National Center for Injury Prevention and Control 

Division of Violence Prevention

Preventing Child Abuse 

and Neglect:

A Technical Package for Policy, Norm, 

and Programmatic Activities

Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 1

Preventing Child Abuse and Neglect: 

A Technical Package for Policy, Norm, 

and Programmatic Activities

Developed by:

Beverly L. Fortson, PhD

Joanne Klevens, MD, PhD, MPH

Melissa T. Merrick, PhD

Leah K. Gilbert, MD, MSPH

Sandra P. Alexander, MEd

2016

Division of Violence Prevention

National Center for Injury Prevention and Control

Centers for Disease Control and Prevention

Atlanta, Georgia
2 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Centers for Disease Control and Prevention

Thomas R. Frieden, MD, MPH, Director

National Center for Injury Prevention and Control

Debra E. Houry, MD, MPH, Director

Division of Violence Prevention

James A. Mercy, PhD, Director

Suggested citation:

Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Preventing 

child abuse and neglect: A technical package for policy, norm, and programmatic activities. 

Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control 

and Prevention.
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 3

Contents

Acknowledgements............................................................................................................................................ 5

External Reviewers............................................................................................................................................... 5

Strengthen Economic Supports for Families............................................................................................13

Change Social Norms to Support Parents and Positive Parenting...................................................18

Provide Quality Care and Education Early in Life ...................................................................................21

Enhance Parenting Skills to Promote Healthy Child Development.................................................25

Intervene to Lessen Harms and Prevent Future Risk.............................................................................29

Sector Involvement ...........................................................................................................................................33

Monitoring and Evaluation.............................................................................................................................35

Conclusion............................................................................................................................................................36

References.............................................................................................................................................................37

Appendix...............................................................................................................................................................46

Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 5

Acknowledgements

We would like to thank several individuals who contributed greatly to the development of this technical package. First, 

we give special thanks to Dr. Linda Dahlberg for her vision, guidance, and support throughout the development of 

this package. We thank Division, Center, and CDC leadership, and members of the CDC Division of Violence Prevention 

Child Maltreatment Workgroup for their careful review and helpful feedback on earlier iterations of this document. 

We thank Alida Knuth for her formatting and design expertise. We also extend our thanks and gratitude to all of the 

external reviewers for their helpful feedback, support and encouragement for this document.

External Reviewers

Marissa Abbott

California Department of Health

Melissa Brodowski

Administration for Children and Families

Lauren Fischman

Administration for Children and Families 

Marilyn Gisser

Washington State Department of Health

Monique Fountain Hanna

Health Resources and Services Administration

Cailin O’Connor

Center for the Study of Social Policy

Diane Pilkey

Health Resources and Services Administration

Janet Rosenzweig

Prevent Child Abuse America

Elaine Stedt

Administration for Children and Families

Kiersten Stewart

Futures Without Violence

Calondra Tibbs

National Association of City and County Health Officials

Julia Wei

California Department of Health

Steve Wirtz

California Department of Health

Mao Yang

Administration for Children and Families
6 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 7

Overview

This technical package represents a select group of strategies based on the best available evidence to help prevent 

child abuse and neglect. These strategies include strengthening economic supports to families; changing social norms 

to support parents and positive parenting; providing quality care and education early in life; enhancing parenting 

skills to promote healthy child development; and intervening to lessen harms and prevent future risk. The strategies 

represented in this package include those with a focus on preventing child abuse and neglect from happening in 

the first place as well as approaches to lessen the immediate and long-term harms of child abuse and neglect. These 

strategies range from a focus on individuals, families, and relationships to broader community and societal change. 

This range of strategies is needed to better address the interplay between individual-family behavior and broader 

neighborhood, community, and cultural contexts.1

This package supports CDC’s Essentials for Childhood framework for preventing child abuse and neglect. In particular, 

it articulates a select set of strategies and specific approaches that can create the context for healthy children and 

families and prevent child abuse and neglect (Goals 3 and 4 of the framework—see below). 

Commitment, cooperation, and leadership from numerous sectors, including public health, education, justice, health 

care, social services, business/labor, and government can bring about successful implementation of this package.

What is a Technical Package?

A technical package is a compilation of a core set of strategies to achieve and sustain substantial reductions in a 

specific risk factor or outcome.2 Technical packages help communities and states prioritize prevention activities based 

on the best available evidence. This technical package has three components. The first component is the strategy or 

the preventive direction or actions to achieve the goal of preventing child abuse and neglect. The second component 

is the approach. The approach includes the specific ways to advance the strategy. This can be accomplished through 

programs, policies, and practices. The evidence for each of the approaches in preventing child abuse and neglect or its 

associated risk factors is included as the third component. This package is intended as a resource to guide and inform 

prevention decision-making in communities and states.

Essentials for Childhood: Steps to Create Safe, 

Stable, Nurturing Relationships and Environments

The Essentials for Childhood framework proposes steps communities can 

consider to promote the types of relationships and environments that help 

children grow up to be healthy and productive citizens. The framework is 

organized around four goals and related steps to promote safe, stable, 

nurturing relationships and environments for children and families.

Four goal areas:

1) raise awareness and commitment;

2) use data to inform actions;

3) create the context for healthy children and families through norms change and programs;

4) create the context for healthy children and families through policies.

www.cdc.gov/violenceprevention/pdf/essentials_for_childhood_framework.pdf
8 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Preventing Child Abuse and Neglect is a Priority

Child maltreatment 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.3 There are four common types of child maltreatment:3

•	 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 inducing or coercing a child to engage 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. 

Child abuse and neglect is highly prevalent. Self-report data suggest that at least 1 in 7 children have experienced 

child abuse and/or neglect in the last year.4

 Not all children, however, experience abuse and neglect at the same rates. 

Younger children are more likely to experience fatal abuse and neglect,5 while 14- to 17-year-olds are more likely 

to experience non-fatal abuse and neglect.4

 Race and ethnicity and family income are also factors that may affect a 

child’s exposure. Child protective services data show high rates of victimization among African-American children. 

African-American children experience abuse and neglect at rates that are nearly double those for white children. These 

differences are generally attributed to various community and societal factors, including poverty as well as differences 

in reporting and investigation.5

 Children living in families with a low socioeconomic status (SES)* have rates of child 

abuse and neglect that are five times higher than those of children living in families with a higher SES.6

 Irrespective of 

data source, definitions, and measures, the true magnitude of child abuse and neglect is likely underestimated, and 

children of all ages, races, and ethnicities deserve safe, stable, nurturing relationships and environments to achieve 

maximal health and life potential.

Child abuse and neglect is associated with several risk factors. Risk for child abuse and neglect perpetration 

and victimization is influenced by a number of individual, family, and environmental factors, all of which interact to 

increase or decrease risk over time and within specific contexts. Risk factors for victimization include child age and 

special needs that may increase caregiver burden (e.g., developmental and intellectual disabilities, mental health 

issues, and chronic physical illnesses).7

 Risk factors for perpetration include young parental age, single parenthood, 

large number of dependent children, low parental income, parental substance abuse, parental mental health issues, 

parental history of abuse or neglect, social isolation, family disorganization, parenting stress, intimate partner 

violence, poor parent-child relationships, community violence, and concentrated neighborhood disadvantage (e.g., 

high poverty and residential instability, high unemployment rates).7 Although risk factors provide information about 

who is most at risk for being a victim or a perpetrator of child abuse and neglect, they are not direct causes and cannot 

predict who will be a victim or a perpetrator. 

