Child Abuse & Neglect 126 (2022) 105489

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Multisystemic therapy for child abuse and neglect: Parental stress

and parental mental health as predictors of change in child neglect
Judith Bauch a, b, Stephanie Hefti a, *, Lara Oeltjen b, Tania Pérez a,
Cynthia Cupit Swenson c, Ute Fürstenau d, Bruno Rhiner d, Marc Schmid a
a
Department of Child and Adolescent Psychiatry, Psychiatric University Clinics Basel, University of Basel, Wilhelm-Klein-Strasse 27, 4002 Basel,
Switzerland
b
Department of Psychology, Friedrich Schiller University Jena, Am Steiger 3, Hs.1, 07743 Jena, Germany
c
Division of Global and Community Health, Medical University of South Carolina, 176 Croghan Spur Road, Suite 104, Charleston, SC 29407, United
States
d
Mental Health Service for Children and Adolescents, Spital Thurgau AG, Schützenstrasse 15, 8570 Weinfelden, Switzerland

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Despite high prevalence, child neglect has long been passed over in research. Serious
Child neglect long-term consequences call for effective intervention programs. However, as a result of the lack
Parental stress of research, there is a lack of effective interventions. In order to develop such intervention pro­
Parental mental health
grams and to maximize the effectiveness of existing programs, it is necessary to examine what
Multisystemic Therapy for Child Abuse and
Neglect (MST-CAN)
factors are related to the reduction of neglect and, subsequently, what change mechanisms their
effectiveness is based on.
Objective: In this intervention study we investigated whether changes in parental mental health
and parental stress after Multisystemic Therapy for Child Abuse and Neglect (MST-CAN), an
effective evidence-based intervention program for child neglect, are related to changes in child
neglect.
Participants and setting: Study participants were 144 parent-child dyads participating in the MST-
CAN program.
Methods: We analyzed changes from pre- to post-treatment in child neglect, parental mental
health, and parental stress, and conducted a multiple regression analysis to examine whether
changes in parental mental health and parental stress predict changes in child neglect.
Result: Our results showed that child neglect, as well as parental stress, significantly decreased
and parental mental health significantly improved during the program. While improvements in
parental mental health were not related to the reduction of child neglect, a decrease in parental
stress significantly predicted the reduction of child neglect.
Conclusion: These findings suggest that parental stress might be a promising target for evidence-
based intervention programs to reduce the occurrence of child neglect. Implications and sug­
gestions for further research are discussed.

* Corresponding author.
E-mail addresses: stephanie.hefti@upk.ch (S. Hefti), lara.oeltjen@uni-jena.de (L. Oeltjen), tania.perez@upk.ch (T. Pérez), swensocc@musc.edu
(C.C. Swenson), ute.fuerstenau@stgag.ch (U. Fürstenau), Bruno.rhiner@stgag.ch (B. Rhiner), marc.schmid@upk.ch (M. Schmid).

https://doi.org/10.1016/j.chiabu.2022.105489
Received 9 November 2021; Accepted 7 January 2022
Available online 25 January 2022
0145-2134/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
J. Bauch et al. Child Abuse & Neglect 126 (2022) 105489

