Parental Worries, Child Maltreatment Risk and Empowerment: How Are They Noticed in Child and Family Services?

Parental empowerment has been related to their well-being and self-efficacy. Learning more about the signs describing child maltreatment risk are crucial for the welfare of children and families. The aim of this study was to assess the risk of child maltreatment (CM) and related worrying factors of parents and associations between the CM risk, worries and parental empowerment. The study is based on self-report surveys administered to parents in primary health care and hospital settings. The risk of CM and related worrying factors were measured by the Brief Child Abuse Potential Inventory (BCAP) from 453 parents. Family empowerment was measured by The Generic Family Empowerment Scale (G-FES). Parents expressed worries such as loneliness and distress (20%), feelings of persecution (9%), family conflict (17%), rigidity (21%) and financial insecurity (4%). The BCAP found 27 parents with increased risk. Parents with CM risk expressed more empowerment in connection to services for their child and family. It is crucial to discuss worries in child and family services before they raise the risk level. Tools such as the BCAP are useful in systematically identifying the child maltreatment risk and parental worries under discussion, offering possibilities for preventing child maltreatment and increasing well-being of children.


Introduction
The anticipation and prevention of problems in the life control of families and increasing awareness about parental worries are crucial for the well-being of children and families. Without adequate support, parental worries such as loneliness and rigidity in child rearing can lead to risk conditions of child maltreatment (CM). Therefore, services should be arranged on the basis of children's and families' needs [1]. The latest research, both in Finland [2][3][4][5][6][7] and globally [8], shows that children and young people experience a wide range of maltreatment at home, including physical, emotional and sexual violence, neglect and witnessing violence between parents. Preventing CM by knowing more about parental worries and possible family risk situations is a priority for multi-professional child and family services [9][10][11].
CM is defined as physical abuse, including violent punishment, sexual and emotional violence and neglect of children under 18 years of age carried out by their caregivers [12]. For example, according to Paavilainen and others [13] family functioning in CM families (meaning interaction, stability, flexibility and roles) is inferior to other families. It could also be connected with poorer family well-being. The parental risk of CM could be estimated by known risk factors in family life [14][15][16][17][18][19]. In addition, by determining a family's level of risk, asking parents their concerns and supporting family functioning, the risk of CM can possibly be reduced and prevented [20,21]. Future research should focus more on basic child and family services to identify those who have a risk of CM and who need more support [22]. Earlier research evidence shows that the accumulation of risk factors puts children at risk for maltreatment. Children exposed to a cumulative risk at least once in early development, compared to those with no risk exposure, showed a significantly higher likelihood of an abnormal level of problem behaviors [23,24]. Therefore, it is necessary to develop ways to notice parental worries before escalating.
One of the Health 2020 priority areas is "investing in health through a life-course approach and empowering people" emphasizing comprehensive, continuous, ethical, safe and sustainable health services [25]. Parental empowerment signifies parents' sense of confidence, for instance, dealing with services use with their children [26][27][28]. Strong empowerment is associated with parents' resilience to demands and their confidence to make decisions and take actions positively affecting their families [29][30][31]. Empowerment is also connected with internal resources [32], creating the conditions that allow the individual to participate and make decisions about their own family, organizations and society. Empowerment varies in different life situations at the levels of individual, family, social network, service system, municipality and society [26,32,33]. In those situations, empowerment includes a parent's sense of knowledge, understanding and rights associated with their child's services and their sense of confidence in collaborating with professionals, participating in decision making and acting in ways that ensure access to the requisite services [26,34].
The aim of this study was to describe parental worrying factors linked to risk of CM and how parents express empowerment connected to health care services, especially for children. We aimed to increase professionals' knowledge and provide early support to prevent CM. The objectives of the study are to describe worries, CM risk and empowerment from a parental perspective. Furthermore, associations between background variables, maltreatment worries, risk and family empowerment are described.

Materials and Methods
In this study, the short form of the Child Abuse Potential Inventory (BCAP) [14,15,35] was used to assess the risk of CM and worrying factors involved in families in the general population. The Generic Family Empowerment Scale (G-FES) was used to measure parental empowerment connected to health care services, especially for children [36,37].
Between January 2017 and March 2018, the BCAP and G-FES were delivered to parents prior to an ordinary appointment to a primary maternity health care clinic, a child health care clinic and a maternity outpatient clinic, or during the child's admission in the general pediatric ward, the surgical ward or the neonatal intensive care unit in the hospital. Surveys were given to parents expecting children and to parents with children of different ages, and could be answered together or separately. In all contexts, after the parents returned the questionnaire, all the worrying items were discussed together with the parent, documented by the nurse and relevant support actions were commenced. Nurses, midwifes and primary health care nurses were trained beforehand on how to use BCAP, encounter and start a solution-based dialogue with the parent, document appropriately sensitive issues and contact and start supportive actions [38].
The study protocol was approved by the Research Ethics Committee of Pirkanmaa Hospital District in Southern Finland (R11198H). Permission was also obtained from the research sites. The information stressed that participation in the study was completely voluntary and free to withdraw at any time [39,40].

