CtddAbuse & iv&W, Vol. 16, pp. 495-51 I, 1992 Printed in the U.S.A. All righha reserved.

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01‘s2134/92 $5.00 + .oo 1992 Pergamon Press Ltd.

FAMILIES AT RISK OF CHILD MALTREATMENT: ENTRY-LEVEL CHA~~ER~STrCS AND GROWTH IN FAMILY FUNCTIONING DURING TREATMENT CATHERINE

C. AYOUB AND JOHN B. WILLETT

Harvard University Graduate School of Education, Cambridge, MA

DAVID S. ROBINSON Mas~chu~tts

Society for the Prevention of Cruelty to Children, Boston

Abstract-Research suggests that perinatal screening and early intervention may reduce the incidence of maltreatment and improve the parenting in at-risk families. The question of whether families with different sets of entry-level characteristics differ in the way that they respond to intervention is asked in this paper. We investigated whether entry-level family functioning and family problems had an impact on length of time in treatment and the improvement or dete~oration of family functioning over time. In our analyses, we used entry-level characteristics to classify families into five homogeneous groups-situationally stressed, chronically stressed, emotionally stressed, multirisk, and violent multirisk-and we found that treatment duration and rate of change in family functioning over time differed in clinically important ways across these groups. Our findings suggest that treatment is likely to be successful in stabilizing and slowly improving the family functioning of the majority of families at risk of child maltreatment. Key Words-Secondary

prevention, Children at risk.

INTRODUCTION MORE THAN TWO MILLION cases of child abuse and neglect were reported to child protection agencies throughout the USA in 1989; about 2.5% of all American children are abused or neglected every year (Daro & Mitchell, 1990). In addition to these reported cases, researchers estimate that about 10% of families in the population have the potential for child abuse (Ayoub & Jacewitz, 1982; Browne & Saqi, 1988; Egeland & Brunnquell, 1979). Maltreatment of the very young child often results in serious long-term emotional, cognitive, and physical difficulties (Aber, Allen, Carlson, & Cicchetti, 1989; Egeland, Sroufe, & Erickson, 1983). Abused children show heightened aggressiveness toward peers as well as avoidance and withdrawal of interaction (Mueller & Silverman, 1989). They have di~culty in school, demonstrating increased frequency of learning disorders, language delays, and other neurologically based handicaps (Martin, 1976). They are more likely to become violent juve-

This research partially supported by the Massachusetts Society for the Prevention of Cruelty to Children (C.C.A. and D.S.R.) and the Spencer Foundation and the William F. Milton Fund (J.B.W.). Received for publication March 18, 199 1; final revision received August 12, 199 1; accepted September IS, 199 1. Requests for reprints may be sent to Catherine C. Ayoub, Ed.D., Harvard University Graduate School of Education, Roy E. Larsen Hall, Appian Way, Cambridge, MA 02 138. 495

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C. C. Ayoub, J. B. Willett, and D. S. Robinson

nile delinquents (McCord, 1983) to demonstrate criminal behavior (Martin, 1980), or to continue an intergenerational cycle of abuse (Kaufman & Zigler, 1989). One strategy for reducing maltreatment is to develop prevention programs that assist and support potentially problematic families. Secondary prevention programs have been developed for families who are at risk of maladaptive parenting and consequently have increased potential for child abuse or neglect (efforts that target a subpopulation of individuals are often referred to as secondary prevention programs, as opposed to primary prevention programs in which the general population is targeted [Caplan, 19641). Recent research suggests that, by perinatal screening and early intervention, the incidence of maltreatment can be reduced and the parenting in at-risk families can be improved (Ayoub & Jacewitz, 1982; Gray, Cutler, Dean, & Kempe, 1977; Wolfe, Edwards, Manion, & Koverola, 1988). Background of the Study

Early research in the field appeared in 1977 (Gray et al., 1977) just as the first small group of secondary prevention programs were founded (Ayoub & Pfeifer, 1977; Gabinet, 1979; Gladstone, 1975). Gray et al., (1977) provided support for the effectiveness of early intervention showing that not only were delivery room and postpartum observations accurate predictors of subsequent high-risk parenting behavior, but also that intervention tended to reduce the frequency of abusive incidents in at-risk families. Following this research, several studies examined the screening and identification of at-risk children (Altemeier, O’Connor, Vietze, Sandler, & Sherrod, 1982; Avison, Turner, & Noh, 1986; Benedict, White, & Cornely, 1985) and standardized abuse-potential screening instruments were created and validated (Bavolek, 1980; Milner & Ayoub, 1980; Milner, Gold, Ayoub, & Jacewitz, 1984; Schneider, Helfer, & Hoffmeister, 1980). These studies demonstrated that at-risk families could indeed be identified in the general population, but the identification of characteristics that differentiate the high-risk from the low-risk family is an area of ongoing controversy. Several retrospective studies of abusive parents and their children have identified indicators of vulnerability toward child maltreatment (Benedict, White, & Cornely, 1985; Lynch, 1975). Lynch (I 975) identified abnormal medical and social factors during pregnancy, labor, delivery and postpartum illness of the mother as adverse factors. Recently, mothers at increased risk for maltreatment have been found to be younger, to have shorter birth intervals, less prenatal care, and are more likely to have had a stillbirth, abortion, or a prior child death (Benedict, White, & Cornely, 1985). In an attempt to refine the list of indicators of increased risk, Browne and Saqi (1988) compared the influence of 13 risk factors. They found that the most important indicators of vulnerability toward maltreatment were: parental indifference or intolerance, a history of family violence, socioeconomic problems, the presence of a premature infant, whether the parent had been abused as a child, whether a stepparent or cohabitee was present, whether the parent was single or separated, whether the mother was under 21 years, a history of drug or alcohol abuse, and separation of mother and child for more than 24 hours at birth. Prospective work with potentially abusive and nonabusive families has extended both knowledge and confusion over the importance of individual and cumulative risk factors in predicting potential for maltreatment. Altemeier, O’Connor, Vietze, Sandler, & Sherrod ( 1982) followed a group of 1400 low-income mothers prenatally and then compared the families in which abuse occurred to those in which there was no abuse. They found that unwanted pregnancy, aggressive parental tendencies, aberrant childhood nurture, and lowered parental self-esteem indicated higher risk. In contrast to the retrospective findings, however, abusive mothers did not differ in the support available from others, their age, education,

