Child Maltreatment and Childhood Injury Research: A Cognitive

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

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

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

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

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

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

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

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

Table I. Sampling of Skill Areas Required to Parent

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

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

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 Information Processing and Prevention 

Stimulus Event

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

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

Other Parental Characteristics Contextual Resources Child Characteristics

Their own caretaking Poverty Age

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

Knowledge Structures or Schema

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

Expectation that parents should be able to get their children to

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

Child Is Unable to Meet Expectation

Executive Functioning Capacities

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

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

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

Interpreting the child’s behavior as being purposefully

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

Parental Response

Harsh physical discipline for bothering them; failure to

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

Figure 1. The cognitive behavioral (CBT) model.

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

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  Azar and Weinzierl
needs of their specific children (e.g., goodness of fit),
and the vicissitudes of the contexts in which they are
rearing them. From this perspective, then, parents’ “fail-
ures,” rather than simply being evidence of a lack of
control or of their being “disinterested” or, worse yet,
“uncaring,” may in fact be the logical outcome of break-
downs in an overtaxed caretaking system (Azar et al.,
1988). Indeed, in societies such as ours, where extended
families are less involved in the raising of children and
where community child care and other resources are lim-
ited, becoming a parent dramatically increases burdens
on the cognitive and behavioral capacities of individual
adults and carries more risk (i.e., tasks that may over-
whelm these capacities) and make “growing into the role”
slowly more difficult. Indeed, it has been questioned
whether our society’s asking parents to “go it alone” is
feasible.
Thus, a model of parenting that focuses on processes
underlying the myriad of responses required to parent
adequately and to orchestrate supportive contexts may
have utility as a foundation for the development of behav-
ioral interventions with parents, as well as the forming of
effective social policy. The model proposed, therefore,
has broad application.
Child Maltreatment and Unintentional Injury:
Evidence for the Role of Human Information
Processing
Research in both child maltreatment and unintentional
injury fit nicely with the three elements of this model. The
empirical work supporting these elements is reviewed, as
well as studies linking these three factors to each other
and to parental behaviors that would increase the risk of
child maltreatment and childhood injury. Work demon-
strating how contextual factors may exacerbate their
impact is also provided.
Unrealistic Expectations and Perceptions
of Control: Maladaptive Knowledge Structures
The first element of the CBT model involves parental
knowledge structures or schemas of what to expect of
children and parents’ roles in relation to them. Schemas
are information structures that exist before a new stimulus
is encountered, and they have both structural elements
and content. Parents’ schemas grow out of their history
with their own caretakers and experiences in relation-
ships more generally (e.g., watching other parents), the
media, and experiences with their own children (Azar,
Nix, & Makin-Byrd, in press). Structurally, child sche-
mas must be flexible and complex enough to deal with
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developmental changes and individual differences (e.g.,
a child with disability may require more sensitive care
and monitoring). Schemas that represent even young
children as functionally equivalent in capacities to those
of adults, as able to take care of their own care needs
(e.g., cook their own meals and get themselves to school
without assistance), and to take care of those of parents
as well (e.g., cross a busy street and do grocery shopping
for the family), may lead to misjudgments that will end
in child “failures” and threaten parents’ efficacy.
Parental role schemas must help adults to maintain
a sense of control and hierarchy in parent–child transac-
tions, such that they sees themselves as “responsible” to
“think” for children (i.e., anticipate risks for them and
teach). More general schema elements about the self
may also play a role. For example, parents who describe
themselves as high on “conscientiousness” have been
found to have children who engage in less risk taking
and have a history of fewer injuries (Morrongiello &
House, 2004). Abusing mothers appear to have an
expectation of being negatively evaluated by others
(Shorkey, 1980). Such an expectancy has been shown to
increase self-criticism, which can disrupt cognitive pro-
cessing and produce negative affect, contributing to less
effective performance (Baldwin, 1997).
In addition, positive biases in child schema, as
opposed to negatively toned content, help parents deal
with the aversiveness (e.g., labeling children’s running
across the street as independence rather than willfulness)
and allow parents some leeway when they make errors
(e.g., reduces negative self-evaluation when their child
“embarrasses” them in public). On the other hand,
schemas must not be so positive that they ignore places
where improvements are needed. That is, when the child
fails to obey a rule regarding a risk such as playing too
near the street, the parent must be able to adjust his or
her expectancies (e.g., see it as incomplete learning) and
engage in protective behavior with toddlers (e.g., being
present when his or her child is outside and erecting a
fence around the yard) and further teaching and provide
appropriate consequences for rule violation with older
children. Most importantly, such events should lead to
parental “learning” that they cannot leave the child open
to the risk. Indeed, risk increases when parents overesti-
mate children’s integration of family rules and do not
give negative consequences for safety rule violations
(Peterson, Bartelstone, Kern, & Gillis, 1995). Similarly,
parents who engage in abuse often argue that their
children “knew” what they were doing. Such parents
react with frustration and harshness, not teaching when
they engage in discipline. Multiple schemas may be

