CHAPTER II:
PREVENTION OF CHILD ABUSE AND NEGLECT

HOME VISITING

Marjorie Kelly, Deputy Director of Children and Family Services Division of the California Department of Social Services states that:

The first thing to do about child abuse and neglect is prevent it from happening in the first place. Parents who feel comfortable and supported in their parenting, who are aware of the different developmental stages children go through, and who are connected to the resources they need are a young child's first line of defense. My goal is to have a home visiting program available to every family that wants it across the state.⁽¹⁰⁾

Definition of Home Visiting:

A program in which a person trained in child development (professional or para-professional) makes regular, schedules visits to homes, with infants or young children or expecting a child, to answer questions, provide information, assist new parents in their parenting and provide early detection of any developmental problems in the children.

Missouri's "Parents as Teachers" program is one of the oldest and most widely replicated. It started in 1981 with four pilot sites and has grown to have some presence in 48 states and six foreign countries.⁽¹¹⁾ This program sends certified parent educators to visit expectant families and teach them how to be "their child's first teacher". Staff members set up group meetings for parents, screen children for early detection of problems, and link parents with other community resources, such as child care, health and social services. Because this state legislated program crosses all socioeconomic and educational boundaries, it attracts both high-risk families and those who need less intensive services and supports." Programs in Missouri are state funded and based in the public schools. Services are available from before birth to kindergarten.

Because the program in Missouri is funded through the Department of Education, most of the evaluations focus on school readiness and savings in special education costs by recognizing developmental delays early. One, in Binghamton, NY, indicated a 50% reduction in child abuse over the control group.⁽¹²⁾ A long term study of 400 Missouri families randomly selected from 37 school districts indicated only two cases of child abuse over the three years of the study.⁽¹³⁾

Hawaii's Healthy Start program is hospital based. New parents are screened using 15 indicators for determining at-risk factors. Those found at risk are offered the home visitation program. 95% accept. Healthy Start provides linkage to a "medical home", visits and referrals to supportive services. Beginning with weekly home visits, the level and intensity of services vary over time with the families' needs and risk levels.⁽¹⁴⁾

A version of the Healthy Start program is a part of a more comprehensive plan that includes parent education classes, a newsletter, a library program for young families and a teen pregnancy prevention program in Hampton, Virginia.⁽¹⁵⁾

High needs families are attracted into a nontargeted program because it does not imply inadequacy or "bad parenting".

The most extensively evaluated program is in Elmira, NY. Four hundred pregnant women were placed in four study groups. They were followed for 15 years. One group was given developmental screenings at 12 and 24 months, another these services plus taxi vouchers for prenatal and well baby care through age two. Group three had home visits by a visiting nurse during pregnancy. Group four had these visits extend until the child's second birthday, provided linkages to other services, and assistance with good parenting skills, developmental issues, etc. At the end of 15 years, group four had less than half the incidents of child abuse of groups one, two and three.⁽¹⁶⁾

Another study in rural New York was mentioned in the federal Office of Juvenile Justice and Delinquency Planning (OCCJP). This was a clinical trial model with two groups, one receiving home visits, help with reaching needed services, health and parent education, and emotional and social support for two years. Two years after the program ended, child abuse reports were 4% for program participants, compared to 19% for the control group.

The clinical studies were with selected groups of mostly low income families, large percentages of single parents, those identified in some way as at-risk in some way. Hawaii screens for risk before referral. The Parents as Teachers model, and the one implemented in Santa Monica, California are "wellness" based, open to anyone, and build on the strengths in the family. Their special needs are met through intensified services.⁽¹⁷⁾

Very early intervention which continues for more than one year, in the form of parental education, is a sound investment that earns back more than the money spent by the time the children are in first grade.

California

The picture in California is hard to define. There are many programs which have some home visiting features but the staff in most of them have never heard of the others. A Western Regional Within Our Reach: Effective Home-based Strategies for Family Support Conference, held for the first time in 1996, reached the staff of many, but not all, programs. The third of these conferences is scheduled for the spring of 1998. California is funding six pilot programs in the 97-98 fiscal year. One, based at San Diego's Children's Hospital is moving county wide by 2002. Another program is opening at Oceanside this spring, 1998.⁽¹⁸⁾

California is funding six pilot programs in the 97-98 fiscal year. One, based at San Diego's Children's Hospital is moving county wide by 2002. Another program is opening at Oceanside this spring, 1998.⁽¹⁹⁾

The Santa Monica/Malibu Unified School District has designed it's own program. This is based on the home visit model, but includes a one morning a week new-parent drop-in where new parents can ask questions and share experiences, a formal parenting education program, Family Support Centers where parents can call for referrals, an outreach program for teen mothers to help them return to school, and a "Mommy's Morning Out" program where trained early childhood educators will keep a baby for the morning so the mother can get her hair done or just have "time out". This is first come, first served with limited space. The program, based on a wellness not a deficit model, has just started, is grant funded, is available in two elementary school attendance areas, and is being evaluated by UCLA.