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497

isolation, family alcohol or drug history, and expectations of the child’s development. In a second study, Egeland and Brunnquell(l979) found that the mother’s understanding of the psychological complexity of the child and her relationship with the infant best distinguished the abusive and nonabusive groups. One limitation of most of these “risk factor” studies is that they assume an additive “main effects” model in which abusive outcomes are a direct and inevitable consequence of specific parental personality characteristics (Parke & Collmer, 1975) or poverty, stress and social isolation (Belsky, 1980; Cicchetti, Taraldson, & Egeland, 1978). Although several researchers have explored the cumulative effects of a limited number of risk factors (Browne & Saqi, 1988) their emphasis was on the specific characteristic and its impact on the predictability of abuse or neglect. In contrast, the central assumption of our research is that multiple transactions among environmental forces, caregiver characteristics, and child characteristics make joint contributions to maladaptive parenting practices and child maltreatment. In our paper, the transactional model (Sameroff & Chandler, 1975) is extended to examine the etiology and intergenerational transmission of child maltreatment, and to investigate transient and enduring potentiating factors (Cicchetti, 1989; Cicchetti & Rizley, 198 1) that increase the likelihood of maltreatment. We have adopted an approach that permits many risk factors to be examined simultaneously. Two further issues arise in the literature. First, preliminary studies have suggested that reduced severity of abuse and neglect is possible with some families (Armstrong & Fraley, 1985; Gabinet, 1979; Hunter, Kilstrom, Kraybill, & Luda, 1978; Seigel, Bauman, Schafer, Saunders, & Ingram, 1980; Wolfe et al., 1988). However, before services are provided, it is important to identify those families most likely to benefit from an intervention. Second, and more generally, there is concern about whether parental, situational, family, and individual change in functioning does occur over time and whether it affects the presence or return of maltreatment. In studies of abusive families, posttreatment reabuse rates of between 18.5% and 66% have been cited (Butterfield, Jackson, & Nangle, 1979; Ferleger, Glenwick, Gaines, & Green, 1988; Herrenkohl, Herrenkohl, Egolf, & Seech, 1979). Another way of looking at the success of intervention has been to study program outcomes. Gabinet (1979) examined at-risk families enrolled in a secondary prevention program and followed their “improvement” over time by examining subjective ratings of parents by their therapists. She found that parents in treatment for 4 to 6 months received better ratings of progress than those in treatment for 7 to 12 months. Then, parents staying in treatment for more than 12 months again improved, surpassing the improvement of those in treatment for 4 to 6 months. However, because only 37% of the families initially enrolled in the program remained active at 12 months, this finding should be interpreted cautiously. Berkeley Planning Associates (1987) in its evaluation of a California secondary prevention program, found similar results. Three quarters of the project clients left the program before their child reached 1 year of age or before program goals were attained. Project staff judged that 49% of families improved, 47% stayed the same, and 3% got worse. However, up to the present, longitudinal changes in family functioning over time have not been mapped in detail. Kowal et al. ( 1989) found that the level of global family functioning at entry into an early intervention program was strongly associated with family functioning at the end of treatment. Mean family functioning did improve between entry and exit, however the findings remain coarse because difference scores were used to summarize longitudinal changes in family functioning. To a large extent, therefore, we do not know what changes occurred in the functioning of at-risk families, how long they continued to benefit from treatment, and what types of families were the most responsive to intervention. Ayoub and Jacewitz (1982) identified five patterns of change in the functioning of at-risk families over time by graphing monthly ratings of family functioning during intervention.

498

C. C.

Ayoub,J. B. Willett,and D. S. Robinson

Each of these growth patterns was associated with a constellation of family problems. Families with transient situational crisis and those with intellectual and cultural deficits showed improvement in family function, whereas families with abusive and neglectful behavior and childrearing difficulties showed a decline in family functioning. Overall, about 25% of the families improved, about 50% made no change, and about 25% got worse despite the intervention. As a result of this preliminary work, the belief that short-term early intervention can prevent child abuse or neglect for all families is now being challenged. Clinical wisdom now suggests that the length of treatment should differ from family to family, and that the outcomes of treatment will vary for families with different problems and patterns of change. Some families may not benefit from intervention and others may not need it. Some families may do well in one treatment program, or for a short length of time, while other families may require longer-term treatment in a different type of intervention. In general, positive change in family functioning seems difficult to achieve and even harder to maintain. A sizable minority of families become more dysfunctional despite intervention, and many do not change at all. Our investigation explores the simultaneous effect of a large number of potentiating factors on the functioning of the family over time. These families at risk of maladaptive parenting often suffer from short-term or long-term coping problems that seriously impair the family’s functioning. Because the interaction and integration of family members largely determines the environment that molds the child’s development (Geismar, 1980), dysfunctional family systems present a potential threat to the child’s well-being (Helfer, 1982). Although family functioning is not the only window through which potential maltreatment of children can be viewed, its role is central among the many influences that are present in abusive and neglectful families (Egeland, Jacobvitz, & Sroufe, 1988; Helfer, 1982). Therefore the early detection of disturbances in family functioning may provide an important component for the timely identification of at-risk families. Purpose of the Study In the current paper, we asked: Do families with different sets of entry-level characteristics differ in the way that they respond to the Project Good Start intervention. In particular, we investigated whether entry-level family functioning and family problems had an impact on length of time in treatment and the improvement or deterioration of family functioning over time. In keeping with an ecological philosophy about the etiology of maltreatment, we considered risk factors in multiple combinations when we described the families. To preserve the richness of our data, we adopted an exploratory multivariate analytic approach. We used cluster analysis to answer our research question and we summarized our findings with a variety of robust descriptive statistics. Our research built on the work of Ayoub and Jacewitz ( 1982) and, by providing a rich clinical description of the at-risk families, extended findings that we have presented in a companion paper (Willett, Ayoub, & Robinson, 199 1).

