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What Can Elder Mistreatment Researchers Learn About Primary Prevention From Family Violence Intervention Models?

What Can Elder Mistreatment Researchers Learn About Primary Prevention From Family Violence... Abstract Elder mistreatment (EM) is a public health problem that harms millions of older Americans each year. Despite growing recognition of its occurrence, there are no evidence-based primary prevention programs. Although EM is distinct from other areas of family violence, including child maltreatment and intimate partner violence, common risk factors and theoretical underpinnings point to opportunities for prevention strategies. Drawing on evidence-based best practices found in other fields of family violence, we identify approaches that could be tested to prevent EM at the hands of family caregivers, who are among the most likely to commit mistreatment. Specifically, we examine home visiting approaches primarily used in the child maltreatment field and identify components that have potential to inform EM interventions, including prevention. We conclude that there is enough information to begin testing a prevention intervention for EM that targets caregivers. Abuse/neglect, Caregiving-informal, Family issues, Intervention, Preventive medicine/care/services Elder mistreatment (EM) is a public health problem that takes a devastating toll on the independence, health, and well-being of millions of older Americans. A national prevalence study indicated that six million people aged 60 and older are victims annually, or about 1 in 10 older adults (Acierno, Hernandez-Tejada, Muzzy, & Steve, 2009). Estimates are even higher globally, reaching one in six older adults (Yon, Mikton, Gassoumis, & Wilber, 2017). If EM were thought of as an illness or syndrome, it would be recognized as a public health crisis (Pillemer, Connolly, Breckman, Spreng, Lachs, 2015). EM has been defined by the National Research Council as: “Intentional actions that cause harm or create a serious risk of harm, whether or not intended, to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder,” as well as “failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (Bonnie & Wallace, 2003, p. 1). Because this definition focuses on a caregiver or trusted other, it excludes self-neglect, but does pertain to physical and psychological mistreatment, financial exploitation, and caregiver neglect. In this article, we focus on mistreatment by a “caregiver,” defined as “a person who bears or has assumed responsibility for providing care or living assistance to an adult in need of such care or assistance” (Bonnie and Wallace, 2003, p. 39). Although the magnitude of EM indicates a need for developing and testing prevention strategies, evidence-based interventions and primary prevention programs for EM are lacking (Pillemer, Burnes, Riffin, & Lachs, 2016; Pillemer et al., 2015; Teresi et al., 2016). Primary prevention, which refers to interventions that intercede to stop abuse from occurring, has not been systematically studied in EM (Teresi et al., 2016). However, research has been conducted on a small number of secondary and tertiary preventive interventions, which seek to stop ongoing abuse and/or mitigate its detrimental effects (e.g., Gassoumis, Navarro & Wilber, 2015). EM research can, however, benefit from evidence developed in other areas of family violence. For example, primary prevention programs have been developed to address child maltreatment and intimate partner violence (IPV), offering possible applications for EM (Teresi et al., 2016). Because family violence occurs throughout the lifespan and similar risk factors are found for child maltreatment, IPV, and EM, prevention strategies for EM should be developed by building on what has been learned from research into other areas of family violence. Indeed, Hamby & Grych (2013) describe abuse in families as “webs of violence” wherein exposure at any point in the lifecourse increases risk of eventually experiencing and/or perpetuating violence. They urge researchers to follow these complex webs across different parts of the lifecourse, comparing and contrasting risk factors, treatment approaches and relevant theories. EM and Caregiving Approximately one-quarter of adults aged 65 and older reported relying to some extent on assistance from a caregiver because of physical and/or cognitive impairments (National Academies of Sciences, Engineering & Medicine [NASEM], 2016). Although studies indicate that most EM is committed by family members (Acierno et al. 2009), the extent to which family caregivers are perpetrators of EM is unclear. Two studies found that 26% of those receiving care from a family member reported experiencing either physical mistreatment or exposure to potentially harmful behaviors (e.g., withholding food) at the hands of a family caregiver (Beach et al., 2005; VandeWeerd, Paveza, Walsh, & Corvin, 2013). In another study, which focused on those caring for family members with Alzheimer’s Disease and related dementias (ADRD), 47% acknowledged committing at least one type of mistreatment, often psychological mistreatment (Wiglesworth et al., 2010). Even as family members are increasingly called upon to provide care to older relatives (NASEM, 2016). Training and support available to caregivers may be sparse or nonexistent, and some proportion of family members may have little ability to adequately provide care. Given the vulnerability of older adults who rely on family caregivers and the documented high rates of mistreatment, prevention programs geared to families would seem to offer a promising first step to reducing the high levels of EM. Given this and the limited state of knowledge on primary mistreatment prevention in this population, approaches to evidence-based prevention interventions in other fields of family violence seem to offer a useful starting point. Shared Theoretical Mechanisms in Family Violence Because EM shares several risk factors with other forms of family violence, strategies based on relevant theories and causal mechanisms from other areas can help researchers identify adaptable prevention strategies that lower risk when developing interventions (Burnes et al., 2016). We discuss several theories divided into three categories: addressing relationship quality and skills, stress and reaction, and knowledge and experience. Although the precise mechanisms of each theory are distinct, intervention components and outcomes discussed subsequently broadly follow this trifurcation. Relationship Quality and Skills Social learning theory Previous exposure to family violence is associated with future perpetration of abuse. As the Adverse Childhood Experiences study demonstrates, exposure to negative experiences early in life (e.g., abuse, domestic violence) increases the likelihood of participating in IPV; those with high ACE scores have five times greater odds of perpetrating physical IPV than those with low scores (Anda et al., 2006). As the web of violence concept suggests, patterns of violence developed over the lifecourse can yield devastating results