National Center for Injury Prevention and Control 

Division of Violence Prevention

Center for Injury Prevention and Control 

f Violence Prevention

Steps to Create Safe, Stable, Nurturing 

Relationships and Environments 

Essentials for Childhood

Steps to Create Safe, Stable, Nurturing 

Relationships and Environments 

Reprinted August 2014 with minor technical edits
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Introduction

Safe, stable, nurturing relationships and 

environments are essential to prevent 

child maltreatment (CM) and to assure that 

children reach their full potential.

This document proposes strategies that communities (“communities” refers to any 

group with shared interests such as neighborhoods, counties, states, and professional 

groups) can consider to promote the types of relationships and environments that help 

children grow up to be healthy and productive citizens so that they, in turn, can build 

stronger and safer families and communities for their children.

Child Maltreatment Is a Significant 

Public Health Problem

CM is a significant public health problem in the United States (U.S.) and around 

the world.1,2 Abused children often suffer physical injuries including cuts, bruises, 

burns, and broken bones. Physical injury is far from the only negative impact of 

maltreatment—it can also affect broader health outcomes, mental health, social 

development, and risk-taking behavior into adolescence and adulthood. 

CM includes all types of abuse and neglect of a child under the age of 18 by a 

parent, caregiver, or another person in a custodial role (e.g., clergy, coach, teacher) 

that results in harm, potential for harm, or threat of harm to a child. There are four 

common types of abuse3

:

■ Physical abuse is the use of physical force, such as hitting, kicking, shaking, 

burning, or other shows of force against a child.

■ Sexual abuse involves engaging a child in sexual acts. It includes behaviors such 

as fondling, penetration, and exposing a child to other sexual activities.

■ Emotional abuse refers to behaviors that harm a child’s self-worth or emotional 

well-being. Examples include name calling, shaming, rejection, withholding love, 

and threatening.

■ Neglect is the failure to meet a child’s basic physical and emotional needs. These 

needs include housing, food, clothing, education, and access to medical care.4
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Maltreatment causes stress that can disrupt early brain development, and serious, 

chronic stress can harm the development of the nervous and immune systems. As a 

result, children who are abused or neglected are at higher risk for health problems as 

adults. These problems include alcoholism, depression, drug abuse, eating disorders, 

obesity, high-risk sexual behaviors, smoking, suicide, and certain chronic diseases.2,5

While it is not easy to determine the magnitude of CM in the U.S., it is substantial. 

According to state Child Protective Service (CPS) agencies, 695,000 children were 

found to be victims of maltreatment in 2010. Another 1,560 children died from CM 

that year.6

 In these CPS cases, children 3 years old and under were at greatest risk, 

and the majority of cases involved neglect.

The official cases tell only part of the story, as many, if not most, are never reported 

to social service agencies or the police.7,8,9 Additional survey results provide an even 

more troublesome picture of this problem. A non-CPS study estimated that one in 

five people in the U.S. experience some form of CM during their childhood.10

Surveys of adults reveal that CM is relatively common. In a national survey, 14.2 

percent of men and 32.3 percent of women reported childhood histories of sexual 

abuse, and 22.2 percent of men and 19.5 percent of women reported experiencing 

physical abuse during their childhood.11
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Safe, Stable, Nurturing Relationships and 

Environments Are Important 

for Preventing Child Maltreatment

Young children experience their world through their relationships with parents and 

other caregivers. Safe, stable, nurturing relationships and environments between 

children and their caregivers provide a buffer against the effects of potential 

stressors such as CM and are fundamental to healthy brain development. They also 

shape the development of children’s physical, emotional, social, behavioral, and 

intellectual capacities, which ultimately affect their health as adults. As a result, 

promoting safe, stable, nurturing relationships and environments can have a positive 

impact on a broad range of health problems and on the development of skills that 

will help children reach their full potential. 

Safety, stability, and nurturing are three critical qualities of relationships that make a 

difference for children as they grow and develop. They can be defined as follows:

■ Safety: The extent to which a child is free from fear and secure from physical or 

psychological harm within their social and physical environment.

■ Stability: The degree of predictability and consistency in a child’s social, 

emotional, and physical environment.

■ Nurturing: The extent to which a parent or caregiver is available and able to 

sensitively and consistently respond to and meet the needs of their child.

Safe, stable, nurturing relationships and environments are important to promote. There is 

reason to believe they can help to:

■ Reduce the occurrence of CM and other adverse childhood experiences

■ Reduce the negative effects of CM and other adverse childhood experiences

■ Influence many physical, cognitive, emotional outcomes throughout a child’s life

■ Reduce health disparities

■ Have a cumulative impact on health

For more information on the importance of safe, stable, nurturing relationships and 

environments:

 www.cdc.gov/ViolencePrevention/pdf/CM_Strategic Direction--Long-a.pdf
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What to Expect in This Guide

This document suggests strategies for communities to consider. It is intended 

for anyone committed to the positive development of children and families, and 

specifically to the prevention of all forms of CM. It is organized into four sections. 