1. Introduction

Child neglect has been perceived as an under-studied issue in the literature on child maltreatment for almost four decades now
compared to other forms of maltreatment such as physical or sexual abuse. Wolock and Horowitz (1984) first referred to this problem
as “the neglect of neglect.” The formulation remains in use today (Dubowitz, 2007; McSherry, 2007; Mulder et al., 2018), and evidence
shows that studies specifically examining child neglect are rare (Mulder et al., 2018; Stith et al., 2009; Stoltenborgh, Bakermans-
Kranenburg, & Van Ijzendoorn, 2013). This state of affairs seems paradoxical given that child neglect is the most prevalent form of
maltreatment (Stoltenborgh et al., 2011; Stoltenborgh, Bakermans-Kranenburg, & Van Ijzendoorn, 2013; Stoltenborgh, Bakermans-
Kranenburg, Van Ijzendoorn, & Alink, 2013).
Serious long-term consequences of child neglect, such as dropping out of school, social impairment, developmental delays, mental
health disorders, chronic diseases, and even suicidality (Choe, 2021; Cohen & Thakur, 2021; Dobson et al., 2021; Gould et al., 2012;
Norman et al., 2012; Power et al., 2020; Turner et al., 2019), call for evidence-based practices that specifically address child neglect.
However, because of the “neglected neglect” there is a lack of effective intervention programs and high-quality outcome evaluations
(Isokuortti et al., 2020). In a meta-analysis examining the effectiveness of intervention programs for child maltreatment, Euser et al.
(2015) found five interventions to be effective in preventing and reducing child maltreatment. Of those five interventions, only two
address child neglect (Parent-Child Interaction Therapy, Chaffin et al., 2004; Multisystemic Therapy for Child Abuse and Neglect
[MST-CAN], Swenson et al., 2010), and only one, namely MST-CAN, showed an effective reduction of child neglect (Swenson et al.,
2010).
One difficulty that arises when developing evidence-based interventions is that multiple factors regarding child, parent, and family
characteristics, and their interaction with one another, influence the risk of child neglect and therefore need to be addressed (Mulder
et al., 2018; Stith et al., 2009). Besides a few risk factors on the child's level (e.g., externalizing behaviors), it is mainly risk factors
relating to parents (e.g., mental health, substance misuse, unemployment), parent-child interaction (e.g., parents' perception of the
child, parental stress), and the family (e.g., conflicts, low social support, socioeconomic status) that are associated with child neglect
(Stith et al., 2009; Zhang et al., 2021).
On a parental level, one substantial risk factor is parental mental health. There is evidence that parents who struggle with mental
health problems are at greater risk of displaying seriously neglectful behavior (Lee et al., 2012; Mulder et al., 2018; Stith et al., 2009).
Parents who suffer from mental health problems might have more difficulties in meeting their children's needs, which makes child
neglect more likely. For a parent suffering from loss of interest, enjoyment of life, or motivation to get up in the morning, it might be
more challenging to prepare regular meals, provide adequate clothing, supervise the child, or respond to the child's emotional needs.
This hypothesis is supported by a study by Roscoe et al. (2018), who reported that the homes of parents with mental health problems
were twice as likely to be assessed as an environment that is not safe for their children. Most of this effect resulted from the fact that
parents' caregiving was impaired due to emotional instability, developmental status, or cognitive deficiency, with parents failing to
meet their child's immediate needs. In a more recent study with a larger sample size and more precise mediation models, the authors
found evidence that failure to meet immediate needs of the child was the major mediator between current and chronic mental health
problems on the one hand and assessments of child safety on the other (Roscoe et al., 2021). The authors concluded that providing
high-quality mental health services for parents might make it possible to recover their caregiving and parenting skills and prevent the
recurrence of maltreatment (Roscoe et al., 2018).
On the level of parent-child interaction, parental stress plays a crucial role for child neglect. Parental stress refers to a negative or
aversive psychological reaction towards parenthood that occurs when parental demands such as caregiving responsibilities exceed
parents' capacities to meet them (Deater-Deckard, 1998, 2004). Besides daily stressors, such as unemployment or a lack of parenting
skills, major life events, such as a child's severe physical or mental illness, are also related to this psychological reaction (Barroso et al.,
2018; Guajardo et al., 2009; Nomaguchi & Johnson, 2016). If parents have enough resources in these situations, such as cognitive
coping strategies or social support, they might be able to cope with their parenting demands and may not experience parental stress.
However, parents who have low resources might not be able to cope with the parental stressors, which might lead to parental stress. In
particular, single parents are at greater risk of parental stress (Anderson, 2008).
Several studies relate parental stress to child neglect. Higher levels of parental stress have been found in parents who were at
greater risk of child neglect (Nair et al., 2003) or who did indeed neglect their children (Lee et al., 2012; Taylor et al., 2009). Parental
stress reported by mothers when their child was aged three years or younger predicted child neglect at the age of five years (Lee et al.,
2012), and chronic parenting stress is associated with child neglect (Mikolajczak et al., 2018). Evidence from a meta-analytic
perspective also suggests parental stress to be a substantial risk factor for child neglect (Stith et al., 2009).
In a stress and coping model of maltreatment, Hillson and Kuiper (1994) give a possible explanation for why the failure to deal with
stressors relating to parenthood might encourage neglectful parenting behavior. Negative feelings of shame, hopelessness, or failure
might emerge because parents do not have the capacity to cope with stressors and parental stress arises. In order to avoid these
emotions, parents might withdraw caring behaviors or engage in activities to distract themselves from the stressful events (Hillson &
Kuiper, 1994). Indeed, studies have reported that parents with high parental stress showed less nurturance, less parental sensitivity,
less parental responsiveness, lower caregiving involvement, and more rejecting responses towards their children (Chan et al., 2018;
Coates & Phares, 2019; Fagan et al., 2007; Kahng et al., 2008; Mori et al., 2009; Pelchat et al., 2003; Pereira et al., 2012; Pereira et al.,
2015; Ponnet et al., 2013; Ward & Lee, 2020). Intervention programs that address parental stress by strengthening parents' resources
and their capacity to cope with parental stressors might reduce the probability of neglectful behavior.

