Child Maltreatment in DSM-5 and ICD-11 AMY M. SMITH SLEP* RICHARD E. HEYMAN* HEATHER M. FORAN†

Child maltreatment is widespread and has a tremendous impact on child victims and their families. Over the past decade, definitions of child maltreatment have been developed that are operationalized, face valid, and can be reliably applied in clinical settings. These definitions have informed the revised Diagnostic and Statistical Manual (American Psychiatric Association, 2013) and are being considered for the International Classification of Disease–11 (World Health Organization). Now that these definitions are available in major diagnostic systems, primary healthcare providers and clinicians who see children and families are poised to help screen for, identify, prevent, and treat child maltreatment. This article reviews the definitions of maltreatment in these diagnostic systems, along with assessment and screening tools, and empirically supported prevention and intervention approaches. Keywords: Child Maltreatment; Child Abuse; Diagnosis; Assessment; Intervention Fam Proc 54:17–32, 2015

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hild maltreatment occurs around the globe, with far-reaching implications for children and their families’ physical and psychological well-being. For many people, the thought of abusing one’s child is so horrific that they tend to think of maltreatment as rare and only occurring in families very unlike their own. This distancing may contribute to a general reluctance to consider that abuse and neglect might be occurring. Even professionals tend not to routinely assess for maltreatment, but many are confident they would “know it when they see it.” That rates of suspected maltreatment reported through mandated reporters and highly trained sentinels are so much lower than rates obtained through anonymous surveys of parents (Sedlak et al., 2010; Slep, Heyman, & Snarr, 2011; Straus, Hamby, Finkelhor, Moore, & Runyan, 1998) would suggest this is not the case. There is a pressing need for professionals working with children to become more sensitized to the possibility of abuse and neglect, familiarize themselves with thresholds defining maltreatment, screen for maltreatment, and know what services to refer families to when maltreatment or high risk for maltreatment is identified. In this paper, we will briefly review the epidemiology of child maltreatment and its impact, present a summary of the definition of child maltreatment in the current revision of the Diagnostic and Statistical Manual (DSM-5, American Psychiatric Association, 2013) and the definitions that might be closer to optimal given existing evidence. We will also describe the screening process for child maltreatment in primary care settings, and review some empirically supported interventions to which families with maltreatment could be *Family Translational Research Group, New York University, New York, NY. † Psychology, Technical University of Braunschweig, Braunschweig, Germany.

Correspondence concerning this article should be addressed to Amy M. Smith Slep, New York University, 345 E 24th St VA-2S, New York, NY 10010. E-mail: [email protected]. 17

Family Process, Vol. 54, No. 1, 2015 © 2015 Family Process Institute doi: 10.1111/famp.12131

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referred and that family therapists could deliver. The implications of these issues for a more coordinated international approach to the definition, screening, and treatment of maltreatment will be considered. International prevalence estimates of maltreatment (which vary due to operationalization differences) suggest the phenomena are far from rare. A review of child physical abuse (CPA) estimates in high-income countries found 1-year prevalence rates of 4–16% (Gilbert et al., 2009). In many countries, such as Romania, India, and the Republic of Korea, rates of CPA occur at alarmingly high rates with one-third to one-half of all children experiencing physical abuse (World Health Organization, 2002). A review of 21 studies, primarily from English-speaking and Northern European countries, found a range of prevalence rates of 7–36% for female victims of child sexual abuse (CSA) and 3–29% for male victims of CSA (Finkelhor, 1994). Childhood prevalence of neglect is estimated at 6–12% in U.S. and U.K. samples (Gilbert et al., 2009). There is a high rate of co-occurrence among the maltreatment types (Gilbert et al., 2009; Higgins & McCabe, 2001). It is estimated that about 35–64% of victims of child maltreatment experience more than one type of maltreatment (Donga et al., 2004; Edwards, Holden, Felitti, & Anda, 2003; Manly, Kim, Rogosch, & Cicchetti, 2001). However, the relative rates of maltreatment types vary by country. In Canada and the United States, neglect is most common (Trocme, Tourigny, MacLaurin, & Fallon, 2003), whereas in Australia, emotional abuse is the most prevalent (Hatty & Hatty, 2001). Cultural differences in child rearing beliefs and practices and in universal social services, combined with different definitions of maltreatment, likely influence variability in prevalence rates. Child maltreatment is consistently found to be a significant predictor of mental health disorders during childhood, and this risk continues into adulthood. Victimized children are more likely to have conduct disorders, attention hyperactivity disorders, depression, academic problems, and delinquency during childhood and adolescence (Maschi, Morgen, Hatcher, Rosato, & Violette, 2009; Teisl & Cicchetti, 2008). In adulthood, maltreatment is associated with substance abuse, depression, PTSD, antisocial personality disorder, and suicidal behaviors (Banyard, Williams, & Siegel, 2001; Draper et al., 2008; Fergusson, Boden, & Horwood, 2008; Malinosky-Rummell & Hansen, 1993; Putnam, 2003; Silverman, Reinherz, & Giaconia, 1996). Child maltreatment victims are at elevated risk for attachment disorders, which can, in turn, contribute to later problems (Felitti & Anda, 2010). Victimization during childhood places individuals at risk for revictimization as well as mental health problems during adulthood (Banyard et al., 2001). In addition, there is strong longitudinal evidence that severe neglect of young children can lead to a wide range of developmental problems including emotional regulation problems, cognitive difficulties, and altered neurological development (Beckett et al., 2006; Manly et al., 2001). This is consistent with the larger literature on the neurobiological correlates of childhood adversity more generally (e.g., Tyrka, Burgers, Philip, Price, & Carpenter, 2013). In addition, there are a variety of physical health problems that have been associated with child maltreatment in large-scale surveillance studies and longitudinal studies following children into adulthood. Child victimization is associated with high rates of type II diabetes, obesity, and cardiovascular disease (Fuller-Thomson, Brennenstuhl, & Frank, 2010; Lissau & Sorensen, 1994; Thomas, Hypponen, & Power, 2008) and is a significant cause of child homicide and unintentional death throughout the world (World Health Organization, 2002).

