Adam M. Tomison, National Child Protection Clearinghouse, Australian Institute of Family Studies
While the protection and support of abused and neglected children is of paramount concern, interest in preventing child abuse and neglect has increased substantially in the last decade, mainly because of the professional community’s discovery of the harmful and expensive outcomes that can result from child maltreatment, such as physical and emotional harm, the intergenerational transmission of abusive behaviour, delinquency and/or adult criminal behaviour (Harrington & Dubowitz 1993).
Much of this conference is focused on assisting professionals to diagnose, assess and treat cases of child abuse and neglect. My presentation focuses on wider systemic issues in child protection and child abuse prevention. It is intended to provide a context for the work of health, medical and social welfare professionals, and to suggest ways forward for the development and enhancement of systems for the prevention and protection of child abuse and neglect. The aim is to stimulate discussion of child abuse prevention strategies by first presenting some of the key components of a child abuse prevention framework, based on current trends in western communities; and second, to discuss the relevance of some of these prevention strategies for the Chinese community.
Please note, the terms child abuse and neglect and child maltreatment are used interchangeably throughout this paper. The term child abuse prevention encompasses the prevention of all forms of child abuse and neglect.
DEFINING PREVENTION
Child abuse prevention is commonly classified into three main levels under a ‘public health’ model: primary, secondary and tertiary prevention (Helfer 1982). Primary prevention is targeted at the community as a whole. Primary programs generally comprise mass media campaigns aimed at both children and adults, or school-based personal safety programs for children. The aim of primary prevention programs is to stop abuse and neglect before it starts (Calvert 1993).
Secondary prevention programs target specific ‘at risk’ sections of the population. That is, those with special needs or who are in need of greater support, such as young parents, single parents, people with physical or intellectual disabilities. Secondary prevention programs can be categorised as enhancing family functioning by providing various forms of family support and, in particular, by teaching parenting skills and increasing parents’ knowledge of child development and behavioural expectations (Calvert 1993).
Tertiary prevention refers to prevention initiatives which are aimed at preventing the recurrence of abuse in those families where children have already been maltreated, these cases generally fall within the responsibility of child protection agencies, with treatment, support and counselling carried out by health and family support services (Calvert 1993).
Child abuse prevention programs have generally consisted of community education designed to raise the public’s awareness of abuse and neglect; family support programs, where parents are provided with parenting skills and knowledge of child development, in conjunction with attempts to reduce family stresses or to teach coping strategies; and teaching children ways of avoiding being maltreated (school-based personal safety programs) (Tomison & McGurk 1996; Tomison 1997). Harrington and Dubowitz (1993) argues that the effective prevention of child maltreatment has been hampered for three main reasons: a lack of political will to prioritise child and family wellbeing which, it is argued, has led to a lack of adequate resources with which to assist families in need; a lack of knowledge about the causes of maltreatment, which has hindered the development of prevention programs; and finally, the lack of methodologically sound evaluation research on prevention programs.
PREVENTION OR PROTECTION?
I would add to Harrington and Dubowitz’s list. In the western world, what resources are available for children’s health and wellbeing and family support, have been mainly allocated to child protection services to investigate and treat the significantly increasing number of reported cases of suspected child abuse and neglect that have been identified in the past five to ten years. There is growing recognition however, that child protection departments, in isolation, cannot adequately protect children and a subsequent re-emphasis on the value of child abuse prevention (Dartington Social Research Unit 1995; Tomison 1996b).
While it is important to have a well-functioning child protection system that can identify, assess and treat maltreated children and their families, and hopefully prevent the recurrence of child maltreatment, it is equally, if not more important, to have an effective child abuse prevention system. These two are not mutually exclusive, many of the services developed to provide support for needy or ‘at risk’ families, are also called upon to assist maltreating families. But preventing child abuse and neglect is socially and economically cheaper than attempting to deal with and remedy the short and long-term effects of child maltreatment once it has occurred. It is important that governments and services do not become too focused on managing and treating current cases of child abuse and neglect and thus fail to work to reduce the likelihood that other families will become abusive or neglectful over time.
