Essentials for Childhood

Creating Safe, Stable, Nurturing

Relationships and Environments
for All Children

Center for Injury Prevention

National
andCenter
Controlfor Injury Prevention and Control
f Violence Prevention Division of Violence Prevention
Creating Safe, Stable, Nurturing
Relationships and Environments
for All Children

Reprinted with major technical edits

 INTRODUCTION
Safe, stable, nurturing relationships and
environments are essential to prevent
early adversity, including child abuse and
neglect, and to assure that all children
reach their full potential.

Promoting safe, stable, nurturing relationships and environments and preventing

child abuse and neglect benefits from comprehensive efforts and action by many
sectors. The framework is designed to allow for comprehensive child abuse and
neglect prevention activities with involvement from multiple sectors.

Child Abuse and Neglect Are Significant

Public Health Problems

Child abuse and neglect (CAN) are significant public health problems in the
United States (U.S.) and around the world.1,2 CAN refers to behavior that results
in harm, potential for harm, or threat of harm directed toward a child under
the age of 18 by a parent, caregiver, or another person in a custodial role (e.g.,
clergy, coach, teacher). There are four common types3:

4
 i
1
2
3
4

introduction
While it is not easy to determine the magnitude of CAN in the U.S., it is substantial.
According to the latest Child Maltreatment Report, made available in January 2019,
the estimated referrals to CPS for investigation response or alternative response
was 4,136,000 in fiscal year 2017. The official cases tell only part of the story, as
many, if not most, are never reported to social service agencies or law enforcement4.
Additional survey results provide an even more troublesome picture of this problem.
A non-CPS study estimated that one in four children in the U.S. experience some
form of child abuse or neglect during their childhood; 74.9% neglect, 18% physical
abuse, and 8.6% sexual abuse5.

Children may also experience other

This document describes adversities during childhood, such
a framework to guide as violence perpetrated by a peer,
communities’ (“community” witnessing violence in the home or
refers to any group with community, or living with someone
shared interests such as who is mentally ill or addicted to
neighborhoods, counties, drugs. Adversities experienced
states, and professional during childhood are often referred
to as Adverse Childhood Experiences
groups) activities that
(ACEs). Children who experience CAN,
will support the types
and other ACEs in childhood may
of relationships and experience physical injuries such as
environments that help cuts, bruises, burns, and broken bones,
children grow up to be in addition to other immediate and long-
healthy and productive term consequences. CAN and other
members of their ACEs may cause high levels of chronic
communities so that they, stress (i.e., toxic stress) that rewires
in turn, can build stronger the brain’s developing architecture
and safer families and (i.e., connections between cognitive,
communities for their emotional, and social development).
children. As a result, children who experience
CAN and other ACEs are more likely to

5
 engage in risky behaviors in adolescence and have health problems as adults. These
problems include alcohol abuse, depression, drug abuse (including opioids), eating
disorders, obesity, sexually transmitted diseases, smoking, suicide, violence towards
others, and many chronic diseases.6,7 Surveys of adults show about 62% report
experiencing at least one ACE with one in four experiencing three or more.8 Surveys
of caregivers show 22% of children have experienced two or more ACEs.9

Safe, Stable, Nurturing Relationships and

Environments Are Important for Preventing Child
Abuse and Neglect and other Adverse Experiences

Young children experience their world through their relationships with parents and
other caregivers. Safe, stable, nurturing relationships and environments for children and
their caregivers provide a buffer against the effects of potential stressors such as CAN
and other ACEs and are fundamental to developing healthy brain architecture. They
also shape the development of children’s physical, emotional, social, behavioral, and
intellectual capacities, which ultimately affect their health as adults. As a result, promoting
safe, stable, nurturing relationships and environments can have a positive impact on a
broad range of health problems and on the development of skills that help children reach
their full potential.

Safety, stability, and nurturing are three critical qualities of relationships and
environments that make a difference for children as they grow and develop. They
can be defined as follows:

Safety: The extent to which a child is free from fear and secure from physical
or psychological harm within their social and physical environment.
Stability: The degree of predictability and consistency in a child’s social,
emotional, and physical environment.
Nurturing: The extent to which children’s physical, emotional, and
developmental needs are sensitively and consistently met.

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

Reduce the occurrence of CAN and other ACEs
Reduce the negative effects of CAN and other ACEs
Improve physical, cognitive, and emotional outcomes throughout a child’s life
Reduce health inequities
Have a cumulative impact on health

For more information on the importance of safe, stable, nurturing relationships and
environments see: https://www.cdc.gov/violenceprevention/childabuseandneglect/
essentials.html

6
WHAT TO EXPECT
i
1
2
This document describes a framework to guide community activities that will 3
support safe, stable, nurturing relationships and environments for children and 4
their families. It is intended for anyone committed to the positive development
of children and families, and specifically to the prevention of all forms of CAN

introduction
and other ACEs. It is organized into four sections. Each section focuses on one
goal of the framework and lays out suggested actions to help you move toward
that goal. While each goal is important, the four goals together are more likely
to build a comprehensive foundation of safe, stable, nurturing relationships and
environments for children and families. The four sections include:

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

relationships and environments for all children
GOAL 2: Use data to inform actions
GOAL 3: Create the context for healthy children and families through norms
change and programs
GOAL 4: Create the context for healthy children and families through policies

This framework is designed to outline critical goals for promoting safe, stable,
nurturing relationships and environments and preventing CAN and other ACEs.
However, exactly how, when, and in what order you focus on each goal (and
associated steps for reaching the goal) will depend on what is already happening
in your community. Therefore, as your community takes on the goals outlined in
the framework, consider your unique needs. Working together, there is much your
community can do to create an environment in which children can—and do—live
life to their fullest potential.