in old age (Hamby & Grych, 2013). Shedding light on such patterns though interviews, Pickering and colleagues observed that adult daughters who reported that they were abused as children often engaged in reciprocal aggression towards their elderly mothers, particularly verbal/psychological abuse (Pickering, Mentes, Moon, Pieters, & Phillips, 2015). Experiences of childhood trauma have also been associated with increased risk of perpetration of neglect among caregivers (Fulmer et al., 2005). Social learning theory explains this patterned violence, wherein behavior is learned through observation and replicated (Bandura, 1977). Extrapolating from this theory, one can posit that abusive behaviors are learned through observation, and are replicated after having been established as normative behaviors. Attachment theory Poor relationship quality between potential victims and perpetrators is also related to risk of child maltreatment, IPV, and EM. In cases of child maltreatment, this includes low levels of maternal warmth (Brown, Cohen, Johnson, & Salzinger, 1998)—associated with physical abuse and neglect—and low levels of attachment (Thornberry et al., 2014). Attachment theory indicates that positive caregiver interactions with a child promote emotional and behavioral regulation while increasing the parent’s investment in the child’s wellbeing (Daro & McCurdy, 2008; Toth et al., 2013). Poor attachment in grown children has been implicated as a factor contributing to neglect of their older parents (Cicirelli, 1986). Stress and Reaction Caregiver stress High stress levels among perpetrators have been identified as a risk factor for family violence (e.g., Tucker & Rodriguez, 2014), including EM, although the evidence is mixed. Pillemer & Finkelhor’s (1989) seminal study showed that higher care needs among recipients—believed to raise levels of caregiver stress—were not associated with EM. Rather, those who mistreated older adults were more likely to have experienced other life stresses (e.g., death of a relative) within the year in which mistreatment occurred. A more recent study found that among caregivers for older adults, more hours spent providing care and higher levels of subjective burden were predictive of physical and psychological mistreatment (Cooper et al., 2010). Similarly, parents who commit child maltreatment find parenting more stressful than other parents (Teresi et al., 2016), suggesting that subjective assessments of caregiving are central to understanding the role of stress in risk of mistreatment. Specifically, parents who commit maltreatment are more reactive to stressful events than those who do not commit mistreatment (Reijman et al., 2016), and may have lower capacity for emotional regulation. Although the EM field is still learning about mechanisms underlying the relationship between stress and mistreatment, recent findings in caregiving show similar results as research in child maltreatment. High subjective burden among caregivers is predictive of potentially harmful behaviors (Arai, Noguchi, & Zarit, 2017). Coping styles are another avenue that should be explored to explain the relationship between stress and mistreatment, as coping can alter the outcome of stress experiences (Knight & Sayegh, 2010). Reactive abuse Rather than care needs per se, certain behaviors are associated with risk. In child maltreatment (Thornberry et al., 2014), IPV (Kuijpers, van der Knaap, & Winkel, 2012), and EM (Cooper et al., 2010), aggressive behaviors from the victim are associated with abuse, potentially eliciting negative reactions from perpetrators. Similarly, older adults who exhibit aggressive behaviors related to behavioral symptoms of dementia are more likely to experience mistreatment than those without dementia (VandeWeerd et al., 2013; Wiglesworth et al., 2010). Knowledge and Experience Low levels of knowledge and experience among caregivers are associated with increased risk of mistreatment. For example, parents with poor understanding of their children’s behaviors are at risk of participating in harmful behavior towards children (Toth et al., 2013). Children displaying certain challenging behaviors (e.g., withdrawal) are also at greater risk of maltreatment (Brown et al., 1998), possibly due to the higher degree of child-rearing skills required of parents. Poor understanding of recipient behaviors may similarly explain high rates of mistreatment among caregivers to people with dementia (e.g., Wiglesworth et al., 2010). Although high-demand caregiving can contribute to EM through stress, inexperience on how to provide care is another factor (Johannesen & LoGiudice, 2013). Indeed, some cases of criminal neglect are nearly indistinguishable from those where caregiver is overwhelmed (DeLiema, Homeier, Anglin, Li, & Wilber, 2016). Factors Unique to EM Although applying risk factors and theories from different forms of family violence, it is important to recognize dynamics that make EM unique. Aging is associated with illnesses and disabilities that may change an adult’s status from independent to dependent, requiring different behaviors from others. For example, family norms of gift-giving may become exploitative if the older adult loses financial decision-making capacity (Wilber & Reynolds, 1996). Further, although the dependency and need for care among some older adults may mirror that seen in children, an important distinction in older adults is the assumption of autonomy. Unless it is legally determined that the older adult lacks capacity, they retain their decision making autonomy, which includes the autonomy to make seemingly poor decisions or to place themselves in harmful or detrimental situations. Community-Based Intervention Models in Family Violence Like theories and risk factors, community-based prevention models for other types of family violence offer useful lessons for addressing EM. We largely focus on home visiting models seen primarily in the child maltreatment field. There are several reasons for doing so. As with parents raising children, family caregiving for older adults takes place primarily within the home. A home setting is valuable for an intervention because it gives providers insight into contextual risks (e.g., substance abuse, signs of neglect) that may not be apparent in other settings (Mosqueda et al., 2016). Further, these approaches enable tailored interventions appropriate for the diverse needs of families, as opposed to more group-based interventions (e.g., group counseling). Home visiting models are particularly attractive in an EM prevention context, as a strong tradition of home-based intervention already exists for family caregivers (NASEM, 2016). In reviewing approaches to community-based intervention, this section aims to identify components that contribute most to success. Table 1 summarizes the intervention models described. Table 1. Prevention Interventions From Child Maltreatment and IPV Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 View Large Table 1. Prevention Interventions From Child Maltreatment and IPV Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 View Large Home Visiting