Factors that protect or buffer children from being abused or neglected are known as protective factors. Supportive 

family environments and social networks consistently emerge as protective factors;7, 8

 however, other factors such 

as parental employment, adequate housing, and access to health care and social services may also serve to protect 

against child abuse and neglect. Unfortunately, no single factor tells the entire story about how and why child abuse 

and neglect occurs, and the risk and protective factors differ depending on the type of child abuse and neglect being 

studied. For additional information on risk and protective factors for child abuse and neglect, see Merrick, Fortson, and 

Mercy9

 and Fortson and Mercy.10 

* Defined as having a household income below $15,000 a year; parents’ highest education level less than high school; or any member of the 

household a participant in a poverty program (e.g., TANF, food stamps, public housing, energy assistance, or subsidized school meals).6
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 9

The health and economic consequences of child abuse and neglect are 

substantial. Child abuse and neglect is associated with negative human, 

societal, and economic impacts. Children who are abused and neglected 

may suffer immediate physical injuries (e.g., cuts, bruises, burns, broken 

bones), as well as emotional and psychological problems (e.g., posttraumatic 

stress, anxiety).11 Child abuse and neglect can also affect broader health 

outcomes, mental health, social development, and risk-taking behavior 

into adolescence and adulthood. Strong evidence confirms that childhood 

violence increases the risks of injury, sexually transmitted infections, 

including HIV, mental health problems, delayed cognitive development, 

reproductive health problems, involvement in sex trafficking, and noncommunicable diseases, which, in turn, can cause damage to the nervous, 

endocrine, circulatory, musculo-skeletal, reproductive, respiratory, and 

immune systems.11,12 Given the high prevalence of child abuse and neglect 

and its vast consequences, the associated economic impact is substantial. In 

the United States, the total lifetime economic burden associated with child 

abuse and neglect was approximately $124 billion in 2008.13

Child abuse and neglect is preventable. Much progress has been made 

in understanding how to prevent child abuse and neglect. Child abuse and 

neglect is the result of the interaction of a number of individual, family, and 

environmental factors.14 Consequently, there is strong reason to believe that 

the prevention of child abuse and neglect requires a comprehensive focus that 

crosscuts key sectors of society (e.g., public health, government, education, 

social services, and justice).15 In addition, there is an important need to 

increase the capacity of state and local governments to implement and scale 

up effective interventions that can reduce child abuse and neglect.16,17

Preventing child abuse and neglect can also prevent other forms of violence. Each of the various forms of 

violence are interrelated and share many risk and protective factors,18 consequences,19,20 and effective approaches 

to prevention.21 Given the overlap of the risk and protective factors for child abuse and neglect and other forms 

of violence, it stands to reason that the primary prevention of child abuse and neglect can prevent other forms of 

violence and abuse.18,22 Moreover, strategies that support the development of safe, stable, and nurturing relationships 

between parents or caregivers and their children could be key in preventing the early development of violent 

behavior in children.23-25 Emerging evidence suggests that by stemming the early development of violent behavior, 

such relationships can also reduce many types of violence occurring in adolescence and early adulthood, such as 

youth violence, intimate partner and dating violence, sexual violence, and self-directed violence.26

Assessing the Evidence

This technical package includes programs, practices, and policies with evidence of impact on child abuse and neglect 

victimization, perpetration, or risk factors for child abuse and neglect. To be considered for inclusion in the technical 

package, the program or policy selected had to meet at least one of these criteria: a) meta-analyses or systematic 

reviews showing impact on child abuse and neglect victimization or perpetration; b) evidence from at least one or 

more rigorous (e.g., randomized controlled trial [RCT] or quasi-experimental design) evaluation study that found 

significant preventive effects on child abuse and neglect victimization or perpetration; c) meta-analyses or systematic 

reviews showing impact on risk factors for child abuse and neglect victimization or perpetration; or d) evidence from 

at least one rigorous (e.g., RCT or quasi-experimental design) evaluation study that found significant impacts on risk 

factors for child abuse and neglect victimization or perpetration. Finally, consideration was given to the likelihood 

of achieving beneficial effects on multiple forms of violence; no evidence of harmful effects on specific outcomes or 

with particular subgroups; and feasibility of implementation in a U.S. context if the program, policy, or practice was 

evaluated in another country. 
10 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Within this technical package, some approaches do not yet have research evidence demonstrating impact on rates 

of child abuse and neglect victimization or perpetration but instead are supported by evidence indicating impacts 

on risk factors for child abuse and neglect (e.g., parenting stress, parental mental health). In terms of the strength of 

the evidence, programs that have demonstrated effects on child abuse and neglect outcomes provide a higher level 

of evidence, but the evidence base is not that strong in all areas. For instance, there has been less evaluation of the 

effects of community and societal level approaches in preventing child abuse and neglect. Thus, approaches in this 

package that have effects on risk factors reflect the developmental nature of the evidence base and the use of the best 

available evidence at a given time.  

It is also important to note that there is often significant heterogeneity among the programs, policies, or practices 

that fall within one approach in terms of the nature and quality of the available evidence. Not all programs, policies, or 

practices that utilize the same approach (e.g., home visitation) are equally effective, and even those that are effective 

may not work across all populations. Very few evaluation studies have assessed outcomes across diverse populations 

(e.g., racial/ethnic; populations with disabilities). Moreover, not all programs were designed for use with diverse 

populations; thus, tailoring of programs and more evaluation may be necessary to address different population 

groups. The examples provided, while not intended to be a comprehensive list of evidence-based programs, policies, 

or practices, illustrate models that have been shown to impact rates of child abuse or neglect or have empirical 

support demonstrating impact on risk factors for child abuse or neglect. In practice, the effectiveness of the programs, 

policies and practices identified in this package will be strongly dependent on the quality of their implementation. 

Implementation guidance to assist practitioners, organizations and communities will be developed separately.

Contextual and Cross-Cutting Themes

The strategies and approaches that have been included in this technical package represent different levels of the social 

ecology, with efforts intended to impact the community and societal levels, as well as individual and relationship levels. 

The strategies and approaches are intended to work in combination and reinforce each other to prevent child abuse and 

neglect (see box below). The strategies are arranged in order such that those strategies hypothesized to have the greatest 

potential for broad public health impact on child abuse and neglect are included first, followed by those that might 

impact more select populations (e.g., first-time parents or those for whom child abuse and neglect is already present).

Preventing Child Abuse and Neglect

Strategy Approach

Strengthen economic 

supports to families

• Strengthening household financial security

• Family-friendly work policies

Change social norms to support 

parents and positive parenting

• Public engagement and education campaigns

• Legislative approaches to reduce corporal punishment

Provide quality care and 

education early in life

• Preschool enrichment with family engagement

• Improved quality of child care through licensing and accreditation

Enhance parenting skills to promote 

healthy child development

• Early childhood home visitation

• Parenting skill and family relationship approaches

Intervene to lessen harms and 

prevent future risk

• Enhanced primary care

• Behavioral parent training programs

• Treatment to lessen harms of abuse and neglect exposure

• Treatment to prevent problem behavior and later involvement in

violence
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 11

The prevention of child abuse and neglect has the potential to impact other forms of violence across the life course. 

Although each of the strategies and approaches was selected based on its potential impact on child abuse and 

neglect, impacts on other forms of violence may be observed, thereby reflecting the interconnectedness and overlap 

between the risk and protective factors for child abuse and neglect and the risk and protective factors for other forms 

of violence.18,21 For example, programs that address the behavior problems of young children have demonstrated 

effectiveness in preventing the recurrence of child abuse and neglect perpetration,27,28 as well as in reducing 

delinquency and crime in later adolescence and adulthood.29 Home visiting programs and early care and education 

programs have been shown to reduce adolescent arrests and delinquency30 and prevent adult involvement in criminal 

behavior.31-33 Thus, implementation of strategies and approaches aimed at preventing child abuse and neglect have 

substantial potential to prevent other types of violence.

Each community and organization working on the prevention of child abuse and neglect across the nation brings 

its own social and cultural context to bear on the selection of strategies and approaches that are most relevant to 

its populations and settings. Practitioners in the field may be in the best position to assess the needs and strengths 

of their communities and work with community members to make decisions about the combination of approaches 

included here that are best suited to their context.

This package includes strategies where public health agencies are well positioned to bring leadership and resources 

to implementation efforts. It also includes strategies where public health can serve as an important collaborator (e.g., 

strategies addressing community and societal level risks), but where leadership and commitment from other sectors 

such as business/labor is critical to implement a particular policy or program (e.g., family-friendly work policies). 

The role of various sectors in the implementation of a strategy or approach in preventing child abuse and neglect is 

described further in the section on Sector Involvement.

In the sections that follow, the strategies and approaches with the best available evidence for preventing child abuse 

and neglect are described.

The strategies and 

approaches that have 

been included in this 

technical package represent 

different levels of the social 

ecology, with efforts intended 

to impact the community 

and societal levels, as well 

as individual and 

relationship levels.
12 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 13

Strengthen Economic Supports for Families

Rationale

Policies that improve the socioeconomic conditions of families tend to have the largest impacts on health.34 Strong 

empirical evidence consistently links low income to children’s development, academic achievement, and health,35,36

including exposure to child abuse and neglect.37 Policies that strengthen household financial security can reduce 

child abuse and neglect by improving parents’ ability to satisfy children’s basic needs (e.g., food, shelter, medical care), 

provide developmentally appropriate child care, and improve parental mental health.

Policies can change the context for families by improving the balance between work and family (“family-friendly 

work”), thereby allowing parents to provide the necessary care for children and increasing the likelihood that children 

experience safe, stable, nurturing relationships and environments. Studies show several “family-friendly” work policies 

reduce risk factors for child abuse and neglect, such as stress and depression.