RESEARCH

DESIGN

Sample Our data were observational and were collected in a naturalistic setting during the operation of an on-going clinical intervention called Project Good Start. The 172 sampled families participated for at least 3 months between July 1984 and December 1986. The 3-month entry

Family functioning during treatment

499

cut-off was adopted for two reasons. First, project clinicians felt that they began to accurately assess family functioning only after working with a client for 3 months. Second, at least three waves of monthly family function scores were required for adequate measurement of change (Willett, 1989). Project Good Start is a broadbased secondary prevention service developed under the auspices of the Massachusetts Society of the Prevention of Cruelty to Children at three inde~ndent sites in Massachusetts. At-risk families were identified during child-~a~ng using clinical criteria that included biological, psychological, social, and interactional alerts validated for this purpose in prior studies (Ayoub, Jacewitz, Gold, & Mimer, 1983; Milner & Ayoub, 1980). Project Good Start used one-to-one intervention within a social service mode. The intervention was home-based and designed to enhance parenting skills, generate community networking, and link the mother, her partner, and her children with necessary services. Licensed social workers provided supportive therapy, case management, client advocacy, and community service referrals. The project also used volunteer parent-aides with many families. For both practical and ethical reasons there was no control group. The data were collected by Project Good Start clinicians in the more than 3.5 communities in Greater Boston and Eastern Massachusetts served by the three sites. The majority (58.2%) of referrals were received through the maternity units of eight local hospitals. Other referrals were accepted from: early intervention/development programs (5.1%), community health clinics (5.5%) social service agencies (11.8%), visiting nurse associations (4.2%), self-referrals (7.2%), and others (8%). Referrals included woman who were either pregnant or had recently given birth. Although the women may have had older children, the youngest was identified as the focus child. Each family was seen and comprehensively assessed by a social worker within 10 days of referral. Families participated on a completely voluntary basis and received services free of charge. No family involved with a protective service agency for active abuse or neglect was accepted. Mother’s age at entry ranged from 14 to 40, and averaged 22.5 years; 36% were teenage mothers, and over 75% were 25 or younger. Just over half were single parents, and three quarters were suffering from financial difficulties. Approximately 44% of the sample were white, 3 1% Hispanic, 9% Portuguese, and the remaining 16% were Asian, African-American, and biracial. Three quarters of the focus children were 3 months or younger and almost 25% were between 4 and 14 months when the family began to receive services. There were approximately equal numbers of boys and girls among the focus children.

Data on each of the sampled families were collected using two principal instruments: (a) the Family Problem Checklist, and (b) the Family Function Scale. In this paper, we made use of cross-sectional data on family problems collected at entry into the Good.Start intervention and ~o~gjt~d~~af data on family functioning collected over a period of many months following entry. Initially data manipulation was required to create measures suitable for use in our data analyses, including: (a) the clustering of family problems on entry into treatment, and (b) the statistical modeling of growth in family functioning over time. We discuss each of these briefly below. ~l~ster~~gfamily ~ro~~e~s on entry into treat?~e~t.The Family Problem Checklist was used on entry into the intervention to record client family problems that were potential obstacles to adequate functioning. The 75 items on the checklist describe: social difficulties encountered by chronically dysfunctional families, personality traits and attitudes characteristic of abusive

500

C. C. Ayoub, J. B. Wiilett, and D. S. Robinson Table 1. Internally Consistent Clusters of Family Problems on Entry into Treatment Cluster Label Violence/Maltreatment (Cronbach’s alpha = .7 1)

Distressed Parenting (Cronbach’s alpha = X55)

Isolation (Cronbach’s alpha = .6 1) Handicapped Child (Cronbach’s alpha = .69)

Problems in the Cluster Parent-child conflict Discipline problems Scapegoated child Child seen as a problem Difficult child Special emotional problems-child Inappropriate/harsh punishment Physical abuse Emotional abuse Physical neglect Medical neglect Serious accidents-child Poor medical compliance Problem with birth control-parent Poor hygiene Poor nutrition Feeding problem Failure to thrive child Spouse abuse Substance abuse Violent temper-parent Deviant extended family Family history of child abuse Unrealistic expectations of child Parental depressions/withdrawal Parental low self esteem Limited parenting skills Family problems Isolated residence Few friends Little relief/continuous childcare Early separation of mother/child Physical handicap-child Chronic medical problem-child intellectual limitation~hild Acute illness in family

families, characteristics of infants or children who were more likely to be abused or neglected, and short-term situational crises that might push families into maladaptive parenting practices. (Ayoub & Jacewitz, 1982, provide a complete description of the items in the Family Problem Checklist.) Rather than carrying each of the 75 potentiating factors forward into subsequent analyses, we created several homogeneous clusters of problems that were used to classify the families, Exploratory oblique component and centroid cluster analysis of client family responses, in conjun~ion with p~n~ipal-components analyses of prelimina~ cluster scores, were used to detect meaningful and internally consistent clusters of problems. Only those problem clusters that were maintained across clustering methods were preserved in subsequent anaylsis (Anderberg, 1973; Hartman, 1976). These analyses suggested that, from among the original 75 items on the Checklist, 40 items could be separated and grouped into four internally consistent ciusters of problems. These were clusters of items describing problems of: (a) distressed parenting, (b) violence/maltreatment, fc) isolation, and (d) child handicap. The problems that make up each of these four clusters are listed in Table 1 along with estimates of Cronbach’s alpha, a measure of internal consistency (Cronbach, 195 1).

