Strategies for identifying and treating adolescents at risk for maltreating their children

Aggression and Violent Behavior, Vol. 3, No. 2, pp. 197–217, 1998 Copyright  1998 Elsevier Science Ltd Printed in the USA. All rights reserved 1359-1789/98 $19.00 1 .00

PII S1359-1789(97)00015-3

STRATEGIES FOR IDENTIFYING AND TREATING ADOLESCENTS AT RISK FOR MALTREATING THEIR CHILDREN Catherine Stevens-Simon and Donna Nelligan University of Colorado Health Sciences Center, The Children’s Hospital

ABSTRACT. Using data published in English since 1970, the analyses presented in this article examine the identification and treatment of the antecedents of child maltreatment by adolescent parents. Reviewed studies indicate that (a) the sensitivity and specificity of predictors of child abuse is poor, (b) children of adolescents are at increased risk for maltreatment, (c) controlling for background sociodemographic factors decreases but does not eliminate this risk, (d) home visitation programs help at-risk adolescent parents improve their parenting skills. Maltreatment of children by their adolescent parents is a preventable problem. Short-term programs that address behavioral manifestations of the social ills and developmental conflicts that antedate child maltreatment without touching the underlying causes are unlikely to be successful.  1998 Elsevier Science Ltd INTRODUCTION

Recognition of the Problem THE MALTREATMENT OF CHILDREN by their adult caretakers is not a new phenomenon. However, the problem received little public attention until the publication of Dr. C. Henry Kempe’s paper ‘‘The Battered Child Syndrome’’ three decades ago (Kempe, Denver, Cincinnati, Droegemueller, & Silver, 1962). This landmark article in which the author described young children who had been repeatedly beaten and neglected by their caretakers spurred action to protect children from intrafamilial violence (Taylor & Newberger, 1979; Wissow, 1995). By the mid-1960s every state in the union had laws mandating reporting of suspect child maltreatment (Taylor & Newberger, 1979; Wissow, 1995). More recently a National Center on Child Abuse and Neglect has been established by the federal government, a committee on Child Abuse and Neglect has been established by the American Academy of Pediatrics, and a National Committee for the Prevention of Child Abuse and Neglect has been created in the private sector.

Correspondence should be addressed to Catherine Stevens-Simon, Department of Pediatrics, Division of Adolescent Medicine, University of Colorado Health Science Center, The Children’s Hospital, 1056 East 19th Street, Denver, CO 80218. 197

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TABLE 1. Definition of the Major Types of Child Maltreatment Physical abuse: Inflicting bodily harm through excessive force or forcing a child to engage in physically harmful activities Sexual abuse: Contact or interaction between a child and an adult, when the child is being used for the sexual stimulation of that adult or another person Emotional abuse: Coercive, demeaning, or overly distant behavior by a caretaker that interferes with a child’s normal social or psychological development Neglect: Failure of a caretaker to provide basic shelter, supervision, medical care, or support for a child Nonorganic failure-to-thrive: Growth failure (weight and height less than the 5th percentile for age or loss of 2 or more standard deviations on the growth chart in a 6 month period of time) without adequate organic explanation Major changes in primary caretaker: Placement outside the home in foster care or change in primary care taker in the home because mother left

Definition of the Problem Child maltreatment is broadly defined as intentional harm or a threat to harm a child by someone acting in the role of caretaker (Taylor & Newberger, 1979; Wissow, 1995). This is a multifaceted problem that is usually divided into the six categories listed in Table 1. Most investigators agree that nonorganic failure-to-thrive and major changes in primary caretaker (the last two categories listed in Table 1) represent major parenting failures that can have deleterious effects on the physical and psychological growth of children (Wissow, 1995). However, many would not include these two events in the definition of child maltreatment. We have included them in Table 1 because both have been used as endpoints in studies of child maltreatment (Altemeier, O’Connor, Sherrod, & Vietze, 1985; Bithoney, McJunkin, Michalek, Snyder, Egan, & Epstein, 1991; Black, Dubowitz, Hutcheson, Berenson-Howard, & Starr, 1995; Gray, Cutler, Dean, & Kempe, 1979; Larson, 1980; Leventhal, Garber, & Brady, 1989; Olds & Henderson, 1989; Wasserman & Leventhal, 1993). The categories listed in Table 1 are not mutually exclusive; many abusive adults inflict more than one type of maltreatment on the same child. For example, it is estimated that at least 10% of children with nonorganic failure to thrive have been physically abused as well (Wissow, 1995).

Epidemiology of the Problem The actual prevalence of child maltreatment in the United States is unknown. However, it is estimated that at least 1.4 million American children are victimized annually (Wissow, 1995). This represents approximately 3% of those less than 18 years old in this country (Wissow, 1995). Despite professional and lay efforts to curb child maltreatment, results of recent surveys indicate that the incidence of child maltreatment is increasing rather than decreasing in the United States (Wissow, 1995). While this may be, in part, a reflection of the recent intensification of medical surveillance for, and reporting of the problem, the worsening poverty, unemployment, and crowding in inner city communities has undoubtedly played an etiologic role as well (Leventhal, 1981; Olds & Henderson, 1989; Olds, Henderson, Kitzman, & Cole, 1995; Wissow, 1995). Children of all ages, sexes, races, and socioeconomic levels are at risk for maltreatment (Kempe, 1976; Leventhal, 1988; Rosenberg & Krugman, 1991; Wissow, 1995; Zuckerman, Augustyn, McAlister Groves, & Parker, 1995). Studies indicate that the prevalence of serious,

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life-threatening abuse deceases with age; 80% of such cases being reported among children who are less than 5 years of age (Wissow, 1995). By contrast, prevalence of less serious forms of physical abuse and the prevalence of emotional abuse increases with age; teenagers being twice as likely to be victimized as preschool-aged children (Wissow, 1995). Physical abuse and neglect are more common in impoverished communities but occur with equal frequency among boys and girls (Wissow, 1995). By contrast, incidence of sexual abuse is relatively constant across income groups, but is reported more frequently among girls than boys (Wissow, 1995). The consensus is that children who have parents, stepparents, or adult caretakers who are very strict and domineering, and children who are either not living with their natural parents or are living in dysfunctional and/or substance-abusing families (with parents who were abused during childhood, parents who communicate poorly, parents who are cognitively impaired, and/or parents who are emotionally immature and needy) are at particularly high risk for maltreatment (Stevens-Simon & Reichert, 1994; Rosenberg & Krugman, 1991; Wissow, 1995). In these families the maltreatment of children is usually not the only form of intrafamilial violence (McKibben, DeVos, & Newberger, 1989; O’Campo et al., 1995; Wissow, 1995; Zuckerman et al., 1995).

