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The Child Abuse Potential (CAP) Inventory.

Applications from 1986 to 2014
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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
forms of abuse, are known to produce severe consequences on
mental health which can emerge both in infancy and in adult age .
Identify potential abuse and risky contexts could decrease the
Even in situation of real abuse, attention to risk factors is needed
in order to identify potential chronic maltreatment and stop a
circle of violence.
The Child Abuse Potential (CAP) Inventory is a widely used
assessment tool that enable to identify physical abuse and at-risk
situations. Considerations about its characteristics allow the
promotion of its use as an important help for programs of
secondary prevention, aimed to prevent the actuation of a risk
situation and of tertiary prevention, in order to stop physical
abuse situations and avoid a possibility of chronicity and
revictimization. A mini review of the literature is proposed,
focusing on the construct validity and the concurrent predictive
validity of the CAP Inventory with the intent to underline its
potentialities and evidences across the time and suggest furthers
investigations.
Keywords- Child Abuse Potential Inventory (CAP Inventory),
physical abuse, review.

I.

INTRODUCTION

According to The World Health Organization, child

all forms of physical
and/or emotional ill-treatment, sexual abuse, neglect, or
negligent treatment or commercial or other exploitation,
survival, development or dignity [1].
In the lasts years, international studies underline how the
dimension of this problem makes it one of the major public
health issues. In high-income countries, between 4 and 16% of
children is physically abused [2]. In 2009 a meta-analysis
aimed to investigate the prevalence of sexual abuse in the
community estimated that 20% of women and 8% of men
experienced some kind of abuse before reaching adulthood [3].
Early adverse experiences are known to produce severe
consequences on mental health, which can emerge both in
infancy and in adult age [2]; maltreatment and abuse
experiences in childhood increase the risk for adult depression,
antisocial behavior, substance abuse, somatic complains,
suicidal ideation and the development of PTSD [4]. Biomedical
researchers increasingly recognize that childhood events,
specifically abuse and emotional traumas, have deep and

enduring effects on the neuro regulatory systems that mediate

medical illness from childhood into adult life [5]. In addition,
such experiences significantly influence attachment and
developmental processes, diverting both the personal and
relational growth [6]. Furthermore, maltreatment, childhood
abuse and neglect could lead to a child's death [7]; in particular,
interesting data from a 2010 French study show that many
children who died from abuse were not identified as abused
before their death [8].
Physical abuse, that occurs when a child suffers injury due
to the action of his or her caregiver [9], can cause physical
pain, injury, or other physical suffering or bodily harm. Studies
about consequences of physical abuse, show that children who
experienced it, are at increased risk of perpetrating violent
behaviors, compared to the ones that did not experience it.
Although researchers find some exceptions [10], child physical
abuse (CPA) has been identified as a risk factor for several
types of interpersonal violence, including peer aggression [11,
12], intimate partner violence (IPV) [13, 14, 15, 16, 17],
serious juvenile offenses [18, 19], violent crime [20] and adult
sexual assault [21]. An association was also found between the
experience of abuse and the potential risk of committing
physical maltreatment in adult age, even if results about this
relation were unclear and reported the role of different factors
[22, 23, 24, 25, 26].
In light of the immediate and long-term consequences of
maltreatment experiences that the literature highlights, we
underline the need for an early identification of abuse situations
or exposure to risky contexts. Detecting potential abuse could
decrease the risk of a
diseases. Moreover, risk factors linked with abuse could have a
direct influence on mental health, causing fear, depression and
feelings of shame that contribute to
; so, this
identification is not only just helpful to avoid the experience of
in
situation of real abuse, attention to risk factors is needed in
order to identify potential chronic maltreatment and stop the
circle of violence.
In the end, the study of risk factors for different kinds of
abuse and the development of strategies to early identify them
could be a starting point to create plans of intervention and to
interrupt the intergenerational transmission of the violence.
The Child Abuse Potential Inventory can, in part, answer
the need of Infant Mental Health services, to have assessment
tools that enable to prevent and identify abuse situations.

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II.

