Assessing physical child abuse risk: The child abuse potential inventory

Clinical Psychology Review, Vol. 14, No. 6, pp. 547-583, 1994 CopySght Q 1994 Elsevier Science Ltd Printed in the USA. AI1 rights resewed 0272.7358/94 $6.00 + .OO

Pergamon

ASSESSING PHYSICAL CHILD THE CHILD ABUSE POTENTIAL

ABUSE RISK: INVENTORY

~0~15. ~~ln~r Northern

AESTRACT.

lb jnvvide

Minois University

information on child abuse assessment,

the psychometric

base

ofthe

Child Abuse Potential (CAP) Inventory, a screening scale fm physical child abuse, is &scribed. A critical rev&w of studies n@rting on the n&abiLity, construct validity, and wdictive (concurrent and future) validity of tfae CAP Inventory physical a&se scale is @vi&d. As part of the

secticm on coltstrtiGt vales, Z summarize the physical child abuse risk fmtors &scribed in the fam~y violence literature and examine th.e ~e~t~hip between each of the risk factors and CAP a&use scores. Incrmtal validity estimates, derived from studies wjwrting p-edictive validity data, are rep-ted. The utility of using the CAP abwe scale in treatment evaluation is aho discussed. Throughout the W&U, incon.G&ncies in study findings and gaps in the psychometric base for the CAP abuse scab are noted.

PSYCHOLOGISTS are increasingly called on to assess the dangerousness of clients. This is especially true in the area of family violence. For example, psychologists may be asked to provide assessment data that can be used to substantiate child abuse and/or identify the abuse perpetrator. In addition, they may be asked to assess risk status following treatment. If an abused child has been removed from the family, psychologists may he requested to make recommendations regarding family reunification, which may involve an estimation of parental risk of child maltreatment. Psychologists may also be asked to provide risk assessments in child custody cases. Whereas psychologists may be expected to provide clinical assessments related to a parent’s risk for child maltreatment,

the appropriateness

of psychologists serving as

expert witnesses in child maltreatment court cases has been questioned. Arguments for limiting psychologists’ involvements as expert witnesses are based on problems with the accuracy of violence prediction (e.g., Melton & Limber, 1989; Monahan, 1976) as well as ethical and roIe considerations (e.g., Melton & Limber, 1989). In a broader context, psychologists are expected to evaluate risk for violence as part of their duty to protect potential victims as stated in the Tarasoff versus Regents of the University of California

case (1976). Although

a few state courts have rejected

Correspondence should be addressed to Joel S. Milner, Director of FamilyViolence Research Program, Department of Psychology,Northern IllinoisUniversity,DeKalb, IL 601152892. 547

548

J. S. Milner

or limited

the duty to protect

courts have accepted

as originally

stated

in the Tamsoff

the basic tenet of the duty to protect,

decision,

most state

with several courts expand-

ing the concept (Appelbaum, 1988; Knapp, Vandecreek, & Shapiro, 1990; Monahan, 1993; Schopp, 1991). Consequently, while there are validity, ethical, and policy concerns

(e.g.,

Caldwell,

Bogat,

& Davidson,

1976) related to the prediction of violence, that require violence prediction.

1988;

Melton

there

are professional

& Limber,

1989;

Monahan,

and legal mandates

To assist psychologists in their attempts to accurately assess violence, Monahan (1993) has suggested a set of guidelines that are designed to form the basis of any professional risk assessment. The first guideline calls for appropriate clinical and legal education.

Clinical

education

includes

a knowledge

of the “basic

concepts

of risk

assessment (e.g., predictor and criterion variables, true and false positives and negatives, decision rules, and base rates)” and a current knowledge of “key findings in risk assessment research” (p. 243). Part of this education involves keeping abreast of current research including a critical knowledge of risk assessment instruments. Because specialized instruments for the assessment of child abuse risk have only recently been developed (see Ammerman & Hersen, 1992, for a review), the purpose of this article is to provide a description of the psychometric properties of one of the most commonly used physical child abuse screening devices, the Child Abuse Potential (CAP) Inventory. Although a technical manual was published in 1986 (Milner, 1986a), recent studies have added substantially to our understanding of the uses and limitations of the CAP Inventory. Following the questionnaire’s release for use in applied settings in 1986, the CAP Inventory has been widely used in a variety of clinical and research applications. Unfortunately, users have not always been attentive to the limitations of the CAP Inventory and misapplications have occurred (e.g., using the physical child abuse scale to screen for sexual child abuse). Furthermore, a survey sent to 550 administrators, direct service providers, and researchers who were thought to have some knowledge of the CAP Inventory revealed that a substantial number of respondents believed that the Inventory had applications beyond those supported by existing validity data (Milner, 1989c). Approximately 23% of the professionals indicated that the Inventory could be used to differentiate ents of failure-t-thrive children. Some

abusive parents, neglectful parents, and parrespondents indicated that the abuse scale

could be used to investigate spouse abuse (17%) and elder abuse (12%). To provide additional clarification of the uses and limitations of the CAP Inventory in child abuse assessment, I focus on the reliability and validity of the primary clinical measure, the physical child abuse scale. An attempt is made to provide an exhaustive review of the published

literature.

Whereas

the review focuses

on studies published

in

scholarly journals, data provided in convention papers, theses, and unpublished reports are also included. Finally, the review serves a second function. It provides a representative summary of adult risk factors found in the literature because the construct

validity

parental

research

risk factors

has examined

the relationship

between

each

of the major

and the CAP abuse scale.

DESCRIPTION OF THE CAP INVENTORY The CAP Inventory

(Form VI) is a 160-item,

self-report

questionnaire

that is answered

in an agree/disagree, forcedchoice format (Milner, 1986a). The questionnaire has a third grade readability level. The current version (Form VI, copyright 1986) of the CAP Inventory contains a 77-item physical child abuse scale. Although changes have occurred in other items, the ‘77-item physical abuse scale has been maintained in its

Assessing Physical Child Abuse Risk

549

current form since 1977. The physical abuse scale contains six descriptive factor scales: distress, rigidity, unhappiness, problems with child and self, problems with family, and problems from others. The CAP Inventory also contains three validity scales: a lie scale, a random response scale, and an inconsistency scale. The validity scales are used in various combinations to form three response distortion indexes: the fakinggood index, the faking-bad index, and the random response index. In addition, two special scales have been developed, which are the egostrength scale (Milner, 1988) and the loneliness scale (Milner, 1990). Whereas data describing the development, structure, and validity of the CAP Inventory are provided in a technical manual (Mimer, 1986a), additional details regarding test administration and scale interpretation are provided in an applied manual (Milner, 1990). In addition to discussions pro vided in the manuals, several articles have discussed the applications and limitations of the CAP Inventory (e.g., MiIner, 1989b, 1991a, 1991~). Critiques of the CAP Inventory by independent reviewers are also available (e.g., Hart, 1989; Kaufman & Walker, 1986; Melton, 1989). Re/iabiliiy

Two types of reliability, internal consistency and tenajmrd stability, have been computed for the CAP Inventory scales (Milner, 1986a; Milner 8c Gold, 1985). Estimates of test reliability are needed for many reasons, including the fact that test reliability generally establishes the upper limits of test validity. Thus, reliability estimates help users form some expectations about test validity. In ternal Consistency A summary of the internal consistency reliabilities for the CAP physical abuse scale are presented in Table 1. Two types of internal consistency are reported for the abuse scale in the technical manual (Milner, 1986a). Split-half reliability estimates are provided for the 77-item abuse scale weighted scoring procedure, and Kuder-Richardson-PO (RR-20) reliability estimates are pre vided for the same 77-item abuse scale, where a nonweighted (i.e., l/O) scoring procedure was used. The reported split-half reliabilities range from 0.96 to 0.98 and the RR-20 reliabilities range from 0.92 to 0.95 for general population (n = 2,062)) at-risk (12= 178)) neglectful (n = 218), and physically abusive (7~= 3 52) groups. Reliabilities based on subgroups drawn from these groups are similar. For example, split-half reliabilities of 0.96 and RR-20 reliabilities of 0.92 are reported for subgroups of nonabusive comparison parents drawn from different sites, such as social service agencies, hospitals, and parent-teacher organizations. Split-half reliabilities ranging from 0.93 to 0.98 and RR-20 coefficients ranging from 0.85 to 0.96 are reported for different gender, age, education, and ethnic groups. Consistent with estimates provided in the technical manual, Milner and Robertson (1990) reported RR-20 estimates of 0.94, 0.93, and 0.92 for physical child abusers (n = 30), intrafamilial sexual child abusers (n = 15), and child neglecters (n = 30). Milner and Robertson also computed reliabilities for three nonmaltreating comparison groups, which had been demographically matched to the three child maltreatment groups, and reported RR-20 estimates of 0.92, 0.91, and 0.74. More recently, Caliso and Milner (1992) reported an internal consistency (alpha) of 0.93 for a combined group of physically abusive and nonabusive mothers (72 = 90). Internal consistency estimates for the abuse scale have been reported for other types of subjects. For example, using a group of mothers (7~= 92) of developmentally

550

J. S. Milner

TABLE

Study

1. Reliability Estimates for the CAP Physical Child Abuse Scale

-~

Group (n)

Reliability Coefficients

-

Internal Consistaq Black, Nair, Right, Wachtel, Roby, & Schuler (in press)

Drug-abusingmothers (n = 60)

0.84

Bringiotti (1992)

Combined group of physicalchild abusers and comparison parents,Argentina (II= 76)

0.94

Burrell,Thompson, & Sexton (1992)

Mothers (n = 113)) 53 of which had children with handicaps

0.91

Cal& & Milner (1992)

Combined group of physicalchild abusers and comparison parents (n = 90)

0.93

de Paul, Arruabarrena,SC Milner (1991)

Physicalchild abusers, Spain (n = 24) Gen. population parents, Spain ( n = 829)

0.91

Kirkham, Schinke, Schilling, Meltzer,& Norehus (1986)

Mothers of developmentally disabledchildren (n=92)

0.91

Milner (1986a) *

Physicalchild abusers ( n = 152) Child neglecters (n = 218) At-riskparents (n = 178) Gen. population (n = 2,062)

0.95-0.98 0.93-0.97 0.95-0.97 0.92-0.96

Milner & Robertson (1990)

Physicalchild abusers (n = 30) Child sexual abusers (n = 30) Child neglecters (n = 30) Three comparison groups f p1=30)

0.94 0.93 0.92 0.74-0.92

Milner, Robertson, & Rogers (1990)

Undergraduatestudents (n = 375)

0.87

Milner (1986a)

Cen. population 1 day (n = 125) 1 week (n= 162) 1 month (n= 112) 3 months (7~= 150)

0.91 0.90 0.83 0.75

Mollerstrom (1993)

Military,Air Force 6 months (n = 22)

0.86

0.90

Temporal Stabiity

*In the Milner (1986a) report, split-halfand RR-20 reliabilityestimateswere provided so more than one reliabilityestimate is listed.

