The public health approach for understanding and preventing child maltreatment: A brief review of the literature and a call to action

Abstract

Over the past 50 years, most major advances in child maltreatment have focused on protecting severely maltreated children and punishing perpetrators. This article argues that it is time to rigorously apply a public health framework to improve our understanding of, and accelerate efforts to, prevent child abuse and neglect. The article describes the fundamentals of a public health approach; discusses how this approach has been applied to improve surveillance of serious maltreatment injuries and fatalities, the understanding of risk and protective factors, and the long-term consequences of maltreatment; and describes how a public health approach is an effective means to prevention.

Full text

e Public Health Approach for
Understanding and Preventing Child
Maltreatment: A Brief Review of the
Literature and a Call to Action
Over the past 50 years, most major advances
in child maltreatment have focused on pro-
tecting severely maltreated children and pun-
ishing perpetrators. is article argues that it is time to
rigorously apply a public health framework to improve our
understanding of, and accelerate eorts to, prevent child abuse
and neglect. e article describes the fundamentals of a pub-
lic health approach; discusses how this approach has been
applied to improve surveillance of serious maltreatment
injuries and fatalities, the understanding of risk and protective
factors, and the long term consequences of maltreatment; and
describes how a public health approach is an eective means
to prevention.
eresa Covington
Michigan Public Health
Institute
17
Child Welfare • Vol. 92, No. 2

Vol. 92, No. 2Child Welfare
18
It has been 51 years since Henry Kempe’s (1962) landmark paper
on the battered child syndrome. Major advances in social services,
criminal justice, medicine, and mental health followed Kempe’s nd-
ings, although most policy initiatives have focused on child victims
coupled with a punitive approach to perpetrators. Even though
Kempe’s work was the rst published study to use public health (PH)
surveillance data to dene the scope of maltreatment,1the advances
that followed did not include many initiatives that addressed child
abuse and neglect within a public health framework. Fortunately,
increasing attention is now being paid to value-added applications of
a public health approach. is paper describes the public health
approach and discusses relevant literature indicating that a PH
approach is essential to achieve a better understanding of child mal-
treatment deaths and serious injuries, and, most importantly, to
improve our ability to prevent these tragedies.
e Public Health Approach
Public health describes a complex system of science, services, pro-
grams, and policies that focus on the health and safety of entire pop-
ulations. Public health brings together knowledge from medicine,
epidemiology, sociology, psychology, criminology, education, and eco-
nomics (Krug & Dahlberg, 2002). It is rooted in a social-ecological
context that views “Health not as disconnected stages unrelated to
each other, but as an integrated continuum moving across the life
course of infancy, early childhood, adolescence, child-bearing years
and old age. is perspective maintains that a complex interplay of
biological, behavioral, psychological, social, and environmental fac-
tors contribute to health outcomes across the course of a person’s life”
(Pies, Kotelchuck, & Parthasarathy, 2008, page ___). A PH approach
is based on the understanding that interventions designed to improve
health are most eective when they reach broad segments of society,
1 His analysis identied only 749 U.S. children as battered in one year, including 33 child deaths—a number
now known to have been signicantly undercounted.

Child WelfareCovington
19
require less individual eort and address socioeconomic determinants
of health, as shown in the following health impact pyramid (Figure
1) (Frieden, 2010).
A basic model of the public health approach includes four steps:
(1) dening and monitoring the problem; (2) identifying risk and
protective factors; (3) understanding the consequences of the prob-
lem; and (4) developing and testing prevention strategies and ensur-
ing their widespread adoption. e approach recognizes the
importance of a person’s life course and that early intervention and
prevention in childhood is important to the prevention of negative
consequences into adulthood. Public health prevention typically
includes three distinct but inter-related stages: primary, secondary,
and tertiary.2For maltreatment, primary is preventing the occurrence
of abuse and neglect before it even happens and is usually applied to
2 Other terms commonly used to describe these stages include universal, selective and indicated.
Figure 1
The Health Impact Pyramid