DEFINING CHILD MALTREATMENT Given the number of families impacted by maltreatment and its far-reaching health consequences, why is screening not universal in healthcare settings? Several challenges www.FamilyProcess.org

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exist: One of the most fundamental is a lack of agreed upon, universal thresholds for distinguishing sub-optimal caregiving from maltreatment, which can be applied reliably in clinical settings. Why have healthcare diagnostic systems and services not sufficiently supported assessment of child maltreatment? Some would argue that child maltreatment should be left to be defined by lawmakers—and operationalized by the Child Protection Services (CPS) and the criminal justice system—rather than by the healthcare system. However, only a small percentage of victims are known to societal agencies (e.g., CPS, criminal justice system). By restricting the surveillance of child maltreatment to societal agencies only, victims and their support systems are forced to invoke these systems or do nothing. If the classification systems included better operationalized definitions, victimized children who receive physical health care (e.g., for routine care, injuries, medical problems) or mental health care (e.g., for behavior problems) may be detected and receive help. The DSM was revised last year and the ICD (International Classification of Disease) is in the process of being revised. These revisions provided an opportunity to elaborate the definitions of maltreatment to encourage better screening and detection of child maltreatment. The DSM differs from the ICD in that it focuses on mental disorders. In contrast, the ICD defines the full spectrum of morbidity and mortality—comprising both physical and mental health diagnoses. In the DSM-5, as in the DSM-IV, child maltreatment categories are found in the V codes (conditions for which people may seek treatment but that are not mental disorders). In the ICD-10, child maltreatment codes are located within the Z codes (which are similar to the V chapter in DSM), the T codes (injury), and the Y codes (external causes of physical injury and death). There are a large number of codes that relate to maltreatment, but none are operationalized. In the case of both the DSM-IV and the ICD-10 (World Health Organization, 1992), no tools were developed to help providers screen for the maltreatment codes. Thus, although both systems recognized the relevance of maltreatment to children’s health, the ways in which maltreatment was historically included did not maximize the potential for these systems to help providers identify and address maltreatment. The child maltreatment criteria that are in the DSM-5 and proposed for the ICD-11 are detailed in Tables 1–4. These revisions have moved these systems closer to supporting appropriate screening and identification of maltreatment by providers. The DSM-5 now includes separate categories for CPA, psychological abuse, sexual abuse, and neglect. Each category has a conceptual definition that distinguishes the threshold from suboptimal but nonabusive parenting; examples are also provided. These criteria were informed by evidence-based definitions that have been reliably used in clinical contexts (e.g., Heyman & Slep, 2006, 2009; Slep & Heyman, 2006). The ICD-11 proposed definitions and the DSM-5 revisions are based on the same evidence-based definitions, but the ICD-11 definitions are less truncated than the adaptation used in the DSM-5. The WHO is currently launching field trials examining the clinical utility of the draft definitions. The inclusion of more specific/more detailed child maltreatment criteria in both of the most widely used classification systems reflects advances made in the science of defining maltreatment that afford a unique opportunity for healthcare providers to improve their practice with respect to child maltreatment. Both classification system revisions were based on scientific fieldwork conducted for over 10 years with the United States Air Force. Although there have been other recent efforts to provide operational definitions for child maltreatment (e.g., Leeb, Paulozzi, Melanson, Simon, & Arias, 2007; Wolfe & McIsaac, 2010), the validation and field testing of these definitions have been limited and applicability across settings is unclear. Thus, child maltreatment criteria that have the strongest evidence at this point are those developed and tested by Slep, Heyman, and colleagues (Heyman & Slep, 2006, 2009; Slep & Fam. Proc., Vol. 54, March, 2015

