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Child Maltreatment and Childhood Injury Research: A Cognitive

Behavioral Approach
Sandra T. Azar, PHD, and Kristin M. Weinzierl, BS
The Pennsylvania State University

Objective Both child maltreatment and childhood injuries affect large numbers of children
each year. In a seminal paper, Peterson and Brown (1994) drew parallels in the antecedents of
both forms of harm and suggested a more unified approach in research efforts and intervention
development. This article provides a unified cognitive model that would both guide research
and inform interventions directed at parents. Methods This article overviews information-
processing elements that may explain parental oversights that would increase risk to children,
including maladaptive parental schema, executive functioning problems, and maladaptive
appraisals. Contextual variables that may negatively impact on information processing are also
included. Results Studies supporting the validity of the model are presented, and implica-
tions for interventions are drawn. Data supporting the effectiveness of cognitive enhancements
to current interventions are given. Conclusions The promise of such a unified model is
discussed, and obstacles to its dissemination are presented.

Key words child abuse; childhood injury; parenting; cognitive behavioral interventions.

Despite society’s deep concern for children, they still equipment, bike helmets, and car seats), with parents
suffer many forms of harm to their health and well-being merely being encouraged to use these passive environ-
(e.g., poverty and poor nutrition). Although macro-level ment interventions (e.g., through pamphlets, media cam-
efforts (e.g., welfare systems, statutes to decrease safety paigns, and subsidies for purchasing). Lizette Peterson,1
hazards, and abuse reporting) can ameliorate their in whose honor this special issue was published, was an
plight, behavioral science efforts that target their main important figure in changing views that more active
caregivers—parents—are important as well (Liller & Sleet, parent intervention could do little. She alerted us to the
2004; Tremblay & Peterson, 1999). This article focuses idea that such injuries are not always random events and
on two areas where this has occurred: child maltreatment are often preventable with some “foresight” by caregivers
and unintentional childhood injuries. The first, child and that the application of behavioral science in interven-
maltreatment, affects over 1 million children each year, tion efforts would be fruitful (Liller & Sleet, 2004; Sleet,
with approximately 2,000 child deaths (Administration Liller, White, & Hopkins, 2004). She considered uninten-
for Children Youth and Families, 2001), and parental tional child injury as being on a continuum with child
behavior is the main target of intervention (Azar & abuse and neglect in origin and delineated common ante-
Wolfe, 1998). Although unintentional injuries (e.g., cedents to the parental oversights that may lead to both
drowning in bathtubs and poisoning) affect a much larger
number of children (8 million each year with over 10,000 1
Lizette Peterson’s death in July 2002 is a major loss to the
deaths; National Center for Injury Prevention, 2001),
field. The work she did on behalf of children was momentous. The
parental behavior is less often targeted (Tremblay & first author’s professional contacts with her were always inspiring,
Peterson, 1999). Until recently, efforts were directed more and she was a major personal and professional support in the
often at improving environmental safety (e.g., playground beginning stages of the first author’s career. She is greatly missed.

All correspondence concerning this article should be addressed to Sandra T. Azar, Department of Psychology,
Moore 541, The Pennsylvania State University, University Park, PA 16802. E-mail: sta10@psu.edu.

Journal of Pediatric Psychology () pp. –, 


doi:./jpepsy/jsi
Advance Access publication February , 
Journal of Pediatric Psychology vol.  no.  © Society of Pediatric Psychology ; all rights reserved.

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Information Processing and Prevention 

forms of harm (Peterson & Brown, 1994). Although not approach, as Peterson argued, provides targets for more
wanting to minimize important differences in the two, she comprehensive preventive efforts that explain failures in
argued for the advantages of having a more unified parental “foresight” that might lead to both maltreatment
approach in research efforts and intervention development. and childhood injury.
Accepting the challenge posed by Peterson, this article
outlines a theory attempting to explain “parental fore-
sight,” evidence supporting it, and its implications for A Cognitive Behavioral Model
intervention in both child maltreatment and childhood This cognitive behavioral (CBT) model encompasses most
injury. This model utilizes constructs from human infor- of the antecedent factors that Peterson and Brown (1994)
mation-processing theory to explain errors in parental outlined, but it prioritizes some as having the most prom-
judgment that increase child risk. It also includes ise for developing parent-based interventions. Building on
contextual variables that have been shown to disrupt the “parent factors” part of their framework, it articu-
human judgment further, increasing such errors. Drawing lates how an expanded set of cognitive factors coupled
parallels between both forms of harm to children and com- with contextual ones work in concert with behavioral
bining them in research and preventive efforts has advan- skill deficits to produce risk to children. To date, inter-
tages for both fields but also is fraught with danger (e.g., a vention in childhood injury has been injury specific and
perception of blaming parents). The approach taken in not focused on processes that underlie all parental risk-
this article, however, we believe, highlights how complex reduction behavior. This model attempts to do this. It
a task preventing harm is for parents and the need for focuses on the way parents identify and generate responses
greater societal efforts to provide parents with supports to to risk. Intervention directed at these “front end” pro-
keep the tasks within adults’ developmental “reach.” cesses would have the most focused impact.
The cognitive factors posited are part of a broader
array of interpersonal capacities crucial not only to
Peterson’s Legacy: Identification of Common parenting but also to operating successfully in all relation-
Antecedents in Harm to Children ships (Azar, 1989a, 2002a) (Table I). The parent func-
tion, as Palkovitz (1996) has said, is not simply “on” or
Effective intervention rests on identification of anteced-
“off ” but rather is part of the flow of all tasks in adult
ents to behavior(s) in question and well-validated theory.
life. The same processes needed in the workplace (e.g.,
In a seminal article, Peterson and Brown (1994) delin-
social skills to interact appropriately with coworkers,
eated common categories of factors playing a role in both
ability to anticipate problems, and self-calming capaci-
child maltreatment and unintentional injuries: sociocul-
ties) are not entirely separate from those required to
tural variables (e.g., poverty, crowding, stress, and social
keep children safe and to reduce the potential for angry
isolation), caregiver variables (e.g., mental illness,
outbursts at them. Failures in parenting that increase child
substance abuse, unrealistic expectations, supervisory
risk grow out of failures in these same general capacities.
patterns, and ineffective discipline), and child variables
Core to implementing all these capacities is infor-
(e.g., age, being distractible, high in activity level, non-
mation processing: knowledge structures, executive
compliant, and impulsive). This framework laid a foun-
functioning, and the cognitive products of the interaction
dation for linking both forms of harm to children.
of these two (Figure 1). Parental information processing
Similarly, maltreatment theorists, rather than seeing
is crucial to both keeping children safe (e.g., anticipating
child abuse and neglect as divorced from other problems
risks) and having the self-regulatory capacities to avoid
of parenting, argued for a continuum of parenting that
engaging in harsh and inappropriate behaviors.2 It
included, at one end, responses or omissions of care that
allows parents to accurately perceive information from
lead to harm (e.g., abuse and neglect) and, at the other,
the environment and to plan, implement, and evaluate
responses facilitating development (Azar, 1986; Azar,
their efforts to prevent harm to children (e.g., anticipate
Barnes, & Twentyman, 1988; Azar & Wolfe, 1998). In
risks, self-regulate when their efforts fail, and identify
an attempt to posit such a continuum view, Azar (1989a,
causes of these failures) and to adapt their responses to
1997, 2002a) described social cognitive and behavioral
changing situations and children’s developmental needs.
parental skill deficits that underlie inadequate parenting
(Table I) and that interact with contextual resources or 2
Children’s information-processing capacities also play a role,
deficiencies to produce varying levels of maladaptive but these are not discussed, given space constraints. Moreover,
responses and environmental risk to children. Pathways given that injury risk is greatest in children’s early years, parents’
among these factors were also posited. Such a unified capacities probably play a greater role in injury prevention.

