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ORIGINAL PAPER Achieving Comprehensive Prevention of Child Abuse and Neglect Heather J. Risser 1 & Kimberly Svevo-Cianci 2 & Elba Jung Karim 3 & Alexandra E. Morford 1 Accepted: 13 August 2019 /Published online: 31 December 2019 # Springer Nature Switzerland AG 2019 Abstract The United States has developed a comprehensive array of child abuse and neglect (CAN) prevention resources and has allocated funding to provide these resources. Policy makers, practitioners, and advocates are committed to CAN prevention. However, the current paradigm used to prevent CAN is inadequate for four reasons. First, system-level policies and infrastructure are not fully aligned with childrens needs for a safe and stable upbringing. Second, access to effective CAN prevention resources is not ubiquitous. Third, most people do not have clear roles in preventing CAN in their everyday lives. Fourth, fear of stigma prevents caregivers from seeking support and accessing services. We must shift the para- digm so that all policies promote child well-being, every family has equitable access to all opportunities, and every individual feels entitled to advocate for and engage in CAN prevention. By embedding an adapted Health Belief Model (aHBM) into an ecological model, we can improve policies, behaviors, and beliefs at all levels of the social ecology in order to shift the paradigm. In order to scale knowledge and advocacy for preventing CAN to the population, we propose a strategy that increases system collaboration, leverages existing infrastructure, and adopts multi-source funding models that invest in prevention services to inoculate society against CAN. Keywords Child maltreatment prevention . Child abuse prevention . Child neglect prevention . Child and family policy . Child well-being promotion . Health promotion . Collaborative care . Integrated care . Parenting Introduction The United States has developed a comprehensive array of child abuse and neglect (CAN) prevention resources and has allocated funding to provide these resources (e.g., International Journal on Child Maltreatment: Research, Policy and Practice (2020) 3:6379 https://doi.org/10.1007/s42448-019-00024-7 * Heather J. Risser [email protected] Extended author information available on the last page of the article

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Page 1: Achieving Comprehensive Prevention of Child Abuse and Neglect · Achieving Comprehensive Prevention of Child Abuse and Neglect Heather J. Risser1 & Kimberly Svevo-Cianci2 & Elba Jung

ORIG INAL PAPER

Achieving Comprehensive Prevention of ChildAbuse and Neglect

Heather J. Risser1 & Kimberly Svevo-Cianci2 & Elba Jung Karim3&

Alexandra E. Morford1

Accepted: 13 August 2019 /Published online: 31 December 2019# Springer Nature Switzerland AG 2019

AbstractThe United States has developed a comprehensive array of child abuse and neglect (CAN)prevention resources and has allocated funding to provide these resources. Policy makers,practitioners, and advocates are committed to CAN prevention. However, the currentparadigm used to prevent CAN is inadequate for four reasons. First, system-level policiesand infrastructure are not fully alignedwith children’s needs for a safe and stable upbringing.Second, access to effective CAN prevention resources is not ubiquitous. Third, most peopledo not have clear roles in preventing CAN in their everyday lives. Fourth, fear of stigmaprevents caregivers from seeking support and accessing services. We must shift the para-digm so that all policies promote child well-being, every family has equitable access to allopportunities, and every individual feels entitled to advocate for and engage in CANprevention. By embedding an adapted Health Belief Model (aHBM) into an ecologicalmodel, we can improve policies, behaviors, and beliefs at all levels of the social ecology inorder to shift the paradigm. In order to scale knowledge and advocacy for preventing CANto the population, we propose a strategy that increases system collaboration, leveragesexisting infrastructure, and adopts multi-source funding models that invest in preventionservices to inoculate society against CAN.

Keywords Child maltreatment prevention . Child abuse prevention . Child neglectprevention . Child and family policy . Child well-being promotion . Health promotion .

Collaborative care . Integrated care . Parenting

Introduction

The United States has developed a comprehensive array of child abuse and neglect(CAN) prevention resources and has allocated funding to provide these resources (e.g.,

International Journal on Child Maltreatment: Research, Policy and Practice (2020) 3:63–79https://doi.org/10.1007/s42448-019-00024-7

* Heather J. [email protected]

Extended author information available on the last page of the article

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Forston et al. 2016; Rudolph et al. 2018; U.S. Department. of Health and HumanServices 2016). Policy makers, practitioners, and advocates are committed to CANprevention. However, the current paradigm used to prevent CAN is inadequate for fourreasons. First, system-level policies and infrastructure are not fully aligned withchildren’s needs for a safe and stable upbringing. Second, access to effective CANprevention resources is not ubiquitous. Third, most people do not have clear role inpreventing CAN in their everyday lives. Fourth, fear of stigma prevents caregivers fromseeking support and accessing services. We must shift the paradigm so that all policiespromote child well-being, every family has equitable access to all opportunities, andevery individual feels entitled to advocate for and engage in CAN prevention.