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TABLE 1 DSM-5 and ICD-11 (Proposed) Definitions and Criteria for Child Physical Abuse

Definition DSM-5 (995.54, V61.21 and Others)

Nonaccidental physical injury to a child by a parent, caregiver, or other individual who has responsibility for the child, regardless of whether the caregiver intended to hurt the child

ICD (Z62.1)

Nonaccidental acts of physical force by a child’s parent/caregiver that result, or have reasonable potential to result, in physical harm to a child or which evoke significant fear

Criteria Examples: ● Behaviors ○ Punching ○ Beating ○ Kicking ○ Biting ○ Shaking ○ Throwing ○ Stabbing ○ Choking ○ Hitting (with a hand, stick, strap, or other object) ○ Burning, or any other method ○ Other ● Injuries ○ Minor bruises ○ Severe fractures ○ Death ● Confirmed or suspected nonaccidental act of physical force ○ Examples: Hitting, slapping ● Act causes (or exacerbates) at least one of the following impacts ○ Any physical injury (examples: bruises, cuts, sprains, broken bones, loss of consciousness, pain that last at least 4 hours) ○ Reasonable potential for significant physical injury ○ Significant fear

Heyman, 2006; Slep, Heyman, & Malik, 2012a; Snarr, Heyman, Slep, Malik, & U.S. Air Force Family Advocacy Program, 2011). The goal was to develop overarching conceptual definitions of each type of maltreatment and specific operationalizations that would have clinical utility and face validity, and to consistently apply them in the course of routine use in the field. A key feature of the conceptual definitions of child psychological abuse, physical abuse, and neglect was the requirement of both specified acts (e.g., nonaccidental use of physical force) and specified impacts (e.g., more than inconsequential physical injury, reasonable potential for more than inconsequential physical injury, more than inconsequential fear reaction, significant somatic symptoms). One important challenge in defining child maltreatment across different cultures has been different uses of physical punishment as normal parenting discipline practices. By requiring impact or high potential for impact in the definition of child maltreatment, “normal” (noninjurious) physical discipline is below the threshold for maltreatment. However, CSA, as defined by this system, is thought to be inherently of high potential to cause impact and thus does not require documentation of impact, only of www.FamilyProcess.org

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TABLE 2 DSM-5 and ICD-11 (Proposed) Definitions and Criteria for Child Psychological Abuse

DSM (995.51, V61.21 and Others)

ICD (Z62.2)

Definition

Criteria

Nonaccidental verbal or symbolic acts by a child’s parent or caregiver that result, or have reasonable potential to result, in significant psychological harm to the child Nonaccidental verbal or symbolic acts by a child’s parent/ caregiver that result in significant psychological harm

● Behaviors (examples) ○ Berating, disparaging, or humiliating ○ Threatening ○ Harming/abandoning people or things the child cares about, or [threatening future] harm/abandon[ment] ○ Confining the child (i.e., child’s arms or legs together or binding a child to furniture or another object, or confining a child to a small enclosed area [e.g., a closet]) ○ Egregious scapegoating of the child ○ Coercing the child to inflict pain on himself or herself ○ Disciplining the child excessively (i.e., at an extremely high frequency or duration, even if not at a level of physical abuse) through physical or nonphysical means ● Impact ○ Significant psychological harm to the child ● Confirmed or suspected verbal or symbolic acts with the potential to cause psychological harm to the child. Examples: ● Berating, disparaging, degrading, humiliating child ○ Threatening child (including, but not limited to, indicating/implying future physical harm, abandonment, sexual assault) ○ Harming/abandoning—or indicating that the parent/caregiver will harm/abandon—people/things that child cares about, such as pets, property, loved ones (including exposing child to criteria-meeting or subthreshold partner maltreatment) ○ Confining child (for example, typing a child’s arms or legs together; binding a child to a chair, bed, or other object; or confining a child to an small enclosed area [such as a closet]) ○ Scapegoating child, i.e., blaming child for things for which they cannot possibly be responsible ○ Coercing the child to inflict pain on him/herself ○ Disciplining child (through physical or nonphysical means) excessively (i.e., extremely high frequency or duration, though not meeting physical abuse criteria) ○ Purposefully indoctrinating child to consider a parent evil, dangerous, or not worthy of affection ● Act causes (or exacerbates) at least one of the following impacts: ○ Psychological harm (for example, significant fear of abusive parent or other psychological distress) ○ Reasonable potential for significant psychological harm (for example, for developing significant psychological problems or for significant disruption of the child’s physical, psychological, cognitive, or social development) ○ Stress-related somatic symptoms that interfere with normal functioning

