National Center for Injury Prevention and Control 

Division of Violence Prevention

Center for Injury Prevention and Control 

f Violence Prevention

Essentials for Childhood

Creating Safe, Stable, Nurturing 

Relationships and Environments 

for All Children

Creating Safe, Stable, Nurturing 

Relationships and Environments 

for All Children

Reprinted with major technical edits
INTRODUCTION 

Safe, stable, nurturing relationships and 

environments are essential to prevent 

early adversity, including child abuse and 

neglect, and to assure that all children 

reach their full potential.

Promoting safe, stable, nurturing relationships and environments and preventing 

child abuse and neglect benefits from comprehensive efforts and action by many 

sectors. The framework is designed to allow for comprehensive child abuse and 

neglect prevention activities with involvement from multiple sectors. 

Child Abuse and Neglect Are Significant 

Public Health Problems

Child abuse and neglect (CAN) are significant public health problems in the 

United States (U.S.) and around the world.1,2 CAN refers to behavior that results 

in harm, potential for harm, or threat of harm directed toward a child under 

the age of 18 by a parent, caregiver, or another person in a custodial role (e.g., 

clergy, coach, teacher). There are four common types3:

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5introduction

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Physical 

Sexual 

Emotional 

Neglect 

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

According to the latest Child Maltreatment Report, made available in January 2019, 

the estimated referrals to CPS for investigation response or alternative response 

was 4,136,000 in fiscal year 2017. The official cases tell only part of the story, as 

many, if not most, are never reported to social service agencies or law enforcement4. 

Additional survey results provide an even more troublesome picture of this problem. 

A non-CPS study estimated that one in four children in the U.S. experience some 

form of child abuse or neglect during their childhood; 74.9% neglect, 18% physical 

abuse, and 8.6% sexual abuse5.

Children may also experience other 

adversities during childhood, such 

as violence perpetrated by a peer, 

witnessing violence in the home or 

community, or living with someone 

who is mentally ill or addicted to 

drugs. Adversities experienced 

during childhood are often referred 

to as Adverse Childhood Experiences 

(ACEs). Children who experience CAN, 

and other ACEs in childhood may 

experience physical injuries such as 

cuts, bruises, burns, and broken bones, 

in addition to other immediate and longterm consequences. CAN and other 

ACEs may cause high levels of chronic 

stress (i.e., toxic stress) that rewires 

the brain’s developing architecture 

(i.e., connections between cognitive, 

emotional, and social development). 

As a result, children who experience 

CAN and other ACEs are more likely to 

This document describes 

a framework to guide 

communities’ (“community” 

refers to any group with 

shared interests such as 

neighborhoods, counties, 

states, and professional 

groups) activities that 

will support the types 

of relationships and 

environments that help 

children grow up to be 

healthy and productive 

members of their 

communities so that they, 

in turn, can build stronger 

and safer families and 

communities for their 

children.
engage in risky behaviors in adolescence and have health problems as adults. These 

problems include alcohol abuse, depression, drug abuse (including opioids), eating 

disorders, obesity, sexually transmitted diseases, smoking, suicide, violence towards 

others, and many chronic diseases.6,7 Surveys of adults show about 62% report 

experiencing at least one ACE with one in four experiencing three or more.8 Surveys 

of caregivers show 22% of children have experienced two or more ACEs.9

Safe, Stable, Nurturing Relationships and 

Environments Are Important for Preventing Child 

Abuse and Neglect and other Adverse Experiences

Young children experience their world through their relationships with parents and 

other caregivers. Safe, stable, nurturing relationships and environments for children and 

their caregivers provide a buffer against the effects of potential stressors such as CAN 

and other ACEs and are fundamental to developing healthy brain architecture. They 

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

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

safe, stable, nurturing relationships and environments can have a positive impact on a 

broad range of health problems and on the development of skills that help children reach 

their full potential.

Safety, stability, and nurturing are three critical qualities of relationships and 

environments that make a difference for children as they grow and develop. They 

can be defined as follows:

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

or psychological harm within their social and physical environment.

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

emotional, and physical environment.

Nurturing: The extent to which children’s physical, emotional, and 

developmental needs are sensitively and consistently met.

