Child abuse and neglect

Aggression and Violent Behavior, Vol. 3, No. 2, pp. 181–196, 1998 Copyright  1998 Elsevier Science Ltd Printed in the USA. All rights reserved 1359-1789/98 $19.00 1 .00

PII S1359-1789(97)00013-X

CHILD ABUSE AND NEGLECT: BEHAVIORAL RESEARCH, TREATMENT, AND THEORY John R. Lutzker University of Judaism

Vincent B. Van Hasselt Nova Southeastern University

Kathryn M. Bigelow University of Kansas

Brandon F. Greene Southern Illinois University at Carbondale

Maria Lynn Kessler The Citadel

ABSTRACT. Described here is behavioral theory, research, and treatment of physical child abuse. A brief history is presented, along with incidence data. Some research has shown successful behavioral assessment and treatment in child abuse; many more issues remain open for additional success with this treatment refractory societal problem. These issues are explored, along with speculation as to why there has not been more research in an area of such vital social importance.  1998 Elsevier Science Ltd THE ABUSE AND NEGLECT of children is not a new phenomenon in the history of humankind; however, its scientific study, particularly in behavioral psychology, is relatively recent (Isaacs, 1982; Lutzker & Van Hasselt, 1992). Until 1962, in fact, there was little formal recognition in the literature of this serious societal disorder. Then, Kempe, Silverman, Steele, Droegemueller, and Silver (1962) published their seminal article, ‘‘The Battered Child Syndrome’’ in the Journal of the American Medical Association. Since then, incidence data have Correspondence should be addressed to John R. Lutzker, Department of Psychology, University of Judaism, 15600 Mulholland Drive, Los Angeles, CA 90077-1599. 181

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been regularly gathered, theories spun, and research conducted on demographic, sociological, and treatment variables. Unfortunately, treatment has generated the least research. The incidence data on child abuse and neglect show that 1,012,000 children were victims of child abuse and neglect (CAN) in 1994 (U.S. Department of Health and Human Services, 1996). In a seminal review, Isaacs (1982) laid out a framework for research in which the principles of applied behavior analysis could be applied to CAN. She first noted that although applied behavior analysis focuses on observable behavior, CAN involves secondary outcome, such as injuries, must deal in intent, and has cultural determinants, thus making the very problem out of the ordinary for most behavior analysis research. After reviewing the handful of behavioral treatment studies that had been reported up to 1982, Isaacs (1982) further noted that future research should take three directions, ‘‘(a) develop a theory of child abuse, (b) improve research methodologies, (c) analyze certain ethical issues pertinent to research with abusive populations’’ (p. 288). She further noted that most research had focused on the parent with little attention paid to the child victim of abuse. In this light, Isaacs (1982) suggested that a focus on child behavioral correlates of abuse such as noncompliance, oppositional behavior, aggression, and negativism might be an additional fruitful avenue of inquiry. She also suggested that skills taught to parents should have a wider berth than studies had described to that point and that there needed to be additional research into what produces stronger ‘‘parent–child bonds’’ (p. 289). In evaluating the methodology in behavioral research in CAN, Isaacs (1982) described five weaknesses to that point: ‘‘The literature contains poor definitions of abuse populations . . .’’ (p. 289); there were a ‘‘lack of outcome data’’ (p. 290); ‘‘The lack of useful reliability data constitutes additional weaknesses’’. . . (p. 290); she called for long-term follow-up; and, she expressed concern that studies to that point had lacked robust experimental designs that showed a clear relationship between treatment and outcome. A major purpose of the current discussion is to evaluate the extent to which these weaknesses have been corrected.

DEFINITIONS AND THEORIES Distinguishing between child abuse and neglect has typically been accomplished by noting that abuse is an act or set of behaviors involving the commission of violence toward a child of a nonaccidental nature. Neglect, on the other hand, involves the omission of nurturing and other behaviors that create a threat to a child’s health and well-being. In general, physical abuse refers to injuries and behaviors toward children that are other than sexual. The focus of our discussion here is the physical, nonsexual abuse of children. Shortly after the publication of the battered child syndrome article (Kempe et al., 1962), theories were developed to account for why parents would intentionally harm their children. The early theories were mostly psychodynamic in nature, focusing on the intrapsychic reasons why such behavior might occur (Ammerman & Hersen, 1990; Spinetta & Rigler, 1972). The nebulous nature of these theories precluded an empirical approach to research and treatment. Sociological and sociocultural explanations were also offered (Gelles, 1980). Conditions such as poverty, unemployment, and poor housing were identified as contributing to child abuse. While these factors may indeed play a role in the problem, such theories do not account for abuse among middle-class families, nor the absence of the abuse among many families in abject socioeconomic circumstances. More recently, developmental-ecological and transactional theories have become the mode in trying to account for the complicated and multifaceted nature of this serious societal problem. The transactional model differentiates between factors that increase and decrease the