a qualifying act. Further, there are conceptually determined exclusions for some types of maltreatment. For example, with physical abuse and neglect, an exclusion criterion exculpates parents who caused injury but not in a maltreating context (e.g., when the parental act was committed to protect the child from imminent harm, during developmentally appropriate play). More details regarding the criteria can be found elsewhere (e.g., Slep, Heyman, Snarr, & Foran, 2012b; Slep et al., 2012a) and the criteria themselves can be found in Tables 1–4, with more detail within the ICD section. The first two studies in developing the child maltreatment criteria addressed content validity of existing definitions based on input from family maltreatment experts and field Fam. Proc., Vol. 54, March, 2015

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TABLE 3 DSM-5 and ICD-11 (Proposed) Definitions and Criteria for Child Sexual Abuse

Definition

Criteria

DSM-5 (995.53, V61.21 and others)

Any sexual act involving a child that is intended to provide sexual gratification to: ● A parent, caregiver, or other individual who has responsibility for the child; OR ● Others (without direct physical contact between child and [other but involving exploitation by the caregiver])

ICD-11 (Z62.3)

Sexual acts involving a child that are intended to provide sexual gratification to an adult

● Behaviors ○ Fondling a child’s genitals ○ Penetration ○ Incest ○ Rape ○ Sodomy ○ Indecent exposure ○ Noncontact exploitation (e.g., forcing, tricking, enticing, threatening, pressuring child to participate in acts [for the gratification of others]) ● Any of the following acts involving an adult and a child: ○ Physical contact of a sexual nature between child and adult. For example, vaginal or anal penetration (or attempted penetration), oral-genital or oral-anal contact, fondling (directly or through clothing) ○ Noncontact exploitation—An adult forcing, tricking, enticing, threatening, or pressuring a child to participate in acts for anyone’s sexual gratification without direct physical contact between child and offender. For example, exposing child’s genitals, anus, or breasts; having child masturbate or watch masturbation; having child participate in sexual activity with a third person (including child prostitution); having child pose, undress or perform in a sexual fashion (including child pornography).

clinicians (Heyman & Slep, 2006; Study 1). Based on the results of these two studies, definitions were revised to improve clarity and clinical utility (Slep & Heyman, 2006). The revised definitions were then tested in a pilot study and iteratively revised during a field trial to improve reliability by raters (Heyman & Slep, 2006; Study 3). In a follow-up field trial, a semi-structured interview was developed to mirror the diagnostic criteria (similar to the Structured Interview for DSM; SCID; First, Spitzer, Gibbon, & Williams, 2007). www.FamilyProcess.org

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TABLE 4 DSM-5 and ICD-11 (Proposed) Definitions and Criteria for Child Neglect

Definition

Criteria

DSM-5 (995.52, V61.21 and others)

Confirmed or suspected egregious act or omission by a child’s parent or other caregiver that deprives the child of basic age-appropriate needs and thereby results, or has reasonable potential to result, in physical or psychological harm to the child

ICD-11 (Z62.4)

Confirmed or suspected egregious act(s) or omission(s) by a child’s parent/caregiver that deprive the child of needed age-appropriate care and that result, or have reasonable potential to result, in physical or psychological harm

Forms of Neglect: ● Abandonment ● Lack of appropriate supervision ● Failure to attend to necessary emotional or psychological needs ● Failure to provide necessary education ● Failure to provide necessary medical care ● Failure to provide necessary nourishment, shelter, and/or clothing ● At least one confirmed or suspected egregious act or omission by a child’s caregiver that deprives the child of needed, age-appropriate care (for example, abandonment, lack of appropriate supervision; exposure to physical hazard; failure to provide necessary education, health care, nourishment, shelter, clothing) ● Act or omission causes or exacerbates at least one of the following impacts: ○ Physical injury or reasonable potential for injury ○ Significant fear or psychological distress ○ Stress-related somatic symptoms ○ Reasonable potential for the development of a psychiatric disorder ○ Reasonable potential for significant disruption of the child’s physical, psychological, cognitive, or social development

Several alterations were made to the decision process to improve information and objective evaluation of each criterion, including the introduction of a computerized decision tree to allow clinicians to consider each criterion separately and take them to the next relevant criterion if warranted (see Heyman & Slep, 2006; Study 4). This approach led to very high reliability between master reviewers’ and in-the-field decisions (92% agreement; kappa = 0.84). Master reviewers included members of the research team and senior Family Advocacy personnel. Based on these findings, the organization (U. S. Air Force and, then, the entire U.S. military) adopted these definitions, policies, and procedures. To further examine reliability under real world conditions, a random selection of 41 Air Force Fam. Proc., Vol. 54, March, 2015

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sites across the world were selected to participate in the dissemination trial. The percent agreement across the sites ranged from 84% for child neglect to 95% for sexual abuse. This represented a significant improvement since the initial results from the first pilot study in which percent agreement ranged from 24% for emotional abuse to 67% for sexual abuse (Slep et al., 2012a).

