Instruments to measure interaction of mothers and newborns: A systematic review.

Interactions between newborns and their parents/primary caregivers are characterized by asymmetric and dependent relationships. This systematic review mapped, identified, and described the psychometric parameters, categories, and items of instruments used to assess mother-newborn interaction. Seven electronic databases were accessed in this study. Furthermore, this research included neonatal interaction studies describing instruments' items, domains, and psychometric properties while excluding studies that focused on maternal interactions and lacked items for assessing newborns. Additionally, studies validated with older infants that did not have a newborn in the sample were used for test validation, which is a criterion used to decrease the risk of bias. Fourteen observational instruments from 1047 identified citations were included that addressed interactions using varying techniques, constructs, and settings. Particularly, we focused on observational settings that assessed interactions with communication-based constructs in the context of proximity or distance as influenced by physical, behavioral, or procedural barriers. These tools are also used to predict risk behaviors in a psychological context, mitigate feeding difficulties, and conduct neurobehavioral assessments of mother-newborn interactions. The elicited imitation was also an observational setting. This study found that the most described properties in the included citations were inter-rater reliability followed by criterion validity. However, only two instruments reported content, construct, and criterion validity, as well as a description of an internal consistency assessment and inter-rater reliability. Finally, the synthesis of the instruments reported in this study can guide clinicians and researchers in selecting the most appropriate one for their own application.

The temporal dimension in the understanding of maternal sensitivity in caregiver-infant interactions: The 'Early Mother-Child Interaction Coding System'.

Caregiver-child interaction is known to play a central role in children's socioemotional development, yet the diversity of measures commonly used to evaluate it call into question the nature of the construct being assessed. Contingency within caregiver-child interactions has been identified as a key dyadic process that requires taking a temporal perspective to evaluating interactions. The Early Mother-Child Interaction Coding System is a psychometrically sound measure that sequentially code the flow of interactive and non-interactive behaviours within a caregiver-infant system. Its use of the framework of nonlinear dynamical systems (NDS) expands our understanding of contingent caregiver-infant dyadic behaviour.

Childhood Victimization by Adults and Peers and Health-Risk Behaviors in Adulthood.

Victimization experienced in childhood has been linked with health-risk behaviors (HRBs) in adulthood. The purpose of this cross-sectional survey was to provide data regarding the HRBs using the ISPCAN Child Abuse Screening Tool Retrospective version (ICAST-R), Spanish version. This aimed to broaden existing knowledge by assessing both being victimized by adults and by peers in a Spanish general population of 348, aged 18-35. Age and timing of the reported victimization were also considered. Victimization: physical, psychological, sexual abuse by adults and/or peers showed a prevalence of 44.54%. Of these, 41.29% reported abuse by both. Children victimized by adults, regardless of type, were significantly associated to be psychologically abused by their peers (p < .001). Moreover, psychological maltreatment by adults was significantly associated with two peer victimizations: Physical and psychological (p < .001 in both). Regarding HRBs, peer victimized groups showed significantly higher levels of severity than non-victimized, with a higher proportion reporting attempted suicide (p < .05) and psychological or psychiatric treatment (p < .05). Participants victimized only by adults reported higher number of HRBs (p < .01), their victimization was associated to more severe abuse of drugs/alcohol (p ≤ .05), and suicide attempts (p < .05). Those victimized by adults and peers received treatment in higher proportion than non-victims (p < .001). Participants reporting victimization since before 5 years to age of 17, compared with non-victimized, showed more substance abuse (p < .05), attempted suicide (p < .01) and receipt of treatment (p < .05). These findings highlight the relevance of ICAST-R in studying HRBs.

The Temporal Dimension in Maternal Sensitivity Predicting Organized Attachment in Children.