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likelihood of maltreatment. This model also distinguishes factors that are enduring over time from factors that are transient (Cicchetti & Rizley, 1981). The developmental-ecological model, proposed by Belsky (1980, 1993) emphasizes the importance of the sociocultural context in which child maltreatment occurs (National Research Council [NRC], 1993). This model views maltreatment in the context of various risk factors that may be present at each of four levels: the individual, family, environment, and culture. The individual, or ontogenetic, level involves individual characteristics such as a parent’s low self-esteem, history of substance abuse, or poor impulse control, or a child with a difficult temperament, low birthweight, or physical or developmental disabilities. Factors within the family may include conflicted or strained relationships and/or violence among family members. Risk factors within the community may include interactions and experiences between families and their surrounding environments, such as their communities, neighborhoods, social systems, or workplaces. The fourth level involves the culture in which families live. This refers to the beliefs and values present in the culture in which families live that may contribute to abuse and neglect. These factors may include general attitudes about children, physical discipline, or violence in general. These factors are recognized as being constant or continually changing, and interacting with one another, consequently increasing, decreasing, or maintaining the likelihood for abuse or neglect within families (Ammerman, 1990). The developmental-ecological model may account for providing more contributing variables to CAN than the previous ones, thus providing the most comprehensive model to date. Missing from this model are the possible role of biological variables and the role of nonbiological intergenerational factors, such as modeling. Behavioral theories (Wolfe, 1992; Wolfe & Wekerle, 1993) have suggested that child abuse may be a function of escalating coercive interactions between parents and their children. Patterson and his colleagues (Patterson, Reid, Jones, & Conger, 1975) have collected considerable data supporting this model. On the other hand, Dumas and Wahler (1985) have data suggesting that aggressive parental behavior toward children frequently has little to do with the child’s behavior at the time and may be more related to setting events that occur some time prior to the abusive incidents with the children. They have referred to such parenting practices as indiscriminate. On the surface, these accounts may seem to countermand each other; however, it is possible that both temporally distant setting events, such as a mother’s boyfriend abusing her the previous night, and temporally proximate stimulus-response events, such as the parent and child arguing with each other, could act together or separately on different days to account for abusive incidents. Without specifically calling his view a theory, Lutzker (1984, 1992) has suggested what might be called a search for an hypothesis. That is, there are a host of multifaceted variables that might lead to child abuse and neglect. In assessing and treating as many of these variables as possible, he has referred to this approach as ecobehavioral . By ecobehavioral it is meant that CAN is a multifaceted problem in need of multifaceted assessment and services, delivered in situ within a developmental and biobehavioral framework, with active programming for generalization of newly learned skills over time, responses, and settings.

RESEARCH: THE KNOWLEDGE BASE Some effort has been made to identify correlates of abuse. That is, are there characteristics of parents, spouses, and even children themselves that put them at identifiable risk? For example, it is fairly well documented that there are some general adult correlates of abuse. These are: poverty, being a single parent, substance abuse, ‘‘impulse control’’ problems, and unemployment or underemployment. Child characteristics that place them more at risk are

