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Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009

Preventing Child Abuse and Neglect with Parent Training: Evidence and Opportunities
Authors: Richard P. Barth

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
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 care-givers 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 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 homeless-ness 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 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.

Domestic Violence
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.

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.