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Appendix D Background Paper: Major Research Advances Since the Publication of the 1993 NRC Report Understanding Child Abuse and Neglect: Highlights from the Literature1 By Rosemary Chalk2 Introduction 120 Definitions and Frameworks 126 Identification, Reporting, and Data Sources 133 Causes 147 Consequences 151 Prevention Efforts 157 Treatment Interventions 167 Services and Systems-Level Issues 175 Social Policy 182 Conclusion 188 References 189 1 This paper was commissioned by the Institute of Medicine (IOM) and National Re- search Council (NRC) to provide background for the January 30-31 Workshop on Child Maltreatment Research, Policy, and Practice for the Next Generation, hosted by the IOM- NRC Board on Children, Youth, and Families. The responsibility for the content of this article rests with the author and does not necessarily represent the views of the IOM, the NRC, or their committees and convening bodies. 2 The author wishes to acknowledge the contributions of several individuals who re- viewed early drafts of this paper, including Lucy Berliner, Mark Chaffin, Lisa Jones, Melissa Jonson-Reid, John Leventhal, Joy Osofsky, Anne Petersen, Andrea Sedlak, and Melissa Welch-Ross. Yeonwoo Lebovitz, IOM research associate, provided extensive bibliographic and research assistance in the preparation of the paper. 119
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120 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE INTRODUCTION The problem of child maltreatment has persisted as one of the most serious threats to child health and safety in the United States. The most recent National Incidence Study (NIS-4) reported that more than 1.25 million children, involving 1 in 58 children from the general population, were abused or neglected by a parent during the 2005-2006 survey peri- od according to the evidence of harm standard (Sedlak et al., 2010b). When the broader standard of endangerment is applied (which includes maltreatment by adult caretakers other than parents, or by teenaged care- takers in the case of sexual abuse), the number of children in substantiat- ed cases increases to nearly 3 million children, involving 1 in 25 children, according to NIS-4 data. More recent data, provided in the FY 2010 report Child Maltreat- ment (HHS, 2011, p. ix), indicates that “the unique victim rate was 9.2 victims per 1,000 children in the population” when considering substan- tiated reports of child abuse and neglect. The overall rate of child mal- treatment deaths, the most tragic consequences of abuse and neglect, was 2.07 deaths per 100,000 children, based on estimates provided by state child welfare agencies (HHS, 2011). The statistical figures mask a complex picture of child maltreatment, one that frequently challenges the general public’s perception of the na- ture of the problem of child abuse and neglect. For example: Maltreatment is frequently viewed as physical or sexual abuse, yet child neglect reports consistently account for the large major- ity of the reported cases in national surveys and official records. The NISs report that the general incidence of child maltreatment declined by 19 percent (harm standard) in the 12 years between the data reported in NIS-3 (which collected data in 1993) and NIS-4 (Sedlak et al., 2010b). This decline occurred during a pe- riod of growth in the child population in the United States. When adjusted to account for such growth, the rate of decline per 1,000 children equals 26 percent, approaching the 1986 incidence level reported in the NIS-2 estimate. Most of the rates of decline can be explained by significant de- creases in reports of physical or sexual abuse of children; the level of child neglect reported in NIS-4 has remained about the same as that reported in NIS-3. Finkelhor and Jones (2006) offer
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121 APPENDIX D additional explanations for the causes of the reported decline in child maltreatment rates. One recent study suggests that the perceived decline in NIS re- ports of abuse and neglect is not consistent with other data re- garding trends in hospital admissions for child maltreatment injuries, which have remained stable from 1997 (Gilbert et al., 2012). However, their analysis relied on data that are not nation- ally representative, excluded indicators of sexual abuse, and also classified as maltreatment cases where injuries in question were classified as of “undetermined cause” (Personal communication, L. Jones, University of New Hampshire, February 10, 2012). Although a relatively small proportion of reported cases of child abuse and neglect meet legal criteria for substantiation, several studies have suggested that unsubstantiated cases face equal risks (Hussey et al., 2005; Kohl et al., 2009). These changes, as well as persistent trends, need to be considered in light of the changing demographics of the U.S. child population. Statistics in the report America’s Children (FIFCFS, 2011), based on data compiled by the Census Bureau through the Current Population Survey, notes that more than one in five children now live in poverty (see www.child stats.gov/americaschildren/eco1.asp). The report states: The percentage of children in families with incomes below the poverty threshold (defined as $21,756), which is a significant risk factor for abuse and neglect, rose from a low of 16 percent in 2000 and 2001 to 21 percent in 2009. The wealth disparities that now characterize American society also affect children: The percentage of children living in families in extreme poverty (defined as 50 percent of $21,756) rose from 6 percent in 2000 to 9 percent in 2009, which is the highest esti- mate for related children since 1997. The percentage of children who lived in families with very high incomes (600 percent or more of the poverty threshold) remained unchanged between 2000 and 2009 (13 percent). The rising number of children living in poverty is particularly noteworthy among younger children. In 2009, 24 percent of related children ages 0 to 5 lived in poverty, compared with 18 percent of older related children.