There is a Parents as Teachers program in Salinas ⁽²⁰⁾ and in National City.⁽²¹⁾ There are a number of similar programs in Islamic centers in the Los Angeles area.⁽²²⁾ This model is used in the Islamic Centers in the Los Angeles area. As more people are aware of the annual Western Conference, a more comprehensive list of California programs should become available.

SUBSTANCE ABUSE TREATMENT FOR PARENTS TO PREVENT CHILD ABUSE AND NEGLECT

A workshop on Child Protection and Substance Abuse Treatment Agencies Working Together for Children was held at the 1998 annual Children's Defense Fund. The presenters were Dr. Sydney Gardner, President of Child and Family Futures, Irvine, CA, Jorge Lopez, Program Associate, Children and Family Futures, St. Helena, CA. and Nancy Young, Ph.D., Director, Child and Family Futures, Irvine, CA. The information in this section comes from that workshop. Several recent reports show that substance abuse affects the welfare of the whole family and that alcohol is the substance that endangers children the most. Mental health, domestic violence, safety of children, and ability to work, are all influenced by substance abuse.⁽²³⁾

It is estimated that 40-80% of the children in the child protection system, nationally come from families with alcohol/drug problems. It is also estimated that 15-40% of parents to be impacted by Welfare Reform (TANF) have substance abuse problems which affect their ability to parent and secure employment.

It is difficult, however, to tell exactly how many families are affected. Few substance abuse treatment programs, for example, ask if clients have children, are on welfare, or are under the jurisdiction of the Child Welfare System. United States is documenting the number of newborns that have been exposed to drugs in-uteri, but ninety-five percent of children affected by substance abuse within their home environments are not discovered at their birth. The Federal Adoptions Act of 1998 requires a federal report on the federal role in child welfare and abuse. Hopefully this federal report will address this relationship between substance abuse and child abuse and neglect.

Substance Abuse Treatment Programs

There is a sense of hopelessness in this country about the effectiveness of substance abuse programs. Most people base their opinion on their experience with one addict.

Despite this perception, substance abuse treatment programs, have been successful. All programs, however, do not help all people. Different people need different programs, different modalities. Successful substance abuse programs for women are:

Substance abuse treatment does not have to pay off for everyone for it to be worth trying for everyone.

• residential,

• ideally for 6-18 months in residence;

• provide: substance abuse counseling, vocational training, medical services, including attention to HIV and Aids, and specialized prenatal and child services.

• are appropriate for minority women.

There is also a need for permanent low-cost housing and jobs for recovering addicts and for subsidies for employers to take graduates of substance abuse programs.

Vocational training is important because the client must develop life and employment skills in order to meet her basic needs so she can overcome her addiction over the long term. Successful programs treat the whole family, accept relapses, follow the client after treatment and know how to measure success so their program can be properly evaluated.

Substance abuse is both a disease and an issue of personal responsbility.

One such successful program provides ten to twelve months in residence with a structured program which decreases in structure as the client is able to assume more personal responsibility. This is followed by a period in a transitional living situation with out-patient services. Long-term recovery from substance abuse was more likely as the stay increases, and reaches almost 100% if the client stays with the support system after being in the residential program. Three months after treatment 17% of those who had completed a shorter program were employed or in a job training program, and 49% of those who completed the full program had achieved this success. Six months after participating in the program, these figures were 48% for those in the shorter program and 63% for those who stayed the full time. Clients of different ethnic groups were equally successful. Most of the clients had been abused as children, victims of rape or abused because of substance abuse.

Need for Collaboration

Four very different clocks affect families impacted by substance abuse:

1. CalWORKS in California limits support to 24 consecutive months at one time and 60 months over a lifetime.

2. Family Reunification is limited to 6- 12 -18 months.

3. Substance abuse recovery is a lifetime process - one day at a time for the rest of one's life.

4. Child development is crucial during the first three years of life.

As of January 1, 1998, there is also, a lifetime ban in California on any kind of aid following a conviction for a drug felony.