System-Level Prevention

Evidence suggests that consistent access to high-quality healthcare, home visiting, childcare,and early education promotes child safety and well-being (e.g., Bradley and Vandell 2007;Vandell et al. 2010; Vandell, Burchinal, & Pierce 2016; https://homvee.acf.hhs.gov/).Likewise, financial and housing stability, violence-free neighborhoods, and access to healthyfood and clean water promote child and family well-being (Benzies and Mychasiuk 2009).However, in the United States, families often do not have equitable access to some of themost essential services often such as high-quality healthcare, childcare, healthy food, andclean water (Stanford Center on Poverty and Inequality 2017; U.S. Census Bureau 2018).By aligning federal, state, and municipal policies with child health promotion needs, we canbe sure that families have the basic foundation on which to raise healthy children. From aninternational perspective, the United States could indentify the U.N. Committee on theRights of the Child (Doek 2009;Doek and Svevo-Cianci 2017; Lee and Svevo-Cianci 2010;UN Committee on the Rights of the Child (CRC) 2011). Furthermore, by investing inuniversal prevention and promotion policies like guaranteed paid parental leave and uni-versal childcare, and reducing community divestment that results in food deserts andinadequate municipal oversight that results in high lead in drinking water (e.g., Flint,Michigan, water crisis), we can provide families with more equitable access to optimaldevelopment. Furthermore, we can engagemultiple systems in coordinatedCANpreventionsimilar to illness and injury prevention initiatives. For example, the American Academy ofPediatrics and the Centers for Disease Control (CDC) have collaborated to set guidelines fora well-child visit schedule that includes suggested anticipatory guidance content andimmunizations. The U.S. Department of Health and Human Services and the U.S. Depart-ment of Education have aligned policies to require documentation and compliance withthese guidelines. All of these agencies, together with state and municipal agencies, andcorporate sponsors have coordinated efforts to provide clear messaging to families andaccess to these services for children.

Ubiquitous Access and Population-Level Prevention

The concept of population-level prevention is that every person feels entitled to healthyrelationships and feels empowered to advocate for and engage in CAN prevention. Todemonstrate these concepts, we will use the handwashing paradigm as an example.Handwashing protocols have become a ubiquitous practice across all settings. Clearinstructions for handwashing are posted in most restrooms, regardless of the setting.

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People believe that they and others are entitled to have access to clean water and soap inevery restroom and to request that others wash hands, and they know how to model thisbehavior for others. In the area of CAN prevention, ubiquitous access would includeaccess to high-quality, effective, and culturally relevant resources for every family.Although the handwashing protocol can be clearly demonstrated in 6–8 steps, themetaphor could serve as a basis for a developmentally calibrated model for changingcomplex beliefs and behaviors (e.g., five steps for brain building: serve and return; seehttps://developingchild.harvard.edu/). Instead of fear of stigma for accessing services,people will see service access as something to which they and others are entitled. Wecould expand on the existing model and infrastructure for changing complex behaviorsrelated to child health. For example, the pediatric setting has an infrastructure for bothpreventing and treating illness and disease with clear guidelines for the schedule andcontent of well-child visits that include prevention resources such as a vaccine scheduleand anticipatory guidance. The sick-child visits and specialty clinics are designed totreat children with acute or chronic illness. The pediatric emergency department isdesigned to treat more serious acute injury or illness with inpatient hospitalization whenmore serious, longer term treatment is needed. Unfortunately, a single vaccine toprevent all child maltreatment is not possible (Alexander et al. 2017; Desai, Reece &Shakespeare-Pellington, 2017). However, a single vaccine does not prevent all child-hood illnesses either. Instead, multiple strategies have been coordinated to accomplishthis goal.

Because pathways to CAN are both equifinal and multifinal, it is difficult to imagineone simple solution to prevent all CAN. However, some other complex equifinal andmultifinal conditions have demonstrated success in finding complex, developmentallytargeted “behavioral vaccines” (e.g., Embry 2011; Van Voorhees et al. 2015). In thisway, we could promote the importance of relational health that realigns societalpriorities to elevate the importance of child safety and development and recognizesthe importance of supporting all families as a conduit to this goal.