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 Azar and Weinzierl

Table I. Sampling of Skill Areas Required to Parent


1. Parenting skills
Problem-solving abilities
A repertoire of child management skills (balance of positive and negative strategies and discipline skills)
Medical care and physical care skills (e.g., ability to identify needs for medical assistance and capacity to select nutritious foods)
Safety and emergency response skills
Capacities for warmth and nurturance (e.g., affective recognition/expression skills)
Sensitive and discriminant interactional response capacities
2. Social cognitive skills
Perspective taking
Problem-solving capacities
Appropriate expectations regarding children’s capacities
Cognitive reflectivity/complexity
Balancing short- and long-term socialization goals
Positive attributional style
Perceptual/observational skills
Self-efficacy
3. Self-control skills
Impulse control
Accurate/adaptive perceptions
A positive interpretive bias
Self-monitoring skills
Assertiveness
4. Stress management
Self-care skills
Relaxation skills
Recreational capacities
Ability to marshal and maintain a social support network
Positive appraisal style
A breadth of coping capacities (problem-focused coping, emotion-focused coping, and avoidant coping)
Financial planning skills
5. Social skills
Interpersonal problem-solving skills
Empathy
Affective recognition/expression skills
Assertiveness
Social initiation skills
Capacities to respond effectively to a breadth of individuals (e.g., family, friends, employers, social workers, and children’s teachers)

Parents need accurate and fine-tuned parental knowledge on information processing. When parents’ cognitive
structures (schema) regarding appropriate behavior to capacities are overwhelmed and/or they have overwhelm-
expect from children and parent’s role in their socializa- ing children, and/or live in chaotic environments, risks
tion, good executive functioning (e.g., good problem to children increase, as well as risks to themselves. Some
solving, perspective taking, decision-making skills, and contexts and some children can be so difficult that they
cognitive flexibility) to orchestrate and evaluate responses, tax even well-functioning parental cognitive systems and
and adaptive appraisals that result from these two factors they make errors in judgments. Indeed, such factors have
(e.g., accurate attributions of causality and appropriate been associated with a higher incidence of child maltreat-
appraisal of one’s own and children’s behavior) to allow ment and childhood injuries.
for the appropriate choice of responses. These capacities Implicit in saying that parenting is skill based is the
are intrinsic to parenting more generally, including nur- idea that it is learned. This flies in the face of prevailing
turing behavior, appropriate disciplining, and managing views of parenting as instinctually driven. All learning
children’s behavior effectively (e.g., sensitivity, clear requires ideal conditions. For parents, this means a history
commands, and applying appropriate and consistent of good caretaking, basic cognitive and behavioral skills,
consequences). Contextual stress can negatively impact low stress (e.g., freedom from environmental distraction,

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Information Processing and Prevention 

Stimulus Event

(e.g., a parent is busy and a 3-year-old child wants his or her


attention and the parent tells the child to leave him or her in
peace; the parent has to work later than usual and there is no
babysitter available; a young child picks up a sharp knife to
cut sandwich)

Other Parental Characteristics Contextual Resources Child Characteristics

Their own caretaking Poverty Age


history/relational High stress Activity level
history (e.g., trauma, Low social support Impulsivity
domestic violence) Neighborhood risks Cognitive capacities
Constitutionally based (memory, executive
cognitive limitations functioning)
Mental illness/substance
abuse

Knowledge Structures or Schema


(e.g., expectations of children, parenting, the self)

Expectation that parents should be able to get their children to


do what they want with one command; children should be able
to stay home alone after school; children can prepare their
own food or if children cuts themselves once, they will learn
knives are dangerous

Child Is Unable to Meet Expectation

Executive Functioning Capacities

Inability to change set and understand it is difficult for 3 year


olds to delay; failure to adjust beliefs about perspective taking
capacity of the child for rule mastery; lack of recognition of
the dangers in this case of trial-and-error learning

Products (e.g., Maladaptive Attributions, Appraisals)

Interpreting the child’s behavior as being purposefully


disobedient and/or not worthy of providing further direction
(“he knows what to do”; “he did it on purpose to make me
angry”); belief in rule mastery; the child will learn to be more
careful next time; negative self evaluation (“what’s wrong
with me, why can’t I get him to listen”)

Parental Response

Harsh physical discipline for bothering them; failure to


provide feedback to facilitate perspective taking and giving
the children something to occupy them; leaving the child
alone unattended; failure to state rules about use of knives and
no action and allowing the child to get hurt

Figure 1. The cognitive behavioral (CBT) model.

mental illness, or substance abuse), and supportive others With this broad array of skills in mind and the
who can provide scaffolding of learning (e.g., partners, conditions required for their development, it can be easily
extended family, and friends). Sadly, parents are expected seen that individuals are not equally prepared for the cul-
to do their job even when these conditions are not met. turally defined demands of their role, the ever-changing