This study analyzed Maternal Sensitivity in the interaction of mother-infant dyads to distinguish different dynamics associated with their attachment group membership - Insecure-Avoidant (A), Secure (B), or Insecure-Resistant (C), with no Disorganized traits - that they developed at 15 months. Participants were 26 eight-month old infants interacting with their mothers in a free-play setting. The analyses used sequential streams of infant actions and maternal responses, and state-space grids to study the temporal organization of the sequences. We examined appropriateness and promptness of the maternal response to infant behavior and a dynamic analysis of the interactive process. In Group B, when the antecedent behavior was infant social approach, the appropriateness of the maternal profile (sensitive vs. intrusive responses) was related to their children's subsequent security. However, how promptly mothers responded was not predictive. Conversely, when the antecedent behavior was infant play, how promptly the mothers responded was associated with securely attached children while mothers' profile of appropriate responses did not distinguish the subsequent quality of attachment. The indices derived from state-space grids were associated with attachment type and distinguished Group C from Groups B and A. However, results from analysis of a specific region of states, 'maternal interfering response to infant social approach,' showed significant discriminant function that correctly classified 78% of Group B, 73% of Group A, and 83% of Group C. Group B infants received less intrusive behavior than their counterparts, and when they did, it involved positive affection or playfulness. Finally, regarding attractors, although more Group B dyads showed multi-stability of coexisting attractors, than Groups A or C, the differences were not statistically significant.

Childhood victimization by adults and peers and health-risk behaviors in adulthood

Victimization experienced in childhood has been linked with health-risk behaviors (HRBs) in adulthood. The purpose of this cross-sectional survey was to provide data regarding the HRBs using the ISPCAN Child Abuse Screening Tool Retrospective version (ICAST-R), Spanish version. This aimed to broaden existing knowledge by assessing both being victimized by adults and by peers in a Spanish general population of 348, aged 18-35. Age and timing of the reported victimization were also considered. Victimization: physical, psychological, sexual abuse by adults and/or peers showed a prevalence of 44.54%. Of these, 41.29% reported abuse by both. Children victimized by adults, regardless of type, were significantly associated to be psychologically abused by their peers (p < .001). Moreover, psychological maltreatment by adults was significantly associated with two peer victimizations: Physical and psychological (p < .001 in both). Regarding HRBs, peer victimized groups showed significantly higher levels of severity than non-victimized, with a higher proportion reporting attempted suicide (p < .05) and psychological or psychiatric treatment (p < .05). Participants victimized only by adults reported higher number of HRBs (p < .01), their victimization was associated to more severe abuse of drugs/alcohol (p ≤ .05), and suicide attempts (p < .05). Those victimized by adults and peers received treatment in higher proportion than non-victims (p < .001). Participants reporting victimization since before 5 years to age of 17, compared with non-victimized, showed more substance abuse (p < .05), attempted suicide (p < .01) and receipt of treatment (p < .05). These findings highlight the relevance of ICAST-R in studying HRBs

No disponible

Parental and Infant Gender Factors in Parent-Infant Interaction: State-Space Dynamic Analysis.

This study aimed to investigate the influence of parental gender on their interaction with their infants, considering, as well, the role of the infant's gender. The State Space Grid (SSG) method, a graphical tool based on the non-linear dynamic system (NDS) approach was used to analyze the interaction, in Free-Play setting, of 52 infants, aged 6 to 10 months, divided into two groups: half of the infants interacted with their fathers and half with their mothers. There were 50% boys in each group. MANOVA results showed no differential parenting of boys and girls. Additionally, mothers and fathers showed no differences in the Diversity of behavioral dyadic states nor in Predictability. However, differences associated with parent's gender were found in that the paternal dyads were more "active" than the maternal dyads: they were faster in the rates per second of behavioral events and transitions or change of state. In contrast, maternal dyads were more repetitive because, once they visited a certain dyadic state, they tend to be involved in more events. Results showed a significant discriminant function on the parental groups, fathers and mothers. Specifically, the content analyses carried out for the three NDS variables, that previously showed differences between groups, showed particular dyadic behavioral states associated with the rate of Transitions and the Events per Visit ratio. Thus, the transitions involving 'in-out' of 'Child Social Approach neutral - Sensitive Approach neutral' state and the repetitions of events in the dyadic state 'Child Play-Sensitive Approach neutral' distinguished fathers from mothers. The classification of dyads (with fathers and mothers) based on this discriminant function identified 73.10% (19/26) of the father-infant dyads and 88.5% (23/26) of the mother-infant dyads. The study of father-infant interaction using the SSG approach offers interesting possibilities because it characterizes and quantifies the actual moment-to-moment flow of parent-infant interactive dynamics. Our findings showed how observational methods applied to natural contexts offer new facets in father vs. mother interactive behavior with their infants that can inform further developments in this field.

