveys and papers, the Committee has identified strength-based
programs across the state that provide powerful supports
to families despite their generally low and unstable budgets.
Among the supports provided by these programs are: flexible,
drop-in childcare; parent social activities; playgroups;
teen centers; health care and education; substance abuse
prevention; domestic violence awareness and services; and
advocacy.
More
and more researchers are improving their methods of evaluating
the impact of prevention and family support programs on
parents and children. Although refining our knowledge about
effective strategies should be ongoing, there are several
prevention and family support programs that have a solid
history of successfully helping parents and children. Many
are effective from both a clinical and fiscal perspective.[266]
A description of selected programs follows:
Parents Helping Parents
Effective
family support programs include self-help/mutual-aide
groups, such as Parents Helping Parents (PHP) where
parents under stress are served anonymously and supportively.
This unique resource assists parents who are isolated,
overwhelmed, or afraid of their anger towards their children.
Groups are led by a trained facilitator (unpaid), in partnership
with a parent leader from the group. Churches and local
agencies donate meeting space. Over 50 groups are currently
meeting in communities across the state each week, including
four prison groups that serve incarcerated parents.
The
concerns parents bring to their PHP group are varied,
as is the severity of their needs. For some parents, PHP
serves as a prevention resource to help them when they
feel isolated, frustrated, and lack trusted friends to
talk to about parenting concerns. For others, PHP can
be a lifeline when serious parenting problems exist, for
example, when abuse or neglect has occurred or children
have been removed from their home. Approximately half
of the organization's members have been involved with
the Department of Social Services.
Groups
that have a "mixed membership," in terms of severity of
parenting issues, usually work very well. Parents with
less severe problems discover that their concerns are
less traumatic that they once thought. They are then able
to gain perspective and discover that their experiences
can be helpful to others. Parents with more severe problems
are relieved to be welcomed with respect by others in
the groups. They come to realize that despite the negative
parenting behaviors, e.g. yelling, hitting, that brought
them to the group, they can learn new skills and a deeper
understanding of their own unmet needs. Through the compassion
of others, they come to see themselves as worthwhile people
in their own right and, eventually, as a support to others.
This dynamic allows some of the neediest parents to gain
hope and appreciation for the strengths they never knew
they had.
Evaluations
of this self-help approach have confirmed several benefits,
including: [267]
- statistically
significant and immediate decrease in frequency of physical
abuse after joining the group;
-
decrease in frequency of verbal abuse, improving with
length of stay in the program;
-
greater parental self-esteem;
-
less social isolation;
-
increased ability to handle stress; and,
-
better understanding of children and their needs.
This
approach is cost effective as well.
PHP weekly support groups cost approximately $600 per
family per year. Costs associated with recruiting and
training of volunteer group facilitators, staffing the
PHP support phone line, and promoting the service statewide
are met through private funds and a small state grant
from DSS.
Parent
Aides
One
of the seminal evaluations of child abuse services, the
1974 Berkeley Planning Study, found results that are still
relevant today.[268] It dealt with the effectiveness of
the lay visitor or parent aide model. Parent aides
are trained, professionally supervised individuals, volunteer
or paid, who assist parents under stress or those at risk
of abuse or neglect. The one-on-one relationship is parent-focused,
non-judgmental, non-authoritarian and nurturing. Parent
aides work in the home to develop parental self-confidence
and esteem; home management, problem solving, communication
and coping skills; and the use of appropriate community
resources.
The
study found important results among parents who were in
traditional treatment or counseling for at least six months,
and who received parent aide services in PHP type self-help
groups. These parents were most likely to show improved
functioning by the end of treatment and had the best chances
of reducing the likelihood of future abuse.
Benefits
for parents included:
-
more positive attitudes towards their children;
-
increased awareness of child development;
-
improved ability to talk about problems and handle crises;
-
more constructive ways of channeling anger;
-
an increased sense of independence;
-
improved self-esteem.
The
study also pointed out that those services that proved
more effective also tended to be those that were the least
expensive.
Here
in Massachusetts, parent aide services essentially provide
home visitation services, but to a population of families
who have already been reported for abuse or neglect and
who are under the care of DSS.
These
private services funded by DSS have just completed their
first year under the Lead Agency Initiative described
earlier in this report. While the newborn home visitation
services provided under Healthy Families operate under
a flexible strength-based model, the DSS-funded Parent
Aide programs struggle under the fiscal constraints of
the managed care model. A discrepancy exists between the
philosophy of strength-based, family-centered assessment
and services espoused by DSS Central Office and the traditional
deficit-based model that has been practiced historically
within local DSS offices, and social services in general.