We could also develop models for people who are not caregivers of a given childthat could guide them in preventing CAN and promoting child well-being. We will usethe example of a comprehensive plan to mitigate global warming. Policies support thismitigation by setting standards for carbon emissions and procedures for compliance.Public planning and the private sector are incorporating renewable energy and energy-efficient design and procedures in projects. Project Drawdown, a comprehensive planto mitigate global warming, focuses on behavioral solutions for individuals(Williamson et al. 2018; https://www.rare.org/report/climate-change-needs-behavior-change/). People have learned a variety of ways to engage in energy conservationfrom simple (turn off electronics when not using them) to complex (various rules foridentifying, cleaning, sorting, and transporting items to be recycled). Furthermore,energy conservation itself required a shift in attitudes, beliefs, and multiple differentbehaviors in different settings with a variety of different options. In a similar way, wecan guide individuals in promoting child well-being for not only their children, but allchildren—even if they are not caregivers.

Our disruptive strategy would be to focus on the whole person, recognizing that byinvesting in children they grow into healthy adults (reducing risk for engaging inbehaviors that result in CAN). By also investing in adults, they are provided withsupport, resources, and knowledge needed to nurture and protect children. All people

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will benefit from an environment of relationships which provide positive experiencesthat foster growth, while reducing exposure to toxic stress and adverse experiences thatthreaten to compromise optimal child development (see https://developingchild.harvard.edu/). This coordinated effort could build on the existing infrastructure andemphasize lifelong learning, social-emotional capacity, self-regulation, and resiliency,focusing on attachment and relational patterns.

To accomplish this, our aim is to create a shared mindset where people feel entitledto the information, tools, skills, resources, and experiential opportunities they need tobuild and maintain a web of healthy social relationships. People feel entitled to policiesthat promote equitable access to services and governance, displacing the currentparadigm in which inequity impacts all levels of the social ecology and parents fearthe involvement of child welfare services and the stigma associated with asking forsupport. This is exacerbated when other adults who are present and could potentiallyintervene question their role and the social acceptability of stepping in to supportcaregivers and children, or help prevent situations that could result in CAN. Futuregenerations would benefit from a healthier and more supportive social fabric and accessto a comprehensive prevention system that promotes child well-being. Informed adultswould understand what types of involvement or assistance to the caregiver and/or thechild are appropriate. Informed and changed social norms would also provide criticaldeterrence of the development of harmful attitudes, beliefs, behaviors, and copingmethods that lead to CAN.

Comprehensive prevention could be seen as a continuum that includes healthpromotion and universal CAN prevention through quaternary prevention (see Fig. 1).

The entire prevention continuum must be embedded within a system that provideshealth equity (Sadana and Blas 2013). Health promotion and universal preventioncultivate environments that support all children and families (Alexander et al. 2017;Linkenbach 2016). This will be accomplished by aligning public policy and providinguniversal prevention resources and support that promotes optimal health and develop-ment (e.g., quality standards for interpersonal relationships. The conceptual frameworkfor this continuum would be based on the CDC Division of Violence Prevention’ssocio-ecological and positive approach to addressing child maltreatment within a publichealth strategy. Safe, stable, and nurturing relationships (SSNRs) between children and

Fig. 1 Conceptualization continuum of comprehensive prevention

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their caregivers are essential for promoting optimal health over the lifespan. Thepromotion of SSNRs within the context of health equity and equitable access toresources promote healthy and optimal developmental trajectories (e.g., Alexanderet al. 2017; Linkenbach 2016; https://www.cdc.gov/violenceprevention/pub/healthy_infants.html).

Primary prevention strategies prevent CAN by reducing risk and promoting protec-tive factors. Secondary or selective prevention strategies reduce the severity, frequency,and impact of CAN for those at risk. Tertiary or targeted prevention strategies reducethe impact of CAN and prevent subsequent CAN. Quaternary prevention strategiesprevent iatrogenesis and intergenerational transmission of CAN.