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1.1. MST-CAN as an effective intervention program for child neglect

An intervention program for families that addresses risk factors for child neglect on several possible levels is the above-mentioned
MST-CAN program (Buderer et al., 2020; Hefti et al., 2020; Swenson et al., 2010). It was developed from standard Multisystemic
Therapy (Henggeler et al., 2009), which originally targeted youths with serious antisocial behavior and their families. The underlying
theoretical framework of MST-CAN is Bronfenbrenner's social ecological model (Bronfenbrenner, 1979). The theory states that in­
dividuals and their development are embedded in and influenced by multiple systems (e.g., parents, siblings, school, work, and
neighborhood), each interacting with the individual as well as the others. MST-CAN identifies risk factors that are conducive to child
neglect and abuse in these systems and in the interactions between them. Evidence-based psychotherapeutic methods (e.g., cognitive
behavioral therapy, behavioral therapy, trauma therapy) are then applied to the child, the parents, and the siblings to address mental
health difficulties on the basis of the risk factors identified.
MST-CAN has been found to be effective in reducing child neglect (Buderer et al., 2020; Swenson et al., 2010). Swenson et al.
(2010) found in their randomized controlled trial (RCT) that MST-CAN was more effective in reducing child neglect 16 months post-
baseline compared to enhanced outpatient treatment, with large effect sizes. Furthermore, MST-CAN successfully addresses risk factors
on the child's level, such as externalizing behaviors (Swenson et al., 2010), and on the parental level, such as mental health or social
support (Hefti et al., 2020; Swenson et al., 2010). A trend in decreasing parental stress has been found on the level of parent-child
interactions (Hefti et al., 2020).

1.2. Purpose of the current study

Previous published studies have reported the positive impact of MST-CAN on subsets of the sample described in the present study: it
significantly reduced child neglect (Buderer et al., 2020), significantly improved parental mental health, and decreased parental stress
(Hefti et al., 2020). What remains unclear is whether and how these changes in parental mental health and parental stress are linked to
changes in child neglect.
Addressing factors related to the reduction of child neglect is fundamental if further work is to determine the mechanisms on which
effective interventions are based. Understanding the theoretical foundation of interventions might facilitate the development and
implementation of intervention programs that target the reduction of child neglect. This is particularly relevant considering the
marked lack of research on the subject of child neglect and strategies for preventing it (Ruiz-Casares et al., 2020). Although there are
some studies examining formal components of effective interventions (Temcheff et al., 2018; van der Put et al., 2018), there is a lack of
studies throwing light on the theoretical conceptualization of intervention programs. Furthermore, understanding specific change
mechanisms in interventions maximizes their effectiveness (Barth, 2009). This is particularly relevant given that in the context of MST-
CAN there are studies reporting its effectiveness, but none of them investigates which characteristics make it a successful model.
Swenson et al. (2010) pointed out that this needs to be addressed in a next step following their randomized controlled trial.
Before change mechanisms can be explicitly examined, the factors to focus on need to be identified. Therefore, in a first step it is
necessary to consider what factors relate to the reduction of child neglect. To the best of our knowledge, there are no studies examining
which of the factors addressed by a neglect-focused intervention program are connected to changes in child neglect. Therefore, the aim
of the current intervention study was to analyze whether changes in parental mental health and parental stress reported by parents are
directly associated with changes in child neglect reported by professionals. We hypothesized that changes in parental mental health
and parental stress after MST-CAN significantly predict changes in child neglect.

2. Methods

2.1. Participants

The participants in the study were parent-child dyads from families who were referred to the MST-CAN intervention program in
Thurgau and Basel in Switzerland between 2011 and 2019 by child welfare agencies or child protection services. Referrals were made
based on a report of physical abuse or neglect in the past 180 days documented by a social worker. Families were included in the
intervention program if the focal child was between the age of 6 and 17 years, and not suicidal, homicidal, psychotic, or diagnosed with
autism spectrum disorder level 2 or 3 (DSM; American Psychiatric Association, 2013). Children were required to be living either with
their families or in foster care with the prospect of being reunited with them soon. Exclusion criteria were active sexual abuse, active
severe domestic violence, and active parental psychosis. All families who met the criteria were included in the intervention program.
The focal child and the focal parent were invited to participate in the study.
Of the families approached (N = 230), 160 parents gave their informed consent to participate in the study. Due to intervention
dropouts, we excluded 16 parent-child dyads (10%). Reasons for drop-out were lack of engagement (n = 8, 50%), out-of-home care
placements (n = 2, 12.5%), administrative withdrawals (n = 2, 12.5%), lack of funding (n = 2, 12.5%), and family relocation (n = 2,
12.5%). Parent-child dyads whose families dropped out of the intervention program did not differ significantly from dyads whose
families completed the intervention program in terms of demographic measures (i.e., age, sex, and household income), severity of
initial child neglect, level of parental mental health, or parental stress. The final sample consisted of a total of 144 parent-child dyads.