T HE CHILD ABUSE POTENTIAL INVENTORY

The Child Abuse Potential (CAP) Inventory is a 160-items

questionnaire for assessing child physical abuse, developed in
1986 by Prof. Joel S. Milner [27]. It is widely used both with
English and not-English speakers and it has been translated in
more than 25 versions. Items are scored on a forced choice
format (agree/disagree), with no limits on time; generally the
assessment lasts about 20 minutes. The main clinical scale of
review of literature regarding the discriminative characteristics
of abusive and not abusive parents. The Abuse Scale is
composed by six interrelating risk factors, representing the
principal ones that contribute to development of abusive
behavior.
The first three scales focus on the intrapersonal area. The
Distress scale (36 items) assesses the personal preoccupation
and feelings, like being sad, alone, depressed, confused, upset,
disoriented, and detects difficulties of adjustment. Rigidity (14
items) refers to the inflexibility in attitude in response to child
behavior. Furthermore, it refers to the idea that children need
rigid and strict rules. Unhappiness (11 items) describes a wide
range of feelings from unhappiness to happiness; it refers to
how the subject evaluate the quality of his life: if he feels
unlucky, inadequate. The other three scales examine the
interpersonal domain; Problems with Child and Self (6 items):
describes a tendency to consider
,
like thinking he has problems or limited competences.
Problems with Family (4 items) addresses problems with
members of the family, such as conflicts or problems getting
along. Problems from Others (6 items) detects the presence of
general difficulties in social relationships: items describe the
perception of the subject that other people caused him a lot of
suffering and that life is hard because of other people.
Relationships in general are experienced as delusions, not as a
resource for life.
In addition, the CAP Inventory includes three validity
scales to assess the degree of presence of three kinds of
distortion in the answers. The Lie scale (18 items) measures the
individual tendency to lie; the Random Response scale (18
items) detects the tendency to answer casually; the
Inconsistency Scale consists in 20 couples of opposite items,
detect the tendency of the subject to give inconsistent answers.
Before considering the global score on the Abuse scale for any
kind of use or classification, it is important to consider the cutoff point of the validity scales, to distinguish between good
protocols and fake ones. For the Lie scale the cut-off is 7
points; for the Random Response Scale and the Inconsistency
scale the cut-off is 6 points. When the subject scores below the
cut-off on the three Validity scales we can consider there is no
kind of distortion in his answers.
CAP Inventory scores range from 0 to 486 points. For
Abuse Scale two cut-off points are reported and used in
literature: 166 and 215. The 215 cut-off point is more
conservative and permits to minimize the number of false
positive protocols. Scores above 215 suggest presence or high
risk of physical abuse. The 166 cut-off point is better used for

screening in normative population suggesting the presence of a

tendency for abuse [28].
A. Psychometric properties
As reported in the first manual of CAP Inventory [27] and
confirmed by review studies [29], the internal consistency
estimates range from .92 to .95 for general population (n =
2,062), at-risk (n = 178), neglectful (n = 218), and physically
abusive (n = 152) parent groups. The test-retest reliabilities
asses the temporal stability of the Abuse scale for 1-day (n =
125), 1-week (n = 162), 1-month (n = 112), and 3-month (n =
150) in the general population; results intervals are: .91, .90,
.83, and .75, respectively. Regarding the construct validity,
CAP Abuse scores are generally associated to personal and
interpersonal risk factors referred in the literature [30, 31, 32].
Subject with high Abuse score present: experience of having
suffered or observed childhood abuse; less family cohesion,
more family conflict and less marital satisfaction; more
domestic violence and social isolation [33]; higher level of life
stress or personal distress; more physiological reactivity to
child-related and not-child-related stimuli [34]; external
attribution of their behavior, rigid interactional style, more
On predictive concurrent validity the Abuse scale permits
to find the expected group difference between child physical
abusers and comparison groups [30, 35]. A First study showed
a 90% of correct classification, while subsequent studies
indicate a lower range, between 80%-90% [36]. Using the 215point cut off score the overall correct classification rates
86,4%: 73.8% of 110 child physical abusers, and 99.1% of 110
matched comparison parents. The data increase at 88.5%, for
the overall classification using the 166-point cut off. Moreover,
after removing invalid protocols, the standard scoring
procedure and the 215-point cut off score correctly classified
81.4% of the child physical abusers and 99.0% of the
comparison parents, for an overall rate of 90.2%. Again, using
the
166-point cut off score a slightly higher overall
classification rate of 92.2% was found.
Regarding the sensitivity and the specificity of the CAP
Inventory, more false negative than false positive
classifications are typically found when physically abusive and
demographically matched comparison parents are studied. This
mean that CAP Inventory is more likely to fail in correct
classify abusive parents than miss-classify demographically
similar non-abusive comparison parents as abusive (false
positive classifications).
With respect to the future predictive validity, a prospective
study with 200 at-risk parents tested at the beginning of a
prevention program and at a follow-up administration, in order
to determine subsequent cases of child maltreatment, showed a
significant relationship (Cramer's V = .34, p < .0001) between
pre-intervention abuse scores and later confirmed child
physical abuse. In another study, CAP Abuse scores obtained
before starting a support program for pregnant mothers was
able to predict future maltreating cases [37].
III.