Sequelae of the Problem The association between child maltreatment and other environmental conditions that are known to predispose children to adjustment disorders makes it difficult to isolate the affects of various types of maltreatment on child and adolescent development (Bayatpour, Wells, & Holford, 1992; Browne & Finkelhor, 1986; Boyer & Fine, 1992; Butler & Burton, 1990; Rosenberg & Krugman, 1991; Taylor & Newberger, 1979; Wissow, 1995). Nevertheless, the consensus is that maltreatment predisposes children to a vast array of emotional and behavioral problems, such as excessive anger, guilt, shame, depression, aggression, and poor selfesteem; and behavioral problems, including school failure, substance abuse, runaway behavior, prostitution, delinquency, teen pregnancy, eating disorders, and suicide (Bayatpour et al., 1992; Brown & Finkelhor, 1986; Boyer & Fine, 1992; Butler & Burton, 1990; Rosenberg & Krugman, 1991; Stevens-Simon & Reichert, 1994; Taylor & Newberger, 1979; Wissow, 1995). Further studies are needed to clarify the extent to which the relationship between maltreatment during childhood and these adverse psychosocial outcomes is associational (due to shared environmental risk factors) and the extent to which it is truly etiologic (due to specific disorders of child and adolescent psychosocial developmental precipitated by maltreatment).

Preventing the Problem The prevention of child maltreatment and its sequelae has been considered at all levels (e.g., primary, secondary, and tertiary prevention) (Brayden et al., 1993; Wolfe & Wekerle, 1993; Wolfe & Korsch, 1994; Zuckerman et al., 1995). Primary prevention strategies target the population as a whole. The aim of these programs is to prevent child maltreatment by changing cultural attitudes and values that favor violence as a means of conflict resolution. Primary prevention programs are based on the premise that children who are raised in abusive or neglectful family environments where they have witnessed violence between parents or been the victims of maltreatment are more likely to rely upon power-assertive behaviors to resolve conflicts (O’Campo et al., 1995; Wolfe & Korsch, 1994; Wolfe & Wekerle, 1993; Zuckerman et al., 1995). It is widely believed that with the appropriate help and support these children and adolescents can learn how to relate to others in a respectful, nonviolent manner. Programs designed to achieve this end typically focus on educating high-school–aged youth and young

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adults about the stresses associated with parenthood and the adverse consequences that domestic and community violence have on the development of children (Johnson, Loxterkamp, & Albanese, 1982; Olds & Henderson, 1989; Zuckerman et al., 1995). Although there have been very few rigorous evaluations of the efficacy of this approach to the prevention of child maltreatment, outcome studies suggest that adolescents who participate in these types of programs acquire relevant information about parenting and exhibit gains in positive parenting attitudes (Elster, Lamb, Tavare, & Ralston, 1987; Field, Widmayer, Greenberg, & Stoller, 1982; Johnson et al., 1982; Olds & Henderson, 1989; Wolfe et al., 1994). Longitudinal studies are needed to determine the extent to which these cognitive gains are associated with behavioral changes and improved child-rearing abilities. Secondary prevention strategies target a subset of the population deemed to be at increased risk for child maltreatment. The aim of these programs is to prevent child maltreatment by providing an in-depth intervention designed to foster positive parenting attitudes and behaviors among high-risk parents. Secondary prevention programs are based on the premise that it is possible to identify and eliminate the personal characteristics and environmental factors that predispose some families to violent interaction styles. Efficacy of this approach to the prevention of child maltreatment depends upon the accurate identification of those at risk and the implementation of effective interventions before abuse occurs (Brayden et al., 1993; Olds & Henderson, 1989). Tertiary prevention strategies target parents who have been identified as abusive or neglectful. These programs seek to stop ongoing child maltreatment by improving the parents’ childrearing skills and interpersonal styles. Although there is some evidence that tertiary prevention programs improve knowledge about child development and nonviolent discipline, the high cost and rate of recidivism make this the least attractive prevention strategy (Taylor & Newberger, 1979; Wissow, 1995). Concern about the disproportionately high rate of maltreatment among the children of adolescent mothers (Brooks-Gunn & Chase-Lansdale, 1991; Chase-Lansdale, BrooksGunn, & Zamsky, 1994; Conger, McCarty, Yang, Lahey, & Burgess, 1984; Hardy & Streett, 1989; Kinard & Klerman, 1980; Olds & Henderson, 1989; Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Pope et al., 1993; Rothenberg & Varga, 1981; Stevens-Simon & Reichert, 1994; Stevens-Simon & White, 1991; Stier, Leventhal, Berg, Johnson, & Mezger, 1993; Taylor, Wadsworth, & Butler, 1983; Zuravin, 1988) prompted this review of the efficacy of secondary prevention programs. This is an attractive strategy for preventing child maltreatment in households headed by adolescent parents because scarce, costly resources can be focused on those who are most likely to benefit from them. However, it is a problematic strategy because it requires that at-risk families be identified accurately before maltreatment occurs. We begin by examining the feasibility of predicting dysfunctional parenting practices with information collected during the prenatal and early postpartum periods. Next we examine the efficacy of specific intervention strategies within the theoretical framework of adolescent cognitive and psychosocial development. We conclude with the description of our own maltreatment prevention program, The Colorado Adolescent Maternity Program for the Prevention of Child Abuse and Neglect.

PREDICTING DYSFUNCTIONAL PARENTING PRACTICES

Objective Quantification of the Risk The first step in developing a truly preventative child maltreatment program is to objectively quantify the abuse potential of parents during the prenatal and early postpartum period (Murphy, Orkow, & Nicola, 1985). Information about the parental, child, and environmental char-

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TABLE 2. Risk Factors for Child Maltreatment Parent characteristics Young age Unmarried Substance users Personality disorders Legal problems Maltreated during childhood Raised in foster care Illness resulting in separation from child Child characteristics Malformed Preterm, low birthweight Abnormal pregnancy Abnormal labor and delivery Illness resulting in separation from mother Unplanned Unwanted Environmental characteristic Poverty Violence Crowding Isolation Large family size

acteristics that differentiate dysfunctional parents from nurturant parents has come from retrospective, case-control studies and prospective, cohort studies. Prospective cohort studies are more expensive and time consuming to conduct than are case-control studies but they are preferable because they are less apt to produce spurious results and less apt to foster interventions that are inappropriate and ineffective because they are based on the misinterpretations of the causal sequences of events antedating child maltreatment (Leventhal, 1981; Olds et al., 1995). Table 2 lists parental, child, and environmental characteristics frequently associated with child maltreatment (Adler, Hayes, Nolan, & Lewin, 1991; Altemeier, O’Connor, Vietze, Sandler, Sherron, 1982; Altemeier et al., 1985; Altemeier, Vietze, Sherrod, Sandler, Falsey, & O’Connor, 1979; Brayden, Altemeier, Tucker, Dietrich, & Vietze, 1992; Brayden et al., 1993; Egeland & Brunnquell, 1979; Fontana & Robison, 1984; Lealman, Haigh, Phillips, Stone, & Ord-Smith, 1983; Leventhal, 1981, 1988; Leventhal, Berg, & Egerter 1987; Leventhal et al., 1989; Lynch, 1975; Smith, Hanson, & Noble, 1973; Wissow, 1995; Taylor & Newberger, 1979). Presence of some of these risk factors (e.g., age and socioeconomic status) can be easily assessed by general practitioners during routine office visits, whereas the detection and objective quantification of others (e.g., inadequate bonding and negative child-rearing attitudes) requires special training in the use of sophisticated assessment tools, the application of which has been limited to research settings. Since abusive families typically exhibit several high-risk characteristics interactional models, which incorporate all three risk categories (e.g., the parents’ early childhood experiences, their current relationships and work, and the salient child and environmental characteristics) have been found to yield the most accurate risk assessments (Bithoney, Van Sciver, Foster, Corso, & Tentindo, 1995; Olds & Henderson, 1989).