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2.2. Intervention

Participating families received two to three MST-CAN treatment sessions per week applied by one therapist. The sessions took place
at the families' homes over a period of six to nine months. Risk factors for child abuse and neglect were identified in an initial diagnostic
assessment spanning several weeks. Based on the risk factors identified and the families' needs, evidence-based intervention methods
were then chosen and applied to the families to address and reduce specific risk factors. If indicated, a psychiatrist provided phar­
macotherapy for the children. An on-call service (24 h a day, seven days a week) was available for all families to manage any crises that
developed outside working hours. A more detailed description of the intervention program and its core treatment principles can be
found in Swenson et al. (2010), Swenson and Schaeffer (2018), and in the MST-CAN manual (Swenson et al., 2011).
Nineteen therapists applied the intervention program. The therapists worked in teams of three to four supported by a crisis
caseworker. They were supervised by a team supervisor, with group supervision sessions on a weekly basis and individual supervision
as needed. The team also had weekly consultations with an MST-CAN expert to support adherence to the model. The caseload was
between three and four cases per therapist. All therapists were required to take a five-day training session in Multisystemic Therapy
(MST; Henggeler et al., 2009), a four-day training session in MST-CAN, and a four-day training session in trauma therapy. Every three
months, all therapists received booster training from their MST-CAN expert to ensure the ongoing quality of the intervention program.
Treatment fidelity was further ensured using the Multisystemic Therapy Adherence Scale – Revised for Child Abuse and Neglect (TAM-
CAN-R; Swenson, 2010). TAM-CAN-R is a revised version of the Therapist Adherence Measure – Revised (TAM-R; Henggeler et al.,
2009), which is a reliable and valid measure of therapists' adherence to the nine core MST treatment principles (Schoenwald et al.,
2008, 2009).

2.3. Data collection

Ethical approval for the study was obtained from two Swiss ethics committees (Ethikkommission Ostschweiz, Ethikkommission
Nordwest- und Zentralschweiz). The data used in the present study were collected between July 2011 and December 2018 in Thurgau
and between November 2014 and September 2020 in Basel. All data presented in this study were collected at the start (pre-treatment)
and at the end of the intervention (post-treatment). Participating parents and children completed a set of questionnaires with the help
of research assistants at these two time points. Both received a shopping gift card after the post-treatment assessment (35 CHF for the
parent and 15 CHF for the child). External assessments of child neglect were conducted at both time points by the caseworker working
for the referring child welfare agency or child protection service.

2.4. Measures

Child Neglect. To measure child neglect we used the Ontario Child Neglect Index (CNI; Trocmé, 1996), which assesses the severity of
child neglect on six scales reflecting different forms of neglect (i.e., supervision, nutrition, clothing and hygiene, physical health care,
mental health care, developmental/educational care). A four- to five-level rating (i.e., “adequate”, “inconsistent”, “inadequate”,
“seriously inadequate”) indicates the severity of each type of neglect and is assigned by a trained child welfare professional. The
underlying model assumes that the six neglect scales represent distinct forms of neglect rather than different components that can be
added together. Therefore, in order to calculate a total score reflecting the severity of neglect, an age score ranging from 0 (13–16
years) to 20 (0–2 years) is added to the highest score among the six scales. The total score for the severity of neglect ranges from 0 to 80,
with higher total scores indicating more severe levels of child neglect. Trocmé (1996) reported a test-retest reliability of the scales
(weighted kappa) varying from 0.83 to 0.91 and an interrater reliability (Pearson's r) for the total score ranging from 0.88 to 0.91. High
correlations between the CNI scales and other neglect scales, such as Child Wellbeing (Magura & Moses, 1986), support strong con­
current validity (Trocmé, 1996). The current study used an unpublished German version of the CNI (Pérez et al., 2017), which was
approved by Trocmé on the basis of a back-translation into English.
Parental Mental Health. To measure parental mental health we applied the Brief Symptom Inventory (BSI, Derogatis & Melisarotos,
1982; German version, Franke, 2000), a 53-item short form of the Symptom Checklist 90 Revised (Derogatis, 1994) that measures self-
reported psychological distress on nine scales (i.e., somatization, obsessive-compulsiveness, interpersonal sensitivity, depression,
anxiety, hostility, phobic anxiety, paranoid ideation, psychoticism). Ratings are based on a five-point scale ranging from 0 (“strongly
disagree”) to 4 (“strongly agree”). Usually, nine scale scores and three global scores can be calculated. For reasons of consistency, in the
current study we calculated the total score for all items and used it as a measure of the severity of mental health symptoms. Higher total
scores indicate higher levels of mental health problems. Franke et al. (2017) reported moderate to high internal consistency of the
scales for the German version, ranging from α = 0.82 to α = 0.93. High correlations with measures of specific mental health disorders
were found, supporting high concurrent validity (Franke et al., 2017).
Parental Stress. To measure parental stress we used the Parental Stress Scale (PSS, Berry & Jones, 1995; German version, Kölch &
Schmid, 2008), which is an 18-item parent self-report questionnaire measuring perceived parenting stress on a five-point scale ranging
from 1 (“strongly disagree”) to 5 (“strongly agree”). Items consist of statements about pleasures (e.g., “I am happy in my role as a
parent”) and strains of parenthood (e.g., “Having children leaves little time and flexibility in my life”). Eight items are inverted. A total
score is calculated by summing all items, with higher scores indicating higher levels of parental stress. Berry and Jones (1995) reported
a reliability of α = 0.83 and a six-week test-retest reliability of 0.81. They also found high correlations with other measures of parental
stress, such as the Parenting Stress Index (Abidin, 1983), supporting strong concurrent validity (Berry & Jones, 1995).