Approaches

Economic supports for families can be strengthened by targeting household financial security and family-friendly work.

Strengthening household financial security can reduce child abuse and neglect by improving parents’ ability to 

satisfy children’s basic needs (e.g., food, shelter, medical care), provide developmentally appropriate child care, and 

reduce parental stress and depression, both risk factors for child abuse and neglect.37 Strengthening household 

financial security may also reduce children’s exposure to crowding and contribute to residential stability and stability 

in child care arrangements. Household financial security can be strengthened in various ways:

•	 Child support payments: States can modify how Temporary Assistance for Needy Families (TANF) benefits 

are affected by child support payments. In many states, the child support payments are used by the state to 

reimburse itself, but states may also elect to allow some or all of the child support payment to be passed on to 

the custodial parent and child without any reduction in the TANF benefits. Allowing child support payments 

to be passed on to the custodial parent in part or in full without reducing TANF benefits increases household 

income. 

•	 Tax credits for families with children (e.g., state and federal Earned Income Tax Credit, EITC) help low income 

families increase their income while incentivizing work or offsetting the costs of child-rearing. The federal EITC 

is a refundable credit originally designed to encourage work by offsetting the impact of federal taxes on lowincome families. The amount of the credit varies depending on income earned through work, marital status, 

and the number of qualifying children. State EITC’s are usually based on a percentage of the federal EITC and 

vary in their eligibility and funding amounts; approximately half of the states in the U.S. have enacted EITCs.38

•	 State options for managing federal nutrition assistance programs: The Supplemental Nutrition Assistance 

Program (SNAP) is a federally funded program managed by the U.S. Department of Agriculture (USDA) 

that provides cash benefits, which can only be used to purchase food, to low income households. States 

have several options that can facilitate access to SNAP (e.g., online application; frequency or simplicity with 

which households report household income or work hours; whether child support is considered in income 

calculations; disqualifications imposed).39 SNAP benefits help low income parents meet children’s basic needs 

for food. Because SNAP benefits allow a parent’s income from other sources to be used on things besides food, 

SNAP decreases family poverty and poverty among children.40 SNAP also reduces the severity of food insecurity.41
14 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

• Assisted housing mobility: States can choose to use the U.S. Housing and Urban Development’s Community

Development Block Grant (CDBG) money to purchase properties in low poverty neighborhoods and lease

them to low income families at lower rent.42 Alternatively, states can use Section 8 Housing Choice Voucher

funds and condition their use to rentals in low poverty neighborhoods, while at the same time coupling them

with measures that prevent discriminating against Section 8 voucher holders.42 Assisted housing mobility

through these programs enables families from high poverty neighborhoods to relocate to more stable, better

resourced, and safer communities while saving on rent. These savings can be used for other necessities.

• Subsidized child care provides vouchers, lower cost child care, or cash transfers to low-income families to

off-set the cost of quality, full-time child care. Subsidized child care improves low income families’ economic

well-being by reducing child-care costs; many parents receiving subsidies report that the subsidies enhance

their financial well-being.43 States can elect to raise income threshold limits to expand eligibility and consider

household expenses when calculating eligibility; expand the definition of approved activities to include

training, education, job search time, rest hours (for parents working second or third shifts), and temporary

leave; increase the amount of the subsidy, provide increases based on the quality of care provided, and

improve monitoring of quality; have graduated phase-out periods that would allow clients to slowly earn their

way off the program rather than face a blunt income threshold; simplify the application process and shorten

wait times for subsidy approval; simplify the verification process, the reapplication process, and reduce the

frequency of recertification to improve continuity of child care; and increase the number of providers with

non-standard hours (e.g., evenings, weekends) or incentivize providers to provide extended hours.

Family-friendly work policies change the context for families by improving the balance between work and family 

while ensuring economic security. This makes it easier for parents to provide necessary care for children. 

• Livable wages allow working parents enough income to cover the costs of living and provide for their

children’s basic needs (e.g., food, shelter, appropriate child and medical care), reducing the likelihood of child

neglect. Its impacts on parental mental health may also improve parenting behaviors.

• Paid leave provides income replacement to workers on leave for family caregiving, bonding with a new child

(paid parental leave), or personal leave taken to recover from a serious health condition (paid sick leave)

or get rested and re-energized (paid vacation). Paid leave can reduce risk factors for child abuse and neglect

(e.g., parental stress).

• Flexible and consistent schedules provide workers with a predictable pattern of work and/or allow for

adaptability within the work environment. Flexible schedules include flexibility in work scheduling (e.g.,

compressed work weeks, flexible beginning/ending times to work day, flexibility in scheduling shifts and

breaks to allow for child care coverage), flexibility in the number of hours worked (e.g., part-time work), and

flexibility in the workplace location (e.g., home office, satellite location, alternate location). Inconsistent

schedules or shiftwork can make it challenging to balance work and family responsibilities, which includes

obtaining stable child care and access to child care assistance.44

Potential Outcomes 

• Improvements in children’s health, development, and health insurance coverage

• Reductions in physical abuse of children

• Reductions in child neglect

• Reductions in unintentional or undetermined causes of childhood injury

• Reductions in maternal depression and parental stress

• Reductions in adolescent risky health behaviors

• Reductions in chronic disease among adults and leading causes of death
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 15

Several approaches 

providing economic 

supports to families 

have demonstrated 

direct effects on child 

abuse and neglect. 

Evidence

Much of the research to date in this area has focused on risk factors; however, several approaches providing economic 

supports to families have demonstrated direct effects on child abuse and neglect. 

Strengthening household financial security

• Child support passed on to families receiving TANF benefits: While household income for low income families

increases modestly when child support is passed on to families, this policy also increases the likelihood that 

non-custodial parents who contribute child support do so in greater amounts.45 A state-wide randomized 

controlled trial of mothers entering the TANF program (n = 13,067) compared those receiving the full amount of 

child support from the non-custodial parent and TANF benefits (intervention group) to mothers who received 

the greater amount of $50 or 41% of the child support paid by the non-custodial parent.45 This amounted to 

$105-$180 extra income per month for families in the intervention group. Children of mothers in the 

intervention group were 10% less likely to have a report of child abuse or neglect that was investigated by child 

protective services. Child support passed on to families may also reduce family conflict46 and the mothers’ repartnering with someone who is not the child’s biological,47 both of which are risk factors for child abuse and 

neglect.37,48

• Tax credits for children and families: The EITC lifts working families out of poverty,49,50 which is a risk factor for

child physical abuse and neglect.37 EITC has impacts on infant mortality, health insurance coverage,51 school

performance

52,53 and maternal stress and mental health problems.54 Research is needed to establish the EITC’s

impacts on child abuse and neglect. Simulations show that a Child Tax Credit of $1000 per child allowance, paid 

to each household regardless of income or tax status, would reduce child poverty in the U.S. from 26.3%to 

23.2%; a $2000 allowance per child would reduce child poverty to 20.4%; a $3000 allowance per child would

reduce child poverty to 17.6%; and a $4000 allowance per child would reduce child poverty to 14.8%.55 
 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 16 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

A study based on variations between provinces and survey data showed child tax credits of $769 (2004 

Canadian dollars) were associated with reductions in grade repetition, children’s hyperactivity-inattention, 

conduct disorder-physical aggression, and emotional disorder/anxiety scores, as well as reductions in maternal 

depression in the overall sample. No impacts were noted on children’s math or vocabulary test scores or 

probability of being diagnosed with a learning disability or prosocial behavior.56 Several of the factors for 

which the child tax credit showed impacts (e.g., maternal depression, children’s hyperactivity, conduct 

disorder) are risk factors for child physical abuse and neglect,37 and impacts on these factors may prevent 

abuse and neglect long-term. 