Assessing Physical Child Abuse Risk

551

disabled children, Kirkham, Schinke, Schilling, Meltzer, and Norelius (1986) reported a RR-20 reliability of 0.91 for the abuse scale. Burrell, Thompson, and Sexton (1992) also reported an alpha of 0.91 for the abuse scale for a group of 113 mothers, 53 of whom had children with handicaps. Black et al. (in press) reported an internal consistency of 0.84 for a group of 60 drug-abusing mothers. In a study that used male and female undergraduate students (n = 375)) Milner, Robertson, and Rogers (1990) reported a RR-20 of 0.87 for the abuse scale. Internal consistency estimates have been reported for a Spanish version of the abuse scale, which was administered in Spain. For the translated scale, de Paul, Arruabarrena, and Milner (1991) reported a RR-20 of 0.90 for a demographically representative group of Spanish parents (n = 829) and a KR-20 of 0.91 for a group of physically abusive Spanish parents (n = 24). Bringiotti (1992) administered a different Spanish translation of the CAP Inventory to abusive and comparison parents (n = 76) in Argentina and reported an alpha of 0.94. In general, the highest estimates of internal consistency have been reported for groups of physically abusive parents. Slightly lower estimates have been reported for other populations, especially populations that were not the initial target population for the abuse scale, such as nonparent undergraduate students. Using the mean internal consistency estimates reported in the technical manual, Milner (1986a) computed a SEM of 19.5 and 18.4 points for comparison parents and physical abusers, respectively, where the abuse scale ranges from 0 to 486 points. This translates into an SEM of 3.9% for abusive subjects, that, for example, is comparable to the SEM on the Wechsler Adult Intelligence Scale-Revised (WAIS-R) performance scale (Wechsler, 1981). The similarity of the SEMs for abusers and nonabusers is desirable because similar SEMs suggest homoscedasticity across different score ranges (i.e., high versus low scores) on the abuse scale. A finding of heteroscedasticity (i.e., different SEMs for abusers and comparison parents) would present problems for abuse score interpretation in screening situations where the respondent’s group membership is not known because the test user would not know which SEM was associated with the respondent’s test score. Temporal Stability

A summary of temporal stability (test-retest) estimates are presented in Table 1. Most of the available temporal stability estimates have been published in the CAP Inventory technical manual (Milner, 1986a). Male and female general population groups were used to obtain test-retest reliabilities for lday (n = 125), l-week (n = 162), l-month (n = 112), and 3month (n = 150) intervals for the abuse scale. For these four-time intervals, the abuse scale test-retest reliabilities were 0.91,0.90,0.83, and 0.75, respectively. Because gain scores (i.e., test score increases at retest) are frequently observed on psychological tests, the possibility of gain scores on the CAP Inventory has been explored (Milner, 1986a). For the lday, l-week, l-month, and 3month intervals, the test-retest abuse score means were 93.6/99-g, 96.7/100.7, 88.3/97.1, and 85.2/85.9, respectively, on a scale with a possible 486 total points, indicating modest abuse scale gain scores across the four time intervals. Abuse scale test-retest reliabilities do not appear to systematically vary as a function of gender, age, educational level, and ethnic background (Milner, 1986a). Finally, in an unpublished report that used a sample of Air Force personnel (n = 23)) Mollerstrom (1993) found an abuse scale test-retest reliability of 0.86 across a 6-month (mean) interval, which is higher than the 3month test-retest estimate of 0.75 reported in the technical manual. Additional test-retest

J. S. Milner

552

data are needed frequently

for intervals

longer

used as an evaluation

than a Smonth

period

tool for interventions

because

the abuse scale is

that last longer

than 3 months.

Demographic Factors Because

demographic

characteristics association review

differences

to be considered between

of the

on a measure

demographic

validity

increase

the need

when validity data are gathered,

research.

factors During

and the

abuse

scores

development

for respondent

a description

is provided of the

of the

prior

GAP

to a

Inventory,

attempts were made to remove items that loaded on demographic variables. However, no psychological test, including the CAP Inventory, is free from demographic moderator

effects.

The question,

therefore,

demographic factors. Using a group of 37.5 male

and

is to what extent female

are abuse scores

undergraduate

students,

affected

Milner

by

et al.

(1990) studied the relationship between abuse scores and demographic characteristics. The analyses indicated nonsignificant correlations between abuse scores and gender (-0.04), age (-0.05), and years of education (0.04). Likewise, Miller, Handal, Gilner, and Cross (1991) reported no abuse score gender differences in a group of Black high school students. Although these findings are encouraging with respect to gender, the Milner et al. (1990) data are limited in their meaningfulness because student samples tend to be homogeneous in their demographic characteristics. This homogeneity results in truncated ranges of scores on many of the demographic variables, such as age and education, which mathematic~ly reduces the likelihood that demographic retationships will be found. Stringer and La Greta (1985) studied the relationship between CAP abuse scores and parents’ marital status, race, age, and educational level, as well as their children’s gender and age. These authors concluded that “demographic variables were not (significantly) correlated with GAP scores” (p. 221). In a group of young female adult nonparents in Canada, Whissell, Lewko, Garriere, and Radford (1990) found no significant correlations between abuse scores and the education of the subjects’ parents (-0.01) and the subjects’ family size (-0.06). When sociodemographic factors were examined, Whissell et al. reported that no significant associations were found between

abuse scores and frequency

of the subjects’

fathers’job

changes

(O.OS), num-

ber of family social service contacts (-0.04), and subjects’ participa~on in a parenting course (0.0’7). Significant, albeit modest, relationships were found between abuse scores and subjects’ age (-O-11), weeks of unemployment of the subjects’ father (0.16),

number

of family moves

the subjects (-0.1’7). Kolko, mothers into high, moderate,

(0.15),

and number

of hours worked

each

week by

Kazdin, Thomas, and Day (1993) divided a group of and low abuse scoring groups and found no differences

in age, racial background, family size, and personal history of treatment. However, higher abuse potential was significantly associated with single parent or nonparent custody and lower socioeconomic status. These results are similar to results reported by Herrick (1982) who found abuse scores were significantly higher for single parents (compared to norm data), while abuse scores were not significantly correlated with the mother’s

age (-O.I2),

length

of previous

marriage

(-O-16),

length

of single

par-

enthood (-0.03), number of children (-0.08), and mean age of children (-0.13). Nealer (1992) studied the relationship between abuse scores and demographic variables in a group of high-risk, male and female parents. Nealer found that abuse scores were significantly, but modestly, related to the two-factor Hollingshead Index (-0.25), income (-0.24), and education (-0.22, reflected). No significant associations

553

Assessing Physical Child Abwe Risk

between abuse scores and age of child (-0.09), (O.Ol), number of adults in the home (-O.lO), dren (0.18), age of the female parent (-O.ll),

gender of child (O.lO), sibling position marital status (0.07), number of chilage of the male parent (-O.lO),

and

race (0.01) were found. Unlike previous studies, Holden, Willis, and Foltz (1989) found higher female abuse scores when testing a mixed group of maltreating (e.g., physical child abusers, sexual child abusers) and comparison parents. In comparing male and female scores, however, it appeared that subjects were not individually matched on maltreatment types (e.g., equal numbers of male and female sex offenders). Although Holden et al. stated that the male-female

ratio across maltreatment

types was not significantly different, no statistical data were provided. If abuse type was not carefully controlled, the observed gender differences could be confounded with maltreatment type. Nevertheless, the Holden et al. finding indicates that additional study is warranted on possible gender differences in abuse scores. Although student samples tend to be homogeneous, some differences have been found using student data. For example data on Black adolescent subjects, reported by Harris and Milner (cited in Milner, 1986a) and Miller et al. (1991)) indicate that Black adolescent ab~usescores are higher than adult (parent) norm abuse scores reported in the technical manual (Milner, 1986a). Haskett, Johnson, and Miller (1994), using a group of predominately (87.5%) Black adolescent mothers, also found higher abuse scores for adolescent mothers; the abuse scores for younger adolescent mothers (15 years and under) were higher than the abuse scores for older adolescent mothers (16 years and older). However, Haskett et al. indicated that it was not known to what degree factors, other than age, associated with the younger mother group may have accounted for the observed age difference. Despite this caveat, support for higher adolescent abuse scores can be found elsewhere. Several studies using primarily white college students (summarized in the technical manual, Milner, 1986a), indicate that college students, many in their late teens, also earned abuse scores that were consistently above the adult (parent) norm abuse scores. A study conducted by the National Committee for Prevention of Child Abuse (NCPCA, 1992) reported a number of significant relationships between demographic variables and abuse scores that contrast with other reports. For example, in a large sample of parents (n = 559)) age was significantly related to abuse scores, with younger parents earning lower scores than older parents. However, the younger parents were also judged to have “fewer risk factors and problems and being less likely to engage in corporal punishment or emotional neglect” (p. 54), suggesting that in this sample age may have been a marker for other important factors. Significant racial differences were also found for abuse scores, with Blacks and Hispanics scoring higher than whites. However, in the sample used in this study minorities also displayed significantly more risk factors, used more corporal punishment, engaged in less adequate supervision, displayed less emotional involvement, and were less compliant than whites, suggesting that race may have been a marker for other variables. The NCPCA (1992) also found that single parents, parents with more children, and parents with less income scored significantly higher on the abuse scale. Again, however, risk factors covaried with these demographic variables. Thus, for each demographic variable, the relationship with abuse scores was confounded with other factors making it unclear if the demographic factor alone had an association with abuse scores. The NCPCA reported that one demographic variable, parent education, was not significantly related to abuse scores. Finally, in an ongoing Air Force program evaluation study that tested different types of offenders (e.g., physical child abusers, child sexual abusers, child neglecters,

554

J. S. M&m

spouse abusers), demographic all maltreatment der (male/female,

with CAP abuse scores. Using

associations were found between

gen-

0.13), race (white/other,

number of children cation,

variables were correlated

types (n = 5,323), significant (-0.09),

-0.04), education (-0.14), age (-0.12), and pay grade (0.10) (Mollerstrom, personal communi-

May 18, 1993). However,

whereas

each of the correlations

because of the large sample size, the variance accounted

was significant

for by the demographic

fac-

tors was small (less than 2%) in every case. In conclusion, although modest relationships are evident between some factors (e.g., education) and abuse scores, the available data do not indicate that demo graphic

factors

produce

major

moderator

variable

problems

for the abuse scale.

Additional data, however, are needed to more fully document the extent of possible cultural differences across a variety of ethnic groups as well as the possible impact of combinations of demographic correlational data, information

factors on abuse scores. Furthermore, in addition to on the impact of demographic factors on abuse scale

classification rates (specificity and selectivity) are needed. This would require a determination of classification rates for demographically different groups of abusive and nonabusive Construct

parents. Validity

A substantial body of literature has accumulated on the construct vaIidity of the CAP Inventory physical child abuse scale. This section on construct validity describes major risk factors mentioned in the family violence literature and then provides a descrip tion of the available research on the relationship between each risk factor and the physical abuse scaie. An overview

of the construct

validity research

is provided

in

Table 2. Social Factors Childhood h&toty of abuse. A relationship between the childhood experience of physical abuse and parental child abuse has been mentioned frequently in the child abuse literature (e.g., Altemeier, O’Conner, Vietz, Sandler, & Sherrod, 1982; Steele, 1987), albeit the quality of research supporting this relationship has been criticized (e.g., Widom, 1989). Assuming that a childhood history of physical abuse is associated with adult child abuse, then a childhood

history of physical abuse should be related to CAP

Inventory abuse scores. Chan and Perry (1981) were the first to study the relationship

between a childhood

history of physical abuse and CAP abuse scores. Ghan and Perry found that undergraduate students who reported physical abuse during childhood, compared to students who did not report childhood

abuse, earned significantly higher abuse scores.

Also using undergraduate students, Milner et al. (1990) found that a childhood history of physical abuse was significantly correlated (0.29) with elevated abuse scores; and, as severity of childhood physical abuse increased so did abuse scores. Furthermore, abuse prior to puberty, compared to abuse after puberty, produced higher abuse scores. Although the correlations were modest, Milner et al. (1990) also reported that the observation of physical child abuse during chiIdhood was significantly correlated (0.15) with abuse scores; being the victim of child sexual abuse and observing child sexual abuse were significantly correlated (0.09 and 0.11, respectively) with abuse scores. In a simiiar study that used female college students, Crouch (1993) reported a significant relationship between a childhood history of physical abuse and abuse scores.