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premature births, developmental or physical disabilities, and being noncompliant (Hersen & Ammerman, 1990). In looking at parents involved in abuse, several factors have been uncovered. Many parents show cognitive deficits in their ability to engage in problem-solving skills related to childcare judgment (Dawson, de Armas, McGrath, & Kelley, 1986). This finding has both research and treatment implications. For example, if parents have deficits in problem-solving skills it is necessary to identify whether or not such individuals are capable of being taught productive problem-solving strategies? In general, the research in this area has been disappointing. In particular, it has not been documented that such parents demonstrate the ability to generalize newly learned problem-solving strategies to actual life situations that repeatedly appear to cause them difficulties (MacMillin, Guevremont, & Hansen, 1988). If this is the case, then treatment aimed at problem-solving may be premature. It may be that problem-solving skills that involve examining alternatives, evaluating consequences, and choosing effective alternatives may be beyond the cognitive capabilities of many parents involved in CAN. Their ‘‘impulse-control’’ deficits may also need amelioration before problem-solving is attempted. Parents with mental retardation are more likely to be able to keep their children if they are provided help with parenting practices and with support (Tymchuk & Andron, 1990). Thus, it would seem critical that these parents receive a variety of support services. Tymchuk and his colleagues (Tymchuk, Andron, & Rahbar, 1988; Tymchuk & Andron, 1988, 1990) have demonstrated considerable success in providing intensive services to parents with developmental disabilities and demonstrating that they are then better qualified to care for their children. Mothers of handicapped children score low on cognitive skills, social skills, and being able to create social skill networks. Further, they score low on life satisfaction measures. Single parents score the lowest on these measures (Kirkham, Schinke, Schilling, Meltzer, & Norelius, 1986). These results should not be surprising in that the challenges to parents who have children with these disabilities are much greater than for the parents of children without disabling conditions. This research would also suggest that unless attempts were made by treatment and service providers to change some of the social ecology related to dissatisfaction in these parents that simplistic parent-training programs might be relatively ineffective. Abusive mothers show deficits in interactive skills. Schindler and Arkowitz (1986) found that these mothers engaged in significantly less behavior toward their children than a group of control mothers. This is consistent with developmental research over the years. It has been well documented that when parents are less than optimally interactive with their children that there are negative developmental and behavioral sequelae for the children (Burgess & Conger, 1978; George & Main, 1979; Conaway & Hansen, 1989; Hart & Risley, 1995). Thus, it would seem imperative that comprehensive treatment should include strategies aimed at increasing parent–child activities. There may even be physiological differences among abusive and nonabusive mothers. Casanova, Domanic, McCanne, and Milner (1992) found that child-abusive mothers showed more generalized sympathetic activation (heart rate and Galvanic Skin Response (GSR)) than control mothers when exposed to child- and nonchild-related stressors. Caution is in order, however, when examining this issue because studies of physiological arousal are conducted in analogue laboratory settings. No research has demonstrated that physiological arousal is causal with respect to poor parenting practices; however, this is an area that will undoubtedly receive more attention. If these correlations continue to appear and if a more direct relationship between arousal and violence can be demonstrated, treatment will need to focus on attempts to reduce the arousal and determine whether or not arousal reduction leads to reductions in violence toward children among the parents in whom this arousal is noted. Finally, Dinwiddie and Bucholz (1993) found that male child and wife abusers had histories

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of disciplinary problems, property destruction, and adult violent behavior. They also had higher than average rates of antisocial disorder, alcoholism, and depression. Thus, it appears that mothers involved in child abuse and neglect may suffer from cognitive deficits and from sociocultural factors, such as poverty and being single. They lack support networks and lack child-interaction skills. Male abusers are more likely to have serious psychiatric disorders and a tendency toward a history of violent behavior. ASSESSMENT

Child Maltreatment As Fantuzzo and McDermott (1992) have noted, ‘‘Our ability to protect child victims and respond to their needs is a direct function of the quality and precision of the assessment procedures we use in this area’’ (p. 12). Indeed, the past decade has witnessed an increase in clinical and investigative attention directed toward the assessment of child maltreatment (cf. Ammerman & Hersen, 1992). Two cardinal features of these efforts have been the provision of: (a) comprehensive, multidimensional assessment that taps a wide range of areas (e.g., violent behavior, child behavior problems, academic and social functioning, physical development); and (b) individually and uniquely tailored, ongoing assessment that is relevant and sensitive to the needs of each child and family (Wolfe, 1988). The specific evaluation strategies that have been employed are: (a) behavioral interviews; (b) self-report measures; and (c) direct observation procedures. Additional attention should be directed toward the integration of a functional assessment approach into the assessment of abusive and neglectful episodes, and the factors that distinguish these from situations in which the potential for abuse or neglect is present, but maltreatment does not actually occur. Behavioral interviews. The purpose of the behavioral interview is to evaluate immediate safety and risk factors, and to ascertain salient issues and circumstances (e.g., family stressors, punitive parenting practices, child characteristics) that may have a bearing on past or current child maltreatment. One of the first such efforts was reported by Wolfe (1988), who developed the Parent Interview and Assessment Guide in order to determine general problem areas and to assess parental responses to child-rearing demands in abusive families. This semistructured interview includes six subsections: family background, marital relationship, areas of perceived stress and supports, symptomatology, emotional reactivity, and child-rearing methods. Wolfe (1988) recommends employment of this instrument in conjunction with other relevant psychometric devices to assess areas of difficulty in these families. Self-report. A number of self-report instruments have been utilized to assess child maltreatment and related problem areas. Perhaps the most widely researched self-report measure devised to detect child risk status is the Child Abuse Potential Inventory (CAPI; Milner, 1986). The CAPI consists of three validity scales (Inconsistency, Lie, Random Responding) and the Abuse Potential Scale, which is composed of six factor scales: Unhappiness, Rigidity, Distress, Problems with Child and Self, Problems with Family, and Problems from Others. Despite adequate psychometric characteristics (e.g., temporal stability, convergent and predictive validity) (Kaufman & Walker, 1986; Milner, 1986, 1994), it has been recommended that the CAPI be employed in conjunction with other indices of abuse due to potential misclassification (Kaufman & Walker, 1986). Classification rates in the 90% range have been reported for various translated versions of the CAPI, but these were cross-validated on participants in Spain and Argentina (Milner, 1994). The validity of the CAPI with other Latino populations has not been demonstrated. If a parent is shown to be at high risk as a function