Mother-Infant Verbal and Nonverbal Interaction as Predictor of Attachment: Nonlinear Dynamic Analyses.

This longitudinal study examined flexibility in early mother-infant interaction at the age of approximately 6 months (N=30) and whether flexibility indices predicted (in) secure child attachment at 15 months. Dyadic flexibility was measured using dynamic systems-based modelling of patterns during mother-child free play in terms of NDS variables derived from SSG: the propensity to change states (dynamic flexibility), number of states visited (diversity) and predictability (dispersion). Results showed significant discriminant functions on the attachment type groups, A, B & C, for the total grid, which included verbal and non-verbal, and for the reciprocal verbal region. Specifically, the prediction outcomes seem to work better in total grid for A-dyads and in the reciprocal verbal region for B and C-dyads. Diversity emerged as the most relevant index in dyadic flexibility: A-dyads showed the least diversity, distinguished them from B-dyads in the verbal regions, (both the reciprocal and non-reciprocal, 'child verbal-mother non-verbal' one), and, from C-dyads in the reciprocal non-verbal region. A-dyads showed remarkably low activity in the regions involving child verbal behavior, showing that children who became avoidant attached at 15 months of age, were mostly silent at approximately 6 months, when they interacted with their mothers. Findings in this study contribute to advancing conceptually informed measurement of dyadic interaction to provide a new perspective on maternal sensitivity and early markers of child insecure/secure attachment.

The mediating role of self-compassion in the relationship between victimization and psychological maladjustment in a sample of adolescents.

The objectives of the present study were to analyze the relationship between victimization and psychological maladjustment in adolescents and the role of self-compassion as a mediator in this relationship. The sample was composed of 109 adolescents aged from 15 to 18 years old with poor school performance. The participants filled out a battery of questionnaires made up of: a socio-demographic data questionnaire; the Juvenile Victimization Questionnaire (JVQ); the Youth Self-Report (YSR); and the Self-Compassion Scale (SCS). Results indicated that victimization was positively associated with psychological maladjustment. Moreover, adolescents reporting poly-victimization showed significantly higher level of psychological maladjustment and different types of victimization show different effects on adolescents' psychological maladjustment. Self-compassion partially mediated the relationship between victimization and psychological maladjustment and reduced negative consequences in adolescents who reported having been victimized. Adolescence is a time of development and search for identity in which strengthening personal protective factors could help overcome any traumas experienced. Therefore, developing self-compassion in adolescence could be a good way to help young people recover from bad experiences and protect themselves against future negative experiences. As self-compassion can be improved with practice it could be included in adolescent intervention and prevention programs.

