JOINING FORCES

Joining Families

Volume 15, Issue 1 • Spring 2015

R E A L W O R L D R E S E A R C H F O R F A M I LY A D V O C A C Y P R O G R A M S

F E AT U R E D I N T E R V I E W

Prevention of Child Maltreatment: Home Visiting,
Early Childhood Care, and Beyond
An Interview with John M. Leventhal, MD
John M. Leventhal, MD

John M. Leventhal, MD is Professor of
Pediatrics at the Yale School of Medicine andan Attending Pediatrician at Yale-New Haven
Children’s Hospital, where he is Medical Directorof the Child Abuse and Child Abuse Prevention Programs. He was graduated from Brown
University in 1969 and Tufts Medical School in
1973, and has been at Yale Medical School since
1973.
From 2001 to 2006, Dr. Leventhal served as
Editor-in-Chief of Child Abuse & Neglect, The
International Journal, the major international
In This issue

The topic of this issue of Joining Forces (JFJF) is the prevention of childmaltreatment. Our interview is with John M. Leventhal, MD, Professor of
Pediatrics, Yale University School of Medicine. He has long been a researcher,writer, and advocate for prevention of child maltreatment. Our interview provides
his current views on home visiting, the most widely accepted child maltreatment
prevention program, as well as his views on the current practice of Child
Abuse Pediatrics. An additional article describes his work in child maltreatment
prevention as it has developed over many years. Building Bridges to Research
describes two measures commonly used in research: meta-analysis and effect size
estimation. Websites of Interest features prominent home visiting program that arenationally and internationally recognized as helpful in reducing child maltreatment
and promoting family health. Finally, we begin a new feature, a summary of recent
research that has practical implications for child abuse prevention.

Contents
Featured Interview: John M Leventhal, MD........................................................... 1
Prevention of Child Maltreatment through Home Visitation and Child Advocacy.. 4
Rates of Infant Abusive Head Trauma in Military Similar to Civilian Rates............ 7
What is the Prevalence of Intimate Partner Violence (IPV).................................... 9
Building Bridges to Research: Meta-analysis and Effect Size.............................. 10
Comparison of Army and U.S. National Child Maltreatment Reports, FY2013.... 11
Websites of Interest............................................................................................ 12

journal on child maltreatment. His research has
focused on the epidemiology of child maltreatment, risk factors for abuse and neglect, distinguishing abusive from unintentional injuries, andprevention. He has published over 175 peerreview articles and chapters and has lectured
nationally and internationally.
Dr. Leventhal has received several awards forhis work including the 2008 George Armstrong
Award from the Academic Pediatric Association
for his lifetime work in child abuse and academic
pediatrics and the 2010 Ray E. Helfer, MD Awardfor his distinguished achievements in the fieldof Child Abuse and Neglect; in 2012 he received
the highest honor from the International Society
for the Prevention of Child Abuse and Neglect
by being selected to deliver the C. Henry Kempe
Memorial Lectureship at the biennial congress.
In 2011, he was appointed to the Committee on Child Abuse and Neglect of the American Academy of Pediatrics and is President
elect of the Helfer Society, an honoraryinternational society for physicians who care
for abused and neglected children.

Dr. McCarroll: Much of your work and writingon the prevention of child maltreatment has
been on home visiting. There have been
many approaches to implementing childhome visiting programs. What is the current
evidence on home visiting in preventing childmaltreatment?
Dr. Leventhal: There is good evidence thathome visiting works (Leventhal, 2005). Basically, these programs can help to prevent childContinued on page 2

I teach our residents
always to ask
parents, “Are there
any concerns about
domestic violence?”
because if people do
not ask about it, it
does not come up.

maltreatment. They are probably more effectivein the randomized trials than when they are
not being studied. The best evidence is fromthe studies by David Olds of the Nurse-Family
Partnership, the NFP (Olds, Sadler, & Kitzman,2007). Sending nurses into the home seems
to be very effective and helpful, particularly
for single mothers, who are often teens, have
limited resources and are often on some kindof support, such as Medicaid. The NFP uses a
broad approach to identify high-risk, first time
mothers. It begins care prenatally and thenworks with parents in the home (Olds, Hill,
O’Brien, Racine, & Moritz, 2003). Key issues are
how to implement home visiting in a community and maintain high quality services when
the program is no longer part of an ongoingstudy.
Another approach is the Triple P (Sanders,
2008). It uses everything from trying to change
some of the perceptions of how children
should be treated in a community to intensive
one-on-one home visiting with families thatare already in trouble. One large study in the
U.S. concluded that it seemed to work (Prinz,
Sanders, Shapiro, Whitaker, & Lutzker, 2009).
I do not know what home visiting is likein the Army, but I would think that families
would appreciate the opportunity to work withJOINING FORCES
Joining Families
Editor-in-Chief
James E. McCarroll, PhD
Email:
James.McCarroll.ctr@usuhs.edu
Joining Forces Joining Families
is a publication of the U. S.
Army Installation Management Command and theFamily Violence and Trauma
Project of the Center for the
Study of Traumatic Stress(CSTS), Bethesda, Maryland
20814-4799, tel. 301-2952470. CSTS is part of the
Department of Psychiatry of
Uniformed Services University of the Health Sciences,which is our nation’s federal
medical school.