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122 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE The reported decline in child maltreatment rates is part of a larger decline in other forms of violent crime, which began in the early 1990s and continues today (Blumstein and Wallman, 2006). In recent decades, however, dramatic shifts have occurred in the American economic arena as well as the racial and ethnic composition of America’s children. Ac- cording to data from the 2010 Census that is included in the America’s Children report, 54 percent of U.S. children were white, non-Hispanic; 23 percent were Hispanic; 14 percent were Black; 4 percent were Asian; and 5 percent were in the category “all other races” (http://www. childstats.gov/americaschildren/demo.asp). Rapid increases have been recorded particularly among the percentage of children who are Hispan- ic, who made up only 9 percent of the child population in 1980 (http://www.childstats.gov/americaschildren/demo.asp). In light of these economic trends and shifting demographics, it is im- portant to consider at this time how the health and safety of children have changed over the past decade. A particular area of interest is research on child maltreatment, which focuses on the characteristics and needs of children and families who experience physical abuse, sexual abuse, emo- tional maltreatment, and neglect. 1993 Academy Study on Child Abuse and Neglect Nearly two decades ago, the National Research Council (NRC) pub- lished the report Understanding Child Abuse and Neglect (NRC, 1993). The report was prepared by a panel of national experts, following a com- prehensive study and critique of the existing research literature as well as discussions with hundreds of practitioners from the social services, healthcare, and legal systems that serve vulnerable children and their families. The NRC report embraced a developmental and ecological per- spective in examining the various dimensions of the problem of child maltreatment, and the study panel offered a general conceptual child- oriented framework to guide new approaches to child and family ser- vices as well as to set priorities that could integrate a diverse, fragment- ed, and interdisciplinary research literature. The 1993 report included 10 chapters that offered a synthesis of the key research studies under the designated topics: 1. Introduction 2. Identification and Definitions 3. Scope of the Problem 4. Etiology of Child Maltreatment
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123 APPENDIX D 5. Prevention 6. Consequences of Child Abuse and Neglect 7. Interventions and Treatment 8. Human Resources, Instrumentation, and Research Infrastructure 9. Ethical and Legal Issues in Child Maltreatment Research 10. Priorities for Child Maltreatment Research Based on this review, the study panel highlighted 17 research priori- ties, organized within a research agenda that addressed four objectives: 1. Clarify the nature and scope of child maltreatment; 2. Provide an understanding of the origins and consequences of child maltreatment in order to improve the quality of future poli- cy and program efforts; 3. Provide empirical information about the strengths and limitations of existing interventions as well as guiding the development of more effective ones; and 4. Develop a science policy for child maltreatment research that recognizes the importance of national leadership, human and fi- nancial resources, instrumentation, and appropriate institutional arrangements. Since the publication of the 1993 report, the field of child maltreat- ment studies has continued to expand. While the Office on Child Abuse and Neglect (formerly the National Center for Child Abuse and Neglect) within the U.S. Department of Health and Human Services (HHS) con- tinued to support a modest research portfolio, other federal sponsors in- vested in child maltreatment studies, including a national consortium on child neglect research organized by several institutes within the National Institutes of Health. In the intervening years, a national child abuse pre- vention initiative within the Doris Duke Charitable Foundation has also emerged. In addition, a wave of animal and human research studies fo- cused on stress, trauma, and the regulation of adverse environmental in- fluences (including threats and violence) has embraced the significance of child maltreatment as a major influence on health and well-being (see, e.g., papers produced by the Center on the Developing Child at Harvard University, http://developingchild.harvard.edu). The expansion of research in the neurosciences, including the devel- opment of new tools that are capable of imaging brain structures and functions, has advanced our understanding of the intricate and complex