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501

Within each cluster of problems, item scores were totalled to represent the number of different problems experienced by each family along each of the four dimensions. In our companion paper (Willett, Ayoub, & Robinson, 1991), we showed that the number of distressed parenting problems and the number of violence/maltreatment problems experienced by a family were predictive of changes in functioning over time. Therefore, in this paper, these two totals form a cornerstone for further analysis. Modeling growth in family functioning over time. Project social workers used the Family Function Scale to rate family functioning monthly on a scale from 1 (completely dysfunctional) to 7 (completely functional). Level 4 families, for instance, accepted assistance but had difficulty following through with suggestions. They were unstable, unpredictable, and more susceptible to crises than families functioning well with external support at level 5. Families rated at level 6 were functioning well with minimal support and were considered to be at only mild risk. Descriptions of other points on the scale are provided by Ayoub and Jacewitz ( 1982). Although such ratings are high-inference measures, estimates of interrater agreement reported in the literature have ranged from .73 to .90 (Ayoub & Jacewitz, 1982). In the current study, the interrater agreement was estimated in a subsample of 10 families on a monthly basis in order to cross-check the rating of all five social workers involved in the project. In this subsample, monthly interrater consistency ranged from .83 to .97 (Cronbach’s alpha). We used growth modeling to summarize changes in functioning over time for each family (see Rogosa, Brandt, & Zimowski, 1982; Rogosa & Willett, 1985; Willett, 1989; Willett, Ayoub, & Robinson, 199 1). Longitudinal changes in family functioning were summarized by the creation of an empirical growth trajectory-a plot of family functioning versus months in treatment-for each of the client families. These trajectories were judged to be adequately represented by a linear growth model and, therefore, each family-functioning growth record was summarized by fitting a straight line to the empirical growth trajectory using ordinary least-squares regression analysis. The estimated slopes of the within-family fits provided estimated monthly rates of change in functioning that were then used as measures of family growth in subsequent analyses. Because we intended to use entry-level family functioning as an independent descriptor of the families, along with the problems they presented on entry, we did not include entry-level family functioning in our estimation of the within-family rates of change in family functioning. Data Analyses We provide a rich and ecologically valid description of classes of families who differ in clinically interesting ways in this paper. Specifically, we describe how different internally homogeneous groups of client families-as distinguished by their entry-level functioning and numbers of family problems-exhibit clinically important differences in the monthly rate of change in family functioning and treatment duration. For these reasons we have adopted an exploratory approach in our data analyses (Mosteller & Tukey, 1977). Cluster analysis was used in two distinct ways in this research. When we developed our measures, we clustered variables (i.e., family problems). When we described clinically interesting classes of families, we clustered families. In order to avoid confusion in the text, we have made intentional and consistent use of the terms “cluster” and “group.” When the former is used it refers to collections of variables (responses to items on the Family Problem Checklist), the latter refers to collections of families. We used the cluster analysis of families-based on our measures of entry-level family functioning and numbers of distressed parenting and violence/maltreatment problems-to

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C. C. Ayoub, J. B. Willett, and D. S. Robinson

classify families into substantively meaningful groups whose treatment history could then be distinguished. Average linkage and centroid cluster analysis suggested that families could be parsimoniously classifed into five groups. In what follows, using a variety of robust statistical summaries, we describe these five groups of families in considerable detail using information available from the complete entry record, regardless of whether that information was used to generate the groupings themselves.

FINDINGS Description of the Client Families on Entry into Treatment Median family functioning on entry into the Good Start intervention was 5, suggesting that the average family was at some risk for maltreatment. Such families were “functioning well, but required instruction and considerable external support” to maintain the status quo (Ayoub & Jacewitz, 1982). The median number of distressed parenting problems was 2. Although all of the “distressed parenting” problems were almost equally likely to occur, parents in families with distressed-parenting problems most often had low self-esteem and limited parenting skills. The median number of violence/maltreatment problems was 2. Most of the parents in families suffering violence/maltreatment problems reported that, in their own extended families, there were other individuals who were violent, who were in jail, or were seriously mentally ill; they also reported being abused themselves as children. Spouse battery, substance abuse, violent temper outbursts, and discipline problems were also reported frequently. Changes in Family Functioning Over Time and Treatment Duration During intervention, the functioning of many families changed over time and, from family to family, there was wide variation in the monthly rates of change. Nine out of every 10 families had estimated monthly rates of change between -.30 and +.43; 37 families did not change at all. Nevertheless, over all the sampled families, the median monthly rate of change in family functioning was very close to zero (median rate of change = .Ol) indicating that, although both functional and dysfunctional growth occurred, there was a slight tendency toward the improvement of function. Most of the monthly growth rates were precisely estimated; standard errors for the estimated growth rates were . 1 or less for approximately 75% of the families examined. However, there were two families whose monthly rates of change had extremely poor precision. These families also had the largest estimated rates of growth, one in a functional direction (estimated growth rate = 2.0, SE = .87) and the other in a dysfunctional direction (estimated growth rate = - 1.5, SE = .50). Both families were members of the program for only 3 months; both received, within the second or third month of treatment, ratings in the “high-risk” category and were referred to the Child Protection Agency. These two families were removed as outliers from our analyses. In additional regression analyses (see Willett, Ayoub, & Robinson, 199 I), we also found that two additional families had large studentized residuals (3.64,3.03) and elevated influence statistics (Cook’s D = .06, .05; Leverage = .12, .19). We also treated these families as outliers in the analyses reported here. The duration of the treatment is an indicator of exposure to the intervention. Because some families completed treatment or withdrew from it, whereas others continued with the intervention beyond the data collection period, we created a dichotomous variable to distinguish those families who left treatment versus those continuing in treatment at the end of data collection. In analyses presented elsewhere, we show that there were no differences in familyfunctioning change between these two groups (Willett, Ayoub, & Robinson, 199 1). Although

503

Family functioning during treatment Table 2. Median Family and Treatment Characteristics for Five Groups of Families Family Characteristics on Entry Median Value (Lower Quartile, Upper Quartile) Group Label

Family Functioning

Distressed Parenting

Violence Maltreatment

Situationally Stressed Chronically Stressed

(5(j6) i (4,4)

(0, :)

(0,

(0, :)

(1,;

P,

Treatment Characteristics Median Value (Lower Quartile, Upper Quartile) Monthly Rate of Change in Familv Function

Treatment Duration

+.ot

8.0 (5, 10) 8.0 (5, 15) 10.0 (5, 14) 7.5 (5.5, 10) 7.0 (4, 10)

(+.lo, 0) +.005 (+.20, -.Ol)

Emotionally Stressed Multirisk

(455) :

(194: (6, :5)

Violent Multirisk (2, 2)

(5, 5)

(1;:7)

