Introduction

From birth to age 17, about one in three children in the United States are the subject of a maltreatment investigation, and about one in nine children have a substantiated investigation (Kim et al. 2017). Child maltreatment has significant negative consequences for children including increased levels of cognitive, psychosocial, and behavioral problems, impaired growth, increased illness, and higher levels of obesity (Institute of Medicine and National Research Council 2014). Understanding the risk and protective factors related to child maltreatment is key for designing effective prevention strategies.

While many prevention programs have focused on parent education (Sumner et al. 2015), certain family challenges—including poverty and substance use—may reduce a parent’s ability to attend parenting classes or incorporate the lessons provided in such programs. To effectively reduce child abuse and neglect and improve family well-being, prevention programs must meet the needs of the community and address these more complex family problems. Moreover, the fidelity of program implementation depends largely on effective collaboration among the researchers who design the intervention and the local professionals who implement it (Green et al. 2016). Beyond effective collaboration between these individuals, there is also a need to match evidence-based programs to local needs (e.g., Centers for Disease Control and Prevention CDC 2010; Israel et al. 1998; Smedley and Syme 2001; Trickett et al. 2011). These efforts must incorporate not only the goals and concerns of the researchers, but also the needs and concerns of members of the community as well (Trickett et al. 2011; CDC 2010).

A large body of research is dedicated to understanding what causes a parent to abuse or neglect their child. In a comprehensive meta-analysis of 155 studies published between 1969 and 2003 on the correlates of maltreatment, Stith et al. (2009) examined 39 factors and found the largest effect sizes related to physical abuse were parent anger/hyper-reactivity, family conflict, and family cohesion; and related to neglect were parent–child relationship, parent perceives child as problem, parent’s level of stress, parent anger/hyper-reactivity, and parent self-esteem. A recent prospective study of child maltreatment by Doidge et al. (2017) found that children were more likely to be maltreated if they: have cognitive or behavioral problems; have younger mothers (under 22 years of age); are in a lower-income household; have parents who experienced unemployment; have parents with substance use or mental health concerns; and had higher levels of social instability (e.g., moving high schools, parents experiencing divorce or separation). Several studies have found that family poverty is associated with increased risk of substandard parenting, including abuse and neglect (Berger et al. 2016; Berger 2004; Cancian et al. 2013; Putnam-Hornstein and Needell 2011; Sabol et al. 2004; Sedlak et al. 2010; Slack et al. 2004). Additionally, problematic substance use is associated with maltreatment (Appleyard et al. 2011).

Understanding the risk factors for child maltreatment is essential for crafting effective maltreatment prevention strategies. Currently, parenting education and home visiting programs are the most common forms of maltreatment prevention programs (Maguire-Jack 2014; Merritt et al. 2018). Prior systematic reviews and meta-analyses have found evidence of effectiveness in preventing maltreatment with home visiting programs (Geeraert et al. 2004; Lee et al. 2008; Mikton and Butchart 2009; MacLeod and Nelson 2000) and parent education (Lee et al. 2008; Mikton and Butchart 2009). Home visiting programs commonly include meeting the parent at their own home to assist with parenting challenges including a focus on knowledge of child development, proper techniques for caring for children, dealing with problem behavior, assisting with school readiness, and a focus on physical health (Merritt et al. 2018). The programs range from a one-time visit from a public health worker to a multi-year program with regular visits from a social worker, nurse, or other professional (Merritt et al. 2018). Parent education programs are typically provided in a group setting with a focus on child development and positive parenting behaviors (Merritt et al. 2018). Child welfare experts also identify respite care, support groups, public awareness campaigns, and school-based/early learning interventions as other common prevention programs across the United States (Slack 2009).

The current study sought to understand how the available maltreatment programs compared to the perceived needs identified by local experts from the fields of child welfare, maltreatment prevention, schools, mental health, substance use, law enforcement, foster care, and others who regularly interface with children. A series of focus groups were conducted in a midwestern state. The research questions were: (1) What are the identified needs of the local citizens and practitioners related to child maltreatment?; and (2) Do the available programs meet the needs of the communities?