• State options for managing federal nutrition assistance programs: Food insecurity is a risk factor for child

abuse and neglect.57 SNAP reduces the severity of food insecurity,41 but does not change the probability of

families being food insecure. A study linking administrative databases found that among children enrolled in

Medicaid, families receiving SNAP or receiving nutrition benefits through the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC) had fewer reports of abuse and neglect than families not

receiving SNAP or WIC.58

• Assisted housing mobility: Housing rental assistance that facilitates moving to better resourced low poverty

communities reduces household victimization, neighborhood social disorder, and increases neighborhood

safety.59 Evidence from the Moving to Opportunity (MTO) experiment found a number of positive outcomes.60-62

The MTO experiment was a large randomized controlled trial conducted in Baltimore, Boston, Chicago, Los

Angeles and New York in which low-income families living in high-poverty neighborhoods were randomly

assigned to one of three groups: a group offered a housing voucher that could only be used to move to a

low-poverty neighborhood (i.e., census tracts with 1990 poverty rates below 10 percent) along with housingmobility counseling; a group offered a Section 8 housing voucher without any location restriction; and a

control group. Participants were originally enrolled in the trial starting in 1994 and then followed for 10-15

years. MTO participants relative to controls experienced less psychological distress and depression,61,62 which

are risk factors for child abuse and neglect.37 Children who moved to the lower poverty neighborhoods

before age thirteen were more likely to attend college and went on to earn 31% more than those who did not

receive the conditional voucher.63 Moreover, the girls raised in lower poverty neighborhoods were more likely

to marry, and when they had children, more likely to maintain a relationship with the father. The girls were

also more likely to live in lower poverty neighborhoods as adults. Thus, the grandchildren of the intervention

group were more likely to be raised by two parents, enjoy higher family incomes and spend their entire

childhood in neighborhoods with lower poverty, potentially breaking the cycle of poverty. Other studies have

found that housing assistance also reduces homelessness,64 a risk factor for placements with relatives or in

foster care.65

• Subsidized child care: Parents receiving child care subsidies tend to choose better quality child care.66 Better

quality child care increases the likelihood that children will experience safe, stable, nurturing relationships

and environments and decreases the risk of maltreatment-related fatalities.67 In multi-level regression analyses

of within-state trends, states meeting demand for child care assistance (i.e., no wait lists) decreased rates of

child abuse and neglect after controlling for states’ childhood poverty, adults without a high school diploma,

unemployment, child burden, and racial and ethnic composition;68 neighborhoods with more licensed child

care spaces relative to child care need, as defined by the number of 0- to 5-year-olds in the neighborhood with

working parents, had lower rates of child abuse and neglect.69 Access to affordable child care also reduces

parental stress,70 and having access to high-quality child care is associated with fewer symptoms of maternal

depression.71 Both parental stress and maternal depression are risk factors for child abuse and neglect.37

Moreover, children who live with unrelated adults are nearly 50 times more likely to die of inflicted injuries

than children who live with both biological parents,67 thereby highlighting the importance of quality child

care, as mothers would not have to leave the child alone with other (unrelated) adults in the home.
Family-friendly work policies 

•	 Livable wages: A matched controlled trial of a guaranteed annual livable income resulted in decreases in 

two of the risk factors for child abuse and neglect perpetration: low levels of education and mental health 

problems.72 Specifically, livable income was associated with improved school performance and graduation 

rates among children; a reduction in hospitalization rates, particularly for injuries; and physician visits, 

especially for mental health.72

•	 Paid leave: Paid maternity leave increases the frequency and duration of breastfeeding.73 Breastfeeding, in 

turn, is potentially protective against child abuse and neglect. In a 15-year cohort study comparing three 

groups of children (i.e., non-breastfed children, children breastfed for fewer than four months, and children 

breastfed for four or more months), the non-breastfed children had a 3.8 times greater risk of experiencing 

child abuse and neglect by their mothers relative to those breastfed for four or more months.74 Children 

breastfed for fewer than four months had a 2.6 times greater risk than those breastfed for four or more 

months. In addition, mothers who are employed prior to child birth and who delay returning to work after 

giving birth experience fewer depressive symptoms than those who return to work earlier.75 This may have an 

impact on child abuse and neglect, as depression is a risk factor for child abuse and neglect.37 Paid family leave 

is also significantly associated with reductions in hospitalizations for abusive head trauma.76 Paid sick days and 

paid vacation are associated with lower rates of depression and stress,77 both of which are risk factors for child 

physical abuse and neglect.37

•	 Flexible and consistent schedules: When the daily timing of work schedules is irregular and unpredictable, 

parents often have difficulty securing consistent, quality child care.78 Children whose parents work 

unpredictable schedules have more cognitive deficits (e.g., memory, learning, problem solving) than children 

whose parents have more predictable schedules.78-80 Moreover, parents who work irregular shift times, in 

contrast with those with more standard, regular shift times, experience greater work-family conflict81 and are 

more likely to be stressed,78 which is a risk factor for child physical abuse and neglect.37 Flexible and consistent 

schedules (i.e., work-life fit), on the other hand, are associated with lower rates of depression and stress,77 both 

of which are risk factors for child physical abuse and neglect.37

Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 17

Parents who 

work irregular 

shift times experience 

greater work-family 

conflict and are 

more likely 

to be stressed.
 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 18

Change Social Norms to Support Parents 

and Positive Parenting

Rationale

Changing social norms that accept or allow indifference to violence is very important to the prevention of child abuse 

and neglect. Social norms are group-level beliefs and expectations about how members of the group behave or 

should behave.82 The group can be large or small, ranging from the cultural norms of an entire country to those of a 

small sub-population. There are a number of norms that relate to child development and child safety, including norms 

for safe sleep, breastfeeding, child passenger safety, talking to young children, and shared responsibility for children. 

One social norm that is particularly relevant to preventing child abuse and neglect relates to how parents discipline 

their children. Another has to do with whether it is appropriate for parents to seek help in parenting. 

In addition to changing social norms related to behaviors, changing the way we think and talk about why child abuse 

and neglect occurs and who is responsible for preventing it (our narrative) are important in informing policy choice 

and change.83 For example, a dominant narrative in the United States is the idea that anyone can get ahead on their 

own if they work hard enough. This focus on individual responsibility ignores contextual causes and societal solutions 

to complex problems such as child abuse and neglect. 

Approaches

Two types of approaches seek to change social norms and the way we think and talk about child abuse and neglect. 

These include public engagement and education campaigns and legislative approaches to reduce corporal punishment.

Public engagement and education campaigns use communication strategies (e.g., framing and messaging or social 

marketing), a range of communication channels (e.g., mass or social media) and community-based efforts (e.g., town 

hall meetings, neighborhood screenings and discussions) to reframe the way people think and talk about child abuse 

and neglect and who is responsible for preventing it. Effective frames highlight a problem and point the audience 

toward solutions.84 

Legislative approaches to reduce corporal punishment can help establish norms around safe, more effective 

discipline strategies to reduce the harms of harsh physical punishment, particularly if paired with engagement and 

education campaigns. No state currently limits the use of corporal punishment in the home, but some states have 

banned its use in alternative care settings (foster care or institutional care), child day care and after school care, 

schools, and juvenile detention facilities.85

Potential Outcomes 

• Shift in perceived responsibility for children—from personal to shared responsibility

• Increase in public support for policies supportive of children and families

• Reduction in beliefs that corporal punishment of children is appropriate

• Reduction in reported use of corporal punishment

• Increase in beliefs that nurturing children at every age is appropriate

• Reduction in beliefs that getting help for parenting is bad

• Increase in seeking help for parenting

• Increase in public awareness of factors that can inhibit or promote healthy child development
Evidence 

There is evidence suggesting that public engagement and education campaigns and legislative approaches to reduce 

corporal punishment can impact behaviors related to child abuse and neglect.

Public engagement and education campaigns. Public engagement and education campaigns using social 

marketing techniques have been used effectively in public health to change behaviors,86 and specifically, for behaviors 

related to child abuse and neglect.87 For example, the Breaking the Cycle campaign, which promoted the benefits of 

not abusing children and helping parents understand the cycle of abuse (i.e., children learn from their parents), was 

effective in changing parents’ emotional abuse of their children and children’s exposure to parental conflict.88 A postcampaign survey showed that up to 44% of parents had contemplated changing their behavior and up to 16% had 

tried to stop yelling at, swearing at or putting their child down and fighting or arguing in front of their children. A 

pre- and post- comparison of another campaign focusing on positive parenting showed a 19% decrease in the stigma 

associated with parents needing help in parenting.89

Legislative approaches to reduce corporal punishment. Evidence suggests that legislative approaches can impact 

the use of severe corporal punishment against children, the understanding of what constitutes violent punishment, 

and attitudes towards the use of such punishment.90-92 Findings from a multi-country study93 and a systematic review 

of the literature94 showed that legislative restrictions on corporal punishment in other countries have been closely 

associated with decreases in support of and use of corporal punishment as a child discipline technique. A comparison 

of five European countries, three of which had bans on corporal punishment and two without,93 found that bans were 

successful in decreasing overall rates of corporal punishment. Countries wherein corporal punishment was lawful had 

higher rates of all forms of corporal punishment than countries with bans in place. Moreover, acceptance of corporal 

punishment was lower in countries with bans on corporal punishment.93

Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 19

Changing social 

norms that accept 

or allow indifference 

to violence is very 

important to the 

prevention of 

child abuse 

and neglect.
20 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 21

Provide Quality Care and Education 

Early in Life 

Rationale

Quality child care and early childhood education can improve children’s cognitive and socioemotional 