CHILD MALTREATMENT ASSESSMENT AND SCREENING Child maltreatment can be challenging to assess. In many settings, parents may be less than forthcoming. Children, depending on age and context, can be unreliable reporters. Many professionals who are comfortable asking about a range of topics are squeamish about assessing possible maltreatment, afraid they will misunderstand, make a difficult situation worse, intrude on a private family matter, or drive a family in need of care away. Given the psychological and physical consequences of maltreatment and the prevalence of maltreatment in the general population, one can imagine that more routine screening for maltreatment among families seeking mental health and medical services for children would have the potential of promoting empirically supported parenting interventions (e.g., Triple P, Sanders, 1999, 2008; Parent–Child Interaction Therapy [PCIT], Eyberg & Robinson, 1982) as a way of further addressing the children’s presenting conditions. Routine administration of screening measures in public health settings would also enable community-level tracking of risk, which might be useful when broader initiatives are put in place to reduce violence or mitigate the impact of stressors such as poverty. There are several issues that warrant consideration in the assessment of child maltreatment. First, it is essential to carefully match the context and the assessment tool. If treatment is being provided to families engaged with child welfare systems, it may be vital to assess whether an alleged incident occurred, and if so, whether it was above or below the threshold for labeling the incident as maltreatment. This requires a very different type of assessment than what might best suit mental health providers who screen parents of children coming to their clinics to determine whether they are at elevated risk for maltreatment so as to inform treatment planning. In this case, directly assessing maltreatment may have consequences that need to be considered because if the provider has a reasonable suspicion of abuse, reporting the parent to the child welfare system would be triggered. Of course, the obligation to protect the child is the primary concern in weighing this decision. Finally, surveillance data, relevant for understanding the rate of maltreatment among a patient population, for example, is likely to be most accurate if those data can be collected anonymously; however, this is not a viable option for healthcare providers seeking information about a particular patient in the exam room. Anonymous assessments help lessen reporting biases (e.g., “faking good” on questionnaires); identifiable assessments likely lead to significant underreporting on direct assessments of maltreatment. One must also consider the age and developmental level of the child in question. Some behaviors, such as shaking, are not particularly harmful to older children, but are potentially fatal to infants. Once children are verbal, they can participate in interviews; once they can read, they can complete questionnaires. One must be sensitive to the cognitive level of the child and match the level of detail sought to the child’s capabilities. For example, a preschooler’s inconsistency in reporting how long ago something occurred (which is developmentally expected) does not negate an otherwise credible report. Children are subject to reporting biases as well (e.g., concern for their own or siblings’ safety; fear of getting parents in trouble); context can dramatically affect the quality of an assessment with a child. Perhaps the best-known assessment tool assessing risk for CPA is the Child Abuse Potential Inventory (CAP, Milner, 1986). It is a 160-item self-report measure consisting of www.FamilyProcess.org