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 Azar and Weinzierl

needs of their specific children (e.g., goodness of fit), developmental changes and individual differences (e.g.,
and the vicissitudes of the contexts in which they are a child with disability may require more sensitive care
rearing them. From this perspective, then, parents’ “fail- and monitoring). Schemas that represent even young
ures,” rather than simply being evidence of a lack of children as functionally equivalent in capacities to those
control or of their being “disinterested” or, worse yet, of adults, as able to take care of their own care needs
“uncaring,” may in fact be the logical outcome of break- (e.g., cook their own meals and get themselves to school
downs in an overtaxed caretaking system (Azar et al., without assistance), and to take care of those of parents
1988). Indeed, in societies such as ours, where extended as well (e.g., cross a busy street and do grocery shopping
families are less involved in the raising of children and for the family), may lead to misjudgments that will end
where community child care and other resources are lim- in child “failures” and threaten parents’ efficacy.
ited, becoming a parent dramatically increases burdens Parental role schemas must help adults to maintain
on the cognitive and behavioral capacities of individual a sense of control and hierarchy in parent–child transac-
adults and carries more risk (i.e., tasks that may over- tions, such that they sees themselves as “responsible” to
whelm these capacities) and make “growing into the role” “think” for children (i.e., anticipate risks for them and
slowly more difficult. Indeed, it has been questioned teach). More general schema elements about the self
whether our society’s asking parents to “go it alone” is may also play a role. For example, parents who describe
feasible. themselves as high on “conscientiousness” have been
Thus, a model of parenting that focuses on processes found to have children who engage in less risk taking
underlying the myriad of responses required to parent and have a history of fewer injuries (Morrongiello &
adequately and to orchestrate supportive contexts may House, 2004). Abusing mothers appear to have an
have utility as a foundation for the development of behav- expectation of being negatively evaluated by others
ioral interventions with parents, as well as the forming of (Shorkey, 1980). Such an expectancy has been shown to
effective social policy. The model proposed, therefore, increase self-criticism, which can disrupt cognitive pro-
has broad application. cessing and produce negative affect, contributing to less
effective performance (Baldwin, 1997).
In addition, positive biases in child schema, as
Child Maltreatment and Unintentional Injury: opposed to negatively toned content, help parents deal
Evidence for the Role of Human Information with the aversiveness (e.g., labeling children’s running
Processing across the street as independence rather than willfulness)
Research in both child maltreatment and unintentional and allow parents some leeway when they make errors
injury fit nicely with the three elements of this model. The (e.g., reduces negative self-evaluation when their child
empirical work supporting these elements is reviewed, as “embarrasses” them in public). On the other hand,
well as studies linking these three factors to each other schemas must not be so positive that they ignore places
and to parental behaviors that would increase the risk of where improvements are needed. That is, when the child
child maltreatment and childhood injury. Work demon- fails to obey a rule regarding a risk such as playing too
strating how contextual factors may exacerbate their near the street, the parent must be able to adjust his or
impact is also provided. her expectancies (e.g., see it as incomplete learning) and
engage in protective behavior with toddlers (e.g., being
Unrealistic Expectations and Perceptions present when his or her child is outside and erecting a
of Control: Maladaptive Knowledge Structures fence around the yard) and further teaching and provide
The first element of the CBT model involves parental appropriate consequences for rule violation with older
knowledge structures or schemas of what to expect of children. Most importantly, such events should lead to
children and parents’ roles in relation to them. Schemas parental “learning” that they cannot leave the child open
are information structures that exist before a new stimulus to the risk. Indeed, risk increases when parents overesti-
is encountered, and they have both structural elements mate children’s integration of family rules and do not
and content. Parents’ schemas grow out of their history give negative consequences for safety rule violations
with their own caretakers and experiences in relation- (Peterson, Bartelstone, Kern, & Gillis, 1995). Similarly,
ships more generally (e.g., watching other parents), the parents who engage in abuse often argue that their
media, and experiences with their own children (Azar, children “knew” what they were doing. Such parents
Nix, & Makin-Byrd, in press). Structurally, child sche- react with frustration and harshness, not teaching when
mas must be flexible and complex enough to deal with they engage in discipline. Multiple schemas may be

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Information Processing and Prevention 