Dose-effect on the mothers and babies attending the Programa de Apoyo Psicológico P/Materno-Infantil© / Efecto de la dosis de intervención del Programa de Apoyo Psicológico P/Materno Infantil© sobre las madres y sus bebés

Se analizan los efectos de la dosis de intervención del Programa de Apoyo Psicológico P/Materno Infantil© (Cerezo 1992). Es un Programa dirigido a toda la población, que apoya a los padres durante los primeros 18 meses de vida del bebé, cuyo objetivo es promover sistemas adaptativos protectores en los niños. Los efectos de la dosis de intervención se evalúan sobre las madres, en sus niveles de distrés o malestar psicológico informado por ellas, y sobre sus bebés, en el tipo de apego que desarrollan evaluado con la "Situación Extraña" de Ainsworth y colaboradores (1978). La muestra son 342 familias que acuden al Programa entre 2 y 4 visitas antes de la evaluación post-intervención. Los resultados indican que se requieren al menos 3 sesiones de intervención para que se produzcan descensos significativos de las puntuaciones que obtienen las madres en distrés entre la evaluación pre y post. La proporción de niños con apego seguro es mayor cuando la familia acude 3 ó 4 visitas que cuando acude 2. También, se observa que las madres de niños con apego inseguro tienen puntuaciones más altas en distrés, y en otros factores que afectan la parentalidad, que las madres de niños con apego seguro

This paper presents an analysis of the intervention dose-effect of the Parent Child Psychological Support Program© (Cerezo 1990) a program aimed at promoting protective adaptive system in children which is offered to all newborns in a given catchment area. The program offers support to parents during the first 18 months of the baby’s life. The program dose-effect is examined regarding the parents by examining the level of distress reported by them and with babies by examining the development of attachment using the Strange Situation test of Ainsworth et al. (1978). The study is based on 342 families who made between 2 and 4 visits to the Pro-gram before being evaluation post-intervention. The results indicate that at least 3 program sessions are required to produce a significant decrease in the distress scores for mothers, between pre and post evaluation. The pro-portion of children with secure attachment is greater when the family attends 3 or 4 times, compared to those who attend on 2 occasions. It was also noted that mothers of children with insecure attachment had higher scores on the maternal distress and other factors affecting parenting than mothers of children with secure attachment

Supporting parenting of infants: evaluating outcomes for parents and children in a community-based program.

This research presents an evaluation of the intervention dose-effect of the Parent-Child Psychological Support Program (PCPS). The PCPS is a universal community-based program to support parenting, during the first 18 months, and to promote protective adaptive systems in children through a schedule of quarterly office-based appointments, starting at 3 months of age. Generally children attend for six visits. When the Program opens in a particular area, parents of all children under 18 months are invited. The different ages of the children who are joining present a unique opportunity to obtain groups to evaluate the program dose-effect using a cohort-sequential design. This dose-effect on parent and infant outcomes was examined by: (1) self-report of parental sense of competence and factors negatively affecting their parenting and (2) the quality of the child's attachment, using Ainsworth's Strange Situation Test. The study was based on 594 families. Results showed dose effects for parental sense of competence, in the parental self-efficacy dimension. The proportion of securely attached children was significantly higher in groups with medium and high program dose. These results were obtained after considering the effect on the parent and child outcomes of two socio-demographic factors that showed differences among the groups under study: single parenthood and working at home. In the variables under study the PCPS, serving a socially deprived area, showed dose effects. The evaluation strategy can be useful for evaluators and planners working with universal programs that offer a longitudinal service.

Mother-infant interaction and quality of child's attachment: a nonlinear dynamical systems approach.

The traditional classification of infant attachment described three distinct types (Ainsworth et al. 1978): Secure (B), Insecure-avoidant (A), and Insecure-resistant (C). Research shows that the quality of infant attachment reflects the child's history of interaction with their primary caregiver and, therefore, maternal sensitivity and appropriateness of maternal responses during the first year of life has been found to predict infant attachment. In this study Nonlinear Dynamic Systems (NDS) approach was applied to broaden the study of maternal sensitivity into the overall temporal organization of mother-infant relationship exchanges. The study focuses on understanding the differences between secure and insecure attached children by applying NDS in two temporal scales: real time and a developmental scale, with the notions of 'flexibility' and 'self-organization', respectively. Infants, classified as securely or insecurely attached at 15 months, had free-play situations with their mothers, at 6 and 12 months of age, videotaped and coded in real time. Results showed that at 6 months dyads from the B group, compared to the non-B group, showed higher flexibility through several NDS indices derived from the State-Space Grid method (SSG). The dyads at 12 months did not show differences in those indices. Moreover, B group showed self-organization by decreasing the number of attractors, from 6 to 12 months of infant's age, in contrast with A and C groups that either showed less self-organization, by increasing the number of attractors, or stayed basically as they were at 6 months. Furthermore, the B group showed an increase in the proportion of attractors with higher values from time 1 to time 2, in contrast to the non-B groups. Findings provide some grounds for using a SSG approach to deepen the construct of maternal sensitivity in dyadic terms.

