In the United States there are an estimated 900 000 children per year who are victims of child maltreatment.1 The majority of them are victims of neglect. Over the past 3 decades, there has been considerable attention to better defining our understanding of the etiology of child maltreatment. Initial work focused on sociological and psychodynamic models of child maltreatment. These models laid the ground work for the current ecological model of child maltreatment.2 The ecological model endorses a complex set of forces that create an environment which places the child at greater risk for becoming a victim of maltreatment. Although historically “bad” or “sick” people abused children, current models view children as embedded in layers and layers of varying positive and negative spheres of influences. These influences change throughout different periods in the life of a child. Each of these forces can be either stressors (risks) or supports (protectors) of the child. The limited understanding of the complexity of risks has resulted in a large variety of approaches to child maltreatment prevention. Strategies that have had the most rigorous evaluation, and strongest evidence, involve in-home visitation with either a nurse3 or a social worker4 and in-hospital parental education and engagement.5 Other promising prevention strategies include parental education about normal infant crying6 and infant soothing techniques,7 parent support programs,8 and community-based family engagement.9 Sadly, many interventions have limited evidence of their effectiveness, and few are subject to rigorous evaluation. This trend is changing. The past decade has seen the rise of evidence-based practice in the child maltreatment–prevention field,10 but randomized trials are still quite rare. This issue of Pediatrics includes the report of a cluster-randomization trial of an intervention that could bring child maltreatment prevention to the pediatric office.11
Dubowitz et al11 help move the field forward by presenting the Safe Environment for Every Kid (SEEK) model. The SEEK model consists of (1) specially trained (resident) physicians, (2) additional parental resource information, (3) administration of a screening questionnaire, and (4) a dedicated study social worker. The simplicity of the intervention is laudable. The authors report that the SEEK model resulted in fewer child protective service reports in the study population. Although the trial involved large numbers (558 parents completed the study), there was a 23% drop-out rate. Because only parents who completed the protocol were analyzed, the higher-risk parents may have selectively dropped out. Because this was a cluster trial, it is unclear if this design may have introduced bias into the final sample.12 Despite this limitation, the magnitude of the effect is quite striking. Because this trial was performed in a pediatric resident continuity clinic, the authors are correct to endorse replication of the model in different practice scenarios before it is widely implemented.
There will be no single silver-bullet program that will “fix the problem of child abuse.” The future of child maltreatment prevention will involve evaluating which mix of programs at what dosage, for what duration, and at which time in a child's life achieves the greatest impact. It will also be important to evaluate how these programs are blended into communities with policies that are optimized for children and families, which will necessitate rigorous, theory-based, prospective, multicommunity studies. A barrier to these efforts is the limited regional or national coordination for child maltreatment–prevention efforts.
Effective, sustainable child maltreatment–prevention strategies will require a shift in thinking from child maltreatment as a disease to thinking that child maltreatment is a symptom of a larger family, community, or societal disease. Other symptoms of the larger societal disease include 9 million children without health insurance,13 25% of 9th-graders not finishing high school,14 12.6 million US households with food insecurity,15 and at least 13 million children living in poverty.16 We need not only to know the physical health of the children we see but also the health of the community in which they live. The underlying, perhaps unstated, goal of child maltreatment–prevention initiatives is a significant improvement in the lives of children, which is a shift from child maltreatment prevention to child well-being promotion.17 We need to use the ameliorative tools we have at our disposal (home visitation, in-hospital education, and now, perhaps, in-office engagement) together in ways to affect larger transformative changes to the social norms.18 Sustainable prevention initiatives will move beyond simply more or better “programs” (ie, a larger “army of therapists”). Sustainable prevention initiatives involve leveraging current, and perhaps future, programs into a change of how we as a society value our children.
- Accepted November 7, 2008.
- Address correspondence to Christopher Spencer Greeley, MD, University of Texas Health Sciences Center, Suite 1425, 6410 Fannin St, Houston, TX 77030. E-mail:
The author has indicated he has no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
- ↵US Department of Health and Human Services, Administration on Children, Youth, and Families. Child Maltreatment 2006. Washington, DC: US Government Printing Office; 2008. Available at: www.acf.hhs.gov/programs/cb/pubs/cm06/cm06.pdf. Accessed January 2, 2009
- ↵Olds DL, Henderson CR Jr, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics.1986;78 (1):65– 78
- ↵Dias MS, Smith K, deGuehery K, Mazur P, Li V, Shaffer M. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics.2005;115 (4). Available at: www.pediatrics.org/cgi/content/full/115/4/e470
- ↵National Center on Shaken Baby Syndrome. Home page. Available at: www.dontshake.org/index.php. Accessed October 22, 2008
- ↵Karp H. The Happiest Baby. Available at: http://thehappiestbaby.com. Accessed October 22, 2008
- ↵DePanfilis D, Dubowitz H. Family connections: a program for preventing child neglect. Child Maltreat.2005;10 (2):108– 123
- ↵Dubowitz H, Feigelman S, Lane W, Kim J. Pediatric primary care to help prevent child maltreatment: the Safe Environment for Every Kid model. Pediatrics.2009;123 (3):858– 864
- ↵Kaiser Commission on Medicaid and the Uninsured. Health coverage for low-income children. Available at: www.kff.org/uninsured/upload/2144–05.pdf. Accessed October 25, 2008
- ↵Laird J, Cataldi EF, KewalRamani A, Chapman C. Dropout and Completion Rates in the United States: 2006 (NCES 2008-053). Washington, DC; National Center for Education Statistics, Institute of Education Sciences, US Department of Education: 2007. Available at: http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2008053. Accessed October 25, 2008
- ↵Kaiser L, Townsend M. Food insecurity among US children. Top Clin Nutr.2005;20 (4):313– 320
- ↵National Center for Children in Poverty. Child poverty. Available at: www.nccp.org/topics/childpoverty.html. Accessed October 25, 2008
- ↵Nelson G, Prilleltensky I. Community Psychology: In Pursuit of Liberation and Well-being. New York, NY: Palgrave Macmillan; 2005
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