Method

Participants

The sample for this qualitative study includes participants from 12 counties in a Midwestern state. Information about these counties is provided in Table 1. A stratified, purposive sampling strategy was utilized. Specifically, the following individuals and/or agencies were targeted for inclusion in the focus groups in each county: biological and foster parents; child protective services; hospitals (especially those focused on the care of children); law enforcement; local child welfare councils; home visiting programs; court-appointed special advocates; schools; judges and/or lawyers who work with probate courts or maltreatment cases; nonprofit agencies focusing on maltreatment prevention; agencies that work with parents who have been referred to CPS; families who have worked with any of these types of agencies or organizations; and behavioral health professionals (both substance use and mental health). Participants were recruited via email. In some instances once contact was made, snowball sampling was utilized to secure participants who were not as easily accessible—particularly families involved with the organizations and agencies being targeted. This process resulted in a range of individuals participating. A detailed breakdown of the composition of each focus group is provided in Table 2.

Table 1 County information
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Table 2 Focus group composition
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Those who participated were asked to provide feedback regarding the needs of their specific county relative to child maltreatment. Each focus group included 7–12 participants, with at least one focus group being conducted in each of the 12 counties. One urban county in the sample had a large population size and therefore two focus groups were conducted. A total of 107 individuals participated in the 13 focus group sessions.

Procedure

During 2016, the focus group sessions were completed with stakeholders in a midwestern state as part of a needs assessment conducted for the purposes of targeting child maltreatment prevention funding. A stratified, purposive sampling strategy was applied to ensure a range of perspectives were included. The number of focus groups conducted was decided by the group requesting the needs assessment and was not specifically designed to reach saturation in a qualitative sense, but rather to provide information from each of the counties requesting the assessment.

Each focus group session was audio recorded, with one moderator and at least one additional researcher present. The moderator was responsible for asking the questions from the interview guide, guiding the conversation, and posing any clarifying or follow-up questions that were either necessary or emerged through discussion. The level of moderator involvement in each focus group varied based on the needs of the group and the moderator’s discretion. This was largely dependent on how much structure was warranted and the dynamics of the group. Additional researchers present during the focus group sessions were charged with taking notes, including information regarding non-verbal behavior, group dynamics, and any emergent themes. The length of each focus group session ranged from 45–90 min (average approx. 60 min). Researchers arranged for the focus group sessions to be held at a time and location convenient for the participants. Once completed, the recording from each focus group session was transcribed and coded. Each transcript was analyzed using constant comparison, in vivo coding, and illustrative verbatim excerpts. Member checking was also employed to validate the content of the interview transcripts and the initial impressions of the data.

Measures

An interview guide was developed for use in each focus group session (see Table 3). This guide included 14 main questions that remained the same across groups, as well as several probing questions that could be asked in addition or as a compliment to the main questions. The focus group sessions were semi-structured, which allowed for participants to react and respond to others’ statements; thus, slight variations were present in the flow of questions and the conversations that took place.

Table 3 Focus group interview guide
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Data Analyses

The current study used qualitative secondary data analysis, which is useful in addressing additional research questions beyond the original scope of a planned qualitative study (Leech and Onwuegbuzie 2008). Supra analysis allows for the examination of new empirical research questions beyond the focus of the original study (Heaton 2004). The focus groups were originally conducted as part of a larger needs assessment for funding decisions around child maltreatment prevention. Through a review of the focus group transcripts, it became apparent to the researchers that significant information was shared—beyond the original scope of the research—specifically related to the match between the programs provided and the local beliefs about the main contributors to abuse and neglect. The researchers chose to conduct a supra analysis to address these additional issues.

After reviewing each focus group transcript for accuracy, they were analyzed using constant comparative analysis. Constant comparative analysis was originally used as an analytical tool in grounded theory, as developed by Glaser and Strauss (1967). However, the underlying principle of comparison—inherent in constant comparative analysis and present in other forms of qualitative research—is now more widely used as an analytical technique outside of the grounded theory approach (Boeije 2002). The traditional steps of constant comparative analysis were followed, including (1) reading through all interview transcripts; (2) open coding to identify concepts and assist in the interpretation of data; (3) axial coding which consists of grouping similar codes into categories; and (4) selective coding to provide a closer analysis for the specific research questions addressed in the study (Emerson et al. 1995; Leech and Onwuegbuzie 2008). Two independent reviewers analyzed the transcripts and followed the steps outlined above. Once emergent categories of information were evident, this information was shared and discussed between the researchers and a final list of broad themes were generated and agreed upon.