activated in any one child-rearing incident (e.g., with
a tantrum in a grocery store, beliefs about how children
should behave in public, how much control a parent
“should” have over children, and how the parent feels
about the self once he or she notices that others are
staring at them all may come into play), and any one of
these schemas may be activated at different points in the
interaction with the child, and parent may cycle through
the process portrayed in Figure 1 over and over again
during the course of the incident.
Peterson and Brown (1994) acknowledged the role
that parental unrealistic expectations play in increasing
risk of childhood injury. The CBT model above, how-
ever, prioritizes a more central role for expectations in
causing child maltreatment and the inadequate monitor-
ing of, and feedback to, children that increase injury
risk. For example, failing to recognize children’s greater
needs for supervision places them in a variety of risk situ-
ations (e.g., leaving them home alone). Moreover, these
expectations may increase the occurrence of lax or inap-
propriate discipline. Failing to provide consequences for
child risk-taking behavior may be due to the mistaken
belief that children “know” the rule (Peterson & Brown,
1994). Similarly, too strong a belief in parents’ role as
one of absolute authority would contribute to overreact-
ing to misbehavior and seeing child noncompliance as a
threat to parental adequacy, even when the noncompli-
ance is due to lack of maturity. These expectations drive
maladaptive automatized processing of events.
Unrealistic expectations in the CBT model are seen as
direct contributors to specific injury events (e.g., beliefs
that children have the ability to engage in self-care, such
as using appliances on their own to prepare food, antici-
pate risks, and consider parental feelings and adjust their
behavior so as not to cause any provocation so as not to
cause any provocation when the parent is upset) (Azar,
1986; Azar & Twentyman, 1984). If such beliefs are held
strongly, when children violate such expectancies, par-
ents cannot blame inadequate rule acquisition or chil-
dren’s development. Child failures can only be labeled as
evidence of poor parenting or, worse yet, of willful nega-
tive behavior. The parent may come to feel helpless in the
face of children and not respond at all or, because of their
frustration, engage in overly harsh punishment which
over time may escalate into abuse. Negative consequences
and education about risky behavior would also not occur,
both of which are crucial to rule learning.
Evidence for such unrealistic expectations of chil-
dren, parental roles, and what are appropriate responses
on parents’ part have been linked to both child maltreat-
ment and childhood injury. Abusive parents and neglectful
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Information Processing and Prevention 
parents have been found to have a higher level of unrealistic
expectations regarding the social-cognitive and physical-
care abilities of children than carefully matched control
mothers (Azar, Robinson, Hekimian, & Twentyman,
1984; Azar & Rohrbeck, 1986; Haskett, Scott, Grant,
Ward, & Robinson, 2003). Other at-risk parent groups
also show such difficulties (e.g., cognitively limited par-
ents, Azar, 1991; substance-abusing mothers, Spieker,
Gilmore, Lewis, Morrison, & Lohr, 2001).
Maltreating parents have maladaptive schema regard-
ing their roles as parents. They more strongly believe
that punishment is what a parent “should do” and that
power-assertive strategies will be effective and that
inductive ones will be less effective (Caselles & Milner,
2000). They have a role definition of parenting that
requires them to have absolute control over their
children (Peterson, Gable, Doyle, & Ewigman, 1997).
This may grow out a lower perception of control as a
parent (i.e., children having more power over outcomes
than they do) and an overly generalized concern regard-
ing dominance (Bugental, Blue, & Cruzcosa, 1989). It has
been argued that individuals with low perceived control
have stored schema regarding power that can be activated
by merely anticipating child difficulties (e.g., hypersen-
sitivity to potential dominance). These schemas have a
distracting quality and may lead to inaction as well as
overly harsh reactions.
Parallel findings have occurred in the childhood
injury literature regarding inappropriate child and
parenting schema. Parents as a group have been found
to underestimate their infants’ motor abilities and curi-
osity (Roberts & Wright, 1982) and overestimate their
children’s ability to maintain their own safety (Peterson,
1989). Peterson and her colleagues (e.g., Peterson,
Mori, & Scissors, 1986) have investigated in detail
children’s abilities to care for themselves when they are
home alone—a situation in which childhood injury is
quite common. Although both parents and their 8- to
10-year-old children believe that children are prepared
to stay at home alone, Peterson et al. (1986) found that
children were able to recognize only a few of their
parents’ rules about what to do in a variety of common
household and emergency situations; recall memory
was even poorer. Latchkey children, for example, dem-
onstrate low self-care abilities regardless of socioeco-
nomic status (SES) or gender (Peterson, 1989). Further,
Peterson noted that parents are often shocked to
know of their children’s responses to questions about