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While the consensus is that it is possible to identify parents who are at risk for maltreating their children with information obtained prenatally and during the puerperium, current data indicate that the sensitivity and specificity of these predictions is low (Brayden et al., 1992; Olds & Henderson, 1989). Most investigators agree that the specificity and negative predictive value of these predictions exceeds their sensitivity and positive predictive value and that the most serious, life-threatening forms of abuse can be predicted with greater accuracy than milder forms of neglect (Altemeier et al., 1972, 1985; Brayden et al., 1993; Egeland & Brunnquell, 1979; Lealman, Haigh, Phillips, Stone, & Ord-Smith, Sadler & Catrone, 1983; Leventhal, 1988; Leventhal et al., 1987, 1989; Taylor & Newberger, 1979; Wissow, 1995). The best model, one developed by Murphy and colleagues (1985) in Denver, Colorado had a specificity of 89.4% (yielding a negative predictive value of 96.8%) and a sensitivity of 80% (yielding a positive predictive value of 52%) (Murphy et al., 1985). By contrast Brayden and colleagues found that specificity and sensitivity of their predictive scale were only 69% and 56.6%, respectively (Brayden et al., 1993). Although the majority of abused children do not have adolescent parents and the majority of adolescent parents do not abuse their children studies show that the explosive combination of parental, child, and environmental characteristics associated with child maltreatment and neglect is a particularly common finding in families headed by adolescent parents (Brooks-Gunn & Chase-Lansdale, 1991; Elster, McAnarney, & Lamb, 1983; Flanagan, McGrath, Meyer, & Garcia Coll, 1995; Parks & Smeriglio, 1990; Panzarine, 1986; Panzarine, Slater, & Sharps, 1995; Stevens-Simon & Reichert, 1994; Stevens-Simon & White, 1991; Zuravin, 1988).

High-Risk Characteristics of Adolescent Parents Although studies of adolescent parenting behavior reveal a wide variation in quality, most investigators have found that younger, psychosocially and cognitively less mature mothers interact differently with their infants than do older mothers. The interaction styles of young mothers have been characterized as less nurturant and more negative and punitive than those of older mothers (Elster et al., 1983; Flanagan et al., 1995; McAnarney, Lawrence, Ricciuti, Polley, & Szilagyi, 1986; Parks & Smeriglio, 1983; Stier et al., 1993). The prodding, pinching, and poking that are part of many adolescent parents’ repertoire are rarely exhibited by their adult counterparts (Flanagan et al., 1995; McAnarney et al., 1986). As a group, adolescent mothers tend to be less verbal with their children, to have less empathy and less ability to modify their behavior in response to their children’s needs, to have a poorer understanding of child development and higher, less realistic expectations for their children’s behavior (East, 1994; Elster et al., 1983; Flanagan et al., 1995; McAnarney et al., 1986; Parks & Smeriglio, 1983; Stier et al., 1993). In addition it has been reported consistently that adolescent parents cope less effectively with the stresses of childrearing, have less confidence in their ability to parent, and have a greater acceptance of physical punishment and abusive disciplinary methods than do adult parents (Elster et al., 1983; Flanagan et al., 1995; McAnarney et al., 1986; Parks & Smeriglio, 1983; Stier et al., 1993). While there is nearly unanimous agreement among health-care providers and social scientists that women who begin childbearing during their teens tend to take a more negative, punitive approach to childrearing than do women who postpone childbearing, there is far less agreement on the meaning and correct interpretation of this association. Despite the wealth of data compiled over the last three decades, it is still unclear if young maternal age actually causes any of the atypical and unconventional mothering behaviors associated with adolescent childrearing. It has been difficult to isolate effects of young maternal age on parenting behavior because many of the preexisting differences between early and late childbearers also affect the risk of dysfunctional parenting and child maltreatment. In most studies, age

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is confounded by other maternal characteristics, factors such as poverty and environmental stress that are known to predispose women of all ages to negative parenting styles. Data showing that a disproportionately large number of adolescent parents come from abusive, neglectful families and that teenagers who were abused as children are more likely to be stressed and depressed, to abuse substances, and to give birth to small, unplanned, preterm infants suggest that the prevalence of personal and environmental risk factors, rather than young maternal age or cognitive and psychosocial immaturity, could account for the overrepresentation of adolescent parents in child maltreatment cases (Elster et al., 1983; Flanagan et al., 1995; Parks & Smeriglio, 1983; Rothenberg & Varga, 1981; Stevens-Simon & Reichert, 1994; Zuravin, 1988). Since statistical controls for the effects of these personal and environmental risk factors for child maltreatment typically reduce the strength of the association between early childbearing and child maltreatment, it seems possible that the same demographic factors which contribute to adolescent childbearing may contribute to the maltreatment of children. However, caution is critical, as many negative adolescent parenting behaviors do not disappear when the differences in the family and cultural backgrounds of early and late childbearers are accounted for (Brooks-Gunn & Chase-Lansdale, 1991; Flanagan et al., 1995). Rather, results of recent well-controlled studies suggest that some of the aberrant parenting behaviors that adolescent mothers exhibit reflect ignorance, inexperience, and their own abusive upbringing, whereas others are a reflection of the young parents’ cognitive and emotional immaturity. As we shall now discuss, certain aspects of adolescent psychosocial and cognitive development appear to contribute to prevalence of negative parenting behavior and child maltreatment associated with childrearing at this age. We shall begin by defining the normal stages of adolescent development and then examine in detail the ways in which the major developmental task associated with each stage of this developmental process conflict with the tasks of maternal role attainment and parenting.