Open coding produced several broad concepts and categories, which were outlined by each researcher. These were further refined into themes through the axial coding process in which the data were more closely explored to ensure all relevant aspects were represented. Once emergent categories of information were evident, all coding information was shared between the researchers and a final list of three broad themes was generated and agreed upon. These overarching themes are: causes of child maltreatment, prevention programs, and service needs. To ensure each theme was thoroughly explained, verbatim excerpts from interview transcripts were incorporated through the process of in vivo coding. Memo writing was utilized throughout the coding process to elaborate on each category and theme, identify aspects worth exploring further, and to note patterns or connections that became evident.

Finally, the process of member checking was conducted to ensure the credibility of the findings. The member checking process involved providing themes to focus group participants and via email to confirm that the themes adequately represented the opinions of the group. Few responded to the request for member checking, but of the 12 who did, respondents agreed with the interpretation of the results.

Reflexivity Statement

This secondary qualitative analysis was conducted by three researchers with varying degrees of familiarity with child maltreatment prevention programs. The first author has master’s degrees in social work and public affairs and a doctorate in social welfare. She has over 10 years of experience in evaluating maltreatment prevention programs, with familiarity in the needs of families attending programs. The second author has a master’s degree in social work and a doctorate in social work. She has not evaluated maltreatment prevention programs, but has experience in qualitative methodology. The third author has a master’s degree and doctorate in public health, is well-versed in the field of family violence and qualitative research, and offers a rich, contextual lens on the problem of child maltreatment. With regard to analysis, the first and second author conducted all of the coding. The second author provided a check on the themes and coding, given the first author’s closeness to the issues. The third author gave an additional eye on the interpretations gleaned from the transcripts. Peer debriefing was conducted with two additional child maltreatment prevention researchers to provide a final review of the themes.

Results

Focus groups with stakeholders in the 12 counties revealed three overarching themes: the causes of child maltreatment, prevention programs, and service needs within each of the counties. Stakeholders identified several sub-themes relative to the causes of child maltreatment, including intergenerational issues (e.g., cycle of violence), poverty, social isolation, and behavioral health issues—both in terms of substance use (e.g., opioid epidemic) and mental health. Several specific maltreatment prevention programs were singled out as particularly beneficial to families in the counties, including parent education programs, mentoring programs, early childhood education, and specialized courts (e.g., drug courts).

Finally, the stakeholders identified some specific service needs, including barriers to receiving services, within their communities. Several types of programs or services were singled out as missing or inadequate, including a lack of affordable housing, affordable and high-quality childcare, behavioral health services, respite services, and accessible transportation. In some instances, funding issues were highlighted with some stakeholders mentioning funding being improperly allocated among the services and programs available in their county. Waitlists were mentioned frequently as a barrier for parents and families, with issues consistently reported in the areas of housing, behavioral health, and childcare. A lack of engagement in and with the programs available was also mentioned as an issue among both families and communities-at-large. More detailed information regarding these themes will be discussed in the following sections.

Perceived Causes of Child Maltreatment

Participants were asked to identify their perceptions of the causes of child maltreatment in their counties with the first question of each focus group session. Their responses, while varied, fell into four main categories: behavioral health issues (including mental health and substance use) with an emphasis on the opioid epidemic and drug use; poverty and related issues (e.g., homelessness); intergenerational issues (e.g., the cycle of violence); and social isolation.

Behavioral health issues

Participants across all 12 counties mentioned behavioral health issues—specifically mental health, substance use, or both—as a cause of child maltreatment. Participants mentioned the combination of “untreated or undiagnosed mental health challenges” and substance use as risk factors for maltreatment. Several participants also specifically focused on the issue of substance use and high rates of “prenatal substance abuse” in their communities. One participant stated: “A lot of the problems we see with abuse and neglect we see from the beginning…it’s hard to do prevention when we’re seeing abuse and neglect occur very young in life, prenatal.” Further, participants also mentioned an increase in the number of kids who are dealing with the long-term impacts that prenatal exposure is having on their lives. One person added:

…I think personally, my belief, is that some of the kids we’re seeing that have all these diagnoses, if you go back and look at, they were prenatally exposed to some of these substances. Ya know, they’re metabolizing through their medications at high rates…nobody can pinpoint exactly what the diagnosis should be for them, and my personal belief is that it’s somehow related to that prenatal drug exposure…some of those really significant drugs, so I think that’s definitely causing some issues at least from juvenile court but also…flows over into Children’s Services, mental health, and drug and alcohol…

Several participants shared these thoughts, indicating that they have seen an uptick in the number of children being referred for services due to parental drug abuse. In fact, one participant stated that “probably 85% of the cases we’re involved in have different drug abuse.”