AssessingPhysical Child Abuse Risk

555

TABLE 2. Construct Validity A Summary of Studies Investigating the Relationship Between Risk Factors and CAP Abuse Scores and an Indication of Whether the Expected Relationship Was Found Study

Construct Childhood history of abuse

Relationship

Subjects Abusers/nonabusers Undergraduates Undergraduates Adolescents

Yes Yes Yes no

Abusers/nonabusers Adolescents

Yes yes

Undergraduates

yes

Undergrads/parents Military, Air Force Undergraduates Adults Mothers

yes yes Yes mixed

Abusers/nonabusers Undergraduates

Yes Yes

(1990) Talbott (cited in Milner, 1986) Whissell, Lewko, Carriere, & Radford (1990)

Abusers/neglecters Young female adult nonparents

Yes Yes

Arruabarrena & de Paul (1992) Caliso & Milner (1992) Chan & Perry (1981) Kolko, Kazdin, Thomas, & Day

Abusers/nonabusers Abusers/nonabusers Undergraduates Mothers

Yes Yes no

Mothers

mixed

Caliso & Milner (1992) Chan & Perry (1981) Crouch (1993) Haskett, Johnson, & Miller (1994) Mee (1983) Miller, Handal, Gilner, & Cross (1991) Milner, Robertson, & Rogers (1990)

Social isolation and lack of social support

Negative family interactions and family problems

Braswell (1990) Burge (1982) Crouch (1993) de Paul & River0 (1992) Kirkham, Schinke, Schilling, Meltzer, & Norelius (1986) Matthews (1984/ 1985) Milner, Robertson, 8c Rogers

Yes

mixed

(1993) Lamphear, Stets, Whitaker, & Ross (1985) Mollerstrom, Patchner, SC Milner (1992) Nealer (1992) Poteat, Cope, Choate, SC Grossnickle (1989) Poteat, Grossnickle, Cope, & Wynne (1990) Whiiell, Lewko, Carriere, & Radford (1990)

Military, Air Force

Yes

Parents Female employees at residential center Female employees at residential center Young female adult nonparents

mixed

Attachment

Mee (1983)

Abusers/nonabusers

mixed

Physiological reactivity

Casanova, Domanic, McCanne, & Milner (1992) Crowe & Zeskind (1992)

Mothers

mixed

Undergraduates

mixed

Yes Yes Yes

(continued on next page)

556

J. S. Milner

TABLE 2. Continued Study

Construct Hager

Adults

(1987)

Pruitt & Erickson Self-esteem and ego-strength

Chan & Perry Fulton,

(1985)

&Anderson

Undergraduates

yes

Adolescent

yes

mothers

(1991) Milner,

(cited in

Undergraduates

yes

(1985)

Undergraduates

yes

Undergt-ads/parents

yes

Young female

yes

1986)

Robertson

& Milner

Robitaille,

Jones,

Robertson,

and distress

yes mixed

Adults

(1981)

Murphy,

Leak & Langholdt

Life stress

Relationship

Subjects

Gold,

& Milner

Whissell,

Lewko,

Radford

(1990)

(1985)

Carriere,

&

adult

nonparents Military, Air Force

yes

Abusers/nonabusers

yes

Mothers

yes

Mee (1983)

Abusers/nonabusers

Milner

Parents

yes mixed

Burge

(1982)

Holden,

Willis, & Foltz (1989)

Kolko, Kazdin, Thomas,

& Day

(1993) (1991b)

Milner, Charlesworth, Gold, & Friesen Talbott

Gold,

(cited in Milner,

Undergraduates/ prison

(1988) 1986)

inmates

Abusers/neglecters/

yes yes

non-maltreaters Knowledge of child development

Fulton,

Murphy,

Osborne,

Williams,

& Tuma

Perceptions of children’s behavior

Adolescent

mothers

yes

Lewko,

Radford

(1990)

Aragona

Rappaport,

no

Undergraduates

(1986)

Whissell,

Carriere,

&

Young female

adult

yes

nonparents

(1983)

Kolko, Kazdin, Thomas,

& Day

Abusive mothers

Yes

Mothers

Yes

Single mothers

yes

Mothers

Yes

(1993) Stringer

Evaluations

& Anderson

(1991)

(1982/

Chilamkurti

1983)

& Milner

(1993)

of children’s behavior Attributions

Ellis & Milner

(1981)

At-risk and general population

regarding their own

Milner & Foody

(1993)

yes

mothers

Undergraduates

mixed

Mothers

yes

and their children’s

Stringer

& La Greta

(1985)

behavior Authoritarianism

Bardua

Abusive/neglectful/

(1987)

comparison Robitaille, Jones, Robertson,

Undergrads/parents

Gold,

& Milner

mixed

parents no

(1985) (continued)

557

Assessing Physical Child Abuse Risk

TABLE 2. Continued Subjects

Relationship

Whissell, Lewko, Carriere, & Radford (1990)

Young female adult nonparents

Yes

Aragona (1983) Arruabarrena & de Paul (1992) de Paul SCRiver0 (1992) Ellis (cited in Milner, 1986) Hager (1987) Kirkham, Schinke, Schilling, Meltzer, & Norelius (1986) Kolko, Kazdin, Thomas, & Day

Mothers Abusers/nonabusers Adults Adults Adults Mothers

Yes Yes yes Yes yes yes

Mothers

Yes

Abusers/nonabusers Undergrads/inmates

Yes Yes

Mothers Parents Adults Undergraduates Undergrads/parents

yes Yes Yes Yes yes

Abusers/neglecters/ non-maltreaters

yes

Black, Nair, Kight, Wachtel, Roby, & Schuler (in press) Herrick (1982)

Drug-abusing mothers

Yes

Single mothers

no

Assertiveness skills

Mee (1983)

Abusers/nonabusers

Yes

Problems in parent-child interactions

Aragona (1983) Hann (1989) Kolko, Kazdin, Thomas, & Day

Mothers Mothers Mothers

yes mixed

(1993) Schellenbach, Monroe, & Merluzzi (1991)

Parents

yes

Mothers Mothers Parents Undergraduates

yes yes yes yes

Study

construct

Negative affect

(1993) Matthews (1984/1985) Milner, Charlesworth, Cold, Gold, & Friesen (1988) Milner, Halsey, & Fultz (1994) Nealer (1992) Pruitt (1983) Robertson & Milner (1985) Robitaille, Jones, Cold, Robertson, & Milner (1985) Talbott (cited in Milner, 1986)

Alcohol and drug use

Harsh discipline strategies and lack of positive parenting behavior

Coping skills

yes

Aragona (1983) Chilamkurti SCMilner (1993) Monroe & Schellenbach (1989) Osborne, Williams, Rappaport, & Tuma (1986) Schellenbach, Monroe, & Merluzzi (1991) Stringer (1982/1983) Wbissell, Lewko, Carriere, & Radford (1990)

Parents

yes

Mothers Young female adult nonparents

yes yes

Mee (1983) Pruitt (1983)

Abusers/nonabusers Adults

no mixed

558

J. S. Milna

Miller et al. (1991) and abuse

scores

studied

the relationship

in a group

of Black

dents. As in the Chan and Perry (1981), ies, Miller

et al. (1991)

significantly al. (1991) scores;

higher found

found

abuse

that those

Milner

that individuals

scores.

between

who witnessed

adolescent

et al. (1990),

violence

and been

history

by Milner

history

stud-

of abuse

had

Miller

had higher

victims of abuse earned

stu-

(1993)

et al. (1990),

in childhood

of abuse

high school

and Crouch

with a childhood

Also, as reported

those who had both witnessed

a childhood

male and female

et

abuse

the highest

abuse scores. However, a recent study (Haskett et al., 1994), that used a group of predominately Black adolescent mothers, failed to find a significant difference between elevated

and normal

scoring

mothers

history of maltreatment index. Studies using adult parent groups

(CAP abuse

scores)

have uniformly

and scores

reported

on a personal

the expected

relation-

ship between a childhood history of abuse and abuse scores. In a group of abusing and nonabusing Australian mothers, Mee (1983) reported a significant relationship between a childhood history of “being knocked around” as a child and elevated abuse scores.

Braswell

(1990)

found

a significant

relationship

(0.38)

between

the exploit-

ing/passive measure on the Life Style Questionnaire and adult abuse scores. Braswell noted that respondents with high scores on this measure tend to feel that their parents were mean and angry with them and may have been abused by their parents. Caliso and Milner (1992) used a modified version of the Conflict Tactics Scale to measure childhood violence and found a significant inverse relationship (-0.25) between parental use of reasoning during childhood and adult abuse scores. A significant association (0.25) was also found between childhood verbal abuse and adult abuse scores; and a significant association (0.48) was found between childhood vialence and adult abuse scores. Caliso and Milner reported that nonabusive mothers with a childhood history of abuse, compared to abusive mothers with a childhood his tory of abuse, were less rigid (CAP rigidity scale) in their child expectations and were happier (CAP unhappiness scale) in their interpersonal relationships. Mee (1983) analyzed data from a subgroup of Australian mothers who had received abuse during childhood but who earned low abuse scores. Mee found that this subgroup of mothers, relative to those who had received childhood abuse and earned elevated abuse scores, was older, appeared to be more appropriately assertive, and had higher levels of attachment. Collectively, the findings indicate that being the victim of childhood abuse and the observation of childhood abuse, as well as the severity of the abuse, are related in the expected manner to CAP abuse scores in adult samples. The uniform nature of these findings

in adult samples

is impressive

given that in each study the childhood

history

of abuse is based on historical recall, which is subject to substantial error. Furthermore, intervening variables (e.g., social support) may in some cases buffer the effects of a childhood history of abuse (e.g., Egeland, Jacobvitz, & Sroufe, 1988), which would reduce the likelihood of detecting an association. Finally, the relationship between a childhood history of abuse and CAP abuse scores is not the result of a tautology. That is, none

of the 77 physical

ing childhood

abuse scale items ask about

being

the victim of or observ-

maltreatment.

So&l isoUion and social support. Studies have frequently reported that abusive parents are socially isolated (see Milner 8c Chilamkurti, 1991). Thus, it has been hypothesized that social isolation and lack of social support should be positively correlated with CAP abuse scores. As expected, using a group of military personnel, Burge (1982) found that respondents who were not involved in activities outside of home and work

Assessing Physical Child Abuse Risk

559

environments had significantly higher abuse scores. These findings are similar to reports that abusive individuals lack affiliations with community organizations, are less likely to use community resources, and are more likely to perceive themselves as socially isolated (e.g., Starr, 1988). Supporting the Burge (1982) findings, Matthews (1984/1985) found a significant correlation (0.63) between the MMPI social introversion-extroversion scale, which is purported to measure social withdrawal and the CAP abuse scale. Similarly, Talbott (cited in Milner, 1986a) reported a significant correlation (0.51) between a measure of social isolation on the Parenting Stress Index and the abuse scale. With respect to social support, Kirkham et al. (1986) found that mothers with elevated abuse scores reported less satisfying socidi networks. Milner et al. (1990) reported abuse scores inversely correlated with the presence during childhood of a caring adult and/or a caring friend, suggesting that these events may serve as moderators of abuse potential. Braswell (1990) reported significant inverse correlations (-0.40 and -0.39, students and parents) between the Social Interest Index, which measures coop erative behavior and the degree to which respondents feel part of a group, and abuse scores. Whissell et al. (1990)) using a group of young female adult nonparents, reported that abuse scores had a significant inverse relationship with all of the social support measures (i.e., Total scale, -0.5’7, and all subscales on the Interpersonal Support Evaluation Scale, plus coping support and family support measures) used in their study. Using a sample of subjects from Spain, de Paul and River0 (1992) found that high abuse scores were associated with respondent reports of lower levels of supportive behaviors on the part of relatives. Likewise, Crouch (1993) found that individuals with low levels of social support compared to those with high levels of social support (as measured by the Social Support Questionnaire, a measure of perceived social support), earned significantly higher abuse scores. Thus, the available data are relatively uniform in indicating that elevated abuse scores are associated with social isolation and the perceived lack of social support. These findings indicate that while the abuse scale may appear to be assessing negative characteristics of the parent, it also correlates with the absence of abuse buffering factors, such as social support. This view is supported by Caliso and Milner (1994)) who combined social support measures with the CAP Inventory in an attempt to improve individual classification rates of the abuse scale. Although the social support measures were found to predict abuse/nonabuse group membership, when combined with the abuse scale the social support measures did not improve the classification rates above that found when the abuse scale was used alone. Theory and research suggest that the current level of family functioning, which may include social support, is associated with physical child abuse (e.g., Bolton & Bolton, 1986). Measuring family characteristics, Chan and Perry (1981) reported a significant relationship (0.41) between the Family Environment Scale (FES) measure of family conflict and abuse scores in a group of students. Lamphear, Stets, Whitaker, and Ross (1985) found that mothers with elevated abuse scores had significantly less family cohesion, expression, and independence, as measured by the FES. Mothers with elevated abuse scores, compared to mothers with low abuse scores, also reported signi~cantly more marital discord on the Marital Adjustment Scale. Poteat, Grossnickle, Cope, and Wynne (1990; also see Poteat, Cope, Choate, & Grossnickle, 1989) found a significant correlation (0.53) between a measure of spouse abuse, the Wife Abuse Inventory, and abuse scores. Mollerstrom, Patchner, and Milner (1992) reported that elevated abuse scores were significantly associated with Fum2y tvwitvnm.