home safety, indicating that they expected their
children to know what to do in these situations. It
appears, then, that these parents’ expectations are
  Azar and Weinzierl
somewhat disconnected from the reality of their chil-
dren’s abilities. At the same time, parents were confi-
dent that their children were prepared to stay home
alone and that they are aware of family rules. Such an
invalid belief in child rule knowledge would increase
child risk.
In contrast to abusive parents, for childhood injury
cases, Peterson and Brown (1994) argue that for parental
role schemas that suggest lower expectation for need to
act, as evidenced by lax control around childhood injuries.
They describe a field study of 1,000 minor injuries where
both parents and children agreed that preventive changes
to the environment, change in rules, and other conse-
quences were needed. Yet, such actions occurred after
injuries in less than 3% of cases. Data suggest that some
parents may mistakenly see minor injuries as “normative”
events and/or beyond their control (Morrongiello &
House, 2004), and this may explain their lack of action.
Perceiving that children have more control over chil-
drearing outcomes than the parent does, for example,
has been shown to be predictive of safety neglect of
infants (i.e., neglect of the provisions of a physically safe
environment) (Bugental & Happeney, 2004). One study
found that some parents, particularly fathers, believe
that minor injuries serve a developmental benefit (e.g.,
children “learn a lesson” and they “toughen” children
up) (Lewis, DiLillo, & Peterson, 2004) and that this too
may explain in part parents’ lack of action. Having this
idea about minor childhood injury would lessen remedi-
ative actions following them (i.e., the parent would
believe too strongly in the idea that a “good” parent lets
his or her child learn by trial and error).
Overall, the evidence supports both Peterson and
Brown’s (1994) and Azar’s (1986, 1997, 2002a) ideas
about the role that unrealistic expectations regarding
children play in potential harm to child. Thus, links
between this cognitive element of the model to both
abuse and neglect and childhood injury appear to exist.
Schemas regarding power relationships with children,
specifically concerns regarding dominance, also seem to
play a role.
Problem Solving, Cognitive Complexity,
and Ability to Change Set: Difficulties
in Executive Functioning
Along with disturbed schema, child risk may increase
with adult difficulties in executive functioning. Execu-
tive functioning involves capacities to perceive stimuli
in the environment in complex enough ways to identify
problems when they occur, emotionally regulate and
inhibit responses, generate specified responses to those
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problems, prioritize, enact responses effectively, and
evaluate the outcomes that result and adjust one’s
behavior when responses are not effective. Executive
functioning involves effortful, as opposed to automa-
tized, processing of information and has been implicated
in adaptive functioning in social realms (Derryberry &
Rothbart, 1997; Kochanska, Murray, Jacques, Koenig, &
Vandegeesi, 1996; McEwen & Magarinos, 1997). It may
be affected by constitutionally based cognitive limita-
tions (e.g., learning disabilities and brain injuries) and
contextual stress.
Typically, executive functioning occurs when
stimuli present some incongruence with preconceived
knowledge structures (expectations), ambiguity, or a
problem to be solved. Given young children’s changing
developmental needs and poor ability to communicate,
parents are faced with a continuous stream of incongru-
ence, ambiguity, and problems. (Indeed, Peterson &
Brown, 1994, cited young child age as a risk.)
Parents must be able to identify and anticipate risks
before they happen (e.g., it requires complex perceptual
abilities), to consider alternative solutions (e.g., balanc-
ing long- and short-term socialization goals for children),
to regulate emotional reactions to what may be extremely
aversive child behavior (e.g., prolonged crying), and,
once responses are enacted, to adjust behavior as diffi-
culties change (e.g., self-regulation, prioritization, and
cognitive flexibility).
Evidence exists for deficits in these processes in
child-maltreating parents. Physically abusive as well as
neglectful mothers show poorer problem-solving capaci-
ties in both childrearing and nonchildrearing situations
(Azar et al., 1984; Hansen, Pallotta, Tishelman, &
Conaway, 1989). Parents at-risk for maltreatment have
also shown deficits here. For example, intellectually low
functioning parents are poorer problem solvers in chil-
drearing situations, and the level of their deficit is asso-
ciated with less synchrony in their interactions with
their preschool children (Azar, 1991; Azar et al., 1999).
Clearly, many forms of executive functioning (e.g., delay
of gratification, self-regulation in the face of provocative
behavior, and organizational abilities) are required to
parent successfully and to do so calmly when child aver-
sive responses cannot be easily resolved or when the
parent is in a strained state. Even positive responses
require the modulation of behavior to fit the situation.
Indeed, parental sensitivity is predictive of secure attach-
ment in infants, which in turn has been linked to their
later social capacities.
Parents who are maltreating show a failure to
discriminate between child behaviors and respond with