Participants specifically mentioned drug use, and the opioid epidemic in particular, as “one of the biggest” causes of maltreatment. One participant stated:

The opiate epidemic…it’s something that has really shocked our system…when you’re talking about addiction, and the cycle of addiction, it doesn’t necessarily coincide with the time frames that our agency has, and specifically getting kids back to where they need to be.

This issue is complicated by a lack of “a robust mental health and addiction services delivery system,” which has resulted in some families falling through the cracks and others not receiving effective or timely intervention. Other participants mentioned drug use, specifically heroin, as being a “contributing factor” to child maltreatment. Their experience with this issue also includes neglect as well. One participant stated:

…but also neglect, because of the drug use, just more in tune to what the parents are into, what there life is, so neglect of their children and being left alone or fending for themselves because they’re [the parents] are so involved in their own lives and how they’re gonna get their drugs the next time.

Carrying on from this statement, another participant added “…the drug epidemic certainly plays a lot into the neglect issue.” While substance use, drug use in particular, is believed to be a cause of child maltreatment, it is the experience of participants in two counties that it more heavily impacts neglect in their communities instead.

Poverty and related issues

Another consistently cited cause of child maltreatment was poverty. The manifestations were described differently, depending on the county, but the overarching idea stayed the same. Poverty was characterized as homelessness or not having a static living situation, financial stress, and not having reliability in your life stemming from a lack of financial stability or sustainable employment. Some participants also touched on self-sufficiency (or a lack thereof) as impacting the rates of poverty in their communities, with one participant stating:

…people need to be able to be self-sufficient after we step away, after all of us step away and that’s the problem…all of our services are fairly short term, we don’t have funding to provide anything more intensive that’s long term so people very quickly have to become self-sufficient to be okay once we’re gone.

The idea of short-term help, at least in terms of financial stability, was mentioned as being important in this context. Participants described the services being provided as merely a bandage to stop the bleeding, but not something that fixes the underlying cause(s). The aid being provided is not available long enough for any real changes to be made. Once the help is gone, participants report that many parents and families are returned to the same state they were in before the intervention.

Intergenerational issues

Participants in all counties named intergenerational issues, in some form, as a cause of child maltreatment in their communities. A common thread was the idea of repeating behaviors across generations—a nod to the idea of there being a cycle of violence. One participant characterized this phenomenon as “cycles of violence, or traditions passed down amongst families…learned as a witnessed behavior.” This participant went on to describe it as parents thinking:

…‘this is the way kids are raised,’ or ‘this is the way kids get tough,’ or ‘this is the discipline you use’ and parents use it on the kids and the kid grows up and then uses it on their kid.

These sentiments were repeated by other participants from the other counties, with many talking about “generational patterns.” Another participant offered the example of working with children in a program 18 years ago, who are now adults who are involved with the same program with their own children. Regardless of its description—as a cycle, or pattern, or something similar—one thing is clear: the participants are witnessing the same behaviors being repeated over time.

Social isolation

Participants in both highly populated and rural counties mentioned the concept of social isolation. In one of the largest counties in the study, a participant described social isolation as “when you feel like you’re not connected to anything or you’re handling the situation solo…when you’re struggling but there’s not a support network around you that can help.” Despite living in a densely-populated area where there is little to no physical distance to make people feel isolated, people are still feeling socially and emotionally isolated. The consensus appears to be that while people may physically be close to one another, they are not connected in a meaningful way.

In other counties, participants talked about poverty, social isolation, and intergenerational family issues as working together in many cases. A participant mentioned “circles of support” and the fact that most of their families either do not have one, or the support system they do have “made them the way they are…they learned their behavior through their families.” Other participants identified social isolation as the result of living in a more rural area of the state, with more physical distance between neighbors. One stated:

I don’t think families have a lot of access to transportation and they live…kind of in these pockets that are very isolated and so I think that is a big issue when it might happen is because everybody doesn’t see it, there’s not a lot of neighbors.