Conflicts Arising From the Superimposition of Adolescence and Parenthood Adolescence is the process of psychological and cognitive growth and development that transforms dependent children into independent, self-sufficient, adults (Sahler & McAnarney, 1981). It is of necessity an egocentric, inwardly focused period of development during which most young people still have difficulty performing tasks that require abstract thinking (Sahler & McAnarney, 1981). By contrast, maternal role attainment is the process of psychological and cognitive growth and development that transforms concrete, egocentric young adults into the formal operational, empathetic parents. The process of maternal role attainment begins during pregnancy and continues during infancy until the reciprocal identities and roles of mother and child are established. It is of necessity an outwardly focused period of development during which women must perform a multitude of tasks that require abstract, ‘‘othercentered’’ thinking (Flanagan, Coppa, Riggs, & Alario, 1994; Flanagan et al., 1995; Hatcher, 1973; Sadler & Catrone, 1983). Adolescence is usually divided into three stages, each of which has its own characteristic behavioral styles and developmental tasks (Sahler & McAnarney, 1981). Normal adolescent cognitive and psychosocial development follows an orderly sequence; the specific conflicts that arise between the tasks of adolescence and those of maternal role attainment vary in relation to the stage of adolescent development (Hatcher, 1973; Sadler & Catrone, 1983). By addressing these potential areas of conflict and demonstrating an ongoing interest in the adolescent’s development, both as an individual and a parent, health-care providers may be able to prevent many of the parenting disorders that are characteristic of each stage of adolescence. Although most teenagers cite their own mothers as their major source of information and advise about childrearing, few identify their mothers as major sources of positive reen-

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forcement about their ability to mother (Panzerine, 1986). Instead, many adolescent mothers turn to their health-care providers for approval of the way they are caring for their infants (Panzerine, 1986; Wessel, 1984). Thus, a working understanding of the normal stages of adolescent psychosocial and cognitive development and an awareness of the ways in which these processes shape an adolescent parent’s actions and responses to various childrearing dilemmas are essential. During the first stage of adolescence (early adolescence; ages 12 through 14 years) young people who have just completed the most rapid phase of pubertal development must come to terms with a new body image (Sahler & McAnarney, 1981). The somatic changes of puberty make many early adolescents self-conscious, they often behave as if they are on a stage performing in front of an ‘‘imaginary audience’’ (Sahler & McAnarney, 1981). The skin, breast, and abdominal changes that accompany pregnancy can be extremely negative experiences for a young person at this stage of development. Thus, during the 9 months of pregnancy when adult mothers are beginning to bond to their children by taking pride and pleasure in the changes their bodies are undergoing, most early adolescents feel embarrassed and even angry about what the fetus is ‘‘doing to them.’’ During the prenatal period, early adolescents may verbalize these feelings of anger and resentment that antedate the birth of their child by describing their fetus as ‘‘mean’’ and characterizing its kicking as ‘‘painful and irritating’’ (Hatcher, 1973; Sahler & McAnarney, 1981). This represents a stark contrast to the typical feelings older mothers describe at the first signs of fetal life. During the second stage of adolescence (middle adolescence; ages 15 to 17 years) young people who have adjusted to the somatic changes of puberty must loosen their emotional ties to their families and establish new, independent identities (Sahler & McAnarney, 1981). The birth of a child usually disrupts this process of emancipation by creating the need for more family support. Some teenagers respond to increased feelings of dependency associated with pregnancy and parenthood by regressing and abdicating all childrearing responsibilities to their parents, whereas others rebel against these feelings by isolating themselves from their families (Hatcher, 1973; Sadler & Catrone, 1983). The cognitive changes associated with middle adolescence make young people defiant, narcissistic, egocentric, and self-reliant. As they shift their primary investment in love and dependence from parents to peers, most teenagers go through a phase where they direct their love and attention toward themselves. The narcissism and egocentrism that are characteristic of this stage of adolescent development make it difficult for many middle adolescents to separate their own feelings from the feelings of others, including their child’s (Hatcher, 1973; Sadler & Catrone, 1983; Sahler & McAnarney, 1981). Cognitive deficits contribute to many of the dysfunctional parenting behaviors middle adolescents exhibit. For example, if a 15- to 16-year-old mother dislikes the taste of her infant’s formula she is apt to attribute the infant’s spitting up to a dislike for the milk. With the best intentions she might inadvertently precipitate failure-to-thrive by substituting a better tasting, but less nutritious beverage. Alternatively, a middle adolescent who is jealous of the attention her newborn gets from friends and family members may compete with the child for attention and verbalize her anger and resentment by admonishing others for ‘‘spoiling’’ her baby. Finally, the parenting problems associated with this stage of adolescent development are compounded by the fact that middle adolescence is typically a period of intense curiosity and risk-taking. This is a period of development when feelings of invincibility and invulnerability allow young people to disregard consequences of their actions and experiment freely with a series of different rolls, identities, and lifestyles (Sahler & McAnarney, 1981). Hence, most middle adolescents find it difficult to assume the mothering identity and to accept the restricted time with peers and limitations on mobility that this role demands (Hatcher, 1973; Sadler & Catrone, 1983;). The middle adolescent’s own unwillingness to accept the mothering identity tends to undermine her confidence in her mothering abilities

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(Hatcher, 1973; Sadler & Catrone, 1983). This makes young people at this stage of development especially vulnerable to criticism from family members, boyfriends, and significant adults. For example, a 15- to 16-year-old mother who had spent the day at the mall with her friends might arrive home to find that her infant had developed a diaper rash in her absence. Misinterpreting the rash as evidence that she is not caring for her infant adequately, it would not be uncommon for her to rush the infant to the emergency room for immediate treatment and reaffirmation of her mothering abilities (Wessel, 1984). By the time they reach the third stage of adolescence (late adolescence; ages 17 through 18 years) most young people have adjusted to both the somatic and cognitive changes of puberty (Sahler & McAnarney, 1981). As late adolescents lose their narcissistic feelings of personal omnipotence, they acquire the ability to consider needs other than their own and develop more stable, mutually intimate, relationships (Sahler & McAnarney, 1981). Similarly, as they begin to develop a sense of their future they acquire the ability to think causally, anticipate events, and reason through problems. These psychosocial and cognitive changes make adolescent parents increasingly capable of raising their children independently and those who choose not to do so typically exhibit poorer parenting attitudes and behaviors than do those who chose to do so (Chase-Lansdale et al., 1994). Studies indicate that children who have the advantage of substantial daily input from grandmothers or other adults do not develop the same behavioral, academic, and health problems and are less likely to be maltreated than are children who are raised primarily by their adolescent mothers (Brooks-Gunn & Chase-Lansdale, 1991; Chase-Landsdale et al., 1994; Pope et al., 1993). Although these findings are typically interpreted as evidence that many of the parenting problems associated with childrearing during adolescence could be mitigated by requiring adolescents to share childrearing responsibilities within multigenerational families, caution is critical. The cross-sectional nature of these data makes it impossible to determine the causal sequence in these frequently reported relationships. Thus, it is unclear if presence of a more mature adult in the home has a direct, beneficial effect on the development of the children of adolescent mothers. It is possible that the same personal attributes and qualities that enable some adolescent mothers to elicit the daily support of adults in their environment may also make them more nurturing parents (Chase-Landsdale et al., 1994; Stevens-Simon & White, 1991). Indeed, the lack of objective evidence that grandmothers are superior parents to their teenage daughters favors the latter explanation (Chase-Landsdale et al., 1994). Similarly, evidence that within multigenerational families the quality of both the mothering and the grandmothering behaviors is inversely related to the age of the adolescent mother suggests that the same factors that prevent some late adolescents from moving out of their parents’ home and completing the normal process of emancipation also make them more dysfunctional parents and their mothers less helpful parenting partners (Chase-Landsdale et al., 1994). Although longitudinal studies are needed, available data suggest that those multigenerational families that are most likely to provide positive parenting are those in which young adolescent mothers cohabitate with their mothers and receive the support that they need to successfully resolve emancipation and identity struggles. Such struggles are characteristic of the early and middles stages of adolescence so that during late adolescence individuals are prepared to move out and establish independent households (Chase-Landsdale et al., 1994). Thus, it seems unlikely that welfare policies that require adolescent parents to live with their parents will have the anticipated effects on the well-being of children, unless they are coupled with programs that address the underlying social ills and developmental conflicts that promote premature and delayed emancipation (Stevens-Simon & Lowy, 1995; Stevens-Simon & White, 1991). Finally, when evaluating an adolescent-headed family, it is important to be aware that the antecedents of adolescent pregnancy are extremely variable (Stevens-Simon & Lowy, 1995;