the broad population of children. Strategies include community and
service provider education, fostering coalitions and networks, chang-
ing organizational practices, and inuencing policy and legislation
(Cohen, 1995). Secondary prevention targets children already at risk
of or being maltreated and works to prevent further harm—e.g., home
visiting for high-risk parents and foster care for children. Tertiary
prevention is designed to mitigate the eects of serious maltreat-
ment—e.g., medical care for seriously injured children.
Child Maltreatment as a Public Health Problem:
Making the Case
Although the contention that “child maltreatment is a public health
problem” has appeared repeatedly in publications during the past 50
years, it was not until late in the past century that the research liter-
ature began describing serious child maltreatment injuries and fatal-
ities as a public health problem—but only within the context of other
forms of violence. Mercy and colleagues published a number of papers
suggesting that a PH approach would emphasize prevention of
injuries resulting from violence rather than treating the health con-
sequences of these injuries, and they made specic references to child
abuse (Mercy, Krug, Dahlberg, & Zwi, 2003); Mercy & O’Carroll,
1988; Mercy, Rosenberg, Powell, Broome, & Roper, 1993). In 1996,
the World Health Commission declared violence to be a major pub-
lic health issue (Krug, Mercy, Dahlberg, & Zwi, 2002), and followed
this declaration with a report that analyzed the health and social
eects, risk and protective factors, and types of prevention eorts that
have been initiated for child abuse (Krug, Dahlberg, Mercy, Zwi, &
Lozano, 2002). e authors contended that child abuse is a public
health issue because “Public health is above all characterized by its
emphasis on prevention. Rather than simply accepting or reacting to
violence, its starting point is the strong conviction that violent behav-
ior and its consequences can be prevented” (p. 5).
Although a good deal of eort in the 1990s was focused on
addressing violence as a public health problem, it was not until this
Vol. 92, No. 2Child Welfare
20

century that child maltreatment in and of itself was described within
a public health framework. Garrison (2005) argued that a major shift
in law, practice, and funding is needed to redirect child welfare reform
eorts from treatment to prevention. A workshop convened by the
U.S. Surgeon General was a major federal acknowledgement that mal-
treatment should be a public health priority (U. S. Oce of the
Surgeon General, 2005). e workshop brought together multiple dis-
ciplines to begin the “discovery of what is needed, what is or is not
working, and what are the opportunities for eective strategies for pre-
venting child maltreatment and promoting child well-being.” Sanders
(2005) presented the case that a public health approach would shift
interventions from the clinical management of individual families to
strategies that aect entire populations, and blend universal and tar-
geted interventions to benet a larger population of families. In 2008,
the CDC developed its strategic direction for child maltreatment pre-
vention as “promoting safe, stable and nurturing relations” (U. S.
Centers for Disease Control and Prevention, 2008; Arias, 2009). e
CDC funded new research on causes of maltreatment and prevention
interventions such as Positive Parenting Programs (Triple P) and
Project SafeCare (U. S. Centers for Disease Control and Prevention,
2010). e CDC also funded an analysis of the role of state health
departments in preventing or responding to maltreatment. e major-
ity of health departments responded that their agencies should play a
role in understanding and preventing child maltreatment, but less than
half had sta dedicated to maltreatment (Richmond-Crum, 2011; U.S.
Centers for Disease Control and Prevention, 2012).
A brief summary of relevant literature is included here to illus-
trate the application of a PH approach to understanding and
responding to serious injuries and deaths from child maltreatment.
Dene and Monitor the Problem
e scope of child maltreatmvent injuries and fatalities in the U.S.
is most commonly ascertained through a number of non-public
health methodologies. Current reporting systems typically only
counts maltreatment when it meets standards requiring penalties in
Child WelfareCovington
21