activated in any one child-rearing incident (e.g., with parents have been found to have a higher level of unrealistic
a tantrum in a grocery store, beliefs about how children expectations regarding the social-cognitive and physical-
should behave in public, how much control a parent care abilities of children than carefully matched control
“should” have over children, and how the parent feels mothers (Azar, Robinson, Hekimian, & Twentyman,
about the self once he or she notices that others are 1984; Azar & Rohrbeck, 1986; Haskett, Scott, Grant,
staring at them all may come into play), and any one of Ward, & Robinson, 2003). Other at-risk parent groups
these schemas may be activated at different points in the also show such difficulties (e.g., cognitively limited par-
interaction with the child, and parent may cycle through ents, Azar, 1991; substance-abusing mothers, Spieker,
the process portrayed in Figure 1 over and over again Gilmore, Lewis, Morrison, & Lohr, 2001).
during the course of the incident. Maltreating parents have maladaptive schema regard-
Peterson and Brown (1994) acknowledged the role ing their roles as parents. They more strongly believe
that parental unrealistic expectations play in increasing that punishment is what a parent “should do” and that
risk of childhood injury. The CBT model above, how- power-assertive strategies will be effective and that
ever, prioritizes a more central role for expectations in inductive ones will be less effective (Caselles & Milner,
causing child maltreatment and the inadequate monitor- 2000). They have a role definition of parenting that
ing of, and feedback to, children that increase injury requires them to have absolute control over their
risk. For example, failing to recognize children’s greater children (Peterson, Gable, Doyle, & Ewigman, 1997).
needs for supervision places them in a variety of risk situ- This may grow out a lower perception of control as a
ations (e.g., leaving them home alone). Moreover, these parent (i.e., children having more power over outcomes
expectations may increase the occurrence of lax or inap- than they do) and an overly generalized concern regard-
propriate discipline. Failing to provide consequences for ing dominance (Bugental, Blue, & Cruzcosa, 1989). It has
child risk-taking behavior may be due to the mistaken been argued that individuals with low perceived control
belief that children “know” the rule (Peterson & Brown, have stored schema regarding power that can be activated
1994). Similarly, too strong a belief in parents’ role as by merely anticipating child difficulties (e.g., hypersen-
one of absolute authority would contribute to overreact- sitivity to potential dominance). These schemas have a
ing to misbehavior and seeing child noncompliance as a distracting quality and may lead to inaction as well as
threat to parental adequacy, even when the noncompli- overly harsh reactions.
ance is due to lack of maturity. These expectations drive Parallel findings have occurred in the childhood
maladaptive automatized processing of events. injury literature regarding inappropriate child and
Unrealistic expectations in the CBT model are seen as parenting schema. Parents as a group have been found
direct contributors to specific injury events (e.g., beliefs to underestimate their infants’ motor abilities and curi-
that children have the ability to engage in self-care, such osity (Roberts & Wright, 1982) and overestimate their
as using appliances on their own to prepare food, antici- children’s ability to maintain their own safety (Peterson,
pate risks, and consider parental feelings and adjust their 1989). Peterson and her colleagues (e.g., Peterson,
behavior so as not to cause any provocation so as not to Mori, & Scissors, 1986) have investigated in detail
cause any provocation when the parent is upset) (Azar, children’s abilities to care for themselves when they are
1986; Azar & Twentyman, 1984). If such beliefs are held home alone—a situation in which childhood injury is
strongly, when children violate such expectancies, par- quite common. Although both parents and their 8- to
ents cannot blame inadequate rule acquisition or chil- 10-year-old children believe that children are prepared
dren’s development. Child failures can only be labeled as to stay at home alone, Peterson et al. (1986) found that
evidence of poor parenting or, worse yet, of willful nega- children were able to recognize only a few of their
tive behavior. The parent may come to feel helpless in the parents’ rules about what to do in a variety of common
face of children and not respond at all or, because of their household and emergency situations; recall memory
frustration, engage in overly harsh punishment which was even poorer. Latchkey children, for example, dem-
over time may escalate into abuse. Negative consequences onstrate low self-care abilities regardless of socioeco-
and education about risky behavior would also not occur, nomic status (SES) or gender (Peterson, 1989). Further,
both of which are crucial to rule learning. Peterson noted that parents are often shocked to
Evidence for such unrealistic expectations of chil- know of their children’s responses to questions about
dren, parental roles, and what are appropriate responses home safety, indicating that they expected their
on parents’ part have been linked to both child maltreat- children to know what to do in these situations. It
ment and childhood injury. Abusive parents and neglectful appears, then, that these parents’ expectations are

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somewhat disconnected from the reality of their chil- problems, prioritize, enact responses effectively, and
dren’s abilities. At the same time, parents were confi- evaluate the outcomes that result and adjust one’s
dent that their children were prepared to stay home behavior when responses are not effective. Executive
alone and that they are aware of family rules. Such an functioning involves effortful, as opposed to automa-
invalid belief in child rule knowledge would increase tized, processing of information and has been implicated
child risk. in adaptive functioning in social realms (Derryberry &
In contrast to abusive parents, for childhood injury Rothbart, 1997; Kochanska, Murray, Jacques, Koenig, &
cases, Peterson and Brown (1994) argue that for parental Vandegeesi, 1996; McEwen & Magarinos, 1997). It may
role schemas that suggest lower expectation for need to be affected by constitutionally based cognitive limita-
act, as evidenced by lax control around childhood injuries. tions (e.g., learning disabilities and brain injuries) and
They describe a field study of 1,000 minor injuries where contextual stress.
both parents and children agreed that preventive changes Typically, executive functioning occurs when
to the environment, change in rules, and other conse- stimuli present some incongruence with preconceived
quences were needed. Yet, such actions occurred after knowledge structures (expectations), ambiguity, or a
injuries in less than 3% of cases. Data suggest that some problem to be solved. Given young children’s changing
parents may mistakenly see minor injuries as “normative” developmental needs and poor ability to communicate,
events and/or beyond their control (Morrongiello & parents are faced with a continuous stream of incongru-
House, 2004), and this may explain their lack of action. ence, ambiguity, and problems. (Indeed, Peterson &
Perceiving that children have more control over chil- Brown, 1994, cited young child age as a risk.)
drearing outcomes than the parent does, for example, Parents must be able to identify and anticipate risks
has been shown to be predictive of safety neglect of before they happen (e.g., it requires complex perceptual
infants (i.e., neglect of the provisions of a physically safe abilities), to consider alternative solutions (e.g., balanc-
environment) (Bugental & Happeney, 2004). One study ing long- and short-term socialization goals for children),
found that some parents, particularly fathers, believe to regulate emotional reactions to what may be extremely
that minor injuries serve a developmental benefit (e.g., aversive child behavior (e.g., prolonged crying), and,
children “learn a lesson” and they “toughen” children once responses are enacted, to adjust behavior as diffi-
up) (Lewis, DiLillo, & Peterson, 2004) and that this too culties change (e.g., self-regulation, prioritization, and
may explain in part parents’ lack of action. Having this cognitive flexibility).
idea about minor childhood injury would lessen remedi- Evidence exists for deficits in these processes in
ative actions following them (i.e., the parent would child-maltreating parents. Physically abusive as well as
believe too strongly in the idea that a “good” parent lets neglectful mothers show poorer problem-solving capaci-
his or her child learn by trial and error). ties in both childrearing and nonchildrearing situations
Overall, the evidence supports both Peterson and (Azar et al., 1984; Hansen, Pallotta, Tishelman, &
Brown’s (1994) and Azar’s (1986, 1997, 2002a) ideas Conaway, 1989). Parents at-risk for maltreatment have
about the role that unrealistic expectations regarding also shown deficits here. For example, intellectually low
children play in potential harm to child. Thus, links functioning parents are poorer problem solvers in chil-
between this cognitive element of the model to both drearing situations, and the level of their deficit is asso-
abuse and neglect and childhood injury appear to exist. ciated with less synchrony in their interactions with
Schemas regarding power relationships with children, their preschool children (Azar, 1991; Azar et al., 1999).
specifically concerns regarding dominance, also seem to Clearly, many forms of executive functioning (e.g., delay
play a role. of gratification, self-regulation in the face of provocative
behavior, and organizational abilities) are required to
Problem Solving, Cognitive Complexity, parent successfully and to do so calmly when child aver-
and Ability to Change Set: Difficulties sive responses cannot be easily resolved or when the
in Executive Functioning parent is in a strained state. Even positive responses
Along with disturbed schema, child risk may increase require the modulation of behavior to fit the situation.
with adult difficulties in executive functioning. Execu- Indeed, parental sensitivity is predictive of secure attach-
tive functioning involves capacities to perceive stimuli ment in infants, which in turn has been linked to their
in the environment in complex enough ways to identify later social capacities.
problems when they occur, emotionally regulate and Parents who are maltreating show a failure to
inhibit responses, generate specified responses to those discriminate between child behaviors and respond with