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of the score on the CAPI, immediate treatment or referral would be indicated. Lower scores on the CAPI may suggest that more assessment should occur and that a more protracted baseline of direct assessment techniques would not be harmful. The Parenting Stress Index (PSI; Abidin, 1986) has been frequently used to assess dysfunctional parent–child relationships and stress in the parenting role. This 101-item, well-validated measure includes a number of Child (e.g, Mood, Acceptability, Adaptability) and Parent Domain Scales (e.g, Depression, Attachment, Social Isolation, Sense of Competence, and an optional Life Stress scale). Also noteworthy is that clinical cut-off scores and a sample profile of 30 abusive families are offered in the PSI manual (Abidin, 1986). The PSI is particularly useful in research that correlates it with other assessment devices and examines possible decreases in PSI scores as one index of successful outcome of treatment. A variety of other self-report instruments also have been employed to assess behavioral excesses or deficits that have been implicated as having a role in child maltreatment. For example, anger and arousal levels have been the target of increased child abuse research over the past decade. Two of the most commonly employed measures in this area have been the Novaco Anger Control Scale (NACS; Novaco, 1975) and the MacMillan-Olson-Hansen Anger Control Scale (MOHAC; MacMillan, Olson, & Hansen, 1988), renamed the Parental Anger Inventory (PAI; DeRoma & Hansen, 1994). The NACS has been used to evaluate anger by presenting a series of provocation situations (e.g., ‘‘You are talking to someone and they do not answer you’’; ‘‘Noise and disorder at the dinner table’’) to which the respondent is asked to endorse the degree of anger he or she would experience in that situation. The MOHAC was specifically constructed to ascertain levels of anger experienced by abusive parents in response to difficult child behaviors. On this instrument, parents rate 50 childrelated situations as problematic or nonproblematic. Further, they are asked to indicate the magnitude of anger elicited in each scenario. The most commonly used measures of child behavior problems in child maltreatment investigations have been the Eyberg Child Behavior Inventory (ECBI; Eyberg & Ross, 1978) and the Child Behavior Checklist (CBCL; Achenbach & Edlebrock, 1983). The ECBI is a short (36 items) measure of child conduct problems that provides intensity and problem scores, and clinical cut-off scores (Eyberg & Ross, 1978). The 118-item CBCL includes Social Competence (Activities, Social, School) and Behavior Problem Scales (e.g., Depressed, Anxious, Social Withdrawal, Delinquent) that vary as a function of child age and gender. This instrument can be scored by hand or computer and yields a behavior profile that can be compared to normative data; the generated profile is highly useful for both clinical and research purposes. Instruments such as these can describe risk level and the level of intervention that may be required, and may match risk level to outcome as well as risk level to a host of other demographic variables. Behavioral assessment of family problem-solving skills has also been a recent focus for research. The Parent Problem-Solving Instrument (Azar, Robinson, Hekimian, & Twentyman, 1984) utilizes a means–end problem-solving approach and contains 10 ‘‘childrearing problem situations’’ that are scored for quantity and effectiveness of problem solutions that are provided. Hansen and his colleagues (Hansen, Pallotta, Tishelman, Conaway, & MacMillan, 1989; Pallotta, Conaway, Christopher, & Hansen, 1989) designed the Parental Problem-Solving Measure (PPSM) to evaluate these skills in both child- and nonchildrelated domains. The PPSM classifies problematic situations into five areas: child behavior and management, anger and stress control, interpersonal problems, financial, and child-care. As with the PPSI, responses to the original 25-item version (Hansen et al., 1989) and a later 15-item version (Pallotta et al., 1989) are rated for number and effectiveness of solutions generated.