the civil and criminal justice systems. For example, the National
Child Abuse and Neglect Data System (NCANDS) is a federal sys-
tem that annually publishes data on children known to or involved
with child protective services (U. S. Administration on Children,
Youth and Families, 2012). e U. S. Children’s Bureau also conducts
an intermittent estimation of the incidence of maltreatment through
the National Incidence Study on Child Abuse and Neglect. e
National Survey of Children’s Exposure to Violence (NatSCEV) is
another nationwide survey of children to ascertain their exposure to
many forms of maltreatment and victimization. NCANDS also
counts child maltreatment fatalities, but mostly only of children
already known to CPS at the time of death. e U. S. Government
Accountability Oce reported that NCANDS is an underestimate
of fatalities, and that “…(C)hild welfare ocials in 28 states thought
that the ocial number of child maltreatment fatalities in their state
was probably or possibly an undercount” (U.S. Government
Accountability Oce, 2011, p. 9). State death records do no better
in counting maltreatment fatalities. Many studies have demonstrated
that maltreatment deaths are highly underreported by this method
(Crume, Diguiseppi, Byers, Sirotnak, & Garrett, 2002; Ewigman,
Kivlahan, & Land, 1993; Herman-Giddens, 1991; Herman-
Giddens, Brown, Verbiest, & Carlson, 1999). A public health sur-
veillance approach to counting maltreatment is more likely to utilize
a broad population approach and identify a larger cluster of children
at risk for and being maltreated than other methods. e CDC
funded eorts to improve the counting of serious maltreatment
injuries and deaths using public health surveillance. ey rst devel-
oped a common set of maltreatment denitions within a public
health framework (Leeb, Paulozzi, Melanson, Simon, & Arias,
2008). ey then funded seven states to improve maltreatment sur-
veillance by using multiple reporting sources. e ndings demon-
strated that by using multiple sources, applying a broader denition
of maltreatment (than CPS alone) and conducting multidisciplinary
case reviews of deaths, many more maltreatment-related fatalities
were identied than through traditional methods, and that the case
Vol. 92, No. 2Child Welfare
22

review multidisciplinary team process was the most eective means
of identifying fatalities from both physical abuse and neglect
(Schnitzer, Covington, Wirtz, Verhok-Oftedahl, & Palusci, 2008;
Wirtz, 2011).3e ndings for serious injuries was less conclusive.
A number of relatively recent papers indicate that researchers are
also beginning to use
PH surveillance methods to count serious maltreatment in spe-
cic populations. Two studies that used a PH approach did improve
and increase the estimate of serious but non-fatal physical abuse of
children by counting hospital visits using codes that are suggestive of
maltreatment (Schnitzer, Slusher, Kruse, & Tarleton, 2011;
Leventhal, Martin, & Gaither, 2012). One study estimated the num-
bers of head injuries secondary to maltreatment through surveys of
pediatric and subspecialty practices (Bennet et al, 2011) and another
through examination of emergency department visits of children
known to CPS but not in out-of-home placement (Schneiderman,
Hurlburt, Leslie, Horwitz, & Zhang, 2011).
e importance of this broader approach to counting maltreat-
ment is that, even if these methods only slightly increase the num-
ber of conrmed and prosecuted cases, we can increase our
understanding of abuse and neglect and work towards more focused
early intervention and prevention eorts. Developing a truer count
of maltreatment can also lead to stronger public policy. For example,
using public health surveillance methods, Fang and colleagues (2012)
estimated the economic cost per child of maltreatment and then esti-
mated that the aggregated lifetime costs for all new 2006 U.S. mal-
treatment cases amounted to 585 billion dollars.
Understand Risk and Protective Factors
A risk factor is something external to or intrinsic to a child that's likely
to increase the chances that maltreatment will occur and a protective
Child WelfareCovington
23
3 All states in the U.S. now have state and/or local child death review teams, and most issue annual reports on
their fatalities that include a special focus on maltreatment. Additionally, the National Center for the Review
and Prevention of Child Deaths has a case reporting system in which 40 states submit comprehensive data
on maltreatment deaths.

factor is something that reduces vulnerability. Understanding risk and
protective factors is critically important because once they are known,
prevention eorts can be targeted to minimize the risks and maximize
the protective factors. ere is a large body of work describing the mul-
tiple and often interrelated risk and protective factors for serious mal-
treatment. It is well-documented that risk factors for serious injuries
include poverty, substance use, low educational achievement, history
of parents’ own victimization, parents’ poor mental health, and eco-
nomically distressed and overcrowded neighborhoods (Coulton,
Crampton, Irwin, Spilsbury, & Korbin, 2007). Other research indi-
cates that gender, race and disabilities inuence risk for maltreatment.
Recent studies have taken a public health approach in identifying pop-
ulations at risk for maltreatment. Berger and colleagues (2011)
demonstrated a relationship between increased abusive head trauma
(AHT) and the economic recession. Another study of the household
composition of fatal child abuse victims found that children living in
households with unrelated adults had nearly six times the risk of dying
from maltreatment-related unintentional injuries (Schnitzer &
Ewigman, 2008).
e sheer number of risk factors complicates the search for causes
of maltreatment. One systematic review reported that “e extent to
which each of these risk factors is causally related to the occurrence
of maltreatment is hard to establish” (Gilbert et al., 2009, page _____).
Not all of these factors are easily modiable.
Our knowledge, however, on risk and protective factors specic
to fatalities is less well known. It is widely accepted among experts
that children dying from maltreatment have similar risks as children
severely maltreated but that predicting which specic children will
be victims of fatal maltreatment is dicult, if not impossible. One
study did nd that it is possible to discriminate between children at
risk for fatalities from physical abuse based on the severity of the non-
fatal physical abuse, but not possible to make predictions for neglect
fatalities (Graham, Stepura, Baumann, & Kern, 2010).
Vol. 92, No. 2Child Welfare
24