Theory-Driven Path to Implementation

Although there are different models that could provide a path to effective implemen-tation, we propose overlaying an adapted Health Belief Model (aHBM) with anecological model (Bronfrenbrenner 1994). The Health Belief Model has been demon-strated to improve health-promoting behavior and behavioral activation by addressing avariety of beliefs about health (Becker 1974; Jones et al. 2014). An aHBM would targetindividual beliefs and behaviors to promote child safety and prevent CAN. By embed-ding an aHBM into an ecological model, we can improve policies, behaviors, andbeliefs at all levels of the social ecology in order to shift the paradigm. To maximize theeffectiveness of changing complex beliefs and behaviors and social norms, we proposeengaging a professional design firm to tailor and implement campaigns targeted tospecific audiences. Strategies could include changing beliefs of policy makers—assisting them in understanding the implications of policy on society and fosteringpolitical will to align policies with health promoting efforts. The messaging wouldpromote an understanding of the benefits of policies and programs to support families.Strategies could also target caregivers to promote understanding of how to buildpositive caregiver-child relationships. Strategies could also include other CAN preven-tion resources designed to empower caregivers to access supports and advocate forchild well-being. To implement this, we propose a phased approach in which we beginwith policy makers and move outward toward a population-based campaign.

Method

System-Level Prevention

To achieve system-level prevention, we need to help policy makers better understandthe empirical evidence that demonstrates that supporting families has broad effective-ness across multiple domains of child health, development, and behavior(transdiagnostic effects that simultaneously prevent multiple negative outcomes andpromote multiple positive outcomes). It would also be helpful to conduct additionalstudies to model the return on investment (ROI) in child and family services. Earlyinvestment in children often has a significant impact on later development(https://www.impact.upenn.edu/our-analysis/opportunities-to-achieve-impact/early-

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childhood-toolkit/why-invest/what-is-the-return-on-investment/). The ROI is likelyexponential when examining the impacts on long-term outcomes and benefits thatlikely extend into the next generation.

Population-Level Prevention

To achieve ubiquitous access and promote population-level feelings/beliefs of entitle-ment to CAN prevention, we propose a theory-driven path to implementation. First, wepropose embedding prevention models into models of implementation to promote aneffective plan for targeting specific beliefs and behaviors. This will be essential as wework within communities to understand and ultimately influence public policy andcommunity social norms, such as those of physical discipline and family safety netsthat prevent child neglect. Second, we propose coordinated initiatives to promotefeelings and beliefs of entitlement to CAN prevention resources in caregivers (e.g.,access to high-quality childcare and parent training). Third, we propose coordinatedinitiatives to promote population-level engagement in CAN prevention. Fourth, wepropose an evaluation of prevention efforts, implementation methods, and effects toguide efforts to scale. In order to scale knowledge and advocacy for preventing CAN tothe population, we propose a strategy that increases system collaboration, leveragesexisting infrastructure, and adopts multi-source funding models that invest in preven-tion services to inoculate society against CAN.

Increase System Collaboration

We propose a bold system collaboration that promotes comprehensive CAN prevention(see Fig. 2). We can embed a collaborative care approach (CCA) within an AssetsBased Community Development Model (ABCD; Blickem et al. 2018; Kretzmann andMcKnight 1996). In this way we hope to create a robust and interlocking system thateliminates redundancy while ensuring population-based CAN prevention from astrength-based, solution-focused perspective (UNCRC GC 13-II).

To implement this, we would draw from the intervention literature and adapt acollaborative care approach (CCA) to provide comprehensive prevention serviceswithin an existing setting (Community Preventative Services Task Force 2012). Col-laborative care models integrate multiple types of service in one care delivery setting(e.g., Glassgow et al. 2018; InCK, https://www.cms.gov/newsroom/fact-sheets/integrated-care-kids-inck-model; Unützer et al. 2013). A CCA would provideCAN prevention in multiple settings (e.g., school, workplace). In places that alreadyuse collaborative care models, the care coordinator could provide CAN preventionservices (e.g., health systems and primary care settings). We propose preventioninitiatives that promote protective factors and strength-based perspectives while reduc-ing risk factors for CAN at the earliest possible opportunity (e.g., U.S. Department ofHealth and Human Services 2016). Where opportunities for prevention do not currentlyexist, they must be embedded into our public health and community infrastructurethrough a CCA.

A comprehensive CAN prevention schedule could be developed with specificprevention strategies for different systems, similar to the vaccine schedule for childrenthat multiple systems use. The child’s primary care provider typically administers the

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vaccines on schedule based on the child’s age. Childcare, school, and some worksettings require proof of these vaccinations. Children and adults can also get requiredvaccinations off schedule or at other locations such as public health offices and drugstores. Similarly, each system would develop a set of CAN prevention strategies andresources that would target different audiences in each system and could function atvarious levels of collaboration (see SAMHSA-HRSA; Heath et al. 2013). For thosejobs which require licensure, proof of completion of a skills-based positive relationshippre-approved course could be implemented, as is commonly done with ethics trainings.

