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Issues in Child Abuse Prevention Number 3 December 1994

Child Abuse Prevention: A Perspective on Parent Enhancement Programs from the United States

Marianne James, Senior Research Officer, Australian Institute of Criminology


CONTENTS

Introduction

Child abuse and neglect are worldwide problems. Over the last twenty years there has been an increasing level of concern with, and a corresponding degree of research into, the causes and correlates of child abuse and neglect. Historically, the United States has been the leader in all aspects of this research, including extensive incidence and prevalence studies. This has resulted in a greater emphasis on preventative measures with appropriate programs being put into place at an empirical level. As many similar intervention and prevention programs are now being practised in Australia, it is important to understand the context as well as the content of both programs and evaluations in the United States, so that Australian policy and procedures can benefit. This paper will therefore provide a background to child abuse and neglect in the United States and examine one perspective on child abuse preventative strategies - parent enhancement programs.

In the United States, child abuse and neglect is defined as the physical or mental injury, sexual abuse or exploitation, negligent treatment, or maltreatment of a child by a person who is responsible for the child's welfare, under circumstances which indicate that the child's health or welfare is harmed or threatened (The Child Abuse Prevention and Treatment Act, P.L. 100-294, 25 April 1988). Each year, there are officially more than 800,000 substantiated cases of child abuse and neglect. About 160,000 of these children suffer life-threatening injuries or long-term impairment, and an estimated 1,100 to 5,000 - most of them under 1-year-old - die annually from the abuse they receive (United States General Accounting Office 1992, p. 10). Incidence and prevalence studies have, however, varied in their findings over the years. For example:

While reports of child abuse in the United States have more than tripled in the last 15 years, it is not clear how much of the increase reflects an actual rise in the number of abuse cases and how much represents increased reporting. The authors of the Health and Human Services sponsored study (National Centre on Child Abuse and Neglect 1988 cited in US General Accounting Office 1992, p. 11) suggested that the increase they reported was probably due more to a greater recognition of abuse than to an increase in its actual occurrence. This same study acknowledged, however, that reported cases are only the tip of the iceberg because many cases are never brought to the attention of the authorities.

Consequences of child abuse

The United States General Accounting Office (1992) has documented that child abuse affects not only the well-being of children but also impacts on the costs of care systems, such as child welfare, education and health. Recent studies have found that abuse can be associated with lower academic achievement, more frequent school dropouts, juvenile delinquency, and higher rates of teenage pregnancy (United States General Accounting Office 1992, p. 12). Examples of these mental, physical and social problems are as follows.

Juvenile delinquency

Juvenile delinquency has been closely associated with abuse. A study comparing young males who had been abused or neglected as children and those who were from homes described by the authors as 'loving' found that 20 per cent of those from abusive or neglectful homes had been convicted of serious crimes, compared with 11 per cent of those from loving homes (McCord 1983, cited in US General Accounting Office 1992, p. 12). Data from another study involving 297 families showed the percentage of adolescents who had spent time in prison was about twice as high among those who had been abused as among those in a comparison group (Herrenkohl et al. 1991, cited in US General Accounting Office 1992, p. 12). A 10-year study of 411 boys found that by the time they had reached 18 years of age, 27 had been convicted of violent offences. Of these violent delinquents, 62 per cent had been exposed to harsh parental discipline compared with 7 per cent of the non-delinquent boys in the study (Farrington 1978 cited in US General Accounting Office 1992, p.13).

Problems in school

Problems with academic performance and social adjustment at school are also associated with abuse. A study of 8,600 public schoolchildren found the academic achievement of maltreated children was significantly lower than that of a similar group of children who had not been maltreated. The effects observed across all grade-levels included lower test scores and grades, as well as the increased likelihood of disciplinary problems and a higher rate of suspensions (Eckenrode et al. 1990 cited in US General Accounting Office 1992, p. 13).

Psychiatric illness and related problems

Studies also link abuse to high rates of psychosis, depression, developmental delays, violence and social aggression, and deficient social skills. For example, one study of abused children found that 40.6 per cent exhibited self-destructive behaviour (such as biting, burning, head banging and suicide attempts), compared with 6.7 per cent of the control group (Green 1978 cited in US General Accounting Office 1992, p. 13).