For the most part each of these four systems ignores the other three. The clocks of the first two are determined in part by the state and county court system. For success, all the systems need to work together. This requires the proper legislation as well as community commitment.

Child Protection Agencies are beginning to form links with alcohol and drug treatment programs to get needed help to children and families. Until now, it has been the practice in some counties for the Child Welfare Worker to remove the children and hand the parent a list of phone numbers of local substance abuse treatment programs with no other information about them. Unfortunately, no local program may be able to help. In most communities programs are seriously over-subscribed and at most, only twenty percent of the slots are available for women.

Better tools are needed to assess the problem in an individual family. The Temporary Aid for Needy Families (TANF) program and the Child Welfare System (CWS) need to develop new screening and assessment tools, followed by an in-depth coordinated assessment which includes evidence of substance abuse and family violence. Then they should guide the parent to appropriate services.

When substance treatment programs work together with county Child Welfare Services, there are challenges for both sides of the partnership. The most success exists where individual relationships are formed between members of both staffs. Otherwise there is a lack of comprehension on both sides of the complexity and limitations of the other system. There has been is a lack of education on both sides about each other's systems. Present funding requirements for collaboration is an important step in the right direction.

There are four levels of collaboration:

1. Agencies use the same vocabulary

2. Agencies work on joint projects

3. Agencies change the rules

4. Agencies have blended funding

(For more on program collaboration, see Chapter VII Collaboration; and Chapter II: Prevention of Child Abuse and Neglect, the sections on Substance Abuse...; and Domestic Violence)

A California Model of County-wide Collaboration

A major investment in staff development and training has been under way in Sacramento County with support from the Annie E. Casey Foundation. In 1993, the County Department of Health and Human Services enacted an initiative to incorporate alcohol and drug services as an integral part of its service delivery systems. The program has three components:

1. Three levels of training to develop the ability of social workers, public health nurses, eligibility workers and neighborhood-based service staff to provide treatment services to alcohol or drug using clients;

2. The expansion of department and community resources, including the development of an automated service requisition and client tracking system and

3. Program evaluation including both short- and long-term outcomes related to family functioning, such as reduction in Child Protection Services referrals, and success in completion of either voluntary or court-ordered treatment plans. By January 1997, over 1,200 health and human service staff members had participated in the training with positive effects shown on the interim evaluation. The net effect for Sacramento County has been an increase in alcohol and drug treatment slots, significantly reducing waiting lists. Sacramento County is currently offering its training package as well as technical assistance to other locales.⁽²⁴⁾

Other Points Made by Workshop Participants:

- Parents fear they will lose their children if they attend drug treatment programs or half way houses in their communities.

- Patients with Diabetics and Hypertension relapse during treatment by failing to follow their required regimen or use their prescribed medication. When they do, medical services do not drop them.

REDUCTION OF DOMESTIC VIOLENCE AS A WAY TO PROTECT CHILDREN AND PRESERVE FAMILIES

For a child to witness domestic violence in the family is to suffer abuse.

The Impact of Domestic Violence on Children

Children who witness violence early in life come to see the world as dangerous and unpredictable, and they feel helpless and incompetent. Between 15-20% of women are battered during pregnancy. Battering causes damage and distress to the fetus. The baby's developing brain and tender nervous system may be over-stimulated repeatedly by the mother's fear and adrenaline. A strong jolt of fear can send convulsion-like tremors through the fetus. Such energy often surges through the baby's brain at the very time when crucial nerve connections are forming.

In homes where domestic violence occurs, children are abused at a rate of 1,500% higher that the national average. Sixty-three percent of boys, aged 11 to 20, arrested for homicide have killed their mother's assaulter. Seventy percent of the children in domestic violence shelters had been physically abused or neglected.⁽²⁵⁾

Need for Collaboration

Protecting Children From Domestic Violence: New Collaborations Between Child Protection and Domestic Violence Agencies was the subject of a workshop at the 1998 Annual Children's Defense Fund Conference.⁽²⁶⁾ The following information was presented:

The prevention of domestic violence in the family as a means of reducing child abuse is a new idea for law enforcement, social services and the courts. If this connection is not made:

I. Social workers may not realize that domestic violence is a factor when they interview a family about suspected abuse or neglect. Often they are not trained to look for signs of domestic abuse, including the types of behaviors that are witnessed in children who have witnessed domestic violence. Therefore social worker is not aware of the whole family situation and works on fixing the other problems in the family but does nothing about the violence.