2 • Joining Forces/Joining Families

Editorial Advisor
COL Anthony L. Cox, LCSW, DCSW,
MSC, USA
Family Advocacy Program Manager
Headquarters, Department of the Army
Editorial Consultant
David M. Benedek, MD, COL, MC, USA
Professor and Scientist
Center for the Study of Traumatic Stress
Uniformed Services University of the
Health Sciences
dbenedek@usuhs.edu

someone coming to their home and talking tothem about child development and parenting.
The home visitor can also work with young
spouses in an effective way to minimize problems such as domestic violence, which can havea very powerful impact on families and children’s development. I teach our residents always
to ask parents, “Are there any concerns about
domestic violence?” because if people do not
ask about it, it does not come up.
Dr. McCarroll: The Army programs screen
mothers prenatally and at birth to identify highrisk people and visit them in their home. Every
Army installation can select its own program.
Dr. Leventhal: There is a training programat Yale-New Haven Children’s Hospital providing pediatric care during the first year of thechild’s life in a group setting. Instead of seeing
one mother and one baby and doing that again
every 20 minutes, we meet with six families at
a time. Residents examine each child, talk to
the mother about her concerns, and then run
the group for about an hour. In the group, we
discuss topics such as post-partum depression,
what it is like to have frustration when caring
for an infant, and how to care for babies more
effectively. We invite fathers and grandmothers
and often they show up as well. An important
advantage of the group is that parents learn
from each other; interestingly, the group createsa social network. It would be interesting to see
if that would work in the Army. There is evena prenatal care program similar to the pediatric group called Centering Pregnancy — The
Center of Your Life [See Websites of Interest].
Families seem to like it a lot.
Dr. McCarroll: Do you have difficulty attracting
families to your home visiting program?
Dr. Leventhal: We have over 100 slots available, both in Spanish and English, and we arealways running about 85% full. We have one
person who focuses on fathers. He has about
20 slots. We offer our home visiting program
to all our first time, socially high risk births at
the hospital; the families are mostly single andabout 25–30% accept the services.
Dr. McCarroll: Do you know why they refuse?
Dr. Leventhal: They say they have enoughsupport. They are living with their mother orthey feel that they and the father can do fine.
Continued on p. 3

Spring 2015

Dr. McCarroll: Do you have any trouble
keeping fathers in the program?
Dr. Leventhal: I think that once they arein the program, we are pretty good at keeping
them hooked in. But, just getting them engaged
is very hard.

In the group, we
discuss topics suchas post-partum
depression, what it islike to have frustration,and how to care forbabies more effectively.

Maltreatment changes
your experience. One
experiences neglect,one experiences
abuse, one
experiences parents
fighting. It becomespart of you in someway.

http://www.CSTSonline.org

Dr. McCarroll: In some of your papers you
used the term disease in referring to childmaltreatment. I am not sure what you meanby that.
Dr. Leventhal: You know it is listed in ICD-9
as a disease, under specific ICD codes 995 forchild abuse (Slep, Heyman, & Foran, 2015).
Dr. McCarroll: There are different ways oftalking about child maltreatment.
Dr. Leventhal: I like to think of it as an experience. Maltreatment changes your experience.
One experiences neglect, one experiences abuse,
one experiences parents fighting. It becomespart of you in some way. When you think about
factors that affect a person’s life trajectory, mostpeople can handle one adverse experience likeabuse or neglect, but handling three or four ismuch more difficult, there is a growing literature on the Adverse Childhood Experiences
study (Felitti et al., 1998). Your cumulative
experience of adverse life events is the thingthat can do you in.
Dr. McCarroll: The U.S. Preventive Services
Task Force found that there is not sufficientevidence to recommend for or against primarycare interventions for child maltreatment.
What is your opinion?
Dr. Leventhal: The primary care approach
to child maltreatment has been limited. The
person who has done the most work with thisis Howard Dubowitz with his Safe Environment for Every Kid (SEEK) program (Dubowitz, Lane, Semiatin, Magder, Venepally, & Jans,
2011). It has a strong evidence base and it
effectively asks parents about problems suchas substance abuse or depression and connects
the families to a social worker who can help. If
you talk to families and connect with them andthey tell you something important about theirlife, you then can link them to services that canbe very helpful. That can diminish the levelof stress in the family and then allow for thatchild to be cared for more in a more nurturing way because you have decreased the stressand cut back on the cumulative number of risk
factors.

Dr. McCarroll: Practitioners in child abuse
prevention have common concerns aboutcommunication, feedback, and information
sharing (Frederico, Jackson, & Dwyer, 2014).
It often seems hard to connect people working
in very disparate areas. They often do nottalk to each other or understand each other’s
terms. For example, child maltreatment
professionals in talking to mental healthprofessionals need to ask the right questions.
In other words, asking about a diagnosis may
not be particularly helpful. But asking, “Whatare the parents’ strengths?” and “What are theparents’ weaknesses, their moods, thoughts
and behaviors, and what are the implicationsof these for day-to-day functioning?” may begood questions. Language is an important
way to connect people and help to understandhow others think and act. This might help inprevention.
Dr. Leventhal: You also have to figure out
who is the patient. The patient may be theperson you are counseling or you are prescribing for, but that patient may have children, andit helps to know how those kids are doing andwhat the risk factors are for those kids. You haveto extend your view of what it means to be aclinician.
Dr. McCarroll: What is your view of treatment
options for children by developmental stage
and type of maltreatment?
Dr. Leventhal: Certainly school age children
and even younger ones with appropriate treatment can be helped. There are parent-childinterventions that are thought to be helpful andthere are good evidence-based approaches totreat traumatized kids and sexually abused kids.
We want to treat them early-on. Sexual abuseis part of a child’s being. Parents and children
themselves have many questions and concerns(Leventhal, Murphy, & Asnes, 2010). Theseexperiences can affect the child when he or she
is an adolescent or when the young adult leaves
the home. I think children who have been sexually abused need some active checking in — notnecessarily mental health treatment, but some
way of re-connecting with someone who canhelp them through the various phases of theirlife. I think of sexual abuse as a chronic disease
and try to work with the pediatricians and ask
them, as they follow these children, to think thatat critical stages they need to re-connect withthese children. They could then get the child into
short-term counseling for three or four sessions
to help the child or adolescent move on.
Continued on p. 8
Joining Forces/Joining Families • 3