Another participant added to this by sharing that there is also a lack of access to the various types of support that are needed and that even if the physical distance was not an issue, there would still be unmet needs due to the limited amount of support available.

Prevention Programs

Participants identified a range of child maltreatment prevention programs available in their counties which fell into three categories: parent education programs (including home visiting), mentoring programs, and specialized courts.

Participants identified several types of parent education programs. These included parenting classes for both mothers and fathers, as described here:

… at [agency], we offer parenting classes for the moms and the dads…one where she can get involved with our mom’s program which is more of an individual and we kind of are flexible to be able to work with her one-on-one but also we are able to do a group parenting class where the father of the baby is also able to be involved.

Mentoring programs for both adults and children were identified as maltreatment prevention programs. The programs available in each county varied, with many appearing to be small scale and localized. Participants also described mentoring that takes place through more informal means, stating:

…the kids that come through our community team, which is a collaborative group, to help children who have issues we do a lot of mentoring or family aid, we have family aids that go into families, so it’s a mentoring process…we try to support families in need that way. And a lot of that is simply to have somebody there who can reflect appropriate behaviors.

In addition to serving to prevent child maltreatment, participants felt that these mentoring programs provided a form of social support for those who were involved, and that they benefitted both parents and children.

Specialized courts, limited to adults only, were the final type of prevention program mentioned by participants. Participants identified specialized courts that are in place for both mental health and drug use. Participants also described a “cooperative program” or “cooperative agreement” in place with a judge in which “…people who have a problem with drugs get service.” While this cooperative agreement is only in place for adults, participants report plans for a juvenile court version of this as well.

Identified Service Needs

While there are a wide range of services and programs available for children and families in each of the 12 counties, participants identified areas where needs were unmet or barriers were in place. Specifically, participants mentioned: funding restrictions to provide needed services; lack of affordable childcare and housing; need for more respite and behavioral health services; transportation issues; waitlists for services; and problems with program engagement.

Funding restrictions

Participants identified a lack of funding for maltreatment programs and restrictions imposed by funding agencies, as barriers to providing service. While needed services may already be in place, the available funding for those services is restricted so that only those most at risk can be helped, leaving out some children and families in need. One participant explained this issue as follows:

…oftentimes all programs come down to funding, right, so the availability of funding and how far that funding stretches…I think there’s a tendency sometimes to focus on lower socioeconomic status individuals because there’s an assumption…and there are a lot of barriers there, but there are just as many barriers in middle class and working class and often more because, by the nature of your income you are less likely to potentially be able to participate in some of those preventative pieces without payment, and there’s nothing wrong with that. I get it, but that sometimes itself can be an access barrier because if I’m a middle class parent, or a working class parent, or whatever that is right above the poverty line…I now have to make a different decision about access if I now have to pay an additional fee…I would be more than happy if we could figure out a system where people who needed help got help, and we didn’t have this funding issue…but since we have that barrier I think as a system, as a county, and as a state we really do have to collectively come together and ask the larger question that is what is it that we want for our parents who have children? Where do we want them to go?

Another issue about funding is where and how it is being distributed. Participants questioned the lack of funding for trauma-informed care, stating:

…but I think that would be beneficial, if we have the funding to really implement a strategic approach to how we can provide that [trauma-informed care] in our community across the board with all types of providers.

Similar sentiments were shared by other participants, who extended the discussion of this issue to question the allocation of funds across the entire state, saying:

…the areas of the state that have the greatest need are not getting proportionally more in direct funding so we are trying to pull off a [program] in [county] that’s resourced for all intents and purposes what [similar county] is funded at, with monumentally greater needs…

Further complicating this issue is the growing requirement for documentation that shows change in the individuals who use a service or program. When evaluating maltreatment prevention programs, demonstrating change can be difficult since the goal is to prevent something from happening in the first place—not change it after the fact. To this end, a participant stated:

…one thing we’re seeing in the funding world is that we’re really making great strides towards evidence-based interventions, but with that comes a lot of funders, like our agency, who we want you to be able to measure everything you do and it’s very, very hard to measure prevention. It’s very hard to know what you don’t know could or could not have happened and I could tell you I think that has played a role in the funding decisions from a federal level all the way down to the local levels. I think it’s very hard to measure prevention and when you can’t measure something it’s even harder to go out and solicit funding for it.

Issues surrounding funding are complicated and complex. However, a common thread uniting this theme is the lack of money to fund everything needed or to help everyone who needs it.