J. S. Milner

560

more family conflict and less family cohesion and expressiveness, FES. Each factor remained significant in a regression analysis, cohesion

accounting

the Lamphear

for the largest

et al. (1985)

proportion

findings

(29.8%)

of greater

marital

as measured by the with lack of family

of the variance. discord,

Supporting

Mollerstrom

et al.

(1992) also reported that elevated abuse scores were significantly related to lower levels of marital satisfaction, as measured by the Index of Marital Satisfaction. Similar to previous reports on the FES, Kolko et al. (1993) above the abuse scale cutoff compared to other family cohesion the FES conflict

found that mothers who had scores mothers, reported significantly less

and expressiveness on the FES. However, no data were reported on scale. Kolko et al. also found that high scoring individuals reported

more “family/spot& Using a Spanish

separations” than other respondents. translation of the CAP abuse scale and the Marital

Scale, Arruabarrena

and de Paul (1992)

found

only a nonsignificant

trend

Adjustment toward an

inverse relationship (-0.23) between abuse scores and marital adjustment using a physically abusive group living in Spain. However, these authors found the expected significant inverse correlation (-0.40) between abuse scores and marital adjustment when high- and lowscoring (abuse scale) general population Spanish subjects were tested. Whissell et al. (1990), using a group of young female adult nonparents, studied the relationship between abuse scores and a Conflict Tactics Scale (CTS) composite measure (i.e., CTS scores “collapsed” across different familial relationships). Whissell et al. found a significant relationship between the child abuse scale and the composite CIS verbal abuse (0.35) and CIS physical violence scores (0.30). Caliso and Milner (1992) also reported a significant relationship between abuse scores and CTS scores for verbal abuse (0.25) and violence (0.48) in a combined group of abusing and nonabusing parents. In contrast, Kolko et al. (1993) failed to find differences in abuse scores between high-scoring and low-scoring mothers on the CTS verbal abuse and violence scales. Using a different measure, Nealer (1992) studied a group of male and female at-risk parents and found that abuse scores were significantly related to prob lems in current family functioning (as measured by the Family Assessment Device), such as problem solving (0.66), communication (0.46), role (0.62), affective responsiveness (0.59), affective involvement (0.55), and behavior control (0.45). In a regression analysis where other variables were controlled, Nealer found that parents with elevated abuse scores still had significantly less healthy family functioning. However, Nealer failed to find an expected relationship between abuse scores and level of family functioning in the family of origin. Although there are inconsistencies, Kolko

et al. (1993),

Lamphear

the data reported

et al. (1985),

Mollerstrom

by Chan and Perry et al. (1992),

(1981),

and Nealer

(1992) indicate that the abuse scale is correlated with family conflict as well as the lack of positive factors, such as family cohesion. These results are congruent with previously discussed findings on social support, which indicated an inverse relationship between social support measures, which often include family support, and abuse scores.

Attachment. Although abusers

not clearly established, it has been suggested that physical child display inadequate mother-child bonding (attachment) during the first year

of their children’s lives (see Tzeng, Jackson, & Karlson, 1991, for a review). Thus, it might be expected that problems with attachment would be associated with CAP abuse scores. Mee (1983) used the Interview Schedule for Social Interaction to study the adequacy of attachment, adequacy of social integration, availability of attachment, and availability of social integration in a group of abusing and nonabusing Australian mothers who had taken the CAP Inventory. Although the examination of abuse scores

561

Assessing Physical Child Abuse Risk

in a heterogeneous that associations

group of abusers can be found,

high- and low-scoring To further

mothers

evaluate

of attachment

and nonabusers

on the four attachment

the attachment

for individual of attachment,

enhance

between

analyzed four derived profiles

in the high- and low-abuse

whereas

the likelihood

differences

measures.

data, Mee (1983)

subjects

this analysis, Mee found that 89% of the low-scoring high adequacy

should

Mee did not find any significant

mothers

potential

groups.

had high availability

only 38% of the high-scoring

mothers

In and

had this

“favored” profile. using welldefined

Whereas the results of this second analysis are encouraging, research models and measures of attachment are needed to explore the pos-

sible relationship

between

attachment

and abuse scores.

Psychophysiological Factors Knutson

(1978)

proposed

that physical

child

abusers

possess

a hyperreactive

trait;

whereas, Bauer and Twentyman (1985) have suggested that abusers may be hyperresponsive to child-related stimuli. Four studies have examined physically abusive parents’ psychophysiological reactivity to child-related stimuli (Disbrow, Doerr, & Caulfield, 1977; Friedrich, Tyler, & Clark, 1985; Frodi & Lamb, 1980; Wolfe, Fairbanks, Kelly, & Bradlyn, 1983). In a review and critique of these articles, McCanne and Milner (1991) noted that, despite inconsistencies in study results, there appears to be consensus that physical child abusers, compared to nonabusers, show more auto nomic reactivity to both crying and smiling children. Consequently, studies have been conducted to determine if elevated CAP abuse scores are associated with increases in psychophysiological reactivity to child-related stimuli. Pruitt and Erickson (1985) used the CAP Inventory to form high- and low-risk groups to study the association between abuse scores and physiological reactivity. As in the studies that used physical child abusers (e.g., Frodi & Lamb, 1980), high- and low-risk participants viewed videotapes of a smiling, crying, or quiescent infant and physiological measures were taken. To reduce the role of prior experience with children, all subjects were adults who were or had been married but were childless. The use of childless adults is important because some authors (e.g., Frodi 8c Lamb, 1980) have suggested that child-related stimuli become aversive and arousing for physical child abusers because of the parent’s prior experience with a difftcult child. Pruitt and Erickson (1985) reported that adults with elevated abuse scores, compared to adults with low scores, showed more reactivity (i.e., higher peak heart rate and skin conductance) when viewing a smiling and crying infant. Although Pruitt and Erickson

may have

misinterpreted

their

skin conductance

data

(see

McCanne

&

Milner, 1991, for a discussion), subjects’ self-report measures of feelings experienced during the videotapes (Pruitt, 1983) supported the heart rate data, indicating that the high-scoring adults were more distressed. The authors concluded that the high-scoring adults were more aroused and defensive in response to the infant tapes regardless of the infant’s affective state. As mentioned, these results were found in subjects before

they had experiences

with their own children.

Thus, not only do these findings

support the construct validity of the CAP abuse scale, but the data suggest that, in some cases at least, parents enter the parent-child relationship with a greater likelihood of autonomic reactivity to child-related stimuli. In another study of psychophysiological Zeskind (1992) formed high- and low-abuse from an undergraduate were measured during

reactivity to infant cries, Crowe and potential groups, using subjects selected

subject pool. Participants’ audiotaped presentations

heart rate and skin conductance of four “normal” phonated infant

562

J. S M&w

cries and four high-pitched, hyperphonated infant cries. Whereas no group differences in heart rate were found during baseline, subjects with high abuse scores, compared

to those

with low abuse

response

to the phonated

observed

for skin conductance.

hyperphonated following from

conditions,

hyperphonated during

cries.

showed Similar

Although

the authors cries

the highly aversive nature

ferences

scores,

infant

“marginally” trends

group differences suggested

may be due

heart

in

were

were not observed

in the

to ceiling-effects

differences

in reactivity

cries.

Despite

cries, Crowe and Zeskind

the responses of the high-scoring subjects to the phonated responses of physically abusive parents reported in previous

rates

differences

that the lack of group

of the hyperphonated

the hyperphonated

higher

toward group

(1992)

resulting

the lack of difconcluded

that

cries were similar to the studies. It is important to

note that Crowe and Zeskind used undergraduate students, who appeared to consist primarily of single, unmarried individuals in their late teens. Because the CAP Inventory was not designed for use with this population, the findings of even limited psychophysiological differences in high- and low-scoring students warrant follow-up. There are few data on the psychophysiological reactivity of physically abusive parents to stressful nonchild-related stimuli, albeit Friedrich et al. (1985) studied physicaIly abusive, neglectful, and comparison parents and reported differential skin conductance changes in response to a noxious tone and to white noise. To examine the relationship between elevated abuse scores and parental psychophysiological reactivity to stressful nonchild-related stimuli, Casanova, Domanic, McCanne, and Mimer (1992) studied the reactivity of matched groups of high- and low-risk mothers (where risk was determined by CAP abuse scores) to four stressful non~hild-related stimuli. The stimuli included: a cold pressor, a film depicting industrial accidents, unsolvable anagrams, and an aversive car horn. High-risk mothers, compared to low-risk mothers, showed greater and more prolonged skin conductance changes in response to the two most stressful (as rated by the mothers) nonchild-related stimuli (i.e., the cold pressor and the film). Finally, Hager (1987) measured psychophysiological responses during the presentation of videotapes showing positive, negative, and abusive interactions. Although skin conductance data were not available, overall changes in heart rate between baseline and presentation of stimuli were signiIicantIy correlated (-0.42) with abuse scores. Furthermore, Hager reported a number of significant facial measures (EMG) and abuse scores, with the strongest changes in frontalis muscle activity and elevated abuse scores.

correlations association

between between

Collectively, psychophysioIogica1 studies involving the CAP Inventory report data that are consistent with the results of similar studies conducted on physical child abusers. That is, groups with elevated CAP abuse scores, like identified physical child

abusers,

nonchild-related

appear

to be more

stimuli.

These

physiologically

findings

reactive

are congruent

to both

child-related

with proposals

and

that abusive

parents possess a hyperreactive trait (Knutson, 1978), and suggest that at-risk parents, as defined by the CAP Inventory, also possess a hyperreactive trait. Cognitive

and Affective

&y&em

mzd ego-q.

Factors Clinical

and empirical

reports consistently

indicate

that phys-

ical child abusers have relatively low levels of seffesteem and ego-strength (e.g., Anderson & Lauderdale, 1982; Milner, 1988; Steele, 1987). Selfesteem may be an important factor in child abuse because low self-esteem has been related to negative perceptions of children (e.g., Mash, Johnston, & Kovitz, 1983) and to an inability to deal with