Programs to Prevent Child Maltreatment Home visiting programs in child maltreatment date back to the 1970s (Toth et al., 2013). Some programs provide generalized supportive services, such as the Healthy Start program, which connects new parents to community resources (Bair-Merritt et al., 2010). Other interventions target specific mechanisms thought to underlie child maltreatment. This strategy is used in the Promoting First Relationships intervention, which aims to improve parents’ sensitivity to child needs and promote attachment (Spieker, Oxford, Kelly, Nelson, & Fleming, 2012). Still other programs are multicomponent, offering a range of services and support to families (MacLeod & Nelson, 2000). Despite variation, some designs and strategies are consistently more successful than others. For example, home visiting interventions that include a training component outperform those without training. Aiming to break cycles of violence and improve relationship quality using tenets of social learning and attachment theories, parents participating in Parent-Child Interaction Therapy are taught parenting skills over 12 to 14 training sessions (e.g., alternatives to physical discipline) (Toth et al., 2013). Other training approaches focus on improving parents’ perceptions of children. In an adapted version of the Healthy Start program, at-risk families were trained to alter negative appraisals of children. At follow-up, the control group had a 24% rate of physical abuse at follow up, whereas those receiving the enhanced version of the Healthy Start intervention showed a rate of 4% (Bugental et al., 2010). Although not specifically designed to prevent child maltreatment, the Family Check-Up model offers several promising approaches. A home visiting program addressing maladaptive behavior patterns in children, it is tailored to the unique needs of families over the course of three visits (Dishion et al., 2015). Parents are interviewed about their situation during the first visit, assessed and observed interacting with the child during the second visit, and receive feedback during a final visit to discuss parenting strengths and weaknesses as well as available services and supports to meet the family’s needs (Smith, Knoble, Zerr, Dishion, & Stormshak, 2014). Although its impact on preventing child maltreatment remains largely unstudied, recent findings by Dishion and colleagues (2015) show lower levels of neglect among families participating in the Family Check-Up program 2 years after the intervention. The Family Check-Up model is based on the transtheoretical model of change, a dynamic and person-centered approach that encourages behavior change in stages based on readiness (Prochaska, Redding, & Evers, 2008). Moving forward through stages is believed to improve self-efficacy, which supports behavior change (Bandura, 1977). In the case of the Family Check-Up model, motivational interviewing techniques prepare parents to change reactions contributing to difficult behaviors such as defiance and poor self-regulation (Dishion et al., 2015). Feedback helps parents recognize areas of strength and areas where they can improve. Community-Based Programs to Prevent Intimate Partner Violence Although home visiting approaches are far more common in child maltreatment interventions, some IPV interventions offer valuable lessons especially given overlapping dynamics with EM that are not seen in child maltreatment (e.g., presumed victim autonomy, longer relationship history). Drawing on child maltreatment, the Family Check-Up model has also been effectively revised to prevent IPV in the form of the Men’s Domestic Abuse Check-Up, a secondary prevention approach. The program is like the Family Check-Up but provides the intervention via telephone to men who self-identify as engaging in violent behaviors toward their partners. As with the Family Check-Up, motivational interviewing and feedback are central (Mbilinyi et al., 2011). In addition, because perpetrators of IPV overestimate the normality of violent behaviors, the program provides participants with a brochure detailing the actual prevalence of interpersonal violence within the general male population. Revealing the discrepancy between participants’ perceptions of IPV occurrence and what is normal promotes self-awareness and draws upon social learning theory, encouraging men to accept a more accurate perspective of IPV. In addition to or as part of home visiting, interventions to improve communication skills between partners reduce revictimization (Whitaker, Murphy, Eckhardt, Hodges & Cowart, 2013). In a seminal study, Markman and colleagues tested the Prevention Relationship Enhancement Program, where couples learned techniques such as active listening and expressive communication during therapy sessions (Markman, Renick, Floyd, Stanley, & Clements, 1993). Researchers found that during 4- and 5-year follow-ups, participants in the intervention reported better communication and lower levels of violence in their relationships than controls. The success of these programs may be attributed to their accounting for varying stages of risk, an important factor to consider since potentially abusive behaviors often increase over time (Whitaker, Hall, & Coker, 2009). Building on Family Violence Interventions to Identify Key Components for a Home Visiting Model to Prevent EM Drawing on lessons learned from child maltreatment and IPV, we argue for the adoption of a home visiting model delivered as a primary prevention intervention for EM. Based on successful models in child maltreatment and IPV the structure of an intervention should target caregivers facing new or changing conditions, take place over several months, and be tailored to individual and family needs, preferences, and culture. Components should include regular assessments, training, and strengths-based feedback. How such an intervention might look is illustrated in Figure 1. Although not exhaustive, these approaches reflect the most promising practices from family violence. Readers seeking additional information about specific program structure and components should review MacLeod & Nelson (2000) and Whitaker and colleagues (2013). Figure 1. View largeDownload slide Model of intervention structure and key components. Figure 1. View largeDownload slide Model of intervention structure and key components. Although we propose a standardized structure and several key components for an intervention, the exact intervention tools will depend on specific risk factors in each family. Previously we suggested risks fall into three general theoretical categories—those related to relationship quality, stress, and knowledge. Responses to risk factors identified during assessment should link to selected tools by way of underlying theory. Whereas training for someone who is experiencing high levels of stress might focus on behavior management and assistance accessing respite, caregivers who are struggling with a difficult relationship history will likely receive greater benefits from counseling. However, because there will likely be overlap in these categories, some cases responses