COMPONENTS OF A CHILD ABUSE PREVENTION STRATEGY
The United States Advisory Board on Child Abuse and Neglect concluded that in order to effectively prevent child abuse and neglect, a new strategy is required: one that is ‘comprehensive, child-centered, family-focused and neighbourhood-based’ (1993:16, as cited in Melton & Flood 1994); one which takes ‘children seriously as individuals’ (1993:17, as cited in Melton & Flood 1994).The following approaches would appear to be key components of any strategy that can effectively prevent child maltreatment.
Child maltreatment is now recognised as a complex phenomenon that may reflect the degree of underlying social problems in a family, community or society (Melton & Flood 1994). Child maltreatment is associated with the occurrence of other individual, family and societal problems (poverty, mental illness, substance abuse, domestic violence, unemployment, lack of social support) (Mulroy 1997). A comprehensive approach must therefore be adopted to address what are often multi-problem, disadvantaged, dysfunctional families (Tomison 1997). An integral component of such a strategy is the development of partnerships between the various professions and agencies involved in child protection, child welfare, family support, education and community health (Powell 1982; Tomison 1996a).
Why is coordination important? This slide taken from my doctoral research provides a good example of the importance of coordination [see overhead]. It shows the formal referrals made between agencies in one small Australian city as 295 suspected cases of child abuse and neglect were identified, assessed and treated. This formal communication was only a small part of full range of contacts the agencies and professionals had as they worked to manage the cases. What this demonstrates is the complexity of interagency work, the potential for errors in communication, and the difficulties of trying to coordinate interagency responses. The more agencies or professionals involved, the more difficult it is to maintain clear communication and effective case coordination. In order to minimise error in child protection or child abuse prevention work, it is vital that there are clear mechanisms for agencies to work together. The development of a key coordinating agency, or the use of multidisciplinary teams for dealing with such matters are successful, although not perfect, approaches that I would recommend.
The African proverb, ‘It takes a village to raise a child’, epitomises the importance of the role of the wider community in raising children and young people.
The larger socio-economic system in which child and family are embedded can influence family functioning, child development and the availability of helping resources, such as universal child and health services, within communities and neighbourhoods, (Garbarino & Sherman 1980; Schorr 1988; US Advisory Board on Child Abuse and Neglect 1993; Hashima & Amato 1994).
In the West, the importance of community is currently undergoing a resurgence of interest (Korbin & Coulton 1996). There has been growing recognition that to truly prevent child maltreatment requires the development of the means to address the societal factors underpinning child maltreatment and other family violence (Altepeter & Walker 1992; Tomison 1997). This in turn, has led to the adoption of comprehensive prevention strategies where the focus is on ‘whole of community’ approaches.
‘Whole of community’ approaches, better known in the United States as ‘comprehensive community initiatives’ represent the most recent generation of a long line of community-level interventions dating back to the 1960s (Kahn & Kamerman 1996; Pawson & Tilley 1998; Kubisch et al. 1998). Such an approach is founded upon the formation and strengthening of partnerships between families, governments, professionals, business, unions and religious organisations, as a means of integrating private and social responsibilities for families (Cass 1994).
Although these initiatives may take a variety of structures and forms, they are all based around the empowerment of local community members to participate in a partnership with government and the professional sector in order to promote the development of healthier communities. That is, positive change is promoted in disadvantaged neighbourhoods for individuals, families and the community as a whole, by involving the community itself in improving physical, social and economic conditions (Kubisch et al. 1998). Participation leads to a greater sense of empowerment when addressing a problem such as child abuse and neglect, with participants having a greater sense of ownership of the plans and activities that result from such a process (Kaufman & Poulin 1994; Smith & Herbert 1997).
An underlying aim of the approach may be the development of a level of self-sufficiency and independent action such that the local community eventually take a greater role in the development of activities and ventures aimed at improving the health and wellbeing of community members, with less involvement by the government or the professional sector (Tomison & Wise 1999).