Safe, stable, nurturing relationships and environments may help to:

Reduce the occurrence of CAN and other ACEs

Reduce the negative effects of CAN and other ACEs

Improve physical, cognitive, and emotional outcomes throughout a child’s life

Reduce health inequities

Have a cumulative impact on health

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

environments see: https://www.cdc.gov/violenceprevention/childabuseandneglect/

essentials.html

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WHAT TO EXPECT

This document describes a framework to guide community activities that will 

support safe, stable, nurturing relationships and environments for children and 

their families. It is intended for anyone committed to the positive development 

of children and families, and specifically to the prevention of all forms of CAN 

and other ACEs. It is organized into four sections. Each section focuses on one 

goal of the framework and lays out suggested actions to help you move toward 

that goal. While each goal is important, the four goals together are more likely 

to build a comprehensive foundation of safe, stable, nurturing relationships and 

environments for children and families. The four sections include:

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

relationships and environments for all children

GOAL 2: Use data to inform actions

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

change and programs

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

This framework is designed to outline critical goals for promoting safe, stable, 

nurturing relationships and environments and preventing CAN and other ACEs. 

However, exactly how, when, and in what order you focus on each goal (and 

associated steps for reaching the goal) will depend on what is already happening 

in your community. Therefore, as your community takes on the goals outlined in 

the framework, consider your unique needs. Working together, there is much your 

community can do to create an environment in which children can—and do—live 

life to their fullest potential.

The Importance of Using 

Evidence-Based Approaches

The information included as part of this framework is based on the best available 

evidence. The strategies and approaches for Goals 3 and 4, for example, are 

summarized in the box on the next page and in CDC’s Technical Package (https://

www.cdc.gov/violenceprevention/pdf/can-prevention-technical-package.pdf). As 

noted in the technical package, while there is a rich scientific literature on the use of 

parenting programs to prevent or reduce CAN, data on policies that may prevent or 

reduce CAN are more limited.

The evidence base for promoting safe, stable, nurturing relationships and 

environments and preventing CAN is not static; it is constantly evolving. Therefore, 

7
we must act on the best evidence available to us today, 

knowing it could change tomorrow. And, as we go, we 

have a responsibility to evaluate our efforts whenever 

possible to add to the evidence base. The Centers for 

Disease Control and Prevention’s (CDC) Division of 

Violence Prevention provides guidance and resources 

to assist with evidence-based decision-making: https://

vetoviolence.cdc.gov/understanding-evidence.

CDC has also proposed strategies for preventing other 

adverse childhood experiences such as witnessing or 

experiencing violence outside the home or witnessing 

intimate partner violence (see https://www.cdc.gov/

violenceprevention/pub/technical-packages.html).

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

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GOAL 1

Raise Awareness and Commitment to 

Promote Safe, Stable, Nurturing 

Relationships and Environments 

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

will require that you partner with others to change beliefs, attitudes, behaviors, 

norms, programs, systems, and policies. Even if you know people or groups who 

are motivated to create this kind of change, you will only see results when the idea 

garners the support of the larger community and its leaders. This means your efforts 

to prevent CAN and other ACEs and promote safe, stable, nurturing relationships 

and environments where you live requires both community and social commitment.

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

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

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

but moves along a continuum from awareness of the problem to commitment to 

the solutions. Observing an impact on safe, stable, nurturing relationships and 

environments and prevention of CAN and other ACEs is more likely as community 

members and leaders move along the continuum toward solutions.

Why Sustained Commitment Is Important

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

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

lack of commitment to do something about it.10 This means it is critical to build 

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

safe, stable, nurturing relationships and environments for all children. You can 

expect sustained commitment to take time, resources, and persistence.11 Sustained 

commitment also requires the continuous use and sharing of new information for 

ongoing public involvement, as well as the translation of technical information for 

the general public, leaders, and decision-makers.

To build awareness and commitment at the community level, you might consider:

1) Partnering with others to build commitment

2) Developing a shared agenda

3) Consistent and strategic messaging

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Step #1

Partner with others to build commitment

Partnering with individuals or groups—in government, the general public, community 

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

awareness to solutions. Your partners can bring in additional support and lend their 

voice and leadership to this effort.

Partnerships can help unite those committed to children and community health 

behind a shared vision so you can work together and collectively make impacts. 

The challenge is complex. One organization cannot do this on its own—there 

is power in numbers. Since there are so many possibilities, it may be helpful to 

prioritize and focus your goals.

Partners participating in existing efforts of implementing the Essentials for 

Childhood Framework include early learning, child care, social services, education, 

housing, Medicaid, community-based organizations, and the business sector. 

The media can be an important partner but is often overlooked. Building a 

relationship with your news outlets will further support your efforts to create 

community and social commitment. Capitalize on this by creating news events 

they can cover, generating editorials, providing community data to help reporters 

‘localize’ a story while using a “landscape” lens (i.e., widening the lens to include 

the historical, cultural, social, economic, and/or political context), and providing 

accurate information about the problem and prevention solutions in ways that 

increase shared commitment (see Step #3).