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Information Processing and Prevention 

matched responses. Trickett and Kuczynski (1986) found, parents may indicate problems in sustaining attention,
in a diary study, an overuse of coercion as the priority one component of being able to shift set.
response to aversive child behavior (i.e., all aversive child Again, although cognitive flexibility was not dis-
responses are seen as similar and, thus, responded to cussed by Peterson, it clearly is required to respond to
similarly). This finding also suggests a lack of cognitive environmental cues and maintaining safety for children.
complexity. Wahler and Dumas (1989) posit an attentional As children change developmentally (e.g., become more
problem in abusers that lead them to track behaviors less mobile), changes are needed in the home (e.g., installing
closely and to respond in an indiscriminative manner. barriers in risky areas). Further, parents whose children
Although not yet studied in the area of childhood are becoming more able to think about family rules must
injury, how poorer ability to identify problematic situa- respond to them appropriately (e.g., give them expla-
tions and anticipate risks would lead to greater harm to nations of why a rule exists). Younger or special needs
children can be easily seen. Indeed, the ability to identify children (e.g., impulsive ones) require more continuous
safety risks and correctly label them in terms of level vigilance, whereas adolescents need more selective moni-
(e.g., medical problems where home treatment is suffi- toring and sensitively delivered direction. Parenting in an
cient vs. ones where emergency care by a physician is affluent and safe suburban neighborhood (e.g., little traf-
needed) is often targeted in safety and medical educa- fic and neighbors who are willing to play a role secondary
tion programs with parents (Gershater-Molko & Lutz- to parents) requires skills that are different from those
ker, 1999). Poorer problem-solving capacities have been that are required in a high-crime, urban setting (e.g., high
found among parents of children showing impulsivity traffic level and isolation from neighbors). In the latter,
problems, a common antecedent of childhood injury neighbors’ skills may compensate for the deficiencies of
(Dix & Lochman, 1990; Edwards, Barkley, Laneri, parents. Similarly, as the family moves to other environ-
Fletcher, & Metevia, 2004; Pakaslahti, Spoof, Asplund- ments (e.g., a playground and visiting another family’s
Peltola, & Keitkangas-Jarvinen, 1998), as well as among house), parents must adjust their vigilance level to protect
families touched by substance abuse, another antecedent their children appropriately. Parental engagement and
of childhood injury (Hops, Tildesley, Lichtenstein, Ary, distraction both have been associated with the level of
& Sherman, 1990). Cognitive complexity may play a supervision parents provided children when observed in a
role in childhood injury as well. “Rule shortages” appear park setting, and more engagement has been found to be
in families about safety issues. Peterson and Saldana negatively correlated with child nonminor injury history
(1996) found that over 83% of child injuries occurred (Morrongiello & House, 2004). Moreover, a parent must
without violation of a safety rule. Often, parents be prepared to deal with his or her own changing needs
regarded the child’s behavior as unacceptable but had (e.g., a parent who has been injured must enlist outside
not specifically forbidden it. assistance to care for his or her mobile toddler).
This last finding suggests that parents were some-
times inconsistent when they impose rules on their Negative and Maladaptive Appraisals of Child
children while at home and that risk increases when Behavior: The Products Resulting From the
they were out in the world (e.g., climbing on playground Operation of Both Maladaptive Schema and
equipment). Also, the failures to take action after inju- Weak Executive Functioning
ries, noted earlier, suggest that parents may be failing to Peterson et al. (1995) recognized the relevance of attri-
evaluate the quality of their solutions and adjusting butions for child behavior to child injury research but
them (i.e., recognizing that not having rules did not work did not include it as one of the contributors to injury.
if the child was injured). This may have dire implica- The CBT model, however, gives a central role to such
tions for young children who lack adult experience (e.g., attributions. As noted earlier, a consequence of unrealis-
well-developed schema regarding safety) and decision- tic expectations is that parents must now explain to
making. Fine-tuned rules form a foundation for their themselves why their child has violated expected stan-
own decision-making rules and capacities. dards. If executive functioning capacities are not strong
Another such capacity that may be linked to child (i.e., parents do not identify their standards as incorrect
risk is the ability to change set. Abusive mothers and and adjust them), they may either see themselves as fail-
ones at higher risk for abuse have been shown to be ures in parenting (i.e., “I can’t get my child to do the
lower in cognitive flexibility (Nayak & Milner, 1998; things other parents can”) (self-blaming) or see their
Robyn & Fremouw, 1996). The “tracking” problems children as deliberately withholding a response well
seen by Wahler and Dumas (1989) in maltreating within their capacity (child blaming). Weak executive