FROM 1986 TO 2014 RESEARCHES

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

continuous process, assessing the capacity of the tool to
measure what it means to asses during the time. In particular,
for the CAP Inventory, that means distinguishing correctly
between abusive and not abusive parents and identifying
appropriately future abusive situations, recognizing at-risk
contexts.
From 1986 to 2014, around 300 scientific studies about the
CAP Inventory are available, according to the consultation of
on line database and a list of publication provided by author.
Excluding review articles, validation studies, proposal of short
form of the instrument, in-depth analysis of single items, single
case or treatment and intervention evaluation, it is possible to
select about 100 scientific papers available on-line, consulting
the main database that we can use to analyze the validity of the
tool. 45 papers can be used to verify the ability of the CAP
Inventory to classify in a dichotomous form high-low risk,
using the two cut-off points. About 56 scientific papers could
be used to a) distinguish abusive and not abusive parents; b)
identify risk factors comparing parents who show and no not
show them.
A. Concurrent predictive validity: abusive and not abusive
parents
Considering those works published between 1986 and 2014
approximately ten studies can be selected as regard the
comparison between abusive and not abusive parents. Some
studies were excluded because of a lack of information in the
paper.
The fist study, conducted by the author of the tool,
compared abusive parents (61), referred by services, with a
control group (177) and a group of nurturing parents (64);
results show a significant difference between the three groups,
with abusive parents reaching scores above the cut off of 215
for Abuse scale (265), while the other two groups reaching
51.9 and 39.6, respectively [39]. In another study 23 motherchild dyads were assessed to code child facial expression
comparing children abused by their mother and not-abused
ones. Regarding the CAP Inventory scores the two groups
show a significant difference (p=.001) [40]. In 1992 and 1994
Caliso and Milner compared 30 abusive mothers, with past
history of child abuse to 60 not abusive mothers: 30 with
history of abuse and 30 without. Both studies highlighted
significant higher Abuse scores for the abusive sample,
respectively 304,4 and 295,2 CAP Abuse scores. Interesting
results emerged comparing the two not abusive groups: even if
their scores were not significantly different, abused mothers
showed scores around the 166 cut-off point, while the not
abused ones obtained scores close to Milner's normative
average point 91 [41, 42]. 59 parents referred by services for
abuse or maltreatment were compared with a control group of
383 parents: data showed significant higher CAP Inventory
scores in the first group with 302.4 Abuse average [43]. In
another study a 231,19 CAP Abuse score was found in a group
of abusive parents but no considerations about the discriminant
capacity of the instrument could be done because of the lack of
data regarding the control group [44]. An interesting study
showed that a sample of 25 abusive mothers, whose children
were under the care of child social services, still had a high

persistence of potential abuse 7 years after a previous episode,

with Abuse score higher than the comparison group [45]. 30
abusive mothers and 30 not abusive mothers were compared on
their expectation about
on their
attitude as a parent about discipline in two different occasions:
while their baby is crying and when he/she is not; the two
groups obtain different CAP Abuse scores, respectively 287.8
and 50 point [46]. Another study found that abusive mothers
obtained CAP Abuse scores above the 215 cut-off point: 239.5
[47].
More recent results comes from two studies, published in
2011 [48] and in 2012 [49]; unfortunately, the first one only
provides CAP scores for a group of abusive parents, without
giving information about the control group. The second study,
instead, distinguishes participants in physical abusive,
neglecting and control individuals, but it does not report CAP
scores.
In conclusion, on the basis of what emerges from the
above-presented studies, the CAP Inventory studies appears to
be an reliable tool that permits to distinguish abusive and nonabusive parents. Even if results are not always easy to explain
and comment, because of some limitations such as lack of data
and differences in sample size, there is a general agreement
among studies about the best CAP Inventory cut-off score,
namely 215 points. As a matter of fact, the only exception is
represented by the a study in which the abusive sample scored
172,36, under 215 but anyway above the 166 cut-off point.
B. Construct validity: associated risk factos
With respect to risk factors associated to the actual
experience of abuse, CAP Inventory was used in a greater
number of studies. Most of them have investigated the role of
traumatic experiences in childhood, such as physical, sexual
abuse and neglect.
In a first study three samples of parents, differently exposed
to risky conditions (physical abuse, sexual abuse and neglect)
were compared with three control groups. Results showed
significantly higher scores for all the three risks groups [50].
Another study has examined the association between past
experience of sexual abuse in infancy and the presence of
specific characteristics of parental attitudes in adult age, like
potential of abuse, nurturing skills, unrealistic expectations on
the child and child punishments. In particular, maternal anger
was investigated as mediator factor of the relationship between
the past experience of being abused and the potential risk to
abuse. 138 sexual abused mothers were compared with 152
not-abused ones; results highlight that the abused sample
shows attitudes and behaviours significantly associated to the
risk of physical abuse [51].
Comparing mothers with a past history of sexual or
physical abuse, no significant difference was found on the CAP
scores, showing no difference on the potential of risk. What is
more interesting here is that both groups show CAP Abuse
scored under the cut-off point; anyway the statistical difference
respect to the control group is confirmed [52].
Another study focused on the relationship between the
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