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Step #2 

Develop a shared agenda (vision, goals, and metrics)

A shared agenda involves having a shared understanding of the problem and 

articulating a shared vision, goals, and metrics. When a group of diverse partners 

agrees on a shared vision for a better future, they can operate under the same 

assumptions, align their efforts, and work collectively toward common goals. Vision 

statements reflect local principles. They can describe what the community will be or 

will gain by aspiring to foster a safe, stable, and nurturing context for growing up, and 

they can clarify the desired outcomes of the effort as a whole.

Creating a vision could be the beginning of this planning process and occur before 

you come up with goals and action steps. You might consider adopting the vision of 

“assuring safe, stable, nurturing relationships and environments for all children.”

The process of developing a shared agenda is as important as the product. A 

good process includes those who care about the issue, deepens relationships, 

and facilitates exploring and learning together with honest dialogue to achieve 

a shared understanding of the problem, a shared vision of what you want to 

achieve, and a few high level goals for what people consider strategic priorities.11

A process designed to promote buy-in and commitment engages diverse partners 

in developing and committing to a solution. Though the process can take time 

and resources, such an investment can be worthwhile. The steps and tenor of the 

process can build trusting relationships and cultivate broad support for the agenda as 

it takes shape, which can facilitate more widespread action later.

Step #3

Consistent and strategic messaging

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

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

they are important. Unfortunately, when raising awareness is mentioned, many 

organizations default to very basic information such as stating that child abuse is 

a problem and that it is bad for children. Most people already know and accept 

these facts. However, many people don’t know how it can be prevented or what 

they can do to solve the problem. In part, this may be due to the highly ingrained 

values of individualism and personal responsibility12, but it also has to do with the 

way child abuse and neglect issues are explained to the public. Stories about crime, 

bad parents, and government failures reinforce the dominant narrative and beliefs 

that the public currently brings to the issue, from misunderstandings about child 

development and discipline to exaggerated beliefs of government inefficiency12. The 

ways in which we, as a society, currently frame the issue may not allow people to 

understand community and societal solutions or primary prevention. 

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Experts and advocates can improve understanding by ensuring their messages 

do not inadvertently reinforce narrow views about the causes of and solutions 

to child abuse and neglect. For example, messages that focus on keeping 

children safe often inadvertently suggest that parents are solely responsible for 

protecting (or failing to protect) children. These messages also often position 

the community as something to fear or protect children from. While parent 

education (i.e., teaching positive parenting skills) is important in our efforts to 

prevent abuse and neglect, we also need to work to create the conditions in 

our communities that are supportive of children and parents so that positive 

parenting is easier. Here are some key points suggested by a leading strategic 

communications consultant for messaging to help increase understanding of 

effective community and societal prevention strategies[*]:

Experts and advocates are encouraged to work with 

a narrative template that answers the following 

questions, in this order:

Why does this matter to all 

of us? 

What‘s the problem or 

challenge? 

How can it be solved? and 

Who can play a role in helping 

solve it? 

When you start with an 

explanation of Why, you give 

your audience a wider lens 

on the issue and a stake in its 

resolution. 

This template also requires 

communicators to connect 

the dots between the problem 

(the What) and the solution 

(the How). 

It ends by having an “ask” 

relevant to your audience that 

explains how they can be part 

of the solution (Who).

*See the evidence in CDC’s Technical Package

https://www.cdc.gov/violenceprevention/pdf/can-prevention-technical-package.pdf

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goal one

Example of Effective Messaging

Why this matters: Assuring safe, stable, nurturing relationships and 

environments for all children is essential for our state’s 

future health and prosperity.

Problem: We now know that early experiences literally build the 

architecture of the brain, and that safe, stable, nurturing 

relationships and environments are key to building a 

solid foundation for future growth. We also know that 

not all children have access to the kinds of experiences 

that will most benefit their development. Some children 

experience adversity that is so severe and persistent that 

it produces toxic levels of stress that harm the brain’s 

developing architecture.

Solution: By investing in and supporting [family-friendly business 

practices like livable wages, and paid family and sick 

leave]/ [high quality child care]/ [high quality early 

education]/ [home visitation programs] we can prevent or 

alleviate the conditions known to produce toxic stress. 

Ask: Visit our website to find out more or share this information 

with your family and friends.

Goal 1 Summary

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

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

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

rates of CAN or other ACEs in your community. Observing an impact on CAN is more 

likely if you combine commitment with comprehensive data, effective programmatic 

strategies, and policy approaches.