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 Azar and Weinzierl

functioning capacities would also prevent them from and their behavior generally as more negative, problem-
generating more benign or helpful attributions (situa- atic, less adaptable, more conduct-disordered, more
tional or developmental ones). Over time, self-blaming temperamental, more aggressive, and more hyperactive
or child blaming would either immobilize them (e.g., (Chilamkurti & Milner, 1993; Mash, Johnston, & Kovitz,
lower their self-efficacy and lead to disengagement in 1983; Reid, Kavanaugh, & Baldwin, 1987). In some cases,
parenting or depression) or result in impulsive, overly these negative appraisals of children have been made in
harsh responses. spite of no differences in child behavior compared to
Parental attributions of negative intent to children controls when rated by independent observers.
have been shown to influence the nature of their Findings also support the role of attributions for
responses to children’s transgressions (Barnes & Azar, understanding injuries. Morrongiello and House (2004)
1990; Dix, Ruble, & Zambarano, 1989). Perceiving one’s found that parents who believed that their child’s health
child as having more control over childrearing outcomes status was due to luck showed decreased supervision
than oneself may contribute to overly harsh responses in and had children who had experienced more injuries.
that parents may more readily see themselves as needing Peterson et al. (1995) found that mothers’ beliefs about
to exert high levels of power assertion to have any affect. the causes of injury were related to whether or not they
Thus, such attributions coupled with expectations of attempted to provide intervention. Mothers who attrib-
absolute control may lead to inappropriate discipline. uted the injury to factors internal to the child (i.e., “it
Failures to make attributions to lack of knowledge was the child’s fault”) were likely to take remediative
on the child’s part (e.g., “he’s only two, he does not action (e.g., lectures and discipline). On the other hand,
understand”) would mean fewer educative responses mothers who believed that their child’s injury was due
that would move a child forward in mastering tasks. to fate were less likely to take remediative action (e.g.,
More importantly, the child’s repeated failures to meet teaching and providing consequences). Indeed, parents
expectations, followed by attributions of blame to the living in poverty who are at greater risk of child
self or the child, would demoralize parents. The child maltreatment and unintentional childhood injury have
may become an aversive stimulus and “living evidence” been shown to make more external attributions for their
of parent’s incapacities (Azar, 1986, 1997). Clearly, a children’s dysregulated behavior (risk taking and aggres-
parent may be less motivated to caregive, and as a result, sion), and thus they would do nothing in response more
the child may be left unattended more, leaving him or than do nonpoor parents (Diriwachter & Azar, 2002).
her open to risks. Bugental and Happeny (2004) have shown lower maternal
Parental negative attributions to children for aver- perception of control in their parent–child relationship to
sive child behavior (e.g., negative intent and negative be related to lower provision of a safe environment for
traits) are seen as playing an essential role in the pro- infants. Overall, the evidence to date supports the rela-
gression toward child maltreatment (Azar, 1989a). In tionship between maladaptive maternal attributions for
general, internal, negative child attributions are related child behavior and responses to that behavior that would
to more power-assertive responses (Dix et al., 1989). increase the risk of injury (lax responses).
Many studies have found negative attributional biases in Maladaptive appraisals have been shown to increase
abusive and at-risk parents (intellectually low functioning parental anger and risk of punitive behavior, as well as
mothers, teenage mothers, and substance-abusing parents) lax parenting. Evidence for this is reviewed below when
compared to controls (Bradley & Peters, 1991; Dadds, links among these information-processing factors and
Mullens, McAllister, & Atkinson, 2003; Dopke & Milner, parental behavior are discussed.
2000; Haskett et al., 2003; Larrance & Twentyman, 1983;
Miller & Azar, 1996; Spieker et al., 2001), although dif- Information Processing and Maladaptive
ferences do not appear under all conditions (Milner & Parental Responses
Froody, 1994). For instance, they occur under cumula- Evidence exists linking these information-processing
tive stress (Azar, 1988). problems to each other and with maladaptive parental
Other appraisals of children have been studied that responses. In a small sample of intellectually low func-
support the idea of a negative bias among maltreating tioning [intelligence quotient (IQ) less than 79] mothers,
and at-risk parents. Abusive mothers and ones identified higher levels of unrealistic expectations regarding chil-
as at-risk for being abusive expect less compliance from dren were associated with poorer problem solving in
their children after disciplining them and judge child childrearing situations, and higher levels of both these
transgressions in many situations as more “wrongful” cognitive problems were associated with less synchronous

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interactions with preschool children (Azar et al., 1999). interactions with vulnerable others (e.g., with pets; Sims
Mothers with higher levels of these cognitive problems et al., 2001).
were less responsive to their children moment by Literature has also drawn links between information-
moment and more discordant when they interacted with processing problems and child risk of injury. Wilson et al.
them, suggesting poorer capacity to perceive their chil- (1991; as cited in Brown & Peterson, 1997) proposed
dren’s cues and respond to them. In more general sam- that developmentally inappropriate expectations may
ples of low SES mothers (including teenage mothers), the lead to inadequate supervision and an increased risk of
more unrealistic expectations parents had of children’s child injury. Peterson’s own research suggests as much:
self-care capacities and ability to understand parental feel- in one study, an inadequate number of rules (which may
ings and thoughts, the stronger negative intent attribu- be interpreted as the result of inappropriate expectations
tions they made to children’s aversive behavior, and the on the part of the parent) were related to the number of
stronger and more coercive the punishments they used injuries sustained by a child (Peterson & Saldana, 1996).
and the less likely were they to use explanation (Azar, Her other findings seem to predict a similar effect: latch-
1989b, 1991; Azar et al., 1999; Barnes & Azar, 1990; key children know very little about their parents’ rules
Dadds et al., 2003). Social workers also rated the children for handling emergencies, although their parents expect
of young mothers who hold higher levels of such expecta- them to be aware of numerous guidelines (Peterson,
tions as being in more jeopardy in terms of child safety 1989). Taken to their logical conclusion, these results
and care (Azar, 1989b). Thus, unrealistic expectations may indicate that the children’s lack of rule knowledge
and negatively biased attributions appear to contribute to (and their parents’ inappropriate expectation of that
harsh parenting practices, failures to engage in socializa- knowledge) is related to risk of injury. Also, the types of
tion practices that would lead to learning of rules and attributions that parents make to children’s risk behav-
self-regulatory behaviors in children, and, overall, height- ior were found to lead to differing levels of mothers’
ened child risk. Important to prevention are the findings engaging in remediative actions (Peterson et al., 1995).
from another study. In that study, these same relation- As noted above, lower perception of control in parent–
ships were found within a large group of adolescents who child relationships has been linked to less provision of
were not yet parents (Azar, 1990). Thus, this cluster of safety in the environment provided to infants (Bugental
cognitive problems may be present before an individual & Happeny, 2004). Thus, links between parental infor-
becomes a parent. mation processing and parental injury prevention
Along with data linking expectations and attribu- behavior appear to exist.
tion, research has also shown that low perceptions of
control are associated with negative affect and increased Context: Interactive Effects of Information
physiological arousal when adults interact with a “diffi- Processing Factors with Stress and Social Isolation
cult” child (Bugental, Blue, & Lewis, 1990; Bugental et Work in both child maltreatment and unintentional
al., 1993; Bugental, Brown, & Reiss, 1996), and these injury highlights the association between contextual
effects occur even in anticipating such an interaction strain (stress level, financial strain, and low social sup-
(Bugental & Cortez, 1988). It has been argued that indi- port) and personal strain (mental illness and substance
viduals with low perceived control have stored schema abuse) and harm to children. In child maltreatment, low
regarding power that can be activated by merely antici- income (Garbarino, 1976), lack of social support, and
pating an interaction involving child difficulties (e.g., high stress (Egeland, Breitenbucher, & Rosenberg, 1980;
hypersensitive to potential dominance). Such activation Gaudin, Polansky, Kilpatrick, & Shilton, 1993) have all
may interfere with executive functioning as described been shown to be antecedents. Other factors, including
above, in that when engaging in interaction with a “diffi- crowding, family chaos, and changes in residence have
cult” child, they show decrements in cognitive function- also been shown to be related to unintentional injury
ing including the inability to recall thoughts after the (Peterson & Brown, 1994). Yet, not all stressed, men-
interaction (Bugental et al., 1996) and the use of less tally ill, substance-abusing, and isolated parents engage
complex and less effective linguistic structures during in child maltreatment, and contextual strain does not
the interaction (Bugental & Lewis, 1999; Bugental & translate into injuries occurring in all families. Some
Shennum, 1984). Essentially, mothers may lose the parents may be less able to balance their resources or the
cognitive functioning capacities needed to control their cadence with which stressors occur.
negative behaviors. Indeed, some data suggest more The CBT model posits that strains and lack of buffers
generalized negative reactions when confronted with to relieve those strains tax the capacities of even