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Direct observation. The heuristic value of direct observation in child abuse research and treatment has been underscored for several years (see Burgess & Conger, 1978; Mash, Johnston, & Kovitz, 1983). These strategies have been conducted in both home and in clinic settings. Observation of behavior in the latter context has had greater support and acceptability due to the advantages of: (a) videotaping parent–child interactions in standardized structured or unstructured formats; and (b) availability and utilization of retrospective videotape feedback to parents (Wolfe, 1988). A number of direct observation coding systems, initially developed to evaluate qualitative and content aspects of parent–child interactions, have been employed in child abuse research. Some of these that are particularly appropriate for use with abusive families include: the Behavioral Observation Scoring System (Burgess & Conger, 1978), Dyadic Parent–Child Interaction Coding System (Eyberg & Robinson, 1981; Eyberg, Bessmer, Newcomb, Edwards, & Robinson, 1994), the Behavioral Coding System (Forehand & McMahon, 1981), and the Family Process Code (Patterson, 1982). Due to the difficulties in directly observing discipline situations, MacMillan, Olson, and Hansen (1991) developed the Home Simulation Assessment (HSA). The HSA provides parents with 10 tasks (e.g., dry the dishes) and asks them to ‘‘do their best’’ to prompt an adult actor (playing the role of a deviant child) to complete the tasks. Ratings of parental responses on the categories of stress, anger, and anxiousness are obtained. The HSA has considerable value in illustrating parent discipline performance in low- and high-demand situations.

TREATMENT

Child Abuse and Neglect Lutzker and Van Hasselt (1992) noted that there have been predominantly two approaches to treating child abuse and neglect: social work programs and behavioral intervention. They further note that the difficulty with social work programs is the lack of individual case material and data, thus causing evaluation and replication to be difficult. Therefore, the focus of this review of treatment is on behavioral interventions. An ideal behavioral intervention begins with a content validation of the dependent and independent variables. This means that experts rate (and subsequently approve or suggest additional) variables. Next, baseline data are collected through repeated direct observation until the data are stable. Intervention is introduced either sequentially if a multiple baseline design is used, or all at once if a withdrawal research design is used (Lutzker, Wesch, & Rice, 1984). Reliability data collected by a second, independent observer are collected during at least 25% of sessions in each condition of the applied research. Follow-up data are collected at 1-, 3-, and 6-month intervals. Finally, social validation data are collected from the recipients of the service as to their opinions regarding the value of the goals, process, and outcome of the intervention. Indirect assessment data from tools such as those described earlier may also be compared to the direct observation data. Early behavioral interventions focused on either parent training or stress reduction. Gilbert (1976) taught parents to praise their children. Although this work was seminal, it was flawed in two ways in particular. First, the data were entirely self-report by the mother. Thus, the report lacked any direct observation measures. Second, it would seem that with the current focus on more comprehensive approaches to the treatment of CAN that simply teaching a mother to praise appropriate behavior would not appear to bode well for durability of treat-

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ment outcome. An example of behavior management skills taught to parents who are abusive can be seen in Wolfe and Sandler (1981). Reading assignments, role-playing, modeling, rehearsal, and feedback were employed to teach child management skills to parents who were abusive. Contingency contracting was also used to reinforce parents with a previously selected reinforcer contingent upon their appropriate use of child management techniques. Prevention of child maltreatment was accomplished by Wolfe, Edwards, Manion, and Koverola (1988). Thirty mother–child dyads were taught fundamental child management skills through modeling, instructions, and therapist and videotape feedback. Mothers were also taught activities aimed at improving the children’s language and adaptive skills. Additionally, Wolfe et al. (1988) used in vivo desensitization for stress reduction. A 3-month follow-up showed improvements in parenting skills and caseworkers rated the children involved in this research as less at risk than their control group counterparts. MacMillan, Olson, and Hansen (1991) evaluated the utility of a parent training program designed to facilitate generalization to high-demand child-management situations. Parents were taught to provide instructions, employ a timeout procedure, engage in positive behavior during play, and implement strategies for managing aggression, tantrums, and negative verbalizations. Observations of parent–child interactions were conducted in the home as well as the clinic. Assessing parent performance in high-demand situations is a particularly important aspect of this research. However, adult actors were used in simulated scenarios, which may have restricted the parents’ performance. In-home observations and training conducted with parents and their own children would further promote improvements in parent performance and generalization. In order to improve judgement related to child care and daily stress, problem-solving skills were taught to a mother who was abusive and neglectful (MacMillan, Guevremont, & Hansen, 1988). Training consisted of modeling the generation of multiple solutions to hypothetical problems, rehearsal, feedback, and the fading of prompts. Increases in the generation of alternative solutions and in the quality of the plans to carry out these solutions were observed in both training and generalization situations. Positive changes were observed in the mother’s insularity, affect, and self-reported stress. However, the use of problem-solving skills in reallife situations was not assessed. While these behavioral approaches offer some hopeful outcomes, the multifaceted nature of child abuse and neglect suggest that more comprehensive behavioral approaches might offer better long-term outcomes. Longer follow-up and program evaluation data would have been more useful. Cognitive-behavioral strategies involving stress management, communication training, and cognitive restructuring have been compared to insight-oriented treatment and a control group (Azar, 1984). Families participated in cognitive restructuring, and stress management. Wolfe (1991) has also suggested teaching parents realistic expectations about the behavior of young children. Again, these strategies seem promising, but logic would suggest that a combination of behavioral strategies might produce the most effective outcomes. This is because to treat only one or two of the factors that are correlated with CAN would seem to delimit outcomes as compared to offering numerous services. For example, in addition to teaching parents realistic expectations, it would probably be even more helpful to teach them infant stimulation skills, affective adult–child interaction skills, activity training, and behavior management. The ecobehavioral model espoused by Lutzker (1984, 1992) involves multifaceted assessment and treatment. This has been applied primarily through Project 12-Ways and systematic replications, Project Ecosystems (Lutzker & Campbell, 1994) and Project SafeCare (Doctor & Lutzker, 1994, 1995; Lutzker, Kessler, & Doctor, 1995). Treatment services have included parent–child training (Dachman, Halasz, Bickett, & Lutzker, 1984; Harrold, Lutzker, Campbell, & Touchette, 1992), stress reduction (Campbell, O’Brien, Bickett, & Lutzker, 1983;

