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1 Introduction and Overview1 In 1993 the National Research Council (NRC) released its landmark report Understanding Child Abuse and Neglect (NRC, 1993). That report identified child maltreatment as a devastating social problem in Ameri- can society. It observed that social service agencies received case reports involving over 2 million children in the year 1990 alone. From 1979 through 1988, about 2,000 child deaths (ages 0-17) resulting from abuse and neglect were recorded annually. As the report noted, the services required for children who have been abused or neglected, including med- ical care, family counseling, foster care, and specialized education, cost many hundreds of millions of dollars annually. At that time, according to the report, research in the field of child maltreatment studies was relatively undeveloped when compared with related fields such as child development, social welfare, and criminal violence. To reduce the physical and emotional tolls of child maltreat- ment, the report called for a wide-ranging research program with four separate objectives: 1. The Nature and Scope of Child Maltreatment. Clarify the nature and scope of child maltreatment, guided by well-developed re- search definitions and instrumentation. 2. The Origins and Consequences of Child Maltreatment. Provide an understanding of the origins and consequences of child mal- treatment in order to better inform theories regarding its etiology 1 This report has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. The planning committee’s role was limited to planning and convening the workshop. The views contained in the report are those of individual workshop participants and do not necessarily represent the views of all workshop partici- pants, the planning committee, or the National Research Council and Institute of Medicine. 1

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2 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE and to establish a foundation for improving the quality of future policy and program efforts to address the problem. 3. Treatment and Prevention of Child Maltreatment. Determine the strengths and limitations of existing approaches and interven- tions in preventing and treating child maltreatment to guide the development of new and more effective interventions. 4. A Science Policy for Research on Child Maltreatment. Develop a science policy for child maltreatment research that recognizes the importance of developing national leadership, human re- sources, instrumentation, financial resources, and appropriate in- stitutional arrangements for child maltreatment research. By pursuing this agenda, the report argued, researchers could “develop knowledge that can improve understanding of, and response to, child maltreatment.” RESEARCH, POLICY, AND PRACTICE FOR THE NEXT DECADE Nearly 20 years later, on January 30-31, 2012, the Board on Chil- dren, Youth, and Families at the Institute of Medicine (IOM) and the NRC held a workshop to review the accomplishments of the past two decades of research related to child maltreatment and the remaining gaps. “There have been many exciting research discoveries since the ’93 re- port,” said Anne Petersen, research professor at the Center for Human Growth and Development at the University of Michigan. She was chair of the panel that produced the report and also chaired the planning com- mittee for the workshop. “But we also want people to be thinking about what is missing.” The workshop brought together many leading U.S. child maltreat- ment researchers for a day and a half of presentations and discussions. Presenters were asked to review research accomplishments, identify gaps that remain in knowledge, and consider potential research priorities. A background paper highlighting major research advances since the publi- cation of the 1993 NRC report was prepared by an independent consult- ant to inform the workshop discussions; this paper is included in Appendix D. In the past two decades, there has also been significant pro- gress in research on child development more generally, but it was beyond the scope of the workshop to consider this broader topic (see Box 1).

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3 INTRODUCTION AND OVERVIEW BOX 1 Research on Child Development As presenters noted throughout the workshop, the past two decades have seen an outpouring of original research and syntheses of research on child maltreatment. There has also been much effort to improve our general understanding of child development and the ways in which the social and physical environments of children interact with their health and development. For example, the National Research Council and Institute of Medicine report From Neurons to Neighborhoods: The Science of Ear- ly Childhood Development (NRC and IOM, 2000) reviewed studies of early childhood development and their implications for policies and pro- grams that affect the lives of young children. This report noted that “an explosion of research in the neurobiological, behavioral, and social sci- ences has led to major advances in understanding the conditions that influence whether children get off to a promising or a worrisome start in life” (p. 1). Much additional research has been undertaken in the 12 years since the report was published, but it was beyond the scope of this workshop to review the broad literature on child development.  A VISION FOR THE FUTURE The workshop was sponsored by the Office on Child Abuse and Ne- glect, which is situated in the Children’s Bureau of the Administration on Children, Youth and Families (ACYF). ACYF is part of the U.S. De- partment of Health and Human Services’ (HHS’s) Administration for Children and Families (ACF). The Children’s Bureau was founded in 1912 to improve the lives of children and families. The centennial of the bureau “provides a wonderful opportunity . . . to step back and reflect on what we know and have learned and to make sure that we are clear about the foundation that has been laid and where we ought to be going in the future,” said Bryan Samuels, Commissioner of the ACYF, in his opening remarks at the workshop. “The timing couldn’t be better.” Samuels noted that there continue to be questions about the fundamen- tal goals and purposes of the field of child maltreatment and the provision of services for children and families. For example, he said, child welfare systems emphasize safety and permanency, but they place less emphasis on the well-being of children. The workshop “is an opportunity to look, in the context of maltreatment, at how we build and improve a system to