development and increase the likelihood that children will experience safe, stable, nurturing relationships and 

environments, both in the child care and education settings and at home. Past research has suggested that states 

meeting the demand for child care assistance68 and neighborhoods with more licensed child care spaces relative 

to child care need69 had lower rates of child abuse and neglect. Difficulties finding quality child care also are linked 

to increased rates of self-reported child neglect among substance abusing mothers.95 Access to affordable, quality 

child care is associated with reduced parental stress70 and maternal depression,71 both of which are risk factors 

for child abuse and neglect.37 Early childhood education that includes parent engagement can also enhance 

parenting practices and attitudes as well as family involvement in children’s education.96 Parents also have 

opportunities to develop social connections to other parents.69 Moreover, attendance at quality and supportive 

schools, which are licensed and accredited, promotes social skill and cognitive development in children, making 

them less likely to exhibit challenging problem behavior at school and at home, which contributes to better 

scholastic achievement and less parental stress and conflict.97 

Approaches

Preschool enrichment with family engagement and improved quality of child care through licensing and 

accreditation are two approaches for enhancing parenting practices, parental education, social support, and 

access to community resources, while simultaneously creating optimal learning environments for young children. 

Preschool enrichment with family engagement programs provide high-quality early education and care to 

economically disadvantaged children to build a strong foundation for future learning and healthy development. 

These programs also provide support and educational opportunities for parents. Services are available to children 

and families provided they meet basic qualifications, such as being residents in a high-poverty school area eligible 

for federal Title I funding, demonstrate need, and agree to participate98 or having incomes at or below the federal 

poverty level. Parent involvement is emphasized as critical in the child’s development and in increasing children’s 

success in school. Programs often begin in infancy or toddlerhood and may continue into early or middle 

childhood. 

Improved quality of child care through licensing and accreditation. Accredited child care ensures that the 

quality of children’s daily experiences are positive and supportive. Based on research and the development of 

young children, the National Association for the Education of Young Children99 has identified program standards 

and criteria for accreditation, which are the quality indicators or characteristics believed to best promote child 

well-being and foster a safe, nurturing, and stimulating environment. These characteristics can help parents make 

better child care choices for their children because they indicate a much greater likelihood of high quality care. 
22 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Potential Outcomes 

• Reduced encounters with child welfare services

• Reduced physical and sexual violence against children

• Lower rates of out-of-home placement

• Higher rates of high school completion, college attendance

and more years of completed education, lower drop-out rates

• Lower rates of juvenile arrests, felony arrests, incarceration

• Lower rates of grade retention and special education services

• Higher rates of health care coverage

• Lower rates of depressive symptoms

• Higher rates of full time employment

• Lower rates of disability

Evidence

Evidence exists that preschool enrichment programs with family engagement and accredited child care can prevent child

abuse and neglect and may provide other benefits to children and families, such as enhanced parent-child interactions.

Preschool enrichment with family engagement programs, in general, have documented positive impacts on the 

child’s cognitive skills, school achievement, social skills, and conduct problems and are effective in reducing child 

abuse and neglect. The effects of one program, Child Parent Centers (CPC), were examined in a 15-year follow-up 

of a group of 1539 low-income minority children (93% black, 7% Hispanic).32 Since 1985, data have been collected 

yearly on educational and family experiences from school records and participant surveys. Relative to the preschool 

comparison group, children who participated in the CPC preschool intervention for 1 or 2 years had a 52% reduction 

in substantiated reports of child abuse and neglect,96 a higher rate of high school completion (49.7% vs 38.5%), and 

lower rates of juvenile arrest (16.9% vs 25.1%), violent arrests (9.0% vs 15.3%), and school dropout (46.7% vs 55.0%) 

when followed to age 20.32 Both preschool and school-age participation in the CPCs were significantly associated 

with a 33% reduction in substantiated child abuse and neglect, lower rates of grade retention and special education 

services. In a 19-year follow-up of the same cohort,100 CPC preschool participants (relative to the preschool comparison 

group) had higher rates of attendance in 4-year colleges (14.7% vs 10.0%) and were more likely to have health 

insurance coverage. Preschool graduates also had lower rates of felony arrests, convictions, incarceration, depressive 

symptoms, and out-of-home placements. Participation in both preschool and school-age intervention, relative to the 

comparison group, was associated with higher rates of full-time employment, higher levels of educational attainment, 

lower rates of arrests for violent offenses, and lower rates of disability. All of these outcomes amount to increased 

benefits to society. A recent study found that the preschool program provided a total return to society of $10.83 per 

dollar invested (18% annual return).101 While the return on investment was not as significant for the school age and 

extended intervention programs as for the preschool program, the return to society was still significant.101

Another program with family engagement, Early Head Start (EHS), was evaluated in a randomized trial of 3,001 families 

via interviews with primary caregivers, child assessments, and observation of parent-child interactions.102 Three-yearold children who participated in EHS had better cognitive and language development and exhibited less aggressive 

behavior than control children, the latter of whom were able to access services in the community but were not 

provided EHS services. Parents of children enrolled in EHS were more emotionally supportive, provided more 

language and learning stimulation, read to their children more, and spanked less compared to control parents. EHS 

was also evaluated using child welfare administrative data collected retrospectively among a subset of participants (n

= 1227) to establish its impact on child abuse and neglect.103 Results indicated that children in EHS had significantly 

fewer child welfare encounters between the ages of 5 and 9 than did children in the control group, and that EHS

slowed the rate of subsequent encounters. Additionally, compared to children in the control group, children in EHS

were less likely to have a substantiated report of physical or sexual abuse but more likely to have a substantiated 

report of neglect.103 As noted by Green et al.,103 EHS likely did not increase rates of child neglect but rather enrollment 

in EHS may have increased the visibility of young children experiencing neglect. The increased rates of neglect may 

therefore be the result of increased monitoring of families receiving EHS services. 
Improved quality of child care through licensing and accreditation. Accredited child care, which ensures 

quality care, is associated with positive outcomes for children. For example, when compared to infants with easy 

temperaments, infants with difficult temperaments who received quality child care had fewer behavior problems 

than those provided lower quality child care.104 Other research suggests that quality child care can counteract a lower 

quality home environment. When children with lower quality home environments and high quality child care were 

compared to children with lower quality home and child care environments, fewer behavior problems (a risk factor for 

child abuse and neglect)37 were noted among the former group.105

Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 23

Accredited child 

care, which ensures 

quality care, is 

associated with 

positive outcomes 

for children.
24 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 25

Enhance Parenting Skills to Promote 

Healthy Child Development

Rationale

A child’s relationship with others inside and outside the family plays a role in healthy brain development, as well as in 

the development of physical, emotional, social, behavioral, and intellectual capacities.106 Parents who have inadequate 

parenting skills37 or are experiencing health or financial issues have more difficulty parenting and providing the care 

and nurturing that is needed for children to have safe, stable, nurturing relationships and environments.107,108 There 

is substantial evidence that parent training programs or behavioral family interventions delivered in clinical settings 

and focused on influencing children’s behavior through positive reinforcement are effective at influencing the childrearing practices of families.109-111 Some evidence also suggests that these types of programs can prevent physical 

abuse and neglect.112 Although the focus may be different, the goal of each of these programs is to provide parents 

with skills that can be used to promote the health and well-being of the child.

Approaches

Several approaches seek to enhance parenting skills and promote healthy child development in ways that prevent 

child abuse and neglect. 

Early childhood home visitation programs provide information, caregiver support, and training about child health, 

development, and care to families in their homes. Home visiting programs often differ depending on the model 

being utilized. Many programs, such as Nurse Family Partnership (NFP), are offered to low-income, first-time mothers 

as they are at higher risk for child abuse and neglect.113 Other home visiting programs, such as Durham Connects, are 

offered to all new parents in certain geographical regions.114 Home visiting programs may be delivered by nurses, 

professionals, or paraprofessionals. The content of programs varies depending on the model being utilized, with some 

being highly manualized (e.g., NFP) and others being more flexible in content delivery (Healthy Families),115 and the 

point at which the program begins varies depending on the model. Some programs begin during pregnancy, while 

others begin after the birth of the child.115

Parenting skill and family relationship approaches provide parents and caregivers with support and teach 

behavior management and positive parenting skills to build strong and safe families that protect children from 

violence and its long-term consequences.