The Importance of Using

Evidence-Based Approaches
The information included as part of this framework is based on the best available
evidence. The strategies and approaches for Goals 3 and 4, for example, are
summarized in the box on the next page and in CDC’s Technical Package (https://
www.cdc.gov/violenceprevention/pdf/can-prevention-technical-package.pdf). As
noted in the technical package, while there is a rich scientific literature on the use of
parenting programs to prevent or reduce CAN, data on policies that may prevent or
reduce CAN are more limited.

The evidence base for promoting safe, stable, nurturing relationships and
environments and preventing CAN is not static; it is constantly evolving. Therefore,

7
 we must act on the best evidence available to us today,
knowing it could change tomorrow. And, as we go, we
have a responsibility to evaluate our efforts whenever
possible to add to the evidence base. The Centers for
Disease Control and Prevention’s (CDC) Division of
Violence Prevention provides guidance and resources
to assist with evidence-based decision-making: https://
vetoviolence.cdc.gov/understanding-evidence.

CDC has also proposed strategies for preventing other

adverse childhood experiences such as witnessing or
experiencing violence outside the home or witnessing
intimate partner violence (see https://www.cdc.gov/
violenceprevention/pub/technical-packages.html).

Preventing Child Abuse and Neglect

Strategy Approach

Strengthen economic • Strengthening household financial security

• Family-friendly work policies
supports to families

Change social norms • Public engagement and education

campaigns
to support parents and • Legislative approaches to reduce corporal
positive parenting punishment

Provide quality care and • Preschool enrichment with family

engagement
education early in life
• Improved quality of child care through licens-
ing and accreditation

Enhance parenting • Early childhood home visitation

• Parenting skill and family relationship
skills to promote approaches
healthy child
development

Intervene to lessen • Enhanced primary care

• Behavioral parent training programs
harms and prevent • Treatment to lessen harms of abuse and
future risk neglect exposure
• Treatment to prevent problem behavior
and later involvement in violence

8
GOAL 1
i
1
2
3
4
Raise Awareness and Commitment to
Promote Safe, Stable, Nurturing

goal one
Relationships and Environments

Providing safe, stable, nurturing relationships and environments for all children
will require that you partner with others to change beliefs, attitudes, behaviors,
norms, programs, systems, and policies. Even if you know people or groups who
are motivated to create this kind of change, you will only see results when the idea
garners the support of the larger community and its leaders. This means your efforts
to prevent CAN and other ACEs and promote safe, stable, nurturing relationships
and environments where you live requires both community and social commitment.

When we talk about community and social commitment in this guide, we mean that
the broader community is committed to ensuring safe, stable, nurturing relationships
and environments for children. This commitment does not stop at awareness
but moves along a continuum from awareness of the problem to commitment to
the solutions. Observing an impact on safe, stable, nurturing relationships and
environments and prevention of CAN and other ACEs is more likely as community
members and leaders move along the continuum toward solutions.

Why Sustained Commitment Is Important

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

is often not the shortage of funds or the absence of “programs” but rather the
lack of commitment to do something about it.10 This means it is critical to build
commitment as a foundation for any meaningful public health initiative, including
safe, stable, nurturing relationships and environments for all children. You can
expect sustained commitment to take time, resources, and persistence.11 Sustained
commitment also requires the continuous use and sharing of new information for
ongoing public involvement, as well as the translation of technical information for
the general public, leaders, and decision-makers.

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

1) Partnering with others to build commitment

2) Developing a shared agenda
3) Consistent and strategic messaging

9
 Step #1
Partner with others to build commitment
Partnering with individuals or groups—in government, the general public, community
organizations, leaders, decision-makers, and media—can help move from
awareness to solutions. Your partners can bring in additional support and lend their
voice and leadership to this effort.

Partnerships can help unite those committed to children and community health
behind a shared vision so you can work together and collectively make impacts.
The challenge is complex. One organization cannot do this on its own—there
is power in numbers. Since there are so many possibilities, it may be helpful to
prioritize and focus your goals.

Partners participating in existing efforts of implementing the Essentials for

Childhood Framework include early learning, child care, social services, education,
housing, Medicaid, community-based organizations, and the business sector.
The media can be an important partner but is often overlooked. Building a
relationship with your news outlets will further support your efforts to create
community and social commitment. Capitalize on this by creating news events
they can cover, generating editorials, providing community data to help reporters
‘localize’ a story while using a “landscape” lens (i.e., widening the lens to include
the historical, cultural, social, economic, and/or political context), and providing
accurate information about the problem and prevention solutions in ways that
increase shared commitment (see Step #3).

10
 i
1
2
Step #2
3
Develop a shared agenda (vision, goals, and metrics) 4
A shared agenda involves having a shared understanding of the problem and
articulating a shared vision, goals, and metrics. When a group of diverse partners

goal one
agrees on a shared vision for a better future, they can operate under the same
assumptions, align their efforts, and work collectively toward common goals. Vision
statements reflect local principles. They can describe what the community will be or
will gain by aspiring to foster a safe, stable, and nurturing context for growing up, and
they can clarify the desired outcomes of the effort as a whole.

Creating a vision could be the beginning of this planning process and occur before
you come up with goals and action steps. You might consider adopting the vision of
“assuring safe, stable, nurturing relationships and environments for all children.”

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

good process includes those who care about the issue, deepens relationships,
and facilitates exploring and learning together with honest dialogue to achieve
a shared understanding of the problem, a shared vision of what you want to
achieve, and a few high level goals for what people consider strategic priorities.11
A process designed to promote buy-in and commitment engages diverse partners
in developing and committing to a solution. Though the process can take time
and resources, such an investment can be worthwhile. The steps and tenor of the
process can build trusting relationships and cultivate broad support for the agenda as
it takes shape, which can facilitate more widespread action later.