Assessing Physical Child Abuse Risk

563

stress (e.g., McCubbin, Cauble, & Patterson, 1982). These latter factors have been mentioned as important in models of physical child abuse (e.g., Milner, 1993) and in the empirical literature on physical child abuse (e.g., Milner & Chilamkurti, 1991). Thus, low selfesteem and ego-strength should be substantially related to abuse potential. Using college students, Chan and Perry (1981) found a significant inverse relationship (-0.73) between self-esteem, as measured by the Tennessee Self-Concept Scale (TSCS), and CAP abuse scores. Chan and Perry indicated that individuals who score low on the TSCS tend to lack self-confidence, feel little personal worth, and have a poor self image. In another study using college students, Robertson and Milner (1983) reported a significant inverse relationship (-0.61) between Barron’s egostrength scale, a special scale of the MMPI, and the CAP abuse scale. Robertson and Milner pointed out that individuals who score low on Barron’s scale tend to demonstrate less personal adaptability and resourcefulness. Robertson and Milner (1985) also reported a significant inverse relationship (-0.43) between the Sixteen Personality Factor (16PF) stability scale, also known as an ego-strength scale, and abuse scores. Robitaille, Jones, Gold, Robertson, and Milner (1985)) using a student group and a parent group, found a significant relationship in each group (0.27 and 0.47) between the Edwards Personal Preference Schedule abasement scale and CAP abuse scores. According to Edwards (1959), abasement scores are associated with several factors including low self-esteem. Leak and Langholdt (cited in Milner, 1986a), using undergraduate students, found a significant inverse relationship (-0.66) between Rosenberg’s measure of selfesteem and abuse scores. Whissell et al. (1990), using young female adult nonparents, reported a significant inverse relationship (-0.57) between the Interpersonal Support Evaluation Scale measure of selfesteem and CAP abuse scores. Finally, Fulton, Murphy, and Anderson (1991) studied a group of adolescent mothers receiving a parenting pro gram. At pretreatment testing, a significant inverse relationship (-0.58) was found between Coopersmith’s Self-Esteem Inventory (SEI) and the abuse scale. At posttreatment, a significant inverse association (-0.75) was also found between the SE1 and the abuse scale. Although self-esteem and egostrength are complex constructs, which limits their meaningfulness, the studies that have investigated relationships between these constructs and abuse scores provide findings that are both uniform and robust. Life stm.ss/distress. In addition to physiological reactivity, perceived stress and selfreports of personal distress are frequently mentioned as important factors in etiological models of physical child abuse (e.g., Azar, 1986, 1989; Milner, 1993; Wolfe, 1987). Perceived stress and associated distress, which may have a variety of mediating effects (e.g., Milner, 1993), are thought to increase the likelihood that parents will react to children’s behavior with verbal and physical aggression. Because stress is thought to precede aggressive behavior, investigators have explored the relationship between stress and CAP abuse scores in nonabusive groups. Burge (1982) studied a male military sample and reported a significant relationship (0.48) between the Schedule of Recent Events (Holmes & Rahe, 1967), a general stress measure, and the CAP abuse scale. Using a different measure of stress, the Hassles and Uplifts Scale (Eanner, Coyne, Schaefer, & Lazarus, 1981), Mee (1983) examined the relationship between stress and abuse scores in a group of Australian mothers (abusers and nonabusers). Mee reported that while mothers with low abuse scores listed a variety of hassles, no item was mentioned by more than 50% of the mothers. In contrast, approximately 60% of the mothers with elevated abuse scores

expressed concerns about being overloaded with family problems, having trouble relaxing, not sleeping enough, and being too far from refatives and friends. Mothers with elevated scores also expressed more concerns abaut money, even though these mothers were not significantly different from the iow-scoring mothers on variables such as income, age, educational level, and number of children. In addition, Mee found that mothers with elevated abuse scores reported significantly fewer uplifts. Consequently, Mee reported that the most marked differences between the high- and low-scoring mothers was in the ratio of hassles to uplifts. In a study using a measure of psychological distress from the Mental Health Index, Milner, Charlesworth, Cold, Cold, and Friesen (1988) found, in groups of undergraduate students (n = 14’7) and prison inmates (n = 1681, signi~cant relationships (0.70 and 0.76) between psychological distress and abuse scores. Whereas the data showing the expected relationships between life stress and personal distress measures and abuse scores provide support for the construct validity of the CAP abuse scale, the data can be criticized for being nonspecific. For example, Grisso (1986), in a review of the CAP Inventory, concluded that additional construct validity data were needed to demonstrate that the abuse scale is not merely a measure of general life stress. Several authors have provided data on this issue. For example, Talbott (cited in Milner, 1986a) administered the Parenting Stress Index (PSI; Abidin, 1983) and the CAP Inventory to a group of neglectful, emotionalIy abusive, and physically abusive parents. In addition to providing a total stress score, the PSI was designed to measure three separate domains of stressors: parentrelated stressors, chiId-related stressors, and life-stress outside of the parent-child relationship. Overall, there was a significant relationship (0.62) between the PSI total scores and CXP abuse scores. A significant relationship (0.69) was observed between parent stress total scores and abuse scores, and a significant relationship (0.44) was observed between child stress total scores and abuse scores. However, no significant relationship (-0.02) was observed between general life stress scores (stress outside of the parent and child domains) and abuse scores. Holden et al. (1989) also administered the PSI and the CAP Inventory to a mixed group of chiId maltreating and nonmaltreating parents and reported significant relationships between the parent and child domain scores and the abuse scale. Unfortunately, Holden et al. only indicated that significant correlations were found on 13 of the 16 PSI scales and did not provide data indicating which scales failed to achieve significance. Although general life stress was not assessed, Kolko et al. (1993) found that mothers scoring above the abuse scale cutoff reported a “significantly greater number of current, but not past, stressful life events” (p. 182) on the Children’s Life Events Inventory, indicating relatively high Ievels of child-related stress. Milner (1991b) noted the need for additional data indicating that the CAP abuse scale is not merely a measure of general life stress and studied the extent to which the abuse scale specificity was impacted by medical conditions thought to be stressful. Using a group of parents (n = 1,151) who presented at a hospital with personal or child-related medical conditions, Mimer found that classification rates were not impacted by child birth (i.e., vaginal delivery with or without complications, n = 432, and planned or emergency C-sections, rr = 2691, indicating that the stress refated to child detivery did not affect the abuse scale specificity. However, the data obtained from parents (n = 450) with children who were brought to the hospital with different types of illness and injury were mure variable, For these parents, there was a modest increase in abuse scores and a related reduction in abuse scale specificity. In these cases, it remains to be determined if the increases in abuse scores reported by Milner

Assessing Physical Child Abuse Risk

565

(1991b) were due to the reactivity of the abuse scale to the stress of having a child with a medical problem or if the increase was due to the abuse scale correctly classifying undetected cases of physical child abuse. Nevertheless, the abuse scale specificity data obtained from mothers of newborns reported by Milner (1991b) support the view that the abuse scale is not merely a general stress measure because there were no elevations in the abuse scores in these sub jects. These data are also consistent with the previously discussed self-report data obtained on the PSI, which indicated that parent-related and child-related stress are associated with abuse scores, but life stress that does not include specific parent and child-related stress is not correlated with abuse scores. Collectively, these data support the view that the abuse scale is not merely a measure of general life stress but rather a measure of stress or distress that is related to the parentchild interaction. Knowledgieof chti deuelopnen Some authors have indicated that physical child abusers lack adequate knowledge of child development (see, e.g., Milner & Chilamkurti, 1991), while others (e.g., Azar, Robinson, Hekimian, & Twentyman, 1984) have failed to find differences between maltreating and comparison parents’ knowledge of develop mental milestones. Given that some evidence exists for a relationship between knowledge of child development and child abuse, the degree to which an individual’s knowledge of child development is related to CAP abuse scores has been investigated. Whissell et al. (1990)) using young female adult nonparents, reported a significant but modest inverse relationship (-0.16) between child development scores, as measured by the Understanding and Knowledge of Child Development scale, and abuse scores. Likewise, Fulton et al. (1991)) using a group of adolescent mothers, found that scores on the Knowledge Inventory of Child Development and Behavior were significantly, but modestly, inversely correlated (-0.26) with abuse scores during pretreatment testing in a program evaluation. A nonsignificant, but slightly larger, inverse relationship (-0.31) was found between child development knowledge and abuse scores during posttreatment testing. A lack of significance in this latter association may have been due to insufficient power because of subject attrition at the posttreatment testing. Finally, Osborne, Williams, Rappaport, and Tuma (1986) failed to find a significant relationship between the Parental Knowledge of Child Developmental Norms and abuse scores in a group of undergraduate students. Given these inconsistent findings, additional data are needed to determine if there is any meaningful relationship between knowledge of child development and abuse scores. Pemepeionsof childwzn’sbehavior. Research indicates that abusive parents, compared to nonabusive parents, view their children as exhibiting more problem behaviors (e.g., WoodShuman 8c Cone, 1986). It is interesting to note that, in several studies where these results were reported, independent observers of children’s behavior did not confirm the differences reported by the abusive mothers (e.g., Mash et al., 1983; Reid, Ravanagh, 8c Baldwin, 198’7). Because abusive parents appear to perceive more childrelated behavior problems, several investigators have explored the relationship between parents’ views of their children’s behavior and abuse scores. Stringer (1982/1983) used the Revised Behavior Problem Checklist (RBPC) to explore the relationship between child behavior problems reported by a group of primarily unmarried Black mothers who earned low abuse scores and a similar group earning high abuse scores. As expected, elevated abuse scores were associated with the total number of child-related problems reported by mothers on the RBPC. Mothers with high abuse scores also rated their children as displaying more problems

J. S. Milner

566

on each of the RBPC subscales. However, between

mothers’

no significant

ratings of child behavior

problems

relationships

were found

and an independent

rater’s

assessment of child compliance. Congruent with the findings of Stringer (1982/1983), Aragona (1983) reported that mothers with elevated abuse scores who were suspected or confirmed for physical child abuse, compared abuse, reported

to mothers with low abuse scores and no known history of

significantly

more

child

problems

and problem

intensity

on the

Eyberg Child Behavior Inventory (ECBI). Atagona also reported that the high scoring mothers had ECBI scores that were similar to ECBI scores obtained from a sample of abusive subjects (Wolfe, Sandier, & Kaufman, 1981). Supporting the observations of Stringer, Aragona did not find significant differences in child compliance to maternal indirect or direct demands across groups. Thus, although group differences in child compliance were not found, both Stringer (1982/1983) and Aragona (1983) reported that high abuse scoring parents perceived more child behavior problems. Kolko et al. (1993) reported that mothers scoring above the abuse scale cutoff, compared to low-scoring mothers, described their children as “exhibiting more fighting, covert antisocial behavior, and self-injury” (p. 179) (Interview for Antisocial Behavior). Mothers scoring above the cutoff also reported more emotional reactivity, activity, and impulsivity (Emotional&y, Activity, Sociability, and Impulsivity-Temperament Scale) and higher levels of externalizing and internalizing behavior (Child Behavior Checklist) in their children. Collectively, results from studies using the abuse scale are congruent with the findings reported in studies using physical child abusers and suggest that respondents with high abuse scores appear to perceive more child behavior problems. As with physical child abusers, however, additional research is needed using independent observers to determine the degree that the child behavior problems are perceived and/or

real.

Evcduuti of &ildrum’s behavior As part of a social information processing model, Milner (1993) has proposed that physical child abusers make different evaluations of their children’s behavior (i.e., evaluate children’s transgressions as more wrong and more blameworthy) and that these evaluations precede abusive behavior. Chilamkurti and Milner (1993) studied the evaluations of children’s transgressions (moral, conventional, personal) and parental disciplinary actions (power assertion, love withdrawal, induction) in high- and low-risk mothers and their children where risk status was determined by scores on the CAP abuse scale. Although no group differences were found for evaluations of moral transgressions, high-risk mothers, compared to low-risk mothers,

evaluated

children’s

conventional

and personal

transgressions

as

more wrong. Thus, differences in parental evaluations of children’s behavior, as predicted by a social information processing model, were found to be associated with risk status as defined by the CAP Inventory. Attributims regarding children’s behtwior. Although data are not consistent with respect to specific attributional differences between abusive and nonabusive parents (Milner, 1993), researchers have investigated the relationship between locus of control measures and the CAP physical abuse scale. Ellis and Milner (1981), using a mixed group of at-risk and general population parents (n = 78), found a significant relationship (0.44) between a measure of external control (Rotter Internal-External Control Scale) and abuse scores, Stringer and La Greta (1985) replicated and extended the findings of Ellis and Milner (1981). Using a group of low SES mothers, Stringer and