Administrative oversight and policies could be scaled across systems to promoteconsistent, basic procedures that everyone can recognize as critical to meeting thechild’s right to protection and safety, and that they are trained and required to uniformlyenforce. For example, when feasible, adult-child interactions (e.g., speech therapysessions) should be visible through a one-way mirror that could be monitored byadministration, paraprofessionals, or parents of the child. Some individual servicescould be offered more effectively in groups with similar-aged peers with similardevelopmental needs (e.g., physical therapy). Offering group-based services could bea more cost-effective option, allowing children to receive more frequent sessions. Theworkforce could be trained in CAN prevention and healthy relationships. Employeetraining and handbooks would reference EndCAN philosophy as part of organizationclimate. EndCAN-supporting companies could be highlighted (such as Best Places toWork for Women). Service integration could manifest as a statewide searchableresource with geolocation like Service Provider IDentification and Exploration Re-source (SPIDER; https://spider.dcfs.illinois.gov/). SPIDER provides real-time informa-tion related to service options and locations for family resources that can be filtered by

Fig. 2 Conceptualization of system collaboration: creating opportunities for prevention messaging

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user preferences and parameters (e.g., zip code, child age, insurance coverage). In orderto reach every family, we could embed innovative technologies within our systems ofcare to increase accessibility and scalability of services, information, and policy(UNCRC GC-13-IV (29)). Leveraging existing infrastructure and building on commu-nity strengths, targeted prevention efforts would be delivered at different time points,with different messaging, marketing, skills, and support.

Prevention initiatives could be embedded in all aspects of community life, integrat-ing audience-appropriate messaging that promotes recognizable and well-understoodbehaviors, similar to other disease prevention initiatives (e.g., handwashing; see Fig. 3).

A model that supports relational health would provide a common model forprofessionals and families to adopt and build upon. This approach would be designedto work across all sectors of government and community institutions, focusing onbuilding social-emotional competencies in children using an intergenerational approachwhich includes caregivers and broader society. This unified model would have com-mon elements related to developing healthy relationships calibrated for audience.

The messaging architecture would center around building communication andemotion regulation skills that engender interpersonal respect, empathy, and positiveemotional responsiveness. Just as we teach people the importance of washing theirhands without them needing to understand microbiology, positive human interactionnorms simply become “what one does” and “what one expects” from oneself andothers. People will recognize behaviors that could threaten the well-being of childrenand intervene. They will feel entitled to promote positive and safe behaviors towardchildren and have clear models for doing so. These prevention initiatives will beimplemented and interwoven across service settings and policy initiatives such thatsupport, touchpoints, and teachable moments can occur in any setting.

Fig. 3 Example of an easily recognized graphic to indicate children need positive physical touch

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Each of our proposed prevention efforts focuses on promoting protective factors andreducing systemic risk factors, including those most salient risk factors relative to themechanisms of perpetration for each developmental age (DA) or type of CAN (e.g.,Forston et al. 2016; U.S. Dept. of Health and Human Services 2016). Effectiveprevention efforts would target all levels of the social ecology (microsystem,mesosystem, exosystem, macrosystem; Bronfrenbrenner 1994).

Prevention implementation at the various levels would occur at different times fordifferent audiences based on the child’s needs and DA. Prevention objectives wouldtarget different proximal and distal causes of CAN. Content and dissemination methodsmay differ for policy information for administrators, practice information for profes-sionals, resources for caregivers, and developmentally appropriate information deliv-ered by embedding messages in apps, children’s programming, curricula, and videogames. These population-based prevention efforts would occur in concert and calibrat-ed sequentially by developmental age to avoid gaps in meeting the family’s needs.

Leverage Existing Infrastructure

Current infrastructure is often underutilized. Rather than building new systems, we canleverage current local, regional, and national infrastructure; formal and informal set-tings to build systems of care to achieve comprehensive prevention (Hernandez andHodges 2003). For instance, the Positive Community Norms Framework (PCN) couldenlist community-wide support in developing leadership skills to foster transformationto higher standards of family relationships and nurturing children to thrive, communi-cating positive norms, and correcting misconceptions. Developing integrated preven-tion initiatives to reduce child maltreatment, ranging from policy changes, resourceallocations, and other systemic changes, could transform the health and well-beingtrajectories of children and families. Specific prevention resources and messagingwould be embedded within the context that each person has a right to this informationand an acknowledgment that we are embarking on a renewed initiative to provide allfamilies with state-of-the-art, effective tools to achieve optimal health.