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Stevens-Simon & White, 1991). Thus, the nature and intensity of the conflicts that arise between the competing developmental needs of adolescence and maternal role attainment are invariably colored by the reasons the adolescent became pregnant. For example, the teenager who becomes pregnant in the hopes of resolving feelings of acute or chronic depression and loneliness is apt to be particularly insensitive to her child’s needs and to misinterpret normal crying as rejection (Panzarine et al., 1995). Alternatively, the teenager who becomes pregnant to hold on to a boyfriend is apt to reject her infant and may even blame the child if he leaves her. As we shall discuss in the next section, health-care providers are in a uniquely helpful position; by addressing areas of potential developmental conflict the provider can facilitate the adolescent mother’s development both as an individual and as a mother.

INTERVENTION

Programs for Elminating Specific Risk Factors Secondary child maltreatment prevention programs are designed to provide in-depth intervention to a subset of the population identified as being at increased risk for a particular problem, in this case, dysfunctional parenting. A variety of models has been proposed, including enhancement of parent–newborn contact and interaction, parenting education, telephone hotlines, crisis or respite care of children, the provision of home-health visitors, enhancement of natural community helpers, provision of increased employment opportunities for parents, and reduction of society’s acceptance of violence (Olds & Henderson, 1989; Wolfe & Wekerle, 1993). Although these strategies differ in detail, they are generally predicated on the notion that maltreatment will be reduced if risk factors are eliminated. Thus, it is imperative that a clear and correct understanding of the causal sequences of events that antedate child maltreatment must be obtained. Unfortunately, many interventions that appear to be theoretically sound have failed to achieve the desired outcome because temporal associations have been mistaken for causality (Stevens-Simon & Lowy, 1995; Stevens-Simon & Reichert, 1994). For example, as noted earlier, it seems probable that welfare reforms requiring adolescent parents to live in their parents’ homes have not had the desired effect on adolescent parenting behavior and child maltreatment (and indeed in some cases have had the opposite effect on the welfare of children in this country because intrinsic qualities of multigenerational families are the most important determinants of the effect of co-residency on childrearing) (Chase-Lansdale et al., 1994; Donovan, 1995; Pope et al., 1993; Stevens-Simon & White, 1991). Taken together, these data suggest that it may be prudent to adopt a broader, developmentally based approach to the parenting conflicts arising from the adolescent emancipation struggle. For example, by helping the adolescent who has rejected all offers of assistance from her family understand why it is important for her, as an individual, to have some free time with her peers, a health-care provider can promote the adolescent mother’s development both as a young woman and as a parent. Longitudinal studies are needed to determine efficacy of intervention efforts directed at optimizing the psychosocial development of adolescent parents at preventing the negative parenting practices that are associated with premature and delayed emancipation. Similar criticism can be made of interventions that rely on providing parenting classes to high-risk adolescents and their families. While such programs are a logical extension of the observed association between lack of knowledge of normal child development and child maltreatment, data collected over the past two decades indicate that group meetings and education sessions do not appeal to the vast majority of adolescents and high-risk young parents (Olds & Henderson, 1989). Ensuring that young parents have realistic expectation

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about children’s needs and competencies is undoubtedly an essential component of any effort to prevent child maltreatment. However, while current data indicate that parenting classes improve knowledge about normal child development and nonviolent discipline tactics there is no concrete evidence that increased knowledge and understanding of child development produces the desired changes in actual parenting behaviors (Johnson, Loxterkamp, & Albanese, 1982; Olds & Henderson, 1989). Rather, the literature suggests that if adolescents are to internalize and operationalize the lessons they learn in the classroom, it may be necessary to make parenting classes part of a more comprehensive intervention. For example, Field and colleagues found that among low income, urban, teenage mothers parenting instruction was associated with greater gains in positive parenting behavior when it was provided within the context of a paid job training program, rather than in the classroom or the home (Field, Widmayer, Greenberg, & Stoller, 1982). Thus, by taking a moment to draw an adolescent mother’s attention to the ways in which her newborn infant expresses feelings and needs during a routine health-maintenance visit, a health-care provider may do more to help the young mother learn that her child has feelings that are distinct from hers. This will promote her cognitive development and her development as a parent and will accomplish much more than a classroom teacher who spends several hours discussing the stages of normal child development. Again, prospective, randomized controlled trials are needed to evaluate efficacy of this developmentally based approach to prevention of child maltreatment by adolescent parents. Finally, studies establishing an association between prematurity, neonatal illness, and child maltreatment suggest that events that interfere with the normal bonding that is supposed to occur between a mother and her newborn during the puerperium can precipitate child maltreatment in vulnerable families (Adler, Hayes, Nolan, & Lewin, 1991; Altemeier et al., 1979, 1982, 1985; Anisfeld & Lipper, 1983; Egeland & Brunnquell, 1979; Gazmararian et al., 1995; Klaus & Kreger, 1972; Olds & Henderson, 1989; Siegle et al., 1980; Zuckerman et al., 1995; Zuravin, 1991). For example, children who were the products of unwanted or complicated pregnancies and children who were very sick at birth and had to be separated from their mothers during the neonatal period are more likely to be described as different and difficult to raise and are more likely to be abused than are their siblings (Adler et al., 1991; Altemeier et al., 1979, 1982, 1985; Anisfeld & Lipper, 1983; Egeland & Brunnquell, 1979; Gazmararian et al., 1995; Klaus & Kreger, 1972; Olds & Henderson, 1989; Siegle et al., 1980; Zuckerman et al., 1995; Zuravin, 1991). Despite the strength of the association between early bonding problems and subsequent child maltreatment, it would be a mistake to assume that the relationship is a causal one or to base interventions on the premise that the ill health that puts parent–child bonding at risk in vulnerable families causes child abuse and neglect. Rather, studies showing that abused women give birth to a disproportionately large number of preterm and unwanted infants suggest that the same maternal qualities that predispose some women to complicated pregnancies and bonding problems during the neonatal period (e.g., substance abuse and unmitigated stress) may also make them abusive, neglectful parents. Indeed, efforts to enhance early mother–infant bonding by providing additional hours of contact between parents and their newborns do not appear to prevent subsequent child abuse and neglect (Olds & Henderson, 1989; Siegle et al., 1980). Rather, the results of most studies suggest that early contact is a necessary but not a sufficient condition for good bonding and attachment (Olds & Henderson, 1989; Siegle et al., 1980). In view of the level of stress in the lives of most high-risk parents, the consensus is that long-term intervention programs that seek to improve the life-course development of high-risk parents by addressing the underlying developmental problems and medical and social ills that predispose them first to adverse neonatal outcomes, then to bonding problems during the puerperium,