matched responses. Trickett and Kuczynski (1986) found,
in a diary study, an overuse of coercion as the priority
response to aversive child behavior (i.e., all aversive child
responses are seen as similar and, thus, responded to
similarly). This finding also suggests a lack of cognitive
complexity. Wahler and Dumas (1989) posit an attentional
problem in abusers that lead them to track behaviors less
closely and to respond in an indiscriminative manner.
Although not yet studied in the area of childhood
injury, how poorer ability to identify problematic situa-
tions and anticipate risks would lead to greater harm to
children can be easily seen. Indeed, the ability to identify
safety risks and correctly label them in terms of level
(e.g., medical problems where home treatment is suffi-
cient vs. ones where emergency care by a physician is
needed) is often targeted in safety and medical educa-
tion programs with parents (Gershater-Molko & Lutz-
ker, 1999). Poorer problem-solving capacities have been
found among parents of children showing impulsivity
problems, a common antecedent of childhood injury
(Dix & Lochman, 1990; Edwards, Barkley, Laneri,
Fletcher, & Metevia, 2004; Pakaslahti, Spoof, Asplund-
Peltola, & Keitkangas-Jarvinen, 1998), as well as among
families touched by substance abuse, another antecedent
of childhood injury (Hops, Tildesley, Lichtenstein, Ary,
& Sherman, 1990). Cognitive complexity may play a
role in childhood injury as well. “Rule shortages” appear
in families about safety issues. Peterson and Saldana
(1996) found that over 83% of child injuries occurred
without violation of a safety rule. Often, parents
regarded the child’s behavior as unacceptable but had
not specifically forbidden it.
This last finding suggests that parents were some-
times inconsistent when they impose rules on their
children while at home and that risk increases when
they were out in the world (e.g., climbing on playground
equipment). Also, the failures to take action after inju-
ries, noted earlier, suggest that parents may be failing to
evaluate the quality of their solutions and adjusting
them (i.e., recognizing that not having rules did not work
if the child was injured). This may have dire implica-
tions for young children who lack adult experience (e.g.,
well-developed schema regarding safety) and decision-
making. Fine-tuned rules form a foundation for their
own decision-making rules and capacities.
Another such capacity that may be linked to child
risk is the ability to change set. Abusive mothers and
ones at higher risk for abuse have been shown to be
lower in cognitive flexibility (Nayak & Milner, 1998;
Robyn & Fremouw, 1996). The “tracking” problems
seen by Wahler and Dumas (1989) in maltreating
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Information Processing and Prevention 
parents may indicate problems in sustaining attention,
one component of being able to shift set.
Again, although cognitive flexibility was not dis-
cussed by Peterson, it clearly is required to respond to
environmental cues and maintaining safety for children.
As children change developmentally (e.g., become more
mobile), changes are needed in the home (e.g., installing
barriers in risky areas). Further, parents whose children
are becoming more able to think about family rules must
respond to them appropriately (e.g., give them expla-
nations of why a rule exists). Younger or special needs
children (e.g., impulsive ones) require more continuous
vigilance, whereas adolescents need more selective moni-
toring and sensitively delivered direction. Parenting in an
affluent and safe suburban neighborhood (e.g., little traf-
fic and neighbors who are willing to play a role secondary
to parents) requires skills that are different from those
that are required in a high-crime, urban setting (e.g., high
traffic level and isolation from neighbors). In the latter,
neighbors’ skills may compensate for the deficiencies of
parents. Similarly, as the family moves to other environ-
ments (e.g., a playground and visiting another family’s
house), parents must adjust their vigilance level to protect
their children appropriately. Parental engagement and
distraction both have been associated with the level of
supervision parents provided children when observed in a
park setting, and more engagement has been found to be
negatively correlated with child nonminor injury history
(Morrongiello & House, 2004). Moreover, a parent must
be prepared to deal with his or her own changing needs
(e.g., a parent who has been injured must enlist outside
assistance to care for his or her mobile toddler).
Negative and Maladaptive Appraisals of Child
Behavior: The Products Resulting From the
Operation of Both Maladaptive Schema and
Weak Executive Functioning
Peterson et al. (1995) recognized the relevance of attri-
butions for child behavior to child injury research but
did not include it as one of the contributors to injury.
The CBT model, however, gives a central role to such
attributions. As noted earlier, a consequence of unrealis-
tic expectations is that parents must now explain to
themselves why their child has violated expected stan-
dards. If executive functioning capacities are not strong
(i.e., parents do not identify their standards as incorrect
and adjust them), they may either see themselves as fail-
ures in parenting (i.e., “I can’t get my child to do the
things other parents can”) (self-blaming) or see their
children as deliberately withholding a response well