(+.07O-.04) -.bs (+.06, -.24) -.40 (p. 18, -.40)

the median time in treatment was 8 months, there were families in the sample who spent as little as 3 or as much as 30 months in the program. Monthly rate of change in family functioning differed enormously among families who received treatment for only a short period of time, but was much less varied among families who were in treatment for longer periods. One potential explanation for this systematic decline in growth-rate variability with treatment duration was that families who changed the most rapidly-either positively or negativelymay have selectively left, or had been removed from, the program. Rapidly improving families may have graduated from the program early; rapidly deteriorating families should have been referred to child protection programs. Then, after many months, only those families who stabilized their functioning over time and used the program to maintain that level would remain. (There are at least two alternative methodological explanations for the declining variation in family-function change with increasing treatment duration. However, for a variety of reasons not discussed here, we believe that the explanation offered above is the most appropriate. For further details, see Willett, Ayoub, & Robinson, 199 1.) Family Type, Treatment Impact, and Duration When families at risk of child maltreatment enter an intervention program like Project Good Start, the admitting clinician can rightly ask: How will the functioning of different types of families change during treatment? Will one class of families improve rapidly with treatment while another remains stable? Are there classes of family whose functioning will decline despite the best the program can offer? Questions like these can begin to be addressed by matching entry-level characteristics of the at-risk families with the rate at which their functioning changes over time. In our analyses, we classified families into five homogeneous groups. In Table 2, we present median, lower quartile, and upper quartile statistics to summarize the entry-level characteristics of each of the five groups of families, their monthly rates of change in family functioning, and their treatment duration. Then, in the following discussion, we paint a brief portrait of each type of family based on the table entries supplemented by summary data extracted from responses to other items on the Family Problem Checklist. Families under situational stress. Out of the 172 families in the sample, we labelled this first group of 45 families as “situationally stressed.” They were reacting to acute situational stressors, accentuated by the crisis of parenthood at entry into treatment. Almost 66% of the

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C. C. Ayoub, J. B. Willett, and D. S. Robinson

parents in the situationally stressed group were single and more than half were teenage. In general, these families were suffering from financial hardship and had limited support systems. Hispanic families made up just over 33% of this group, and many of these were recent immigrants with cultural and language difficulties. All of the situationally stressed mothers were the primary caretakers of their children and they got little relief from child care. Their histories were absent of intergenerational problems, marital strife, chronic emotional difficulties, past family violence, and maltreatment. As can be seen in Table 2, situationally stressed families tended to enter the Good Start program functioning at a high level and suffered almost no problems of distressed parenting and violence/maltreatment. They tended to stay in treatment about 8 months and their family functioning increased more rapidly with treatment than among any other group in the sample. Families under chronic stress. We labelled the 20 families in this second group as “chronically stressed.” They were also struggling with the developmental crisis of parenthood as well as significant financial problems and had little social support when they entered the Good Start program. Almost 50% of the families had only a single parent and 33% of the parents were teenagers. However, unlike situationally stressed families, these families were likely to have at least one additional chronic stressor that increased the day-to-day tension on the family system. For instance, 36% of the families had ongoing difficulties with their intimate relationships, whether with a spouse or partner. A second major source of chronic stress was that more than one third of these families had a child with a chronic illness or a child who was handicapped. These chronically stressed families were the only group in which ill children predominated. From Table 2, we see that chronically stressed families may have approximately one problem of distressed parenting and two problems of violence/maltreatment. Nevertheless, mothers typically remained undepressed and are not in conflict with their children. Neither did they have low self-esteem despite their chronic stressors. Chronically stressed families entered the program in considerable family disarray (median entry-level functioning = 4) and, because their family systems were disorganized, they did not follow through even with outside support. At times of crisis, the chronically stressed family’s behavior may be unpredictable and the parent’s judgement impaired. Chronically stressed families stayed in treatment for about 8 months and their family functioning improved slowly over time. Families with parental emotional distress. The largest group in the sample was made up of 87 families with significant signs of “parental emotional distress” on entry into the program. Emotionally distressed families shared the financial burdens, little relief from child care, and limited social supports of situationally and chronically stressed families. The group also included a large percentage of single mothers (42%) and of teenage parents (4 1%). However, in addition to these shared problems, parents in this group had emotional difficulties, including low self-esteem and depression. They were also lacking in basic parenting skills and more than 33% of them had members of their extended families who were problematic or deviant. Table 2 suggests that emotionally distressed families entered Project Good Start at a level of functioning that required ongoing outside support and direction if the family was to maintain adequate functioning. However, once offered support, emotionally distressed families could maintain their well-being. Families in this group exhibited three of the five distressed-parenting problems, on average, and they also tended to suffer two problems of violence and maltreatment. Change for emotionally distressed families was very close to zero, a finding that may be a consequence of the long-term nature of their multiple emotional difficulties. They stayed in treatment the longest of any group (median = 10 months).

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Multirisk families. The 12 families in the fourth group suffered from multiple problems and fit the description of “multirisk” families (Cicchetti & Toth, 1987; Johnson, 1979). Their individual and family crises were multiple and of complex caution; many of their dilhculties were of a critical nature and of long-term duration (Johnson, 1979). These families had a variety of difficulties in the realms of individual emotional and family problems, history of violence, and disturbed parent-child relationships. They also shared common problems with some of the other groups, including individual emotional and family problems. For the multitisk family, individual emotional problems for either or both parents usually included low self-esteem and depression; additionally, 33% of the parents were substance abusers. Family problems were also commonplace with multirisk families and included marital and partner problems, with 33% of the couples reporting spouse battering. Their extended families also created tension rather than provided support because they were conflictual or deviant in their behavior. A number of parents in this multirisk group of families were abused as children and many had a history of abuse within their present homes. In contrast to the families in the previous three groups, the multirisk families were engaged in specific conflicts with their children. These parents saw their children as difficult and different, and they had unrealistic expectations of them. Emotional abuse of the children was common in half of multirisk households. Multirisk families seemed disorganized at entry and their functioning seemed to be deteriorating. They could follow through and meet their own needs and those of their children only part of the time. A number of multirisk families were avoidant and unwilling to engage in intervention. On average the multirisk family had four out of five distressed parenting problems, and seven violence/maltreatment problems. The rate of change in the family functioning of multirisk families was primarily negative despite program intervention. Keeping multirisk families interested in treatment was also difficult, and they stayed in treatment about 7 months.