Step #3
Consistent and strategic messaging
Others will be more likely to join you in working toward safe, stable, nurturing
relationships and environments for all children if you are able to communicate why
they are important. Unfortunately, when raising awareness is mentioned, many
organizations default to very basic information such as stating that child abuse is
a problem and that it is bad for children. Most people already know and accept
these facts. However, many people don’t know how it can be prevented or what
they can do to solve the problem. In part, this may be due to the highly ingrained
values of individualism and personal responsibility12, but it also has to do with the
way child abuse and neglect issues are explained to the public. Stories about crime,
bad parents, and government failures reinforce the dominant narrative and beliefs
that the public currently brings to the issue, from misunderstandings about child
development and discipline to exaggerated beliefs of government inefficiency12. The
ways in which we, as a society, currently frame the issue may not allow people to
understand community and societal solutions or primary prevention.

11
 Experts and advocates can improve understanding by ensuring their messages
do not inadvertently reinforce narrow views about the causes of and solutions
to child abuse and neglect. For example, messages that focus on keeping
children safe often inadvertently suggest that parents are solely responsible for
protecting (or failing to protect) children. These messages also often position
the community as something to fear or protect children from. While parent
education (i.e., teaching positive parenting skills) is important in our efforts to
prevent abuse and neglect, we also need to work to create the conditions in
our communities that are supportive of children and parents so that positive
parenting is easier. Here are some key points suggested by a leading strategic
communications consultant for messaging to help increase understanding of
effective community and societal prevention strategies[*]:

Experts and advocates are encouraged to work with

a narrative template that answers the following
questions, in this order:
Why does this matter to all
of us?

What‘s the problem or

challenge?

How can it be solved? and

Who can play a role in helping

solve it?

When you start with an

explanation of Why, you give
your audience a wider lens
on the issue and a stake in its
resolution.

This template also requires

communicators to connect
the dots between the problem
(the What) and the solution
(the How).

It ends by having an “ask”

relevant to your audience that
explains how they can be part
of the solution (Who).

*See the evidence in CDC’s Technical Package

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

12
 i
1
2
Example of Effective Messaging 3
4
Why this matters: Assuring safe, stable, nurturing relationships and
environments for all children is essential for our state’s

goal one
future health and prosperity.

Problem: We now know that early experiences literally build the

architecture of the brain, and that safe, stable, nurturing
relationships and environments are key to building a
solid foundation for future growth. We also know that
not all children have access to the kinds of experiences
that will most benefit their development. Some children
experience adversity that is so severe and persistent that
it produces toxic levels of stress that harm the brain’s
developing architecture.

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

practices like livable wages, and paid family and sick
leave]/ [high quality child care]/ [high quality early
education]/ [home visitation programs] we can prevent or
alleviate the conditions known to produce toxic stress.

Ask: Visit our website to find out more or share this information
with your family and friends.

Goal 1 Summary
Individuals and communities must be committed to the vision of safe, stable,
nurturing relationships and environments for all children and willing to take action
in support of that vision. While commitment is critical, this alone will not change the
rates of CAN or other ACEs in your community. Observing an impact on CAN is more
likely if you combine commitment with comprehensive data, effective programmatic
strategies, and policy approaches.

For more information on potential partners, building a shared agenda, and raising
awareness see: https://www.cdc.gov/violenceprevention/pdf/efc-building-community-
commitment.pdf.

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

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

13
 GOAL 2
Use Data to Inform Solutions

To adequately address any public health issue, using the information you have
available is critical. This factual information—data—will help you understand
the size and nature of the problem in your community, how to best direct your
community’s prevention resources, how to determine whether your process is
working, and how to monitor the ultimate impact of any interventions (such as a
new program or policy).

To start, it may be helpful to do an environmental

scan to know who is doing what related to safe,
stable, nurturing relationships and environments
for children and whether the groups/organizations
are collecting any data. This will help in the
identification of potential partners who may be
doing this work or be interested in partnering with
you. It is also important to learn what you can about
any community, environmental, and social factors
that might be related to the problem. Pulling all of
this information together is not an easy task, but
it is crucial information that can be fed into the
other efforts (e.g., building community and social
commitment, understanding parenting norms,
evaluating policy changes).

Keep in mind you will face some challenges

in collecting, analyzing, and using this kind of
information. You are more likely to find existing
information that focuses on risk factors and negative
outcomes, like measures of CAN and other ACEs,
out-of-home placements in foster care, or children
living in poverty. Other existing data may be fragmented and collected for a
variety of purposes with varying definitions and criteria.

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

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

2) Take stock of existing data
3) Identify and fill critical data gaps
4) Use the data to support other action goals and steps

14
 i
1
2
Step #1 3
Use partnerships to help identify, gather 4
and synthesize relevant data

goal two
Data can be a powerful tool to highlight the realities of life for children and families
in your community and for demonstrating success as you work together to make
positive changes. However, any one organization or any one data source alone
provides a limited view of the problems as well as the opportunities in your
community. Multiple data sources allow for a more comprehensive understanding
of the issues and multiple avenues for raising awareness and implementing
change. Consider partnerships with others who collect and analyze data and are
in a position to make data-informed decisions about programs or other strategies
that improve the lives of children.

Public health agencies can serve as a coordinator for this effort, since they often
have staff with strong data skills and are typically familiar with the convener role. It
is critical to reach out to a variety of partners. This could include several agencies
or offices within state or local public health or social services departments,
such as Maternal and Child Health, Injury Prevention, Mental Health, Early
Childhood Education, and Children and Families/Social Services. You may also
find it useful to work with other groups in your community, including schools
and health care systems, child care and early learning agencies, housing,
education, transportation, employment agencies, law enforcement, criminal
justice, professional societies, non-governmental groups, and researchers at local
universities. All of these can be strong partners.