Background Variables
Background questions are listed in Table 1.

Brief Child Abuse Potential Inventory (BCAP)
The BCAP [35] is a short version of the CAP [14] and has been shown to be a valid screening measure, especially for child physical abuse potential on several countries [35,41], including Finland [15,16,42,43]. According to Milner and Crouch [42], the BCAP is the most psychometrically sound scale of all CAP short versions that have been developed. In the Finnish general population, internal reliability of the BCAP was good (Cronbach's alpha 0.770) [6]. The BCAP was created to retain as much shared variance with the full measure as possible, a stable factor structure and a useful validity scale, and to maximize the BCAP's predictive validity [35]. The BCAP is a forced-choice (agree-disagree) selfreport questionnaire that consists of 25 items and 9 validity items. Seven descriptive factor scales are included: distress, family conflict, rigidity, happiness, feelings or persecution, loneliness, and financial insecurity. Validation of the BCAP among the Finnish general population resulted in a structure with five sub-scales: loneliness and distress (9 items), problems with others (4), family conflict (3), rigidity (3) and financial insecurity (2) [6]. Factors used combine measuring the risk-no risk cut-off point. In the BCAP, each item receives a score of 1 [35,41].
In our study, the BCAP was utilized in a novel way: as a basis for a solution-based dialogue using single items as discussion topics. This was carried out as part of the comprehensive family care to provide early support to prevent CM. We aimed at understanding in detail worries expressed by parents, for example, if a parent agreed with the item "other people have made my life hard", a professional would ask "can you describe in what ways do people make your life hard?" We also counted the risk level, but we did not use this as the only basis of clinical care. We wanted to know if the novel way to use BCAP is useful or not. We also only found 27 families with CM risk in our data and did not want to make conclusions that were too detailed based on the results of 27 families.

The Generic Family Empowerment Scale (G-FES)
Empowerment was measured by the Generic Family Empowerment Scale (G-FES) [36,37], which is based on the Family Empowerment Scale developed for families of children with emotional disabilities [26]. This study used one dimension approach (service situation) to the generic version of the FES (12 items, α = 0.84). It refers to parents' confidence to obtain and influence the services that their children need and use. The G-FES has a 5-point Likert-type rating scale (1 = fully disagree to 5 = fully agree). Higher scores indicate higher levels of empowerment. The original FES [26,36] and the G-FES [44] have proved to be valid and reliable instruments.

Analysis
In the G-FES scale, the variables were combined into three answer categories: "disagree" (1 = fully disagree and 2 = partly disagree), "no opinion" (3 = no disagree, no agree) and "agree" (4 = partly agree and 5 = fully agree). Concerning the BCAP, the risk values were categorized "no risk" (values between 0-5) and "risk" (values over 5). The long CAP Inventory cut-off point of 100 has been used in Finnish setting, which is almost 20% of the maximum score (486). Based on the same reasoning, the appropriate cut-off point for the BCAP would be five [6]. Loneliness and distress, problems with others, family conflict, rigidity and financial insecurity were categorized as zero-point "no worries" and one-point "worries" [6]. Descriptive analysis (e.g., describing of worries) was used for these categorized variables, but comparative analysis was used for continuing variables.
Descriptive statistics were used to examine the demographic data. Statistical analyses were performed using SPSS version 22.0. Frequencies and percentages were computed to describe the data. Fisher's exact test was used to examine the associations between the central variables in relation to family risk. The level of statistical significance was set at p < 0.05. Association between variables was calculated with correlation analysis, Mann-Whitney U test and Kruskall-Wallis H test, depending on variables distribution.

Description of Participants
The BCAP and the G-FES was delivered to 759 parents, of whom, 464 returned the questionnaires. From a reliability point of view, we applied the rule used in the CAP Inventory, that if a respondent has more than 10% missing responses, the questionnaire should be considered invalid. Therefore, those 11 parents having at least three missing responses were excluded from further analysis [6]. Of the final sample of the 453 parents who answered the questionnaire, 373 mothers and 80 fathers were included. The mothers were mostly between 31 and 35 years of age (31%). Most of the parents had one to three children (79% mothers and 83% fathers). Some parents were expecting their first child (See Table 1).

Parental Worries and Risk of Child Maltreatment
There were 426 parents with no CM risk and 27 parents with risk (value over 5) (see Table 1). Though the risk seemed to increase with age and seemed to be more common in parents expecting their first child, statistical significances were not found. The results of the BCAP showed that 20% of parents reported being worried about loneliness and distress (76% had no worries), 9% reported worries of having problems with others (90% had no worries), 17% reported family conflict (83% had no worries), 21% reported rigidity (74% had no worries) and 4% reported financial insecurity (96% had no worries).
Statistically significant (p < 0.001) differences were found between parents in BCAP sub-scales as follows: There was no association found with gender (see Table 2). Older parents more often experienced family conflict (less than 25 Table 2).

Parental Empowerment
Parental empowerment was quite high in all parents (see Table 3). There was only statistical significance between no-risk and risk parents answers; "When necessary, I take the initiative in looking for services for my child and family". Risk parents in this situation were more empowered (p = 0.023).  No statistically significant association was seen between empowerment and background variables in the risk parents' group (see Table 4).