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Kiesel, Lutzker, & Campbell, 1989), self-control training for parents and children, assertiveness training, reciprocity counseling (Campbell et al., 1983), job-finding, money management, nutrition training (Sarber, Halasz, Messmer, Bickett, & Lutzker, 1983), home safety (Barone, Greene, & Lutzker, 1986; Tertinger, Greene, & Lutzker, 1984), home cleanliness (Lutzker, 1990; Watson-Perczel, Lutzker, Greene, & McGimpsey, 1988), behavioral pediatrics (Kiesel, Lutzker, & Campbell, 1989), and prevention for single mothers by teaching them infant stimulation (Lutzker, Lutzker, Braunling-McMorrow, & Eddleman, 1987) and health care skills (Delgado & Lutzker, 1988; Feldman, Case, Garrick, MacIntyre-Grande, Carnwell, & Sparks, 1992). Parent–child training was offered by Dachman et al. (1984) in the form of teaching a mother to use contingent descriptive praise with her son in three settings in the home. Additionally, she was taught to give clear, precise commands and to avoid using imprecise commands. Generalization data were collected in untreated situations and surreptitious data were collected on the mother’s use of criticism of her son. Multiple baseline data showed that the parent training procedures that relied on modeling and feedback improved mother and child behavior, and that without direct treatment, the mother’s use of criticism was dramatically reduced. The author’s point out that while formal data were collected only on a handful of parent–child behaviors, several other ecobehavioral services were offered concurrently to the family. Thus, as with much of the research reported from the ecobehavioral model, it is difficult to isolate all of the variables that may have contributed to success within individual families. In this case, for example, during treatment, the counselors helped the mother secure improved housing, a variable that could have certainly reduced family stress and added to positive parent–child interactions. Finally, no data were collected on mother–child interactions outside of the home. Planned activities training (PAT) (Harrold, Lutzker, Campbell, & Touchette, 1992) involves emphasis on antecedent behavior management rather than a focus on consequences as more commonly used in contingency management training (CMT). Parents are taught to organize and plan activities with their children with the goal of preventing challenging behavior. Additionally, they are taught to manage time and to use incidental teaching during activities. Harrold et al. (1992) studied mothers with children who were at high risk for CAN because of their severe behavioral excesses or deficits associated with their developmental disabilities. The research compared PAT to CMT by having some mothers trained PAT and then CMT after baseline and some mothers trained in the opposite order. The dependent measures involved data on positive mother and child behaviors, child compliance, mothers’ use of the independent variables, and on mothers’ preferences for PAT or CMT. Both PAT and CMT were effective in producing considerable improvements in mother and child behavior, and the mothers preferred PAT to CMT. Lacking in this research was a demonstration that PAT could be used in the absence of CMT and lacking were data from community settings. Stress reduction techniques were reported by Campbell et al. (1983) in a study in which the mother reported multiple severe migraine headaches each week. She was a rare selfreferral who was concerned that without help in learning to manage her daughter’s behavior that she would kill her. Functional assessment data revealed that the daughter displayed nearly no instruction-following behavior and that the mother lacked effective child management skills. Further, she was disabled by her headaches and was unhappy in her marriage. The Campbell et al. (1983) research is a good example of both the positive and problematic aspects of the ecobehavioral approach. The withdrawal design data showed that stress reduction techniques along with self-monitoring of stress-producing situations was quite effective in dramatically reducing the frequency and duration of the mother’s headaches. After there was a significant reduction in headaches, the counselors proceeded with parent training. Additionally, marital counseling in the form of reciprocity counseling (Azrin, Naster, & Jones,