Proteger a la infancia: Apoyando y asistiendo a las familias / No disponible

Las investigaciones realizadas en las últimas décadas han permitido identificar los factores de riesgo y los procesos relevantes en ladinámica del maltrato infantil, subrayando la importancia de las actuaciones dirigidas a las familias con el objetivo de intervenir enlas relaciones familiares disfuncionales promoviendo el buen trato a la infancia.El presente trabajo se centra en el contexto familiar como objetivo de intervención, especialmente en su vertiente de contexto para ladetección temprana y la prevención. Se aborda el tema de las buenas prácticas parentales y el apoyo a familias en la crianza de sushijos como factores protectores.Se presenta el Servicio Especializado de Atención a la Familia e Infancia como ilustración de una actuación de intervención y losprogramas “Apoyo Personal y Familiar” (APF) y Programa de Apoyo Psicológico P/Materno Infantil © (PAPMI), como ilustracionesde programas de prevención evaluados, dirigidos al apoyo a los padres y a la promoción del buen trato a la infancia.Los datos subrayan la importancia de la prevención primaria especialmente en momentos de crisis económica en los que pueden aumentarlos factores que afectan negativamente a la interacción familiar (AU)

Research carried out in recent decades has identified risk factors and relevant processes in the dynamics of child abuse. Such researchhas highlighted the importance of assisting families, with a view to intervening in dysfunctional parent-child relations and promotingpositive parenting, especially for younger children. The present paper focuses on the family context as a target of intervention,especially in the area of early detection and prevention. We consider good parenting practices and support for families in child-rearingas protective factors. The “Servicio Especializado de Atención a la Familia e Infancia” programme is presented as an illustrationof intervention. Two evidence-based programmes are also presented as illustrations of prevention strategies: “Apoyo Personal y Familiar”(APF) and Parent Child Psychologycal Support Program (PCPS). The main goals of these programmes are to provide supportfor parents in their child-rearing and to promote children’s well-being. Our paper highlights the importance of primary preventionand family intervention, which are particularly relevant in times of economic crisis, because those factors affect family life and increasethe risk situation for children (AU)

Mother-infant interaction and children's socio-emotional development with high- and low-risk mothers.

Charting the dynamic character of mother-infant interaction requires using observational systems of sequential coding in real time. A longitudinal study was designed to approach maternal sensitivity in a more complex way using sequential analysis. The study was conducted with 20 high- and 20 low-risk mothers and their infants (aged: 3, 12 and 15 months) to examine the relation among mothers' risk status for physical abuse and their maternal interactive profiles, using micro-social sequential analyses, and the subsequent quality of attachment developed by their children at 15 months of age. Results showed significantly different timings in maternal responses in high- and low-risk groups, that the high-risk mothers were less sensitive: more intrusive and less discriminate regarding their infant's behavior. Significant differences between groups were also found after infant difficult behavior. High-risk mothers' infants were significantly more likely to develop insecure attachment. Sensitivity is proposed as a constellation of timings in early mother-infant interaction.