Step #2
Take stock of what data already
exist in your community
An important step in preventing CAN and in supporting safe, stable, nurturing
relationships and environments for children in your community is to find the
best available information that describes the problem and its causes. Consider
the following:

Vital statistics
• Birth and death records (look especially for births to teen mothers and
child homicide and unintentional injury deaths among children under 5
years of age)
• Child fatality review records

15
 Health data
• Hospital emergency department or discharge data
• Prenatal care coverage, month initiated, and services included (e.g., are
pregnant women being screened for depression, exposure to partner
violence, or substance abuse; if so, are they being referred to evidence-
based services, and what percentage of those referred actually receive
the service?)
• Ambulatory care visits for mental illness, including substance abuse
among women of reproductive age
• Length of wait list for treatment of substance abuse
• Coverage and dosage of well-baby visits and services offered for all chil-
dren (e.g., evaluation of social-emotional development and anticipatory
guidance based on Bright Futures guidelines) and for children at risk or
with developmental problems
• Coverage of family planning services

Criminal justice data

• Police reports of events or arrest records, especially for partner violence
• Programs offered to incarcerated parents (e.g., parenting or problem solv-
ing skills training)

Child care and welfare data

• Reports to child protective services, substantiated reports of abuse and
neglect, or out-of-home placements (number and geographic location)
• Services provided to parents and children (Are services evidence-based? Do
services reach all who need them?)
• Length of wait list for child care programs such as center-based
Early Head Start
• Length of wait list for child care subsidies
• Number and location of families receiving Temporary Assistance for Needy
Families (TANF); Supplemental Nutrition Assistance Program (SNAP); State
Children’s Health Insurance Program (SCHIP)/Medicaid

Educational data
• Length of wait list for pre-K programs such as Head Start
• Sex education programs being used in schools (Are they evidence-based?)
• School dropout rates

16
 i
1
In addition, you can review various state or national level surveys or data from 2
surveillance systems, some of which can provide data specific to your area. 3
These include:
4

goal two
Census data may also help you better understand your community’s household
and neighborhood demographics, which will provide a better sense of what life
is like for the children in your area. Census data include information such as the
number of households headed by single parents, the number of young or school-
age children, the number of rental units versus owned homes, unemployment
rates, and the number of households living below the poverty level.

Currently, several federal public health agencies and non-governmental

organizations offer data about children and the conditions in which they live.
These organizations provide a great deal of information on various indicators
(e.g., child well-being, child abuse and neglect). Once you have pulled together
information from a variety of sources, you will need to synthesize the findings on
the magnitude of CAN and other ACEs and the conditions which contribute to it
in your community, including why some children are at greater risk than others.
Here’s an example of the data California is tracking (https://www.kidsdata.org/
topic/95/childhood-adversity-and-resilience/summary#).

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

households, it is important to examine the root causes (e.g., the conditions
in which parents are trying to raise their children and how these conditions
were created and are sustained) of CAN and other ACEs. The World Health
Organization’s Commission on the Social Determinants of Health’s (CSDH)
framework13 has been useful in organizing data to reduce inequities in CAN

17
 (see page 19). In the first box on the right of the CSDH framework, you see the
socioeconomic and political context. This includes our societal values which
underlie our policy decisions related to education, labor, health care, taxes, the
safety net, and other. Policies may create differential opportunities (see second
box on the right) for getting a good education which determines what kind
of job you can get which determines your income. As a result, some people
may end up in a certain socioeconomic position. Your socioeconomic position
determines where you can live, what services you have access to, where your
children will grow, learn, and play; and can increase exposure to stressors that
can increase partner conflict and violence and mental illness (see the first left box
on intermediary determinants).13 Living conditions lead to the inequitable burden
of health issues and life opportunities (box with outcomes). This framework also
has a crosscutting box. This cross-cutting box represents organized communities
changing the narrative to build commitment to support families and reduce
inequities by class and race. The CSDH has summarized the theoretical and
empirical support for this framework.13

Your partners can help gather data on what is already being done to address the
problem. This information will help you make informed decisions about which
evidence-based strategies most closely address the needs in your community. You
will also have an understanding of what gaps exist, what efforts need to align, and
where work still needs to be done in order to measure, monitor, and assure safe,
stable, nurturing relationships and environments.

Step #3
Identify and fill critical data gaps
Where gaps in information are identified, your partnerships can help garner
support for new data collection efforts. This may include developing a new
survey or adding questions to existing surveys. CDC’s Uniform Definitions for
Child Maltreatment)—available at https://www.cdc.gov/violenceprevention/
childabuseandneglect/index.html —can help you create new or edit existing
data collection instruments and ensure they are as consistent and comparable
as possible. Data gaps also may become a programmatic or policy initiative. For
example, you may want to approach a decision-maker or program implementer to
get new data generated. Opt-in internet panels are a relatively inexpensive way
to generate reliable data.14 Other data such as Child Fatality Review records can
provide valuable insights for protecting children.

18
 i
Indicators For Reducing Inequities In Child Abuse
1
And Neglect And Other ACEs
2
3
4

goal two

Note. The crosscutting box (identified in light blue box above) represents efforts focused on changing the
narrative (see Goal 1 on Raising Awareness and Commitment) and building commitment for policies (see first
box on the left) that will reduce inequities by race, gender, and income (second box on the left). Reducing
inequities in socioeconomic position will lead to improved living conditions (or safe, stable, nurturing
environments) for families (third box) that will reduce the likelihood of children’s exposure to partner
violence and maternal depression (third box). These improved conditions are expected to increase safe,
stable, nurturing relationships and reduce child abuse and neglect, especially its inequitable distribution by
social class and race/ethnicity.
Data sources for each indicator included in the framework are available in: Essentials for Childhood:
Indicators of Impact (available upon request at https://cdcpartners.sharepoint.com/sites/NCIPC/DVP/PPTB)

19
 Kansas Essentials for Childhood (called The Power of the Positive; www.
kansaspowerofthepositive.org) received private funding to add the ACEs module
to the Kansas BRFSS in 2014 and again in 2015. These data were shared with
Kansas state legislators to inform them about ACEs across the state. In 2017
and 2018, Kansas directed Temporary Assistance to Needy Families funding to
evidence-based home visitation programs ($3 million) and pre-K programs ($4.2
million) and supported additional pre-K programs ($4.2 million) with tobacco
settlement dollars.