Transportation

Another issue experienced across the counties revolved around transportation. A lack of reliable or accessible public transportation was mentioned by participants, with several naming this issue as the biggest barrier facing families in their counties and the main reason services may not be utilized. Participants described providing money for transportation for their families and some agencies purchasing vans to transport clients to and from appointments. One participant explained how their agency took over transportation, stating:

…we ended up taking managing oversight of the transportation, and the real issue with that is the amount of time it takes to get approvals and to work through the bureaucracy. So we have a lot of vision for what we’d like it to do to improve the availability to the general public for more instant, unplanned transportation, but that’s kind of like a 5 year plan- we’re going on three years now so… eventually we’d like to have more routes and set on points. But at least we have a desire to go there.

In some counties, this is a significant enough barrier that the agencies are utilizing their own staff and funding to manage transportation services for the entire county.

Behavioral health and respite services

Participants identified a need for more behavioral health services, particularly identifying the need for sober and recovery housing, residential drug and alcohol treatment, and substance use prevention programs for youth. While services already exists in each county, it is not enough to meet the needs of the people living there. One participant explained the need for more behavioral health care options stating:

…there’s been some efforts to try to bring in other mental health providers. And there’s varying successes I guess…trying to give people options, but I think that we still are in a situation, where we could- it would be beneficial to our community to have some more options for people…local mental health/ behavioral health system has pretty much reduced their ability to respond to our system, folks around the, it’s more of a triage to care, so, there is some difficulty in general mental health.

In these counties, it appears only a minimum level of behavioral health care is available and expanded care options are warranted, given the information provided by participants.

An unmet need that was identified by participants is respite services. One participant explained that respite services allow for parents to “get time to calm down that would help a lot” and that it would be a “huge benefit” to them. Another participant characterized respite as providing a “physical safe space that can be accessed by either the request of the parent or the child”—something that is needed by both. Other participants described the need for respite services in the context of families with high needs, specifically children with developmental disabilities or severe behaviors. One participant explained it as follows:

…if we have families that have high needs, child(ren) with developmental disabilities, we do provide respite but then finding a respite provider for someone with severe behaviors or if they’re a fire setter, forget it. We’re never gonna find, sometimes the families do need that or if I need a night of sleep and they have to work, I don’t understand how they’re even functioning and I can’t do anything because I’m like I put you on the list for respite and no one wants to take it.

Ultimately, it appears that participants in these counties feel that respite services would function much like maltreatment prevention programs for both parents and children.

Waitlists for services

Participants identified waitlists for services as a barrier for the families. These waitlists span several types of services and agencies. One type of agency where waitlists were common is not-for-profits due to a lack of funding. One participant added that even child protective services is having issues with waitlists, stating:

…I actually just had a conversation with [child protective services], I mean like that they are going to have a waitlist where children will be placed in residential. I mean like dollars is a huge, huge gap right now.

Waitlists in behavioral health were common with participants identifying waitlists for mental health services being 3–5 months long and medication management being 8–10 months long. Participants also mentioned waitlists for childhood mental health services, with travel to other counties sometimes required unless it is a crisis. Participants also indicated a waitlist for mental health courts, as well as the “local behavioral health services system.”

Parenting programs, early childhood education programs, and housing each had waitlists in several counties. Participants mentioned waitlists for early education and home visiting and housing programs—which was estimated at 300 people “easily.” In one county, a participant estimated the waitlist to be three years for children who do not meet the eligibility requirements for the early intervention home visiting program.

Program engagement

Participants described problems with parent engagement in their programs. Some cited a lack of buy-in and motivation as primary factors impacting engagement, while others did not have an explanation. Participants indicated that they have had low attendance for parenting and mentoring programs, as they have a “challenging” time getting families to attend that type of program. Some participants stated that their programs are free and they still have trouble getting families to attend. One noted that they “had great giveaways but just couldn’t get people to attend like we had hoped.” Participants also touched on the issue of motivation and the desire to access services, characterizing the situation this way:

I think desire is the issue…agencies can make accessing services easy but that doesn’t get people in the door wanting to be there if there isn’t that want or that need to be there. And even when courts mandate the need for service, I mean the motivation for service isn’t there…If the desire and motivation and determination isn’t there, you can’t force it. And even if you try they’re not going to fully participate, which means you’re just wasting your time and they’re probably just going to repeat, repeat that behavior. So that’s something we have to take a look at.