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well-functioning parents and that, coupled with higher by exposing them to a childrearing failure (e.g., they
levels of the cognitive disturbances outlined above, mis- were given puzzles to teach their preschool children on
haps become more likely. It is clear that stress decreases which failure was highly likely, but they were given the
cognitive functioning and performance declines occur expectancy that they would be able to teach them). It
when one must focus on multiple tasks. Distractability, was found that mothers who were high in life event
narrowing of perceptual capacities, and overwhelmed stress over the last 6 months and who had higher levels
problem solving under conditions of crises may lead to of unrealistic expectations of children were the only
misjudgments or oversights. For example, negative child mothers who attributed failure to something about
attributions are especially common when parents are in themselves or their child (this despite the fact the task
a negative mood state (Dix, Rheinhold, & Zambarano, was in fact too hard). Similarly, examining maternal
1990). Some evidence has begun to emerge that chronic cognition in disciplinary situations (a stressful situation)
levels of stress may influence brain functioning, in some and using a diary methodology, researchers were able to
cases perhaps permanently, thus producing more find that mothers with higher levels of unrealistic expecta-
chronic cognitive problems in executive functions tions were more likely to make negative, stable, and inter-
(Stein, Hanna, Koverola, Torchia, & McClarty, 1997). nal child attributions and to use more power-assertive
Conversely, cognitive problems can exacerbate the strategies and less adaptive and inductive ones (Azar et al.,
negative effects of stress on parenting. For example, 1999; Barnes & Azar, 1990).
women who had less complex expectations about
parenthood before their children’s birth had worse
adjustment after the birth (i.e., reported higher depres-
Implications for Interventions and Prevention
sion, lower self-esteem, and poorer marital adjustment) Behaviorally based interventions and prevention efforts
(Pancer, Pratt, Hunsberger, & Gallant, 2000). This effect targeting parents have been effective at reducing child
held even when they encountered higher levels of stress maltreatment and childhood injury rates (Azar & Wolfe,
after the birth. Similarly, violations of expectation 1998; Peterson & Brown, 1994). Cognitive theorizing
regarding the transition to parenthood (i.e., about their regarding parenting difficulties has begun to be success-
relationships with their spouses, physical well-being, fully integrated into these parent interventions and
maternal competence, and maternal satisfaction) also prevention efforts. Targets include efforts to challenge
predict poorer maternal adjustment (Kalmuss, Davidson, and restructure parental schema regarding children and
& Cushman, 1992). Thus, mismatches between expected their role as parents and improve problem-solving
role functioning and realities would lead to a greater capacities, as well as working on negative biases in their
experience of stress. appraisals of their children’s behavior (Azar, 1989a; Azar
Under conditions of low resources, situational fac- & Twentyman, 1984; Azar et al., in press; Barth, Blythe,
tors may also be interpreted as safer than they actually Schinke, Stevens, & Schilling, 1983; Bugental &
are out of necessity (or perceived necessity). That is, Johnston, 2000; Milner, 2003). Azar (1989a, 1997)
lack of safety may “need” to be ignored. A single parent describes the challenging of expectations regarding
with an ill infant and two older children may feel that it children and biased attributional processes, using CBT
is better to leave the infant in the care of siblings and go strategies. Azar and Cote (in press) and Barth et al.
out into the cold on a winter night to get them food than (1983), for example, provide scripts for cognitive restruc-
risk the infant’s illness worsening. Also, a financially turing where distortions are identified and gently
destitute parent may out of necessity elect to try to care challenged. Role plays, experimentation (e.g., demon-
for child illness without a physicians’ input rather than strations of children’s incapacities using Piagetian
incur debt. conservation tasks as an example), and reframing can
Also, as the earlier discussion suggests, under the also be used. In some cases, misattributions made to
ambiguity that stress may produce (e.g., interactions children can be clinically conceived as failures to distin-
with an unpredictable and difficult child; Bugental et al., guish the child from other related adults in their lives
1990, 1993, 1996), maladaptive schema and attributional with whom the parent has conflicted relationships. For
biases may operate more strongly. In a laboratory study example, in the midst of an aggressive tantrum, a child
of the effects of stress, Azar (1988) explored the interac- may not be distinguished from his or her absent father
tive impact of life stress and higher levels of maternal whom he or she resembles and who battered and devalued
unrealistic expectations of children. She manipulated the mother. With this association comes a heighten
level of childrearing stress with nonmaltreating mothers harshness which will be diffused if the clinician can help