Step #4
Use the data to support other action goals and steps
Now that you have this information, you can use it to make the other action
steps a reality. For example, incorporating local data as you raise awareness in
support of the vision may make the issues more salient for the partners you are
trying to engage (see Goal 1, partnering with others). You may want to highlight
the economic returns on investing in children. Short documents with specific
data points for decision-makers are helpful. Take advantage of the variety of
information available. Compiling information from multiple sources helps articulate
a comprehensive picture of what life is like for children in your community. This
will help you determine where to invest in prevention—who is most at risk?
What conditions need to be improved so all children can thrive? What programs
and policies would best address the most prevalent risk factors and improve
conditions for families?

Goal 2 Summary
Understanding the prevalence and impact of CAN and other ACEs in your
community, the behaviors and conditions that increase their likelihood, and the
policies that create and recreate these conditions provides critical information
to inform and support the other goals. Data provides a foundation for engaging
partners, underscores your efforts to build commitment, informs decision-makers,
and helps you focus and monitor your prevention efforts for the greatest impact.

20
 GOAL 3
i
1
2
3
4
Create the Context for Healthy Children
and Families through Norms Change

goal three
and Programs

Parents and caregivers are a child’s first exposure to the world around them. The
quality of relationships between children and their parents and caregivers, and
the environment in which those relationships develop, play a significant role in
a child’s cognitive, emotional, physical, and social development. Research has
demonstrated the benefits of safe, stable, nurturing relationships and environments
and, conversely, the negative outcomes attributed to CAN and other ACEs.

Here are three steps you might consider to support parents and caregivers in
providing safe, stable, nurturing relationships and environments:

1) Promote the community norm that we all share responsibility for the
well-being of children
2) Promote positive community norms about parenting programs and
acceptable parenting behaviors
3) Implement evidence-based programs for parents and caregivers

21 21
 Step #1
Promote the community norm that we all share
responsibility for the well-being of children
No family exists in a vacuum; therefore, supporting families in providing safe,
stable, nurturing relationships and environments is a shared responsibility.
Everyone in your community—both parents and those without children—can
champion or contribute to efforts to change policies in support of families,
increase access to high quality child care and education, develop safe places
or neighborhood activities where children are watched and supervised, and
families can gather, interact, and get to know each other. Neighborhood
associations can link families to available resources and other neighborhood
adults to help with household tasks and to help in watching out for each other’s
children in the neighborhood.

This step also ties into raising awareness and enlisting partners when building
commitment (see Goal 1). This can be accomplished by explaining why this matters
and what we can do collectively to support children and families. For example,
people may have influence in a particular sector (e.g., business, social services,
education) where they can promote family-friendly policies or activities. See
supplement on building commitment: https://www.cdc.gov/violenceprevention/pdf/
efc-building-community-commitment.pdf.

Step #2
Promote positive community norms about parenting
programs and acceptable parenting behaviors
Caregivers (i.e., parents as well as family, friends, and neighbors who help with
childcare) may be reluctant to participate in parenting programs because they
think they should be able to care for the child on their own or because the need
to learn about parenting implies they are “bad” caregivers. Your community can
promote norms emphasizing that learning effective parenting skills is a process
and every caregiver can use help at times.

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

behaviors and skills. They may need extra support in using those new skills
at home if what they learn is different from those practiced by other family
or community members. You can identify local parents to serve as mentors
to promote positive parenting and help change community norms about
parenting behaviors in your community. Parents can be particularly powerful
role models and voices in these efforts, because other parents will see them
as credible and experienced.

22
 i
1
2
More information on changing norms is available here: https://www.cdc.gov/ 3
violenceprevention/pdf/efc-promoting-positive-community-norms.pdf.pdf and
here: https://www.cdc.gov/violenceprevention/pdf/CAN-Prevention-Technical- 4
Package.pdf.

goal three
Step #3
Implement evidence-based programs for
parents and caregivers
Programs that teach caregivers positive child-rearing and child management skills
are the most basic approach to facilitating safe, stable, nurturing relationships and
environments. Your community can support all caregivers by providing access
to evidence-based parent training. A lot is known about how to foster caregiver
skills that promote positive child development, prevent and treat child behavior
problems, and prevent CAN.

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

whenever possible, it is recommended that your community implement effective and
promising interventions (see pages 25-27 of https://www.cdc.gov/violenceprevention/
pdf/CAN-Prevention-Technical-Package.pdf for effective parenting approaches).
Choosing strategies that have been tested in rigorous research trials and are
evidence-based increases the chance that the programs parents participate in will
actually make a difference in their lives and the lives of their children. However, this
may be easier said than done. These sub-steps may be necessary:

23
 Evidence-Based and Promising
Programs and Strategies

Examples of programs and strategies that have been shown to prevent CAN
include but are not limited to:

Nurse-Family Partnership (NFP)

http://www.nursefamilypartnership.org
Registered nurses make ongoing home visits to first-time moms and their babies.
The program focuses on improving maternal and child health, maternal life course
(financial status, educational and employment choices, partner relationships,
and future pregnancy planning), and parenting of infants and toddlers. For other
evidence-based home visiting programs see:
http://homvee.acf.hhs.gov/HomVEE_Executive_Summary_2015.pdf

Early Head Start

https://eclkc.ohs.acf.hhs.gov/programs/article/early-head-start-programs
Early Head Start is a child development and parenting education program
delivered through center-based services, home visits, or both. The program helps
parents build skills to assist their child’s development, increase family literacy,
and promote healthy parent-child relationships. It also helps families transition
their children into Head Start or other preschool programs when the child reaches
three years of age and offers family advocacy, resources, and referrals to other
community services.