Healthcare A key to leveraging existing infrastructure and building collaboration isaugmenting established patterns of access. Research has demonstrated improved accessto care with expanded education and outreach, additional resources, extended hours ofoperation, and use of the presumptive eligibility policy within Medicaid (Glassgowet al. 2018; Shah et al. 2018). The OB-GYN setting could provide an opportunity forfocusing on safe care for the newborn and targeted support for optimizing childdevelopment.

Messaging and resources could be delivered via text throughout the perinatal periodwith coordinated in-person prevention messaging during maternal doctor visits, ultra-sounds, and well-child visits in the pediatric or family practice settings. Pediatric well-child visits could provide a natural setting for disseminating prevention resources andimplementing many aspects of prevention (e.g., Breitenstein et al. 2016; Glassgowet al. 2018). Currently, only 19 states require a child to have a physical medical exambefore starting school; 41 states require a vision screening. A policy that requires allchildren to have exams and/or screenings could provide opportunities for prevention.Behavioral health anticipatory guidance could be established for all healthcare and

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vision appointments. Delivery of this anticipatory guidance (which currently exists formany developmental milestones) could be supplemented through mobile health appsand broader social messaging. For example, texts could promote positive self-care,developmental milestones, emotion regulation guidance, and resources for managingdevelopmentally targeted child behaviors. Two-way texting and short message service(SMS) could elicit simple feedback in the form of yes-no questions inquiring whether acaregiver is interested in getting more information on any specific topic, and multime-dia messaging service (MMS) could provide tutorials on various relevant topics.Providing this information in healthcare settings as health promotion could reducethe stigma of parents seeking support. Research has demonstrated the feasibility andeffectiveness of providing parenting services and parent training in healthcare settings(e.g., Breitenstein et al. 2016; Risser et al. 2016; Tapia et al. 2006).

Childcare and Preschool Childcare services and preschools often provide very littlesupport and guidance to caregivers, perhaps out of fear of offense. However, using astrength-based approach, trained childcare professionals could more effectively engageparents in collaborations of positive child development and connect families to helpfulresources (e.g., Illinois Action for Children). These settings provide opportunities forchildcare workers and teachers to promote and model appropriate interactions andconnect families to community resources. Children would also be taught to expectconsistent, connected relational responses from adults, which would later translate to abetter understanding of healthy relationships.

Schools Universal risk reduction could include meal programs for all children andfamilies through the schools and during school breaks (currently implemented in manyschool districts). School staff could connect families to all forms of support andresources (e.g., health insurance, local and federal financial assistance programs). Freein-school dental and vision screenings that are currently offered could be expanded toinclude all schools. Many schools include social-emotional learning (e.g., Calm Class-room and other curricula) that could be expanded. Developmentally appropriate cur-ricular units on healthy relationships that teach effective healthy coping and effectivecommunication skills could be integrated into health education classes or individualcourses at all ages. Messaging with clear skills checks could be embedded incoursework and curricula. K-12 schools, colleges, and universities already have infra-structure for mandated staff training (e.g., child abuse and sexual assault response;safety plans) and have ubiquitous health and well-being messaging. We propose addingtrauma-informed CAN prevention strategies to existing staff training and informationfor accessing community resources.

Communities Departments of public health, community agencies, and park districtsengage in many innovative projects that integrate health promotion and violenceprevention across the community (Chicago Department of Public Health 2016;Healthy Chicago 2.0). These are natural settings for providing resources and preventionservices, as well as for updating policy to promote health equity and access. The periodof early childhood requires nurturing care, nutrition, safety and security, responsivecaregiving, and early education (Advancing Early Childhood Development: FromScience to Scale 2016). Birth to Three programming focuses on cognitive, speech,

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and physical development. Valuable information could easily be integrated into servicedelivery, such as information about healthy adult-child and parent-child interaction andnonviolent discipline. Home visiting for new parents has an established infrastructurethat implements evidence-based prevention models for promoting healthy child devel-opment and preventing CAN. These resources could be expanded to include someaspect of video conferencing check-ins and phone coaching to reach more families in auniversal prevention approach.

Faith-Based Organizations Many faith-based organizations partner with public healthdepartments or other community service agencies to provide wellness programming totheir congregations. For example, faith-based organizations in rural counties providedtargeted prevention services to reduce risk for cardiovascular disease (Zimmermannet al. 2018). Faith-based organizations can partner with communities to promotepositive parenting, child and youth development, and thriving family relationships(through parenting and child/youth programs) and provide leadership in promotingpolicies that keep youth safe from CAN.