Violent multirisk families. This last group consisted of only four families. However, it was a group quite distinct from the others. These families were not only multirisk, they were also extremely violent, both toward other adults and their children. They tended to use violence to meet their critical needs. Multiple situational, individual, family, and parent-child relationship problems placed the violent multirisk family at the highest risk for child maltreatment and at the extreme for dysfunctional family interaction on entry into intervention. These violent multirisk families were all teenagers. Three out of four of the teenage couples were married. They shared financial problems with the other groups, but were not isolated or limited in their social supports. On the contrary, they sought out family and friends who lived deviant lifestyles. The young parents in the violent multirisk families had many individual emotional problems. They suffered from low self-esteem, depression, and limited parenting skills as well as acute anxiety and violent temper outbursts. Three out of four of the parents were substance abusers. There was also an adult with chronic medical problems in each violent, multirisk family; however, these families also had histories of medical noncompliance. Other family di~culties included both problematic extended families and histories of spouse battering. The parent-child relationships within the four violent multirisk families were highly conflictual and disturbed. Parents and children complained of problems with discipline and the children were frequently subjected to harsh or inappropriate punishment. Children were often in conflict with their parents and had diagnosable emotional problems; they were seen by their parents as difficult. The violent multirisk parents admitted to not wanting their children. Additionally, their children suffered from poor hygiene, poor nut~tion, and were

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frequently physically and medically neglected when they entered treatment. Over 25% of the children had had a serious accident in the 6 months prior to entry into the program.

DISCUSSION There is a considerable variation in the nature of families identified as “at risk” of problems in parenting and child maltreatment, based on entry characteristics, monthly change in family functioning, and duration in treatment. The five family groups we identified exemplify the diversity of the at-risk population. Additionally, these family groups were easily placed on Sameroff and Chandler’s continuum of caretaking causality within a transactional model framework and illustrate the complex multiple forces that influenced the development of maladaptive parenting and child maltreatment. This conceptualization of a continuum has important implications for the identification and treatment of at-risk families. Our findings do suggest that treatment is likely to be successful in stabilizing and improving the family functioning of the majority of families at risk of child maltreatment. However, problems of distressed parenting and violence/maltreatment, evident at entry, interact to defer successful treatment. A major implication of our research was the need to distinguish among families who, on entry into a secondary intervention program, exhibited varying combinations of potentiating factors. Our categorization of families was not intended to be universal or invariant, but it does represent a continuum of family difficulty. Families presenting with depression or withdrawal, low self-esteem, along with limited parenting skills and unrealistic expectations of their children, were most likely to show little change in treatment. When these families also experienced spousal violence, substance abuse, a history of parent/child conflict, or past maltreatment of siblings accompanied by specific conflictual relationships with one of their children (including difficulties such as harsh punishment, seeing the child as a problem or as different, using the child as a scapegoat, or having trouble with discipline), their tendency to deteriorate was even greater. As indicated above, there appear to be salient groups of potentiating factors that interact to increase vulnerability or ameliorate risk. However, there were also characteristics commonly identified as “risk factors” by other researchers that are present across groups that may identify at-risk families as a whole, but do not seem to differentiate the family groups based on the nature of their monthly change in family functioning or their duration in treatment. For example, all of the family groups described here contain a sizable number of teenage parents, single parents, or parents who were suffering financial or employment stresses. However, there were important differences in the interaction of potentiating factors within the family groups that distinguished them from each other. It was only the multirisk and violent multirisk families that showed significant difficulties in the parent-child relationship. These were also the two groups of families that continued to deteriorate for at least the first 20 months in treatment (see Willett, Ayoub, & Robinson, 1991 for further details). Based on these findings, a two-tiered approach to the identification and treatment of at-risk families is supported. Browne and Saqi (1988) discuss such a system. They recommend that general screening for parent (and some child) characteristics should be followed by specific assessment of the parent-child relationship. This advice appears sound given the nature of the multirisk and violent multirisk families identified in this research. The two-tiered assessment offers the treatment provider with an area of critical focus for the assessment of change and an indicator of the safety of the child. Such knowledge may help professionals set more focused and realistic goals for treatment and better estimate the time and effort required before positive change is possible.

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The challenge for both the family and provider is to maintain the treatment for a long period. The most difficult families are often the ones who are seen as “failures” in short-term treatment programs that may simply be setting them up to fail. Unfortunately, with the reduction of federal and state aid, attempts to provide “brief’ interventions have proliferated. Our findings argue against a “quick fix” and suggest that continuous long-term early intervention is one way that improvement in family function can be ensured with families at serious risk of maltreatment. It is clear from these analyses that severely dysfunctional families are being identified and included in secondary prevention programs. In these programs, the child’s safety should be carefully monitored in families that show continuing high levels of dysfunctioning, particularly in those who present or develop conflictual relationships. Treatment programs should view such monito~ng as an integral part of the treatment process. If children do remain in high-risk homes, then outside supports, such as daycare and involvement with significant supportive others, should to be made available. Protective Service referrals should be encouraged when needed. The majority of the parents in our sample were those with individual emotional problems complicated by difficult family relationships. Parents like these, with problems that included emotiona depression, low self-esteem, and limited parenting skills, were able to show improvement in family functioning with home-based intervention. However, the rate of improvement was generally less than in the situational and chronically stressed groups. They also remained in treatment longer than the families in any other group. Within this group of families there were a sizable minority of families that showed no change at all in family functioning over time, even after an intervention of long duration. The presence of such families in our sample, however, cannot be construed directly as evidence of the failure of the intervention. These may be families for whom functioning might otherwise have declined had not the Project Good Start treatment been available-the intervention may have acted to maintain their family functioning at its entry level. This notion is congruent with the fact that remediation of individual emotional problems like depression and low self-esteem usually requires extended, ongoing therapeutic work, often before change can occur or be maintained. If this is the case, then intervention is certainly warranted. On the other hand, of course, the “no-change” families may simply not have benefitted from intervention at all. Whatever the case, this group of families deserves further focused investigation in order to evaluate which of these two alternatives is correct. One question that must be addressed in future work is how the individual and family emotional potentiating factors change over time. Do their emotional states change with treatment? If not, how can treatment intervention be refined to have a greater impact? Do these parents develop conflictual relationships with their children during treatment, and how is this related to ongoing individual emotional issues? These questions will help us understand if this group of families can benefit from treatment and if they need follow-up throughout their child’s early years and on into the school years, or if several years of early intervention are su~cient. The families in acute or chronic crisis may be able to be served by sensitive primary prevention programs that offer services to a broad base of families based on general population characteristics-new mother’s groups, child health clinics, parenting education courses. The crisis families that suffered neither from problems of violence and maltreatment nor of distressed parenting most o&en did not need extended specialized intervention in spite of a number of other “risk factors”-single parents, teenage parents, parents with handicaps children, families in financial distress, or early separation of mother and child-that may have increased their stress. Our findings indicated that these families had the greatest rates of improvement and, in fact, those in treatment for the least amount of time show the greatest