were classified as abused or not abused: CAP scores underline
a significant difference in the two groups [53].
Others two interesting studies conducted in 2007 compared
caregivers who have experienced traumatic events in
childhood, in adult age, in both conditions or never. In the first
study a significant difference was found between the control
group and the other three ones, while there were no differences
regarding the age of the individual when the abuse occurred
(childhood, adult or both periods) [54]. In the second study the
child abuse experience was classified as mild, moderate, severe
or extreme; no information were provided about the
significativity of CAP inventory score, anyway all this groups
had high Abuse scores [55]. Experience of violence in
adulthood was also studied by a research in which mothers who
experiences Intimate Partner Violence during pregnancy were
compared to mothers who did not suffer from this condition;
also in this case results showed a significant difference in CAP
Abuse scores [56].
Two studies have investigated the role of adolescent
pregnancy. The fist analyzed the correlation between potential
of child abuse and parental attitudes in 66 adolescent mothers.
Results showed a significant difference in Abuse scores for
mothers younger than 16 and older than 16; that means,
younger mother are at major risk [23]. The second study
investigated differences of attachment models in children of
adolescent and not-adolescent mothers. The potential of
physical abuse was studied in order to highlight a difference
between the two groups even if in both cases CAP Scores were
under the 166 cut off point [57].
Another risk factor investigated by CAP Inventory was the
substance abuse: in one study 159 mothers and 290 fathers with
a diagnosis of addiction or substance abuse were involved,
together with a control. Parents from the SUD (substance use
disorders) groups showed significant higher scores on the CAP
Abuse scale [58].
In a study aimed to investigate the association between
child aggressiveness and the presence of substance abuse in
their father, it was highlighted that fathers with a history of
substance abuse had higher CAP Inventory scores, compared
with no users, even if results were under the 166 cut-off point
[59].
With respect to other clinical conditions, depressed mothers
were studied to identify if depression could be a risk factor for
physical abuse; what emerged was a significant difference
between the two samples (depressed, not depressed) [60].
The potential of physical abuse was also investigated as
associated to some paternal characteristics, such as parental
level of stress and personal value assigned to corporal
punishment. In two different studies control parents were firstly
compared to parents with high parental stress and low belief in
corporal punishment and secondly with parents with high belief
in punishment but low parental stress. ANOVA results showed
that the relationship between parental stress and potential risk
of physical abuse is mediated by belief on corporal
punishment; in particular, in the two groups with strong
believes on punishment, CAP Abuse scores were different

depending on the fact that high level of stress were detected or

no; on the contrary, in the two groups with low punishments no
difference was pointed out both for high and low levels of
parental stress as assessed by the CAP scores [61].
IV.

CONCLUSIONS

In conclusion, since the CAP Inventory has been applied in

a considerable number of empirical studies, enough data are
available in order to analyze its psychometric characteristics
across the time.
To date, available studies investigating its concurrent
predictive validity seems to underline the capacity of the CAP
Inventory to distinguish abusive and not-abusive parents.
Anyway, considering the literature on the CAP Inventory, there
is a relative lack of studies comparing abusive and not-abusive
parents; between 2004 and 2014 only few studies have used the
CAP Inventory with abusive parents; moreover, a control
group is not always reported and/or authors do not provide data
about Abuse scores of the abusive group. This can be explained
considering that in the first years after the publication of a new
assessment tool there was a greater need for proofs of its
construct validity. Anyway, after more than thirty years from
the first diffusion of the CAP Inventory it might be important
to have further and more updated data assessing its construct
validity, in order to provide normative data for the current
population of parents, reporting all the distinctive features of
the current society.
With respect to construct validity, studies underline the
capacity of CAP Inventory to detect risky situation; in
particular, substance abuse and childhood abuse experiences
seem to represent the major risk factors. Further data are also
needed to investigate other possible risk factors, such as
pregnancy in the teenage, parental depression and other types
of parental characteristics and clinical conditions.
Moreover, it is important to mention that drawing
conclusion might be difficult because of the differences
between the various studies as regards methods, participants,
sample size. In this sense, a meta-analytic study is highly
recommended in order to improve the quality and the validity
of the considerations about the psychometrical properties of the
CAP Inventory as they might have changed during the time.
In the end, drawing conclusions and reflections about the
characteristics of the CAP Inventory will foster its application
in a wider range of studies and clinical context. For example it
can be an useful source of information for secondary
prevention programs, which aim to prevent the actualisation of
a risk situation, and for tertiary prevention protocols, which
intend to stop abuse situations and to avoid the repetition of
chronic cycle of revictimization.
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