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2.5. Data analyses

Missing Values. Missing data for both time points were present on item level in BSI and PSS, and on the total-score level in CNI. The
missing rate on item level was 1.78% (SD = 0.63) at pre-treatment and 22.54% (SD = 0.47) at post-treatment. The missing rate of CNI
total scores was 15.28% at pre-treatment and 22.92% at post-treatment. The reason for a higher proportion of missing data post-
treatment was study drop-out in 31 cases (21.5%). Study completers did not differ significantly from study dropouts with respect
to CNI, BSI, and PSS total scores pre-treatment. Missing rates for control variables used in the main analysis were 1.39% (parental age)
and 0.69% (intervention duration).
To account for missing values, we applied multiple imputations by chained equations (MICE; van Buuren & Groothuis-Oudshoorn,
2011) in R (R Core Team, 2013). We decided to use multiple imputation (MI) instead of more widely used methods, such as complete-
case analysis or mean substitution, because these latter methods can lead to serious biases, an underestimation of standard errors, and a
substantial loss of statistical power if data are not missing completely at random (MCAR) (Schafer & Graham, 2002; Sterne et al.,
2009). We cannot assume MCAR in intervention studies because in practice it is the least common missing data mechanism (Rioux &
Little, 2021). Therefore, we used MI, which is expected to be fairly robust and recommended as a state-of-the-art imputation method if
data are missing at random (MAR) (Schafer & Graham, 2002). We included the following auxiliary measures in the imputation model:
parent's sex, child's age and sex, household income, single parenthood, and parent's education level. Further, all variables used in the
analysis were included in the imputation model. We generated 15 imputed datasets using a predictive mean matching (PMM) method
by applying the MIDAStouch procedure (Gaffert et al., 2016). PMM generates the least biased estimates as well as better model
performances compared to other MI procedures (Marshall et al., 2010). Furthermore, studies have shown MIDAStouch to be superior
to other existing PMM methods (Gaffert et al., 2016). The main analyses were performed for all imputed data sets, and results were
pooled.
Preliminary Analyses. After the imputation process, we performed a first graphical analysis to ensure that the MICE algorithm
converged and imputations were plausible. Demographic sample characteristics were presented using descriptive measures. We then
examined whether significant changes in the total BSI, PSS, and CNI scores from pre-treatment to post-treatment implied improve­
ments in parental mental health and a reduction of parental stress and neglect after the intervention program. Because we expected
positive changes in the three measures, we performed one-tailed paired t-tests.
Main Analyses. For the main analyses we subtracted the total scores post-treatment from the total scores pre-treatment for CNI, BSI,
and PSS, resulting in change scores. Higher change scores indicated greater reductions in neglect and parental stress, as well as greater
improvements in mental health. We used Pearson's correlation to analyze interrelationships between change scores and relevant
control variables.
A first linear regression model (Model 1) was then calculated to examine whether changes in parental mental health predict
changes in neglect. A second linear regression model (Model 2) was computed to analyze whether changes in parental stress were
related to changes in neglect. Effects were controlled for parental age, as well as sex, intervention duration, and neglect at pre-
treatment. All continuous measures were mean centered before being entered in the models. As parent-child dyads were nested in
therapists, we calculated cluster-robust standard errors for linear models using the “miceadds” package (Robitzsch & Grund, 2020).

3. Results

3.1. Preliminary analyses

Graphical diagnostic inspections revealed that the MICE algorithm converged well on item level and on total-score levels without
showing any trends. The distributions of the imputed values did not show any systematic discrepancies with the distribution of the
observed values, indicating plausible imputations.
Table 1 summarizes the descriptive characteristics of the sample. The parents had a mean age of 39.54 years (SD = 8.11) and most
of them were female (85.4%). Fifty-nine percent of the children were boys. The children had a mean age of 9.82 years (SD = 3.22).

Table 1
Descriptive characteristics of the sample.
Measure n % M (SD)

Parent age 39.54 (8.11)

Child age 9.82 (3.22)
Parent sex
Female 123 85.4%
Male 21 14.6%
Child sex
Female 59 41.0%
Male 85 59.0%
Single parenthood 78 54.2%
Parent unemployed 19 13.2%
Household income below Swiss poverty line 47 32.6%
Intervention duration 257.21 (40.81)

Note. Intervention duration was measured in days.