Interacción temprana madre-hijo y factores que afectan negativamente a la parentalidad / Early mother-infant interaction and factors negatively affecting parenting

El modelo del procesamiento de información social contribuye a identificar los procesos psicológicos subyacentes al constructo de «sensibilidad» en interacción madre-hijo. Los estados emocionales negativos por inadecuada autorregulación materna ante los estresores afectan sus habilidades atencionales y estadios del procesamiento de las señales infantiles llevándola a actuaciones menos sensibles: respuestas inoportunas, asincrónicas, particularmente insatisfactorias cuando el bebé manifiesta quejas/ llanto porque no le proporcionan la autorregulación emocional necesaria. Este estudio microsocial explora perfiles interaccionales secuenciales de reacciones maternas a conductas infantiles positivas/neutras vs. difíciles y los compara en dos grupos de díadas, uno con madres con alto nivel de factores negativos para la parentalidad y otro con bajo nivel. Las circunstancias desfavorables de madres del grupo alto y sus efectos negativos sobre la interacción se observaron en ciertas reacciones que no discriminaban el antecedente infantil y particularmente tras los estados de arousal negativo del bebé cuando el papel regulador materno es más necesario

The social information-processing model contributes to identifying the psychological processes underlying the construct «sensitivity» in early mother-child interaction. Negative emotional states associated with inadequate self-regulation in coping with stressors affect the mother’s attention skills and the processing of the baby’s signals. This leads to less synchronous parental practices, particularly unsatisfactory when the baby is unhappy, or crying because the required self-regulation is not provided. This micro-social research studies the sequential profile of maternal reactions to the baby’s positive/neutral vs. difficult behaviours and compares them in two groups of dyads, one with mothers who reported high levels of distress and other negative factors for parenting and another group with low levels. The unfavourable circumstances of the high stress group and their negative effects on interaction were observed in some indiscriminate maternal responses and particularly as they reacted to their baby’s difficult behaviour, when the mother’s regulatory role is more necessary

The mothering of conduct problem and normal children in Spain and the USA: authoritarian and permissive asynchrony.

Ninety-two clinic-referred and nonclinical mother-child dyads in Spain and the USA were observed in their home settings under naturalistic conditions for a total of 477 hours. Children in the clinic-referred dyads were considered troubled because of conduct problems. The observations were aimed at assessing two forms of mother-child asynchrony, either of which was expected to differentiate clinic referred from nonclinical dyads. Authoritarian asynchrony was defined as a mother's indiscriminate use of aversive reactions to her child, whereas the permissive form entailed indiscriminate positive reactions. Results showed the American mothers to generate more permissive asynchrony, whereas the Spanish mothers were inclined in the authoritarian direction. Only authoritarian asynchrony differentiated the clinical versus nonclinical dyads in each country. Discussion was centered on the greater salience of aversive as opposed to positive maternal attention, and cultural differences between countries that might have accounted for the different parenting styles.

The mothering of conduct problem and normal children in Spain and the USA: authoritarian and permissive asynchrony

Ninety-two clinic-referred and nonclinical mother-child dyads in Spain and the USA were observed in their home settings under naturalistic conditions for a total of 477 hours. Children in the clinic-referred dyads were considered troubled because of conduct problems. The observations were aimed at assessing two forms of mother-child asynchrony, either of which was expected to differentiate clinic referred from nonclinical dyads. Authoritarian asynchrony was defined as a mother’s indiscriminate use of aversive reactions to her child, whereas the permissive form entailed indiscriminate positive reactions. Results showed the American mothers to generate more permissive asynchrony, whereas the Spanish mothers were inclined in the authoritarian direction. Only authoritarian asynchrony differentiated the clinical versus nonclinical dyads in each country. Discussion was centered on the greater salience of aversive as opposed to positive maternal attention, and cultural differences between countries that might have accounted for the different parenting styles (AU)