will look very similar (e.g., caregiver stress caused by lack of knowledge and preparation). Figure 2 illustrates an intervention based on a hypothetical case where stress-based risk factors are central; Supplementary Figures 1 and 2 illustrate what an intervention might include for the other theoretical mechanisms discussed. Figure 2. View largeDownload slide Example of Intervention Approach Addressing Stress Theories. Figure 2. View largeDownload slide Example of Intervention Approach Addressing Stress Theories. Target Caregivers at the Start of Caregiving and Those Facing Changing Conditions As Teresi and colleagues (2016) point out, interventions in child maltreatment are most effective when delivered before maltreatment occurs. Similarly, primary EM prevention programs implemented near the beginning of a caregiving journey or at critical junctures after a change in care level occurs may be most effective. For example, an intervention could target caregivers following a hospital transition. However, unlike new parents who readily identify with this role, caregivers who are just beginning this role may require additional guidance during recruitment given a tendency to not yet perceive themselves as caregivers (NASEM, 2016). Take Place over an Extended Period Further, in reviews of both child maltreatment and IPV interventions, the most successful home visiting programs were found to be relatively intensive and moderately long in duration. Based on studies from other forms of family violence, regular and frequent visits—perhaps 12 or more (MacLeod & Nelson, 2000)—over at least 6 months are most likely to improve the chances of success of a home visiting intervention. Even longer intervention periods may be appropriate, possibly lasting 2 years or more, depending on other design components (e.g., qualifications of the interventionist) (Daro & McCurdy, 2008). Tailored to Individual and Family Needs, Preferences, and Culture Interventionists should utilize the flexibility of a multicomponent approach to deliver services and supports that meet the unique needs of families wherever they are on the spectrum between a healthy and abusive relationship. For example, interventionists in the Healthy Start program individualize the intervention to families by guiding them to relevant services based on specifically identified needs, and decrease the number of visits as parent competency grows (Bair-Merritt et al., 2010). Multicomponent options may also be preferable compared to “one-size-fits-all” approaches (e.g., Alkema, Reyes & Wilber, 2006), as some families will be more amendable to and will engage with some interventions tools more than others. In addition, an EM intervention should meet the needs of culturally and ethnically diverse caregiving dyads and families. The Family Check-Up model’s success in racially and ethnically diverse samples has been attributed to its ability to address multiple types of stressors linked to culturally specific norms and attitudes (Smith et al., 2014). Guided by Regular Assessment To effectively meet specific and evolving needs and identify whether progress has been made toward reducing risk, family assessment at baseline and regularly thereafter is necessary. Assessment, as described here, is both a means of evaluating a program, and a component of the intervention itself. In the Family and Men’s Check Up models, assessment is the cornerstone of increased self-awareness underlying behavior change in these transtheoretical model-inspired programs (Prochaska et al., 2008). Although assessment should avoid being burdensome, it is important to include contextual factors such as family dynamics as well as characteristics of the caregiving situation that are likely to evolve (e.g., cognitive impairment of care recipient). An assessment should inform a care plan (i.e., intervention components and tools) that is specific to the needs of the family. Inclusion of a Training Component A home visiting model to prevent EM among caregiving dyads should also include a caregiver training component in most cases. The success of training is observed in the positive results of Parent-Child Interaction Therapy (Toth et al., 2013). Success is attributed not only to skill-building in areas of weakness but also increase in self-efficacy supporting behavior change. Like training options offered in caregiver and child maltreatment interventions, content for an EM intervention might include practical demonstrations on how to provide care, money management, and managing difficult care recipient behaviors. Training could also address relationship quality, especially in situations involving recipients with dementia or those who may have difficulty appropriately expressing their needs. In line with Promoting First Relationships (Spieker et al., 2012), relationship quality can be improved by assisting caregivers in understanding recipient needs. Dyad training on communication skills (e.g., active listening) could be useful in some cases (e.g., Markman et al., 1993). However, because there are likely limitations of such training in families with long-standing relationship conflicts; such training, if used, should include realistic goals as to what can be accomplished (e.g. de-escalation, reduction of potentially harmful interactions). This approach is supported by the transtheoretical model, where progress is tailored to the individual (Prochaska et al., 2008). Provision of Strengths-Based Feedback Strengths-based feedback builds self-efficacy, encourages participant retention, and motivates progress toward acquiring the skills necessary to provide quality care. Such feedback should be provided following assessment, reassessment, and while providing training modules. Components of social learning theory found in the transtheoretical model of change suggest that self-efficacy can encourage engagement in interventions (Prochaska et al., 2008), which has been illustrated in Family Check-Up programs (e.g., Dishion et al., 2015). Although self-efficacy has long been considered an outcome of caregiver interventions (NASEM, 2016), an EM intervention should also consider self-efficacy as a moderator. Conclusion Evidence-based primary prevention strategies from other fields of family violence offer a useful starting place for interventions to prevent EM. Of particular interest are home visiting models aimed at caregivers, which offer opportunities and approaches to target underlying risk factors shared among different forms of family violence. We describe starting points for such an intervention but acknowledge that any program will be shaped by the available resources and specific agency goals. Regardless, given what we know about prevention programs from child maltreatment and IPV, we believe there is adequate information to pilot a promising prevention intervention for EM. Funding This project was supported by Award No. 2016-ZD-CX-K008, awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. 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What Can Elder Mistreatment Researchers Learn About Primary Prevention From Family Violence Intervention Models?