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Over half of the parents raised their children as single parents (54.2%). One third of the sample had a household income below the
Swiss poverty line (32.6%).
The pooled results of one-sided paired t-tests presented in Table 2 showed significant changes from pre- to post-treatment regarding
total scores for CNI, BSI, and PSS. Child neglect decreased significantly from pre-treatment (M = 42.97, SD = 18.65) to post-treatment
(M = 24.64, SD = 19.19), t(74.70) = 9.23, p < .001. Parents reported significantly fewer mental health symptoms at post-treatment (M
= 20.91, SD = 22.48) compared to pre-treatment (M = 24.75, SD = 25.46), t(131.33) = 1.79, p = .038. Parental stress showed a
significant decrease from pre-treatment (M = 40.49, SD = 11.04) to post-treatment (M = 36.91, SD = 9.36), t(102.24) = 4.16, p < .001.

3.2. Predictors of change in child neglect

Changes in Parental Mental Health as Predictor of Changes in Child Neglect. The first linear regression model (Model 1) evaluated
whether changes in parental mental health predicted changes in neglect after adjusting for parents' age as well as sex, intervention
duration, and neglect at pre-treatment. Results are presented in Table 3. Change scores for parental mental health did not significantly
predict change scores for neglect (b* = 0.08, t(71.93) = 1.02, p = .310). A significant effect was found for intervention duration (b* =
0.17, t(52.10) = 1.98, p = .050). A longer intervention duration was associated with a stronger decrease in neglect. The strongest
significant effect was found for neglect at pre-treatment. More severe neglect pre-intervention predicted higher reductions in neglect
after the intervention program (b* = 0.54, t(120.70) = 7.83, p < .001). Model 1 explained 33.3% of the variance (R2Adjusted = 0.309).
Changes in Parental Stress as Predictor of Changes in Child Neglect. The second linear regression model (Model 2) calculated the effect
of changes in parental stress on changes in neglect after adjusting for parents' age as well as for sex, intervention duration, and neglect
at pre-treatment. Results are shown in Table 4. Change scores for parental stress significantly predicted change scores for neglect (b* =
0.29, t(83.56) = 3.98, p < .001). A higher decrease in parental stress was associated with a stronger reduction of neglect. A significant
effect was found for intervention duration, with longer intervention durations predicting stronger reductions in neglect (b* = 0.19, t
(53.89) = 2.32, p = .022). As in Model 1, the strongest effect was found for neglect at pre-intervention (b* = 0.51, t(104.40) = 7.84, p
< .001). More severe neglect at pre-intervention significantly predicted a stronger decrease in neglect. Model 2 explained 40.9% of the
variance (R2Adjusted = 0.387).

4. Discussion

Child neglect has long been neglected in research compared to more prominent forms of child maltreatment. As a result, there is a
considerable lack of evidence-based intervention programs targeting child neglect. In order to develop effective intervention programs
and to make them more efficacious, it is necessary to examine what mechanisms of change lead to the reduction of child neglect. In
order to do so, the factors associated with changes in child neglect need to be known. In this intervention study we examined the
relationship between factors that changed after MST-CAN, an effective evidence-based intervention program, and changes in child
neglect. Our findings indicate that, while improvements in parental mental health are not related to a decrease in child neglect,
positive changes in parental stress predict the reduction of child neglect. Because of the immense lack of neglect-focused studies,
especially on the change mechanisms of intervention programs, there is not a clear state of the art with which our main findings could
be compared. Instead, we aim to discuss our results from a theoretical point of view, draw out practical implications, and point out
suggestions for future research on the topic.

4.1. Predictors of change in child neglect

First, in line with our hypothesis we found that positive changes in parental stress significantly predicted the reduction of child
neglect. This finding is not surprising, given that parental stress has been investigated as a key determinant of parenting practices,
notably of dysfunctional parenting practices related to child outcomes (Abidin, 1992; Jones et al., 2021). However, what remains
unknown is how parental stress impacts caregiving behavior and, in particular, neglect. In line with Wekerle et al. (2006) we suspect
that parental stress impairs and narrows parents' capacity to perceive positive aspects of parenthood. Instead, it may lead parents to
focus on negative perceptions of their parenting role and may evoke aversive feelings. This assumption is supported by a study by
Respler-Herman et al. (2012), who found high parental stress to be associated with less positive perceptions of parenting. A lack of
positive perceptions of their parenting role, together with negative emotions that go along with parental stress, might result in parents
avoiding behaviors and stressors that are related to parenthood. Parents might withdraw from caregiving behaviors in order to avoid
aversive feelings and stressors (Hillson & Kuiper, 1994). Strengthening parents' resources for dealing successfully with parental

Table 2
Mean differences of CNI, BSI, and PSS total scores from pre- to post-treatment.
Measure M SD M SD t(df) p

Pre-treatment Post-treatment

CNI TS 42.97 18.65 24.64 19.19 9.23(74.70) <0.001

BSI TS 24.75 25.46 20.91 22.48 1.79(131.33) 0.038
PSS TS 40.49 11.04 36.91 9.36 4.16(102.24) <0.001

Note. TS = total score, CNI = Child Neglect Index, BSI = Brief Symptom Inventory, PSS = Parental Stress Scale.