116,117 Programs may be targeted to parents of children in a specific age 

range or for parents in general.116 Parents typically receive information about child development and the causes and 

consequences of violence, anger management skills, problem-solving skills, and discipline techniques not involving 

physical punishment.116 
26 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Potential Outcomes 

•	 Reductions in child abuse and neglect perpetration

•	 Reductions in risk factors for child abuse and neglect 

(e.g., parental substance use, criminal involvement, 

timing of subsequent births, child behavioral problems) 

•	 Improved parent-child interactions (e.g., increased 

nurturing) 

•	 Improved parenting behaviors (e.g., child behavior 

management), including reductions in use of harsh 

verbal and physical discipline

•	 Improved violence prevention-related knowledge, 

behaviors, and beliefs 

•	 Fewer emergency room visits and hospital stays

•	 Reductions in use of welfare

•	 Reductions in criminal behavior

•	 Reductions in youth substance use and arrests

Evidence

Approaches that enhance parenting skills and promote healthy child development have demonstrated effects in 

preventing child abuse and neglect, although the level of effectiveness varies by model and program.

Early childhood home visitation. The evidence of effectiveness for home visiting programs is mixed, with some 

models showing few or no effects and others showing strong effects.118-120 These mixed effects likely arise because the 

content of home visiting models varies. The Nurse Family Partnership (NFP) program, for example, has documented 

a 48% relative reduction in child abuse and neglect, as well as reductions in risk factors (e.g., parental substance 

use, timing of subsequent births, child behavioral problems) associated with child abuse and neglect.24 The NFP

program also reduced the number of subsequent pregnancies, the use of welfare, and criminal behavior in women 

who participated in the home visiting program, when compared to women in the comparison group.24,121 Moreover, 

reductions have been noted in substance use and arrests among the children who participated in NFP.

30 Reductions 

in child protective services reports also have been documented up to three years for families in the Netherlands 

receiving NFP compared to those receiving usual care.122 At 6-months, Durham Connects, a home visiting program 

wherein nurses assess health and psychosocial risk across four domains and 12 factors, documented fewer emergency 

medical care episodes, and more community connections, more positive parenting behaviors, participation in higher 

quality out-of-home child care, and lower rates of anxiety than control mothers, as well as higher quality home 

environments compared to controls.123 At 12-months, 50% fewer total emergency medical care use was documented 

for Durham Connects families relative to controls.124 The Home Visiting Evidence of Effectiveness Review120 identifies other 

home visiting models that may work for communities, depending on available resources and the context in which the 

home visiting model is delivered. 

Parenting skill and family relationship approaches. Parenting skill training approaches have consistently 

demonstrated positive effects in preventing child abuse and neglect. One program, Adults and Children Together 

Against Violence: Parents Raising Safe Kids (ACT), which teaches positive parenting skills, documented reductions in the 

use of harsh verbal and physical discipline and an increase in nurturing behavior at post-treatment and at a threemonth follow-up.117 In other research, significantly lower instances of spanking and hitting children with objects were 

observed among those who received the training when compared to a group who did not receive the training.116

Significant improvements were also observed from baseline to post-treatment for parents who received the training in 

violence prevention-related knowledge, behaviors, and beliefs as well as parenting skills.116
Several of the behavioral parent training programs, including The Incredible Years and SafeCare, have been used with 

universal populations and at-risk samples (in addition to children and families where abuse and neglect has already 

occurred) to enhance parenting skills, promote optimal child development, and prevent child abuse and neglect. 

The Incredible Years is designed for parents of young children up to 12 years of age to promote emotional and social 

competence and to prevent, reduce, and treat behavioral and emotional problems in children.125 The program lasts 

for 9 to 20 sessions, depending on whether the population is a prevention or treatment group.125 In evaluations of The 

Incredible Years with at-risk samples, parents demonstrated lower negative and higher positive parenting scores after 

participating in the program than those parents who did not participate.126 SafeCare is an in-home parenting program 

for parents of children 0 to 5 that targets risk factors for child neglect and physical abuse. In the program, parents 

are taught: (1) how to interact in a positive manner with their children, plan activities, and respond appropriately to 

challenging child behaviors (parent-child interactions module); (2) to recognize hazards in the home to improve the 

home environment (safety module); and (3) to recognize and respond to symptoms of illness and injury, in addition 

to keeping good health records (health module).127 Low-income mothers receiving the parent-child interactions 

module of SafeCare demonstrated more frequent use of positive parenting strategies and engaged in more responsive 

parenting than mothers in a wait-list control group.128

Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 27

Approaches that 

enhance parenting 

skills and promote 

healthy child 

development have 

demonstrated effects 

in preventing child 

abuse and 

neglect.
28 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 29

Intervene to Lessen Harms 

and Prevent Future Risk

Rationale

Exposure to child abuse and neglect negatively impacts short- and long-term mental and physical health and wellbeing, as well as biological systems and structures.15,36,129,130 Moreover, children with histories of abuse and neglect 

are at risk of perpetrating maltreatment and other types of violence as adults and are at risk of future and multiple 

victimization experiences.131-135 Some evidence suggests that behavioral parent training programs can prevent the 

recurrence of physical abuse and neglect.27,28 These programs are often focused on those who have demonstrated 

risk factors for physical abuse and neglect, such as contact with the child welfare system. In instances when abuse 

and neglect have occurred and symptoms such as behavior problems, posttraumatic stress, anxiety, and depression 

are present in the child, the symptoms can be treated successfully with evidence-based treatment programs.136 Thus, it 

stands to reason that treatment of children and families in which abuse has occurred may work to mitigate the health 

consequences of child abuse and neglect exposure, prevent recurrence of child abuse and neglect, decrease the risk for 

other types of violence later in life, and decrease the likelihood that individuals will abuse their own children later in life.

Approaches

Several approaches have been identified to prevent abuse and neglect, its recurrence, and the negative outcomes 

associated with abuse and neglect. The approaches described below serve to intervene to lessen harms and prevent 

future risk posed by child abuse and neglect exposure or its associated risk factors.

Enhanced primary care may be used to identify and address psychosocial problems in the family that serve as risk 

factors for child abuse and neglect. Primary care providers are trained to identify and address factors (e.g., parental 

depression, substance abuse, major stress, utilization of harsh punishment, intimate partner violence) that increase risk 

for child abuse and neglect.137 Follow-up is often conducted with a social worker to address problems and/or provide 

referrals to community resources. Parents also receive handouts that include information on problems addressed with 

the social worker, as well as information on local resources.137 

Behavioral parent training programs may reduce the recurrence of child abuse and neglect while teaching parents 

specific skills to build a safe, stable, nurturing relationship with their children. Behavioral parent training programs 

are typically delivered to a single family or a group of families in a structured format over the course of about 12-16 

sessions. Children targeted by the programs usually range in age from 0 to 12, although the specific age range is 

dependent on the model chosen. Topics covered in these programs often range from parent-child interactions and 

relationship enhancement skills to child behavior management and discipline skills.

Treatment for children and families to lessen the harms of abuse and neglect exposure. Therapeutic treatment

can mitigate the health consequences of abuse and neglect exposure, decrease the risk for other types of violence 

later in life, and decrease the likelihood that individuals will abuse their own children. These treatments are typically 

delivered by trained professionals in a 1-1 or group setting and over the course of 12 or more sessions. Treatment is 

often provided to children at varying ages and stages of development, and as such, may engage both the child and 

parent in the treatment process. 

Treatment for children and families to prevent problem behavior and later involvement in violence. Therapeutic 

treatments are typically delivered by highly trained professionals in a 1-1 or group setting and over the course of several 

months. Given the focus on youth and the role of parents and caregivers in monitoring and guiding the child’s behavior, 

parents and caregivers are often included in the treatment process or the child’s entire social network may be engaged. 

Children of all ages may participate in these programs, although the specific age of children targeted often depends on 

the specific program being implemented. 
30 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Potential Outcomes 

•	 Fewer delayed immunizations

•	 Reductions in abuse and neglect perpetration

•	 Reductions in short- and long-term trauma-related symptoms of the child, including internalizing (e.g., 

posttraumatic stress, depression, anxiety) and externalizing (e.g., sexualized behaviors, aggressive behavior) 

symptoms

•	 Improved parent-child interactions, parenting behaviors, and family functioning

•	 Reductions in parental depression, emotional distress, and substance use

•	 Decreased number of and time spent in out-of-home placements

•	 Reductions in substance use among youth

•	 Reductions in re-offending

Evidence

A large body of evidence highlights the importance of intervening with those who have experienced and those at risk 

of perpetrating abuse and neglect. Abuse and neglect often tend to be cyclical; thus, success in interrupting the cycle 

of violence can prevent the exposure of many children to abuse and neglect.