Prevention of Child Maltreatment through Home
Visitation and Child Advocacy: A Pediatric Approach
By James E. McCarroll, PhD, and Robert J. Ursano, MD

Dr. Leventhal has beena tireless advocate forchild maltreatment
prevention, a field thatfor many has seemedhopeless. Through his
research, teaching andwriting, he has neverlost hope that prevention
can be successful.

Dr. Leventhal has been a tireless advocate
for child maltreatment prevention, a field thatfor many has seemed hopeless. Through his
research, teaching and writing, he has neverlost hope that prevention can be successful.
He has monitored developments promoting
prevention and periodically updated his review
of progress. Child maltreatment prevention canoccur through (1) general programs to support
parents (good housing, financial support, available and affordable child care) and (2) targeted
programs such as home visiting (Leventhal,
1996).
Home visiting to prevent child abuse in the
U.S. was proposed by Henry Kempe (1976).
He suggested a system of lay home visitors
on a national level that would have contact
with mothers-to-be prenatally and then visit
in the home until the child reached school
age at which point Kempe believed that theteacher could take over. His ideal home visiting
candidate was the successful mother, one who
could act as a bridge between the families andthe health care system. This seminal article
provided many of Kempe’s observations on theparent-child relationship prenatally and postpartum, as well as the importance of positive
family circumstances, and special care for highrisk families. His observations are still current.
A review of Kempe’s vision and the current
state of child prevention emphasized Kempe’ smajor themes: recognition of the rights of thechild, inciuding identification of children at
risk in standard pediatric care, and widespread
adoption of child maltreatment prevention(Chaiyachati & Leventhal, 2014).
Since Kempe’s time, home visitation has
been implemented in many locations both asresearch and as service. Dr. Leventhal has long
been an advocate for home visiting as a meansof preventing child maltreatment as well as for
improving the lives of children and families.
[See boxes (1) Elements Necessary for a Successful Home Visiting Program and (2) Challenges Facing Home Visiting Programs.]
The interest in home visiting has advanced
internationally since Kempe suggested it as ameans of preventing child maltreatment. As
interest has increased, so have the approaches.
However, as with all new programs, research is

4 • Joining Forces/Joining Families

necessary to test effectiveness (MacMillan, Wathen, Barlow, Fergusson, Leventhal, & Taussig,2009).
In addition to the challenges noted by Dr.
Leventhal, there are many other challenges
in implementing home visiting. For example,
Eckenrode et al. (2000) found that when women
who were home visited had more than 28
incidents of intimate partner violence (IPV)
during the study period of 15 years, the effectiveness of home visiting was substantiallyreduced. The harmful effects of violence onchildren were further shown in a study of Child
Protective Services (CPS) reports of families
who participated in home visiting (Duffy,
Hughes, Asnes, & Leventhal, 2014). Of a totalof 1,125 families studied, 15.6% had at least
one CPS report in the period 2006-2008. A risk
score was constructed for each family member
based on six risk factors (histories of CPS, IPV,
mental health, sexual abuse, substance abuse
and criminal involvement) and the number ofcaretakers in the home. Families with a substantiated report (25.2%) were compared to thosewith an unsubstantiated report. Families with asubstantiated first report had a higher numberof paternal risk factors, maternal and paternal
IPV, and maternal criminal history.
Prevention of child maltreatment can also
occur through advocacy. Dr. Leventhal hasemphasized the need for funding for research,funding for successful programs to reach families in need of services such as through home
visitation, and for legislation to support childmaltreatment prevention (Leventhal, 2002).
More specifically, to promote prevention he suggested that clinicians (1) should recognize earlysigns of abuse and neglect and report them tochild protective services agencies, (2) advocate
for prevention during early childhood in orderto prevent adult mental health problems, (3)educate the public about the complexities ofchild maltreatment and successful models of
prevention, and (4) advocate for more funding
focused on prevention and the consequences ofmaltreatment.
Dr. Leventhal has said that continued advocacy for prevention needs to include strengthening current practices, developing innovative
approaches to prevention, and encouraging
Spring 2015

Dr. Leventhal has
said that continued
advocacy for prevention
needs to include
strengthening current
practices, developing
innovative approaches
to prevention, andencouraging thefederal government
to develop an agenda
for child maltreatment
prevention.