Associations between Family Empowerment and Risk of Child Maltreatment
There was some association between BCAP sub-scales and empowerment (see Table 5). Loneliness and distress were associated with five empowerment answers. In all cases, those who were not lonely, were more empowered. Problems with others was associated only for the answer: "my opinion is just as important as a professional's opinion" (different opinion, M = 4.13; same opinion, M = 3.80; p = 0.009). Family conflict was associated with four answers, and in all cases, the same opinion for problems with family was associated with less empowerment. Rigidity was associated with two answers: "able to work with agencies and professionals" (different opinion, M = 4.74; same opinion, M = 4.64; p = 0.038) and "stay in regular contact with professionals" (different opinion, M = 4.26; same opinion, M = 4.06; p = 0.014). In both cases, rigidity was associated with less empowerment. Financial insecurity was associated with four answers (see Table 5). In these cases, insecurity was associated with less empowerment.

Discussion
According to the results of the study, parental empowerment concerning their participation in their children's services was considered to be good. Mothers felt more empowered than fathers in service situations; however, mothers were also the majority of respondents participating the survey. This is well recognized in Finland [37], and there is a clear need to enhance fathers' attendance in family services. Families with no child or one child were more able to make good decisions and wanted professionals to ask their opinion. Families with more children were able to work with professionals and stay in regular contact with them. Empowerment increased for families when they knew the steps required when needing help; they could make good decisions and had a good understanding of the service systems. In earlier studies, these associations have been contradictory [37,[44][45][46][47][48]. According to [49], parents appreciate listening, having their views and feelings acknowledged and getting practical support.
Our data included 27 parents with CM risk. The BCAP seems to work well in finding CM risk. However, the number of families with CM risk in our data is so small that no conclusions can clearly be reached. The BCAP has not previously been used in the sub-scale item level, but in this study, variation in parental worries in item level besides just counting the risk point value was explored. This scale was used to show how parental worries have been expressed already before the risk level cut-off point. The scale was aimed to find worries that should be identified to help parents before they reach the risk level. This way of using the scale developed interesting results and showed that under the risk cut-off point, there were already worries, such as loneliness or rigidity in child rearing, that were important issues to discuss with parents. All items as parents express them are useful in starting discussion with parents. In screening parental maltreatment risk only, the BCAP total score should be considered. Van Looveren et al. [50] also considers this scale useful for assessing CM risk in a systematic manner. During the COVID-19 pandemic, some new studies have shown that families are now lonelier than evert [51,52]. Loneliness was also one of the risk conditions of CM in our study. There have also been shortcomings in receiving support from professionals in child and family services [53]. This may even decrease families' welfare and cause polarization.
However, in this study, it was found that in searching for worries by items, the BCAP can be useful in universal services where all parents with children visit. Parents' answers to the items advance starting discussion concerning parent welfare, e.g., based on a parent telling their feelings alone or having rigid child-rearing thoughts. In clinical practice with parents, starting a discussion based on the worries that parents express by answering the scale items is easier than starting discussion about the risk level based on a mere number that is over a cut-off point. The number itself does not tell us anything about family life; there still remains the need to ask parents to talk about the situation as the basis of further intervening and support [54]. And when the professional who starts a discussion with parent(s) about their life situation sees that that there are several family worries, perhaps over the counted risk level, there is always the possibility to procure multi-professional assessment and support. It is also necessary to start a discussion about CM risk, if the cut-off point is reached.
There are, however, some limitations to this research. The data were collected in seven different units in two different areas of Finland as a part of a research and development project. There is no complete estimate of total sample or power analysis. The response rate of families was 61%, with fathers participating well. However, due to the small number of respondents, the response rate for some variables was quite low, which made it difficult to complete statistical analyses and draw strong conclusions. It is challenging to motivate respondents to participate in this kind of study, which deals with sensitive family issues. However, it is crucial to obtain research evidence on parents' own experiences concerning their family life and services intended to help them and their children. The number of families with CM risk could be even higher among those families who did not participate in this study. Even anonymous feedback from families concerning the services was very challenging to obtain. This can be due to sensitivity of the topic under our study.

Conclusions
Nursing and other professionals working with parents or with those who are expecting children, need tools such as the BCAP, to recognize parents' worries and families in risk situations. In the review on evaluating risks, Gillingham [9] concluded that risk to the safety and welfare of children is difficult to predict and manage. In our present study, we showed that it is possible to identify parents with CM risk using the BCAP. This instrument can be used in many kinds of services meant for families with children. It can serve as a starting point for discussion and as part of a systematic assessment of a family's situation to help recognize the worries of parents. In this way, it is possible to have an impact on those worries before they escalate in order to increase the well-being of children.  Data Availability Statement: Sharing the data compromises ethical standards as it is sensitive data from families. The data included worries and risks, which the parents, besides other private issues on family life, offered to researchers in their answers. They were assured their answers would not be shown to any other parties, except for the research team. Accordingly, the authors are not able to share the data.

Conflicts of Interest:
The authors declare no conflict of interest.