Enhanced primary care programs, such as the Safe Environment for Every Kid (SEEK) model, have demonstrated 

positive effects on child abuse and neglect. For example, families who participated in the SEEK program had fewer 

reports to child protective services than families who completed services as usual (13.3% and 19.2%, respectively); 

reported fewer occurrences of severe physical assault (average weighted score: 0.11 and 0.33, respectively); and 

were more likely to adhere to medical care (4.6% and 8.4%, respectively) and ensure their children had timely 

immunizations (3.3% and 9.6%, respectively).137 SEEK also resulted in less maternal psychological aggression (effect 

size = -0.16) and fewer minor maternal physical assaults (effect size = -0.16).138 

Behavioral parent training programs such as Parent-Child Interaction Therapy (PCIT), The Incredible Years, and

SafeCare demonstrate success in preventing recidivism for abuse in families with substantiated cases of child abuse 

and neglect, and in reducing child abuse and neglect risk factors in high-risk families (e.g., those who use harsh/

punitive parenting practices).27,28,139-141 A study conducted with parents reported to CPS found fewer re-reports 

of physical abuse and/or neglect at a 36-month follow-up for parents who completed SafeCare (15% recidivism) 

than families who completed services as usual (46% recidivism).142 Physically abusive parents in the child welfare 

system who participated in PCIT had significantly fewer re-reports of physical abuse than parents who participated 

in services as usual (19% vs 49%).27 In a study of families with chronic and severe neglect and/or physical abuse 

histories, PCIT plus a motivational enhancement was effective in reducing future child welfare reports, with a stronger 

effect observed when children were returned to the home sooner rather than later.28 The Incredible Years is effective 

in reducing harsh parenting and conduct problems and increasing positive discipline and nurturing parenting.143

In a study of primarily neglectful biological and foster parents, positive parenting skills increased for parents who 

participated in The Incredible Years program (when compared to controls), and the improvements were greatest when 

parents attended six or more sessions.144

Treatment for children and families to lessen the harms of abuse and neglect exposure, such as Trauma-Focused 

Cognitive Behavioral Therapy (TF-CBT), is effective in reducing symptoms of posttraumatic stress disorder (PTSD), 

depression, and behavior problems at post-treatment and for PTSD at 12 months post-treatment.145 Other research 

has suggested that post-treatment improvements in trauma-related symptoms for the child (e.g., posttraumatic 

stress, depression, fear, sexualized behavior, anxiety, shame, behavioral issues) are sustained at 6 and 12 months posttreatment, as are parenting-related behaviors and parental emotional distress and depressive symptoms.146 
Treatment for children and families to prevent problem behavior and later involvement in violence often 

address the behavioral consequences of experiencing child abuse and neglect. The effectiveness of the Children with 

Problematic Sexual Behavior Cognitive-Behavioral Treatment Program: School-age Program was examined in a 10-year 

prospective study of 135 children aged 5-12 with sexual behavior problems and significant reductions in re-offending 

were noted for the CBT treatment group when compared to a play therapy group (2% vs 10%).147 In a comparison of 

this same group of children to a general clinic comparison, no differences were noted between groups in nonsexual 

offenses.147 In other research, CBT resulted in improvements in child sexual behavior problems at post-treatment and/

or follow-up.148,149 Another program, Multisystemic Therapy (MST), is an intensive treatment program designed for 

chronic and violent juvenile offenders 12 to 17 years of age. The program engages the child’s entire social network 

(e.g., family, school and teachers, neighborhood and friends) as a means of preventing problem behavior and later 

involvement in violence.150 The program is associated with improved parent-child interactions, decreased symptoms 

for the youth and caregiver, improved parenting behaviors, increased social support, and decreased out-of-home 

placements (63% fewer days).151-153 Moreover, at a 24-month follow-up, decreases were observed in rates of child 

maltreatment and time youth spent in out-of-home placements.153 A recent meta-analysis of the effects of MST found 

small but significant treatment effects on delinquency, psychopathology, substance use, family factors, out-of-home 

placement and peer factors.154

Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 31

A large body of 

evidence highlights 

the importance of 

intervening with those 

who have experienced 

and those at risk of 

perpetrating abuse 

and neglect.
32 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 33

Sector Involvement

Public health can play an important and unique role in addressing child abuse and neglect. Public health agencies, 

which typically place prevention at the forefront of efforts and work to create broad population-level impact, can bring 

critical leadership and resources to bear on this problem. For example, these agencies can serve as a convener, bringing 

together partners and stakeholders to plan, prioritize, and coordinate child abuse and neglect prevention efforts. Public 

health agencies are also well positioned to collect and disseminate data, implement preventive measures, evaluate 

programs, and track progress. Although public health can be a lead in preventing child abuse and neglect, the strategies 

and approaches outlined in this technical package cannot be accomplished by the public health sector alone. 

Other sectors vital to implementing this technical package include, but are not limited to, education, government 

(local, state, and federal), social services, health services, business/labor, justice, housing, media, and organizations 

that comprise civil society such as faith-based organizations, youth-serving organizations, foundations and other 

non-governmental organizations. Collectively, these sectors can make a difference in preventing child abuse and 

neglect by impacting the various contexts that contribute to and support safe, stable, nurturing relationships and 

environments for children.

The strategies and approaches described in this technical package are summarized in the Appendix, along with the 

relevant sectors that are well positioned to lead implementation efforts. For example, business/labor and government 

entities are in the best position to implement programs and policies that Strengthen Economic Supports for Families. 

These types of supports go beyond individual behavior change and require commitment and support from those 

sectors that can directly address some of the underlying risks and the environmental contexts that increase the 

likelihood of child abuse and neglect. Public health entities can play an important role by gathering and synthesizing 

information to inform policy, raise awareness, and evaluate the effectiveness of various policies. Moreover, 

partnerships with non-governmental and community organizations can be instrumental in increasing awareness of 

and garnering support for policies affecting children and families.

The public health sector has been at the forefront of many public engagement and education campaigns focused on 

changing social norms and positively impacting health behavior (e.g., drinking and driving, smoking cessation, and 

nutrition). It is well suited to take on a similar leadership role in changing social norms in support of parents and positive 

parenting to prevent child abuse and neglect. Legislative approaches to reduce corporal punishment, on the other hand, 

fall within the realm of local, state, and federal legislative bodies. These are the entities which draft and enact legislation. 

Similar to other policy changes, public health can be helpful in gathering information to inform policy, including research 

on policy alternatives and their impact, working with other agencies within the executive branch of their state or local 

governments on implementation of policies, and evaluating the effectiveness of measures taken. 

The social services and public health sectors are vital for implementation and continued provision of Quality Care 

and Education Early in Life. As the lead sector in implementing programs such as Child-Parent Centers and Early Head 

Start throughout the country, the social services sector is helping to ensure that families and communities receive 

the skills and services necessary to promote the physical, cognitive, social, and emotional development of young 

children, thereby preparing them for future growth and development. Business/labor and government entities are 

in the best position to ensure Quality Care through licensing and accreditation. Public health can assist by educating 

communities and other sectors about the importance of ensuring a comprehensive integrated array of quality child 

care and early childhood education services and supports for families to prevent child abuse and neglect and improve 

health outcomes across the life span. The public health sector can work with communities to complete a community 

health assessment to better identify gaps in services and the highest burden of child abuse and neglect within the 

community. The public health sector can also play a vital role in continuing research that documents the benefits of 

quality child care and early childhood education on child health and development, family well-being, and child abuse 

and neglect prevention, as this evidence is important in making the case for continued support of these programs for 

children and families in need.
Finally, the technical package includes a number of approaches to Enhance Parenting Skills to Promote Healthy Child 

Development and Intervene to Lessen Harms and Prevent Future Risk of child abuse and neglect. The health care, public 

health, justice, and social services sectors can work collaboratively to identify and assist at-risk families and those for 

whom abuse and neglect is already present. In addition to having licensed providers trained to recognize and address 

risk factors for child abuse and neglect, the health care sector can coordinate wrap-around behavioral health and 

social services to address the health consequences of abuse and neglect and the conditions that may put the family at 

risk of recidivism. 

Regardless of strategy—action by many sectors—will be necessary for the successful implementation of this package. 

In this regard, all sectors can play an important and influential role in supporting safe, stable, nurturing relationships 

and environments and preventing child abuse and neglect. 

 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 34
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 35

Monitoring and Evaluation

Monitoring and evaluation are necessary components of the public health approach to prevention. Timely and 

reliable data are necessary to monitor the extent of the problem and to evaluate the impact of prevention efforts. Data 

also are necessary for program implementation, as planning, implementation, and assessment all rely on accurate 

measurements of the problem. 