Involving and motivating the community in working to prevent child maltreatment and other social ills is a vital component of any prevention strategy. Here in China there has been a tradition of providing strong government and community support for families, with the wider community sharing the responsibility for childrearing and the general welfare of all community members (Funder & Davis 1987). This collective responsibility can be harnessed and developed for use in the prevention of child abuse and neglect, in the creation of solutions for existing community problems, and as a vehicle for the promotion of positive childrearing strategies and the minimisation of the potential for child abuse and neglect.
I am led to believe however, that this strong social infrastructure has begun to dissipate as China has begun the move away from collectivism towards a free market economy. The prevention of child maltreatment and other social ills requires that the social infrastructure is maintained. Where possible, professionals should be advocating for the continuation of a strong system of child and family support.
It is also important to note that such community-building initiatives, like many of the strategies outlined today, are reliant on the community’s acknowledgment of the problem of child maltreatment and their desire to combat it. I will return to the issue of community education later on in the paper.
It is important that families who are not coping with childrearing, or who require some form of social support or assistance are encouraged to seek help prior to their becoming abusive or neglectful. Universal or primary prevention services, in conjunction with agencies that target ‘at risk’ populations are required to provide support to families at an early stage.
Yet preventative efforts in many countries are still mainly based around tertiary prevention. As I noted earlier, the majority of resources are provided to children and their families after they have been identified as having been involved in a confirmed incident of maltreatment, leaving inadequate services available to a significant number of parents who are at risk of losing control with their children and who could benefit from early intervention (Werkele & Wolfe 1993). This trend is currently occurring in Australia, where families must present with a significant problem in order to be prioritised for assistance.
It is only by changing child welfare systems’ priorities and protocols to encourage families to seek assistance without the threat of protective intervention, that the welfare system will become more client-focused and better able to identify and remedy potentially abusive situations (Wolfe 1991). The alternative is effectively the creation of maltreating families as a result of the lack of assistance that may have prevented the family’s problems becoming severe, or manifesting as child maltreatment or other family violence.
The prenatal/perinatal period, in particular, is a period of developmental transition that provides an ideal opportunity to enhance parental competencies and to reduce the social and environmental risks that may have implications for the lifelong developmental processes of both children and parents (Holden, Willis & Corcoran 1992). Given that research into the factors affecting neurodevelopment (e.g. Perry et al. 1996; Perry 1997) now indicates that a less than adequate or abusive developmental environment can impact negatively and permanently on children’s neurophysiological development, the first three years of a child’s life is becoming the primary age for early intervention.
It should be noted that a focus on the birth to three age group does not however, imply that early intervention cannot occur at other points in children’s development, merely that a focus on the early years may produce the greatest social and physiological gains. One small United States program, the Perry Preschool Project followed children from participation in the Project as young children into adulthood. The students showed better social competence, less criminality, less use of welfare services and greater career success (Schweinhart et al. 1993). It was calculated that by the age of 27 years, for every dollar spent on the program, there was a subsequent saving of over seven dollars (Barnett 1993).
Other important early intervention programs are home visiting programs [such services have had some success carrying out an ‘early detection’ role and identifying families at risk before family dysfunction reaches a level requiring protective intervention (Olds et al. 1986a; Olds et al. 1986b; Olds et al. 1997; Chalk & King 1998]; and the universal services model popular in the Scandinavian countries, which involves antenatal/postnatal parent education, health checks at maternity health centres; maternal and child health services, that play a significant role in the protection of infants and preschool children; and the provision of a universal day care service for preschool children. The long-term needs of children are taken care of via the education system (Kahn 1990). These Scandinavian family support programs that strengthen and promote ‘well functioning, independent, self-supporting families that produce children who, in turn, will become independent, self-supporting adults’ (Pransky 1991:59) have both social and political appeal.
CHILD ABUSE PREVENTION IN CHINA
In the remainder of the paper I will attempt to apply aspects of the child abuse prevention strategy I have described to the Chinese situation, focusing on two inter-related issues in particular: the role of community education and the development of a coordinated child abuse prevention system.