within their capacity (child blaming). Weak executive
  Azar and Weinzierl
functioning capacities would also prevent them from
generating more benign or helpful attributions (situa-
tional or developmental ones). Over time, self-blaming
or child blaming would either immobilize them (e.g.,
lower their self-efficacy and lead to disengagement in
parenting or depression) or result in impulsive, overly
harsh responses.
Parental attributions of negative intent to children
have been shown to influence the nature of their
responses to children’s transgressions (Barnes & Azar,
1990; Dix, Ruble, & Zambarano, 1989). Perceiving one’s
child as having more control over childrearing outcomes
than oneself may contribute to overly harsh responses in
that parents may more readily see themselves as needing
to exert high levels of power assertion to have any affect.
Thus, such attributions coupled with expectations of
absolute control may lead to inappropriate discipline.
Failures to make attributions to lack of knowledge
on the child’s part (e.g., “he’s only two, he does not
understand”) would mean fewer educative responses
that would move a child forward in mastering tasks.
More importantly, the child’s repeated failures to meet
expectations, followed by attributions of blame to the
self or the child, would demoralize parents. The child
may become an aversive stimulus and “living evidence”
of parent’s incapacities (Azar, 1986, 1997). Clearly, a
parent may be less motivated to caregive, and as a result,
the child may be left unattended more, leaving him or
her open to risks.
Parental negative attributions to children for aver-
sive child behavior (e.g., negative intent and negative
traits) are seen as playing an essential role in the pro-
gression toward child maltreatment (Azar, 1989a). In
general, internal, negative child attributions are related
to more power-assertive responses (Dix et al., 1989).
Many studies have found negative attributional biases in
abusive and at-risk parents (intellectually low functioning
mothers, teenage mothers, and substance-abusing parents)
compared to controls (Bradley & Peters, 1991; Dadds,
Mullens, McAllister, & Atkinson, 2003; Dopke & Milner,
2000; Haskett et al., 2003; Larrance & Twentyman, 1983;
Miller & Azar, 1996; Spieker et al., 2001), although dif-
ferences do not appear under all conditions (Milner &
Froody, 1994). For instance, they occur under cumula-
tive stress (Azar, 1988).
Other appraisals of children have been studied that
support the idea of a negative bias among maltreating
and at-risk parents. Abusive mothers and ones identified
as at-risk for being abusive expect less compliance from
their children after disciplining them and judge child
transgressions in many situations as more “wrongful”
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and their behavior generally as more negative, problem-
atic, less adaptable, more conduct-disordered, more
temperamental, more aggressive, and more hyperactive
(Chilamkurti & Milner, 1993; Mash, Johnston, & Kovitz,
1983; Reid, Kavanaugh, & Baldwin, 1987). In some cases,
these negative appraisals of children have been made in
spite of no differences in child behavior compared to
controls when rated by independent observers.
Findings also support the role of attributions for
understanding injuries. Morrongiello and House (2004)
found that parents who believed that their child’s health
status was due to luck showed decreased supervision
and had children who had experienced more injuries.
Peterson et al. (1995) found that mothers’ beliefs about
the causes of injury were related to whether or not they
attempted to provide intervention. Mothers who attrib-
uted the injury to factors internal to the child (i.e., “it
was the child’s fault”) were likely to take remediative
action (e.g., lectures and discipline). On the other hand,
mothers who believed that their child’s injury was due
to fate were less likely to take remediative action (e.g.,
teaching and providing consequences). Indeed, parents
living in poverty who are at greater risk of child
maltreatment and unintentional childhood injury have
been shown to make more external attributions for their
children’s dysregulated behavior (risk taking and aggres-
sion), and thus they would do nothing in response more
than do nonpoor parents (Diriwachter & Azar, 2002).
Bugental and Happeny (2004) have shown lower maternal
perception of control in their parent–child relationship to
be related to lower provision of a safe environment for
infants. Overall, the evidence to date supports the rela-
tionship between maladaptive maternal attributions for
child behavior and responses to that behavior that would
increase the risk of injury (lax responses).
Maladaptive appraisals have been shown to increase
parental anger and risk of punitive behavior, as well as
lax parenting. Evidence for this is reviewed below when
links among these information-processing factors and
parental behavior are discussed.
Information Processing and Maladaptive
Parental Responses
Evidence exists linking these information-processing
problems to each other and with maladaptive parental
responses. In a small sample of intellectually low func-
tioning [intelligence quotient (IQ) less than 79] mothers,
higher levels of unrealistic expectations regarding chil-
dren were associated with poorer problem solving in
childrearing situations, and higher levels of both these
cognitive problems were associated with less synchronous