Adults and Children Together Against Violence: Parents Raising Safe Kids
(ACT Raising Safe Kids)
http://www.apa.org/act/
The ACT Raising Safe Kids program is a parent training program that discusses
knowledge and beliefs around child development and the importance of healthy
parent-child relationships for children. Parents also learn positive parenting skills
that create safe, stable, healthy and nurturing environments and relationships that
prevent children’s exposure to abuse and adversities.

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

https://www.seekwellbeing.org/
Using a self-administered questionnaire, parents of young children are screened
for parental depression, substance abuse, financial and parenting stress, use of
harsh punishment, and partner violence, all of which are factors that increase
risk for CAN. Primary care providers are trained to discuss positive screens with
the parents, along with potential strategies for addressing them. A social worker

24
 i
1
2
3
follows-up with additional strategies to address the problems and/or provide
referrals to community resources. Parents also receive handouts that include 4
information on problems addressed with the social worker, as well as local

goal three
resources for any issues that might arise.

Multi-component Programs (Child-Parent Centers)

http://cps.edu/Schools/EarlyChildhood/Pages/Childparentcenter.aspx
Center-based multi-component programs provide comprehensive educational and
family support to low-income children and their parents. The approach is child-
centered and individualized, with an emphasis on enhancing the child’s social and
cognitive development in a stable, enriched learning environment. Parent-focused
activities include enhancing parents’ personal development; promoting positive
parent-child interactions; providing information on nutrition, health, and safety; and
providing referrals to appropriate services.

Parent-Child Interaction Therapy (PCIT)

http://www.pcit.org
PCIT improves the quality of parent-child relationships and changes how
parents and children interact with one another. Parents learn specific skills to
build a nurturing and secure relationship with their children while increasing
their children’s desirable behavior and decreasing negative behavior. Coaches
work directly with parent-child pairs to help them learn new skills. In addition
to impacting physical abuse and neglect outcomes, this program has shown
improvements in parenting behavior and child behavior problems.

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

demonstrate improvements in parenting behavior and child behavior problems
and other violence outcomes. For example:

Incredible Years
http://www.incredibleyears.com
This training series for parents, teachers, and children promotes emotional
and social competence with the goal to prevent, reduce, and treat aggression
and emotional problems in children zero to 12 years-old. The parent training
component emphasizes parenting skills and approaches known to promote
children’s social competence, reduce behavior problems, and improve children’s
academic skills.

For additional information on characteristics of effective parenting programs, see

page 26. For additional information on determining the types of programs that will
work best for the caregivers in your community, see page 27.

25
 Goal 3 Summary

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

community context that supports effective parenting is critical to ensuring children
experience safe, stable, nurturing relationships and environments. In general,
parents benefit from feeling consistent support from their work, family, friends, and
the broader community.

Characteristics of Effective
Programs to Provide Safe, Stable,
Nurturing Relationships and
Environments for Children
A number of programs have been shown, through rigorous studies, to be effective in
decreasing CAN. Some programs have shown promise of achieving desired results for CAN
but need more rigorous evaluation. Other programs, although not evaluated for reducing
CAN, have been shown to improve positive parenting behavior, reduce challenging child
behaviors, and improve relationships between children and their caregivers.

Effective parenting programs typically:

Videos and tip sheets for effective positive parenting strategies are available in English
and Spanish at: https://www.cdc.gov/parents/essentials/index.html

26
 i
1
2
Considerations for Implementing 3
Programs to Promote Safe, 4
Stable, Nurturing Relationships and

goal three
Environments for Children
When determining the types of programs that will work best for the caregivers in
your community, keep the following in mind:

27
 GOAL 4
Create the Context for Healthy Children
and Families through Policies

The promotion of safe, stable, nurturing relationships and environments and the
prevention of CAN and other ACEs is not a simple process. It includes building
commitment, using data to inform actions, and supporting parents and caregivers in
the community. The policies in place in communities also may help ensure children
in the community lead healthy and safe lives.

Like other activities for

supporting safe, stable,
nurturing relationships
and environments for
children, collaboration and
partnerships are necessary
to help decision-makers
have the information they
need to make informed
decisions on the conditions
that support all children
and families. Implementing
policies that support
safe, stable, nurturing
relationships and environments for children and caregivers requires effort from
organizations in both the public and private sectors, governmental and non-
governmental organizations—e.g., from state and local health departments, the
media, businesses, schools, and faith-based and community-based organizations.
Historically, policies that improve the socioeconomic conditions of families or that
structure the environment so that healthy choices are the easy choices have had the
largest impacts on health.16 But, it is also important to consider the potential impacts
on children and families when creating or changing any policy.

The two steps to inform policies that might support safe, stable, nurturing
relationships and environments are:

1) Identify and assess which policies may positively impact the lives of children and
families in your community
2) Provide decision-makers and community leaders with information on the
benefits of evidence-based strategies and rigorous evaluation

28
 i
1
2
3
4

goal four
Step #1
Identify and assess which policies may
positively impact the lives of children
and families in your community
There are many policies that already provide some support to children
and families. Communities might consider the policies outlined in CDC’s
technical package, which are based on the best available evidence
and have demonstrated effects in reducing CAN (https://www.cdc.gov/
violenceprevention/pdf/can-prevention-technical-package.pdf). Some cities
and counties have passed ordinances to enact these policies. There are
other examples of opportunities to positively impact the lives of children
and families. Although the examples that follow have not been rigorously
evaluated to establish their potential impact on CAN or safe, stable, nurturing
relationships and environments, there is evidence that these policies
strengthen families. Depending on a variety of factors, some types of policies
may be out of your sphere of influence. However, understanding the breadth of
policies that can strengthen families may be helpful to identifying opportunities
to collaborate with other sectors and engage in related activities or initiatives
within your community.

29
 Examples of organizational
or internal policies

Types and
Levels of Policies
Organizational or internal
policies: Rules and practices
that an organization or agency
sets for how it does business,
conducts its activities, or
interacts with staff and
constituents.