the federal government to develop an agenda
for child maltreatment prevention (Leventhal,2005). There are many other issues for which
advocacy is necessary. Krugman and Leventhal(2005) noted historical and chronic fundamental issues leading to shortcomings in thechild protective system: low levels of funding,inadequate training of child protection workers
and clinicians, overburdened child protective
workers, poor supervision of workers, poor
quality of clinical work, inadequate communication among providers about children atrisk, failure to consider the diagnosis of childmaltreatment, failure to focus on the child’s
safety and the child’s and family’s need fortherapeutic services, and criminalization of thechild protection process.
There have been many developments in thefield of pediatrics that have benefited the recognition and prevention of child maltreatment.
Recently, two of these occurred to further theprevention and treatment of child maltreatment protection (Giardino, Hansen, Hill, &Leventhal, 2011). First was the recognition of
the subspecialty of Child Abuse Pediatrics by
the American Board of Pediatrics, a three year
graduate medical education training program.
Board certification was awarded to 191 pediatricians in 2010. A second major change was
the development by the National Associationof Children’s Hospitals and Related Institutions(now called Children’s Hospital Association) ofa framework to highlight and characterize therole of child abuse protection teams at children’s hospitals.
Dr. Leventhal and colleagues have studied
the functioning of hospital-based child protection teams in order to improve their effectiveness (Kistin, Tien, Bauchner, Parker, & Leventhal, 2010). This work included a self-evaluation
tool to assess the functioning of a child protection team (Kistin, Tien, Leventhal, & Bauchner,2011).
Dr. Leventhal has taught and published on awider variety of child maltreatment topics thanprevention. One of these topics is child sexual
abuse. Two recent articles dealt with children’s
disclosures of sexual abuse (Schaeffer, Leventhal, & Asnes, 2011) and practical clinical strategies for evaluation of parent and child concerns
about sexual abuse (Leventhal, Murphy, &Asnes, 2011). The aim of the former article wasunderstanding children’s willingness to disclosesexual abuse as protocols for forensic interviewing do not include what prompted children todisclose or what made them wait to tell about
it. The latter article described six concerns ofparents and four of children when children areevaluated for sexual abuse.
Dr. Leventhal (2001) reviewed the progressof the development of home visiting programs and suggested three important issues in
research as well as in implementation: replication of the findings, influence of family factors,
and variability in the application of the models.
These issues are still important in any home

Challenges Facing Home Visiting Programs— Bringing Programs to Scale■■ Costs■■ Maintaining quality■■ Flexibility and adaptability to fit the strengths and needs of communities■■ Societal changes that may affect parents’ availability and willingness to participate■■ The need for community-based services for other problems such as depression, IPV,
substance abuse, illiteracy, and other issues brought to light through home visiting■■ Attracting fathers to participate in caretaking and in home visiting, and■■ Research and evaluation to test effectiveness, modifications, different populations andprogram strengths and weaknesses.

Reference

Leventhal JM. (2001). The prevention of child abuse and neglect: successfully out of the blocks.
Child Abuse & Neglect; 25: 431-439.

http://www.CSTSonline.org

Joining Forces/Joining Families • 5

Prevention of Child
Maltreatment , from page 5

Dr. Leventhal (2001)
reviewed the progressof the development ofhome visiting programs
and suggested threeimportant issues in
research as well as
in implementation:
replication of thefindings, influenceof family factors,
and variability in theapplication of themodels.

visiting research.
While child maltreatment may be seen bysome as hopeless, there is optimism as childmaltreatment rates are decreasing. Home
visiting program are a substantial intervention
for high risk mothers and families, but home
visiting has many challenges and is not a cure
all for maltreatment or unhealthy life styles.
However, challenges are just what they seem —obstacles to overcome.

Giardino AP, Hansen N, Hill KS, & Leventhal JM.
(2011). Child abuse pediatrics: New specialty,
renewed mission. Pediatrics; 128: 156–159.

References

Kistin CJ, Tien I, Leventhal JM, & Bauchner H.
(2011).A novel self-evaluation tool to assess
the team function of a child protection team.
Academic Pediatrics; 11(6): 451–459.

Chaiyachati BH, & Leventhal JM. (2014). Henry
Kempe’s vision: Preventing child abuse thenand now. Clinical Child Psychology and Psychiatry, published online 6 February 2015. doi:
1177/1359104513519554
Duffy JY, Hughes M, Asnes AG, & Levental JM.
(2014). Child maltreatment and risk pattern
among participants in a child abuse prevention program. Child Abuse & Neglect; http://dx.doi.org/10.1016/jchiabu.2014.11.005.
Eckenrode, J, Ganzel B, Henderson CR, Smith
E, Olds DL, Powers J, …Sidora K. (2000).
Preventing child abuse and neglect witha program of nurse home visitation: thelimiting effects of domestic violence. Journalof the American Medical Association; 284:
1385–1391.

Kempe CH. (1976). Approaches to preventing
child abuse. American Journal of Diseases ofChildhood; 130: 941–947.
Kistin CJ, Tien I, Bauchner H, Parker V, & Leventhal JM. (2010). Factors that influence theeffectiveness of child protection teams. Pediatrics; 126(1): 94–100.

Krugman RD, & Leventhal JM.(2005). Invited
Commentary. Confronting child abuse andneglect and overcoming gaze aversion: the unmet challenge of centuries of medical practice.
Child Abuse & Neglect; 29: 307–309.
Leventhal JM. (1996). Twenty years later: We doknow how to prevent child abuse and neglect.
Child Abuse & Neglect; 21: 647–653.
Leventhal JM. (2002). Editorial: Preventing childabuse and neglect. We (you, your colleagues
and I) have to do more. Clinical Child Psychology and Psychiatry, 7(4), 501–504.