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and, ultimately, to a variety of violent interpersonal interactions during the childrearing years are needed to prevent child maltreatment (Brayden et al., 1993; Stevens-Simon & Reichert, 1994).

Programs for Improving the Life-Course Development of High-Risk Parents Even though it seems clear that the lack of planning and ill health that complicate some pregnancies do not actually cause even the most vulnerable parents to maltreat their children, studies documenting short-term and long-term effects of adverse neonatal outcomes on families emphasize the importance of optimizing pregnancy outcomes of adolescent and other high-risk mothers (Anisfeld & Lipper, 1983; Lozoff, Brittenham, Trause, Kennell, & Klause, 1977; Lynch, 1975; McCormick, Shapiro, & Starfield, 1982). Comprehensive, multidisciplinary, adolescent-oriented prenatal care programs that provide both the social support and the education needed to eliminate high-risk health-related behaviors are among the most effective ways to overcome personal and environmental factors that predispose adolescent mothers to adverse neonatal outcomes, bonding problems during the puerperium, and excessive family stress and intrafamilial violence throughout the childrearing period (Elster, Lamb, Tavare, & Ralston, 1987; O’Campo et al., 1995; Stevens-Simon & McAnarney, 1991; Stevens-Simon & McAnarney, 1994; Stevens-Simon, Wallis, & Allan-Davis, 1995; StevensSimon & White, 1991). The comprehensive, multidisciplinary approach appears to be critical, as results of several recent studies demonstrate that simply providing social and emotional support in the absences of education designed specifically to extinguish detrimental behaviors (e.g., simply educating pregnant women about the dangers associated with smoking during pregnancy, without providing the emotional support needed to stop smoking) does not prevent adverse pregnancy outcomes (Belizan et al., 1995; Bryce, Stanley, & Garner, 1991; Olds & Henderson, 1989; Olds, Henderson, Tatelbaum, & Chamberlin, 1986; Oakley, Rajan, & Grand, 1990). Preventing adverse pregnancy outcomes is only the first step toward preventing maltreatment of children by their adolescent parents; sick, preterm, and unwanted infants are only one of many sources of stress in these young people’s lives (Stevens-Simon & White, 1991; Stevens-Simon & Reichert, 1994). Other factors known to contribute to the stress of childrearing in adolescent-headed families include rapid repeat pregnancy, which reduces the amount of time and resources that can be spent on the first child, and educational deficits that preclude gainful employment and necessitate long-term welfare dependency (Furstenberg, Brooks-Gunn, & Morgan, 1987; Stevens-Simon & Reichert, 1994; Stevens-Simon & White, 1991; Zuvarin, 1988). Adolescent-oriented maternity programs that end at delivery or during the puerperium have little enduring effect on maternal or child health. However, current data suggest that extending these types of programs beyond the immediate postpartum period (and providing aggressive clinic-based and home-based postpartum follow-up) with a strong emphasis on future-oriented academic and vocational goals and achievement, self-sufficiency skills, self-esteem, family planning, and normal child development is one of the most effective ways to empower young parents and reduce the frustration and anger that precipitate child maltreatment (Elster et al., 1987; Stevens-Simon, Fullar, & McAnarney, 1989; StevensSimon & Reichert, 1994; Stevens-Simon & White, 1991). These types of programs appear to be particularly effective when they include a home visitation component (Gray et al., 1979; Hardy & Streett, 1989; Kemp, 1976; Larson, 1980; Olds & Henderson, 1989; Olds & Kitzman, 1990). Home visitation has a number of characteristics that make it particularly wellsuited for the prevention of maltreatment in adolescent-headed households: (a) home visitors provide a means of reaching out to parents who do not trust formal service providers and

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may be reluctant to seek care that involves potentially threatening group experiences (this is particularly important in caring for families headed by adolescent mothers, as these young women are often very distrustful of the social service system and defensive about their need for this type of assistance); (b) home visitors can acquire a more accurate and complete understanding of all the factors in the home and family that influence the quality of childrearing (this is particularly important in caring for families headed by adolescent mothers, as these young women usually rely extensively on the support of family members and many have difficulty articulating their needs clearly and completely); and (c) presence of a visitor in the home serves as a visible reminder to parents that excessive punishment and neglect of children is not condoned in our society (again this is particularly important in caring for multigenerational families in which dysfunctional parenting is a cyclic, intergenerational phenomenon). There have been several randomized controlled trials of the efficacy home visitation to promote positive parenting behaviors and prevent child maltreatment. The earliest trial was carried out in Denver, Colorado. The investigators used a combination of intensive pediatric consultation and home visitors who offered anticipatory guidance and crisis support to women identified as being at risk for abuse and neglect. Although the study was unable to demonstrate any statistically significant treatment differences in reported and verified cases of child maltreatment, number of accidents, immunization status, or development, visited mothers were less likely to bring their children to the hospital with serious, life-threatening injuries (Gray et al., 1979). In a second study, investigators in Washington, DC demonstrated that providing low-income, minority, adolescent mothers with a visiting nurse who offered both additional support and education about parenting and normal child development was associated with improvements in maternal self-esteem, decreased maternal depression, more appropriate mothering behaviors, a more child-oriented home environment, and improvements in infant attachment and cognitive and language development (Gutelius, Kirsch, MacDonald, Brooks, & McErlean, 1977; Gutelius, Kirsch, MacDonald, Brooks, McErlean, & Newcomb, 1972). The sample size did not allow the investigators to make a meaningful assessment of the impact of their intervention on child maltreatment. Nevertheless, the decreased incidence of maternal depression is an important finding, as studies indicate that depressed mothers tend to see their children as more troublesome and that children often respond to maternal depression by developing problem behaviors (Fergusson, Hons, Horwood, & Shannon, 1984; Flanagan et al., 1994; Panzerine et al., 1995; Zuckerman, Amaro, & Bauchner, 1989). During the 1980s, several additional randomized controlled trials of the efficacy of home visitation to improve the health and welfare and prevent the maltreatment of children were conducted. With the exception of a program that lasts only for the first 3 postpartum months (Seigle et al., 1980) the results of these studies demonstrate that home visitation is associated with improvements in the physical and mental health of mothers and their infants, improvements in parenting attitudes and behaviors, and a decrease in verified episodes of child abuse and neglect (Black et al., 1995; Brayden et al., 1993; Field et al., 1982; Gray et al., 1979; Hardy et al., 1989; Larson, 1980; Olds et al., 1986b). Visited mothers have been found to be less restrictive and punitive and report fewer feeding problems, accidents, and emergency room visits. The consensus that emerges from these studies is that home visitation is most effective when it is initiated during the prenatal period and coupled with intensive prenatal and postnatal counseling, health education, and medical care (Bithoney et al., 1991; Black et al., 1995; Brayden et al., 1993; Larson, 1980; Olds et al., 1990; Seigle et al., 1980). Although visiting nurses are able to mitigate some of the stress associated with poverty by linking families with needed services, there are limits to what they can do alone. For example, the widespread acceptance of violence in many communities can make it difficult for a nurse to teach parents