Understand the Long- Term Consequences of Serious
Maltreatment
In addition to the immediate physical and emotional harm children
suer from maltreatment, including serious or permanent physical
injuries and sometimes death, many child victims who survive expe-
rience numerous and long lasting health and developmental conse-
quences (Shonko & Gardner, 2012; Gilbert et al., 2009).
Understanding these consequences helps to make the case that pre-
venting serious injuries and fatalities while children are young is crit-
ical to promoting their health and welfare into adulthood. Many of
these consequences are based on new learning about children’s brain
development (Shonko & Phillips, 2000; Anda et al, 2006). Two
studies have examined subsequent injury to maltreated children. A
longitudinal study found that low income children who had experi-
enced a rst incident of maltreatment had almost twice the risk of
dying from accidents and recurring maltreatment than other low-
income children not maltreated ( Jonson-Reid, Chance, & Drake,
2007). A more recent study made a similar nding for children less
than ve years old, and found that children with prior CPS reports
died from intentional injuries at a rate 5.9 times greater than chil-
dren with no CPS reports (Putnum-Hornstein, 2011).
e Adverse Childhood Experience Study (ACES) singularly
spawned numerous studies pointing to poor long term medical and
public health outcomes related to early adversities (Felitti et al., 1998).
Other studies document specic negative outcomes, including men-
tal health problems (Fergusson, Boden, & Horwood, 2008); suicide
risks (A, Boman, Fleisher, & Sareen, 2009); early sexual activity
(Ompad, Ikeda, & Shah, 2005; Black et al, 2009); substance abuse
(Oshri, Tubman, & Burnette, 2012); intimate partner violence
(Taylor, Guterman, & Lee, 2009); delinquency (Yampolskaya,
Armstrong, & McNeish, 2011); and chronic health problems lasting
throughout adulthood (Widom, Spatz, Czaja, Bentley, & Johnson,
2012; Zlotnick, Tarn, & Soman, 2012).
Child WelfareCovington
25

Implement Prevention Programs
An understanding of the consequences of maltreatment makes it
obvious that greater attention needs to be placed early and often on
preventing maltreatment. A public health approach to maltreatment
is vitally important because it includes primary prevention which can
more readily impact larger segments of potentially at-risk children
than secondary and tertiary prevention that protects and treats abused
children. Eichner (2004) argues that adopting a public health
approach will mean that the “state’s presence in the lives of families
is no longer a sign of failure but an active partner in securing a child’s
welfare” (p. 461).
A PH model utilizes science to design, implement, and evaluate
population-based prevention strategies; and then works to replicate
and disseminate those strategies that are shown to actually work (evi-
dence based). A comparison of two government reports;, both of
which describe emerging and promising practices for maltreatment
prevention, illustrates that the eld of maltreatment prevention is
increasingly focused on a public health approach. e 2002 report
presented a framework for prevention and described a number of pri-
mary, secondary and tertiary programs (omas, Leicht, Hughes,
Madigan, & Dowell, 2002). However, it oered little information
regarding the most eective interventions. In contrast, the 2012
report included four key areas of evidence in the framework, includ-
ing “Conceiving a broader denition of well-being, promoting pro-
tective factors as key strategies to enhance well-being, supporting
evidence-informed and evidence-based practices and strengthening
critical partnerships and networks ” U.S. Administration for Children
and Families, 2012, p. 3).
A number of systematic reviews and reports have been published
in the past several years summarizing the scope of a PH approach to
child maltreatment (but not fatality) prevention. One review of sys-
tematic reviews focused on seven types of mostly primary prevention
approaches: home visiting, parent education, child sex abuse preven-
tion, abusive head trauma prevention, multiple-component inter-
ventions, media based interventions, and support and mutual aid
Vol. 92, No. 2Child Welfare
26

