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The Child Abuse Potential (CAP) Inventory


Applications from 1986 to 2014

Chiara Sacchi, Alessandra Simonelli


Department of Developmental Psychology and Socialization
University of Padova
Italy
chiara.sacchi@studenti.unipd.it

Abstract Traumatic experiences in childhood, as different enduring effects on the neuro regulatory systems that mediate
forms of abuse, are known to produce severe consequences on medical illness from childhood into adult life [5]. In addition,
mental health which can emerge both in infancy and in adult age. such experiences significantly influence attachment and
Identify potential abuse and risky contexts could decrease the developmental processes, diverting both the personal and
risk of childs death, health problems and later mental diseases. relational growth [6]. Furthermore, maltreatment, childhood
Even in situation of real abuse, attention to risk factors is needed abuse and neglect could lead to a child's death [7]; in particular,
in order to identify potential chronic maltreatment and stop a interesting data from a 2010 French study show that many
circle of violence. children who died from abuse were not identified as abused
before their death [8].
The Child Abuse Potential (CAP) Inventory is a widely used
assessment tool that enable to identify physical abuse and at-risk Physical abuse, that occurs when a child suffers injury due
situations. Considerations about its characteristics allow the to the action of his or her caregiver [9], can cause physical
promotion of its use as an important help for programs of pain, injury, or other physical suffering or bodily harm. Studies
secondary prevention, aimed to prevent the actuation of a risk about consequences of physical abuse, show that children who
situation and of tertiary prevention, in order to stop physical experienced it, are at increased risk of perpetrating violent
abuse situations and avoid a possibility of chronicity and behaviors, compared to the ones that did not experience it.
revictimization. A mini review of the literature is proposed,
Although researchers find some exceptions [10], child physical
focusing on the construct validity and the concurrent predictive
validity of the CAP Inventory with the intent to underline its
abuse (CPA) has been identified as a risk factor for several
potentialities and evidences across the time and suggest furthers types of interpersonal violence, including peer aggression [11,
investigations. 12], intimate partner violence (IPV) [13, 14, 15, 16, 17],
serious juvenile offenses [18, 19], violent crime [20] and adult
Keywords- Child Abuse Potential Inventory (CAP Inventory), sexual assault [21]. An association was also found between the
physical abuse, review. experience of abuse and the potential risk of committing
physical maltreatment in adult age, even if results about this
I. INTRODUCTION relation were unclear and reported the role of different factors
According to The World Health Organization, child [22, 23, 24, 25, 26].
maltreatment could be identified as all forms of physical In light of the immediate and long-term consequences of
and/or emotional ill-treatment, sexual abuse, neglect, or maltreatment experiences that the literature highlights, we
negligent treatment or commercial or other exploitation, underline the need for an early identification of abuse situations
resulting in actual or potential harm to the childs health, or exposure to risky contexts. Detecting potential abuse could
survival, development or dignity [1]. decrease the risk of a childs death, health problems and mental
In the lasts years, international studies underline how the diseases. Moreover, risk factors linked with abuse could have a
dimension of this problem makes it one of the major public direct influence on mental health, causing fear, depression and
health issues. In high-income countries, between 4 and 16% of feelings of shame that contribute to a childs isolation; so, this
children is physically abused [2]. In 2009 a meta-analysis identification is not only just helpful to avoid the experience of
aimed to investigate the prevalence of sexual abuse in the abuse but also for preventing childs stigmatization. Even in
community estimated that 20% of women and 8% of men situation of real abuse, attention to risk factors is needed in
experienced some kind of abuse before reaching adulthood [3]. order to identify potential chronic maltreatment and stop the
circle of violence.
Early adverse experiences are known to produce severe
consequences on mental health, which can emerge both in In the end, the study of risk factors for different kinds of
infancy and in adult age [2]; maltreatment and abuse abuse and the development of strategies to early identify them
experiences in childhood increase the risk for adult depression, could be a starting point to create plans of intervention and to
antisocial behavior, substance abuse, somatic complains, interrupt the intergenerational transmission of the violence.
suicidal ideation and the development of PTSD [4]. Biomedical The Child Abuse Potential Inventory can, in part, answer
researchers increasingly recognize that childhood events, the need of Infant Mental Health services, to have assessment
specifically abuse and emotional traumas, have deep and tools that enable to prevent and identify abuse situations.