interactions with preschool children (Azar et al., 1999).
Mothers with higher levels of these cognitive problems
were less responsive to their children moment by
moment and more discordant when they interacted with
them, suggesting poorer capacity to perceive their chil-
dren’s cues and respond to them. In more general sam-
ples of low SES mothers (including teenage mothers), the
more unrealistic expectations parents had of children’s
self-care capacities and ability to understand parental feel-
ings and thoughts, the stronger negative intent attribu-
tions they made to children’s aversive behavior, and the
stronger and more coercive the punishments they used
and the less likely were they to use explanation (Azar,
1989b, 1991; Azar et al., 1999; Barnes & Azar, 1990;
Dadds et al., 2003). Social workers also rated the children
of young mothers who hold higher levels of such expecta-
tions as being in more jeopardy in terms of child safety
and care (Azar, 1989b). Thus, unrealistic expectations
and negatively biased attributions appear to contribute to
harsh parenting practices, failures to engage in socializa-
tion practices that would lead to learning of rules and
self-regulatory behaviors in children, and, overall, height-
ened child risk. Important to prevention are the findings
from another study. In that study, these same relation-
ships were found within a large group of adolescents who
were not yet parents (Azar, 1990). Thus, this cluster of
cognitive problems may be present before an individual
becomes a parent.
Along with data linking expectations and attribu-
tion, research has also shown that low perceptions of
control are associated with negative affect and increased
physiological arousal when adults interact with a “diffi-
cult” child (Bugental, Blue, & Lewis, 1990; Bugental et
al., 1993; Bugental, Brown, & Reiss, 1996), and these
effects occur even in anticipating such an interaction
(Bugental & Cortez, 1988). It has been argued that indi-
viduals with low perceived control have stored schema
regarding power that can be activated by merely antici-
pating an interaction involving child difficulties (e.g.,
hypersensitive to potential dominance). Such activation
may interfere with executive functioning as described
above, in that when engaging in interaction with a “diffi-
cult” child, they show decrements in cognitive function-
ing including the inability to recall thoughts after the
interaction (Bugental et al., 1996) and the use of less
complex and less effective linguistic structures during
the interaction (Bugental & Lewis, 1999; Bugental &
Shennum, 1984). Essentially, mothers may lose the
cognitive functioning capacities needed to control their
negative behaviors. Indeed, some data suggest more
generalized negative reactions when confronted with
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Information Processing and Prevention 
interactions with vulnerable others (e.g., with pets; Sims
et al., 2001).
Literature has also drawn links between information-
processing problems and child risk of injury. Wilson et al.
(1991; as cited in Brown & Peterson, 1997) proposed
that developmentally inappropriate expectations may
lead to inadequate supervision and an increased risk of
child injury. Peterson’s own research suggests as much:
in one study, an inadequate number of rules (which may
be interpreted as the result of inappropriate expectations
on the part of the parent) were related to the number of
injuries sustained by a child (Peterson & Saldana, 1996).
Her other findings seem to predict a similar effect: latch-
key children know very little about their parents’ rules
for handling emergencies, although their parents expect
them to be aware of numerous guidelines (Peterson,
1989). Taken to their logical conclusion, these results
may indicate that the children’s lack of rule knowledge
(and their parents’ inappropriate expectation of that
knowledge) is related to risk of injury. Also, the types of
attributions that parents make to children’s risk behav-
ior were found to lead to differing levels of mothers’
engaging in remediative actions (Peterson et al., 1995).
As noted above, lower perception of control in parent–
child relationships has been linked to less provision of
safety in the environment provided to infants (Bugental
& Happeny, 2004). Thus, links between parental infor-
mation processing and parental injury prevention
behavior appear to exist.
Context: Interactive Effects of Information
Processing Factors with Stress and Social Isolation
Work in both child maltreatment and unintentional
injury highlights the association between contextual
strain (stress level, financial strain, and low social sup-
port) and personal strain (mental illness and substance
abuse) and harm to children. In child maltreatment, low
income (Garbarino, 1976), lack of social support, and
high stress (Egeland, Breitenbucher, & Rosenberg, 1980;
Gaudin, Polansky, Kilpatrick, & Shilton, 1993) have all
been shown to be antecedents. Other factors, including
crowding, family chaos, and changes in residence have
also been shown to be related to unintentional injury
(Peterson & Brown, 1994). Yet, not all stressed, men-
tally ill, substance-abusing, and isolated parents engage
in child maltreatment, and contextual strain does not
translate into injuries occurring in all families. Some
parents may be less able to balance their resources or the
cadence with which stressors occur.
The CBT model posits that strains and lack of buffers