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1973) was provided. Multiple baseline designs used in parent training and marital counseling showed that the training procedures were responsible for improvements in the marriage and in the mother’s child-management skills. The overall success of this treatment, however, would need to be attributed to the combination of ecobehavioral services offered, although no research design was used to document this. In fact, it would have been impossible for practical and ethical reasons to establish such design features. Program evaluation data from Project 12-Ways have suggested that this approach is superior to services not employing the ecobehavioral model offered by Project 12-Ways. Recidivism was significantly less for the Project 12-Ways families, even after 4 years since being served (Lutzker & Rice, 1987). Also, it was noted that the families referred to Project 12Ways may have been more severe in terms of their history of contact with the child protective service than the comparison families (Wesch & Lutzker, 1991). Unfortunately, no cost-benefit analysis data have been reported as a form of program evaluation with Project 12-Ways. Such data would be useful in comparing the costs of this service to other more traditional service delivery systems in child abuse. Also, it would be helpful to compare the global program evaluation data of recidivism to specific outcome measures, such as goal attainment within families. Social validation data were collected from parents served by Project Ecosystems and from agency personnel who refer families to Project Ecosystems (O’Brien, Lutzker, & Campbell, 1993). These data suggested considerable satisfaction with the ecobehavioral services offered by Project Ecosystems. It would be helpful to have collected other program evaluation data, such as a comparison of placement frequencies between families served by Project Ecosystems and other similar projects within the region.

FUTURE DIRECTIONS AND NEEDS In just 35 years or so, child abuse has moved from being formally recognized as a societal problem to a problem for research and treatment. Research has involved demographic data, etiological factors of spouses, parents and children, and some treatment. The behavioral treatment literature has moved from single-case reports and a focus on one or two treatment variables to a focus on several variables and often to in situ multifaceted efforts. On one hand, it seems as though progress has been made in this area, given the number of reports suggesting clinical improvements, or with program evaluation data suggesting reductions in recidivism. On the other hand, in our own behavioral treatment literature, there appears to be some significant ‘‘holes.’’ For example, there are only a handful of researchers reliably producing any literature in this area. The point is that there are a mere handful of applied behavior analysts working on a societal problem of enormous importance. Why, especially given that there are considerable funding opportunities? One reason may be that the multifaceted nature of the problem requires an effort that necessarily means ‘‘slippage’’ from the tight models generally produced in behavior analysis. In child abuse, families are often not likely to be willing or able to go to a clinic. This necessitates the in situ aspect of the ecobehavioral model (which also makes more sense with respect to programming for generalization). If there are, in fact, problems ranging from child-rearing practices, intrapersonal difficulties of the parents or spouses, such as character disorders, impulse control problems, substance abuse, and so on, economic factors, cognitive deficits, and other deficits in the family ecosystem, such as social support or employment, doing the kind of ‘‘clean’’ treatments and research designs expected from Applied Behavior Analysis becomes extremely difficult. There are also practical problems associated with the delivery of behavioral or ecobehav-

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ioral services with families involved in violence (Lutzker, 1994). These include the frequent need to send counselors in pairs because of burnout with these difficult families, compliance problems with these kinds of families who more often than not have had services forced upon them, and even the danger of serving families in many urban communities. These are significant problems that undoubtedly keep many researchers from serving these populations. Although there are a number of approaches that look favorable, the comparable paucity of hard data means that we have as yet been unable to do finer-grained analyses of our extant treatments. For example, are there components of parent training programs that are more effective than others? How important at all is parent training if the family’s entire social ecology has multiple problems? Is it more important to teach a job skill to an unemployed parent and help arrange for child care than it is to teach her child behavior management (Brunk, Henggeler, & Whelan, 1987; Caldwell & Bradley, 1984; Moos & Moos, 1976)? These are relevant concerns. For example, in the case of indiscriminate parenting (Dumas & Wahler, 1985), the temporally proximate three-term contingencies (antecedents, behaviors, consequences) between a parent and child may have less to do (or nothing to do) with a child-abusive incident perpetrated by the mother in the afternoon than temporally more distant setting events, such as the mother’s boyfriend having abused the mother the previous night, and the utility company threatening to cut-off the electricity that morning. In these cases, better assessment of setting events and treatment, such as problem-solving, money management, and stress reduction, seem more relevant than parent training. Problem-solving seems to be a particular deficit for many of these families. In child abuse and neglect, we often see mothers who make poor decisions about care, such as leaving an older child to care for a younger child when the older child is still too young to be so entrusted. Many single mothers allow men into their lives who abuse the children and the woman, and take resources from the family without making any positive contributions. We have seen no empirical literature dealing with teaching the women in these situations how to avoid these cohabitation arrangements that appear to be so detrimental. The demographic data seem fairly evident that character disorder among the males involved in child abuse and psychiatric disorders and substance abuse among men and women involved in family violence are frequent predictors of these problems. Again, we see nothing that applied behavior analysis has offered in the way of treatment or prevention strategies to deal with these phenomena. It may be that the issue with the serious problems of substance abuse and psychiatric and character disorders may be in the very early childhood identification of these problems and the hope for intensive early interventions that include problem-solving, social skill training, self-control training, relationship training, and possibly, medication. Another area that behavior analysis has not broached is the direct treatment of the children who have suffered abuse. Very little has been added in this area since Isaacs (1982) expressed her concerns over this paucity. Although some behavior therapy literature has dealt with spouses, no behavior analysis literature has tackled the child victim. It is clear from the psychological literature and popular press that the psychological ‘‘baggage’’ that goes along with child abuse is long-lasting and severe. It might be possible for behavior analysis methodology to be used to assess some currently nonbehavioral treatments focused on adult victims of child abuse and upon child victims of abuse. Further, we should explore more strategies aimed at teaching children how to recognize and avoid abuse. For example, it might be possible to teach a child the parental behaviors that might act as discriminative stimuli to signal the child that current avoidance of the parent will prevent an abusive incident. Also, we may be able to use behavior analysis methodology to assess behaviors of children that set the occasion for abuse, or behaviors that suggest that the child has been sexually abused. For example, it has been suggested that child victims of sexual abuse often ‘‘act out’’ sexually, yet we have no empirical data to support such an assertion.