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nonviolent discipline methods. Thus, in this context it may make sense to complement a home visitation program with public education campaigns aimed to promote nonviolent methods of interpersonal interaction in general and childrearing in particular. Finally, evidence of diminishing effect after program termination emphasizes the necessity of long-term interventions that address underlying etiologic mechanisms. In light of the complexity of the social problems that antedate child maltreatment, it is unreasonable to expect ongoing gains after short-term interventions have been removed (Olds, Henderson, & Kitzman, 1994; Olds et al., 1995). If the United States is to achieve its child safety and welfare objectives for the year 2000, a commitment to long-term solutions that involve political and social change is essential. Addressing only behavioral manifestations of the social ills that antedate child maltreatment, without ameliorating the causes, will not improve the health and well-being of adolescent parents and their children. Rather, evidence that adolescents who become abusive, neglectful parents are more likely to deliver prematurely, to come from dysfunctional families that provide little support, and to live in chaotic social environments (in which the stresses of daily living foster depression, school failure, and repeat pregnancy) suggest the need for comprehensive, multidisciplinary, adolescent-oriented programs that begin during the prenatal period and continue through the preschool years (Stevens-Simon & Reichert, 1994). Recognition of this need prompted the development of The Colorado Adolescent Maternity Program for the Prevention of Child Abuse and Neglect in Denver Colorado.

The Colorado Adolescent Maternity Program for the Prevention of Abuse and Neglect The Colorado Adolescent Maternity Program for the Prevention of Child Abuse and Neglect is a comprehensive, multidisciplinary, prenatal, delivery, and postpartum care program that uses a case-management format to integrate services provided by physicians, midwives, physician’s assistants, social workers, dieticians, and community outreach workers to simultaneously addresses the parental, environmental, and child characteristics that predispose adolescents to a multitude of violent intrafamilial interactions, including the maltreatment of their children. The primary goal is to reduce the number of adolescent parents who risk losing custody of their children because of abuse, neglect, or nonorganic failure-to-thrive. Secondary goals include reducing incidence of adverse pregnancy outcomes, high-school dropout, and repeat adolescent pregnancies. Selection of the various components of the program was based on results of studies reviewed in the preceding sections of this article. Taken together, these data suggest that to be maximally effective child maltreatment prevention programs should: (a) focus therapeutic interventions on those at greatest risk and (b) address medical, educational, and psychosocial needs of the entire family, concurrently (Black et al., 1995; Olds & Kitzman, 1990). This implies that the first step in the development and implementation of a successful child maltreatment prevention program is to objectively quantify the abuse potential of families in the target population. To this end the Family Stress Checklist developed by Murphy and colleagues (1985) is routinely administered to all newly enrolled prenatal patients. In our experience, approximately 35% of young mothers-to-be score in the range reported to be associated with child maltreatment (e.g., the moderate-to-high risk range, greater than 25 points) (Murphy et al., 1985). These investigators found that 40% of the adult prenatal patients they interviewed in a public health clinic in Denver, Colorado had moderate-to-high scores (e.g., greater than 25 points) on the Family Stress Checklist. Two years later, 23% of these women had severely abused or neglected their children, whereas only 9% of the lower scoring women had done so. Gray and colleagues (1979) reported that adult mothers-to-be whose scores on the Family Stress Checklist suggested that they were at increased risk for

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child maltreatment were less well educated and more transient than lower-risk peers. Our analyses have revealed a similar pattern. We found that during the prenatal period, adolescents who have moderate-to-high scores on the Family Stress Check are less likely to be enrolled in school than are their lower scoring peers (54% compared to 37%; p 5 .007). We have also found that pregnant teenagers who move and leave the program while they are still pregnant are significantly more likely to have moderate-to-high scores on the Family Stress Check than are pregnant teenagers who remain in the Colorado Adolescent Maternity Program until they deliver (69% compared to 33%; p 5 .03). Having identified a high-risk cohort of parents, the next step in the process of child maltreatment prevention is development and implementation of intervention strategies. To this end we developed an intensive, multidisciplinary prenatal and postpartum program that simultaneously addresses the medical, educational, and psychosocial needs of adolescent parents and their children. The program is based on the premise that reduction in prevalence of three of the most frequently reported stressors in adolescent-headed families (the birth of an abnormal or preterm baby, school dropout, and repeat adolescent pregnancy) will be associated with a reduction in the incidence of all forms of child maltreatment (Stevens-Simon & Reichert, 1994). During the prenatal period we focus on the prevention of preterm deliveries. It has been documented repeatedly that adolescents give birth to a disproportionately large number of preterm infants (Stevens-Simon & White, 1991). Furthermore, the risk of preterm delivery appears to increase with subsequent pregnancies and a history of maltreatment during childhood in this age group (Stevens-Simon & McAnarney, 1991, 1994; Stevens-Simon & Reichert, 1994; Stevens-Simon & White, 1991). Although the reasons that adolescents are at increased risk for preterm delivery have not been fully elucidated, studies indicate that it is possible to eliminate much of the risk by providing pregnant adolescents with early, consistent prenatal care (Stevens-Simon & White, 1991; Stevens-Simon et al., 1995). Selection of the various components of the prenatal intervention program was based on results of studies that indicate that among adolescents, prenatal care is most effective when provided within the context of comprehensive, multidisciplinary programs designed to meet their unique nutritional, psychosocial, and educational needs. Results of these studies suggest that the benefits of special, adolescent-oriented prenatal care programs could be mediated by improvements in maternal nutritional status and weight gain and by closer attention to the diagnosis and treatment of lower genital tract infections and nonobstetric, psychosocial problems (StevensSimon & McAnarney, 1991; Stevens-Simon & White, 1991; Stevens-Simon et al., 1995). We have found that this approach to prenatal care is effective; adolescents who obtain prenatal care in our program give birth to significantly fewer preterm infants than do other adolescents who deliver at the same hospital (Stevens-Simon et al., 1995). We find it particularly encouraging that neither birth weight nor gestational age vary significantly in relation to Family Stress Checklist scores because it has been reported that women who have been abused and women who are at increased risk for abusing their children are more likely to give birth to preterm infants (Amaro, Fried, Cabral, & Zuckerman, 1990; Newberger et al., 1992; StevensSimon & McAnarney, 1994; Stevens-Simon & Reichert, 1994). During the postnatal period we focus on the prevention of school dropout and repeat pregnancies. It has been documented consistently that failure to finish high school and repeat adolescent pregnancies exacerbate the medical, social, and economic problems associated with childbearing at this age (Stevens-Simon & Lowy, 1995; Stevens-Simon & McAnarney, 1991; Stevens-Simon et al., 1989, 1995; Stevens-Simon, Roghmann, & McAnarney, 1990; Stevens-Simon & White, 1991). Not only does risk of adverse neonatal and maternal outcomes increase with subsequent adolescent pregnancies, but the likelihood of completing high school, having a job, and being self-supporting decreases as well. Although reasons for