The
fiscal charge given to the Lead Agencies sometimes undermines
implementation of the Parent Aide model, which is fundamentally
grounded in the development of a relationship between
the Parent Aide and parent. The relationship and trust
building that are so essential to the success of this
parent support cannot be accomplished within rigid, limited
timelines. Outcome measures that are limited to a short
time (3 months of service) are simply unrealistic and
inappropriate for many families who could make significant
gains given the chance to work within an uncompromised
Parent Aide model.
Many
Parent Aide programs report that, despite waiting lists,
they are now providing lower levels of service than they
had been historically. This threatens the ability of programs
to retain experienced, trained staff, maintain program
quality, and, in some cases, even keep their doors open.
The Association of Massachusetts Parent Aide Programs,
a longstanding voluntary organization of Parent Aide programs,
continues to advocate for the integrity of its model even
within the managed care system. If managed care is concerned
with meaningful client outcomes and reducing costs in
the long term, it cannot afford to reduce Parent Aide
services in the short term.
Family
Nurturing Program
The
Family Nurturing Center of Massachusetts helps build nurturing
communities where children are cherished, families are
supported, and private and public policies promote healthy
human development. It develops and pilots innovative family
support and educational programs, then mentors others
who adapt them for use within their own organizations
and communities. By working in partnership with others,
the FNC changes attitudes and practices of both families
and the professionals who deliver services to them. Using
this approach, the Center has successfully spread nurturing
values and creative new family support programs across
Massachusetts.
One
of the cornerstones for the work of the Family Nurturing
Center is the Family Nurturing Program. The Family
Nurturing Programs are validated, internationally recognized
programs that promote nurturing relationships among all
family members while building community connections to
support positive parenting attitudes and behaviors. Developed
over twenty years ago by the National Institute of Mental
Health and child abuse researchers Bavolek and Comstock,
the Nurturing Programs are now operating in the U.S.,
Canada, Mexico, Europe, South America, and Israel.
Nurturing
Programs are weekly classes that families, adults and
children take together. Programs are held in convenient,
safe and nurturing environments and involve adults and
children in interactive, fun, age-appropriate activities
that promote nurturing attitudes and behaviors. Programs
range in duration from 9-23 sessions and address the following
topics: communication skills, identifying and expressing
feelings, nurturing discipline techniques, use of personal
power, managing conflict and confrontation, promoting
positive self-esteem, empathy, alternatives to physical
punishment, and information about age-appropriate expectations
for children.
Nurturing
Programs are targeted to: prenatal families, teen parents,
parents of school age children, parents with infants and
toddlers, families struggling with substance abuse treatment
and recovery, foster and birth families, Spanish speaking
families, Cape Verdean Creole-speaking families, and more
recently, the Father's Nurturing Program.
Extensive
evaluation has shown the program to be effective in changing
both negative parenting attitudes and behaviors.[269]
Families that participate demonstrate:
-
significant increase in family cohesion, communications
and organization,
-
marked decrease in family conflict,
-
significant decrease in reliance on abusive discipline
techniques.
The
success of this approach can be seen further in the high
numbers of families who begin and complete the programs
and who report high rates of satisfaction. The programs
are free for the families and most often include a meal
and transportation. Program costs are underwritten through
private and state grants.
The
Family Nurturing Program was initially piloted in Massachusetts
in 1990 as part of a five-year, federally funded demonstration
project called Dorchester CARES, of which MCC was a founding
partner. Today, the Family Nurturing Center works with
organizations statewide to provide direct nurturing programs
to families, and extensive training and consultation to
communities interested in developing Nurturing Programs
in their area.
As
more and more families and community groups experience
the success of Nurturing Programs, the demand for more
programs increases. Currently, there are waiting lists
for many community programs and in many places there is
limited access to programs. Clearly, this proven effective
family support program needs to be expanded where it currently
exists and developed in other communities statewide.
Shaken
Baby Syndrome Prevention
In 1996,
six months before the highly publicized death of 17-month-old
Matthew Eappen in Massachusetts, MCC launched its statewide
"Never Shake a Baby" Campaign to reduce infant death
and disability due to Shaken Baby Syndrome (SBS). Through
television, radio and the print media, parents and caretakers
have been offered information about the devastating results
that can occur from this type of assault on an infant or
young child. Coping with infant crying and fussiness, often
the triggers of SBS, has been an important feature of the
Campaign's message.
Now
operating under MCC's "Prevent Child Abuse Massachusetts"
(PCA) program, the campaign has reached thousands of parents
directly through brochures and printed materials, requests
on PCA's 800-CHILDREN line, and through campaign
information distributed by hospitals, clinics, birthing
classes, schools, libraries, etc. Over 500,000 teaching
brochures have been distributed throughout Massachusetts
and in several other states (Wisconsin, New Hampshire, Delaware,
etc.) that have adopted the brochure as their core teaching
tool.