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Stilwell, Lutzker, and Greene (1988) evaluated a sexual abuse prevention program for preschoolers that employed storytelling and class discussion. Puppets and flannel board figures were used to role-play saying ‘‘no’’ and telling trusted authority figures about inappropriate touches. This research demonstrated that children’s verbal responses do not reflect the correct demonstration of actual behavioral responses. Training in such skills must employ repeated behavioral assessment and rehearsal in a variety of more natural situations and settings in order to teach children to demonstrate appropriate preventative behaviors. Poche, Brouwer, and Swearingen (1981) employed modeling, behavioral rehearsal, and social reinforcement to teach self-protection to children to prevent the opportunity for abduction. Training took place in a schoolyard, while generalization was assessed in a community setting. Children demonstrated an improvement in self-protective skills, and these responses were generalized to novel locations and individuals. This is an excellent example of the type of research that is needed to evaluate interventions that are employed to teach children selfprotection and the recognition and prevention of abuse. To what extent has behavior analysis advanced in child abuse since Isaacs’ (1982) commentary? She has suggested that a theory of child abuse should be spun. As reviewed here, many have been offered, and while the ecologically based theories are in the most current fashion, it would be safe to say that the field still lacks a cohesive, comprehensive, wellaccepted theory. This is probably due to the relative paucity of hard empirical data. Isaacs (1982) also suggested that research methodologies need improvement. To a large extent this has occurred, at least compared to what was available in the literature in 1982. However, there remains a comparative handful of published articles using robust research designs demonstrating treatment efficacy in any large numbers of families involved in child abuse. With the exception of Project 12-Ways, recidivism data from large-scale treatment-oriented projects are very hard to find. Finally, Isaacs (1982) had noted that ethical issues should be analyzed pursuant to child abuse. While largely beyond the scope of the current discussion, this has occurred with more frequency than was the case in 1982. Thus, there clearly have been improvements since Isaacs’ review; however, it would behoove applied behavior analysis to expand these efforts because its methodology has much to offer the broader interdisciplinary field of child abuse and neglect.

SUMMARY AND CONCLUSIONS Child abuse has received some, but comparatively little, attention from applied behavior analysis/behavioral psychology. These fields offer a methodology that can shed empirical light on an area that still badly needs reliable and valid data. This includes defining abuse and neglect empirically, improving behavioral assessments, helping courts deal from a database regarding family preservation, and more multifaceted treatments. On the other hand, behavioral practitioners will need to be willing to tread into the murkier waters of difficult to control environments with subjects who are often not as willing or easily managed as many behavior analysts are used to treating and studying. There are documented successes with behavioral strategies in physical child abuse and neglect, and teaching parenting skills to parents with cognitive deficits. There have been few, but successful, program evaluations. We need much more data on ‘‘normative’’ practices of families not involved in violence or neglect. Very little has been done in the area of sexual abuse, as well as few efforts aimed at treating victims or preventing victimization. It is clear that applied behavior analysis and behavioral psychology have approached child abuse from a scientific, empirical perspective, but more efforts would be welcome. We must, however, be willing to take some chances and to approach this societal problem from a more

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