2. Perpetrators of the violence are not held accountable. Only an arrest would do this, but the police often further victimize the woman by only listening to the man's description of the problem.

The victim of violence is in a game that she cannot win, because very time she figures out what to do, the rules change. Eventually, she doesn't even know whether she wants to win.

3. If the social worker does realize there is domestic abuse involving the children, they focus on the victim, urging her to leave the perpetrator of the abuse, or the children are taken away from her because she is unable to protect the children. The social worker is often unaware of the barriers to leaving an abusive situation that women face, such as the need for housing, employment, and child care.⁽²⁷⁾

Model Program to Help Mothers who Suffered Domestic Abuse

A Families First Program in Detroit, Michigan found that they needed to educate social workers, police and judges about what domestic violence is; that it can be economic coercion or threats to hurt children as well as physical abuse. Families First trainers developed a graph which showed the types of control abusers use, as an educational tool for the social workers and police, and found that it served also as an eye-opener for the victim, to help her see that she was indeed being abused.

For the program to work successfully, a Collaboration was developed with Families First, child welfare services, law enforcement and the courts. First, trust between the agencies had to be developed. This meant talking together for a year to allow time agency personnel to discuss frustrations with their client communities before the training could start. It took Families First months to train the child welfare workers and police to make the paradigm shift regarding domestic violence. Most social workers in the community now consider domestic violence when investigating child protective issues. Intervention now includes working with the victim and the children to develop a plan for safety. The social worker assesses the domestic violence and trains the victim about the options she has, including leaving. The case worker helps the victim think through what is going on, so that she can assess the danger to herself and the children. The social worker develops a safety net for the family. Each case is very different. With support systems in place the victim will usually leave permanently. Now the collaboration and training is being extended to foster care, family reunification and adult protection care social workers.⁽²⁸⁾

Need for Coordination between Health, Justice and Social Workers

In 1994 the National Conference on Family Violence: Health and Justice convened to foster a collaborative approach to family violence between the health, justice and social services. The following is a report of those proceedings.⁽²⁹⁾

In the past advocates for the safety of children from abuse and of women from domestic violence have rarely talked with one another about coordinating prevention and intervention. Furthermore, professionals within the various specialized fields are often separated by discipline-specific systems, languages, and routines. Many health, justice, and social services professionals believe that the remaining barriers dividing those who work to protect families and communities against violence and abuse must be overcome.

Both health and justice professionals play significant roles in the identification, intervention and prevention of family violence. Health care providers are often the primary identifiers of battered women and children. Intervention by professionals in the fields of social services, law enforcement, and justice must accompany or closely follow that by medical practitioners so that survivors are afforded immediate protection and provided with the knowledge, information, and support necessary to escape continued violence.⁽³⁰⁾ Improved coordination between medical personnel and social workers would facilitate prompt reporting to child and adult protective services.⁽³¹⁾

The police play a key role in protecting family members by enforcing orders of protection and arresting perpetrators who violate them.⁽³²⁾ There is a need to train police on how to deal with children who have witnessed domestic violence. They do not realize the effect the violence can have on children which in turn affects how they behave.⁽³³⁾

Both the workshop and the conference noted the need to change attitudes of the society, including the police, about domestic violence. One suggestions was to have victims participate in focus groups with the police and the public.

Without careful interdisciplinary case collaboration, policies and practices that make one group of victims safer may unwittingly endanger or harm another.

Judge Leonard Edwards of the Santa Clara Superior Court recommended:

1. Develop a coordinated system within the community to ensure that the victim is not re-abused by the system designed to protect her. If she and her children have been abused by the same perpetrator, various aspects of the case such as child abuse, divorce, civil suit and criminal case would be handled by lawyers, judges, and different courts.

2. To integrate these efforts toward legal remedies, establish a local, multidisciplinary family violence coordinating council to coordinate the work of the justice system and receive input and recommendations from members of other systems, including health and social services.