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change (see Willett, Ayoub, & Robinson, 199 1). Such families appeared to be those that had the resources to improve and maintain their family functioning ifthey were supported early in the life of their child. Information obtained about the different interconnecting potentiating factors within the family groups emphasizes the need to tailor group-specific interventions. It is not reasonable to expect that one intervention format will work for all families. Just as a complex combination of potentiating and compensatory factors affect the potential for child maltreatment, the intervention with families must also be varied and individualized to meet the prominent needs of each individual family. For example, perhaps treatment planning for parenting education should be carried out with a family’s entry-level family functioning, distressed parenting, and violence/maltreatment data in mind. The needs of the isolated, young mother with financial difficulties may be quite different from the teenager with significant individual emotional problems, a history of substance abuse, and violence both within her present family and in her family history. This should be carefully considered before including them in the same treatment program simply because they are both teenage parents. By focusing on the factors that seem to differentiate the groups (such as parent-child conflict, individual emotional problems, and spousal violence) rather than dividing families along less salient demographics (single parents, teenage mothers, mothers of premature infants), critical treatment orientations can be more readily developed. An understanding of the heterogeneity of the at-risk population should be useful for administrators and program planners. They can now consider the specific entry characteristics of the clients they serve in order to better estimate ways in which they wish to allocate resources and measure “success.” If a program is serving many violent and nonviolent multirisk families, the expectation of positive change with only a brief intervention is unrealistic; the goal of having no child appear maltreated during the course of the intervention may also be unattainable. On the other hand, if programs exclude multirisk families, they should not claim that they are serving families at the highest risk for child maltreatment. Although some treatment programs have been reluctant to take families that show signs of violence or maltreatment on entry, our work illustrates that if very needy families can be persuaded to stay in treatment for about 2 years, they may be able to improve their functioning (see Ayoub, Willett, & Robinson, 1991). Therefore, families with these presentations should be prepared for long-term intervention. The constellation of family problems apparent at entry should be carefully evaluated when a decision is made to accept or refuse the family, and programs should be developed to suit their needs. For example, a 3-month “parenting course” may not be in the best interest of the parent with violence/maltreatment difficulties, whereas it may be very helpful for the parent with situational or even chronic stressors. On-going programs, to which clients can return if a crisis arises, may be most utilized by families with chronic stressors and those with emotional stressors. These are families who may not be in need of services all the time, but do require a lifeline when their already stressful lives become stretched. Maintaining connections with such families may be a valuable enterprise, whereas the effort for continued connection with families in acute crisis who are able to develop their own social networks may be less critical. Additionally, offering lifelines to multirisk families is often not enough to get them to seek outside help in a crisis and therefore this may be an ineffective intervention for them without other outreach. A number of these suggestions have been implemented in Project Good Start. With information about family type, for instance, the staff has been able to tailor intervention to the families involved. Our findings also indicate that monthly rates of change in family functioning tended toward zero for families who stayed in Project Good Start for more than a year. One potential explanation for this finding is that families who improve rapidly during treatment are “graduated” from Good Start in the belief that they could maintain their functioning alone. On the

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other hand, families whose functioning declined rapidly needed more than a voluntary early intervention program to assure the safety of their children and were referred to Protective Services. These joint processes of graduation and referral act left only “zero-growth” families behind in the Good Start program. Although we could not test this hypothesis with our data, the narrative information on the families added credence to this belief. Families with longterm emotional and family difficulties, but without serious conflictual parent-child relationships and family violence, were those who stayed in treatment the longest. Although they were willing to engage in treatment, something many of the families in the last two groups were not willing to do, they had problems that require long-term intervention. Their problems also tended to create more difficulty over time if remediation was not attempted. However, if our conjecture is correct, then the membership of newly inaugurated treatment programs is bound to look very different from programs that have been servicing at-risk families for several years. As time passes, more long-term “zero-growth” families will take up space in any program leaving less opportunity for newly detected at-risk families to obtain treatment. As the program matures, it will show fewer new clients served and less change in those receiving services. This phenomenon was suspected by Ayoub, Jacewitz, Gold, & Milner ( 1983) when they demonstrated that the families active in a secondary prevention program were at higher risk than those evaluated in the same program 3 years before. From the perspective of program development, this issue of (apparently) diminishing returns is one that must be addressed. Funding agencies and communities need to understand the slow nature of change with at-risk families so that unrealistic expectations do not cripple service delivery. Our study suffers from a number of limitations. First, all data were collected by the professional working with the family. Direct information from the family and from other treatment sources should be collected in future research. Second, the “problems” recorded at entry were all measures of vulnerability and did not include protective factors. Data being collected presently includes measures of both vulnerability and protective factors. Third, our measure of family functioning was too coarse, and its range too restricted, to characterize the growth trajectory of family functioning effectively. In future research, a more sensitive instrument must be designed and administered. Fourth, for both ethical and practical reasons, our research design did not include a control group of dysfunctional families who were not treated. For this reason our findings are exploratory and require confirmation in future well-controlled studies. Finally, we had no client follow-up information and therefore we cannot tell whether treatment-related gains in family functioning were maintained on cessation of treatment. Such follow-up measurements are necessary if the true effectiveness of any intervention is to be evaluated. Despite these limitations, we have demonstrated the beginning of the development of a transactional model of assessing families at risk of child maltreatment through the exploration of the heterogeneity of families at entry into a secondary prevention program and the impact of the combination of potentiating factors on their change in family functioning and duration in treatment. The need to develop different assessment and treatment strategies for this heterogenous population is clear. The use of powerful new growth-modeling techniques is useful in investigating rates of change over time and holds promise for additional investigation of the interaction of potentiating factors over time in treatment. Such longitudinal studies of this population will add greatly to the quality of intervention, evaluation of program effectiveness, and ultimately to the well-being of families and children at risk of maltreatment. REFERENCES Aber, L., Allen, J., Carlson, V., & Cicchetti, D. (1989). The effects of maltreatment on development during early childhood: Recent studies and their theoretical, clinical, and policy implications. In D. Cicchetti & V. Carlson (Eds.), Child mn/treutment (pp. 579-619). Cambridge: Cambridge University Press.