For more information on potential partners, building a shared agenda, and raising 

awareness see: https://www.cdc.gov/violenceprevention/pdf/efc-building-communitycommitment.pdf.

See the evidence in CDC’s Technical Package: https://www.cdc.gov/

violenceprevention/pdf/can-prevention-technical-package.pdf.

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GOAL 2

Use Data to Inform Solutions

To adequately address any public health issue, using the information you have 

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

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

community’s prevention resources, how to determine whether your process is 

working, and how to monitor the ultimate impact of any interventions (such as a 

new program or policy).

To start, it may be helpful to do an environmental 

scan to know who is doing what related to safe, 

stable, nurturing relationships and environments 

for children and whether the groups/organizations 

are collecting any data. This will help in the 

identification of potential partners who may be 

doing this work or be interested in partnering with 

you. It is also important to learn what you can about 

any community, environmental, and social factors 

that might be related to the problem. Pulling all of 

this information together is not an easy task, but 

it is crucial information that can be fed into the 

other efforts (e.g., building community and social 

commitment, understanding parenting norms, 

evaluating policy changes).

Keep in mind you will face some challenges 

in collecting, analyzing, and using this kind of 

information. You are more likely to find existing 

information that focuses on risk factors and negative 

outcomes, like measures of CAN and other ACEs, 

out-of-home placements in foster care, or children 

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

variety of purposes with varying definitions and criteria.

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The four steps below may assist you as you begin this process:

 1) Use partnerships to help identify, gather and synthesize relevant data

2) Take stock of existing data

3) Identify and fill critical data gaps

4) Use the data to support other action goals and steps

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Step #1

Use partnerships to help identify, gather 

and synthesize relevant data

Data can be a powerful tool to highlight the realities of life for children and families 

in your community and for demonstrating success as you work together to make 

positive changes. However, any one organization or any one data source alone 

provides a limited view of the problems as well as the opportunities in your 

community. Multiple data sources allow for a more comprehensive understanding 

of the issues and multiple avenues for raising awareness and implementing 

change. Consider partnerships with others who collect and analyze data and are 

in a position to make data-informed decisions about programs or other strategies 

that improve the lives of children.

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

have staff with strong data skills and are typically familiar with the convener role. It 

is critical to reach out to a variety of partners. This could include several agencies 

or offices within state or local public health or social services departments, 

such as Maternal and Child Health, Injury Prevention, Mental Health, Early 

Childhood Education, and Children and Families/Social Services. You may also 

find it useful to work with other groups in your community, including schools 

and health care systems, child care and early learning agencies, housing, 

education, transportation, employment agencies, law enforcement, criminal 

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

universities. All of these can be strong partners.

Step #2

Take stock of what data already 

exist in your community

An important step in preventing CAN and in supporting safe, stable, nurturing 

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

best available information that describes the problem and its causes. Consider 

the following:

Vital statistics

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

child homicide and unintentional injury deaths among children under 5 

years of age)

• Child fatality review records

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Health data

• Hospital emergency department or discharge data

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

pregnant women being screened for depression, exposure to partner 

violence, or substance abuse; if so, are they being referred to evidencebased services, and what percentage of those referred actually receive 

the service?)

• Ambulatory care visits for mental illness, including substance abuse 

among women of reproductive age

• Length of wait list for treatment of substance abuse

•	 Coverage	and	dosage	of	well-baby	visits	and	services	offered	for	all	children (e.g., evaluation of social-emotional development and anticipatory 

guidance based on Bright Futures guidelines) and for children at risk or 

with developmental problems

• Coverage of family planning services

Criminal justice data

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

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

Child care and welfare data

• Reports to child protective services, substantiated reports of abuse and 

neglect, or out-of-home placements (number and geographic location)

• Services provided to parents and children (Are services evidence-based? Do 

services reach all who need them?)

• Length of wait list for child care programs such as center-based 

Early Head Start

• Length of wait list for child care subsidies

• Number and location of families receiving Temporary Assistance for Needy 

Families (TANF); Supplemental Nutrition Assistance Program (SNAP); State 

Children’s Health Insurance Program (SCHIP)/Medicaid

Educational data

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

• Sex education programs being used in schools (Are they evidence-based?)

• School dropout rates

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In addition, you can review various state or national level surveys or data from 

surveillance systems, some of which can provide data specific to your area. 