Responses to child abuse

Dealing with abuse is complicated by the fact that no single cause for it has been identified. The personal situational 'risk' factors that have been linked to a higher probability of abusive behaviour include a variety of stresses, such as sole parent status, parental isolation, poor coping abilities, lack of social skills, drug and alcohol abuse, unemployment and low income. It is recognised that a history of abuse in a parent's childhood increases the likelihood of child mistreatment, although, as in Australia, it is also recognised that not all abused children become abusive parents (Garberino 1990 cited in US General Accounting Office 1992, p. 13).

In the United States, efforts to address abuse have been described as a continuum of care. At one end of the continuum are activities to prevent abuse before the first incident occurs. Treatment for abused children and their families constitutes the next portion of the continuum. These efforts are typically the responsibility of local protective service agencies. The agencies work with children and families to solve their problems and, if possible, preserve the family unit. The remaining services on the continuum are those involved with removing children from dangerous abusive environments and placing them in foster care or adoptive homes.

Prevention programs, the first part of this continuum, include primary and secondary efforts. Primary prevention programs are aimed at the population in general. These include programs available to all schoolchildren and campaigns to raise public awareness using radio or television messages. Secondary prevention programs are directed at specific populations identified as being at increased risk of becoming abusive. As is the case in Australia, prevention programs are important, not only because they aim at averting - rather than treating - the human suffering caused by abuse but also because they reduce the need for other types of programs which specifically address the long-term consequences of abuse.

In 1974, the US Child Abuse Prevention and Treatment Act established the National Center for Child Abuse and Neglect as a federal focal point for prevention and treatment efforts. Emphasis was placed on abuse prevention programs and, accordingly, programs which attempted to reduce parental stresses caused by risk factors such as low self esteem and poor parenting skills were put into place. It was also envisaged that these populations would benefit, through increased parental employment and healthier children. Child abuse prevention programs in the United States therefore became closely related to other types of prevention and family support programs, such as public health nurse visitor and peer support activities. The shared goal of all these programs is to strengthen and improve the general family environment rather than solving individual specific problems. By assisting with elimination of factors such as social isolation and financial difficulties, family or individual well-being is promoted.

Evaluation and experience indicate that prevention works

In the United States, program evaluations along with nearly two decades of program experience indicate that prevention programs can be effective. Rigorous evaluations measuring the impact of programs on child abuse and neglect using control or comparison groups have been rare, but findings from those that have been undertaken have been positive. The more common evaluations of the programs' short-term effects - such as client satisfaction, parenting skills, and incidence of reported child abuse - have also shown positive results. Taken together with evidence provided by other studies and reports, the indications are that the parent enhancement programs can prevent abuse (United States General Accounting Office 1992, p.15).

Few studies have evaluated abuse prevention services from a cost benefit perspective. The evidence from the studies carried out suggests, however, that abuse prevention programs can save money by reducing future costs associated with abuse. Because prevention programs often link parents with health and social services, they can improve child and parent well-being in other less direct ways, such as by helping to increase the employability of low-income families or guiding them to obtain needed health services.

In 1992, the General Accounting Office examined several prevention programs in various parts of the United States. They focused on prevention activities that take place before the first instance of abuse. The General Accounting Office specifically intended to gain a clearer picture of how federal programs provide incentives for - or impediments to - effective intervention. The objectives were to determine:

The studies discussed below illustrate some of the prevention research that has taken place in the United States.

>University of Colorado Study

In 1971, a team of researchers at the University of Colorado began a study, using groups of 150 new mothers, to predict which parents were at risk of becoming abusive and to determine how to prevent the abuse. The team published a report in 1979 discussing the feasibility of predicting the potential for child abuse and other abnormal parenting practices (Gray 1979 cited in US General Accounting Office 1992, p.á18). The team found that prevention services provided to parents who were at risk of becoming abusive could significantly improve the infants' chances of avoiding serious physical injury requiring hospitalisation.