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statements to which respondents are asked to agree/disagree (77 of these comprise the total Abuse Risk subscale). Although all items assess risk factors of CPA, none directly assess violence toward children. The reliability of CAP scores is very good (test–retest reliabilities from 1 day to 3 months: 0.75–0.91; Milner, 1986). The validity is also well established. Scores on the CAP Abuse Risk subscale discriminate between abusive and nonabusive parents well (Milner, 1986, 1994; Milner, Gold, & Wimberley, 1986), especially under ideal conditions. This widely used measure clearly has strong psychometrics, but also a number of other attractive qualities. First, it does not directly assess parenting behavior, which makes it useful when clinicians may want to understand risk for maltreatment without confronting maltreatment directly. This also makes the CAP a useful measure for parents referred for an incident of abuse, who might be sensitized to reporting on their parenting, and in situations in which understanding risk for additional incidents might be critical. Second, it has validity scales that indicate when a parent is trying to “fake good,” which sometimes happens when parents are being evaluated for their fitness, as in the case of custody evaluations. On the other hand, because the CAP does not directly assess maltreatment, it is not helpful in determining whether an incident was below or above a maltreatment threshold. Also, it was developed specifically in reference to CPA perpetrators and may not be as sensitive and specific in identifying perpetrators of child psychological abuse, sexual abuse, or neglect. Because it is designed to be administered to the perpetrating parent, it cannot help when the child is the assessment target. Finally, the full scale is rather long, which makes it difficult to use as a screening tool. To address the concern about the length of the measure, Ondersma, Chaffin, Mullins, and LeBreton (2005) developed a shortened form of the CAP, the Brief Child Abuse Potential Inventory (BCAP). The BCAP comprises 24 abuse and 9 validity items; it was developed to fit on one page and to be a viable screening tool. It was empirically developed using data on the complete CAP and has strong psychometrics. Using receiver operator characteristic curves, the area under the curve for the BCAP was 98% for predictive CAP cutoff scores, with sensitivity and specificity over 0.90 when using both less and more conservative CAP cutoff scores as the criteria. BCAP scores were also able to predict future abuse, with CAP scores not adding significantly to the prediction afforded by the BCAP. Thus, in screening situations where the objective is to identify risk for child abuse and the potential perpetrator is available to complete the screen, the BCAP is a strong option. The parent–child version of the Conflict Tactics Scale (CTS-PC; Straus et al., 1998) is another widely used option to assess parental physical and psychological aggression and abuse toward children. This is a face-valid questionnaire that asks about the frequency of specific aggressive acts. Thus, it can be a very helpful tool for understanding aggression and abuse in families if reporting biases are not a concern (as in anonymous data collection). The CTS-PC does not assess injury or context. It also does not assess sexual abuse or neglect. To directly assess child maltreatment based on the definitional criteria reviewed above, we have developed several instruments that can be used in different settings. For anonymous survey assessment, a 28-item parent report for physical and emotional child maltreatment has been developed and validated (see Slep et al., 2012b). The CPA module comprises 18 items assessing the commission of various aggressive acts by parents in the previous year toward each of their children (e.g., “I spanked child on the bottom with a bare hand”; “I hit child with a fist”). Parents indicated whether they did the behavior (a) to teach; (b) to punish; and/or (c) because they were frustrated/lost their cool. Reasons were provided because pilot work indicated that parents were more willing to report behaviors of questionable social desirability if they could provide the reasons for their behavior. Fam. Proc., Vol. 54, March, 2015

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Follow-up questions asked about (a) where on the child’s body the acts were directed; and (b) whether injuries resulted from acts endorsed. The child emotional abuse module inquired about the frequency of ten behaviors toward the child (e.g., “I called child names that could really hurt, such as ‘worthless,’ ‘stupid,’ ‘slut’ ”). Follow-up questions asked, “What happened as a result?” and included several psychological impacts (e.g., “child seemed down or depressed for more than 2 weeks afterward”). In addition, a short screener that can be used in clinical settings or surveillance studies has also been developed (see Slep et al., 2012b) by isolating the smallest subset of items from the full scale that would support the most sensitive and specific identification of maltreatment as defined by the new DSM-5 and pending ICD-11 criteria reviewed in Tables 1–4. The CPA screener includes three items and results in high sensitivity, but only modest specificity. The items ask about behaviors typically considered corporal punishment (spanked on the bottom with bare hand, slapped child’s hand, grabbed) and thus are not as sensitive to administer as more severe acts or impacts might be. The screener has 97–98% sensitivity, meaning it identifies the vast majority of parents who, if more fully assessed, would be positive for CPA, but it only exhibits 51–52% specificity. The modest specificity means that approximately half the parents who screen positive may engage in corporal punishment, but do not meet criteria for CPA. Because of this, the screener is useful in the context of a two-stage screening process, where this brief screen triggers more intensive screening for physical abuse, or in clinical contexts where specific identification of abuse might be less important than identifying or ruling out high-risk status. Child emotional abuse can be screened using four items: calling child names that could really hurt, threatening to harm something important to child, threatening to hurt or abandon child, and mocking/putting child down in front of others (see Slep et al., 2012b). Sensitivity was 93–98% and specificity was 92–97%. Thus, this screener has a very high likelihood of identifying parents who, in fact, meet criteria for emotional abuse, and screening out those who do not. As with all measures of sensitive health information, it is important that parents understand the implications of their answers prior to administration. If the screener is being administered for clinical purposes, clinicians need to be clear about whether their purpose is to identify abuse, which will require a follow-up interview, or whether their purpose is to identify risk, which can be done with the screener alone. In addition, maltreatment as defined by the above criteria can be assessed in face-toface clinical contexts with a semi-structured interview developed during the field trials based on the format of the SCID (First et al., 2007). Separate modules can be used to assess abuse (physical, emotional, and sexual), and neglect (Heyman & Slep, 2006; Slep & Heyman, 2006). Different versions have been developed to be administered to adult perpetrators, child victims (although clearly very young children would not be reliable reporters), and nonoffending parents or other witnesses (e.g., older sibling). Given the potential impact of child maltreatment, this tool can help guide interviewers and facilitate more accurate assessment of child maltreatment. Although a variant of this interview was used in the field trials (Heyman & Slep, 2006, 2009; Slep & Heyman, 2006) evaluating the definitions, the psychometrics of these interviews have not been evaluated. The interviews can be found in Slep et al. (2012b). This semi-structured interview is best suited for circumstances where it is important to clearly understand if maltreatment (and not sub-threshold problematic parenting) occurred. If an interview indicates maltreatment above the diagnostic threshold (or subthreshold but raised concerns), it is critical to address child safety. If the revelation is in a research setting, it is important that safety protocols are in place that would connect the participant with an appropriate provider to develop safety plans and provide resources as well as manage reports to CPS. If the interview occurred in a clinical setting, planning www.FamilyProcess.org