Continued on p. 10

A Successful Home Visiting Program Should:■■ Begin early and include the prenatal period,■■ Occur frequently,■■ Build a relationship with the family,■■ Train the home visitor to recognize early signs of child maltreatment and intimate
partner violence (IPV) so that appropriate services can be provided,■■ Provide effective guidance about parenting using an evidence-based parenting
curriculum,■■ Not lose sight of the child’s needs while working with the parents,■■ Be concrete such as help with organization, housing, and the like,■■ Include fathers, and■■ Make adjustments to meet the family’s needs and progress.

Reference

Leventhal JM. (1996). Editorial: Prevention and beyond (2) — Targeting abuse and neglect.
Clinical Child Psychology and Psychiatry; 1(4): 501–503.

6 • Joining Forces/Joining Families

Spring 2015

Rates of Infant Abusive Head Trauma in Military
Similar to Civilian Rates
By James E. McCarroll, PhD, and Robert J. Ursano, MD

Why is this Article Important?
Risk factors in the
military cohort included
male sex, prematurebirth, a major birthdefect, young maternalage, lower sponsor
rank, and current
maternal military
service.

■■ Abusive head trauma (AHT) in infants
can cause death and poor developmental outcomes.
■■ Preventing AHT and reducing its risk
are key Army Family Advocacy Program (FAP) goals.
■■ Risk factors for AHT in a militarycohort were: male sex, premature birth,a major birth defect, young maternalage, lower sponsor rank, and current
maternal military service.
■■ Practitioners should be aware of theincreased risk for AHT in families withan active duty mother or with additional care takers in the home.

Summary

AHT rates of infants born to militaryfamilies during 1998–2005 were compared tocivilian AHT rates. DOD data were obtained
from the DOD Birth and Infant Health Registry, which captures health care utilization datafrom birth to one year of age or until the infant
is no longer receiving DOD-sponsored care.
Military AHT cases were estimated as substantiated, probable, and possible, based on as theInternational Classification of Diseases-9-Clinical Modification (ICD-9-CM) and the Military
Family Advocacy Program classifications. Rates
per 100,000 and confidence intervals (CI) of
AHT for these three classifications were 34.0
(CI=29.6-38.4), 39.2 (CI=34.4-43.9), and 44.8
(CL=39.7-49.8), respectively.
The Kids’ Inpatient Databases for 1997,
2000, and 2003 were used to estimate theincidence of traumatic brain injury (TBI) in
infants of civilian families (Ellingson, Leventhal, & Weiss, 2008). The Ellingson et al. criteria
for estimating AHT rates were more stringent
than the military classifications. Their criteria
were based only on the presence of an E-code

http://www.CSTSonline.org(external injury) from the ICD-9-CM in an
inpatient population. When the military rate
included substantiated AHT cases (34/100,000,
CI=29.6-38.4) that rate was within the confidence interval for the KIDs database for
2003, 32.2 (CI=26.9-37.4) indicating that the
military and civilian rates were similar. Applying the more stringent Ellingson et al. definitions to the military reduced the military ratefurther to 25.6/100,000. These results suggestthat (1) the military population is not at excess
risk for AHT compared to civilian populationsand (2) civilian data may underestimate thescope of AHT.
Risk factors in the military cohort included
male sex, premature birth, a major birth defect,
young maternal age, lower sponsor rank, andcurrent maternal military service. Note that
this study could not identify the perpetrator of
the AHT. However, compared to families witha non-military mother, infants born to military
mothers were at 3.6 times higher risk; single
military mothers had 3.1 times greater odds ofan AHT infant case; and dual military families
had 2.5 time greater odds. It is likely that inmany of the cases with military mothers, thatthe non-military male was the perpetrator.

Future Research

A good project for a military researcher isto understand the characteristics of increased
risk for families with military mothers andto develop prevention programs for thesefamilies.

References

Gumbs GR, Keenan HT, Sevick CJ, Conlin AMS,
Lloyd DW, Runyan DK, …Smith TC. (2013).
Infant abusive head trauma in a militarycohort. Pediatrics; 132: 668-678.
Ellingson KD, Leventhal JM, & Weiss HB. (2008).
Using hospital discharge data to track inflicted traumatic brain injury. American Journalof Preventive Medicine; 34(S): S157-S168.

Joining Forces/Joining Families • 7

John M. Leventhal, MD
Interview, from page 3

Neglect is a chronic
problem for manyfamilies who need
substantial supports.
Often, mental healthand drug use are also
involved. Trying tofigure out how to help
those families is a huge,huge problem.

Think of a brokenbone that results froma car accident versus
one from physicalabuse. These brokenbones are the same,but the broken bonefrom physical abuse
is a marker of how
the child has beentreated in the family.

Dr. McCarroll: You were a co-author on a2009 Lancet article about child maltreatment
prevention (MacMillan, Wathen, Barlow,
Fergusson, Leventhal, & Taussig, 2009). That
article discussed the difficulty of preventing
psychological abuse as well as chronicneglect.
Dr. Leventhal: This is where clinical practiceneeds to step up and start looking for families
that are really challenged by their kids. I talkto our residents about how to engage families,
and to ask families “What is it like to take careof your son?” “What do you like best about
your son?” “What do you like least about him?”
These are good questions to begin to understand what it is like for the parent to care forher child, but asking these sorts of questions,listening to the responses and acting on these
responses takes time. “What is it like when you
feed your baby?” “What is it like when you takecare of your baby?” “What is it like when yourbaby cries?” We can then start to understandthe experiences of being a parent. That becomes a place where the clinician can get someleverage and promote a different way of thinking. The time is in the listening.
I do not think anyone has figured out how
to leverage adequate resources to prevent
neglect, like the lack of shelter, food, clothing, supervision, and medical and dental care.
Neglect is a chronic problem for many families
who need substantial supports. Often, mental
health and drug use are also involved. Trying tofigure out how to help those families is a huge,huge problem.
With regard to psychological abuse, thinkof a broken bone that results from a car accident versus one from physical abuse. These
broken bones are the same, but the brokenbone from physical abuse is a marker of how
the child has been treated in the family and thelikely occurrence of psychological abuse andinadequate nurturing that accompanies thephysical harm.
Abusive head trauma is also an important
problem. There is substantial morbidity andmortality from this type of abuse. We havedone a good job getting people to use infant
car seats every single time they put a baby ina car. We also have done a pretty good job of“Back to sleep.” But as a society, we have done
less well helping parents not shake or slamtheir infants. Crying and other behaviors ofinfants can be very frustrating and overwhelming for parents. The problem is to figure out
how to help the parent so that every time the8 • Joining Forces/Joining Families