Each section focuses on one goal and lays out suggested steps to help you move 

toward that goal. While each individual goal is important, the four goals together 

are more likely to build the comprehensive foundation of safe, stable, nurturing 

relationships and environments for children. The four sections include: 

GOAL 1: Raise awareness and commitment to promote safe, stable, nurturing 

relationships and environments and prevent child maltreatment

GOAL 2: Use data to inform actions

GOAL 3: Create the context for healthy children and families through norms 

change and programs

GOAL 4: Create the context for healthy children and families through policies

This guide is designed to point out critical goals and potential steps for promoting 

safe, stable, nurturing relationships and environments and preventing CM. However, 

exactly how, when, and in what order you take on each step will depend on what is 

already happening in your community. Therefore, as your community takes on the 

action steps outlined in this guide, consider your unique needs. Working together, 

there is much your community can do to create an environment in which children 

can—and do—live life to their fullest potential. 
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The Importance of Using 

Evidence-Based Strategies

The steps in this document are based on the best evidence available. For 

example, Step 3 in Goal 3 refers to a rich scientific literature, including 

several strategies that have been rigorously evaluated and shown to 

prevent or reduce CM. On the other hand, Step 2 in Goal 4 on promoting 

policies is built on less rigorous evidence.

The evidence base for promoting safe, stable, nurturing relationships 

and environments and preventing CM is not static; it is constantly 

evolving. Therefore, we must act on the best evidence available to us 

today, knowing it could change tomorrow. And, as we go, we have a 

responsibility to evaluate our efforts whenever possible to add to the 

evidence base. The Centers for Disease Control and Prevention’s (CDC) 

Division of Violence Prevention provides guidance and resources to assist 

with evidence-based decision-making using a continuum of evidence of 

effectiveness: 

www.cdc.gov/violenceprevention/pub/UnderstandingEvidence_prt1.html 
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Goal 1

Providing safe, stable, nurturing relationships and environments for all children 

requires changing attitudes, behaviors, norms, and policies. Even if you know 

people or groups who are motivated to create this kind of change, you will only see 

results when the idea garners the support of the larger community and its leaders. 

This means your efforts to prevent child maltreatment (CM) and promote safe, 

stable, nurturing relationships and environments in your community requires both 

community and social commitment. 

When we talk about community and social commitment in this guide, we mean that 

the broader community is committed to ensuring safe, stable, nurturing relationships 

and environments for children. This commitment does not stop at awareness, but 

moves along a continuum from awareness of the problem to solution. Observing 

an impact on safe, stable, nurturing relationships and environments and CM is 

more likely as community members and leaders move along the continuum toward 

solutions.

Why Sustained Commitment Is Important

It is worth noting the biggest obstacle to improving health throughout a community 

is often not the shortage of funds or the absence of “programs” but rather the 

lack of commitment to do something about it.12 This means it is critical to build 

commitment as a foundation for any meaningful public health initiative, including the 

steps to support safe, stable, nurturing relationships and environments and prevent 

CM. You can expect creating commitment to take time, resources, and persistence.13

It requires the continuous use of new information and ongoing public involvement, 

as well as the translation of technical information for the general public, leaders, and 

decision-makers.

Raise Awareness and Commitment to Support 

Safe, Stable, Nurturing Relationships and 

Environments and Prevent Child Maltreatment
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To build awareness and commitment at the community level you might consider: 

1) Adopting the vision of “assuring safe, stable, nurturing relationships 

and environments for every child and preventing child maltreatment”

2) Raising awareness in support of the vision 

3) Partnering with key stakeholders to unite behind the vision 

Step #1 

Adopt the vision of “assuring safe, stable, nurturing relationships and 

environments for every child and preventing child maltreatment” 

Creating a vision is typically the beginning of a planning process during which you 

come up with goals, objectives, and action steps. You might consider adopting the 

vision of “assuring safe, stable, nurturing relationships and environments for every 

child and preventing child maltreatment” and the goals, objectives, and action steps 

proposed in this document.

Step #2

Raise awareness in support of the vision 

Others will be more likely to join you in working toward safe, stable, nurturing 

relationships and environments for all children if you are able to communicate why 

they are important and how they fit into the prevention of CM. 

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NOTE OF CAUTION: When raising awareness is mentioned, many organizations 

default to very basic information such as stating that child abuse is a problem and 

that it is bad for children. Most people already know and accept these facts. What is 

critical in this step is communicating something that will bring new supporters into 

the fold. For the best results, you will need to do this in a way that your community 

members, leaders, and decision-makers both understand and value. Depending on 

what field you are in, and who you are engaging, the strategies you use and steps you 

take may be simple or more involved. Some information and resources that can help 

you accomplish this include:

■ The consequences of CM can last a lifetime and include negative impacts on 

social, emotional, and physical health. We can reduce the leading causes of illness 

and death in our community by assuring safe, stable, nurturing relationships and 

environments for our children. 

• The Effects of Childhood Stress on Health Across the Lifespan 

www.cdc.gov/ncipc/pub-res/pdf/Childhood_Stress.pdf

• http://developingchild.harvard.edu/resources/

■ CM takes a huge economic toll on our society through child welfare costs, physical 

and mental health costs, special education costs, and legal system costs.