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Abstract

Abstract Elder mistreatment (EM) is a public health problem that harms millions of older Americans each year. Despite growing recognition of its occurrence, there are no evidence-based primary prevention programs. Although EM is distinct from other areas of family violence, including child maltreatment and intimate partner violence, common risk factors and theoretical underpinnings point to opportunities for prevention strategies. Drawing on evidence-based best practices found in other fields of family violence, we identify approaches that could be tested to prevent EM at the hands of family caregivers, who are among the most likely to commit mistreatment. Specifically, we examine home visiting approaches primarily used in the child maltreatment field and identify components that have potential to inform EM interventions, including prevention. We conclude that there is enough information to begin testing a prevention intervention for EM that targets caregivers. Abuse/neglect, Caregiving-informal, Family issues, Intervention, Preventive medicine/care/services Elder mistreatment (EM) is a public health problem that takes a devastating toll on the independence, health, and well-being of millions of older Americans. A national prevalence study indicated that six million people aged 60 and older are victims annually, or about 1 in 10 older adults (Acierno, Hernandez-Tejada, Muzzy, & Steve, 2009). Estimates are even higher globally, reaching one in six older adults (Yon, Mikton, Gassoumis, & Wilber, 2017). If EM were thought of as an illness or syndrome, it would be recognized as a public health crisis (Pillemer, Connolly, Breckman, Spreng, Lachs, 2015). EM has been defined by the National Research Council as: “Intentional actions that cause harm or create a serious risk of harm, whether or not intended, to a vulnerable elder by a caregiver or other person who stands in a trust relationship to the elder,” as well as “failure by a caregiver to satisfy the elder’s basic needs or to protect the elder from harm” (Bonnie & Wallace, 2003, p. 1). Because this definition focuses on a caregiver or trusted other, it excludes self-neglect, but does pertain to physical and psychological mistreatment, financial exploitation, and caregiver neglect. In this article, we focus on mistreatment by a “caregiver,” defined as “a person who bears or has assumed responsibility for providing care or living assistance to an adult in need of such care or assistance” (Bonnie and Wallace, 2003, p. 39). Although the magnitude of EM indicates a need for developing and testing prevention strategies, evidence-based interventions and primary prevention programs for EM are lacking (Pillemer, Burnes, Riffin, & Lachs, 2016; Pillemer et al., 2015; Teresi et al., 2016). Primary prevention, which refers to interventions that intercede to stop abuse from occurring, has not been systematically studied in EM (Teresi et al., 2016). However, research has been conducted on a small number of secondary and tertiary preventive interventions, which seek to stop ongoing abuse and/or mitigate its detrimental effects (e.g., Gassoumis, Navarro & Wilber, 2015). EM research can, however, benefit from evidence developed in other areas of family violence. For example, primary prevention programs have been developed to address child maltreatment and intimate partner violence (IPV), offering possible applications for EM (Teresi et al., 2016). Because family violence occurs throughout the lifespan and similar risk factors are found for child maltreatment, IPV, and EM, prevention strategies for EM should be developed by building on what has been learned from research into other areas of family violence. Indeed, Hamby & Grych (2013) describe abuse in families as “webs of violence” wherein exposure at any point in the lifecourse increases risk of eventually experiencing and/or perpetuating violence. They urge researchers to follow these complex webs across different parts of the lifecourse, comparing and contrasting risk factors, treatment approaches and relevant theories. EM and Caregiving Approximately one-quarter of adults aged 65 and older reported relying to some extent on assistance from a caregiver because of physical and/or cognitive impairments (National Academies of Sciences, Engineering & Medicine [NASEM], 2016). Although studies indicate that most EM is committed by family members (Acierno et al. 2009), the extent to which family caregivers are perpetrators of EM is unclear. Two studies found that 26% of those receiving care from a family member reported experiencing either physical mistreatment or exposure to potentially harmful behaviors (e.g., withholding food) at the hands of a family caregiver (Beach et al., 2005; VandeWeerd, Paveza, Walsh, & Corvin, 2013). In another study, which focused on those caring for family members with Alzheimer’s Disease and related dementias (ADRD), 47% acknowledged committing at least one type of mistreatment, often psychological mistreatment (Wiglesworth et al., 2010). Even as family members are increasingly called upon to provide care to older relatives (NASEM, 2016). Training and support available to caregivers may be sparse or nonexistent, and some proportion of family members may have little ability to adequately provide care. Given the vulnerability of older adults who rely on family caregivers and the documented high rates of mistreatment, prevention programs geared to families would seem to offer a promising first step to reducing the high levels of EM. Given this and the limited state of knowledge on primary mistreatment prevention in this population, approaches to evidence-based prevention interventions in other fields of family violence seem to offer a useful starting point. Shared Theoretical Mechanisms in Family Violence Because EM shares several risk factors with other forms of family violence, strategies based on relevant theories and causal mechanisms from other areas can help researchers identify adaptable prevention strategies that lower risk when developing interventions (Burnes et al., 2016). We discuss several theories divided into three categories: addressing relationship quality and skills, stress and reaction, and knowledge and experience. Although the precise mechanisms of each theory are distinct, intervention components and outcomes discussed subsequently broadly follow this trifurcation. Relationship Quality and Skills Social learning theory Previous exposure to family violence is associated with future perpetration of abuse. As the Adverse Childhood Experiences study demonstrates, exposure to negative experiences early in life (e.g., abuse, domestic violence) increases the likelihood of participating in IPV; those with high ACE scores have five times greater odds of perpetrating physical IPV than those with low scores (Anda et al., 2006). As the web of violence concept suggests, patterns of violence developed over the lifecourse can yield devastating results in old age (Hamby & Grych, 2013). Shedding light on such patterns though interviews, Pickering and colleagues observed that adult daughters who reported that they were abused as children often engaged in reciprocal aggression towards their elderly mothers, particularly verbal/psychological abuse (Pickering, Mentes, Moon, Pieters, & Phillips, 2015). Experiences of childhood trauma have also been associated with increased risk of perpetration of neglect among caregivers (Fulmer et al., 2005). Social learning theory explains this patterned violence, wherein behavior is learned through observation and replicated (Bandura, 1977). Extrapolating from this theory, one can posit that abusive behaviors are learned through observation, and are replicated after having been established as normative behaviors. Attachment theory Poor relationship quality between potential