to relieve those strains tax the capacities of even
  Azar and Weinzierl
well-functioning parents and that, coupled with higher
levels of the cognitive disturbances outlined above, mis-
haps become more likely. It is clear that stress decreases
cognitive functioning and performance declines occur
when one must focus on multiple tasks. Distractability,
narrowing of perceptual capacities, and overwhelmed
problem solving under conditions of crises may lead to
misjudgments or oversights. For example, negative child
attributions are especially common when parents are in
a negative mood state (Dix, Rheinhold, & Zambarano,
1990). Some evidence has begun to emerge that chronic
levels of stress may influence brain functioning, in some
cases perhaps permanently, thus producing more
chronic cognitive problems in executive functions
(Stein, Hanna, Koverola, Torchia, & McClarty, 1997).
Conversely, cognitive problems can exacerbate the
negative effects of stress on parenting. For example,
women who had less complex expectations about
parenthood before their children’s birth had worse
adjustment after the birth (i.e., reported higher depres-
sion, lower self-esteem, and poorer marital adjustment)
(Pancer, Pratt, Hunsberger, & Gallant, 2000). This effect
held even when they encountered higher levels of stress
after the birth. Similarly, violations of expectation
regarding the transition to parenthood (i.e., about their
relationships with their spouses, physical well-being,
maternal competence, and maternal satisfaction) also
predict poorer maternal adjustment (Kalmuss, Davidson,
& Cushman, 1992). Thus, mismatches between expected
role functioning and realities would lead to a greater
experience of stress.
Under conditions of low resources, situational fac-
tors may also be interpreted as safer than they actually
are out of necessity (or perceived necessity). That is,
lack of safety may “need” to be ignored. A single parent
with an ill infant and two older children may feel that it
is better to leave the infant in the care of siblings and go
out into the cold on a winter night to get them food than
risk the infant’s illness worsening. Also, a financially
destitute parent may out of necessity elect to try to care
for child illness without a physicians’ input rather than
incur debt.
Also, as the earlier discussion suggests, under the
ambiguity that stress may produce (e.g., interactions
with an unpredictable and difficult child; Bugental et al.,
1990, 1993, 1996), maladaptive schema and attributional
biases may operate more strongly. In a laboratory study
of the effects of stress, Azar (1988) explored the interac-
tive impact of life stress and higher levels of maternal
unrealistic expectations of children. She manipulated
level of childrearing stress with nonmaltreating mothers
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by exposing them to a childrearing failure (e.g., they
were given puzzles to teach their preschool children on
which failure was highly likely, but they were given the
expectancy that they would be able to teach them). It
was found that mothers who were high in life event
stress over the last 6 months and who had higher levels
of unrealistic expectations of children were the only
mothers who attributed failure to something about
themselves or their child (this despite the fact the task
was in fact too hard). Similarly, examining maternal
cognition in disciplinary situations (a stressful situation)
and using a diary methodology, researchers were able to
find that mothers with higher levels of unrealistic expecta-
tions were more likely to make negative, stable, and inter-
nal child attributions and to use more power-assertive
strategies and less adaptive and inductive ones (Azar et al.,
1999; Barnes & Azar, 1990).
Implications for Interventions and Prevention
Behaviorally based interventions and prevention efforts
targeting parents have been effective at reducing child
maltreatment and childhood injury rates (Azar & Wolfe,
1998; Peterson & Brown, 1994). Cognitive theorizing
regarding parenting difficulties has begun to be success-
fully integrated into these parent interventions and
prevention efforts. Targets include efforts to challenge
and restructure parental schema regarding children and
their role as parents and improve problem-solving
capacities, as well as working on negative biases in their
appraisals of their children’s behavior (Azar, 1989a; Azar
& Twentyman, 1984; Azar et al., in press; Barth, Blythe,
Schinke, Stevens, & Schilling, 1983; Bugental &
Johnston, 2000; Milner, 2003). Azar (1989a, 1997)
describes the challenging of expectations regarding
children and biased attributional processes, using CBT
strategies. Azar and Cote (in press) and Barth et al.
(1983), for example, provide scripts for cognitive restruc-
turing where distortions are identified and gently
challenged. Role plays, experimentation (e.g., demon-
strations of children’s incapacities using Piagetian
conservation tasks as an example), and reframing can
also be used. In some cases, misattributions made to
children can be clinically conceived as failures to distin-
guish the child from other related adults in their lives
with whom the parent has conflicted relationships. For
example, in the midst of an aggressive tantrum, a child
may not be distinguished from his or her absent father
whom he or she resembles and who battered and devalued
the mother. With this association comes a heighten
harshness which will be diffused if the clinician can help