Youth-Serving Groups Groups such as Big Brothers/Big Sisters and other mentoringand youth-serving groups can be ideal places to engage in relationship building andprovide access to tools, skills, and resources for promoting optimal child developmentand preventing CAN. They could also serve as natural places for training the volunteerworkforce in CAN prevention.

Parent and Caregiver Support Parent and caregiver support services should be en-hanced (Gadsden et al. 2016). Increased availability and access for parents andcaregivers to community-based, strength-based, culturally relevant, trauma-informedparenting resources and support could serve large numbers of families over time. Parentwarm-lines—free, confidential, and anonymous phone support services—could beequipped with HIPAA-compliant teleconference capabilities to promote outreach andsupport to parents and caregivers with on-demand videos on infant care, parentingpractices, coping skills, injury prevention, emotion regulation, or other topics. Publicservice campaigns aimed at decreasing stigma associated with seeking support andpromoting the use of resources could help shift perspectives. The goal would be tomove thinking from parent support is remediation for deficient parenting skills toparent support is something to which all parents and caregivers are entitled. We wantto shift the paradigm so that all new parents and existing parents and caregivers expectsocial support and resources to be accessible to them (Forston et al. 2016;https://developingchild.harvard.edu/). In fact, a public health approach to supportingfamily well-being would include a model such as in Norway, where the InternationalChild Development Program (ICDP) is offered free of charge by the Ministry ofChildren, Equality, and Social Inclusion to all parents identified with need or interest(Sherr et al. 2011). Public health approaches could also include embedding parentresources into primary and specialty care (Breitenstein et al. 2016; Glassgow et al.,2017; Risser et al. 2016).

While parents of children already receiving prevention services may be a good placeto start, a desired universal approach would begin with ensuring all parents have accessto essential services such as providing strength-based, culturally appropriate, trauma-

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informed, and developmentally relevant information on parenting. This can be donethrough community-based parenting training and support groups, which offer knowl-edge, coaching, feedback, practice, and tailored support for diverse parents withvarying needs. While such programs build parent confidence, family relationships,pro-social attitudes, and community inclusion, and connections to other resourcesfamilies need, they also help to identify parents who need more intensive assistanceat the earliest stage possible to prevent neglect or abuse. Parallel work would be neededto train professionals on being strength-based, culturally appropriate, and trauma-informed, as many have not yet been exposed, or have effectively adopted a trauma-informed approach. Furthermore, some professionals have experienced trauma them-selves, and need support to ensure their capacity to offer trauma-informed and sensitivecare to others.

Multi-sourced Funding

Prevention services that address secondary, tertiary, and quaternary prevention typicallyinclude more intensive services, serve fewer people, and have higher costs. Byinvesting in universal and primary prevention, we can prevent the need for higherlevels of prevention and more costly intervention services (Bilson et al. 2017). Com-prehensive preventive services funded across the lifespan to prevent CAN and promotepopulation-based health require integrating multiple systems of financing. For example,many of the services for secondary, tertiary, and quaternary prevention (e.g., childtherapy, substance abuse and psychiatric treatment for parents) could be funded bytraditional Medicaid, Medicare, Affordable Care Act products, or private insurance. Infact, research suggests that the Affordable Care Act’s Dependent Care Expansion(DCE) increased utilization of mental health treatment by those with high needs(Breslau et al. 2018). The CDC’s technical package for preventing CAN suggests avariety of financing options at various levels of the prevention continuum (e.g., taxcredits, child support payments, subsidized child care; Forston et al. 2016). Part of aneffective financing solution could leverage the Families First legislation; Medicaid1115 waiver; Maternal, Infant, and Early Childhood Home Visiting (MIECHV)funding; Affordable Care Act’s health home provision; Medicaid and insurance billing;and public-private partnerships, as well as a cost-effective staffing structure that utilizesparent peer specialists, paraprofessionals, and student interns.

Funding must be strategically applied to increase access to evidence-based preven-tion services and promote belief and behavior change and population-level engagementin CAN prevention. This way caregivers can promote protective factors within theirchildren and family within a community-based system that supports individual andfamily change. Those who are engaging in unhealthy behaviors and relationships canaccess interventions to prevent intergenerational transmission of unsafe and harmfulbehaviors toward themselves and others within communities and systems that supportthis change. We propose integration of parallel and seamless initiatives regarding CANprevention and promotion of healthy relationships. This can be implemented in a seriesof phases in which initiatives are piloted and tested, then replicated and scaled in amanaged way to be sure that messaging and implementation are culturally sensitive andappropriate for specific targeted audiences.