3. Another proposed improvement in the judicial system is the establishment of Unified Courts in every state.⁽³⁴⁾ (See also Chapter I: The Juvenile Court, the last paragraph and Appendix A, last paragraph)

Domestic Violence Is Also a Barrier to Work:

Oregon is two years ahead of rest of country on Welfare Reform. They found that domestic violence is an incredible barrier to employability. Now clients for workfare are assessed for domestic violence.⁽³⁵⁾

Programs for Perpetrators of Domestic Violence

A batterer who is motivated and feels remorse can be helped. Man Alive is a program in California jails for reduction of violence by incarcerated perpetrators. All the facilitators are former batterers. The inmates are given training in developing communications skills to keep the family relationship.⁽³⁶⁾

At the 1998 ICAN conference in Los Angeles, a workshop on The Courts Response to Domestic Violence and Child Abuse, three judges described their specialized courts to deal with perpetrators of domestic abuse. Each of the judges from the Long Beach, Pasadena and Rio Hondo Courts had set up or were about to set up specialized courts in which they require that the perpetrators attend several months of rehabilitation programs for domestic violence. If the offenders do not attend and get involved in the program they are sent to jail. The judges send them to programs they know are effective and are in constant contact with the program staff to monitor the progress of the offender. The success of many of the perpetrators is impressive. Families come to the court to thank the judges. The offenders are referred to substance abuse treatment, parenting classes. All three judges stated that the courts are where domestic violence has to be addressed because they are the only ones with the authority to make the perpetrator address the problem.

Serial Batterers are Different:

A serial batterer generally does not possess a conscience. Professionals report that therapy with a serial batterer is rarely successful. While the habitual offender may enter a treatment program, he rarely completes it. He generally enters counseling only to manipulate his partner into dropping criminal charges and returning to him. The safest recourse for victims of chronic abuse is to end the relationship, once a personal safety plan has been established.⁽³⁷⁾

OTHER CHILD ABUSE AND PREVENTION PROGRAMS

Maternal and Child Health Program (MCH):

This program is directed at reducing the incidence of low birth-weight, premature delivery, mortality, and preventive diseases and handicaps among children. The state MCH program supports the infrastructure of a county-based MCH service delivery system, and assists county health departments, community clinics, and other local and regional organizations to deliver services throughout the state. It runs projects with local health departments, such as the Comprehensive Perinatal Services Program, Adolescent Family Life Program, High-Risk Infant Follow-Up, Perinatal Substance Abuse Pilot Project, the Sudden Infant Death Syndrome Program, and the Childhood Injury Prevention Program. The majority of MCH funds comes from the federal Title V block grant. The state must maintain at least its pre-1989 funding level. Most of MCH's money goes for perinatal services.⁽³⁸⁾

Special Supplementary Program for Women, Infants and Children (WIC):

This is a program that provides extra nutrition for low income pregnant women, their babies and young children.

Extra milk and food is also available to pregnant and lactating teens through the school lunch program.

Office of Family Planning/Teen Pregnancy (OFP)

OFP's charge is to make comprehensive medical assistance, knowledge, and services related to planning families available to all low income state citizens of childbearing age. OFP contracts with local public and nonprofit agencies to provide services, and also funds information and education programs serving youth, including family life education for youth, teacher training, and parenting education. Expanded teen counseling services are provided to TANF, GAIN, foster care, and other teenagers who are at high risk of unintended pregnancy. Although funding has stayed level since 1992, the program has declined somewhat in real terms.⁽³⁹⁾

Emergency Preparedness and Injury Control Program (EPIC)

EPIC includes a variety of small programs and activities. Among other things, EPIC conducts control programs for prevention of unintentional and intentional injuries. Injury control program functions include educational and informational activities. EPIC programs especially relevant to children include domestic and community violence prevention. There is a small Childhood Injury Prevention Program (CHIPP) in the MCH branch.⁽⁴⁰⁾

Unintentional and intentional injuries are the leading cause of death among California boys and girls age 1-20. Injury prevention program funding for children is disproportionately low in relation to injuries and death. The state's contribution to the EPIC program is less than three-quarters of a million dollars, roughly the expected cost of imprisoning a single youth under the "three strikes" law.

Access for Infants and Mothers Program (AIM)

AIM subsidizes private health insurance coverage for maternity, delivery and infant care services up to two years for uninsured low-income women. The program began in 1992 and enrollment is limited to the number of women who can be served with the funds.⁽⁴¹⁾

Healthy Start

Healthy Start is a recent state-funded program which provides grants to schools and local governments to establish school-linked integrated services programs. The goal is to provide efficient, cost-effective services to families with an emphasis on prevention and convenience. Services are often located at or near a school site. Staff in Healthy Start programs are trained to help families with multiple problems, be they education, healthcare, or social.⁽⁴²⁾

School Age Parenting and Infant Development Programs

These are provided as part of the high school curriculum for school age parents and pregnant teens. The programs care for the infants and train their parents as well as provide special school nutrition supplements for the pregnant and lactating pupils and other support services. Legislation currently pending in Sacramento would expanded this program to include all qualifying students.

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