• The Economic Burden of Child Maltreatment in the 

United States and Implications for Prevention 

www.cdc.gov/ViolencePrevention/childmaltreatment/EconomicCost.html 

■ We have good information on strategies that can assure safe, stable, nurturing 

relationships and environments and prevent CM, we just need to invest in those 

strategies.

• See information on evidence-based programs and strategies in Goal 3.

Step #3

Partner with others to unite behind the vision 

Partnering with individuals or groups—from the general public, community 

organizations, leaders, decision-makers, and media—can help move from awareness 

to solutions. These partners can bring in additional support and lend their voice and 

leadership to your effort.

Partnerships can help unite those committed to children and community health 

behind the vision so you can work together. Most of the time, one organization can’t 

do this on its own—there is power in numbers. Since there are so many possibilities, 

it may be helpful to prioritize and focus your goals.
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Don’t overlook the media as a potential partner. Building a relationship with 

your news outlets will further support your efforts to create community and social 

commitment. Capitalize on this by creating news events they can cover, generating 

editorials, providing community data to help reporters ‘localize’ a story, and providing accurate information about the problem and prevention solutions.

Goal 1 Summary

Individuals and communities must be committed to the vision of safe, stable, 

nurturing relationships and environments for all children and willing to take action 

in support of that vision. While commitment is critical, this alone will not change 

the rates of CM in your community. Observing an impact on CM is more likely if 

you combine commitment, along with comprehensive data, effective programmatic 

strategies, and policy approaches.
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“Building a relationship with your news 

outlets will further support your efforts to 

create community and social commitment.”
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To adequately address any public health issue, using the information you have 

available is critical. This factual information—data—will help you understand 

the size and nature of the problem in your community, how to best direct your 

community’s prevention resources, and to monitor the ultimate impact of any 

interventions (such as a new program or policy).

To start, you need to learn how people in your community think and feel 

about child maltreatment (CM) prevention. It is also important to learn what 

you can about their relationships to one another, as well as any community, 

environmental, and social factors that might be related to the problem. Pulling 

all of this information together is not an easy task, but it is crucial information 

that can be fed into the other goals, from building community and social 

commitment, to understanding parenting norms, to evaluating policy changes. 

Keep in mind you will face some challenges in collecting, analyzing, and 

using this kind of information. You are more likely to find existing information 

that focuses on risk factors and negative outcomes, like measures of child 

maltreatment and neglect, out-of-home placements in foster care, or children 

living in poverty. Other existing data may be fragmented and collected for a 

variety of purposes with varying definitions and criteria. 

The four steps below may assist you as 

you begin this process:

1) Build a partnership to gather and 

synthesize relevant data 

2) Take stock of existing data

3) Identify and fill critical data gaps 

4) Use the data to support other 

action steps

Goal 2

Use Data to Inform Solutions
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Step #1 

Build a partnership to gather and synthesize relevant data

Data can be a powerful tool to highlight the realities of life for children in your 

community and for demonstrating success as you work together to make positive 

changes. However, any one organization, or any one data source, provides a limited 

view of the problems as well as the opportunities in your community. Multiple data 

sources allow for a more comprehensive understanding of the issues and multiple 

avenues for raising awareness and implementing change. Consider partnerships with 

others who collect and analyze data and are in a position to make data-informed 

decisions about programs or other strategies that improve the lives of children. 

Public health agencies can serve as a coordinator for this effort, since they often 

have staff with strong data skills and public health agencies are typically familiar 

with the convener role. In this role, it is critical to reach out to a variety of partners. 

This could include several agencies or offices within the health department, such 

as Maternal and Child Health, Injury Prevention, Mental Health, and Children and 

Families/Social Services. You may also find it useful to work with other groups 

in your community, including school and health care systems, law enforcement, 

criminal justice, professional societies, non-governmental groups, and researchers at 

local universities. All of these can be strong partners. 

Step #2 

Take stock of what data already exist in your community 

An important step in preventing child maltreatment and supporting safe, stable, 

nurturing relationships and environments for children in your community is to find 

the best available information that describes the issues. Available resources that 

will help you better understand the specifics of child health and well-being in your 

community include:

■ Vital statistics

•	 Birth and death records (look especially for births to teen mothers and child homicide 

deaths among children under 5 years of age)

• Child fatality review records 
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■ Health data 

• Hospital emergency department or discharge data

• Prenatal care coverage, month initiated, and services included (e.g., are pregnant 

women being screened for depression, exposure to partner violence, or substance 

abuse; if they are, are they being referred to evidence-based services, if they are, what 

percent of those referred actually receive the service) 

• Ambulatory care visits for mental illness, including substance abuse among women of 

reproductive age

• Length of wait list for treatment of substance abuse

• Coverage and dosage of well-baby visits and services offered for all children (e.g., 

evaluation of social emotional development and anticipatory guidance based on 

Bright Futures guidelines) and for children at risk or with developmental problems

• Coverage of family planning services

■ Criminal justice data

• Police reports of events or arrest records especially for partner violence 

• Programs offered to incarcerated parents (e.g., parenting or problem solving skills 

training) 

■ Child protection and welfare data

• Reports to child protective services, substantiated reports of abuse and neglect, or outof-home placements (number and geographic location)

• Services provided to parents and children reported (evidence-based? reach all who 

need?)