These include:

Child Fatality Review Data [CFRD]

National Violent Death Reporting System [NVDRS]

Youth Risk Behavior Surveillance System [YRBS]

Behavioral Risk Factor Surveillance System [BRFSS]

National Child Abuse and Neglect Data System [NCANDS]

National Survey of Family Growth [NSFG]

National Survey of Children’s Health [NSCH]

National Health and Nutrition Examination Survey [NHANES]

Pregnancy Risk Assessment Monitoring System [PRAMS]

National Health Interview Survey [NHIS]

National Immunization Survey [NIS]

Census data may also help you better understand your community’s household 

and neighborhood demographics, which will provide a better sense of what life 

is like for the children in your area. Census data include information such as the 

number of households headed by single parents, the number of young or schoolage children, the number of rental units versus owned homes, unemployment 

rates, and the number of households living below the poverty level.

Currently, several federal public health agencies and non-governmental 

organizations offer data about children and the conditions in which they live. 

These organizations provide a great deal of information on various indicators 

(e.g., child well-being, child abuse and neglect). Once you have pulled together 

information from a variety of sources, you will need to synthesize the findings on 

the magnitude of CAN and other ACEs and the conditions which contribute to it 

in your community, including why some children are at greater risk than others. 

Here’s an example of the data California is tracking (https://www.kidsdata.org/

topic/95/childhood-adversity-and-resilience/summary#).

To reduce CAN’s inequitable burden on children living in low socioeconomic 

households, it is important to examine the root causes (e.g., the conditions 

in which parents are trying to raise their children and how these conditions 

were created and are sustained) of CAN and other ACEs. The World Health 

Organization’s Commission on the Social Determinants of Health’s (CSDH) 

framework13 has been useful in organizing data to reduce inequities in CAN 

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(see page 19). In the first box on the right of the CSDH framework, you see the 

socioeconomic and political context. This includes our societal values which 

underlie our policy decisions related to education, labor, health care, taxes, the 

safety net, and other. Policies may create differential opportunities (see second 

box on the right) for getting a good education which determines what kind 

of job you can get which determines your income. As a result, some people 

may end up in a certain socioeconomic position. Your socioeconomic position 

determines where you can live, what services you have access to, where your 

children will grow, learn, and play; and can increase exposure to stressors that 

can increase partner conflict and violence and mental illness (see the first left box 

on intermediary determinants).13 Living conditions lead to the inequitable burden 

of health issues and life opportunities (box with outcomes). This framework also 

has a crosscutting box. This cross-cutting box represents organized communities 

changing the narrative to build commitment to support families and reduce 

inequities by class and race. The CSDH has summarized the theoretical and 

empirical support for this framework.13

Your partners can help gather data on what is already being done to address the 

problem. This information will help you make informed decisions about which 

evidence-based strategies most closely address the needs in your community. You 

will also have an understanding of what gaps exist, what efforts need to align, and 

where work still needs to be done in order to measure, monitor, and assure safe, 

stable, nurturing relationships and environments.

Step #3

Identify and fill critical data gaps

Where gaps in information are identified, your partnerships can help garner 

support for new data collection efforts. This may include developing a new 

survey or adding questions to existing surveys. CDC’s Uniform Definitions for 

Child Maltreatment)—available at https://www.cdc.gov/violenceprevention/

childabuseandneglect/index.html —can help you create new or edit existing 

data collection instruments and ensure they are as consistent and comparable 

as possible. Data gaps also may become a programmatic or policy initiative. For 

example, you may want to approach a decision-maker or program implementer to 

get new data generated. Opt-in internet panels are a relatively inexpensive way 

to generate reliable data.14 Other data such as Child Fatality Review records can 

provide valuable insights for protecting children.
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Indicators For Reducing Inequities In Child Abuse 

And Neglect And Other ACEs

Note. The crosscutting box (identified in light blue box above) represents efforts focused on changing the 

narrative (see Goal 1 on Raising Awareness and Commitment) and building commitment for policies (see first 

box on the left) that will reduce inequities by race, gender, and income (second box on the left). Reducing 

inequities in socioeconomic position will lead to improved living conditions (or safe, stable, nurturing 

environments) for families (third box) that will reduce the likelihood of children’s exposure to partner 

violence and maternal depression (third box). These improved conditions are expected to increase safe, 

stable, nurturing relationships and reduce child abuse and neglect, especially its inequitable distribution by 

social class and race/ethnicity. 

Data sources for each indicator included in the framework are available in: Essentials for Childhood: 

Indicators of Impact (available upon request at https://cdcpartners.sharepoint.com/sites/NCIPC/DVP/PPTB) 
Kansas Essentials for Childhood (called The Power of the Positive; www.

kansaspowerofthepositive.org) received private funding to add the ACEs module 

to the Kansas BRFSS in 2014 and again in 2015. These data were shared with 

Kansas state legislators to inform them about ACEs across the state. In 2017 

and 2018, Kansas directed Temporary Assistance to Needy Families funding to 

evidence-based home visitation programs ($3 million) and pre-K programs ($4.2 

million) and supported additional pre-K programs ($4.2 million) with tobacco 

settlement dollars.