victims and perpetrators is also related to risk of child maltreatment, IPV, and EM. In cases of child maltreatment, this includes low levels of maternal warmth (Brown, Cohen, Johnson, & Salzinger, 1998)—associated with physical abuse and neglect—and low levels of attachment (Thornberry et al., 2014). Attachment theory indicates that positive caregiver interactions with a child promote emotional and behavioral regulation while increasing the parent’s investment in the child’s wellbeing (Daro & McCurdy, 2008; Toth et al., 2013). Poor attachment in grown children has been implicated as a factor contributing to neglect of their older parents (Cicirelli, 1986). Stress and Reaction Caregiver stress High stress levels among perpetrators have been identified as a risk factor for family violence (e.g., Tucker & Rodriguez, 2014), including EM, although the evidence is mixed. Pillemer & Finkelhor’s (1989) seminal study showed that higher care needs among recipients—believed to raise levels of caregiver stress—were not associated with EM. Rather, those who mistreated older adults were more likely to have experienced other life stresses (e.g., death of a relative) within the year in which mistreatment occurred. A more recent study found that among caregivers for older adults, more hours spent providing care and higher levels of subjective burden were predictive of physical and psychological mistreatment (Cooper et al., 2010). Similarly, parents who commit child maltreatment find parenting more stressful than other parents (Teresi et al., 2016), suggesting that subjective assessments of caregiving are central to understanding the role of stress in risk of mistreatment. Specifically, parents who commit maltreatment are more reactive to stressful events than those who do not commit mistreatment (Reijman et al., 2016), and may have lower capacity for emotional regulation. Although the EM field is still learning about mechanisms underlying the relationship between stress and mistreatment, recent findings in caregiving show similar results as research in child maltreatment. High subjective burden among caregivers is predictive of potentially harmful behaviors (Arai, Noguchi, & Zarit, 2017). Coping styles are another avenue that should be explored to explain the relationship between stress and mistreatment, as coping can alter the outcome of stress experiences (Knight & Sayegh, 2010). Reactive abuse Rather than care needs per se, certain behaviors are associated with risk. In child maltreatment (Thornberry et al., 2014), IPV (Kuijpers, van der Knaap, & Winkel, 2012), and EM (Cooper et al., 2010), aggressive behaviors from the victim are associated with abuse, potentially eliciting negative reactions from perpetrators. Similarly, older adults who exhibit aggressive behaviors related to behavioral symptoms of dementia are more likely to experience mistreatment than those without dementia (VandeWeerd et al., 2013; Wiglesworth et al., 2010). Knowledge and Experience Low levels of knowledge and experience among caregivers are associated with increased risk of mistreatment. For example, parents with poor understanding of their children’s behaviors are at risk of participating in harmful behavior towards children (Toth et al., 2013). Children displaying certain challenging behaviors (e.g., withdrawal) are also at greater risk of maltreatment (Brown et al., 1998), possibly due to the higher degree of child-rearing skills required of parents. Poor understanding of recipient behaviors may similarly explain high rates of mistreatment among caregivers to people with dementia (e.g., Wiglesworth et al., 2010). Although high-demand caregiving can contribute to EM through stress, inexperience on how to provide care is another factor (Johannesen & LoGiudice, 2013). Indeed, some cases of criminal neglect are nearly indistinguishable from those where caregiver is overwhelmed (DeLiema, Homeier, Anglin, Li, & Wilber, 2016). Factors Unique to EM Although applying risk factors and theories from different forms of family violence, it is important to recognize dynamics that make EM unique. Aging is associated with illnesses and disabilities that may change an adult’s status from independent to dependent, requiring different behaviors from others. For example, family norms of gift-giving may become exploitative if the older adult loses financial decision-making capacity (Wilber & Reynolds, 1996). Further, although the dependency and need for care among some older adults may mirror that seen in children, an important distinction in older adults is the assumption of autonomy. Unless it is legally determined that the older adult lacks capacity, they retain their decision making autonomy, which includes the autonomy to make seemingly poor decisions or to place themselves in harmful or detrimental situations. Community-Based Intervention Models in Family Violence Like theories and risk factors, community-based prevention models for other types of family violence offer useful lessons for addressing EM. We largely focus on home visiting models seen primarily in the child maltreatment field. There are several reasons for doing so. As with parents raising children, family caregiving for older adults takes place primarily within the home. A home setting is valuable for an intervention because it gives providers insight into contextual risks (e.g., substance abuse, signs of neglect) that may not be apparent in other settings (Mosqueda et al., 2016). Further, these approaches enable tailored interventions appropriate for the diverse needs of families, as opposed to more group-based interventions (e.g., group counseling). Home visiting models are particularly attractive in an EM prevention context, as a strong tradition of home-based intervention already exists for family caregivers (NASEM, 2016). In reviewing approaches to community-based intervention, this section aims to identify components that contribute most to success. Table 1 summarizes the intervention models described. Table 1. Prevention Interventions From Child Maltreatment and IPV Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 View Large Table 1. Prevention Interventions From Child Maltreatment and IPV Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 Intervention name Intervention program Relevant references Healthy Start Within 1 week after birth, a trained paraprofessional visits the home of an at-risk family to provide direct services (e.g., education on child development, positive appraisal), as well as links to relevant supports and services in the community. Visits occur until the child is aged 3 to 5 years old. Frequency of visits varies by risk for family violence. Bair-Merritt et al., 2010; Bugental et al., 2010 Promoting First Relationships A weekly 10-session intervention to improve parent-child relationships by helping caregivers understand the child’s needs and behaviors. Video feedback of parent-child interactions is used to help parents better interpret child behaviors. Activities are guided by trained interventionists and include feedback on strengths and weaknesses. Toth et al., 2013; Spieker et al., 2012 Parent-Child Interaction Therapy Originally aimed at parent(s) with children aged two to seven with behavioral problems, this intervention is provided over the course of 12 to 14 weekly sessions and aims at improving relationship quality and disrupting coercive tendencies between parents and children. During the first seven sessions parents follow the child’s lead during play in order to strengthen the relationship. In the final seven sessions, the parents are taught skills to direct the child’s behavior, thereby better managing it. Toth et al., 2013 Family Check-Up Comprised of three sessions, the Family Check-Up begins with an interview with the parent(s) to learn about the family situation and engage in motivational interviewing techniques. This