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Evaluation of Prevention Efforts

We propose an integrated methods approach that combines aspects of process evalu-ation, continuous quality improvement (CQI; e.g., Holweg 2008), economic andoutcome evaluation.

Process Evaluation

A series of process evaluations could assess whether prevention initiatives are beingimplemented as intended and what iterative changes have occurred to adjust to differentaudiences. We propose an examination of the extent to which selected communitypractices are being implemented as designed (fidelity), as opposed to changes that havebeen made as a result of CQI or other system factors. It will be important to documentchanges in practice and cost in order to determine the relative impact on preventionoutcomes and cost effectiveness. This can be accomplished with a series of site visits,shadowing, document review, and interviews. Levels of program implementation couldbe examined using the RE-AIM framework (Reach, Effectiveness, Adoption, Imple-mentation, Maintenance; Glasgow et al. 1999; see Fig. 4).

Continuous Quality Improvement

CQI is the systematic process of examining practices, processes, and initiatives todetermine what is working as intended and what barriers exist to achieving preventiongoals. This data is used in decision-making to improve policy, practice, and processes(e.g., U.S. Department of Health and Human Services n.d.).

Outcome Evaluation

Outcome evaluations on prevention initiatives, particularly those with multipletargets, are complex. An outcome evaluation plan will need to be developed by a

RE-AIM Indicator Description

ReachNumber of eligible parents; Number receiving prevention resource promotion marketing

EffectivenessPre-post scores on measures/observations of risk and protective factors; feelings of entitlement to various resources

Adoption

Provider perspectives about prevention resources and what is needed to adopt the initiative or promote feelings of entitlement in parents

ImplementationDescription of implementation delivery and the extent to which fidelity was maintained or changes occurred as a result of CQI

Maintenance

Provider perspectives on the extent to which prevention resources could become a standard of care practice and what is needed/required

Fig. 4 RE-AIM sample constructs table

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team of experts who focus on a set of predictors and prevention outcomes to beevaluated. Random coefficient model techniques (hierarchical linear models;HLM) could be used to estimate change trajectories across multiple time points,with time being treated as a random variable. These models do not require everysubject to be assessed at a fixed time point, so these models will be amenable topractical limitations on how/when data is acquired in natural settings. HLMmodels fit growth trajectories to each person’s repeated measures, estimatingaverage levels and rates of change at the individual level as a function of time.The relationship between individual-level characteristics and differences in theseaverage levels and rates of change over time and between communities can becompared with estimate prevention outcomes.

Cost-benefit Analysis

We could conduct a cost-benefit analysis of specific prevention initiatives.Consistent with the SAMHSA Children’s Mental Health Initiative, we anticipatethat the prevention initiatives and system changes will result in decreased useof higher intensity therapeutic and psychiatric services, reduced time in out ofhome placements, and decreased use of high-cost emergency room (ER) andhospital inpatient services (e.g., SAMHSA 2015). While we estimate the reduc-tion in ER and inpatient costs may be the shorter term primary economicbenefit, significant cost savings could occur in over a longer time horizon thatresults in higher quality of life and reduction in disease burden, morbidity, andmortality that while harder to measure represents a substantial return on invest-ment. Additional short-, medium- and long-term outcomes could be assessed.

Conclusion

We propose a comprehensive prevention strategy that disrupts all forms of CAN inour lifetime. The disruption concept encourages us to think big while taking stepstoward that goal every day. Just as the handwashing protocol, covering yourmouth when you cough with the inside of your elbow, and complex, integratedchild well-care visits and the immunization schedule became a ubiquitous methodfor preventing illness, we propose that access to essential resources and CANprevention should be demanded by everyone. Thus, support for families wouldbecome an expectation and standard to which every family feels entitled (ratherthan feeling stigmatized), and every person feels prepared and entitled to supportchildren and families in preventing CAN. This can be accomplished by leveragingand coordinating existing systems and financing within an asset-based communitydevelopment approach—an approach which affords equitable opportunities foroptimal health and child development along the full continuum of prevention.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict of interest.

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Affiliations

Heather J. Risser1 & Kimberly Svevo-Cianci2 & Elba Jung Karim3& Alexandra E.

Morford1

Kimberly [email protected]

Elba Jung [email protected]

Alexandra E. [email protected]

1 Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

2 Changing Children’s Worlds Foundation, Geneva, IL, USA

3 Roots and Wings Counseling Consultants, LLC, St. Charles, IL, USA

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