As it
moves to the next phase of its campaign, PCA Massachusetts
is seeking to replicate a successful, eight-county SBS prevention
pilot effort in Western New York State. Coordinated through
Children's Hospital of Buffalo, the effort targeted new
parents within hospitals with a combination of written SBS
information, video presentation, and signed parental statement
acknowledging understanding of the information.[270] The
counties have documented a 75 percent decrease in reported
SBS cases. Prior to the effort, one case was identified
every seven weeks; the number has now dropped to one case
every eight months.
Brockton
and Haverhill are two communities that have taken the lead
locally to reduce SBS injuries and death. The former effort
was launched by the District Attorney's Office in collaboration
with local hospitals, agencies and schools; the latter by
the mother of an SBS victim who works in her community to
educate medical professionals, school children and the general
public.
Massachusetts
does not currently have a formal curriculum in place to
teach middle school and older children about SBS prevention.
However, such tools have been developed using demonstrations,
video, and discussion materials to help young teens learn
about SBS as they begin to take independent care of their
siblings and other children. This type of curriculum is
seen as an effective way to reach future mothers and
fathers.
Child
Sexual Abuse Prevention and Treatment
Currently,
Massachusetts lacks a comprehensive, statewide strategy
to reduce sexual assaults against children and to address
the critical lack of effective evaluation and treatment
resources for both child victims and for child, youth, and
adult offenders.
Successful
prevention and treatment strategies in other states should
be accessed and replicated. For example, a coordinated
effort in Vermont resulted in a reduction of proven cases
by 51 percent between 1990-1998. Partnerships among
the State child protective agency, law enforcement, the
Attorney General's office, child advocacy groups, public
health agencies, and the media were cited as instrumental
in this dramatic reduction of child sexual abuse. Through
a recently launched, large-scale public education campaign
conducted in partnership with non-profit organizations,
Vermont seeks to identify even more cases of unreported
child sexual abuse.[271]
Although
many Massachusetts schools do provide prevention education
curricula around "stranger danger" issues and "good touch/bad
touch," it is not clear just how effective these programs
are in actually protecting children when they are in threatening
situations. Although they do increase awareness, it has
been shown that these programs are more effective for older
children - younger children require more frequent exposure
to program materials. Though some children exposed to these
programs may have benefited from increased awareness about
sexual abuse, it is not evident that children who actually
experienced threats and assaults were able to limit their
seriousness.[272] Though prevention curricula should be
part of a comprehensive strategy, they cannot be the center
of it. Other complementary strategies will need to be considered
as part of an effective statewide prevention effort.
In developing
a comprehensive plan to address child sexual abuse, Massachusetts
should seriously explore models that can address the population
of offenders who wish to stop their offending and need support
to do it. Some states have initiated broad public awareness
campaigns aimed directly at sexual abusers. Through a special
hotline established in Vermont, for example, sexual abuse
perpetrators were guided to seek treatment and to accept
responsibility for their actions. Outcome data from the
Vermont effort should be carefully reviewed.
Massachusetts
should also explore ways to involve the media as partners
in educating the public about the impact of child sexual
abuse. Such partnerships could help educate citizens about
how to talk to their children about sexual abuse; signs
to be aware of in both child victims and adult perpetrators;
how to address factors that make disclosure among children
difficult. These can be complex dynamics, but with clear
and consistent public education messages, many families
and communities can be strengthened in their vigilance against
this devastating threat.
RECOMMENDATIONS
- Fund universal, voluntary newborn home visiting
for all new parents.
Massachusetts can be proud of its success in making available
newborn home visitation support to all parents 20 and
under that seek it. The state must now move to benchmark
when and how it will phase in universal home visitation
for all new parents, irrespective of parental age.
- Expand funding for proven effective family support
programs so they are accessible to all Massachusetts parents
who seek them.
Family supports that have documented their effectiveness
in preventing child abuse and neglect and in reducing
the stresses associated with child maltreatment must be
expanded where they currently exist and their availability
extended statewide.
- Expand Shaken Baby Syndrome prevention efforts.
Massachusetts should replicate efforts that have succeeded
in reducing infant death and disability due to Shaken
Baby Syndrome. Initiatives aimed at educating new parents
within birthing hospitals, and special outreach to young
men - the most frequent perpetrators of SBS - should be
implemented. All state agencies involved with parents
and children should incorporate SBS prevention education
into their training and direct service programs.
- Establish a statewide Sexual Abuse Prevention and
Treatment Strategy.
Massachusetts must develop a comprehensive, coordinated,
statewide strategy to effectively reduce sexual assaults
against children and to address the critical lack of effective
evaluation and treatment resources for both child victims
and for child, youth, and adult offenders. Public education
efforts involving the media should be an integral part
of the strategy. Such coordinated efforts, in Vermont,
for example, have reduced proven cases by 51 percent over
a decade. Massachusetts should set a similar goal and
work to achieve it.
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Section
V: Preventing the Hurt:
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