Regulatory policies: Rules,

principles, or methods established
by government agencies that have
regulatory authority for products
or services.

Legislative policies: Laws or

ordinances passed by local, state,
or federal governing bodies.

30
 i
1
abuse. In addition, community-based organizations and schools have incorporated 2
child sexual abuse prevention programs into their activities. Some have suggested
3
that the declines in child sexual abuse may be, in part, attributable to sexual
abuse prevention programs, norms changes, and social control efforts; therefore, 4
expansion of these current prevention efforts may be beneficial.24-25

goal four
Example of regulatory policies

Examples of legislative policies

31
 especially teen pregnancies, are high in your community, school boards
might check the evidence base for the sex education programs being used
in schools. Cities, counties, or states might consider policies for increasing
access to family planning services.

Step #2
Provide decision-makers with
information on the benefits of evidence-
based strategies and rigorous evaluation
A commitment to a rigorous science base demands that development and
implementation of programs and policies to promote safe, stable, nurturing
relationships and environments are based on reliable data and sound evidence
of effectiveness. Decision-makers might be more supportive of evidence-based

32
 i
1
programs and policies once they are well-informed of the benefits of having 2
scientific evidence. This might lead decision-makers to: 3
4

goal four
For example, Massachusetts Essentials for Childhood created an infographic
summarizing the evidence around paid family leave’s effects on children, parents,
and businesses.

Goal 4 Summary
Informing policies to improve the provision of safe, stable, nurturing relationships
and environments requires the efforts of many, including state and local health
departments, the media, and community organizations. In addition, it may be helpful
to ensure that there is awareness of the societal factors that help children thrive and
policies that are supportive of healthy child development; and that resources exist to
support the policies’ long-term implementation and evaluation. There are resources
available that can help you better understand using policies to support children and
families such as the Essentials for Childhood Policy Guide: http://www.astho.org/
Prevention/Essentials-for-Childhood-Policy-Guide.

Conclusion
While CAN is a significant public health problem, it is also a preventable one.
Essentials for Childhood: Creating Safe, Stable, Nurturing Relationships and
Environments is designed to assist you in your prevention efforts, by building
commitment, using data to inform action, and creating the context for healthy
children and families through norms change, programs, and policies. The goals and
action steps suggested as part of this framework, along with your commitment to
preventing CAN, can help create neighborhoods, communities, and a nation where
every child can thrive.

Acknowledgments
We would like to acknowledge the CDC colleagues who guided the development of the
first edition of this document: Sandra Alexander, Erica Mizelle, Janet Saul, Lynn Jenkins,
Sharyn Parks, Linda Anne Valle, and Joanne Klevens.

The Knowledge to Action Prevention Consortium and external reviewers Michelle

Hughes, Mark Chaffin, and Leah Devlin provided valuable input to shape the first edition
of this document.

We would also like to acknowledge the CDC colleagues who updated this document:
Joanne Klevens, Sandra Alexander, and Beverly Fortson, and Lynn Davey of Davey
Strategies who provided guidance and content on strategic messaging.

33
References
1 World Health Organization and International 11 Born P. (2017). How to develop a common
Society for Prevention of Child Abuse and Neglect. agenda for a collective impact. Tamarack,
(2006). Preventing child maltreatment: a guide to Canada: Tamarack Institute. Available
taking action and generating evidence. Geneva at: https://www.tamarackcommunity.
(Switzerland): World Health Organization. ca/hubfs/Resources/Publications/
CommonAgendaforCollectiveImpact.pdf
2 Centers for Disease Prevention and Control. (2018).
Child abuse prevention. Available at: https://www. 12 Frameworks Institute. (2004). Making the public
cdc.gov/features/healthychildren/index.html case for child abuse and neglect. Washington, DC:
Frameworks Institute. Available at:
3 Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. http://www.frameworksinstitute.org/toolkits/canp/
(2008). Child maltreatment surveillance: uniform resources/pdf/MakingthePublicCasefor
definitions for public health and recommended ChildAbuseandNeglectPrevention_2004.pdf
data elements, version 1.0. Atlanta (GA): Centers
for Disease Control and Prevention, National 13 World Health Organization Commission on Social
Center for Injury Prevention and Control. Determinants of Health. (2010). A conceptual
framework for action on the social determinants
4 MacMillan HL, Jamieson E, Walsh CA. (2003). of health. Geneva: World Health Organization.
Reported contact with child protection services Available at: http://www.who.int/social_determinants/
among those reporting child physical and sexual corner/SDHDP2.pdf
abuse: results from a community survey. Child
Abuse and Neglect; 27: 1397–408. Available at: 14 Ansolabehere S, Rivers D. (2013). Cooperative
https://www.acf.hhs.gov/sites/default/files/cb/ survey research. Annual Review of Political Science;
cm2017.pdf 16:307-329.