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the parent to see the overgeneralized response she is live conflicts with children (i.e., reduces arousal and
having and help her discriminate the child from these the distractability that may interfere with new skill
more aversive figures in her life. This process is what mastery). Anger and stress management training empha-
social cognitive theorist call changing a schema through size cognitive flexibility (e.g., “He is only two—it won’t
subtyping (Fiske & Taylor, 1991). Similarly, alternative work this time, but maybe next time”; “what else can I
attributions might be gently offered to the mother when do?”). Work on safety, hygiene, and medical care deci-
a negative bias emerges in her interpretations (e.g., sions focuses on identification capacities and response
“How awful it must be to feel your child is intentionally generation (Lutzker et al., 1998). Therapist modeling
trying to embarrass you in the store . . . . I wonder if and multiple trials with visual checks are used (e.g.,
there is another explanation for why he acted that pictures of various levels of child injury symptoms).
way?”). Similar challenging can occur around safety CBT interventions have been successful with mal-
hazards (e.g., “he knows what to do when I am not at treating parents (Azar & Twentyman, 1984; Kolko, 1996)
home with him after school”). These may be reframed and clinical populations at risk of childhood injury [e.g.,
similarly (e.g., “it sure would be nice if he could remem- parents of aggressive youth (Stern & Azar, 1998) and dis-
ber the rules when you are not around and it is really ruptive childhood disorders (Johnston, 1996)].
hard to find a babysitter for him, but I wonder if . . . ”). Prevention work targeting parental thinking in at-
The key again is repeated gentle challenging. risk parents (targeting appraisal, problem solving, self-
Peterson et al. (1997) also highlighted the need to efficacy, attributions, and religious and cultural beliefs),
challenge conflicts between cultural and religious beliefs in addition to behavioral skills, has shown reductions in
and therapy goals, using persuasion (e.g., challenging of harsh discipline, child maltreatment, and childhood
role schema such as “a good mother is one who main- injury, as well as shown improvements in children’s
tains strong and absolute control over her children, usu- health outcomes (Bugental et al., 2002; Olds et al., 1998;
ally by physical force”) and attempting to increase Peterson et al., 1997; Peterson, Tremblay, Ewigman, &
flexibility in thinking about childrearing and in behav- Popkey, 2002; Sanders et al., in press).
ioral responses. Provision of counterintuitive information These preliminary studies suggest that targeting
is described by Azar and her colleagues above (e.g., cognitive factors along with behavioral changes will
“your attention is your child’s paycheck, paying too have beneficial effects in reducing harm to children and
much attention to your child’s negative behavior by may even impact positively on child health. Clearly,
yelling at them rewards it”). Extensive use of such more work is needed to replicate these effects. Dissemi-
metaphors is useful (e.g., “children’s good behavior is nation, however, may be a problem. To date, most pro-
like a plant and their bad behaviors are weeds, which grams offered to parents in both child maltreatment and
will you water?—time out is like ‘weed killer’ ”; “pro- injury prevention have been either watered-down com-
ducing change using harsh punishment is like hitting binations of personal counseling or didactic parenting
something too hard with a hammer, you get results but classes (United States Advisory Board on Child Abuse
may split the wood”; Peterson et al., 1997; “asking your and Neglect, 1995). Some evidence suggests that little
child to do that would be like me asking you to fix a intervention at all occurs. “Cognitive” problems within
carburetor and threatening you with punishment if you societies may be at fault (Azar, 2002b). Parenting is still
cannot”; Azar, 1989a). Metaphors enhance persuasion seen as an instinctually driven and not requiring com-
by helping organize and process a large amount of infor- plex learning processes. In addition, those most in need
mation (Sopory & Dillard, 2002), thus compensating for of services are the poor, and society has been ambivalent
poor executive functioning and facilitating learning. in its willingness to provide supports to such individuals
Executive functioning capacities themselves can also (e.g., seeing them as helpless and hopeless; Azar, 1996).
be targeted. Problem-solving training has been included Such biased schemas interfere with “adaptive” policy.
in behavioral parent training (Azar, 1989a; Azar & Cognitive work is needed on a more grand scale to
Wolfe, 1998; Stern & Azar, 1998). It includes identifica- counteract such forces (e.g., media campaigns and work
tion skills (What is the problem? Whose problem is it?), with legislators). The CBT model emphasizes the idea
generation of alternative solutions, consideration of the that overwhelmed parents have more difficulty carrying
potential effects of each, response selection, enactment out their jobs in the same way that overtaxed traffic
of responses, and evaluation of their effects. Role plays controllers or other professional groups charged with
are useful, as well as videotaped interactions, for teach- monitoring of others do. That is, seeing parenting as
ing “thinking” skills in a more relaxed setting than in involving complex cognitive capacities elevates the role

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 Azar and Weinzierl

and would foster more complex and sensitive actions on Azar, S. T. (1991, November). Is the cognitively low
society’s part. functioning mother at risk for child maltreatment?
The unified approach suggested by Peterson and Paper presented at the annual meeting of the
Brown (1994) offered future directions for work in Association for Advancement of Behavior
maltreatment and unintentional injury. The cognitive Therapy, New York.
approach attempts to operationalize such a unified Azar, S. T. (1996). Cognitive restructuring of
approach and provides more refined directions for professionals’ schema regarding women
research and intervention work. It must be emphasized, parenting in poverty. Women & Therapy, 18,
however, that no amount of parental supervision and fore- 149–166.
sight can prevent all harm to children. Environmental Azar, S. T. (1997). A cognitive behavioral approach to
changes, therefore, need to continue to be instituted (e.g., understanding and treating parents who physically
requiring car seats and use of smoke detectors), especially abuse their children. In D. Wolfe & R. McMahon
for parents whose lives and circumstances of living tax even (Eds.), Child abuse: New directions in prevention
a well-functioning cognitive system (Tremblay & Peterson, and treatment across the life span (pp. 78–100).
1999). Subsidized child care, support groups, and crisis New York: Sage.
lines may all reduce maltreatment, as well as childhood Azar, S. T. (2002a). Adult development and
injuries, by reducing parental stress. Prevention, however, parenting. In J. Demick (Ed.), Adult development
that targets cognitive functioning may work in conjunction (pp. 391–416). New York: Sage.
with environmental scaffolding to increase parental “fore- Azar, S. T. (2002b, November). Intervening in child
sight” capacities and reduce child risk further. maltreating families: A historical socio-political
perspective. Paper presented at the annual
Received April 14, 2003; revisions received August 26, meeting of the Association for the advancement
2004; accepted August 26, 2004 of Behavior Therapy, Philadelphia, PA.
Azar, S. T., Barnes, K. T., & Twentyman, C. T. (1988).
Developmental outcomes in physically abused
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