In order to collect the most accurate information on the magnitude of child abuse and neglect and on the impact of 

implemented programs, practices, and policies, data collection should adhere to three key parameters: (1) uniform 

surveillance definitions should be used across disciplines; (2) case definitions should be applied consistently across 

data collection sites; and (3) data collection should occur on a regular, ongoing basis. Child abuse and neglect has long 

been examined through a social service and child protection lens, but incidents of child abuse and neglect often come 

to the attention of multiple agencies and sectors, including legal and medical communities, researchers, practitioners, 

advocates, and public health officials. As such, it is common for each agency and sector to employ unique definitions, 

thereby limiting communication across disciplines and hampering efforts to identify, assess, track, treat, and prevent 

child abuse and neglect effectively. 

Surveillance data help researchers and practitioners track changes in the burden of child abuse and neglect. 

Surveillance systems exist at the federal, state, and local levels. It is important to assess the availability of surveillance 

data and data systems across these levels to identify and address gaps in the systems. At the federal level, the National 

Child Abuse and Neglect Data System (NCANDS) is an example of a surveillance system that provides data for child 

abuse and neglect. The NCANDS is a voluntary data collection system that gathers information from all 50 states, the 

District of Columbia, and Puerto Rico about reports of child abuse and neglect made to Child Protective Services. 

NCANDS was established in response to the Child Abuse Prevention and Treatment Act of 1988, and the data are 

used to examine trends in child abuse and neglect across the country. Key findings are published in the Child Welfare 

Outcomes Reports to Congress and annual Child Maltreatment reports. 

Data from state or local Child Death Review teams offer another source to identify deaths in which child abuse and 

neglect caused or contributed to the fatality and to obtain insight into gaps in services, systems, and modifiable risk 

factors. Information from these reviews can be used at the local, state, and federal levels to focus planning and policy 

development, quality improvement and health systems development, and to enhance efforts to develop and maintain 

risk reduction and prevention programs for child abuse and neglect.155

While NCANDS provides official reports of child abuse and neglect, the National Survey of Children’s Exposure to 

Violence (NatSCEV) provides self-reported data on violence against children through a nationally representative 

random-digit dial survey of children (0-9) and youth (10-18). Youth report on their own victimization experiences 

(over 50 forms of victimization assessed for the past 12 months and over the lifetime) across five general areas (i.e., 

conventional crime, child abuse and neglect, peer and sibling victimization, sexual victimization, and witnessing 

violence). Caregivers report on these victimizations for children. Of course, state estimates of child abuse and neglect 

are as important as national estimates. As such, monitoring of child abuse and neglect at the state level is critical if we 

are to understand the magnitude of the uptake of prevention strategies and their impact. No matter the data source 

specified, it is important that routine and ongoing monitoring align with the work of multiple federal, state-level, 

and local partners and agencies so that we may achieve a more comprehensive understanding of the problem and 

effective prevention efforts in this area. 

It is also important to track progress of prevention efforts and to evaluate the impact of those efforts, including the 

impact of this technical package. Evaluation data, produced through program implementation and evaluation, is 

essential in providing information on what does or does not work to reduce rates of child abuse and neglect and 

associated risk and protective factors.
Much progress has been made in recent years to build the evidence base for child abuse and neglect prevention 

through research. However, additional research is needed to expand the inventory of effective child abuse and 

neglect prevention strategies, as well as the evidence base for protective factors that exist in individuals, families, 

and communities and risk factors that go beyond the individual and family. Prevention practitioners play a large role 

in building the evidence base by evaluating programs for impact on rates of child abuse and neglect and risk and 

protective factors. The field will advance if research continues to test programs born out of the field for effectiveness 

and identifies and tests programs for priority populations. Research is also needed on the impact of community 

and societal strategies, including policies and community environmental change, to reduce rates of child abuse and 

neglect and increase safe, stable, nurturing relationships and environments for children and families. Lastly, it will be 

important for researchers to test the effectiveness of combinations of the strategies included in this technical package. 

Conclusion

Child abuse and neglect is a serious public health issue with far-reaching consequences for the youngest and most 

vulnerable members of society. Every child in the United States is better when he/she and his/her peers have safe, 

stable, nurturing relationships and environments. Thus, we all have a vested interest in ensuring that other children, 

not just our own, have safe, stable, nurturing relationships and environments. This technical package includes 

strategies and approaches that ideally would be used in combination in a multi-level, multi-sector approach to 

prevent child abuse and neglect. It includes strategies and approaches that are in keeping with CDC’s emphasis on 

primary prevention, or preventing child abuse and neglect from happening in the first place, as well as approaches 

to lessen the short- and long-term harms of child abuse and neglect. The hope is that multiple sectors, such as public 

health, health care, education, justice, social services, and business will use this technical package as a guide and join 

CDC in efforts to prevent child abuse and neglect and its consequences. Each of the strategies and approaches that 

have been identified is supported by research that directly reduces child abuse and neglect or reduces the risk factors 

for child abuse and neglect. This technical package is designed with the intent that monitoring and evaluation will 

play a key role in implementation, and as new evidence related to a strategy or approach emerges in the literature, the 

technical package can be refined to reflect the most current knowledge to date in the field.

While child abuse and neglect is a significant public health problem, it is also a preventable one. The policy, norm, and 

programmatic strategies and approaches identified herein are intended to help guide the creation of neighborhoods 

and communities where every child has safe, stable, nurturing relationships and environments and a world where 

every child can thrive.

 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 36
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 37

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Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 45
46 Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities

Appendix: Summary of Strategies and 

Approaches to Prevent Child Abuse and Neglect

Strategy Approach/Program,

Practice or Policy

CAN 

Perpetration

CAN 

Victimization

Risk Factor 

for CAN Lead Sectors1

Strengthen 

economic supports 

to families 

Strengthening household financial security

Business/Labor

Government 

(local, state, 

Federal)

Child support payments  

Tax credits 

State nutrition assistance 

programs

 

Assisted housing mobility 

Subsidized child care  

Family-friendly work policies

Business/Labor

Government 

(local, state, 

Federal)

Livable wages 

 Paid leave  

Flexible and consistent schedules 

Change social 

norms to support 

parents and 

positive parenting

Public engagement and education campaigns

Public Health

Breaking the Cycle 

Legislative approaches to reduce corporal punishment Government 

(local, state, 

Federal) Bans pertaining to home, school, 

other settings 

Provide quality care 

and education early 

in life

Preschool enrichment with family engagement Social Services

Public Health Child Parent Centers  

Early Head Start  

Improved quality of child care through licensing and accreditation

Business/labor

Government 

(local, state, 

Federal) Licensing and accreditation 

1

This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy, there 

are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing the specific 

programmatic activities.

 2Program was designed to address the harms of abuse and neglect (e.g., PTSD, depression).
Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities 47

Strategy Approach/Program,

Practice or Policy

CAN 

Perpetration

CAN 

Victimization

Risk Factor 

for CAN Lead Sectors1

Enhance parenting 

skills to promote 

healthy child 

development

Early childhood home visitation

Public Health

Health Care

Nurse Family Partnership  

Durham Connects 

Parenting skill and family relationship approaches

Public Health

Social Services

Adults and Children Together 

Against Violence: Parents Raising 

Safe Kids (ACT)

 

Incredible Years 

Safe Care 

Intervene to lessen 

harms and prevent 

future risk

Enhanced primary care Public Health

Health Care Safe Environment for Every Kid 

(SEEK)  

Behavioral parent training programs

Public Health

Social Services

Parent-Child Interaction Therapy 

(PCIT)  

Safe Care  

Incredible Years 

Treatment to lessen harms of abuse and neglect exposure Health Care

Social Services

Justice

Trauma-Focused Cognitive 

Behavioral Therapy (TF-CBT) N/A2 N/A2 

Treatment to prevent problem behavior and later involvement in violence

Health Care

Social Services

Justice

Children with Problematic Sexual 

Behavior Cognitive-Behavioral 

Treatment Program: School-age 

Program



Multisystemic Therapy (MST)  

1

This column refers to the lead sectors well positioned to bring leadership and resources to implementation efforts. For each strategy, there 

are many other sectors such as non-governmental organizations that are instrumental to prevention planning and implementing the specific 

programmatic activities.

 2Program was designed to address the harms of abuse and neglect (e.g., PTSD, depression).


For more information

To learn more about preventing child abuse and neglect, 

call 1-800-CDC-INFO or visit CDC’s violence prevention 

pages at www.cdc.gov/violenceprevention.

AK2016

TM

National Center for Injury Prevention and Control

Division of Violence Prevention