5 Finkelhor D, Turner HA, Shattuck A, & Hamby 15 Kaminski JW, Valle LA, Filene JH, Boyle CL. (2008). A
SL. (2015). Prevalence of childhood exposure meta-analytic review of components associated with
to violence, crime, and abuse: Results from parent training program effectiveness. Journal of
the National Survey of Children’s Exposure to Abnormal Child Psychology; 36:567–89.
Violence. JAMA Pediatrics; 169(8): 746-754.
16 Frieden TR. (2010). A framework for public action: the
6 Felitti V, Anda R, Nordenberg D, Williamson D, health impact pyramid. American Journal of Public
Spitz A, Edwards V, et al. (1998). Relationship of Health; (100)4:590.
childhood abuse and household dysfunction to
many of the leading causes of death in adults. 17 Stith SM, Liu T, Davies LC, Boykin EL, Alder MC,
American Journal of Preventive Medicine; Harris JM, et al. (2009). Risk factors in child
14(4):245–58. maltreatment: a meta-analytic review of the literature.
Aggression and Violent Behavior; 14:13-29.
7 Hughes K, Bellis MA, Hardcastle KA, Sethi D,
Butchart A, Mikton C, et al. (2017). The effect of 18 Dubay L, Holahan J, Cook A. (2007). The uninsured
multiple adverse childhood experiences on health: and the affordability of health insurance coverage.
a systematic review and meta-analysis. Lancet Health Affairs; 26(1):w22–w30.
Public Health; 2: e356-366.
19 Caputo RK. (2006). The earned income tax credit:
8 Merrick MT, Ford DC, Ports KA, Guinn AS. (2018). a study of eligible participants vs. non- participants.
Prevalence of Adverse Childhood Experiences Journal of Sociology and Social Welfare; 33(1):9–29.
from the 2011-2014 Behavioral Risk Factor
Surveillance System in 23 States. JAMA Pediatrics; 20 Zedlewski SR, Adams G, Dubay L, Kenney GM.
172(11):1038-1044. (2006). Is there a system supporting low-income
families? Washington (DC): Urban Institute. Available
9 Child and Adolescent Health Measurement at: http://www.urban.org/url.cfm?ID=311282.
Initiative. Data Resource Center for Child and
Adolescent Health. 2016 National Survey of 21 Dorn S. (2008). How policy makers could use
Children’s Health (NSCH) data query. Retrieved automation to help families and children. Big Ideas
10/18/18 from www.childhealthdata.org for Children: Investing in our Nation’s Future.
Washington (DC): First Focus. Available at: https://
10 Catford J. (2006). Creating political will: moving from firstfocus.org/resources/report/big-ideas-investing-
the science to the art of health promotion. Health nations-future.
Promotion International; 21(1):1-4.
22 Huston AC, Miller C, Richburg-Hayes L, Duncan 32 Newman KS, Chen VT. (2007). The missing class:
GJ, Eldred CA, Weisner TS, et al. (2003). New portraits of the near poor in America. Boston (MA):
hope for families and children: five year results Beacon Press.
of a program to reduce poverty and reform
welfare. New York: Manpower Demonstration 33 Rassian KN, Bullinger LR. (2017) Money
Research Corporation. matters: Does the minimum wage affect child
maltreatment rates? Children and Youth Services
23 Dubowitz, H., Feigelman, S., Lane, W., & Kim, J. Review; 72:60-70.
(2009). Pediatric primary care to help prevent child
maltreatment: The Safe Environment for Every Kid 34 National Institute for Early Education Research.
(SEEK) model. Pediatrics; 123(3), 858-864. (2016). State(s) of Head Start. Available at: http://
nieer.org/headstart
24 Saul J, Audage NC. (2007). Preventing child sexual
abuse within youth-serving organizations: getting 35 Dawcett CJ, Huston AC, Imes AE, Gennetian L.
started on policies and procedures. Atlanta (GA): (2008). Structural and process features in three
Centers for Disease Control and Prevention, types of child care for children from high and
National Center for Injury Prevention and Control. low income families. Early Childhood Research
Quarterly; 23: 69–93.
25 Finkelhor D, Jones L. (2006). Why have child
maltreatment and child victimization declined? 36 Guterman K. (2015). Unintended pregnancy as a
Journal of Social Issues; 62(4):685–716. predictor of child maltreatment. Child Abuse &
Neglect; 48: 160-169.
26 Parkins D. (2015). It’s expensive to be poor. The
Economist, Sept 3. Available at: https://www. 37 Mental Health America. (2018). 2017 state
economist.com/united-states/2015/09/03/its- of mental health in America: Access to care.
expensive-to-be-poor Available at: http://www.mentalhealthamerica.net/
issues/2017-state-mental-health-america-access-
27 Fellowes M. (2008). Reducing the high costs of care-data
being poor. Testimony before the Subcommittee
on Housing and Community Opportunity of the 38 Freudenberg N, Ruglis J. (2007). Reframing school
House Committee on Financial Services, 110 dropout as a public health issue. Preventing
Congress, 2nd session. (March 8, 2008). Chronic Disease; 4(4).

28 McKernan SM, Ratcliff C, Kuehn D. (2011). 39 Boccanfuso C, Kuhfeld M. (2011). Multiple

Prohibitions, price caps, and disclosures: a responses, promising results: evidence-based,
look at state policies and alternative financial non-punitive alternatives to zero tolerance.
product use. Washington (DC): Urban Institute. Washington (DC): Child Trends. Available at:
Available at: https://www.urban.org/research/ https://www.childtrends.org/publications/multiple-
publication/prohibitions-price-caps-and- responses-promising-results-evidence-based-
disclosures-look-state-policies-and-alternative- nonpunitive-alternatives-to-zero-tolerance
financial-product-use.
40 Durant, J., & Elsom, R. (2012). Physical punishment
29 Bhatia R, Katz M. Estimation of health benefits of children: lessons from 20 years of research.
from a local living wage ordinance. American Canadian Medical Association Journal; 184 (12):
Journal of Public Health 2001; 91(9):1398–1402. 1373-1377.

30 Sedlak AJ, Mettenburg J, Basena M, Petta I, 41 Gershoff, E. T., & Grogan-Kaylor, A. (2016).
McPherson K, Greene A, Li S. (2010). Fourth Spanking and child outcomes: Old controversies
national incidence study of child abuse and new meta-analyses. Journal of Family
and neglect (NIS-4): Report to Congress. Psychology; 30(4), 453-469.
Washington, DC: U.S. Department of Health and
Human Services, Administration for Children 42 Zolotor AJ, Puzia ME. (2010). Bans against corporal
and Families. punishment: a systematic review of the laws,
changes in attitudes and behaviors. Child Abuse
31 Kayla Fontenot, Jessica Semega, and Melissa Review; 19:229–47.
Kollar (2018). Income and Poverty in the United
States: 2017. U.S. Census Bureau. Available at:
https://www.census.gov/library/publications/2018/
demo/p60-263.html