Step #4

Use the data to support other action goals and steps

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

steps a reality. For example, incorporating local data as you raise awareness in 

support of the vision may make the issues more salient for the partners you are 

trying to engage (see Goal 1, partnering with others). You may want to highlight 

the economic returns on investing in children. Short documents with specific 

data points for decision-makers are helpful. Take advantage of the variety of 

information available. Compiling information from multiple sources helps articulate 

a comprehensive picture of what life is like for children in your community. This 

will help you determine where to invest in prevention—who is most at risk? 

What conditions need to be improved so all children can thrive? What programs 

and policies would best address the most prevalent risk factors and improve 

conditions for families?

Goal 2 Summary

Understanding the prevalence and impact of CAN and other ACEs in your 

community, the behaviors and conditions that increase their likelihood, and the 

policies that create and recreate these conditions provides critical information 

to inform and support the other goals. Data provides a foundation for engaging 

partners, underscores your efforts to build commitment, informs decision-makers, 

and helps you focus and monitor your prevention efforts for the greatest impact.

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GOAL 3

Create the Context for Healthy Children 

and Families through Norms Change 

and Programs

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

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

the environment in which those relationships develop, play a significant role in 

a child’s cognitive, emotional, physical, and social development. Research has 

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

and, conversely, the negative outcomes attributed to CAN and other ACEs.

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

providing safe, stable, nurturing relationships and environments:

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

well-being of children

2) Promote positive community norms about parenting programs and 

acceptable parenting behaviors

3) Implement evidence-based programs for parents and caregivers

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Step #1

Promote the community norm that we all share 

responsibility for the well-being of children

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

stable, nurturing relationships and environments is a shared responsibility. 

Everyone in your community—both parents and those without children—can 

champion or contribute to efforts to change policies in support of families, 

increase access to high quality child care and education, develop safe places 

or neighborhood activities where children are watched and supervised, and 

families can gather, interact, and get to know each other. Neighborhood 

associations can link families to available resources and other neighborhood 

adults to help with household tasks and to help in watching out for each other’s 

children in the neighborhood.

This step also ties into raising awareness and enlisting partners when building 

commitment (see Goal 1). This can be accomplished by explaining why this matters 

and what we can do collectively to support children and families. For example, 

people may have influence in a particular sector (e.g., business, social services, 

education) where they can promote family-friendly policies or activities. See 

supplement on building commitment: https://www.cdc.gov/violenceprevention/pdf/

efc-building-community-commitment.pdf.

Step #2

Promote positive community norms about parenting 

programs and acceptable parenting behaviors

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

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

think they should be able to care for the child on their own or because the need 

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

promote norms emphasizing that learning effective parenting skills is a process 

and every caregiver can use help at times.

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

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

at home if what they learn is different from those practiced by other family 

or community members. You can identify local parents to serve as mentors 

to promote positive parenting and help change community norms about 

parenting behaviors in your community. Parents can be particularly powerful 

role models and voices in these efforts, because other parents will see them 

as credible and experienced.

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More information on changing norms is available here: https://www.cdc.gov/

violenceprevention/pdf/efc-promoting-positive-community-norms.pdf.pdf and 

here: https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-TechnicalPackage.pdf. 

Step #3 

Implement evidence-based programs for 

parents and caregivers

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

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

environments. Your community can support all caregivers by providing access 

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

skills that promote positive child development, prevent and treat child behavior 

problems, and prevent CAN.

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

whenever possible, it is recommended that your community implement effective and 

promising interventions (see pages 25-27 of https://www.cdc.gov/violenceprevention/

pdf/CAN-Prevention-Technical-Package.pdf for effective parenting approaches). 

Choosing strategies that have been tested in rigorous research trials and are 

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

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

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

Build community receptivity, capacity, and resources to implement evidenceMake it easy for parents and caregivers to participate in parenting programs. 

23
Evidence-Based and Promising 

Programs and Strategies

Examples of programs and strategies that have been shown to prevent CAN 

include but are not limited to:

Nurse-Family Partnership (NFP)

http://www.nursefamilypartnership.org 

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

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

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

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

evidence-based home visiting programs see: 

http://homvee.acf.hhs.gov/HomVEE_Executive_Summary_2015.pdf

Early Head Start

https://eclkc.ohs.acf.hhs.gov/programs/article/early-head-start-programs 

Early Head Start is a child development and parenting education program 

delivered through center-based services, home visits, or both. The program helps 

parents build skills to assist their child’s development, increase family literacy, 

and promote healthy parent-child relationships. It also helps families transition 

their children into Head Start or other preschool programs when the child reaches 

three years of age and offers family advocacy, resources, and referrals to other 

community services.