• Length of wait list for early child care and education programs such as Early Head Start 

• Length of wait list for child care subsidies

• Number and location of families receiving Temporary Assistance to Needy Families 

(TANF); Supplemental Nutrition Assistance Program (SNAP); State Children’s Health 

Insurance Program (SCHIP)/Medicaid

■ Educational data

• School dropout rates

• Length of wait list for pre-K program such as Head Start

• Sex education programs being used in schools (e.g., are they evidence-based?)

■ Demographic data

• Children living in poverty (number, proportion, and location)

• Parents unemployed (number, proportion, and location) 
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In addition, you can review various state or national level 

surveys or data from surveillance systems, some of which 

can provide data specific to your area. These include:

■ Child Death Review Data

■ National Violent Death Reporting System [NVDRS]

■ Youth Risk Behavior Surveillance System [YRBS]

■ Behavioral Risk Factor Surveillance System

■ National Child Abuse and Neglect Data System 

[NCANDS]

■ National Survey of Family Growth [NSFG]

■ National Health and Nutrition Examination Survey 

[NHANES]

■ Pregnancy Risk Assessment Monitoring System 

[PRAMS]

■ National Health Interview Survey [NHIS]

■ National Immunization Survey [NIS]

Census data can also help you better understand your 

community’s household and neighborhood demographics, 

which will provide a better sense of what life is like for the 

children in your area. Census data include information 

such as the number of single parent headed households, 

the number of young or school-age children, the number 

of rental units versus owned homes, unemployment 

rates, and the number of households living below the 

poverty level.

Currently, several federal public health agencies and nongovernmental organizations offer data about CM (see 

box). 

These organizations provide a great deal of information 

on various indicators (e.g., child well-being, child 

maltreatment). Once you have pulled together 

information from a variety of sources, you will need to 

synthesize the findings on the magnitude of CM and the 

conditions which contribute to it in your community. 

This information will help you make informed decisions 

about which evidence-based programs or other strategies 

most closely address the needs in your community. You 

will also have an understanding of what gaps exist and 

where work still needs to be done in order to measure 

and monitor safe, stable, nurturing relationships and 

environments.

Resources

CDC’s National Center for Injury 

Prevention and Control

www.cdc.gov/ViolencePrevention/

childmaltreatment

CDC’s National Center for 

Health Statistics 

www.cdc.gov/nchs 

National Center for Education 

Statistics

http://nces.ed.gov 

Department of Justice’s Bureau 

of Justice Statistics

http://bjs.ojp.usdoj.gov 

Annie E. Casey’s Kids Count

www.kidscount.org

The Forum on Child and 

Family Statistics

www.childstats.gov 

Maternal and Child Health 

Bureau at the Health Resources 

Services Administration

www.mchb.hrsa.gov/mchirc/chusa

Children’s Bureau of the 

Administration for Children 

and Families

www.childwelfare.gov/

systemwide/statistics

Child Trends Data Bank

 www.ChildTrends.org 

Child Death Review

www.childdeathreview.org 
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Step #3 

Identify and fill critical data gaps 

Where gaps in information are identified, use your partnerships to develop new data 

collection efforts. This may include developing a new survey or adding questions to 

existing surveys. CDC’s uniform definitions for child maltreatment (CM)—available at 

www.cdc.gov/violenceprevention/pdf/CM_Surveillance-a.pdf—can help you create 

new or edit existing data collection instruments and ensure they are as consistent 

and comparable as possible. Data gaps could actually become a programmatic or 

policy initiative. For example, you may want to approach a decision-maker or program 

implementer to get new data generated. Other activities such as Child Death Review can 

provide valuable insights for protecting children.

Washington State’s Family Policy Council (www.fpc.wa.gov) uses data to inform 

prevention and programmatic activities. They focused on reducing Adverse Childhood 

Experiences (ACEs) using data from the Behavioral Risk Factor Surveillance System 

(BRFSS). They made strategic investments in efforts to improve physical and mental 

health outcomes in the state. The Family Policy Council’s approach to building local 

capacity and using data to inform practice and policy was recommended by the Institute 

of Medicine in its 2009 report, Preventing Mental, Emotional and Behavioral Disorders 

Among Young People—Progress and Possibilities (September 2009). 

Step #4 

Use the data to support other action goals and steps

Now that you have this information, you can use it to make the other action steps a 

reality. For example, incorporating local data as you raise awareness in support of the 

vision may make the issues more salient for the partners you are trying to engage (see 

Goal 1, Action Step 2). You may want to highlight the costs to your community, state, 

and society when CM is not prevented. Short documents with specific data points for 

decision-makers are helpful. Take advantage of the variety of information available. 

Compiling information from multiple sources helps paint a comprehensive picture of 

what life is like for children in your community. This will help you determine where to 

invest in prevention—who is most at risk? What risk factors are most prevalent? What 

programs and policies would best address the most prevalent risk factors?