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II. THE CHILD ABUSE POTENTIAL INVENTORY screening in normative population suggesting the presence of a
The Child Abuse Potential (CAP) Inventory is a 160-items tendency for abuse [28].
questionnaire for assessing child physical abuse, developed in A. Psychometric properties
1986 by Prof. Joel S. Milner [27]. It is widely used both with
As reported in the first manual of CAP Inventory [27] and
English and not-English speakers and it has been translated in
confirmed by review studies [29], the internal consistency
more than 25 versions. Items are scored on a forced choice
estimates range from .92 to .95 for general population (n =
format (agree/disagree), with no limits on time; generally the
2,062), at-risk (n = 178), neglectful (n = 218), and physically
assessment lasts about 20 minutes. The main clinical scale of
abusive (n = 152) parent groups. The test-retest reliabilities
the CAP Inventory is the 77 items Abuse scale. It is based on a
asses the temporal stability of the Abuse scale for 1-day (n =
review of literature regarding the discriminative characteristics
125), 1-week (n = 162), 1-month (n = 112), and 3-month (n =
of abusive and not abusive parents. The Abuse Scale is
150) in the general population; results intervals are: .91, .90,
composed by six interrelating risk factors, representing the
.83, and .75, respectively. Regarding the construct validity,
principal ones that contribute to development of abusive
CAP Abuse scores are generally associated to personal and
behavior.
interpersonal risk factors referred in the literature [30, 31, 32].
The first three scales focus on the intrapersonal area. The Subject with high Abuse score present: experience of having
Distress scale (36 items) assesses the personal preoccupation suffered or observed childhood abuse; less family cohesion,
and feelings, like being sad, alone, depressed, confused, upset, more family conflict and less marital satisfaction; more
disoriented, and detects difficulties of adjustment. Rigidity (14 domestic violence and social isolation [33]; higher level of life
items) refers to the inflexibility in attitude in response to child stress or personal distress; more physiological reactivity to
behavior. Furthermore, it refers to the idea that children need child-related and not-child-related stimuli [34]; external
rigid and strict rules. Unhappiness (11 items) describes a wide attribution of their behavior, rigid interactional style, more
range of feelings from unhappiness to happiness; it refers to negative evaluation of childrens attitude.
how the subject evaluate the quality of his life: if he feels On predictive concurrent validity the Abuse scale permits
unlucky, inadequate. The other three scales examine the to find the expected group difference between child physical
interpersonal domain; Problems with Child and Self (6 items): abusers and comparison groups [30, 35]. A First study showed
describes a tendency to consider negatively ones own child, a 90% of correct classification, while subsequent studies
like thinking he has problems or limited competences. indicate a lower range, between 80%-90% [36]. Using the 215-
Problems with Family (4 items) addresses problems with point cut off score the overall correct classification rates
members of the family, such as conflicts or problems getting 86,4%: 73.8% of 110 child physical abusers, and 99.1% of 110
along. Problems from Others (6 items) detects the presence of
matched comparison parents. The data increase at 88.5%, for
general difficulties in social relationships: items describe the
the overall classification using the 166-point cut off. Moreover,
perception of the subject that other people caused him a lot of
after removing invalid protocols, the standard scoring
suffering and that life is hard because of other people.
procedure and the 215-point cut off score correctly classified
Relationships in general are experienced as delusions, not as a
81.4% of the child physical abusers and 99.0% of the
resource for life.
comparison parents, for an overall rate of 90.2%. Again, using
In addition, the CAP Inventory includes three validity the 166-point cut off score a slightly higher overall
scales to assess the degree of presence of three kinds of classification rate of 92.2% was found.
distortion in the answers. The Lie scale (18 items) measures the
Regarding the sensitivity and the specificity of the CAP
individual tendency to lie; the Random Response scale (18
Inventory, more false negative than false positive
items) detects the tendency to answer casually; the
classifications are typically found when physically abusive and
Inconsistency Scale consists in 20 couples of opposite items,
demographically matched comparison parents are studied. This
like I like most people and I do not trust most people to
mean that CAP Inventory is more likely to fail in correct
detect the tendency of the subject to give inconsistent answers.
classify abusive parents than miss-classify demographically
Before considering the global score on the Abuse scale for any
similar non-abusive comparison parents as abusive (false
kind of use or classification, it is important to consider the cut-
positive classifications).
off point of the validity scales, to distinguish between good
protocols and fake ones. For the Lie scale the cut-off is 7 With respect to the future predictive validity, a prospective
points; for the Random Response Scale and the Inconsistency study with 200 at-risk parents tested at the beginning of a
scale the cut-off is 6 points. When the subject scores below the prevention program and at a follow-up administration, in order
cut-off on the three Validity scales we can consider there is no to determine subsequent cases of child maltreatment, showed a
kind of distortion in his answers. significant relationship (Cramer's V = .34, p < .0001) between
pre-intervention abuse scores and later confirmed child
CAP Inventory scores range from 0 to 486 points. For physical abuse. In another study, CAP Abuse scores obtained
Abuse Scale two cut-off points are reported and used in before starting a support program for pregnant mothers was
literature: 166 and 215. The 215 cut-off point is more able to predict future maltreating cases [37].
conservative and permits to minimize the number of false
positive protocols. Scores above 215 suggest presence or high III. FROM 1986 TO 2014 RESEARCHES
risk of physical abuse. The 166 cut-off point is better used for
Even if the CAP Inventory is reported to have good
psychometric properties, also as regards the translated versions