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Table 3
Linear regression model 1.
Measure b* SEab* t 95% CI p

LL UL

Parent sex − 0.05 0.22 − 0.22 − 0.48 0.38 0.832

Parent age 0.06 0.08 0.68 − 0.11 0.22 0.499
Intervention duration 0.17 0.09 1.98 0.00 0.34 0.050
CNI pre-treatment TS 0.54 0.07 7.83 0.40 0.67 <0.001
BSI CS 0.08 0.08 1.02 − 0.07 0.23 0.310

Note. TS = total score, CS = change score, CNI = Child Neglect Index, BSI = Brief Symptom Inventory, CI = confidence interval, LL = lower limit, UL
= upper limit.
R2 = 0.333, R2Adjusted = 0.309.
a
Cluster-robust standard errors.

Table 4
Linear regression model 2.
Measure b* SEab* t 95% CI p

LL UL

Parent sex − 0.13 0.20 − 0.63 − 0.53 0.27 0.529

Parent age 0.03 0.08 0.38 − 0.13 0.20 0.701
Intervention duration 0.19 0.08 2.32 0.03 0.35 0.022
CNI pre-treatment TS 0.51 0.07 7.84 0.38 0.64 <0.001
PSS CS 0.29 0.07 3.98 0.15 0.43 <0.001

Note. TS = total score, CS = change score, CNI = Child Neglect Index, PSS = Parental Stress Scale, CI = confidence interval, LL = lower limit, UL =
upper limit.
R2 = 0.409, R2Adjusted = 0.387.
a
Cluster-robust standard errors.

demands in their interactions with their children might lead parental stress to decrease and new perspectives on pleasures of
parenthood to emerge. This could reinforce parents in devoting themselves to their children's needs, which might result in less
neglectful behavior. Given that single parents are at greater risk of experiencing parental stress (Anderson, 2008) and over half of our
sample raised their children as single parents, addressing parental stress becomes even more relevant.
Second, surprisingly, we did not find an association between improvements in parental mental health and the reduction of child
neglect. At first sight this finding seems contradictory to our hypothesis. However, it is possible that our measurement of parental
mental health was too unspecific, and that we might have seen different results if we had measured mental health in a more differ­
entiated manner. Mental health problems from a depressive or detached spectrum might impair parenting differently than problems
from an obsessive-compulsive or anxious spectrum. It is not unlikely that the absence of a correlation between changes in mental
health and changes in child neglect is due to the aggregation of heterogenous mental disorders in a single measure. Another expla­
nation might be that changes in parental mental health are indirectly associated with changes in child neglect, given that it is possible
that changes in parental stress mediate this relationship. Parents whose mental health improves because of specific individual psy­
chotherapeutic methods might have greater capacity to focus simultaneously on the family intervention. They might therefore benefit
more from it, resulting in less parental stress, improved parenting, and possibly less child neglect. Kahng et al. (2008) reported partial
support for this hypothesis by showing a relationship between changes in parental mental health and changes in parental stress.
Mediating effects of parental stress could be another explanation for why we did not find a direct association between changes in child
neglect and parental mental health; it is still possible that the latter could be important for changes in child neglect.
Third, in both models we found the child neglect at pre-treatment control variable to be predictive of reduction of child neglect.
This finding is not surprising given that as a consequence of regression to the mean the change between baseline and follow-up is
related to the initial level, particularly in high-risk samples such as ours (Twisk & Proper, 2004; Yudkin & Stratton, 1996). Never­
theless, the size of the effect in both models indicates that the intervention program was notably beneficial for families starting the
program with a high severity of child neglect. As the program was designed for high-risk families, this is not surprising, but it is still a
very positive finding.
Intervention duration significantly predicted a decrease in child neglect in both models. In the context of MST-CAN, this finding
implies that, in a range of six to nine months, a longer intervention duration was associated with a greater reduction in child neglect.
However, we cannot draw out conclusions or implications for general intervention programs, given the restricted range of intervention
length. Furthermore, the existing literature reports mixed results regarding the effect of intervention length on efficacy. While Euser
et al. (2015) found interventions with an average length (6–12 months) to be most effective, van der Put et al. (2018) found no
significant effect of intervention duration on the effectiveness of curative interventions for child maltreatment. Considering the mixed
results in the sparse literature, the broad context of child maltreatment investigated in the study by van der Put et al. (2018), and the
low range of intervention length in our study, it is not possible to generalize our findings outside the context of MST-CAN.