the parent to see the overgeneralized response she is
having and help her discriminate the child from these
more aversive figures in her life. This process is what
social cognitive theorist call changing a schema through
subtyping (Fiske & Taylor, 1991). Similarly, alternative
attributions might be gently offered to the mother when
a negative bias emerges in her interpretations (e.g.,
“How awful it must be to feel your child is intentionally
trying to embarrass you in the store . . . . I wonder if
there is another explanation for why he acted that
way?”). Similar challenging can occur around safety
hazards (e.g., “he knows what to do when I am not at
home with him after school”). These may be reframed
similarly (e.g., “it sure would be nice if he could remem-
ber the rules when you are not around and it is really
hard to find a babysitter for him, but I wonder if . . . ”).
The key again is repeated gentle challenging.
Peterson et al. (1997) also highlighted the need to
challenge conflicts between cultural and religious beliefs
and therapy goals, using persuasion (e.g., challenging of
role schema such as “a good mother is one who main-
tains strong and absolute control over her children, usu-
ally by physical force”) and attempting to increase
flexibility in thinking about childrearing and in behav-
ioral responses. Provision of counterintuitive information
is described by Azar and her colleagues above (e.g.,
“your attention is your child’s paycheck, paying too
much attention to your child’s negative behavior by
yelling at them rewards it”). Extensive use of such
metaphors is useful (e.g., “children’s good behavior is
like a plant and their bad behaviors are weeds, which
will you water?—time out is like ‘weed killer’ ”; “pro-
ducing change using harsh punishment is like hitting
something too hard with a hammer, you get results but
may split the wood”; Peterson et al., 1997; “asking your
child to do that would be like me asking you to fix a
carburetor and threatening you with punishment if you
cannot”; Azar, 1989a). Metaphors enhance persuasion
by helping organize and process a large amount of infor-
mation (Sopory & Dillard, 2002), thus compensating for
poor executive functioning and facilitating learning.
Executive functioning capacities themselves can also
be targeted. Problem-solving training has been included
in behavioral parent training (Azar, 1989a; Azar &
Wolfe, 1998; Stern & Azar, 1998). It includes identifica-
tion skills (What is the problem? Whose problem is it?),
generation of alternative solutions, consideration of the
potential effects of each, response selection, enactment
of responses, and evaluation of their effects. Role plays
are useful, as well as videotaped interactions, for teach-
ing “thinking” skills in a more relaxed setting than in
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Information Processing and Prevention 
live conflicts with children (i.e., reduces arousal and
the distractability that may interfere with new skill
mastery). Anger and stress management training empha-
size cognitive flexibility (e.g., “He is only two—it won’t
work this time, but maybe next time”; “what else can I
do?”). Work on safety, hygiene, and medical care deci-
sions focuses on identification capacities and response
generation (Lutzker et al., 1998). Therapist modeling
and multiple trials with visual checks are used (e.g.,
pictures of various levels of child injury symptoms).
CBT interventions have been successful with mal-
treating parents (Azar & Twentyman, 1984; Kolko, 1996)
and clinical populations at risk of childhood injury [e.g.,
parents of aggressive youth (Stern & Azar, 1998) and dis-
ruptive childhood disorders (Johnston, 1996)].
Prevention work targeting parental thinking in at-
risk parents (targeting appraisal, problem solving, self-
efficacy, attributions, and religious and cultural beliefs),
in addition to behavioral skills, has shown reductions in
harsh discipline, child maltreatment, and childhood
injury, as well as shown improvements in children’s
health outcomes (Bugental et al., 2002; Olds et al., 1998;
Peterson et al., 1997; Peterson, Tremblay, Ewigman, &
Popkey, 2002; Sanders et al., in press).
These preliminary studies suggest that targeting
cognitive factors along with behavioral changes will
have beneficial effects in reducing harm to children and
may even impact positively on child health. Clearly,
more work is needed to replicate these effects. Dissemi-
nation, however, may be a problem. To date, most pro-
grams offered to parents in both child maltreatment and
injury prevention have been either watered-down com-
binations of personal counseling or didactic parenting
classes (United States Advisory Board on Child Abuse
and Neglect, 1995). Some evidence suggests that little
intervention at all occurs. “Cognitive” problems within
societies may be at fault (Azar, 2002b). Parenting is still
seen as an instinctually driven and not requiring com-
plex learning processes. In addition, those most in need
of services are the poor, and society has been ambivalent
in its willingness to provide supports to such individuals
(e.g., seeing them as helpless and hopeless; Azar, 1996).
Such biased schemas interfere with “adaptive” policy.
Cognitive work is needed on a more grand scale to
counteract such forces (e.g., media campaigns and work
with legislators). The CBT model emphasizes the idea
that overwhelmed parents have more difficulty carrying
out their jobs in the same way that overtaxed traffic
controllers or other professional groups charged with
monitoring of others do. That is, seeing parenting as
involving complex cognitive capacities elevates the role
  Azar and Weinzierl
and would foster more complex and sensitive actions on
society’s part.
The unified approach suggested by Peterson and
Brown (1994) offered future directions for work in
maltreatment and unintentional injury. The cognitive
approach attempts to operationalize such a unified
approach and provides more refined directions for
research and intervention work. It must be emphasized,
however, that no amount of parental supervision and fore-
sight can prevent all harm to children. Environmental
changes, therefore, need to continue to be instituted (e.g.,
requiring car seats and use of smoke detectors), especially
for parents whose lives and circumstances of living tax even
a well-functioning cognitive system (Tremblay & Peterson,
1999). Subsidized child care, support groups, and crisis
lines may all reduce maltreatment, as well as childhood
injuries, by reducing parental stress. Prevention, however,
that targets cognitive functioning may work in conjunction
with environmental scaffolding to increase parental “fore-
sight” capacities and reduce child risk further.
Received April 14, 2003; revisions received August 26,
2004; accepted August 26, 2004
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