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TABLE 3. Lesson Plan for the First 16 Home Visits Introduction to parenting program Introduction to parenthood Developmental stages Safety Review development and personal safety Recognizing and understanding feelings Identifying different types of feelings Developing of positive concept of yourself and your baby Self-concept Review feelings and needs Confrontation and criticism Personal power Spoiling Anger and stress Discipline Review communication skills and techniques for shaping behavior

such diminished likelihood remain to be fully elucidated, consensus is that adolescents who can control their fertility reap numerous benefits for themselves and their children (BrooksGunn & Chase-Lansdale, 1991; Furstenberg et al., 1987; Stevens-Simon & Lowy, 1995; Stevens-Simon & White, 1991). Selection of the various components of the postpartum intervention was based on results of studies indicating that adolescent mothers who are cared for by their infant’s health-care provider receive more regular care, are more compliant with contraceptive prescriptions, are more likely to return to school following delivery, and postpone second pregnancies for longer periods of time than do their peers who receive medical care in other settings ( Stevens-Simon & Lowy, 1995; Stevens-Simon et al., 1989; StevensSimon & White, 1991). To this end, adolescent parents and children who are enrolled in the Colorado Adolescent Maternity Program for the Prevention of Child Abuse and Neglect are seen by the same health care and social service providers. Clinic visits are scheduled at monthly intervals during the first year of life and then every 2 to 3 months until the child is 2 years old. At each clinic visit the health care and social service providers review the infant’s health and developmental milestones, the parents’ general physical and mental health, their use of contraceptives, and their goals for the future. To reinforce the ‘‘in-clinic’’ teaching, the parents are is given an information sheet that lists a series of age-appropriate, development-promoting games to play with their child and the description of a career option that they might consider for themselves. Finally a home visitor begins to work individually with each family during the prenatal period. The home visitor meets with families at each prenatal visit and makes at least once home visit during the prenatal period. Following delivery, families are routinely visited at weekly intervals for the first 4 months of their newborn’s life, and then every month or two (with decreasing frequency) until the child is 2 years old. The goal of the home visitation component of the program is to promote responsible, nurturant parenting behavior and to stop transmission of negative parenting attitudes and styles to the next generation by developing an individualized program to eliminate specific behaviors and attitudes that place the family at increased risk for child maltreatment. Each visit takes at least 1 hour and includes extensive counseling and anticipatory guidance as well as medical, educational, and social service referrals to meet individual family needs. Counseling is semistructured. The home visitor follows a loosely structured lesion plan during the first 16 postpartum visits (see Table 3) and then follows the pattern of counseling outlined in Dr. Marianne

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Neifert’s (1986) book Dr. Mom, supplemented by her own experience and common sense. Frequent contact with the mother during the prenatal and early postpartum periods results in the development of a high degree of rapport between the visitor and the family, so that both parties look forward to their weekly contacts. Most of the counseling is directed and concentrated on day-to-day situations, such as the importance of obtaining contraceptive supplies on time and safety-proofing the home so that the toddlers can have a wide range of development-promoting experiences. Particular emphasis is placed on language development (parents are encouraged to listen to their children and read to them daily), the necessity of love, trust, honesty, patience, and consistency in childrearing (parents are encouraged to cuddle their infants and respond promptly to their ‘‘cues’’ and needs, and to talk gently to and praise achievements of their toddlers). The importance of peace and quiet and nonviolent interactions between adults in the home (the detrimental effects of observed violence on child development) is stressed in every lesson plan. Formal developmental assessments are made every six months (Denver Developmental Screening Test at 6 and 18 months and The Bayley Test at 12 and 24 months) (Bayley, 1992; Frankenberg, Dodds, Archer, Shapiro, & Bresnick, 1992) in an effort to identify infants who are not responding socially and toddlers who are not responding verbally. Although it is still too early to conduct a meaningful evaluation of the efficacy of the postpartum portion of the program, preliminary results are encouraging. After controlling for differences in school enrollment at the time of conception, the rate of school enrollment 6 months following delivery is nearly the same in the among adolescent mothers with high and low scores on the Family Stress Checklist. Although incidence of maltreatment is higher among the 1-year-old children of adolescents who have high scores on the Family Stress Checklist than it is among the infants of their lower scoring peers (7% compared to 3%), the rate of maltreatment in the high-risk group compares favorably with previously published rates of maltreatment in high-risk intervention groups. Gray and colleagues (1979) reported that half of the infants born to adult mothers with high scores on the Family Stress Checklist had experienced some form of maltreatment by the time they were 2 years old, despite implementation of a clinic and home-based maltreatment prevention program.

Future Research During the last two decades, most studies of child maltreatment by adolescent parents have been observational. While such studies have generated a wealth of correlational data, their designs preclude inferences about causality. In this paper we have tried to highlight some of the most glaring gaps in our knowledge about the relationship among maternal age, dysfunctional parenting, and child maltreatment variables. Since effective intervention requires an understanding of causal mechanisms it is imperative that: 1. Future studies of the relationship between maternal age, dysfunctional parenting, and child maltreatment be designed to address testable hypotheses. 2. Sample size calculations be performed so that negative correlations are not prematurely misconstrued as proof that the factors are unrelated. 3. Multivariant analytical techniques be employed so that confounding and interactive effects can be examined and specific programs can be developed to target various subgroups of high-risk young parents before they become abusive and neglectful. 4. Evaluation be an ongoing process. Interventions should be evaluated periodically to determine their efficacy. Investigators and clinicians should not assume that what works today will work tomorrow. Rather they must remain prepared to adjust the content and

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