is followed by an assessment, which includes a questionnaire and observation of the parent and child interacting. At the third session, feedback is provided on the family’s strengths and weaknesses, as well as a discussion of accessing additional supportive services. Dishion et al., 2015; Smith et al., 2014 Men’s Domestic Abuse Check-Up Men respond to program recruitment invitations and are asked to complete a survey about their interpersonal relationships and engagement in aggressive or violent behaviors towards their partners. They are provided with a personalized survey summary which presents their responses alongside answers from the general population, which often serves to highlight participants’ deviation from societal norms. Participants then engage in individual telephone counseling with study personnel trained in motivational interviewing techniques to promote change. Mbilinyi et al., 2011 Prevention Relationship Enhancement Program Couples are taught skills (e.g., active listening) to better manage negative affect and improve communication. Skills are taught during five sessions, scheduled 1 week apart, with three to five other couples, lasting for 3 hr each. Sessions are devoted to one or two topics and led by trained psychology undergraduate and graduate students. Outside of sessions, couples are assigned reading and asked to complete exercises. Markman et al., 1993 View Large Home Visiting Programs to Prevent Child Maltreatment Home visiting programs in child maltreatment date back to the 1970s (Toth et al., 2013). Some programs provide generalized supportive services, such as the Healthy Start program, which connects new parents to community resources (Bair-Merritt et al., 2010). Other interventions target specific mechanisms thought to underlie child maltreatment. This strategy is used in the Promoting First Relationships intervention, which aims to improve parents’ sensitivity to child needs and promote attachment (Spieker, Oxford, Kelly, Nelson, & Fleming, 2012). Still other programs are multicomponent, offering a range of services and support to families (MacLeod & Nelson, 2000). Despite variation, some designs and strategies are consistently more successful than others. For example, home visiting interventions that include a training component outperform those without training. Aiming to break cycles of violence and improve relationship quality using tenets of social learning and attachment theories, parents participating in Parent-Child Interaction Therapy are taught parenting skills over 12 to 14 training sessions (e.g., alternatives to physical discipline) (Toth et al., 2013). Other training approaches focus on improving parents’ perceptions of children. In an adapted version of the Healthy Start program, at-risk families were trained to alter negative appraisals of children. At follow-up, the control group had a 24% rate of physical abuse at follow up, whereas those receiving the enhanced version of the Healthy Start intervention showed a rate of 4% (Bugental et al., 2010). Although not specifically designed to prevent child maltreatment, the Family Check-Up model offers several promising approaches. A home visiting program addressing maladaptive behavior patterns in children, it is tailored to the unique needs of families over the course of three visits (Dishion et al., 2015). Parents are interviewed about their situation during the first visit, assessed and observed interacting with the child during the second visit, and receive feedback during a final visit to discuss parenting strengths and weaknesses as well as available services and supports to meet the family’s needs (Smith, Knoble, Zerr, Dishion, & Stormshak, 2014). Although its impact on preventing child maltreatment remains largely unstudied, recent findings by Dishion and colleagues (2015) show lower levels of neglect among families participating in the Family Check-Up program 2 years after the intervention. The Family Check-Up model is based on the transtheoretical model of change, a dynamic and person-centered approach that encourages behavior change in stages based on readiness (Prochaska, Redding, & Evers, 2008). Moving forward through stages is believed to improve self-efficacy, which supports behavior change (Bandura, 1977). In the case of the Family Check-Up model, motivational interviewing techniques prepare parents to change reactions contributing to difficult behaviors such as defiance and poor self-regulation (Dishion et al., 2015). Feedback helps parents recognize areas of strength and areas where they can improve. Community-Based Programs to Prevent Intimate Partner Violence Although home visiting approaches are far more common in child maltreatment interventions, some IPV interventions offer valuable lessons especially given overlapping dynamics with EM that are not seen in child maltreatment (e.g., presumed victim autonomy, longer relationship history). Drawing on child maltreatment, the Family Check-Up model has also been effectively revised to prevent IPV in the form of the Men’s Domestic Abuse Check-Up, a secondary prevention approach. The program is like the Family Check-Up but provides the intervention via telephone to men who self-identify as engaging in violent behaviors toward their partners. As with the Family Check-Up, motivational interviewing and feedback are central (Mbilinyi et al., 2011). In addition, because perpetrators of IPV overestimate the normality of violent behaviors, the program provides participants with a brochure detailing the actual prevalence of interpersonal violence within the general male population. Revealing the discrepancy between participants’ perceptions of IPV occurrence and what is normal promotes self-awareness and draws upon social learning theory, encouraging men to accept a more accurate perspective of IPV. In addition to or as part of home visiting, interventions to improve communication skills between partners reduce revictimization (Whitaker, Murphy, Eckhardt, Hodges & Cowart, 2013). In a seminal study, Markman and colleagues tested the Prevention Relationship Enhancement Program, where couples learned techniques such as active listening and expressive communication during therapy sessions (Markman, Renick, Floyd, Stanley, & Clements, 1993). Researchers found that during 4- and 5-year follow-ups, participants in the intervention reported better communication and lower levels of violence in their relationships than controls. The success of these programs may be attributed to their accounting for varying stages of risk, an important factor to consider since potentially abusive behaviors often increase over time (Whitaker, Hall, & Coker, 2009). Building on Family Violence Interventions to Identify Key Components for a Home Visiting Model to Prevent EM Drawing on lessons learned from child maltreatment and IPV, we argue for the adoption of a home visiting model delivered as a primary prevention intervention for EM. Based on successful models in child maltreatment and IPV the structure of an intervention should target caregivers facing new or changing conditions, take place over several months, and be tailored to individual and family needs, preferences, and culture. Components should include regular assessments, training, and strengths-based feedback. How such an intervention might look is illustrated in Figure 1. Although not exhaustive, these approaches reflect the most promising practices from family violence. Readers seeking additional information about specific program structure and components should review MacLeod & Nelson (2000) and Whitaker and colleagues (2013). Figure 1. View largeDownload slide Model of intervention structure and key components. Figure 1. View largeDownload slide Model of intervention structure and key components. Although we propose a standardized structure and several key components for an intervention, the