Assessing Physical Child Abuse Risk

567

La Greta found a significant relationship between Levenson’s Locus of Control Scales and the abuse scale. For mothers of sons, there were significant correlations between external control by powerful others (0.66) and by chance factors (0.44) and abuse scores. For mothers of daughters, there were significant correlations between external control by powerful others (0.44) and by chance factors (0.45) and abuse scores. The finding that an external locus of control is associated with abuse scores is important because external individuals, compared to internal individuals, have been described as incompetent, anxious, and distressed (Lefcourt, 1976); characteristics that have been associated with physical child abuse. Furthermore, Phares (1976) has indicated that the antecedents of externality include parental behavior such as “rejection, hostile control, lack of warmth, withdrawal,* and inconsistent in the individual’s family of origin. To the extent that these characteristics covary with a chiidhood history of abuse, they may be related to the previously discussed relationship between a childhood history of abuse and CAP abuse scores. This possibility needs additional exploration. Milner and Foody (1993) studied attributions for positive and negative children’s behavior made by subjects with high and low abuse scores. Although no group differences in attributions were found, the group with low abuse scores, but not the group with high abuse scores, showed a change in their attributions (toward unstable and unintentional) when they were presented with mitigating information related to children’s behavior. These findings indicate that those with elevated abuse scores are less likely to change their views of a child’s responsibili~ for behavior when information is available that mitigates children’s responsibility. These att~butional data combined with the previously reported data, which indicate that abuse scores are related to differences in parental perceptions and evaluations of children’s behavior, suggest that CAP abuse scores are associated with several types of cognitive activities that are believed to be related to physical child abuse. Authoriti&. In a summary of the literature, Robitaille et al. (1985) noted that authoritarian individuals have been described as rigidly conforming to social norms, as behaving in a controlled manner, as supporting punitive measures, and as demanding submission from others. Because each of these factors appear to be similar to characteristics used to describe physical child abusers, Robitailie et al. investigated the relationship between an authoritarian measure, the Public Opinion Scale (POS), and abuse scores in college student and parent groups. However, no significant correlations were found between the POS measure and abuse scores in either the student (-0.02) or the parent (0.18) group. Bardua (1987) explored the relationship between the POS and abuse scores in neglectful, physically abusive, and comparison parents in England. POS and abuse score correlations calculated for each group failed to reveal any significant correlations; the largest correlation being 0.17 for the comparison parents. However, when Bardua combined all three study groups, the POS and abuse scores were significantly correlated (0.50). These results suggest that within each group (maltreating and comparison), there was homogeneity of test scores, but between groups there were differences in the range of scores so that the combination of groups resulted in a significant correlation. Supporting Bardua’s (1987) report of a relationship between abuse scores and authoritarian attitudes, Whissell et al. (1990) reported that abuse scores were significantly correlated with the need for control/obedience and the use of volatile punishment in a group of young female adult nonparents. These results led Whissell et al.

568

J. S. Milner

to conclude

that respondents

itarian approaches

ducted thus far, additional and authoritarianism

with elevated abuse scores tended to agree “with author-

to discipline”

(p. 204). Given the modest findings in studies con-

research exploring

the relationship

between

abuse scores

is needed.

Negative affect. Although

the extent to which affective states are marker or causal fac-

tors in physical child abuse is unclear, there are several negative affective states that appear to be adult risk factors for physical child abuse (e.g., see Milner & Chilamkurti, 1991). These affective states include depression, anxiety, and anger. Almost without exception, studies have reported the expected relationships between measures of negative affect and CAP abuse scores. Matthews (1984/1985),

using a sample of abusive and comparison

parents, found a

significant relationship (0.60) between MMPI depression scores and CAP abuse scores. Robitaille et al. (1985)) using students, found a significant relationship (0.27) between the Edwards Personal Preference Schedule (EPPS) abasement factor and abuse scores. Edwards (1959), in the EPPS manual, indicated that those with elevated abasement scores feel depressed by their inability to handle life situations. Talbott (cited in Milner, 1986a), using maltreating and nonmaltreating parents, found a significant relationship (0.71) between the PSI subscale measuring parent depression and abuse scores. The parent depression scale is believed to measure feelings of guilt, unhappiness, and depression. Kirkham et al. (1986)) studying mothers of handicapped children, reported a significant correlation (0.71) between the Beck Depression Inventory (BDI) and the CAP abuse scale. Nealer (1992)) using a group of male and female atrisk parents, also found a significant association (0.68) between BDI scores and abuse scores. Milner et al. (1988)) employing undergraduate students and a prison sample, reported significant relationships (0.63 and 0.71 for students and prisoners) between the Mental Health Index (MHI) measure of depression and abuse scores. Using Spanish translations of the CAP Inventory and the BDI, Arruabarrena and de Paul (1992) found significant correlations between depression and abuse scores. The correlation was 0.87 for a maltreating group and 0.49 for a general population group. Although these data indicate that the CAP abuse scale is substantially related to depression, depression is a complex construct and is associated with a number of personal characteristics. Supporting this view, Milner et al. (1988) found that when the MHI depression measure was entered into a regression analysis with other MHI measures, the MHI loss of behavioral/emotional control factor emerged as the factor accounting for most of the variance (47%) with the depression factor accounting for only a modest portion of the variance (3%) after the loss of control factor was removed. With respect to anxiety, Pruitt (1983) concluded that respondents with elevated abuse scores were extremely responsive to anxiety-evoking and threatening situations. Robertson and Milner (1985) f ound a significant relationship (0.49) between the 16PF questionnaire anxiety factor and abuse scores. Similarly, significant relationships were found between the 16PF apprehension and tension factors and abuse scores. Supporting the Robertson and Milner (1985) findings, Ellis (cited in Milner, 1986a) found a significant relationship (0.49) betw een the 16PF anxiety factor and abuse (0.60) scores. In addition, Mimer et al. (1988) f ound a significant relationship between the MHI anxiety scores and abuse scores. Aragona (1983), using the State-Trait Personality Inventory (STPI), found that mothers with elevated abuse scores, compared to mothers with low abuse scores, had significantly higher trait anxiety and trait anger across all situations studied. Only trends toward group differences in state anxiety were observed. With regard to state

569

Assessing Physical Child Abuse Risk

anger, the degree

of state anger in the high-scoring

mothers varied as a function

the situation studied. That is, mothers with high abuse scores, compared ing mothers, children;

did not show differences

after nondirectional

interactions

of

to low-scorwith their

but mothers with high abuse scores did show a signiftcant increase in state

anger after parent-directed interactions with their children. Talbott (cited in Milner, 1986a) also reported that trait and state anxiety were significantly correlated (0.61 and 0.70, respectively)

with abuse scores.

Studies have provided information on the relationship between other aspects of a respondent’s negative affectivity and abuse scores. Haskett et al. (1994) reported that while an adolescent’s feelings regarding the acceptance of pregnancy were not significantly correlated (0.09) with abuse scores before delivery, the adolescent’s feelings about

pregnancy

(degree

of acceptance)

were

significantly

inversely

correlated

(-0.64) with abuse scores following pregnancy. Using a variety of measures, Pruitt (1983) concluded that those with elevated abuse scores tended to be moody, touchy, emotionally labile, overreactive, restless, and aggressive. Based on correlations with MMPI scales, Matthews (1984/1985) reported that those with elevated abuse scores could be described as immature, emotionally unstable, lacking in frustration tolerance, irritable, having poor impulse control, prone to temper outbursts, aggressive, and assaultive. Using the 16PF, Robertson and Milner (1985) reported that individuals with elevated abuse scores were immature, emotionally unstable, and had a low frustration tolerance. Hager (1987) reported that abuse scores were significantly correlated with feelings of “anger with contempt or disgust” in subjects responding to positive, negative, and abusive interactions. Likewise, Milner et al. (1988) reported MHI correlations with the abuse scale, which indicated that highscoring respondents tended to be easily upset, unstable, emotional, and “likely to fight.” Kolko et al. (1993) found that mothers with abuse scores above the cutoff, compared to mothers with low abuse scores, reported more psychological dysfunction on the Hopkins Symptom Checklist-90. Finally, Milner, Halsey, and Fultz (1994) reported that high-scoring mothers reported more sadness, distress, hostility, unhappiness, and less feelings of quietness following a presentation of a crying child video. Milner et al. (1994) also provided some evidence for the presence of emotional contagion (mirroring the child’s affective state) in mothers with high abuse scores. Collectively, investigators describe results that indicate a substantial relationship between negative affect and physical child abuse scores. The findings support previously reviewed reports of increased physiological reactivity and distress in abusive and at-risk subjects. Furthermore, the data are consistent with general models of aggression that posit a major role for affect in mediating

aggressive behavior

(e.g., cognitive-

neoassociationistic model, Berkowitz, 1990) and specific cognitive/behavioral models of physical child abuse (Milner, 1993), where affective states are thought to interfere with information processing activities. Behavioral

Factors

Akohol ad drug use. The role of alcohol and drug use in physical child abuse has been widely debated (see Milner & Chilamkurti, 1991). In a review of the child abuse literature involving alcohol use, Leonard and Jacob (1988) concluded that if alcohol use or alcoholism is related to child abuse “it will not account for major portions of variance in child abuse” (p. 387). Little information is available on the possible associations between alcohol and drug use. and CAP abuse scores. One self-report study (Herrick, 1982), which investigated the association between alcohol use and abuse scores in a

570

J. S. Milner

group of single mothers, press)

found

nificantly

found

that a group

higher

no significant

of drug-abusing

relationship.

mothers,

In contrast,

compared

abuse scores in testing which was conducted

Black et al. (in

to norm

data, had sig-

prior to a treatment

pro

gram. However, it is not clear to what extent this finding was due to the drug use or to other factors (third variables) correlated with both drug use and CAP abuse scores. ASS~&W?WSS ski&

Clinical

observations

suggest

that

physical

child

abusers

often

exhibit explosive aggression and are not appropriately assertive. Using an Assertion Inventory, Mee (1983) investigated assertiveness skills in high- and low-scoring (CAP abuse scale) Australian mothers, ed that 62% of the high-scoring

some of whom were identified abusers. Mee reportmothers were classified as unassertive, whereas only

22% of the low-scoring mothers appeared to be unassertive. In contrast, only 25% of the high-scoring mothers were classified as appropriately assertive, while 56% of the low-scoring mothers were classified as appropriately assertive. For the high-scoring mothers who were previously identified child abusers, none were classified as appropriately

assertive

whereas

83% were classified

Pamnt-child interactions. Numerous

studies

as unassertive. report

that

physically

abusive

parents,

compared to nonabusive parents, are less responsive to their children’s behavior (see Mimer & Chil~kurti, 1991, for a review). Amgona (1983) studied parent-child interactions in groups of high- and low-scoring (CAP abuse scale) mothers. Aragona observed that high-scoring mothers, compared to low-scoring mothers, were less responsive to their children’s behavior in unstructured interactions. Furthermore, across structured and unstructured play situations, high-scoring mothers displayed more rigid interactional styles with their children. Kolko et al. (1993) found that mothers scoring above the abuse scale cutoff, compared to low-scoring mothers, exhibited less child centeredness and showed less general acceptance of their children, as measured by the Child Rearing Interview and the Parenting Behavior Inventory (PBI). Kolko et al. also found that high-scoring mothers reported significantly greater use of psychological control strategies with their children, as measured by the FBI. At the same time, the children of the high-scoring mothers reported that their mothers provided less enforcement of home rules. Hann (1989), using a group of mothers of 3 to 6-month old infants, failed to find a significant association (-6.04) between social responsiveness to infants and CAP abuse scores. However, in an analysis where abuse scores and other stress and social support measures were used to form support-stress groups, Hann (1989) reported a significant linear trend (r = 0.34) across the groups in social responsiveness, where social responsiveness increased as stress decreased and support increased. Based on these findings, Hann concluded that when abuse scores are combined with other stress and support measures, the combinations are related to social responsiveness. In other research on parenting behavior and stress, Schellenbach and associates (Monroe & Schellenbach, 1989; Schellenbach, Monroe, & Merluzzi, 1991) found that parents’ abuse scores were significantly associated (0.72) with rejection of their children Furthermore, Schellenbach et al. found that for those with elevated abuse scores, stress increased the magnitude of the parental rejection. This finding, which indicates that parents with elevated abuse scores exhibit more aversive parenting behavior when stressed, warrants additional study. have been Pammtd~p~~~ SErategies, Phys ical child abusers, compared to nonabusers, observed to use harsher disciplinary strategies and less praise and rewards with their

571

Assessing Physical Child Abuse Risk

1984; Burgess & Conger, 1978; Kavanagh, children (e.g., Bousha dc Twentyman, Youngblade, Reid, & Fagot, 1988). Whereas belief in the value of punishment, as measured on the Adult-Adolescent