The role of community education
Many of the above components rely on the professional and wider community’s knowledge of the child maltreatment problem, and their motivation to affect changes. In the past three decades western communities have been bombarded with media reports of severe maltreatment, child deaths and the removal of children from their families. Most people now recognise that child abuse and neglect is an important social ill that must be remedied. However, most lack a detailed understanding of types and forms of maltreatment, or the means of addressing the issue, beyond making a report to child protection services. Media coverage has been generally superficial and sensationalist, ignoring the broader social issues underpinning child maltreatment, yet the media has been essential to the growth of societal awareness of child abuse and neglect (Gough 1996) and has frequently influenced the day-to-day administration of child protection and social welfare policy (Scott 1995).
Child deaths, or other indications of the failure of the child protection system to adequately protect children, often result in the allocation of more resources to child protection, but at the expense of primary and secondary prevention services (Scott 1995; Wilczynski, as quoted in Loane 1997). Yet a response focused on child protection at the expense of prevention may further damage professionals’ potential to prevent maltreatment and thus lead to more child abuse tragedies (Scott 1995).
What are the implications for child abuse prevention in China?
It is my understanding that there are currently few child abuse cases reported in China, and that most of the reported cases are comprised of physical or sexual abuse incidents. The Chinese media, particularly the local papers now frequently publicise physical and sexual abuse cases. There is less acknowledgment of emotional abuse or neglect issues although there is some evidence that this is changing (Hesketh & Lynch, 1996).
Overall, it appears that the Chinese community has some awareness of the more obvious forms of child abuse, but is likely to require further education to make them better informed of the nature and extent of physical and sexual abuse. In addition, there would seem to be a need to highlight emotional abuse and neglect as equally important issues for the wider community, and also for professionals who work with children and families. Although they may be less visible, research shows that a prolonged exposure to emotional abuse or neglect may be just as harmful, or more harmful in the long-term, than exposure to a physical or sexual abuse (Tomison 1995; Tomison & Tucci, 1997).
How can the Chinese public be educated on child maltreatment and child abuse prevention?
From my understanding of Chinese society, on the one hand it has been characterised by strong community involvement and shared responsibility for childrearing (Funder & Davis, 1987), but on the other hand, the disciplining of children is seen as a private, family matter. Raising a family issue publicly is strongly opposed on the grounds that it brings shame to the family and results in the loss of ‘face’.
Above and beyond educating the public to report obvious or serious forms of child abuse, child abuse prevention is about reducing or modifying parental attitudes and behaviours that might lead to child maltreatment and to encourage families to seek help when can no longer cope, but before they become abusive or neglectful. What is required is public education that not only works to identify and prevent inappropriate behaviour, but that also provides positive alternatives for parents and families. Families are more likely to accept a public education message if first, they believe it is addressed to them, second, if they are presented with information on changes that are positive rather than negative, and third, they can see rewards flowing from the changes they make.
For example, if the aim is to prevent the physical punishment of children and a community education campaign poster is developed that shows a bruised child with the message ‘I only gave him a little hit — it wasn’t that bad’, many parents will not see that they may accidentally do the same thing to their child if they use physical punishment. They will see the message as targeting ‘abusers’ not normal parents and therefore fail to change their attitudes or behaviours.
Other problems with such an approach are that first, no alternative positive strategy for disciplining the child is offered and second, there is no incentive offered that makes the change appear beneficial.
If the campaign were about providing ‘101 alternatives to hitting a child’, or ‘use words that help not hurt’, where all parents are explicitly included in the audience, where the scenario is relevant for all parents, where positive alternatives to negative behaviour are provided and where rewards are identified (usually a happy child and positive, effective parent-child interactions), the extent to which the message is taken on board is substantially increased.
Campaigns that focus on encouraging families to praise children, or to take a child for a regular health check, or that involve other non-stigmatising situations that every parent can relate to, and that can be seen to offer rewards for the family, are more likely to be taken on board. Similarly, if the aim is to break down parental reluctance to seek assistance when faced with a difficult child (perhaps a ‘little emperor’), a campaign should be developed that promotes positive images of parents seeking help and benefiting from it.