The participants feel—regardless of the type of service or the ease of access—families will not participate unless they are intrinsically motivated to do so. External sources of motivation (e.g., giveaways, making events free) have a limited effect on client behaviors in these counties.

Lack of affordable childcare and housing

Participants mentioned a lack of safe and affordable housing as a major concern and “huge barrier.” One participant stated: “Not very many…safe options for families…you’re unfortunately living in situations that put some families at huge risks.” Participants related that this issue primarily stems from a lack of emergency and transitional housing resources.

A lack of affordable, high-quality childcare was also mentioned. Concerns in this area focused on two separate issues: (1) a lack of childcare options for parents who are participating in programs or are at appointments, and (2) a lack of affordable, high-quality childcare options for families living at or below the poverty level. Participants acknowledged that offering childcare at agency events increases attendance and is beneficial for families as families cannot often not afford it themselves. In a similar vein, participants touched on a lack of childcare impacting parent’s attendance at appointments and in relative placements where the cost of childcare becomes so prohibitive that they can’t take a child on because they can’t afford their daycare. One participant added “we have state licensed day care providers and their prices are so extraordinary that a regular person can’t afford it.”

Participants noted that eligibility requirements keep changing (going up) for state childcare services, meaning fewer and fewer people are qualifying for reduced rates. The high cost of childcare has led some parents to forego it altogether, opting instead to stay at home all day with their child(ren). In one county, a participant explained:

We have childcare services available in County G but the problem is when we’re dealing with people in poverty they’re not working 9 to 5. They’re not working Monday through Friday. And having good, attuned, nurturing childcare available to these kids whose mom works til 11 o’clock at night or works Saturdays and they’re not going just to some neighbor down the street.

Across counties, there is a need for growth in the options that are available for both housing and childcare, with affordability, quality, and safety being paramount.

Discussion

This secondary qualitative analysis sought to understand what is believed to be the predicating factors that lead to maltreatment in 12 counties in a midwestern state as well as the connection between the maltreatment prevention services and those factors. The focus groups suggested that parenting education, home visiting, mentoring programs, early childhood education programs, and specialized courts made up the prevention continuum in the counties. Stakeholders identified behavioral health issues of parents, poverty, intergenerational maltreatment, and social isolation as the perceived causes of maltreatment. Participants also expressed barriers for parents in receiving services related to funding challenges, transportation, lack of engagement of families, behavioral health issues of parents, and poverty. The challenges to engaging parents who are most at need has been identified in prior work (Daro and Benedetti 2013; Wagner et al. 2003), as has the complex relationship between poverty and maltreatment (Drake and Jonson-Reid 2013).

These findings suggest that there is some alignment of the needs of families in these 12 counties with the services that are provided. Specifically, because participants identified behavioral health issues as a perceived cause of maltreatment, home visiting programs can assist with connecting parents to behavioral health services. Additionally, knowing that participants believed social isolation and intergenerational transmission of maltreatment to be causes, group-based parenting education programs can assist with reducing social isolation and are designed to change parenting knowledge and behaviors that could be related to the issue of intergenerational transmission of maltreatment.

However, the participants identified several important barriers for families that may make it more difficult for families to be impacted by these strategies. The stakeholders identified transportation barriers, unmet economic and behavioral health needs of parents, and a lack of engagement by parents. These issues are likely intertwined. Parents who are unable to afford transportation or quality housing are unlikely to be able to have the time or ability to come to a parenting education program. Home visiting is more likely to be effective for this population, since parents can receive services in their own home. However, parents who are struggling with addiction or working multiple jobs to afford their housing may be unlikely to be able to even receive those services without first having these basic needs met. Prior research on the engagement of families in home visiting programs found that those who were low-income were more likely to have never received a visit (Wagner et al. 2003). Additionally, although home visiting programs have the potential to be resource connectors, a national study of home visiting programs in the United States found that fewer than half of participants had ever discussed with their home visitor other services that might help their family (Lanier et al. 2015).