Family Support Center in Yeadon, Pennsylvania

This evaluation - published in 1981 - studied 46 families and their 74 pre-school age children in Yeadon, Pennsylvania, participating in a program to reduce child abuse (Armstrong 1981 cited in US General Accounting Office 1992, p.19). The families selected were considered at risk of abuse based on a stress index developed by the program. Services were provided on a voluntary basis. Families received a combination of services that began with weekly nurse or social work home visits - continuing for an average of 10 months. After the first 3 months of home visits, families joined a family education and activity group, which met at a community church twice a week for 14 weeks. At the conclusion of this activity, parents joined peer support groups, which met once a month in parents' homes. During the 10 months of the program, there were only four incidents of abuse or neglect. Using a comparison group of at-risk parents from a previous study, the program reported that this represented a reduction in the abuse rate from an expected 18 per cent to about 5 per cent.

Elmira Prenatal/Early Infancy Project

This research project at the University of Rochester (Olds 1992 cited in US General Accounting Office 1992, p. 25) is one of two recent studies providing particularly strong empirical evidence that child abuse prevention works. This project, which was completed in the early 1980s, evaluated a program of prenatal and postnatal visits by nurses to rural homes in the vicinity of Elmira, New York. The project reported that families who received home visiting had an abuse rate 50 per cent lower than those who did not receive the services. Among the high-risk group of low income sole parent families headed by teenage women, who received home-visiting services until their children were 2-years old, the abuse rate was 4 per cent compared to a rate of 19 per cent for a similar high risk group who did not receive the home-visiting services.

The program is designed to begin during pregnancy and continue until the child is 2-years-old. The home visits centre on three major activities: providing parent education, enhancing social support by family and friends, and linking the family with other health and human services. In addition to reducing child abuse, the project reported improvements in the lives of the poor sole parent families headed by women who received home visits. These included almost doubling the number of months they were employed and a 40 per cent reduction in subsequent pregnancies within 4 years after the birth of the first child.

The researchers report that such programs have the greatest chance of being effective, if they:

Hawaii's Healthy Start

Healthy Start accepts pregnant women and mothers with children up to the age of 3 months. Clients are identified primarily through an early identification process conducted in the hospital at the time of birth. Clients may also be identified prenatally through referrals from physicians and public health agencies (US General Accounting Office 1992, p. 50). It began in 1985 as a 3-year demonstration project in one area of the main island of Hawaii in response to growing numbers of reports of child abuse. In 1988, Healthy Start received approval as a state program and expanded its services to other locations. About 55áper cent of the families in Hawaii with a newborn baby were screened in 1992 and it is expected that this figure will rise to 90 per cent by 1995.

Services covered by Healthy Start are voluntary and continue until children are 5-years-old. The frequency of the home visits range from weekly to quarterly, depending on the clients' assessed level of need. Services include counselling and assistance in obtaining needed resources - such as housing, financial assistance, medical aid, nutrition, respite care, employment and transportation. In addition, lay home visitors promote positive child development by focusing on parent-child bonding to assure social and emotional growth in the infant and early childhood stages.

Webster Avenue Family Resource Center (New York)

The Webster Family Resource Center in New York, provides a variety of programs, including parent education and support, social events, child care, and counselling (US General Accounting Office 1992, p. 21). The programs are aimed at improving parenting skills and reducing risk factors, such as isolation and low self-esteem, which are often associated with child abuse. Webster Avenue Center periodically evaluates its programs and staff from the perspective of its clients and has collected and analysed parent feedback since 1988.

The responses indicate a very positive client view of program results. For example, 84 per cent of the clients stated that the programs helped them to better understand their child a lot or quite a bit, 88 per cent said the programs helped them feel a lot or quite a bit better about themselves as parents, and 97 per cent said they made new friends (United States General Accounting Office 1992, p. 22).

Birth To Three (Oregon)

Birth to Three is a centre-based parent support program in Eugene, Oregon, that has been in operation since 1978 and is open to the public. Under an evaluation requirement imposed by the state, which helps fund the program, a random list of 100 participants per quarter is submitted to the state's Child Protective Services (CPS) office and compared to the names on reports of abuse (US General Accounting Office 1992, p. 22). The program director said that, of the most recent 600 names submitted, only 1 had been reported to CPS for child abuse an incidence rate less than one-tenth the estimated average national reporting rate, according to the 1988 national incidence study published by the Health and Human Services Department (National Center on Child Abuse and Neglect cited in United States General Accounting Office 1992, p. 10).