The school system is a particularly good venue for the education of the young. It provides excellent access to children, young people and their families for the purposes of child abuse prevention, or the development of health attitudes and behaviours . Here the aim is primarily to educate the next generation of parents, teaching a variety of health and life skills, including parenting skills, peer relations and general coping skills (Conte & Fogarty 1990).
Health promotion versus prevention
I would term this approach a health promotion approach (Tomison 1997). Child abuse prevention traditionally reflects a negative, problem-focused approach, where the objective is preventing a social ill rather than the promotion of positive, life-enhancing strategies, such as good interpersonal relationships, appropriate parenting and pro-child policies. Thus, any models framed around prevention rather than promotion may be considered to offer a somewhat restrictive means to address social ills (NSW Child Protection Council 1995). While such messages are a necessary part of public education, at the very least they need to be combined with more positive messages.
Taking an example from an allied health field, the prevention of mental disorder in the community is generally described as mental health promotion (i.e. encouraging the development of positive mental health) rather than mental illness prevention (the prevention of a social ill). It appears that a similar ‘revolution’ has begun among professionals working in the child protection and child welfare arenas. Specific child abuse prevention programs have also adopted a ‘positive’ approach to ensuring children are cared for adequately. For example, the Positive Parenting Program developed at the University of Queensland is a parenting education program where, as the title suggests, the focus is on the enhancement of good parenting rather than the minimisation of bad parenting.
The over-riding philosophy is simple, to effect change requires the target population to accept and act on the message being conveyed. Engaging with families and overcoming resistance to change is paramount in any attempt to change community attitudes or behaviour. Such an approach fits with the recent trend towards developmental prevention strategies, which have the dual aim of preventing the development of child maltreatment by reducing the incidence of specific risk factors that increase the likelihood of child abuse or neglect, while simultaneously working to promote protective factors, such as more effective general coping skills, which can reduce the risk of child maltreatment (Tremblay & Craig 1995).
Developing a child abuse prevention system
I am led to believe that China is in the process of developing effective child protection systems. I would argue that this is a perfect time to also work on the development of a child abuse prevention system As I indicated earlier, child protection and child abuse prevention should not be considered as two distinct entities. Typically, the services that provide the bulk of the diagnosis, assessment and support of maltreating families also work with families who are ‘at risk’ of becoming abusive or neglectful, along with wider population who are not at risk of becoming abusive. Where possible, agencies and professionals in health, welfare and education need to be aware of the role they can play in the child protection system (i.e. tertiary prevention) and also in the prevention of child maltreatment by working with families to minimise the potential for abuse or neglect.
I will briefly comment on two issues that should be considered when developing child protection or child abuse prevention service networks.
First, professional education of the various agencies and professionals is vital. Although I am sure you will face a lack of resources, I would suggest that professional education on child maltreatment, its identification, assessment and treatment needs to be offered as widely as possible. Agencies that fulfil a primary or secondary preventative role, (and they may not be aware that they do this), should be educated and encouraged to take up a preventative role. China has a very solid health and family support base, this system should be assisted to recognise its role in the prevention of child maltreatment and to actively pursue community education and other preventative work with families. Conferences like this are ideal venues for the professional education of the wider family support system.
Second, effective interagency coordination and communication is necessary for the effective management of ‘at risk’ or maltreating families. The more agencies that are involved in a case, the greater the potential for errors, for duplicated services, the failure to provide services and poor casework. The overhead I presented before ably demonstrates the complexity of links that may develop in any child protection network. Thus, a key coordinating body, or a multidisciplinary teams approach should be considered as two means of enhancing the protective response.
In concluding, I would like to commend Professor Jiao for organising this Conference and thank him for inviting me to come and present to you. I hope this is the beginning of a long friendship between my agency and professionals working with child abuse and neglect in China. I look forward to exploring ways for Australia’s National Child Protection Clearinghouse to support you in your work.
XIE XIE!
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