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with the child or parent for the child’s safety should be conducted, as well as making appropriate referrals to CPS. In clinical settings, it is important to also consider what diagnoses might be co-morbid. For instance, are there co-morbid depressive or anxiety disorders? Ideally, the information gleaned from the interview will promote more precise treatment planning, which will improve the health and wellbeing of children and their families. In addition, more precise child maltreatment research will ultimately result in improved prevention efforts. It is worth noting that child neglect is more challenging to assess than is abuse. This is likely because it may include omissions or acts. Because people have much more difficulty reporting what they did not do in particular circumstances, as opposed to what they did, it has been difficult to develop adequate parent-report measures that map well onto the operationalized criteria for neglect. At this point, only the structured interview is recommended as a neglect assessment.

EMPIRICALLY SUPPORTED INTERVENTIONS Although several prevention and intervention programs have been found to be effective in reducing child maltreatment risk for parents, or addressing the consequences of maltreatment for children, some of the most widespread treatment models are without evidence or have been found to be ineffective (see Barth et al., 2005). Thus, prior to instituting more regular screening for child maltreatment in clinical practice, it is important for providers to investigate the extent to which empirically supported interventions are available within their communities and build appropriate referral networks. Some providers might find that empirically supported interventions cannot be easily located in their area. Fortunately, many of the best interventions are now being disseminated and supported in a manner not previously seen with evidence-based family interventions. Mental health providers can obtain solid training and, for some interventions, even supervision, through workshops or over the Internet. Primary care providers can consider embedding some of the most flexible interventions within their practice by having the nursing staff trained to provide consultations within the context of normal care. There are several interventions available that focus on improving parenting and the quality of parent–child relationships. Some parenting interventions also target parental mental health (i.e., mother depressive symptoms, substance abuse). Theoretically, many of the interventions are designed to reduce risk for child maltreatment through their effects on parenting skills, as well as parental mental health, parent–child relationships, and children’s externalizing behavior. Although the focus varies somewhat across interventions and depends on the age of the child for which the intervention was designed, all of the interventions that have been effective at reducing maltreatment risk focus on the parent–child relationship and/or parenting skills. Below, we review some of the promising and effective interventions related to child maltreatment, including prevention programs and psychotherapies. One of the most extensively evaluated prevention and treatment programs for parenting is the Triple P Positive Parenting Program (e.g., Sanders, 2012). It has been tested in several countries, and meta-analyses of randomized controlled trials (RCTs) document its effectiveness (e.g., Nowak & Heinrichs, 2008). This program was developed to reduce child emotional and behavioral problems through the teaching of parenting skills (Sanders, 2008). In addition to impacting child mental health outcomes, a large population-based study in South Carolina demonstrated a decrease in risk in child maltreatment for counties in which Triple P was implemented (Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009). This program, when fully implemented, includes several intensities or doses of intervention, from information to light touch consultations that can be provided Fam. Proc., Vol. 54, March, 2015