Goal 2 Summary

Understanding the prevalence and impact of CM in your community—and how people 

think and feel about this issue—provides critical information to inform and support the 

other action goals. Data provides a foundation for engaging partners, underscores your 

efforts to build commitment, informs decision-makers, and helps you focus and monitor 

your prevention efforts for the greatest impact.
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Goal 3

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Parents and caregivers are a child’s first exposure to the world around them. The 

quality of relationships between children and their parents and caregivers, and the 

environment in which those relationships develop, play a significant role in a child’s 

cognitive, emotional, physical, and social development. Research has demonstrated 

the benefits of safe, stable, nurturing relationships and environments and, conversely, 

the negative outcomes attributed to child maltreatment (CM) and other adverse 

conditions in childhood. 

Here are three steps you might consider to support parents and caregivers in 

providing safe, stable, nurturing relationships and environments: 

1) Promote the community norm that we all share responsibility for the 

well-being of children 

2) Promote positive community norms about parenting programs and 

acceptable parenting behaviors

3) Implement evidence-based programs for parents and caregivers

Step #1 

Promote the community norm that we all share responsibility for the 

well-being of children

No family exists in a vacuum; therefore, supporting families in providing safe, stable, 

nurturing relationships and environments is a shared responsibility. Everyone in 

your community—both parents and those without children—can champion or 

contribute to efforts to develop safe places or neighborhood activities where children 

are watched and supervised, and families can gather, interact, and get to know each 

other. Neighborhood associations can link families and other neighborhood adults 

together to help with household tasks and to watch out for each other’s children in 

the neighborhood. 

Create the Context for Healthy 

Children and Families through Norms 

Change and Programs
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This step can also tie into raising awareness and enlisting partners when building 

commitment (see Goal 1, Steps 2 and 3). This can be accomplished through 

emphasizing how all members of the community can identify and engage in 

activities that may support children and families. For example, people may have 

influence in a particular sector (e.g., business, social services, education) where they 

can promote family-friendly policies or activities.

Step #2

Promote positive community norms about parenting programs and 

acceptable parenting behaviors

Caregivers (i.e., parents as well as family, friends, and neighbors who help with 

childcare) may be reluctant to participate in parenting programs because they think 

learning about parenting implies they are “bad” caregivers. Your community can 

promote norms emphasizing that learning effective parenting skills is a process and 

every caregiver can use help at times.

Caregivers who do go to parenting programs will be learning new parenting 

behaviors and skills. They may need extra support in using those new skills at home 

if what they learned is different from those practiced by other family or community 

members. You can identify local parents to serve as mentors that promote positive 

parenting in order to help change community norms about parenting behaviors in 

your community. Parents can be particularly powerful role models and voices in 

these efforts, because other parents will see them as credible and experienced.

Step #3 

Implement evidence-based programs for parents and caregivers

Programs that teach caregivers positive child-rearing and child management skills 

are the most basic approach to facilitating safe, stable, nurturing relationships and 

environments. Your community can support all caregivers by providing access to 

evidence-based parent training. A lot is known about how to foster caregiver skills 

that promote positive child development, prevent child behavior problems, and 

prevent CM. 

Most communities have a range of programs to support caregivers; however, 

whenever possible it is recommended that your community implement effective 

and promising interventions (see list on page 26 for examples of evidence-based 
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strategies and the box following Goal 3 for characteristics of effective parenting 

programs). Choosing strategies that have been tested in rigorous research trials (i.e., 

evidence-based) increases the chance that the programs parents participate in will 

actually make a difference in their lives and the lives of their children. However, this 

may be easier said than done. These sub-steps may be necessary:

■ Build community receptivity, capacity, and resources to implement 

evidence-based strategies to promote safe, stable, nurturing relationships 

and environments. Your community must be willing and able to implement 

programs that promote safe, stable, nurturing relationships and environments for 

children. Some essential factors that you may need to build include community 

support, parent leader support, funding (including redirecting funds from strategies 

that are not evidence based), community infrastructure, and capacity to implement and evaluate programs.

■ Make it easy for parents and caregivers to participate in parenting 

programs. Caregivers may find it difficult to participate for logistical reasons, 

including cost, childcare needs, scheduling conflicts, inconvenient location, and 

lack of transportation. By offering low-cost or free programs, implementing the 

program at a convenient time and in an accessible location, and providing child 

care and transportation options (e.g., vouchers for public transit, van pools, etc.), 

you will make it possible for parents to attend a program that would otherwise be 

inaccessible.
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Evidence-Based and Promising 

Programs and Strategies

Examples of programs and strategies that have been shown to prevent CM include but are 

not limited to:

■ Parent-Child Interaction Therapy (PCIT)

www.pcit.org

PCIT improves the quality of parent-child relationships and changes how 

parents and children interact with one another. Parents learn specific skills to 

build a nurturing and secure relationship with their children while increasing 

their children’s desirable behavior and decreasing negative behavior. Coaches 

work directly with parent-child pairs to help them learn new skills. In addition 

to impacting CM outcomes, this program has shown improvements in parenting 

behavior and child behavior problems.

■ Triple P (Positive Parenting Program)

www.triplep-america.com

Triple P is a system of parenting and family support to address parents’ varied 

needs. There are five levels of intervention, ranging from media strategies 

to increase awareness and acceptance, to brief consultation on common 

developmental issues, to intensive approaches to address problems with parenting 

and child behavior. In addition to impacting CM outcomes, this program has 

shown improvements in parenting behavior and child behavior problems.