While parent education programs play a significant role in the prevention continuum and have evidence of effectiveness, Maslow’s (1943; 1954) hierarchy of needs would suggest that parents struggling with poverty and substance use issues may not be able to take in parenting information or develop new skills when their basic physiological needs are not being met. Maslow’s hierarchy of needs suggests that people become aware of their needs in a prescribed manner. The theory proposes that individuals must meet their physiological needs first—including things like food and shelter—and that individuals are unable to take steps to meet needs at higher levels until these basic needs are met. The second tier includes the needs of safety and security. The third tier includes intimate relationships and friends. This framework suggests that parents whose basic physiological and safety needs are not met may not be able to take in information related to improving their relationship with their child. In addition, parents struggling economically or with substance use issues may need assistance overcoming those issues before they are able to focus on improving their parenting techniques.

It is important to note that some home visiting strategies specifically target substance use and poverty as part of their intervention. For example, Nurse Family Partnership specifically aims to reduce substance use and increase education and workforce participation among parents involved in the program (Olds 2006). Such programs are likely to be more effective because of their focus on the entire context of the parent and their focus on assisting parents in meeting basic needs in addition to other tasks. While many home visiting programs—like Nurse Family Partnership (Olds 2006)—use this approach, if services are not present within the community to assist with these basic needs, the home visitors do not have options to present. The participants identified several unmet needs within the community that require additional attention to prevent maltreatment. Specifically, more behavioral health services as well as affordable and quality housing and childcare for families. It is essential to meet the economic and behavioral health needs of families before the current maltreatment prevention services will be able to reach the most at-risk populations with these strategies.

One challenge in doing so is that home visiting programs are structured to focus on a wide variety of outcomes (e.g., school readiness, parenting skills, disease management), leaving visiting nurses, social workers or paraprofessionals with little preparation and few opportunities to address a family’s more basic needs. Unfortunately, behavioral health issues and economic hardship frequently undermine the effectiveness of home visiting programs (Cluxton-Keller et al. 2014; Dauber et al. 2017; Jones et al. 2017)

Our findings suggest that home visiting programs should aim to increase their flexibility and ability to address such concerns. A number of recent efforts offer a blueprint for doing so, by supplementing existing home visiting programs with processes to screen and refer clients with behavioral health concerns (Dauber et al. 2017; Goodson et al. 2013; Silverstein et al. 2017).

Limitations and Future Research

Selection bias could potentially be a threat to credibility in the original study design. A mix of purposive and snowball sampling was utilized in the original study to locate enough participants from each county participating in the focus groups. This could have resulted in some bias in our sample, as those who ultimately took part in the focus groups may have had different opinions and perceptions than eligible individuals who did not participate. In terms of focus group makeup, there was limited participation from biological and foster parents. Furthermore, the parents participated alongside professionals and practitioners in the focus groups, which may have hindered their full participation.

Transferability may also be a concern. When considering the findings of this study, the results could truly only be transferred to other contexts or settings that are similar to those detailed here. To enhance transferability, descriptive information for both the state and counties from which the participants were sampled has been included; further, information about child maltreatment and substance use rates have also been provided.

Finally, this analysis was conducted as a secondary analysis of qualitative data. As such, the authors did not design the study or focus group guide with the specific research questions of the current study in mind. Therefore, the number of focus groups conducted was not driven by whether saturation was reached related to the current study. Further, the authors found no significant outliers within the data; this may be a function of using focus groups and could therefore be seen as a potential limitation of this method of analysis. Specifically, it is possible that individuals held significantly different views than those expressed, and may have chosen not to speak up out of discomfort with not conforming to the group.

The current study expands on previous research by examining the alignment between stakeholders’ perceptions of maltreatment prevention needs and the service array. Given the findings related to the importance of reducing poverty and improving behavioral health of parents (both substance use and mental health), future research should explore the effectiveness of such strategies in preventing maltreatment. Future studies may include adding such strategies into existing maltreatment prevention efforts to assess the added value of such interventions or examining the long-term maltreatment outcomes of specific poverty reduction and/or substance use treatment programs. For example, estimating the relative effectiveness of up-stream policies including living wage policies and social welfare programs such as universal health care and generous paid parental leave policies in reducing maltreatment is critical for understanding how to make significant change on these outcomes. This work has already begun, with recent innovative work showing that increases in the minimum wage are related to decreased new child maltreatment reports (Raissian and Bullinger 2017). Due to the complex nature of child maltreatment with multiple influences at all levels of the social ecology (Belsky 1980), exploring whether intervening on these influences at the societal level is crucial for building a multi-level effort to reduce child abuse and neglect.