Adults and Children Together Against Violence: Parents Raising Safe Kids

(ACT Raising Safe Kids)

http://www.apa.org/act/

The ACT Raising Safe Kids program is a parent training program that discusses 

knowledge and beliefs around child development and the importance of healthy 

parent-child relationships for children. Parents also learn positive parenting skills 

that create safe, stable, healthy and nurturing environments and relationships that 

prevent children’s exposure to abuse and adversities.

Primary Care Services (Safe Environment for Every Kid; SEEK)

https://www.seekwellbeing.org/ 

Using a self-administered questionnaire, parents of young children are screened 

for parental depression, substance abuse, financial and parenting stress, use of 

harsh punishment, and partner violence, all of which are factors that increase 

risk for CAN. Primary care providers are trained to discuss positive screens with 

the parents, along with potential strategies for addressing them. A social worker 

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follows-up with additional strategies to address the 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 local 

resources for any issues that might arise. 

Multi-component Programs (Child-Parent Centers)

http://cps.edu/Schools/EarlyChildhood/Pages/Childparentcenter.aspx 

Center-based multi-component programs provide comprehensive educational and 

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

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

activities include enhancing parents’ personal development; promoting positive 

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

providing referrals to appropriate services.

Parent-Child Interaction Therapy (PCIT)

http://www.pcit.org 

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

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

build a nurturing and secure relationship with their children while increasing 

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

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

to impacting physical abuse and neglect outcomes, this program has shown 

improvements in parenting behavior and child behavior problems.

Some programs do not have evidence of changing CAN outcomes but do 

demonstrate improvements in parenting behavior and child behavior problems 

and other violence outcomes. For example:

Incredible Years

http://www.incredibleyears.com 

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

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

and emotional problems in children zero to 12 years-old. The parent training 

component emphasizes parenting skills and approaches known to promote 

children’s social competence, reduce behavior problems, and improve children’s 

academic skills.

For additional information on characteristics of effective parenting programs, see 

page 26. For additional information on determining the types of programs that will 

work best for the caregivers in your community, see page 27.

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Goal 3 Summary

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

community context that supports effective parenting is critical to ensuring children 

experience safe, stable, nurturing relationships and environments. In general, 

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

the broader community.

Characteristics of Effective 

Programs to Provide Safe, Stable, 

Nurturing Relationships and 

Environments for Children

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

decreasing CAN. Some programs have shown promise of achieving desired results for CAN 

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

CAN, have been shown to improve positive parenting behavior, reduce challenging child 

behaviors, and improve relationships between children and their caregivers.

Effective parenting programs typically:

Provide opportunities for caregivers to actively practice and receive feedback 

Emphasize building positive and nurturing caregiver-child relationships and 

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

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

Videos and tip sheets for effective positive parenting strategies are available in English 

and Spanish at: https://www.cdc.gov/parents/essentials/index.html

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Considerations for Implementing 

Programs to Promote Safe, 

Stable, Nurturing Relationships and 

Environments for Children

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

your community, keep the following in mind:

Consider delivery options.

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

Create opportunities to involve 

Strive for consistency among 

27
GOAL 4

Create the Context for Healthy Children 

and Families through Policies

The promotion of safe, stable, nurturing relationships and environments and the 

prevention of CAN and other ACEs is not a simple process. It includes building 

commitment, using data to inform actions, and supporting parents and caregivers in 

the community. The policies in place in communities also may help ensure children 

in the community lead healthy and safe lives.

Like other activities for 

supporting safe, stable, 

nurturing relationships 

and environments for 

children, collaboration and 

partnerships are necessary 

to help decision-makers 

have the information they 

need to make informed 

decisions on the conditions 

that support all children 

and families. Implementing 

policies that support 

safe, stable, nurturing 

relationships and environments for children and caregivers requires effort from 

organizations in both the public and private sectors, governmental and nongovernmental organizations—e.g., from state and local health departments, the 

media, businesses, schools, and faith-based and community-based organizations. 

Historically, policies that improve the socioeconomic conditions of families or that 

structure the environment so that healthy choices are the easy choices have had the 

largest impacts on health.16 But, it is also important to consider the potential impacts 

on children and families when creating or changing any policy.