■ Nurse-Family Partnership (NFP)

www.nursefamilypartnership.org 

Registered nurses make ongoing home visits to first-time moms and their babies. 

The program focuses on improving maternal and child health, maternal life course 

(financial status, educational and employment choices, partner relationships, and 

future pregnancy planning), and parenting of infants and toddlers.

■ Hospital-based abusive head trauma prevention approaches 

(Pennsylvania Abusive Head Trauma Prevention Program)

These programs give parents of newborns information about the serious adverse 

effects of shaking an infant and offer guidance on how to handle a crying infant 

and avoid shaking. The information is provided before parents take the baby home 

from the hospital after delivery.
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■ Multi-component programs (Child-Parent Centers)

Center-based multi-component programs provide comprehensive educational and 

family support to low-income children and their parents. The approach is childcentered and individualized, with an emphasis on enhancing the child’s social and 

cognitive development in a stable, enriched learning environment. Parent-focused 

activities include enhancing parents’ personal development; promoting positive 

parent-child interactions; providing information on nutrition, health, and safety; 

and providing referrals to appropriate services. 

Some programs do not have evidence of changing CM outcomes, but do demonstrate 

improvements in parenting behavior and child behavior problems. These programs include 

but are not limited to: 

■ Incredible Years

www.incredibleyears.com 

This training series for parents, teachers, and children promotes emotional and 

social competence with the goal to prevent, reduce, and treat aggression and 

emotional problems in children 0 to 12 years old. The parent training component 

emphasizes parenting skills and approaches known to promote children’s social 

competence, reduce behavior problems, and improve children’s academic skills.

■ Strengthening Families for Parents and Youth

www.extension.iastate.edu/sfp

This education and support program focuses on increasing family skills to 

support healthy child development. Sessions for parents and children address 

communication skills, family functioning, social-emotional development, and 

healthy behavior. Family sessions offer the opportunity to practice new skills 

presented in the curriculum. The program recommends ongoing family support 

groups and booster sessions.

■ Early Head Start

www.ehsnrc.org

This child-development and parenting-education program is delivered through 

center-based services, home visits, or both. The program helps parents build skills 

to assist their child’s development, increase family literacy, and promote healthy 

parent/child relationships. It also helps families transition their children into Head 

Start or other preschool programs when the child reaches 3 years of age and 

offers family advocacy, resources, and referrals to other community services.
28

Goal 3 Summary

It is important to remember parenting does not occur in a vacuum. Creating a 

community context that supports effective parenting is critical to children 

experiencing safe, stable, nurturing relationships and environments. In 

general, parents benefit from feeling consistent support from their family, friends, and 

the broader community. 

Characteristics of Effective 

Programs to Provide Safe, Stable, 

Nurturing Relationships and 

Environments for Children

A number of programs have been shown, through rigorous studies, to be effective 

in decreasing CM. Some programs have shown promise of achieving desired results 

for CM but need more rigorous evaluation. Other programs, although not evaluated 

for reducing CM, have been shown to improve positive parenting behavior, reduce 

challenging child behaviors, and improve relationships between children and their 

caregivers. 

Effective parenting programs typically:

■ Provide opportunities for caregivers to actively practice and receive feedback as 

they learn and apply the new parenting behaviors.14 This is in contrast to classes that 

just talk to caregivers about parenting. Having parents practice the skills with their 

own children during program sessions is particularly effective.

■ Teach parents the correct use of time out, an effective alternative to physical 

discipline.

■ Emphasize building positive and nurturing caregiver-child relationships and 

interactions. This includes teaching caregivers how to effectively communicate 

and play with their children. 

■ Help caregivers respond consistently to the child’s behavior, no matter the location 

or situation. Promoting consistency across all of a child’s caregivers is critical.
29goal three

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3

4

Considerations for Implementing 

Programs to Promote Safe, Stable, 

Nurturing Relationships and 

Environments for Children

When determining the types of programs that will work best for the caregivers in your 

community, keep the following in mind:

■ Consider delivery options. It is important to consider the best settings to reach 

parents in your community, as well as how parents get information. Parenting 

information can be disseminated in many ways, not just through formal programs. 

This can include offering general parenting information through the media, in 

primary health care, through schools, and in faith communities. However, the 

research suggests that information alone is not enough. Parents need to see and 

practice the new behaviors.

■ Choose programs that are appropriate for the child’s developmental stage. This 

is important because children at different developmental stages require different 

parenting behaviors. A child’s entry into a new developmental stage may provide a 

“moment of opportunity” when parents may be more receptive to certain programs. 

■ Create opportunities to involve other 

caregivers. Grandparents, other extended 

family, friends, and neighbors provide 

important support for parents and can 

encourage newly learned parenting 

practices. Engaging other caregivers 

in using those practices also provides 

consistency for the child.

■ Strive for consistency among programs 

within a community. Receiving different 

or conflicting information from multiple 

programs can make it more difficult for 

parents to learn and consistently apply skills 

they need to positively impact their children. 