Family Support Program (California)

The Family Support Program in Sacramento, California, provides volunteer mentors and parenting education to families at risk of abuse. Mentors make weekly home visits to provide parenting and nutrition suggestions, respite care, and transportation. They also teach parents about the development and growth of their children. Most participating families volunteer to receive services and, according to the program director, 80 per cent have incomes below the poverty level. Fewer than 10 per cent of all program participants have later been reported for abuse, and fewer than 1 per cent of those who receive a mentor remain in the high-risk category (United States General Accounting Office 1992, p. 22).

Studies of costs and benefits

The effectiveness of prevention activities must also be viewed from the perspective of their cost. Very little analysis has been done to estimate the total cost of preventing child abuse or the long-term social costs of not preventing it.

The General Accounting Office (1992) identified four studies that suggest that although prevention can be costly, it can pay for itself in the long run.

The most thorough analysis the General Accounting Office found of the immediate and long-term monetary effects of not preventing abuse was carried out by Daro (1988 cited in US General Accounting Office 1992, p. 24). This study examined research on a variety of outcomes of abuse, such as juvenile delinquency and the need for special medical services and educational programs. Using conservative estimates of abuse and treatment prevalence rates from several studies, it calculated the potential dollar costs resulting from abuse. For example, assuming a 20 per cent delinquency rate among adolescent victims, the study estimated that it would cost over US$14.8 million if these youths required an average of 2 years in a correctional institution. It estimated that if 1 per cent of severely abused children suffered permanent disabilities, the annual cost of community services for treating developmentally disabled children would increase by US$1.1 million. Finally, it estimated that the cost in future lost productivity of severly abused children is US$658 million to US$1.3 billion annually, even if their impairments limited their potential earnings by just 5 to 10 per cent.

The cost of not preventing abuse may be best demonstrated using a specific program. For example, program projections for Hawaii's Healthy Start indicate that in 1993 the cost to provide the full 5 years of service to a family would be about US$7,800. However, this cost may be justified in cost-benefit terms because of the cost of child abuse which includes, but may not be limited to, the costs of the immediate consequences of child abuse, such as hospitalisation and foster care. The cost of hospitalising an abused child for 1 week ranges from US$3,000 to US$15,000 while providing foster care for 1 year costs more than US$6,000 (US General Accounting Office 1992, p. 24). Adding the costs of the potential long-term consequences of abuse could raise this amount substantially. For example, the Hawaii program estimates the cost of incarcerating a juvenile for 1 year at about US$30,000, the cost of providing foster care to an abused child to age 18 at US$123,000, and the cost of institutionalising a brain-damaged child for life at US$720,000 (United States General Accounting Office 1992, p.24).

In addition to the benefit of reducing the direct cost of abuse, the program delivers other benefits. Potential savings resulting from improved family health and improved education and employment opportunities for the parents - goals of the program that can benefit not only those who would have become abusive, but the other participants as well - increase the likelihood that the total savings can offset total costs (General Accounting Office 1992, p. 24).

The Michigan Children's Trust Fund recently compared the costs of preventing child abuse with the costs resulting from maltreatment (US General Accounting Office 1992, p. 25). The analysis estimated the annual cost of a child abuse prevention program that starts prenatally to educate and support parents, and works intensively with them during the first year of their child's life. It noted that this kind of program not only reduces abuse, but can also help children come into the world healthier, creating additional cost savings by reducing the number of low birthweight babies. The analysis estimated the annual costs to address the results of maltreatment, which included the costs associated with medical treatment for injuries sustained by abused children, special education, foster care, adult and juvenile criminality, adult psychological problems and lost productivity. The study showed that the costs associated with dealing with the results of child abuse is nearly 20 times the cost of the education and home visitor programs.

Another recent cost study also suggests that prevention can pay for itself. A 1990 report on the Elmira Prenatal/Early Infancy Project (Olds et al. 1992 cited in US General Accounting Office 1992, p. 25) - discussed earlier - suggests that program costs can be offset in a relatively short time. The study concluded that by supporting children from low-income families the program's cost could be offset within four years. It also suggested that frequent home visiting by nurses during pregnancy and the first 2 years of the child's life can significantly reduce many health and social problems - including child abuse - commonly associated with childbearing among adolescent, unmarried, and low-income parents.