Parenting

Inventory

@API),

was not significantly

cor-

related with abuse scores (Haskett et al., 1994), Stringer (1982/1983) reported that mothers with high abuse scores, compared to those with low abuse scores, reported “more strong methods of physical discipline (e.g., rod or belt) .” Aragona (1983) reported that mothers

with elevated abuse scores used significantly

more criticism

and tend-

ed to use less praise than mothers with low abuse scores. Schellenbach and associates (Monroe & Schellenbach, 1989; Schellenbach et al., 1991) found that parents’ abuse scores were significantly correlated with parental need to control (0.50) and to punish (0.60) children. Whissell et al. (1990), using a group of young female nonparents, found that abuse scores were significantly associated with a need for control/obedience and the volatile use of punishment (i.e., “swift retribution”). Chilamkurti and Milner (1993) reported that during discipline high-risk mothers, compared to low-risk mothers (defined by the CAP Inventory), used power assertion (verbal and physical force) more often and induction (reasoning and explanation) less often with their children. Osborne et al. (1986)) using undergraduate students, reported that those with elevated abuse scores, compared to low-scoring individuals, had less “understanding of behavioral principles as they relate to children,” albeit there were no reported differences in beliefs about child management and guidance. The latter finding is similar to the report by Haskett et al. (1994) that a belief in the value of punishment was not correlated with abuse scores. Congruent with previously discussed studies indicating that highscoring individuals are more reactive to stress, Schellenbach et al. (1991) reported that stress increased the magnitude of the relationships between abuse scores and the need to control and punish children. In terms of construct validity, studies reporting associations between the use of aversive disciplinary strategies and abuse scores are important because these are the parenting designed to predict.

behaviors

that the CAP physical

abuse

scale was

Co@% skiUs. Although there is scant literature on general coping and problemsolving deficits in physically abusive parents, the view that physical child abusers may have general coping deficits has been speculated (see Hansen, Pallotta, Tishelman, Conaway, & MacMillan, 1989, for a review) and recently a comprehensive stress and coping model of child maltreatment has been proposed (Hillson & Kuiper, in press). The view that abusers lack coping skills is also congruent with previously reviewed studies indicating that abusers and at-risk parents have lower levels of self-esteem, are more reactive Consequently,

to stress, and feel less effective in their ability to cope with life stress. the possibility of a relationship between coping skills and abuse scores

has received some attention. Mee (1983), developed a brief coping measure for use in her study of coping in high- and low-scoring (CAP abuse scale) groups of abusing and nonabusing Australian mothers. No significant differences in the number of cop ing methods used was found. Mee did report that high-scoring mothers tended to report less perceived efficacy in their coping methods. In another attempt to show an association between coping and abuse scores, Pruitt (1983) administered the CAP abuse scale and the General Strategies Checklist, which is a self-report scale that purports to measure 15 coping strategies, to a group of adult nonparents. Pruitt found high-scoring (abuse scale) subjects differed significantly from low-scoring subjects on only two of the coping measures: the rational investigation coping strategy and the adopt a role/obedience/compliance coping strategy.

572

J. S. Milner

The

general

lack of an association

between

coping

strategies

and abuse

scores

in

the studies reported by Mee (1983) and Pruitt (1983) is surprising. However, the Mee coping scale was a brief measure with unknown psychometric qualities developed by Mee for use in her study. In the Pruitt

(1983)

study, high- and

low-scoring

(abuse

scale) groups were formed. These groups were composed of the upper and lower thirds of a general population sample, with most of the high-scores falling in the normal range

of abuse scores.

Given these limitations,

are inadequate to inform us about the possible strategies and abuse scores. Although it is clear appears

that research

ficult because

on the relationship

between

of the paucity of well-validated

it appears

that the existing

studies

relationship between general coping that additional studies are needed, it coping

coping

and abuse scores will be dif-

and parenting

measures.

PREDICTIVE VALIDITY Cuncurren t Pr~~~joff When

a measure

purports

to be a screening

scale for current

physical

child

abuse,

concurrent predictive validity data are needed to support this application. Although the demonstration of group differences (abusers vs. nonabusers) is important, evidence of group differences is not sufftcient to demonstrate concurrent predictive validity. Beyond the differentiation of groups, data on indi~dual classification rates (selectivity and specificity) and misclassification rates (false positives and false negatives) are needed (Milner, 198613). Initial classification rates reported for the abuse scale based on discriminant analysis for physical child abusers and matched comparison subjects were in the 90% range (e.g., Milner & Wimberley, 1980). In subsequent studies using discriminant analysis, where more diverse populations were examined, classification rates have been in the mid-80% to the low-90% range (e.g., Milner, Gold, & Wimberley, 1986, Milner & Robertson, 1989). Correct classification rates in the 90% range, again based on discriminant analysis, have also been reported for different Spanish translations of the abuse scale that were cross-validated on physical child abusers and matched comparison subjects in Spain (de Paul, 1988; de Paul et al., 1991) and in Argentina (Bringiotti, 1992). Although encouraging, the individual classification rates based on disc~minant analysis represent the upper limits of classification because such a procedure provides the optimal rates for each sample tested. Fortunately, several studies have reported abuse scale classification rates determined by the standard weighted scoring procedure. Milner (1989a) found that, prior to eliminating invalid protocols and using the 215point cutoff score described in the technical manual (Milner, 1986a), 73.8% of the physical child abusers, and 99.1% of the comparison parents were correctly classified, resulting in an overall classification rate of 86.4%. Slightly higher overall rates (88.5%)

were observed

when the alternate

based on signal detection theory physical child abusers and 99.0%

166point

cutoff

score

for an overall rate of 90.2%. Again, slightly higher overall correct (92.2%) were found when the 166point cutoff score was used. Using

the standard

scoring

was used, a cutoff

(Milner, 1986a). For valid protocols, 81.4% of the of the comparison parents were correctly classified

procedure,

the 215point

cutoff

classification

score,

rates

and all proto-

cols, Caliso and Milner (1992) reported that 87.7%, 73.3%, and 100% of their physical child abusers, with a childhood history of abuse, nonabusive comparison parents with a childhood history of abuse, and nonabusive comparison parents without a childhood history of abuse, were correctly classified. Using the alternate 166point cutoff score and all protocols, 96.7%, 60.07 O, and 83.3% of the physical child abusers

Assessing Physical Child Abuse Risk

573

with a childhood history of abuse, nonabusive comparison parents with a childhood history of abuse, and nonabusive comparison parents without a childhood history of abuse, were correctly classified. Because invalid protocols were not removed by Caliso and Milner, it is not known to what extent the classification rates might have been improved if only valid protocols were examined, as in the Milner (1989a) study. However, Caliso and Milner did report data which indicated that classification rates for nonabusive parents with a childhood history of abuse might be improved through the use of the abuse scale rigidity and unhappiness factor scales. Although there have been exceptions (e.g., Caliso 8c Milner, 1992), in most studies where the abuse scale classification rates have been determined for physical child abusers and matched comparison subjects, more false negative than false positive clas sifications have been observed. These outcomes tend to occur both in studies using discriminant analysis and in those using the standard weighted scoring procedure. Additional data are available on the abuse scale specificity based on the testing of a variety of nonabusing groups. For example, 100% correct classification rates have been reported for groups of low-risk mothers (Lamphear et al., 1985), nurturing mothers (Milner, 1986a, 1989a), and nurturing foster parents (Couron, 1981/1982). In a large-scale study (n = 1,151) on the effects of medical stressors on the abuse scale specificity, no distortions in the abuse scale classification rates were found in mothers with vaginal and C-section delivery, with and without complications (Milner, 1991b). However, some reduction in abuse scale specificity was observed when parents of children with certain types of child injury (e.g., severe burns) and illness (e.g., gastric problems) were tested. Although it is possible that some of the observed reductions in abuse scale specificity were due to undetected child abuse, the data on parents of children with medical injuries and illnesses suggest that the abuse scale specificity may be affected when a parent has a child with certain medical problems (Milner, 1991b). When abuse scale classification rates have been reported for maltreatment groups other than recently identified, nontreated physical child abusers, the correct classification rates have been lower. For example, testing a mixed group of child abusers and neglecters and a group of comparison parents, Couron (1981/1982) found a correct classification rate of 72.6% for the abuse scale. When a stress measure, demographic characteristics, and the abuse scale were combined in a discriminant analysis, the overall correct classification rate increased to 90.3%. One study has reported correct classification rates that were well below the rates reported by others for the abuse scale. When all protocols were used, Holden et al. (1989) reported a correct classification rate of 25% for a mixed group of sexually and physically abusive parents who were referred from a treatment group. When invalid protocols were removed, Holden et al. found a rate of 28% correct classifications for the mixed group. However, the abuse scale classification rate for the subgroup of physical child abusers was not reported. Furthermore, physical child abusers who have received treatment should not be included in a group to determine the concurrent predictive validity of the abuse scale because treatment has been shown to lower abuse scores (e.g., Milner, 1986a). Haddock and McQueen (1983) studied the abuse scale classification rates in institutional physical child abusers and matched nonabusive institutional employees. Using the abuse score, work satisfaction items, and demographic variables, a discriminant analysis correctly identified 92.9% of the abusive and nonabusive employees. Although these results appear encouraging, the correct classification rate for the abuse scale alone was not reported. Furthermore, Haddock and McQueen indicated that the groups were demographically matched on several variables, including

574

J, S. Milner

marital status. However, in the analysis, marital status was significantly predictive of group membership, suggesting that matching was not achieved on this variable. Matthews ~1984/1985) studied the abuse classification rates for “mildly” abusive and comparison parents. To provide a stringent test of the abuse scale validity, Matthews excluded moderate and severe physical child abusers. Furthermore, the comparison parents had children with emotional and behavioral problems. Finally, both abusers and nonabusers were already receiving treatment. Using a cut-off score developed from one-half of the study sample, Matthews (1984/1985) reported a correct classification rate of 72.7% for the abuse scale. Given that only mild abuse cases were included, that the comparison group had children with problems, that both groups were in treatment, and that a local sample cutoff was used, direct comparisons to other concurrent validity studies should be made with caution. What is apparent from the Matthews (1984/1985) study and the other studies where groups other than untreated, recently identified physical child abusers were used is that classification rates in these studies have been lower. Finally, several studies indicate that the abuse scale exhibits some ability to screen groups other than physically abusive parents. The abuse scale has been shown to detect parentai risk status (Milner & Ayoub, 1980), level of parental risk status (e.g., Ayoub, Jacewitz, Gold, & Milner, 1983; Monroe & Schellenbach, 1989), and level of care in day-care workers (Atten & Mimer, 1987), albeit these findings represent group, not individual, discrimination ability. Despite the substantial number of available studies indicating individual and group discrimination, more research on individual classification rates for different maltreating and risk groups is needed to fully understand the screening ability and limitations of the abuse scale. In addition, data on the screening of caretakers other than parents (e.g., daycare workers, big brothers/big sisters, etc.) are needed. Future Prediction

Beyond concurrent prediction, predictive validity data that describe the ability of the CAP abuse scale to forecast future events are needed. Two studies provide preliminary data on the ability of the CAP abuse scale to predict future child maltreatment by parents. Milner, Gold, Ayoub, and Jacewitz (1984) reported a prospective study, where a group (n = ZOO)of at-risk parents were tested at the beginning of a hospital based prevention program and followed across time to determine subsequent child maltreatment. Following the initial testing, 42 parents were reported and confirmed for child maltreatment: 11 for physical child abuse, 15 for child neglect, and 16 for failure-tothrive. A significant relationship (Cramer’s V = 0.34, omega squared = 0.32) was found between abuse scores and subsequent physical child abuse. A significant, but modest, relationship (Cramer’s V = 0.19) was found between abuse scores and later child neglect. No significant relationship (Cramer’s V = 0.12) was found between abuse scores and later occurrence of failure-to-thrive children. Milner et al. (1984) pointed out, however, that although all parents who later abused earned abuse scores above the abuse scale cutoff, the majority of subjects earning elevated pretreatment abuse scores did not abuse. Because parents were tested only during a pretreatment assessment, it might be assumed that some of the parents would have their abuse scores reduced by treatment (i.e., treatment successes), while others would not show change during treatment (i.e., treatment failures). Because posttreatment abuse scores were not collected, it was impossible to determine how many of the parents with elevated pretreatment abuse scores were actually treatment