baby cries the parent says, “I know what to do
and if the baby cries, I am not going to get frustrated even if I am an impulsive guy.” A recent
study compared abusive head trauma (AHT) to
children of military parents to a civilian population (Gumbs, Keenan, Sevick, Conlin, Lloyd,… Smith, 2013). When similar case definitions
were applied to both populations, the rate of
AHT was similar. [See separate summary formore details about this study.]
Dr. McCarroll: How do you teach about childmaltreatment fatalities?
Dr. Leventhal: The problem is that thesecases are rare. They are very rare. We focus onserious abuse and try not to miss those. We
teach about how to evaluate injuries in young
children. Because the fatalities are just not that
common, we focus on the more commonly seenkind of injuries such as bruising, fractures, andhead injuries making sure that those due toabuse do not get missed in emergency departments. We also make sure that serious neglect is
not missed because that too can lead to death.
Dr. McCarroll: Thank you for your time and foryour work.
Dr. Leventhal: Thank you. It has been a great
pleasure for me.

References

Dubowitz H, Lane WG, Semiatin JN, Magder
LS, Venepally M, & Jans M.(2011). The Safe
Environment for Every Kid Model: Impact onpediatric primary care professionals. Pediatrics;127(4): 962–970.
Felitti VJ, Anda RF, Nordenberg D, Williamson
DF, Spitz AM, Edwards V, … Marks JS.(1998).
Relationship of childhood abuse and household dysfunction to many of the leading causesof death in adults. American Journal of Preventive Medicine; 14(4): 245–258.
Frederico M, Jackson A, & Dwyer J. (2014). Child
protection and cross-sector practice: An analysis of child death reviews to inform practicewhen multiple parental risk factors are present.
Child Abuse Review; 23(5): 104–115.
Gumbs GR, Keenan HT, Sevick CJ, Conlin AMS,
Lloyd DW, … Smith TC. (2013). Infant abusive
head trauma in a military cohort. Pediatrics;
132: 668-678.
Leventhal JM. (2005). Getting prevention right:
maintaining the status quo is not an option.
Child Abuse & Neglect; 29: 209–213.
Continued on page 9
Spring 2015

John M. Leventhal, MD
Interview, from page 8

Leventhal JM, Murphy JL, & Asnes AG. (2010).
Evaluations of child sexual abuse: Recognition of overt and latent family concerns. Child
Abuse & Neglect; 34: 289–295.

MacMillan HM, Wathen CN, Barlow J, Fergusson DM, Leventhal JM, & Taussig HN.
(2009). Interventions to prevent childmaltreatment and associated impairment.
Lancet; 373: 250–266.
Olds DL, Sadler L, & Kitzman H. (2007). Programs for parents of infants and toddlers:
recent evidence from randomized trials. Journal of Child Psychology and Psychiatry 48:3/4:
355–391.
Olds DL, Hill PL, O’Brien R, & Racine, D. (2003).
Taking preventive interventions to scale: The

Nurse-Family Partnership. Cognitive andBehavioral Practice; 10: 278-290.
Prinz RJ, Sanders MR, Shapiro CJ, Whitaker DJ, &Lutzker JR. (2009). Population-based prevention of child maltreatment: The U.S. Triple P
system population trial. Prevention Science; 10:
1–12.
Sanders MR. (2008). Triple P-Positive Parenting
Program: Towards an empirically validated
multilevel parenting and family support
strategy for the prevention of behavior andemotional problems in children. Clinical Childand Family Psychology Review; 2(2): 71–90.
Slep AM, Heyman RE, & Foran HM. (2015).
Child maltreatment in DSM-5 and ICD-11.
Family Processes, e-print ahead of publication.
doi: 10.1111/famp.12131.

What is the Prevalence of Intimate Partner Violence(IPV), its Health Consequences, and Approaches toIntervention?
By James E. McCarroll, PhD

Why is this Article Important?

Definitions of IPV have
expanded to include
stalking, control ofreproductive andsafe sex choices, andpatterns of IPV.

■■ This article is a summary of a substantial body of current knowledge
about IPV.
■■ It is helpful for providers to have acurrent summary of the major topics in IPV that can be useful withpatients, colleagues, and for practitioners outside family violence.