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in child care or primary care settings, to more intensive workshops and individualized treatment. A second program with strong evidence of its preventive impacts is the Nurse-Family Partnership. This program was designed to improve child and maternal outcomes through intervention with low-income, first-time mothers and their infants; it has been shown to be effective in reducing risk for child maltreatment even at long-term follow-ups (e.g., 15 years later) (Olds et al., 1997). The program involves home visits before and after the birth of the child by a nurse or paraprofessional to provide support and education for a range of topics including child safety, nutrition, alcohol use, and the parent–child relationship. The program has been widely implemented and three RCTs support its efficacy when implemented with fidelity (Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Olds et al., 2002, 2004). There is strong evidence for reducing parents’ child maltreatment risk with PCIT, an intervention that could be delivered by a family therapist or other mental health provider. PCIT was originally designed for children ages 2–7 with externalizing behaviors (Eyberg & Robinson, 1982; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998). The program has approximately 15 sessions and targets parent–child interaction such that parents deliver more consistent consequences for negative child behaviors, more positive reinforcement for positive child behaviors, and less hostility and criticism. The therapist observes the parent interact with the child through a one-way mirror and coaches the parent through a “bug-in-the-ear” device until the parent achieves preset criterion levels of a series of parenting skills. PCIT has been evaluated in several RCTs, including studies of parents who were maltreating (e.g., Chaffin et al., 2004). Several programs are also available to improve family functioning and positive parenting among adolescents and their parents in families at risk for maltreatment (Santisteban et al., 1997, 2003). For example, brief strategic family therapy has been shown to lead to improvements in family functioning as reported by parents and adolescents who received the program (Cohen’s d = 0.58 for parent report, 0.42 for adolescent report). Further, these improvements were maintained 1 year later, and brief strategic family therapy outperformed individual psychodynamic child therapy and a recreation control condition at the follow-up. This program has been adapted for use in several diverse groups in the United States, as well as in Chile, Germany, and Sweden (SAMSHA, 2008). Systematic Training for Effective Parenting (STEP) is a psychoeducational group parenting intervention. It is designed to reduce dysfunctional parenting behaviors and has been tested in several samples of abusive parents (Fennell & Fishel, 1998; Huebner, 2002). STEP was effective in reducing child abuse potential. In addition to, or instead of, interventions that target parenting, there are also several effective programs for helping children who have been maltreated or are in families in which they are exposed to intimate partner violence. For example, “Alternatives for families: A Cognitive-Behavioral approach” (AF: CBT, Kolko, Iselin, & Gully, 2011; Kolko & Swenson, 2002) was developed for families with children between the ages of 5 and 17 who are at risk for abuse or have a history of abuse. This intervention package includes components for the parent and for the child that are delivered separately and some components that are delivered in joint sessions. For older children and adolescents, individual Trauma Focused Cognitive Behavior Therapy (TF-CBT, Cohen, Mannarino, & Deblinger, 2006) is another option to help trauma-related symptoms such as depression and anger. The treatment is designed to include both parents and children (ages 3–18) and typically lasts 12–16 sessions. Online training tools for TF-CBT are available for practitioners (i.e., http://tfcbt.musc.edu). Cognitive-Behavioral approaches for addressing trauma symptoms in children without a

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parent-directed treatment component are also empirically supported (March, AmayaJackson, Murray, & Schulte, 1998). Among families with intimate partner violence, several studies have documented that child–parent psychotherapy is effective in reducing child and mother PTSD symptoms, as well as other behavioral problem outcomes (Lieberman, Ghosh Ippen, & Van Horn, 2006; Lieberman, Van Horn, & Ghosh Ippen, 2005; Toth, Rogosch, Manly, & Cicchetti, 2006). In addition, there is a version for toddlers that focuses on improving the parent–child relationship and fostering secure attachments (Toth et al., 2006). The therapeutic focus on improving the parent–child relationship appears to show promise as a means for reducing child maltreatment (Cicchetti, Rogosch, & Toth, 2006; Stronach, Toth, Rogosch, & Cicchetti, 2013; Toth, Maughan, Manly, Spagnola, & Cicchetti, 2002). As this review demonstrates, there are several efficacious prevention and treatment options that appear to reduce risk for child maltreatment or ameliorate sequelae of abuse. Furthermore, these interventions vary in the training and background of the providers and the intensity of the intervention. Some could be easily imbedded into primary care settings while others could be easily incorporated into a family therapist’s practice. The potential benefit for children and families is tremendous if efficacious interventions can be successfully embedded throughout more of the health and mental care settings that families already use. Some, but not all, of the above-described programs have been evaluated in a variety of countries. Although the definitional criteria for maltreatment described in this paper are such that cultural norms and variations can influence their application without altering the criteria themselves, parenting is strongly influenced by culture. Before implementing an intervention developed in North America, Europe, or Australia in the context of a very different culture (e.g., rural Africa, China), it would be critical to evaluate the fit of the intervention with cultural norms and tailor the intervention to make it relevant and acceptable while ensuring that the “active ingredients” of the intervention are retained. This is not a simple task. It requires a careful marriage of what is known about the intervention’s mechanisms of action with expertise in the specific culture for which the intervention is being adopted.

CONCLUSIONS Child maltreatment is a very costly problem, both financially (Fang, Brown, Florence, & Mercy, 2012) and in terms of the obvious impact on children. A major hurdle to identifying children and families in need of support has been a lack of clear criteria to support accurate identification. A reliable and face-valid criteria set now exists and has influenced both the recent DSM-5 and upcoming ICD-11. With the emergence of clearer diagnostic criteria, along with a range of assessment tools, the stage is set for a wider range of primary care and mental health providers to begin more systematic screening for maltreatment. By pairing this with increased dissemination of empirically supported and promising interventions for parents and children, many more families in need will be identified and helped. Although data on cost-effectiveness are limited, the benefits of providing evidence-based programs targeting maltreatment and its consequences seems to outweigh the costs of these implementations (Cunningham, Bremner, & Boyle, 1995; Prinz et al., 2009). REFERENCES American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders, 5th ed. Arlington, VA: American Psychiatric Publishing.

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