Assessing Physical Child Abuse Risk

575

successes or were failures in test prediction of subsequent abuse. In addition, it is unlikeiy that all cases of subsequent abuse were identified. Despite the fact that Mimer et al. counted all subjects with elevated pretreatment abuse scores who later were not detected as abusive as failures in test prediction, a significant predictive relationship was found. Ayoub and Milner (1985) reported additional predictive validity data in a study that investigated descriptive factors associated with parents of failure-to-thrive children. Parents’ abuse scores were not associated with parents’ clinical ratings of failure&&rive factors, which is similar to the findings of Milner et al. (1984) who failed to find an association between abuse scores and later occurrence of failure-t-thrive cases. However, Ayoub and Milner (1985) did find that abuse scores were significantly associated with subsequent reports of child neglect in parents of failure-to-thrive children. Although the abuse scale was not designed to detect child neglect, the data from Milner et al. (1984) and Ayoub and Miiner (1985) suggest that in some situations elevated abuse scores are related to later child neglect. However, it is also possible that the neglect cases had concurrent undetected physical child abuse, which contributed to the observed association between abuse scores and child neglect. Although difficult and expensive to obtain, additional prospective data are needed to fully describe the abuse scale’s ability to forecast abuse and neglect. Not only are studies needed where at-risk groups not receiving treatment are tested and followed, but data are needed where testing follows treatment to determine rates of recidivism prediction. Finally, studies are needed that describe the predictive ability of the abuse scale with nonparent caretakers, such as the prospective studies reported by Townsend (1984) and Lipscomb (1989/1990) that attempt to predict child abuse by institutional caretakers. hcremental

Validity

Different types of incremental validity are described in the technical manual (Milner, 1986a). The degree of incremental validity provided by a test score is determined by the psychometric properties of the test and the base rates for the behavior in the pop ulation tested. Situations where base rams are appro~a~ly~/50 (e.g., ab~/nonabuse) are optimal for a test to provide incremental validity. Tests are not likely to provide substantial increments in predictive validity in situations where base rates are relatively low or high. With extremely low or high base rates, actuarial prediction will exceed individual test prediction. In these situations, single tests should not be used. The alternative approach is to use several tests in a multistage screening process, where base rates are raised at each screening stage. The technical manual (Milner, I986a) provides incremental validity estimates for both concurrent and future prediction of physical child abuse. To determine incremental validity estimates, data obtained from previous studies were used to calculate validity coefficients, where the CAP abuse scale was treated as a continuous variable and was correlated with an abuse/nonabuse criterion (Milner, 1986a). Incremental validity coefficients for valid protocols were 0.62 and 0.86 for concurrent prediction and 0.34 for future prediction. For additional understanding of the error reduction provided by the abuse scale, these validity coefftcients were used to determine coefftcients of alienation and associated indexes of forecasting efficiency (Milner, 1986a). The coefftcient of alienation and forecasting efficiency indexes were 0.787 and 21.3% and 0.510 and 49.02, respectively, for concurrent prediction. The coefficient of aiienation and forecasting efficiency index were 0.825 and 17.5% for future prediction.

576

J. S. Milner

Using the abuse scale as a dichotomous scale (rather than an interval scale) and abuse/nonabuse behavior as dichotomous outcomes, the incremental validity estimate lambda was calcufated (Milner, 1986b). Lambda is appropriate for use in estimating incremental validity where data are configured in a two by two contingency table (elevated and nonelevated abuse scores by actual abuse and nonabuse) representing the percentages of correct and incorrect classifications. Lambda was calculated only for the two concurrent validity studies because these two investigations were the only studies that included the necessary comparison subjects. Lambda’s for the two concurrent prediction studies for valid protocols were 0.83 in both cases. It is readily apparent that the lambdas were much higher than the previously reported incremental validity estimates. These results indicate that the abuse scale provides more incremental validity when it is used as a dichotomous scale (normal range/elevated range) rather than as an interval scale where each increment in abuse score is viewed as meanin~ul. Further, all estimates of incremental validity represent the upper limits of incremental validity. The estimates, which suggest there are substantial increases in predictive validity through use of the abuse scale, are based on data sets that are structured to provide optimal estimates. First, only valid protocols were used. Second, each of the concurrent validity studies used to determine incremental validity used discriminant analysis, which provides optimal classification rates. Third, and probably most important, the concurrent validity studies on which the incremental validity estimates were based used equal numbers of subjects (abusers/nonabusers, 50/50 base rate), which maximized the validity estimates. While subsequent research (e.g., Milner, 1989a) has demonstrated that the standard scoring procedure produces results only modestly below that obtained from discriminant analysis, the issue of base rates enhancing or maximizing the incremental validity estimate remains a critical concern. Specifically, as base rates vary from the ideal of 50/‘50, the incremental validity provided by the abuse scale will decline dramatically. Even the high incremental validity estimates reported here cannot adequately protect against low base rate problems. EVALUATION

OF TR~TMENT

AND PREVENTION PROGRAMS

The W abuse scale has been used successfully to evaluate a variety of tertiary and secondary prevention programs. Although most of the program evaluations have been in applied settings and have not resulted in journal publications, several reports are available. D’Agostino, Chapin, and Moore (1984) used the abuse scale to evaluate a multim~al, 9O-day intervention program for court-referred abusive and neglectful parents and reported a significant decrease across pre and posttrea~ent abuse scores. Talbott (cited in Milner, 1986b) used the abuse scale to evaluate an inhome treatment program that targeted male and female parents who were neglectful, emotionally abusive, and/or physically abusive. Like D’Agostino et al. (1984), Talbott found a significant decrease across pre and posttreatment abuse scores. In addition, the abuse scale is currently being used in a world-wide Air Force Family Advocacy program evaluation of interventions with physical child abusers (Mollerstrom, Mimer, & Patchner, 1992). Although the Air Force study is still underway, preliminary analyses indicated a significant decrease in pre and posttreatment abuse scores, and the abuse score decrease was maintained at a &month follow-up (Mollerstrom, 1993). Thomasson et a1. (1981) used the abuse scale to evaluate a l&session family-life education program for high-risk male and female rural parents. The program included communication skills training, parenting education, ancillary income support, and

577

Assessing Physical Child Abuse tik

small group discussions. Significant decreases across pre and posttreatment abuse scores were observed. Differences between pretreatment and follow-up abuse scores were also significant.

Supporting

most resistive to change,

clinical

Thomasson

reports

that severely abusive parents are the

et al. reported

that the abuse score decreases

were larger for parents with only moderately elevated pretreatment abuse scores relative to those parents with extremely elevated abuse scores. This contrasts with statistical expectations the mean artifacts.

that higher scores will show larger changes Barth

(1989)

used an abbreviated

because

of regression

to

version of the CAP abuse scale

to evaluate a task-oriented, home-based intervention program offered to high-risk families. Across a 6-month intervention period, Barth found a significant reduction in abuse scores. As part of their evaluation of a home inte~en~on program for drugabusing women, Black et al. (in press) found a significant decrease in the treatment group’s abuse scores between pretesting and testing conducted after 18 months. No significant abuse score changes were observed in a control group. It is interesting to note, however, that when Black et al. conducted additional multivariate analyses where infant birth weight, maternal education, and the faking-good CAP Inventory were used as covariates, the intervention and control differ in their pattern of scores over the intervention period.”

index from the groups “did not

Using young at-risk parents, Wolfe, Edwards, Manion, and Koverola (1988) reported that abuse scores significantly decreased between pretreatment and follow-up testing for a parent-training treatment group; whereas no significant change was observed for an information (control) group. Interestingly, Wolfe et al. found that the CAP Inventory distress scale was the only pretreatment measure that distin~ished parents who “never began treatment or left treatment” from those who remained in treatment. In a large scale evaluation of multisite, multi-intervention programs conducted by the NCPCA (1992), interventions produced significant decreases in abuse scores between pre- and post-treatment testing. Although there was sample shrinkage, additional significant abuse score decreases were observed at follow-up. In another analysis, after controlling for demographic and site differences, abuse score decreases were found to be significantly related to length in treatment. Similar to the data on drop outs reported by Wolfe et al. (1988), the NCPCA found that parents (n = 158) who dropped-out of treatment had significantly higher abuse scores than parents (n = 398) who completed treatment. However, these findings contrast with a report by Black et al. (in press) who conducted an evaluation of a home-based inte~ention for drugabusing mothers and did not find differences in abuse scores between subjects who completed their study and those who dropped-out. At present, it appears that additional data are needed on the utility of using the full abuse scale, as well as the abuse factor scales (distress, rigidity, unhappiness, problems with child and self, problems with family, and problems from others) to predict treatment dropouts. Using agency (e.g., county health referred adolescent mothers, Fulton treatment

decrease

department, et al. (1991)

in abuse scores resulting

public schools) referred and selfreported a significant pre-, post-

from a 4month

intervention

program

that provided child development and parenting skills training. Mollerstrom (1993) reported that an Air Force intervention program for high-risk mothers of newborns, which was implemented by nurses, produced significant reductions in abuse scores across the intervention period. Other applications of the abuse scale in clinical evaluations have been reported. For example, in a case study, Cox-Jones, Lubetsky, Fultz, and Kolko (1990) reported a reduction in the abuse score from an elevated range to a normal range between pre and posttreatment testing of a mother of a chronic fire setting youth. The abuse score reduction was maintained at a 3-month follow-up.

578

J. S. Milw

In summary, the CAP Inventory appears to have sufficient sensitivity to detect glob al treatment effects, when the intervention goal is to reduce participants’ risk for physical child abuse. information follow-up

However,

is needed abuse scores

WHAT

as mentioned

in the predictive

on the relationship and behavioral

between

outcomes

DOES THE CAP INVENTORY

validity section,

the observed

such as subsequent

additional

posttreatment

and

child abuse.

ABUSE SCALE MEASURE?

In conclusion, apart from the finding that the CAP Inventory has some ability to correctly classify physically abusive and comparison parents, what can be said about the meaning of elevated CAP Inventory abuse scores? Based on the literature reviewed, it is apparent that respondents with elevated abuse scores have an array of personal and interpersonal in identified physical child

characteristics that are similar to characteristics abusers. For example, those with elevated abuse

found scores

are likely to report the receipt and observation of childhood abuse and are less likely to report the existence of social support, such as a caring adult or caring friend in their early environment or in their adult environment. Those with elevated scores are also less likely to use community resources and may be less likely to accept or remain in treatment. Physiologically, respondents with elevated abuse scores appear to be hyper-reactive to both child-related and stressful nonchild-related stimuli. The psychophysiological data are supported by self-report data which indicate that high-scoring individuals report high levels of life stress and feelings of distress. High-scoring respondents appear to have low self-esteem and a poor self-image. Those with elevated abuse scores tend to be withdrawn and report less life satisfaction. Whereas they tend to dis play fewer appropriate assertiveness skills, those with high abuse scores appear to be depressed, anxious, and angry. They tend to have somatic complaints, report more physical illness, and are likely to have a history of emotional problems. Those with elevated abuse scores tend to have poorly developed cognitive skills, show evidence of confused thinking patterns, and report unique perceptions of the world. Persons with elevated abuse scores tend to have difficulty in interpersonal relationships including familial relations and they may manifest high levels of parent-child interactional stress. Relative to low scoring subjects, those with high abuse scores appear to be less available to their children and less responsive to temporal changes in their children’s behavior. Those with elevated abuse scores tend to perceive behavior problems in their children, evaluate their children’s minor transgressions as more Ywrong,n and use less praise and more verbal and physical assault as methods

of discipline.

Taken

together,

these personal

and interactional

characteris-

tics, that are related to elevated CAP abuse scores, are characteristics that are associated with problems in parent-child interactions and are risk factors that increase the likelihood

of both concurrent

and future

physical

abuse.

Preparation of this article was supported in part by National Institute of Mental Health Grant MH34252.

Acknowledgment

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