"I view it as a public health problem," said Angelo Giardino, a child abuse expert and pediatrician at Children's Hospital of Philadelphia. "It's very amenable to prevention. We've learned how it is that a kid comes to be injured."
Experts have constructed risk models that show a number of factors either raise or lower the danger of abuse.
"Doctors think of it as an ecological model," Giardino said. "The kids, caregivers, family, neighborhood - everything acts on each other."
"One of the risk factors for child abuse is family isolation," said Giardino, referring to parents who can't turn to anyone for help. "It breeds hopelessness and an inability to deal with stress."
Child abuse affects all ethnicities and all income groups, but the poor are disproportionately represented. Children from families with incomes under $15,000 are 25 times more likely to be abused and neglected than those from families with incomes over $30,000, a study by the federal Department of Health and Human Services found.
The statistics may be misleading to some extent, Giardino said, because abuse in wealthier families is less likely to be found out.
Much of the pioneering work on preventing child abuse comes from David Olds, a University of Colorado pediatrician. He has shown that sending skilled nurses into poor communities to meet with single pregnant women before their first child is born can dramatically lower the risk that the child will ever be abused.
The program has been replicated in 125 communities across the country.
The oldest children in Olds' study are turning 15. Comparing them with similar families who did not get nurse visits, Olds found:
* A 79 percent reduction in child abuse and neglect.
* A 44 percent reduction in maternal behavioral problems caused by their use of alcohol and drugs.
* 69 percent fewer arrests among the mothers.
* 54 percent fewer arrests and 69 percent fewer convictions among the 15-year-olds.
* 58 percent fewer sexual partners among the 15-year-olds.
* 28 percent fewer cigarettes smoked and 51 percent fewer days consuming alcohol among the 15-year-olds.
* Four dollars saved for every dollar invested.
Olds isn't certain why the practice of sending in nurses - they continued to visit for about 2 1/2 years - has such a dramatic effect. But he has some ideas.
"One is improved neurological functioning of the baby because of the prenatal component of the program," he said. Healthy babies are less stressful to parents.
"Second, it helps parents make decisions and gives them the skills and resources to become competent parents. Third, it helps parents take charge of their lives in terms of becoming self-sufficient."
"If there are fewer children to care for, it gives the parents breathing room to nurture the first child more effectively," he said, explaining that mothers in the program have fewer babies and space them apart. "It engages other family members, reducing stress in the household. All of those elements are known risk factors for the emergence of child abuse and neglect."
Three programs that would send nurses into poor communities, based on Olds' model, are planned in Berks, Luzerne and Erie Counties in Pennsylvania, said David Racine, president of Philadelphia-based Replication and Program Strategies, a nonprofit that has been charged with developing the technique nationwide.
"We have a high degree of confidence that when it is carried out in the way it has been designed, the program stands a good chance of producing outcomes - preventing child abuse, limiting welfare dependence, delaying second pregnancy," Racine said.
There are other programs that help parents cope, including group sessions where parents can meet other parents, and where counselors can lend an ear.
"We believe both the parents and the children are victims in child abuse," said Vivian Drayton, executive director of Stop Child Abuse Now, a nonprofit program in Philadelphia. "Ninety percent of those who harm their children have been harmed themselves."
Drayton's group sends professionals into homes to counsel new parents and also vaccinates children against diseases.
"We work with those families intensely so they will not become another statistic, so they won't harm or be harmed," she said.
Most child welfare agencies are a long way from making the David Olds' prototype of prevention their primary mission. They are too busy dealing with crises.
Philadelphia's Department of Human Services (DHS) is no exception.
It has a Parent Action Network - parent support groups with a mission of abuse prevention. About 250 parents are enrolled.
* Most of the debate on child welfare revolves around agencies such as DHS, which works with 10,000 families a year. Critics say they do a poor job of ensuring the safety of children. "It only responds to the worst cases," said Frank Cervone, a lawyer at Philadelphia's Support Center for Child Advocates, referring to DHS. "It's a system that lives on triage. Triage is no way to live from day to day."
A decade ago, the state Department of Public Welfare revoked DHS's license. In 1990, the American Civil Liberties Union and another nonprofit advocacy group, Children's Rights Inc., filed a lawsuit against DHS for failing to protect children. That case was settled this year.