Conclusion

The current body of research and evaluation of child abuse prevention programs in the United States, though limited, demonstrates that child abuse prevention can be effective. The evidence accumulated to date indicates that prevention programs can have a variety of positive measurable effects. Such programs help parents develop the skills they need to raise their children. They provide support systems to turn to when difficult situations occur, and they link families with needed health and social support agencies, such as those that provide counselling, day care, and employment services. Research suggests that these efforts can also reduce the dollar costs often associated with abuse and family dysfunction (United States General Accounting Office 1992, p. 43).

The more significant question for future evaluations is not so much whether prevention works, but rather which approach is most effective for a certain population, under a given set of circumstances. Experts agree that there is no single cause of child abuse. Therefore, there can be no single program model or strategy that will work for everybody. Factors that increase an individual's vulnerability to abuse, both as individuals and perpetrators, can differ considerably among different populations. As a result, evaluations need to address program effectiveness under constantly changing social and economic conditions, as well as the effectiveness of successful models that are implemented in different locations. To the extent possible, this research should be longitudinal - so that the long term program effects can be measured - and should use control comparison groups - so that program benefits can be measured (United States General Accounting Office 1992, pp. 43-4).

Measurements of the cost benefits of preventing child abuse is another area of evaluation that needs emphasis. Prevention can be costly, though the limited analysis and research conducted do suggest that such programs can pay for themselves in reducing the need for a wide range of services, including special education, law enforcement and health care. Rigorous evalu-ations are necessary to provide evidence that prevention programs reduce child abuse and save money by eliminating some of the social costs associated with troubled families. More social research is needed. It is important to keep in mind, however, that cost savings should not be the only criterion for measuring program worth. Policy makers also need to consider the human benefits of preventing child abuse and neglect. Programs that provide such benefits can be worthwhile public investments (US General Accounting Office 1992, p. 44).


References

United States General Accounting Office 1992, Child Abuse Prevention Programs Need Greater Emphasis, Report to the Chairman, Subcommittee on Oversight of Government Management, Committee on Governmental Affairs, US Senate, Washington DC.

Note: All the references in this paper are as cited in United States General Accounting Office 1992:

American Association for Protecting Children 1986, Highlights of Official Child Abuse and Neglect Reporting, American Humane Association (in conjunction with the National Center on Child Abuse and Neglect), Denver, Colorado.

Armstrong, K.A. 1981, A Treatment and Education Program for Parents and Children Who Are at Risk of Abuse and Neglect, Child Abuse and Neglect, vol. 5, pp. 167-75.

Daro, D. 1988, Confronting Child Abuse: Research for Effective Program Design, The Free Press, Macmillan Inc., New York.

Eckenrode, J., Laird, M. & Doris, J. 1990, Maltreatment and the Academic and Social Adjustment of School Children, Cornell University, Ithaca, New York.

Farrington, D.P. 1978, 'The family background of aggressive youths', in Aggression and Anti-Social Behaviour in Childhood and Adolescence, eds L.A. Hersov & M. Berger, Pergamon Press, New York.

Garberino, J. 1990, 'Child abuse: Why?' The World and I, June.

Green, A.H. 1978, 'Self destructive behavior in battered children', American Journal of Psychiatry, May.

Gray, J. et al. 1979, 'Prediction and prevention of child abuse and neglect', Journal of Social Issues, vol. 35, no. 2, pp. 127-39.

Herrenkohl, R. et al. 1991, The Relationship Between Early Childhood Abuse and Neglect and Adolescent Deviance, Centre for Social Research, Lehigh University, Bethlehem, PA.

Kempe et al. 1962, 'The battered child syndrome', Journal of the American Medical Association, vol. 181, no. 1, July.

McCord, J. 1983, 'A 40-year perspective on effects of child abuse and neglect', Child Abuse and Neglect, vol. 7, pp. 265-70.

National Center on Child Abuse and Neglect 1988, Study Findings, Study of National Incidence and Prevalence of Child Abuse and Neglect, Department of Health and Human Services, Washington DC.

National Center for Prevention of Child Abuse 1992, Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1991 Annual Fifty State Survey, Chicago, Illinois.

Olds, D. 1992, What Do We Know About Home-Visitation as a Means of Preventing Child Abuse and Neglect? Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, New York.