groups (Mikton & Butchart, 2009). A paper published in 2009
reviewed research on primary prevention strategies that target chil-
dren ages 0-5, including early education programs, home visitation
programs, and secondary prevention programs targeted to selective
at risk populations (Daro, Barringer, & English). MacMillan and col-
leagues (2009) conducted systematic reviews of a number of these
programs. Numerous studies report on specic programs and/or pro-
gram components found to be eective in reducing maltreatment and,
in some cases, improving caregiver outcomes. Studies evaluating
home visitation programs are some of the most prominent, and have
been summarized by Azzi-Lessing (2011) and Olds and colleagues
(1995, 1997, and 2004). Triple P, a population-level primary preven-
tion parent and family support program, has also been widely stud-
ied and has actually been shown to reduce substantiated cases of
maltreatment, and out-of-home placements (secondary prevention)
(Prinz , Sanders, Shapiro, Whitaker, & Lutzker, 2009; Nowak &
Heinrichs, 2008). It remains uncertain whether strategies and pro-
grams that have been found to be eective in preventing child mal-
treatment will also be eective in preventing child maltreatment
related fatalities. Two of the prevention programs that have some of
the strongest experimental or quasi- experimental evidence of eects
on prevention of child maltreatment, Nurse Family Partnership and
Chicago Parent Child Centers, have been found to achieve signi-
cant eects on rates of child maltreatment over 15 years—i.e., a sub-
stantial percentage of the eects on child maltreatment of these
programs have been delayed into the school age years, well past the
age when most maltreatment-related child deaths occur. Home vis-
itation programs have not demonstrated an eect on child maltreat-
ment fatalities to date. ere is a possibility that new prevention
programs/ strategies will be required to impact child maltreatment
death rates for children 0-3, the age group in which 80% of mal-
treatment fatalities occur. ere are currently eorts underway to eval-
uate programs that help parents understand the dangers of forceful
shaking and manage inconsolable crying, a key precipitating factor
in abusive head trauma injuries and deaths.
Child WelfareCovington
27

ere are some examples of secondary prevention eorts origi-
nating in the child welfare system that demonstrate the importance
of linking primary with these secondary prevention approaches.
Pecora and colleagues (2012) summarized many of these evidence-
informed interventions, and described gaps in knowledge not only of
primary prevention but of child-welfare based interventions, such as
dierential response. Two papers describe how reviews of child mal-
treatment fatalities can result in signicant improvements in child
welfare systems’ response to and the prevention of child deaths
(Palusci, Covington, & Yager, 2010; Sanders & Colton, 1999).
Despite the work that has already been done, there are signicant
gaps in our knowledge on what strategies can be eective at either or
both the primary and secondary levels to prevent serious injuries and
maltreatment fatalities. Policy debates are also focused on the costs
and benets of expensive secondary prevention programs that tend
to have a high cost per family versus primary prevention programs
that are less costly per family. A public health approach to preven-
tion may lead to innovative approaches that also address other mod-
iable risks that are not currently well understand, such as the role of
mental health on caregiver capacity and child well-being.
Conclusion
In 2011, e Children’s Bureau documented over 3 million reports
of child maltreatment, with an estimated 681,000 child victims and
1,570 fatalities (U. S. Administration for Children, Youth and
Families, 2012). ese staggering numbers suggest that the preven-
tion of maltreatment is unlikely to occur by only intervening and pro-
tecting children once harm has been alleged in a CPS report. Far
greater emphasis must be placed on a public health approach that
includes primary prevention to help families and children before
abuse or neglect occurs.
In 2012, Zimmerman and Mercy summed up the value of the
public health approach to child maltreatment by asking that we;
“…Imagine a community where all the adults who interact with
Vol. 92, No. 2Child Welfare
28

children…actively engage in preventing child maltreatment before
an incident of abuse or neglect occurs. Imagine a community where
there is a wide continuum of prevention activities that extends well
beyond providing direct services to individual families; a contin-
uum that includes public education efforts to change social norms
and behavior, neighborhood activities that engage parents, and pub-
lic policies and institutions that support families” (p. 4).
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