Key points by the author:■■ IPV affects women and men regardless of the demographics.
■■ One in three women and one in fourmen experience IPV in their lifetime.
■■ Health issues, not acute injuries, arethe most common complaints ofpatients who experience IPV.
■■ The role of the medical provider isto acknowledge the problem, assess
safety, refer when appropriate, anddocument medically.
Definitions of IPV have expanded toinclude stalking, control of reproductive andhttp://www.CSTSonline.org

safe sex choices, and patterns of IPV. The latterdelineates IPV in terms more complex than just
victim and perpetrator. It includes the conceptsof situational couple violence, intimate terrorism, violent resistance, and mutual violent control. Prevalence of IPV is discussed by gender,
age, race, sexual orientation, and socioeconomic
status, as well as its prevalence in various healthcare settings: primary and specialty care, ED,obstetrics and reproductive health. There is extensive discussion of IPV health consequences,both medical and behavioral, including mental
health, suicide, homicide, pregnancy, adolescenthealth, and injury.
Screening is extensively discussed with thepros and cons of screening and case finding.
[See Joining Forces Joining Families, Volume
14, No. 2, Summer 2014, for an interview withHarriet MacMillan, MD, in which she discussed
the difference in these two approaches tointervention in IPV. Dr. MacMillan presented astrong argument for case finding over universal screening.] In the article summarized here,
Sugg presents a detailed description of current
thinking about IPV screening including thosechanges due to the Affordable Care Act.
The study of intervention for IPV has lacked
controlled studies that point the way toward
an effective approach. Research is hampered byContinued on page 10
Joining Forces/Joining Families • 9

BUILDING BRIDGES TO RESEARCH

Meta-analysis and Effect Size
By James E. McCarroll, PhD

Meta-analysis
combines theresults of manystudies to identify
consistent patternsof agreement or
disagreement.

The effect size isa measure of thedifference between
two outcomes suchas a treatment group
and a control group.

Prevention of Child
Maltreatment, from page 6

In this article, we describe two concepts
that are frequently encountered in scientificand medical literature on family maltreatment:
meta-analysis and effect size. Meta-analysis is astatistical technique that combines the resultsof several or many studies in order to identify
consistent patterns of agreement or disagreement in results. In meta-analysis, the studies
themselves are the units of analysis (Greenland, 1998). Meta-analysis can be controversial
depending on the purpose of the analysis. One
possible research goal is to look for an overall summary of an effect across studies, theso-called synthetic approach. For example, insocial science, reviewers of a topic may facehundreds of studies and want to synthesize asummary position on the topic in question. A
different approach is to look for study-specificeffects such as the identification and quantification of differences, a so-called analytic goal.
The effect size is a measure of the difference
between two outcomes, such as a treatmentgroup compared to a control group. The effectsize, then, is the magnitude of the treatment
effect. Effect size can be categorized as strong,
moderate, or weak. There are different measuresof effect size such as the correlation coefficient,the mean difference, and the regression coefficient. Note that the effect size is different fromstatistical significance, a measure of the probability of the outcome due to chance.
In reading scientific literature it is importantto read the section in the paper on the limitations of the report, a necessary requirement for
publication of most journals. These can alert
the reader to many caveats such as selecting or
excluding certain types of studies (such as thosewith negative results and those that appear to
be too small to be meaningful), consistency inmeasures, and possible biases.

Leventhal JM. (2001). The prevention of childabuse and neglect: successfully out of theblocks. Child Abuse & Neglect, 25: 431–439.

Prevalence of IPV, from page 9

Leventhal JM, Murphy JL, & Asnes AG. (2010).
Evaluations of child sexual abuse: Recognition of overt and latent family concerns. Child
Abuse & Neglect, 34: 289–295.
Leventhal JM. (2005). Editorial: Getting prevention right: maintaining the status quo is not
an option. Child Abuse & Neglect, 29, 209–213.
Schaeffer P, Leventhal JM, & Asnes AG. (2011).
Children’s disclosures of sexual abuse:
Learning from direct inquiry. Child Abuse &Neglect, 35, 343–352.

Reference

Greenland S. (1998). Meta-analysis. In KJ Rothman & Sander Greenland. Modern Epidemiology, 2d Edition. Philadelphia: Lippincott-Raven
Publishers, pp. 643-673.

many contingencies that involve methodology,
safety, ethical, and legal issues. Nevertheless,
Sugg presents four key components of intervention: when seeing patients, providers canacknowledge that IPV is a serious problem that
affects health, assess safety, referral, and documentation. Legal issues vary from state to state,
but Sugg gives highlights of the legal issues tobe considered.
Finally, Sugg addresses the barriers that thepatient in a violent relationship faces in terms ofleaving or not leaving, issues that providers also
must consider when considering intervention.

Reference
Home visiting programs are a substantial intervention for high risk
mothers and families, but home visiting has many challenges and is nota cure all for maltreatment or unhealthy life styles.

10 • Joining Forces/Joining Families

Sugg N. (2015). Intimate partner violence prevalence, health consequences, and intervention. Medical Clinics of North America; 99(3):629–649.

Spring 2015

Comparison of Army and U.S. National Child
Maltreatment Reports, FY2013
By James E. McCarroll, PhD

The overall rate ofmaltreatment in the
Army is approximately
31% lower than in the
U.S. The rate of neglect
is about 43% lower
than in the U.S. andthe rate of child sexual
abuse is less than half
the U.S. rate.

This article compares Army child maltreatment data for FY2013 with the U.S. national
data from Child Maltreatment 2013, the mostrecent U.S. national data available. Child
Maltreatment 2013 is a report of child maltreatment victims reported by the 50 states, theDistrict of Columbia and the Commonwealthof Puerto Rico to the National Child Abuse andNeglect Data System (NCANDS) as requiredby the Child Abuse Prevention and Treatment
Act (CAPTA). Army data reported here arefrom the Army Central Registry (ACR) of childmaltreatment.
Victims and Rates. There were 678,932 victims of child abuse and neglect in the U.S. fora total victim rate of 9.1/1,000 children in the
U.S. for FY2013. There were 3,132 Army childvictims for an overall rate of 6.3/1,000.