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[38], the validation of a test should be considered more as a persistence of potential abuse 7 years after a previous episode,
continuous process, assessing the capacity of the tool to with Abuse score higher than the comparison group [45]. 30
measure what it means to asses during the time. In particular, abusive mothers and 30 not abusive mothers were compared on
for the CAP Inventory, that means distinguishing correctly their expectation about their childs obedience and on their
between abusive and not abusive parents and identifying attitude as a parent about discipline in two different occasions:
appropriately future abusive situations, recognizing at-risk while their baby is crying and when he/she is not; the two
contexts. groups obtain different CAP Abuse scores, respectively 287.8
and 50 point [46]. Another study found that abusive mothers
From 1986 to 2014, around 300 scientific studies about the obtained CAP Abuse scores above the 215 cut-off point: 239.5
CAP Inventory are available, according to the consultation of [47].
on line database and a list of publication provided by author.
Excluding review articles, validation studies, proposal of short More recent results comes from two studies, published in
form of the instrument, in-depth analysis of single items, single 2011 [48] and in 2012 [49]; unfortunately, the first one only
case or treatment and intervention evaluation, it is possible to provides CAP scores for a group of abusive parents, without
select about 100 scientific papers available on-line, consulting giving information about the control group. The second study,
the main database that we can use to analyze the validity of the instead, distinguishes participants in physical abusive,
tool. 45 papers can be used to verify the ability of the CAP neglecting and control individuals, but it does not report CAP
Inventory to classify in a dichotomous form high-low risk, scores.
using the two cut-off points. About 56 scientific papers could
be used to a) distinguish abusive and not abusive parents; b) In conclusion, on the basis of what emerges from the
identify risk factors comparing parents who show and no not above-presented studies, the CAP Inventory studies appears to
show them. be an reliable tool that permits to distinguish abusive and non-
abusive parents. Even if results are not always easy to explain
A. Concurrent predictive validity: abusive and not abusive and comment, because of some limitations such as lack of data
parents and differences in sample size, there is a general agreement
Considering those works published between 1986 and 2014 among studies about the best CAP Inventory cut-off score,
approximately ten studies can be selected as regard the namely 215 points. As a matter of fact, the only exception is
comparison between abusive and not abusive parents. Some represented by the a study in which the abusive sample scored
studies were excluded because of a lack of information in the 172,36, under 215 but anyway above the 166 cut-off point.
paper. B. Construct validity: associated risk factos
The fist study, conducted by the author of the tool, With respect to risk factors associated to the actual
compared abusive parents (61), referred by services, with a experience of abuse, CAP Inventory was used in a greater
control group (177) and a group of nurturing parents (64); number of studies. Most of them have investigated the role of
results show a significant difference between the three groups, traumatic experiences in childhood, such as physical, sexual
with abusive parents reaching scores above the cut off of 215 abuse and neglect.
for Abuse scale (265), while the other two groups reaching
In a first study three samples of parents, differently exposed
51.9 and 39.6, respectively [39]. In another study 23 mother-
to risky conditions (physical abuse, sexual abuse and neglect)
child dyads were assessed to code child facial expression
were compared with three control groups. Results showed
comparing children abused by their mother and not-abused
significantly higher scores for all the three risks groups [50].
ones. Regarding the CAP Inventory scores the two groups
Another study has examined the association between past
show a significant difference (p=.001) [40]. In 1992 and 1994
experience of sexual abuse in infancy and the presence of
Caliso and Milner compared 30 abusive mothers, with past
specific characteristics of parental attitudes in adult age, like
history of child abuse to 60 not abusive mothers: 30 with
potential of abuse, nurturing skills, unrealistic expectations on
history of abuse and 30 without. Both studies highlighted
the child and child punishments. In particular, maternal anger
significant higher Abuse scores for the abusive sample,
was investigated as mediator factor of the relationship between
respectively 304,4 and 295,2 CAP Abuse scores. Interesting
the past experience of being abused and the potential risk to
results emerged comparing the two not abusive groups: even if
abuse. 138 sexual abused mothers were compared with 152
their scores were not significantly different, abused mothers
not-abused ones; results highlight that the abused sample
showed scores around the 166 cut-off point, while the not
shows attitudes and behaviours significantly associated to the
abused ones obtained scores close to Milner's normative
risk of physical abuse [51].
average point 91 [41, 42]. 59 parents referred by services for
abuse or maltreatment were compared with a control group of Comparing mothers with a past history of sexual or
383 parents: data showed significant higher CAP Inventory physical abuse, no significant difference was found on the CAP
scores in the first group with 302.4 Abuse average [43]. In scores, showing no difference on the potential of risk. What is
another study a 231,19 CAP Abuse score was found in a group more interesting here is that both groups show CAP Abuse
of abusive parents but no considerations about the discriminant scored under the cut-off point; anyway the statistical difference
capacity of the instrument could be done because of the lack of respect to the control group is confirmed [52].
data regarding the control group [44]. An interesting study
showed that a sample of 25 abusive mothers, whose children Another study focused on the relationship between the
were under the care of child social services, still had a high moderate factor of percepted support in early adolescent age
and the risk of abusive behavior in adult age. Based on the