Strauss, M.A. 1978, Family Patterns and Child Abuse in a Nationally Representative American Sample, University of New Hampshire, Durham, NH, Child Abuse and Neglect Second International Congress, London September 12-15.

Acknowledgment

This paper has been adapted from the United States General Accounting Office report, Child Abuse Prevention Programs Need Greater Emphasis, with permission. This publication is held in the Library of the National Child Protection Clearing House.


Prevention programs in the United States of Americe

Birth to Three
3411-1 Willamette
Eugene, Oregon. 97405

Brehon Institute of Human Services, Inc
425 East Call Street
Tallahassee, Florida. 32301

Early Parenting Project
San Francisco General Hospital
Department of Pediatrics
1001 Potrero Avenue, Room 6D-40
San Francisco, California. 94110

Families First
Michigan Dept of Social Service
Office of Child and Family Services
235 South Grand Avenue
Lansing, Michigan. 48909

Family Enhancement Program
Illinois Department of Children
and Family Services
406 East Monroe
Springfield, Illinois. 62701

Family Service Agency
1757 Waller Street
San Francisco, California. 94117

Family Support Program
3701 Branch Center Road
Suite 115
Sacramento, California. 95827

First Steps Program
Washington Department of Social and Health Services
Division of Children and Family Services
Olympia, Washington. 98504

Foster Grandparent Program
Woodhull Medical and Mental Health Center
760 Broadway
Brooklyn, New York. 11206
Harborview Medical Center
325 Ninth Avenue, Room 635
Seattle, Washington. 98104

Healthy Start
Hawaii Department of Health
Family Health Services Division
Maternal and Child Health Branch
741-A Sunset Avenue, Room 204
Honolulu, Hawaii. 96816

Healthy Start
Florida Department of Health and Rehabilitative Services
1317 Winewood Boulevard
Tallahassee, Florida. 32399

Hephzibah Children's Association
946 North Boulevard
Oak Park, Illinois. 60301

Insights - Teen Parent Program
1811 Northeast 39th Avenue
Portland, Oregon. 97212

Medina Children's Services
123 16th Avenue
PO Box 22638
Seattle, Washington. 98122

Memphis New Mothers Study
Shelby County Health Department
814 Jefferson Avenue
Memphis, Tennessee. 38105

Mini O'Beirne Crisis Nursery
423 North Seventh Street
Springfield, Illinois. 62702

North Lawndale Family Support Initiative
c/- National Committee for Prevention of Child Abuse
322 South Michigan Avenue
Suite 1600
Chicago, Illinois. 60604

Parent Place
600 Broadway
Longview, Washington. 98632

Parent Aide Program
Children's Hospital and Medical Center
4800 Sand Point Way Northeast
PO Box C5371
Seattle, Washington. 98105

Parent to Parent
2990 Experiment Station Drive
Hood River, Oregon. 97031

Parents Too Soon
Illinois Department of Children and Family Services
406 East Monroe
Springfield, Illinois. 62701

Parents Anonymous
PO Box 4295
Tallahassee, Florida. 32315

Parents Anonymous
1305 4th Avenue
Suite 310, Cobb Building
Seattle, Washington. 98101

Parent Outreach Program
4800 Northeast 74th
Portland, Oregon. 97218

Passage House
c/- New York State Department of Social Services
40 North Pearl Street, 11th Floor
Albany, New York. 12243

Program for Early Parent Support (PEPS)
4649 Sunnyside Avenue North
Room 346
Seattle, Washington. 98103

Project Safety Net
Florida Department of Health and Rehabilitative Services
1317 Winewood Boulevard
Tallahassee, Florida. 32399

The Ounce of Prevention Fund of Florida
123 North Monroe Street
Tallahassee, Florida. 32301

The Parent and Child Place
2211 Wabash Avenue
Springfield, Illinois. 62704

Washington Heights - Inwood Coalition, Inc
652 West 187th Street
New York, New York. 10033

Webster Avenue Family Resource Center
283 Webster Avenue
Rochester, New York. 14609

Well Family Project
PO Box 1067
Okanogan, Washington. 98840

(Source: US General Accounting Office 1992)


ISSN 1321-2540
ISBN 0 642 22241X

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