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4 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE address the healing and recovery for children who have been exposed to it, as well as to, in some respects, learn how we do a better job of pre- venting maltreatment.” Research is a critical contributor to policy and practice, said Samuels. When he was director of the Illinois Department of Children and Family Services, he relied heavily on the research literature to produce a better child welfare system even as the system got smaller. Research results on the prevention of child maltreatment informed policies to reduce the in- cidence of maltreatment, while understanding the consequences of mal- treatment informed responses. Drawing on this knowledge, Samuels said, he was able to make “significant changes in the system.” The objective of the workshop, he said, should be not just to under- stand the current system, but to provide a vision for the future of re- search, policy, and practice. ABOUT THIS SUMMARY This document is intended to summarize the presentations and dis- cussions at the IOM/NRC workshop Child Maltreatment Research, Poli- cy, and Practice for the Next Generation. The summary also highlights participant suggestions for future research priorities, policy actions, and practices that would enhance understanding of child maltreatment and efforts to reduce and respond to it. The workshop speakers and presenta- tion topics were selected to cover a range of important issues in child maltreatment research, policy, and practice. However, it was impossible to include all potential topics during the course of a day-and-a-half work- shop and, in their presentations, speakers could not exhaustively cover all relevant findings and issues for each topic. Consequently, some relevant topics could not be included in the workshop and, by extension, are not included in this workshop summary. Whenever possible, ideas presented at the workshop are attributed to the individual who expressed them. Any opinions, conclusions, or rec- ommendations discussed in this workshop summary are solely those of the individual participants and should not be construed as reflecting con- sensus or endorsement by the workshop, the Board on Children, Youth, and Families, or the National Academies. The workshop agenda is in Appendix B and a list of registered participants is in Appendix C. The 21 presentations at the workshop are divided into eight chapters following this introductory chapter. (For clarity, the presentations have

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5 INTRODUCTION AND OVERVIEW been somewhat reorganized from the agenda.) Chapter 2 summarizes the keynote address at the workshop, which looked back to the research done in the 20 years since Understanding Child Abuse and Neglect and for- ward to the research that still needs to be done. Chapter 3 examines the medical and psychosocial assessment of child abuse and neglect as the instigating event in the provision and planning of services. Chapter 4 considers social trends and child maltreatment trends, largely on a na- tional level, and probes the relationships among those trends. Chapter 5 considers the causes and consequences of child maltreatment, with a par- ticular emphasis on the neurobiological effects of abuse and neglect. Chapter 6 looks at research on primary, secondary, and tertiary preven- tions and the impact of this research on policy and practice. Chapter 7 discusses the design and delivery of services, including implementation research. Chapter 8 looks at system-level issues in responding to child maltreatment, including responses in different countries, alternative child welfare services, and legal action to build evidence-based systems. Chap- ter 9 provides Petersen’s final observations on themes that arose during the workshop and lists selected suggestions for future research priorities proposed by presenters during the workshop. At the time of the workshop, an IOM/NRC consensus study on child maltreatment research was being planned. The workshop presentations and discussions, as summarized here, could serve as a source of infor- mation for the committee that will be convened to conduct the consensus study. There continues to be discussion about the definition of types of child abuse and neglect. Individual states set their own definitions of child abuse and neglect while meeting minimum federal standards. Fur- thermore, workshop participants noted the research challenges stemming from a lack of consensus on definitions of child abuse and neglect; this is discussed in Chapter 2, Chapter 4, Appendix D, and various other places throughout the workshop discussions. For the purposes of initial illustra- tion only, therefore, Box 2 presents example definitions of the major types of child abuse and neglect from a Children’s Bureau publication (HHS, 2008).

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6 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE BOX 2 Defining Major Types of Child Abuse and Neglect The Federal Child Abuse Prevention and Treatment Act (CAPTA, 42 U.S.C.A. § 5106g) sets a minimum set of acts or behaviors that define child abuse. States provide their own definitions on child abuse and ne- glect that meet these minimum standards. Furthermore, there is little consensus on definitions used in research. The following definitions are provided in a Children’s Bureau publication as examples; actual defini- tions vary by state (HHS, 2008). “Physical abuse is nonaccidental physical injury (ranging from minor bruises to severe fractures and/or death) as a result of punching, beat- ing, kicking, biting, shaking, throwing, stabbing, choking, hitting (with a hand, stick, strap, or other object), burning, or otherwise harming a child, that is inflicted by a parent, caregiver, or other person who has responsi- bility for the child…. Neglect is the failure of a parent, guardian, or other caregiver to provide for a child’s basic needs…. Sexual abuse includes activities by a parent or caregiver such as fon- dling a child’s genitals, penetration, incest, rape, sodomy, indecent expo- sure, and exploitation through prostitution or the production of pornographic materials…. Emotional abuse (or psychological abuse) is a pattern of behavior that impairs a child’s emotional development or sense of self-worth, This may include constant criticism, threats, or rejection, as well as withholding love, support, or guidance.” SOURCE: HHS, 2008.