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Childhood History Questionnaire scores, university students depending on the fact that high level of stress were detected or
were classified as abused or not abused: CAP scores underline no; on the contrary, in the two groups with low punishments no
a significant difference in the two groups [53]. difference was pointed out both for high and low levels of
parental stress as assessed by the CAP scores [61].
Others two interesting studies conducted in 2007 compared
caregivers who have experienced traumatic events in IV. CONCLUSIONS
childhood, in adult age, in both conditions or never. In the first
study a significant difference was found between the control In conclusion, since the CAP Inventory has been applied in
group and the other three ones, while there were no differences a considerable number of empirical studies, enough data are
regarding the age of the individual when the abuse occurred available in order to analyze its psychometric characteristics
(childhood, adult or both periods) [54]. In the second study the across the time.
child abuse experience was classified as mild, moderate, severe To date, available studies investigating its concurrent
or extreme; no information were provided about the predictive validity seems to underline the capacity of the CAP
significativity of CAP inventory score, anyway all this groups Inventory to distinguish abusive and not-abusive parents.
had high Abuse scores [55]. Experience of violence in Anyway, considering the literature on the CAP Inventory, there
adulthood was also studied by a research in which mothers who is a relative lack of studies comparing abusive and not-abusive
experiences Intimate Partner Violence during pregnancy were parents; between 2004 and 2014 only few studies have used the
compared to mothers who did not suffer from this condition; CAP Inventory with abusive parents; moreover, a control
also in this case results showed a significant difference in CAP group is not always reported and/or authors do not provide data
Abuse scores [56]. about Abuse scores of the abusive group. This can be explained
Two studies have investigated the role of adolescent considering that in the first years after the publication of a new
pregnancy. The fist analyzed the correlation between potential assessment tool there was a greater need for proofs of its
of child abuse and parental attitudes in 66 adolescent mothers. construct validity. Anyway, after more than thirty years from
Results showed a significant difference in Abuse scores for the first diffusion of the CAP Inventory it might be important
mothers younger than 16 and older than 16; that means, to have further and more updated data assessing its construct
younger mother are at major risk [23]. The second study validity, in order to provide normative data for the current
investigated differences of attachment models in children of population of parents, reporting all the distinctive features of
adolescent and not-adolescent mothers. The potential of the current society.
physical abuse was studied in order to highlight a difference With respect to construct validity, studies underline the
between the two groups even if in both cases CAP Scores were capacity of CAP Inventory to detect risky situation; in
under the 166 cut off point [57]. particular, substance abuse and childhood abuse experiences
Another risk factor investigated by CAP Inventory was the seem to represent the major risk factors. Further data are also
substance abuse: in one study 159 mothers and 290 fathers with needed to investigate other possible risk factors, such as
a diagnosis of addiction or substance abuse were involved, pregnancy in the teenage, parental depression and other types
together with a control. Parents from the SUD (substance use of parental characteristics and clinical conditions.
disorders) groups showed significant higher scores on the CAP Moreover, it is important to mention that drawing
Abuse scale [58]. conclusion might be difficult because of the differences
In a study aimed to investigate the association between between the various studies as regards methods, participants,
child aggressiveness and the presence of substance abuse in sample size. In this sense, a meta-analytic study is highly
their father, it was highlighted that fathers with a history of recommended in order to improve the quality and the validity
substance abuse had higher CAP Inventory scores, compared of the considerations about the psychometrical properties of the
with no users, even if results were under the 166 cut-off point CAP Inventory as they might have changed during the time.
[59]. In the end, drawing conclusions and reflections about the
With respect to other clinical conditions, depressed mothers characteristics of the CAP Inventory will foster its application
were studied to identify if depression could be a risk factor for in a wider range of studies and clinical context. For example it
physical abuse; what emerged was a significant difference can be an useful source of information for secondary
between the two samples (depressed, not depressed) [60]. prevention programs, which aim to prevent the actualisation of
a risk situation, and for tertiary prevention protocols, which
The potential of physical abuse was also investigated as intend to stop abuse situations and to avoid the repetition of
associated to some paternal characteristics, such as parental chronic cycle of revictimization.
level of stress and personal value assigned to corporal
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