Child Maltreatment Victim Rates/1,000

U.S. National Army
Total child maltreatment
9.1
6.3
Neglect
7.5
4.3
Physical abuse
1.7
1.4
Emotional abuse
0.8
0.7
Sexual abuse
0.8
0.3
Other maltreatment*
0.9
NA*Other maltreatment refers
to state codes not recognized by NCANDS. These
could include threatenedabuse, parent’s drug or
alcohol abuse, safe relinquishment of a newborn,and others.
http://www.CSTSonline.org

Most Common Maltreatments in the U.S.
In the U.S., the most commonly substantiatedtype of maltreatment was neglect (79.5%). Other maltreatments were: physical abuse, 18.0%;
psychological abuse, 8.7%; sexual abuse, 9.0%;
and other maltreatment, 10.0%). (Percentages
are greater than 100% because some children
had more than one type of maltreatment.)
Most Common Maltreatments in the
Army. The most commonly substantiated typeof maltreatment in the Army was also neglect(60%). Other maltreatments were physicalabuse, 20%; emotional abuse, 16%; and sexual
abuse, 4%.
Substantiation of Cases. In the U.S., approximately 3.9 million children were the subject of at least one report to Child Protective
Services agencies. Approximately one-fifth ofchildren (17.5% substantiated, 0.9% indicated,
and 0.4% alternative response victims) werecounted as victims.
In the Army, there were 7,662 child refer-rals. A total of 3,812 incidents (50%) were
substantiated (met criteria) for inclusion in the
ACR.
Fatalities of Children in the U.S. An
estimated 1,520 children in the U.S. died fromabuse or neglect for a national fatality rate of
2.04/100,000. Almost 75% of all child fatalities
were less than three years old. Boys (2.36/1,000)
had a higher fatality rate than girls (1.77/1,000).
Almost 80% of fatalities were caused by one orboth parents. (Fatality rate data from the Army
are not available in the same form as reported
in Child Maltreatment.)
Child Victimization Rate by Child Age.
Children under one year of age in the U.S.
had the highest victimization rate, 23.1/1,000.
The rate for infants (less than one year old)in the Army was 8.4/1,000. For one-year olds,
7.9/1,000; for two-year olds, 7.7/1,000.

Conclusions

1. The overall rate of maltreatment in the
Army is approximately 31% lower than in
the U.S. The rate of neglect is about 43%
lower than in the U.S. and the rate of childsexual abuse is less than half the U.S. rate.
The rates of the other maltreatment types(physical and emotional) are slightly lower
than the U.S. rates.
2. The Army substantiates a higher percentage
of child maltreatment incidents (50%) thanthe U.S. (about 20%).
3. Child maltreatment rates of children in the
Army were about 31% lower than the rates
in the U.S.
4. The most frequently found type of childmaltreatment, neglect, is lower in the Army(60%) than in the U.S. national data (81.8%).
Physical abuse maltreatment in the Armywas slightly larger (20%) than the U.S. data(18%). Emotional abuse in the Army (16%)
was approximately twice that of the civilian community (8.7%) and the sexual abusemaltreatment in the Army (4%) was lessthan half that of the U.S. (9%).

Reference

U.S. Department of Health and Human
Services, Administration on Children, Youthand Families, Children’s Bureau. (2015). Child
Maltreatment 2013. (See http://www.acf.hhs.gov/
programs/cb/research-data-technology.)
Joining Forces/Joining Families • 11

Websites of Interest
The interview with Dr. Leventhal stresses the importance of home visiting in preventing child maltreatment.
The following are the most widely supported and researched
programs.
THE NURSE-FAMILY PARTNERSHIP is one of the most
adopted home visiting programs in the U.S. It has verystrong research support over several decades of follow-up of
home-visited families.
http://www.nursefamilypartnership.org/.
The TRIPLE P is an internationally adopted program forparenting that includes strategies to manage children’s behavior and build healthy relationships.
The Triple P has a website for practitioners
http://www.triplep.net/glo-en/home/ and one for parents
http://www.triplep.net/glo-en/home/.
HEALTHY FAMILIES AMERICA http://www.healthyfamiliesamerica.org/about_us/index.shtml is a program for
expectant mothers and new parents to receive educationand support.
CENTERING PREGNANCY http://centeringhealthcare.
org/pages/centering-model/pregnancy-overview.php (notedby Dr. Leventhal in his interview) is a form of pediatricgroup care that includes health assessment, education andsupport.
Child abuse prevention resource guide 2015-acf is acomprehensive guide to service providers to prevent childmaltreatment. It includes protective factors to build family strengths and promote optimal child development.
https://www.childwelfare.gov/topics/preventing/preventionmonth/resource-guide/?utm_source=Gateway&utm_
medium=Elert&utm_campaign=NCAPM15
The annual Child Maltreatment publication is available
at the CHILDREN’S BUREAU http://www.acf.hhs.gov/
programs/cb. (Search under research-data-technology.)
This report gives the latest U.S. national, child maltreatment
statistics and additional data by states. This website also
gives many references and resources for federal government
programs and reports.

12 • Joining Forces/Joining Families

Spring 2015