You may need to examine current programs 

and identify inconsistencies or conflicting 

messages. Receiving the same messages 

from multiple sources reinforces the 

information, so it will “stick” and be used. 
30
31goal four

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3

4

As we have discussed throughout this guide, promoting safe, stable, nurturing 

relationships and environments and preventing child maltreatment (CM) is not 

a simple process. It includes building commitment, using data to inform the 

actions you take, and supporting parents and caregivers in your community. 

The policies in place in communities can also help ensure children in your 

community lead healthy and safe lives.

Similar to the other sections in this guide, helping decision-makers make 

informed decisions around conditions that support safe, stable, nurturing 

relationships and environments requires collaboration and partnerships in your 

community. Supporting policies that support safe, stable, nurturing relationships 

and environments for children requires efforts from organizations in both the 

public and the private sector—e.g., from 

state and local health departments, the 

media, business, schools, faith-based, and 

community organizations. Historically, 

policies that improve the socioeconomic 

conditions of families or that structure 

the environment so that healthy choices 

are the easy choices have had the 

largest impacts on health.12 But it is 

also important to consider the potential 

impacts on children and families when 

creating or changing any policy.

Goal 4

Create the Context for Healthy Children 

and Families through Policies
32

The two steps to inform policies that might support 

safe, stable, nurturing relationships and environments 

are: 

1) Identify and assess which policies may 

positively impact the lives of children and 

families in your community 

2) Provide decision-makers and community 

leaders with information on the benefits 

of evidence-based strategies and rigorous 

evaluation 

Step #1

Identify and assess which policies may positively 

impact the lives of children and families in your 

community 

There are many policies that already provide some 

support to children and families. Communities 

might consider some of the following examples or 

opportunities to positively impact the lives of children 

and families. It is important to note that while the 

examples that follow have not been evaluated to 

establish their potential impact on CM or safe, stable, 

nurturing relationships and environments, there is 

evidence that these policies strengthen families. 

Depending on a variety of factors, some types of 

policies may be out of your sphere of influence. 

However, understanding the breadth of policies that 

can strengthen families may be helpful to identifying 

opportunities to collaborate with other sectors and 

engage in related activities or initiatives within your 

community. 

Examples of organizational or internal policies

■ One area where there has been dramatic positive 

change has been in the reduction of child sexual 

abuse, which has declined by almost 50 percent over 

the past two decades. Youth-serving organizations, 

Types and 

Levels of 

Policies

Organizational or 

internal policies:

Rules and practices that an 

organization or agency sets 

for how it does business, 

conducts its activities, or 

interacts with staff and 

constituents.

Regulatory policies:

Rules, principles, or methods 

established by government 

agencies that have regulatory 

authority for products or 

services.

Legislative policies: 

Laws or ordinances passed 

by local, state, or federal 

governing bodies.
33goal four

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3

4

such as Scouts, summer camps, and after-school programs have implemented 

policies on screening, selecting, and training employees and volunteers, policies 

on unacceptable interactions between individuals (e.g., policies against one-onone contact between adult volunteers and youth participants), and policies on 

how to respond to allegations of child sexual abuse. In addition, communitybased organizations and schools have incorporated child sexual abuse prevention 

programs into their activities. Some have suggested that the declines in child 

sexual abuse may be in part attributable to sexual abuse prevention programs, 

norms changes, and social control efforts, therefore, expansion of these current 

prevention efforts may be warranted.15,16

■ Parental stress is an important risk factor for CM.17 Government agencies might 

reduce this stress by helping parents who are already dealing with the stress 

of insufficient income or unemployment to overcome complicated rules and 

application procedures that leave too many eligible children and families from 

accessing supports such as Medicaid, Children’s Health Insurance Programs, 

food stamps, and other types of assistance for families at risk.18,19,20 For example, 

government agencies or community-based organizations could facilitate 

access to needed supports by automatically enrolling families in all relevant 

programs simultaneously or offering “one 

stop shops.”21 Government agencies could 

decide to couple income supports with other 

supports. For example, there is evidence that 

income supplements together with child care 

and affordable health insurance can improve 

parenting behaviors,22 suggesting these efforts 

might reduce CM as well. 

■ Primary health care organizations can make it 

their policy to deliver components of evidencebased programs such as Triple P as their 

standard of care. More specifically, community 

health centers or private pediatric practices can make anticipatory guidance 

and brief consultation on common developmental issues part of their standard 

protocol during well-baby visits. They can also coordinate with other more 

specialized services to provide more intensive approaches to address problems 

with parenting and child behavior. 
34

Example of regulatory policies

■ Lower-income families often pay more 

than middle- and high-income families 

for the same consumer products 

such as financial services, cars, and 

groceries.23,24 In part, this is due to a 

lack of low-cost alternatives in their 

communities but also because of 

business practices that unnecessarily 

drive up prices (e.g., subprime interest 

rates for payday, auto title, or pawnshop 

loans).25 Some cities, counties, or states 

have also addressed this issue by introducing regulations to reduce interest rates 

for loans or eliminating payday loans for vulnerable families.26

Examples of laws or ordinances

■ Low income has long been associated with maltreatment, albeit more consistently 

with child neglect.27 Unfortunately, one in five children in the U.S. live in poverty28

and an additional 22 percent of the U.S. population is considered “near poor.”29

State policies that increase economic self-sufficiency for lower income families 

(e.g., livable wages, subsidies for basic needs) might alleviate some of the stress 

that contributes to CM. A study conducted by San Francisco’s health department 

showed that raising the minimum wage to a living wage for city contractors would 

result in multiple health and education benefits.30 These findings were considered 

in city policy discussions on raising wages, and a year later, city residents approved 

an ordinance raising the minimum wage for over 50,000 workers. 