Ira Schwartz, dean of the University of Pennsylvania's School of Social Work, reviewed some DHS case files as part of the lawsuit. Based on his analysis, he concluded that the caseload for many of the city's social workers exceeded state guidelines of one caseworker for every 30 client-families. Some families that were supposed to be getting services had no caseworkers at all.
He also determined that 46 percent of the children in DHS custody had been there for five years or more, an indication of how long it takes the system to place children in stable homes and how much children are bounced around.
That gives "the impression to prospective adoptive parents that there is something severely wrong with the child, which, of course, makes them less likely to be adopted," Schwartz wrote.
DHS disputes Schwartz's conclusions, saying his analysis was based on the worst cases and old information. For example, DHS Commissioner Joan Reeves said, the average caseload was one worker for every 20.5 families, well within state guidelines.
Social workers have exceedingly difficult jobs, she said. They "go into neighborhoods where police officers go with backup."
"To be consistently criticized without taking into account the conditions these folks have to work in is really unfair," Reeves said.
Philadelphia has about 19 child abuse deaths a year, she said. While the agency was working to reduce that number, she said, "I hate to say it, but there are some things we cannot prevent. There are some situations where we visit a home one day and everything is fine, and the next day, a child is dead."
Schwartz's colleague at Penn, Richard Gelles, has argued in Congress that agencies such as DHS - operated according to laws that vary from state to state - need to be radically overhauled.
Gelles wants them to be modeled after police departments. Children from troubled homes should be rapidly removed. If their birth parents don't quickly get their act together, Gelles wants the children to be put up for adoption.
If the birth parents have severe drug problems, Gelles wants them to prove they can be good parents rather than have the state show that they are inadequate.
"My biggest goal is that children grow up in permanent settings," he said. "That should be the primary goal of child-welfare systems."
Gelles applauds Congress' 1997 Adoption and Safe Families Act, which places an emphasis on child protection and makes adoption easier. Philadelphia has seen a sharp rise in adoptions as a result.
Although the political climate has suited Gelles' ideas, he has critics. Children's rights are not the only priority, they say. Keeping families intact is important, too.
Marcia Robinson Lowry, who spearheads Children's Rights Inc., the New York-based public-interest group that filed the lawsuit against DHS and a fierce critic of child-welfare agencies nationwide, disagrees with Gelles.
"In the first instance, we need to address the problems and see if they can be solved," she said. "If they can't, [then] say, 'We've really given you a fair shot and you haven't taken it and we now have to look to your child.' "
Martin Guggenheim, a New York University law professor, said the 1997 adoption law was part of a larger ideology in Congress to crack down on the poor.
He said he was "tremendously" bothered that Gelles and Congress "speak as if we really have tried as best we could as a society to improve the lives of these families. Anyone who has been in the communities where these children come from knows that is a lie."
"If we love children, we have to love their parents. The fact is these are black and brown children. We neither love them nor their parents."
Joseph Crumbley, a Philadelphia psychologist and the author of Transracial Adoptions and Foster Care, said that removing children from troubled homes could have long-term consequences for the adopted child if not done right: Most children in public welfare systems are minorities, while most adopting families are white.
"Even though abuse and neglect is traumatic, there is another trauma that is just as important," he said. The child will later ask, " 'Why didn't my family keep me, why didn't my community keep me, why didn't people of my race keep me? What was wrong with them, what was wrong with me?' You have to look at those issues. We are setting children up for emotional trauma when you remove them from their families."
* By the time a child is in so much danger that removal is in order, there are few good options left.
Prevention, by definition, works when it is applied early, before families go into crisis. That shift in focus might require society to look at child abuse differently.
"As a community, we have a sense it happens to those people, not us," said Toni Seidl, a senior health consultant at the Support Center for Child Advocates.
People don't approach neighbors who are screaming at their children because it seems like an invasion of privacy, she said, so people "wait till they hear a head bang and then they call the police anonymously."
Instead, Seidl said, why not ask the angry parent, " 'Can I help you?' It's hard to be a parent."
"People will stop on the highway for a hurt dog, but you don't see anyone stopping in a supermarket for a parent saying hurtful things to their child," she said. "We've lost the ability to reach out."
"You don't want to say, 'It takes a village to raise a child,' " she said. "But it does."