exact intervention tools will depend on specific risk factors in each family. Previously we suggested risks fall into three general theoretical categories—those related to relationship quality, stress, and knowledge. Responses to risk factors identified during assessment should link to selected tools by way of underlying theory. Whereas training for someone who is experiencing high levels of stress might focus on behavior management and assistance accessing respite, caregivers who are struggling with a difficult relationship history will likely receive greater benefits from counseling. However, because there will likely be overlap in these categories, some cases responses will look very similar (e.g., caregiver stress caused by lack of knowledge and preparation). Figure 2 illustrates an intervention based on a hypothetical case where stress-based risk factors are central; Supplementary Figures 1 and 2 illustrate what an intervention might include for the other theoretical mechanisms discussed. Figure 2. View largeDownload slide Example of Intervention Approach Addressing Stress Theories. Figure 2. View largeDownload slide Example of Intervention Approach Addressing Stress Theories. Target Caregivers at the Start of Caregiving and Those Facing Changing Conditions As Teresi and colleagues (2016) point out, interventions in child maltreatment are most effective when delivered before maltreatment occurs. Similarly, primary EM prevention programs implemented near the beginning of a caregiving journey or at critical junctures after a change in care level occurs may be most effective. For example, an intervention could target caregivers following a hospital transition. However, unlike new parents who readily identify with this role, caregivers who are just beginning this role may require additional guidance during recruitment given a tendency to not yet perceive themselves as caregivers (NASEM, 2016). Take Place over an Extended Period Further, in reviews of both child maltreatment and IPV interventions, the most successful home visiting programs were found to be relatively intensive and moderately long in duration. Based on studies from other forms of family violence, regular and frequent visits—perhaps 12 or more (MacLeod & Nelson, 2000)—over at least 6 months are most likely to improve the chances of success of a home visiting intervention. Even longer intervention periods may be appropriate, possibly lasting 2 years or more, depending on other design components (e.g., qualifications of the interventionist) (Daro & McCurdy, 2008). Tailored to Individual and Family Needs, Preferences, and Culture Interventionists should utilize the flexibility of a multicomponent approach to deliver services and supports that meet the unique needs of families wherever they are on the spectrum between a healthy and abusive relationship. For example, interventionists in the Healthy Start program individualize the intervention to families by guiding them to relevant services based on specifically identified needs, and decrease the number of visits as parent competency grows (Bair-Merritt et al., 2010). Multicomponent options may also be preferable compared to “one-size-fits-all” approaches (e.g., Alkema, Reyes & Wilber, 2006), as some families will be more amendable to and will engage with some interventions tools more than others. In addition, an EM intervention should meet the needs of culturally and ethnically diverse caregiving dyads and families. The Family Check-Up model’s success in racially and ethnically diverse samples has been attributed to its ability to address multiple types of stressors linked to culturally specific norms and attitudes (Smith et al., 2014). Guided by Regular Assessment To effectively meet specific and evolving needs and identify whether progress has been made toward reducing risk, family assessment at baseline and regularly thereafter is necessary. Assessment, as described here, is both a means of evaluating a program, and a component of the intervention itself. In the Family and Men’s Check Up models, assessment is the cornerstone of increased self-awareness underlying behavior change in these transtheoretical model-inspired programs (Prochaska et al., 2008). Although assessment should avoid being burdensome, it is important to include contextual factors such as family dynamics as well as characteristics of the caregiving situation that are likely to evolve (e.g., cognitive impairment of care recipient). An assessment should inform a care plan (i.e., intervention components and tools) that is specific to the needs of the family. Inclusion of a Training Component A home visiting model to prevent EM among caregiving dyads should also include a caregiver training component in most cases. The success of training is observed in the positive results of Parent-Child Interaction Therapy (Toth et al., 2013). Success is attributed not only to skill-building in areas of weakness but also increase in self-efficacy supporting behavior change. Like training options offered in caregiver and child maltreatment interventions, content for an EM intervention might include practical demonstrations on how to provide care, money management, and managing difficult care recipient behaviors. Training could also address relationship quality, especially in situations involving recipients with dementia or those who may have difficulty appropriately expressing their needs. In line with Promoting First Relationships (Spieker et al., 2012), relationship quality can be improved by assisting caregivers in understanding recipient needs. Dyad training on communication skills (e.g., active listening) could be useful in some cases (e.g., Markman et al., 1993). However, because there are likely limitations of such training in families with long-standing relationship conflicts; such training, if used, should include realistic goals as to what can be accomplished (e.g. de-escalation, reduction of potentially harmful interactions). This approach is supported by the transtheoretical model, where progress is tailored to the individual (Prochaska et al., 2008). Provision of Strengths-Based Feedback Strengths-based feedback builds self-efficacy, encourages participant retention, and motivates progress toward acquiring the skills necessary to provide quality care. Such feedback should be provided following assessment, reassessment, and while providing training modules. Components of social learning theory found in the transtheoretical model of change suggest that self-efficacy can encourage engagement in interventions (Prochaska et al., 2008), which has been illustrated in Family Check-Up programs (e.g., Dishion et al., 2015). Although self-efficacy has long been considered an outcome of caregiver interventions (NASEM, 2016), an EM intervention should also consider self-efficacy as a moderator. Conclusion Evidence-based primary prevention strategies from other fields of family violence offer a useful starting place for interventions to prevent EM. Of particular interest are home visiting models aimed at caregivers, which offer opportunities and approaches to target underlying risk factors shared among different forms of family violence. We describe starting points for such an intervention but acknowledge that any program will be shaped by the available resources and specific agency goals. Regardless, given what we know about prevention programs from child maltreatment and IPV, we believe there is adequate information to pilot a promising prevention intervention for EM. Funding This project was supported by Award No. 2016-ZD-CX-K008, awarded by the National Institute of Justice, Office of Justice Programs, U.S. Department of Justice. 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Journal

The Gerontologist – Oxford University Press

Published: Jul 16, 2019

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