■ Access to high-quality child care can affect parents’ ability to work and to support 

a family as well as children’s exposure to safe, stable, nurturing relationships and 

environments. Programs such as Early Head Start are able to serve less than 

4.3 percent of those eligible.31 Quality of child care is also highly variable with 

economically disadvantaged children receiving lower-quality child care than other 

children.32 If in your data gathering efforts you find long waiting lists for Early Head 

Start or Head Start, perhaps your city, county, or states can decide to increase 

funding for these programs or facilitate access to private child care through 

their expansion of eligibility standards. Currently, the federal government sets a 

maximum eligibility level equal to 85 percent of a state’s median income (SMI), 

however, only one state has expanded access to the federal limit and 5 states have 

eligibility levels of 40 percent or less than the SMI.33,34 In addition, 42 states have 

reimbursement rates that fall below the 75th percentile of the current market rate 

value for child care.26
35goal four

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4

■ Unintended pregnancy is a strong risk factor for child physical abuse.18 Unintended 

pregnancy is also associated with other risk factors for CM such as depression or 

partner violence.35 However, unintended pregnancies are highly preventable. If 

unintended pregnancies, especially teen pregnancies, are high in your community, 

school boards might check the evidence base for the sex education programs being 

used in schools. Cities, counties, or states might consider policies for increasing 

access to family planning services. 

■ Substance abuse, depression, and other mental illnesses increase the risk for CM 

and other adverse child outcomes. However, financial and other barriers to care 

keep almost half of those afflicted with mental illness from receiving treatment.36

Policies that decrease financial barriers to mental health care for parents not 

qualifying for Medicaid—such as those facilitating coverage among the uninsured 

or underinsured—may contribute to better access to mental health care. Beginning 

in 2014, based on the Affordable Care Act, mental health and substance use 

disorder services will be part of the essential benefits package (i.e., health care 

services that must be covered by certain plans). The private sector could also 

play a role, for example, through employee assistance programs or by supporting 

community services. 

■ High school completion leads to better paid employment and health which could

indirectly improve parenting through its impacts on family income, parental 

exposure to stressors, access to information and resources, development of life 

skills, and the quality of social support.37 If high school drop-out is a prevalent 

problem in your community, school boards might consider policies that improve 

school retention and high school graduation rates such as use of non-exclusionary 

strategies to address children’s disciplinary problems in schools.38 

■ Many instances of physical abuse begin as physical punishment in response to 

child misbehavior.39 Research calls this discipline practice into question for other 

reasons as well: 1) physical punishment does not appear to improve children’s long 

term behavior, and 2) use of physical punishment is associated with higher levels 

of aggression in children.40,41 Legal bans on corporal punishment are associated 

with decreases in support of and use of physical punishment as a child discipline 

technique.42 
36

Step #2

Provide decision-makers with information on the benefits of evidencebased strategies and rigorous evaluation

A commitment to a rigorous science base demands that development and 

implementation of programs to promote safe, stable, nurturing relationships and 

environments are based on reliable data and sound evidence of effectiveness. 

Decision-makers might be more supportive of evidence-based programs once they 

are well-informed of the benefits of having scientific evidence. This might lead 

decision-makers to consider:

■ Requiring that programs selected for funding have evidence of effectiveness or at 

least have shown promising results 

■ Requiring that funded programs without a strong evidence base be evaluated to 

determine whether or not the strategy is effective 

Goal 4 Summary

Informing policies to improve the provision of safe, stable, nurturing relationships 

and environments requires the efforts of many, including state and local health 

departments, the media, and community organizations. In addition, it is critical to 

ensure that there is awareness of the policies and that resources exist to support 

the policies’ long-term implementation and evaluation. There are resources 

available that can help you better understand using policies to support children and 

families, such as the Systems of Care Policy Action Guide (www.childwelfare.gov/

management/reform/soc/communicate/initiative/pag/multiparty.cfm.)
Conclusion
While child maltreatment is a significant public health problem, 

it is also a preventable one. Essentials for Childhood: Steps to 

Create Safe, Stable, Nurturing Relationships and Environments

is designed to assist you in your prevention efforts, through 

building commitment, using data to inform action, supporting 

parents and caregivers directly through parenting programs, 

and by informing policies that strengthen families and 

protect children. The steps suggested here, along with your 

commitment to preventing child maltreatment, can help create 

neighborhoods, communities, and a world in which every child 

can thrive.

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Acknowledgments

We would like to acknowledge the CDC colleagues who guided the development of 

this document: Sandra Alexander, Erica Mizelle, Janet Saul, Lynn Jenkins, Sharyn Parks, 

Linda Anne Valle, and Joanne Klevens. 

The Knowledge to Action Prevention Consortium and external reviewers Michelle 

Hughes, Mark Chaffin, and Leah Devlin provided valuable input to shape the document.