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Hunter, R., Kilstrom, N.. Kraybill, E., & Luda, F. (1978). Antecedents of child abuse and neglect in premature infants: A prospective study in a newborn intensive care unit. Pediatrics, 61, 629-637. Johnson, S. (1979). High-risk parenting. Philadelphia, PA: J. B. Lippincott Company. Kaufman, J., & Zigler, E. (1989). The intergenerational transmission of child abuse. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment (pp. 129- 152). Cambridge: Cambridge University Press. Kowal, L., Kottmeier, C., Ayoub, C., Komives, J., Robinson, D., &Allen, J. (1989). Characteristics of families at risk of problems in parenting: Findings from a home-based secondary prevention program. Child Welfare, 58, 529-

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Martin, H. (I 980). The consequences of being abused and neglected. In H. Kempe and R. Helfer (Eds.), The battered child (3rd ed.) (pp. 347-366). Chicago, IL: University of Chicago Press. McCord, J. (1983). A forty year perspective on effects of child abuse and neglect. Child Abuse & Neglect, 7,265. Mimer, J., & Ayoub, C. (1980). Evaluation of “at risk” parents using the Child Abuse Potential Inventory. Journalof Clinical Psychology, 36, 945-948. Milner, J., Gold, R., Ayoub, C., & Jacewitz, M. (1984). Predictive validity of the child abuse potential inventory. Journal of Consulting and Clinical Psychology, 52, 879-884. Mosteller, F., & Tukey, J. (1977). Data analysis and regression: A second course in statistics. Reading, MA: AddisonWesley. Mueller, E., & Silverman, N. (1989). Peer relationships in maltreated children. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment (pp. 529-578). Cambridge: Cambridge University Press. Parke, R., & Collmer, C. (1975). Child abuse: An interdisciplinary analysis. In E. Hetherington (Ed.), Review of child development research, (Vol. 5) (pp. 509-590). Chicago, IL: University of Chicago Press. Rogosa, D., Brandt, D., & Zimowski, M. ( 1982). A growth curve approach to the measurement ofchange. Psychological Bulletin, 90, 726-748. Rogosa, D., & Willett, J. B. (1985). Understanding correlates of change by modeling individual differences in growth. Psychometrika, 50, 65-72. Sameroff, A.. & Chandler, M. ( 1975). Renroductive risk and the continuum of caretaking causality. In F. Horowitz (Ed.), Review ofchild develobmen; research (Vol. 4) (pp. 25-53). Chicago, IL: University of Chicago Press. Schneider. C.. Helfer. R.. & Hoffmeister. J. (1980). Screening, for the notential to abuse: A review. In H. Kempe & R. Helfer (Eds.), The hatiered child (3rd ed.) (pp. ‘420-430).Chicago; IL: University of Chicago Press. Siegel, E., Bauman, K., Schafer, E., Saunders, M., & Ingram, D. (1980). Hospital and home support during infancy: Imnact on maternal attachment. child abuse and neglect and health care utilization. Pediatrics. 66, 183-190. Willett, J. B. (1989). Some results on reliability for the longitudinal measurement of change: Implications for the design of studies of individual growth. Educational and Psychological Measurement, 49, 587-602. Willett, J. B., Ayoub, C. C., & Robinson, D. (199 1). Using linear growth modeling to examine systematic differences in growth: An example ofchange in functioning of families at risk of maladaptive parenting, child abuse, or neglect. Journal of Consulting and Clinical Psychology, 59, 1-9. Wolfe, D., Edwards, B., Manion, I., & Koverola, C. (1988). Early intervention for parents at risk of child abuse and neglect: A preliminary investigation. Journal of Consulting and Clinical Psychology, 56, 40-47.

R&n&-La recherche dtmontre que le dtpistage p&inatal et l’intervention precoce reduisent I’incidence de la maltraitance et ameliorent la capacite a etre parent des fqmilles a risque. Cet article tente de repondre a la question suivante: est-ce que les familles, presentant differentes caracteristiques a I’inclusion dans l’etude different dans leurs reponses a l’intervention? Nous avons Ctudit I’impact du fonctionnement familial et des problemes famihaux a I’inclusion dans I’ttude sur la duree du traitement et sur I’amtlioration ou la deterioration de ce fonctionnement au tours de temps. Dans notre analyse nous avons utilist les caracteristiques a l’inclusion dans I’etude pour classer les families en cinq groupes homogenes (stress de situation, stress chronique, stress Cmotionnel, risques multiples et risques multiples lies a la violence). Nous avons trouve que la duree du traitement et la variation au tours du temps dans le fonctionnement familial different entre ces groupes de facon importante sur le plan clinique. NOSobservations suggerent que le traitement a de bonnes chances d’aniver a stabiliser et a ameliorer lentement le fonctionnement familial de la majorite des families a risque de maltraiter leur enfant. Resumen-Las investigaciones sugieren que, por deteccibn perinatal e intervention temprana, puede reducirse la incidencia de maltrato y mejorarse el modelo de crianza en familias de alto riesgo. En este trabajo preguntamos: Las familias con diferentes caracteristicas de entrada difieren en la forma que responden a la intervention. Investigamos si el funcionamiento de la familia en el nivel de entrada y 10s problemas familiares tienen un impact0 en el tiempo de tratamiento y en la mejoria o deterioro del funcionamiento de la familia a lo largo de1 tiempo. En nuestros analisis, usamos caracteristicas de entrada para clasificar las familias en cinco grupos homogtneos-situacionalmente tensos, emocionalmente tensos, multi-riesgo, y violent0 multi-riesgo-y encontramos que la duracibn de1 tratamiento y el ritmo de cambio en el funcionamiento de la familia diferia de manera clinicamente importante a lo largo de1 tiempo en estos grupos. Nuestros hallazgos sugieren que el tratamiento probablemente tendra Cxito en estabilizar y lentamente mejorar el fimcionamiento de la mayoria de las familias en riesgo de maltrato a 10s nifios.

Families at risk of child maltreatment: entry-level characteristics and growth in family functioning during treatment.

Research suggests that perinatal screening and early intervention may reduce the incidence of maltreatment and improve the parenting in at-risk famili...
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