The two steps to inform policies that might support safe, stable, nurturing 

relationships and environments are:

1) Identify and assess which policies may positively impact the lives of children and 

families in your community

2) Provide decision-makers and community leaders with information on the 

benefits of evidence-based strategies and rigorous evaluation

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Step #1

Identify and assess which policies may 

positively impact the lives of children 

and families in your community

There are many policies that already provide some support to children 

and families. Communities might consider the policies outlined in CDC’s 

technical package, which are based on the best available evidence 

and have demonstrated effects in reducing CAN (https://www.cdc.gov/

violenceprevention/pdf/can-prevention-technical-package.pdf). Some cities 

and counties have passed ordinances to enact these policies. There are 

other examples of opportunities to positively impact the lives of children 

and families. Although the examples that follow have not been rigorously 

evaluated to establish their potential impact on CAN or safe, stable, nurturing 

relationships and environments, there is evidence that these policies 

strengthen families. Depending on a variety of factors, some types of policies 

may be out of your sphere of influence. However, understanding the breadth of 

policies that can strengthen families may be helpful to identifying opportunities 

to collaborate with other sectors and engage in related activities or initiatives 

within your community.

29
Examples of organizational 

or internal policies

Parental stress is an important risk factor for CAN.

Primary health care organizations can make it their policy to deliver evidenceOne area where there has been 

Types and 

Levels of Policies 

Organizational or internal 

policies: Rules and practices 

that an organization or agency 

sets for how it does business, 

conducts its activities, or 

interacts with staff and 

constituents. 

Regulatory policies: Rules, 

principles, or methods established 

by government agencies that have 

regulatory authority for products 

or services. 

Legislative policies: Laws or 

ordinances passed by local, state, 

or federal governing bodies.

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abuse. In addition, community-based organizations and schools have incorporated 

child sexual abuse prevention programs into their activities. Some have suggested 

that the declines in child sexual abuse may be, in part, attributable to sexual 

abuse prevention programs, norms changes, and social control efforts; therefore, 

expansion of these current prevention efforts may be beneficial.24-25

Example of regulatory policies

Lower-income families often pay more than middle- and high-income 

Examples of legislative policies

Low income is associated with CAN, albeit more strongly with child neglect.

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

Unintended pregnancy is a risk factor for child abuse and neglect.

31
especially teen pregnancies, are high in your community, school boards 

might check the evidence base for the sex education programs being used 

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

access to family planning services.

Substance abuse, depression, and other mental illnesses increase the risk 

High school completion leads to better paid employment and health, which 

Many instances of physical abuse begin as physical punishment in response 

Step #2 

Provide decision-makers with 

information on the benefits of evidencebased strategies and rigorous evaluation

A commitment to a rigorous science base demands that development and 

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

relationships and environments are based on reliable data and sound evidence 

of effectiveness. Decision-makers might be more supportive of evidence-based 

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programs and policies once they are well-informed of the benefits of having 

scientific evidence. This might lead decision-makers to:

Require that strategies selected for funding have evidence of effectiveness or at 

Require that funded strategies without a strong evidence base be evaluated to 

For example, Massachusetts Essentials for Childhood created an infographic

summarizing the evidence around paid family leave’s effects on children, parents, 

and businesses. 

Goal 4 Summary

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

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

departments, the media, and community organizations. In addition, it may be helpful 

to ensure that there is awareness of the societal factors that help children thrive and 

policies that are supportive of healthy child development; and that resources exist to 

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

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

families such as the Essentials for Childhood Policy Guide: http://www.astho.org/

Prevention/Essentials-for-Childhood-Policy-Guide.

Conclusion

While CAN is a significant public health problem, it is also a preventable one. 

Essentials for Childhood: Creating Safe, Stable, Nurturing Relationships and 

Environments is designed to assist you in your prevention efforts, by building 

commitment, using data to inform action, and creating the context for healthy 

children and families through norms change, programs, and policies. The goals and 

action steps suggested as part of this framework, along with your commitment to 

preventing CAN, can help create neighborhoods, communities, and a nation where 

every child can thrive.

Acknowledgments

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

first edition of this document: Sandra Alexander, Erica Mizelle, Janet Saul, Lynn Jenkins, 

Sharyn Parks, Linda Anne Valle, and Joanne Klevens. 

The Knowledge to Action Prevention Consortium and external reviewers Michelle 

Hughes, Mark Chaffin, and Leah Devlin provided valuable input to shape the first edition 

of this document.

We would also like to acknowledge the CDC colleagues who updated this document: 

Joanne Klevens, Sandra Alexander, and Beverly Fortson, and Lynn Davey of Davey 

Strategies who provided guidance and content on strategic messaging.

33
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