Se observaron a noventa y dos díadas madre-hijo clínicas y no clínicas en España y USA en el hogar durante 477 horas en total. Los niños de las díadas clínicas se consideraron desajustados por sus problemas de conducta. El objetivo era evaluar dos formas de asincronía madre-niño, que se esperaba diferenciaran las díadas clínicas delas no-clínicas. La «asincronía autoritaria» se definió como el uso materno de reacciones aversivas indiscriminadas hacia el niño, y la «asincronía permisiva» como reacciones indiscriminadas pero positivas. Los resultados mostraron que las madres americanas generaban más asincronía permisiva y las españolas más asincronía autoritaria. Solo la asincronía autoritaria diferenciaba las díadas por su status: clínico versus no clínico en ambos países. La discusión se centró en la mayor saliencia de la atención aversiva frente a la positiva y en aspectos culturales que pueden dar cuenta de los diferentes estilos parentales (AU)

Cambio y estabilidad en los factores que afectan negativamente a la parentabilidad / Change and stability of the factors that affected parenting negatively

En la prevención del maltrato infantil, un área de interés lo constituye el estudio de las variables relacionadas con los factores que afectan negativamente la parentalidad. El propósito de este estudio longitudinal fue detectar en un año las variables que predicen «cambio» (Aumento o disminución) y «no cambio» de esos factores, dentro del programa de prevención «Apoyo Psicológico Materno-Infantil». 520 madres y sus niños de 3 a 18 meses constituyeron el grupo del cual se obtuvo una muestra aleatoria de 85. Los resultados de los análisis discriminantes mostraron que se predice mejor la estabilidad que el cambio. La historia de disciplina punitiva de la madre, la baja satisfacción materna y la percepción de su bebé cuando tenía tres meses explicaban el mantenimiento elevado de dichos factores, mientras que la buena relación de pareja y el mayor nivel de participación en el programa explicaban el mantenimiento bajo en los mismos

In child maltreatment prevention field and parenting support, is very relevant the study of the variables related with the change or stability of those factors that affect parenting negatively. The purpose of this longitudinal study was to detect the predictors of change (increase or decrease) and no-change of those negative factors that affect parenting, in a period of a year, in the context of a preventive programme «Mother child psychosocial support». 520 mothers and their babies aged from 3 to 18 months old constituted the group from which a sample of 85 was randomly selected. The results showed that «no-change» is better predicted than change. Punitive discipline in mother's childhood, low maternal satisfaction and reporting something they don't like in their 3 month babies, predicted to maintenance of high score in the factors under study. Good marital relationship and more visits to the Program predicted the maintenance of low score in those factors

Improving child maltreatment detection systems: a large-scale case study involving health, social services, and school professionals.

OBJECTIVES: The purpose of this 5-year study was to improve detection in two consecutive phases: (a) To close the gap between the number of identified cases and the actual number of cases of child abuse by increasing detection; and (b) To increase the possibility of a broader spectrum of detection. METHOD: The Balearic Islands (one of the Autonomous Communities of Spain, with 161,287 children under 18 years old) was selected as the study area. Phase 1: front-line professionals (181) from all the health and social services agencies were trained in detection. Phase 2, school professionals (251) from all schools in the territory were also trained. The independent factor was the intervention provided to the professionals with training and support. A pre-post design was used over the area, divided in territories, in which the program was gradually implemented to provide within-territory and between-territories controls. RESULTS: Phase 1: Comparison before-after implementation of the program showed that detection was tripled in the Balearic Islands (from .58 to 1.77 per 1,000 children). An unplanned generalization effect was found, and post hoc analysis considering only the islands showed the expected increase. Phase 2: A subsequent increased detection rate was found in Child Protection Services cases 2.18 per 1,000. Of those new cases, 24.5% came from schools, after controlling for duplication. CONCLUSIONS: This detection system showed positive changes after training and supporting frontline health and social services professionals. However, these professionals only have occasional contacts with the child population. Therefore, to broaden the spectrum of detection and to reach more maltreated children, who are less likely to be visible to CPS, it is necessary to train and support school professionals because of the frequency of their contacts with children on an almost daily basis.