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Finally, parents' sex and age were not associated with changes in child neglect, indicating that parents of different ages and sexes
did not differ in their responsiveness to the intervention program.

4.2. Strengths and limitations

The present study has several limitations. The first limitation relates to the design of our study, which was not conducted as an RCT.
Therefore, there is no evidence that changes in neglect, parental stress, or parental mental health resulted from the intervention
program. However, an assumption of causality is supported by findings from an RCT study that reported evidence for a causal rela­
tionship between the same intervention program and two of the outcome measures (Swenson et al., 2010). In addition, we only
assessed the analyzed measures at two time points. Therefore, it is not clear whether changes in parental stress were followed by
changes in child neglect or the other way round. Only results showing that an assumed change process (e.g., in parental stress) during
an intervention precedes a change in the outcome measure (e.g., child neglect) can give evidence that the process is based on the
proposed mechanism. It is therefore necessary to assess change during the course of an intervention (Kazdin & Nock, 2003). Future
research examining mechanisms of change should address these limitations by conducting studies based on an experimental design
with assessments during the intervention.
Second, whereas child neglect was assessed from an external as well as professional perspective by caseworkers familiar with the
families, which represents a strength of our study, parental stress and parental mental health were measured using self-report ques­
tionnaires. The disadvantage of this method is that it can be biased, for example by social desirability or respondents' mental health
status. Future research should consider using multi-method assessment, including observational methods and clinical interviews, to
obtain less potentially biased data.
A third limitation was that we did not assess parents' motivation. We cannot assume parental motivation to be on the same level for
all families. Different levels of parental motivation might have led to different levels of engagement and possibly impacted the effect of
the intervention program on the outcome measures. Because we used changes scores for outcome measures in the analyses, parental
motivation might have confounded our results. Studies showing an association between intervention outcomes and motivation support
this possibility (Gregertsen et al., 2019). This relationship becomes even more relevant in the context of our study, considering that
parental motivation plays a crucial role in family intervention outcomes in particular (Haine-Schlagel & Walsh, 2015; Karver et al.,
2006). Therefore, we strongly recommend including parents' motivation in future intervention research to control for this confounding
factor.

4.3. Implications

The reported results suggest that effective intervention programs for child neglect should not only consider factors on a parental
level alone, such as parental mental health, but also, and mainly, risk factors that emerge in daily parent-child interaction, such as
parental stress. Programs should provide parents with resources and coping skills for dealing with parental demands and stressors that
emerge in their daily relationships with their children, so as to activate and increase the pleasures of parenthood as well as parenting
skills. This can be done using specific interventions that strengthen socio-emotional skills such as mentalization, self-control, and
emotion regulation (Wang, 2021). Nevertheless, the importance of high-quality mental health services for parents should not be
overlooked. Given that many parents who show neglectful behavior suffer from mental health problems (Mulder et al., 2018), and that
parental mental health disorders are strongly associated with mental health disorders in their children (McLaughlin et al., 2012),
parents should simultaneously be provided with mental health services, as proposed by Roscoe et al. (2018). All in all, the focus should
lie on factors regarding parent-child interaction, but factors on a parental level should not be excluded. Only when interventions
address risk factors on multiple levels and consider an ecosystemic approach can effectiveness be achieved: child neglect is a highly
complex topic (Ruiz-Casares et al., 2020).
We can draw out several implications of our findings in the context of MST-CAN. First, the current study strengthens the evidence
for the effectiveness of this intervention program in reducing child neglect. It can be interpreted as a reliable program that should be
considered for implementation in the field of reactive prevention strategies and evidence-based practices for child neglect. Second, the
findings of the present investigation can be seen as a first step in examining change mechanisms related to MST-CAN. Our identifi­
cation of potentially relevant factors will be fundamental to further work investigating change mechanisms. Once there is a theoretical
concept that can explain why change is occurring, the program used in this study can be adjusted and the focus can be shifted towards
those factors. Our findings might be helpful for therapists working in the practical field of child welfare and MST-CAN in particular,
enabling them to focus their work on crucial factors in their daily efforts to minimize the recurrence of child neglect.
Further research is necessary to analyze the theoretical foundations on which effective interventions for child neglect and their
change mechanisms are based, with the objective of developing and strengthening evidence-based interventions and maximizing their
effectiveness. The current investigation can be seen as a first step towards an understanding of the effectiveness of neglect-focused
interventions. Our results suggest that changes in parental stress may be a promising factor for future research to focus on. Howev­
er, much more work needs to be done, and a deeper and well-grounded investigation of change mechanisms, including mediating
effects, is required.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Declaration of competing interest

Dr. Cynthia Cupit Swenson is a consultant in the development of MST-CAN programs through MST Services, LLC, which has the
exclusive licensing agreement through Medical University of South Carolina for the dissemination of MST technology. The Psychiatric
University Clinics Basel implemented two MST teams in Basel-Stadt, Switzerland in 2014.

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