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124 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE processes associated with the regulation of adverse stimuli. Additional biological studies, focused on other systems such as the immune function and interactions between genetic structures and the social environment, are shaping the ways in which researchers view complex interactions among threats and protective factors in forming the pathways to and con- sequences of child maltreatment. Research that is focused on selected childhood injuries, such as head trauma, has also converged with studies of child maltreatment, especially in highlighting selected stages of devel- opment (e.g., infancy) or child behaviors (e.g., prolonged crying) that may be especially vulnerable to particular forms of abuse or trauma among young children. Purpose and Scope of This Paper This paper highlights some of the major research advances since the publication of the 1993 NRC report, with a particular emphasis on stud- ies published in the past decade. The objective is to provide an initial guide to recent research that offers a significant guide for our under- standing of a multifaceted and disturbing subject, in preparation for a January 2012 workshop on child abuse and neglect research convened by the Institute of Medicine (IOM) and the NRC. The paper is designed for a general audience that may not be acquainted with the full range of rele- vant studies in the social, behavioral, health, and biological sciences. This paper cannot offer a comprehensive review of the literature concerned with child maltreatment or cover all the topics addressed in the initial 1993 study. Rather, it provides a brief overview of selected research within most of the nine categories that mirror the chapters of the original report (the topic of ethical and legal issues is not addressed in this paper, although there is a brief section on social policy that incorpo- rates some of this discussion). In keeping with the original NRC report, the paper has a child orien- tation rather than a broader review of perpetrator, family, neighborhood, or cultural characteristics associated with abuse and neglect, which de- serve further attention in a more comprehensive analysis. Research stud- ies focused on specific aspects of child welfare, such as the experience with alternative forms of foster care placements or disproportionality in the foster care population, are not addressed. Nor is attention directed toward topics such as the reliability of child testimony, or interventions in judicial settings for victims of child abuse and neglect. While these other areas are certainly suitable for a more comprehensive research re-
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125 APPENDIX D view, they fell beyond the scope of what was feasible to address in the 3- month time period for this effort. Research Methods The research studies selected for inclusion in this paper were identi- fied through a search of the bibliographic databases operated by the Web of Science and a comprehensive library search function of the National Academy of Sciences, which includes 13 separate databases (e.g., Aca- demic Search Premier, SCOPUS, and Science Direct). The initial search focused on the identification of research review papers that received a significant number of citations in other articles and narrowed the list to 30 from the top-ranking 50 articles. The initial database review was then supplemented by searches of additional research sources, such as the Na- tional Criminal Justice Research Service, the Child Abuse and Neglect Digital Library maintained by Cornell University, and websites main- tained by selected HHS agencies, including the Administration for Chil- dren and Families (ACF), Health Resources and Services Administration (HRSA), Centers for Disease Control and Prevention (CDC), National Institutes of Health, and Substance Abuse and Mental Health Services Administration (including the Catalog of Federal Domestic Assistance and other background materials that describe grants supported by these agencies). In some cases, reports not archived in the scientific biblio- graphic databases were identified through searches of websites of select- ed academic and professional organizations (e.g., the American Academy of Pediatrics, American Psychological Association, or Mt. Hope Family Center). Early drafts of the paper were reviewed by mem- bers and staff of the IOM-NRC planning committee for the January 2012 workshop as well as by workshop speakers and participants; their sug- gestions were particularly helpful in highlighting specific areas of em- phasis and gaps in the literature review. This paper strives to highlight areas of research that are characterized by multiple, theory-informed empirical studies with study populations that include children and families who have experienced abuse and ne- glect. Where possible, attention is directed toward those interventions that are the focus of comprehensive research reviews, striving to create a reliable evidence base to guide policy and practice. The author recogniz- es that multiple other studies exist that focus on common risk factors for abuse and neglect (e.g., depressed parents, domestic violence, or sub- stance abuse). For the most part, these research areas are not included
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126 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE unless the study specifically addressed child maltreatment issues as a primary outcome of interest. DEFINITIONS AND FRAMEWORKS Child maltreatment studies are consistently challenged by variations in definitions that characterize the events, behaviors, and experiences under review. Coulton et al. (2007) highlight the importance of distin- guishing among the definition, recognition, reporting, and agency admin- istrative classifications of child maltreatment cases that are recorded by social services agencies, and the types of child maltreatment behaviors or experiences that are self-identified by victims or offenders. These differ- ences are not just semantic; the datasets that support official reports of child maltreatment may differ in important ways from other types of ad- ministrative records or self-report data that are obtained through house- hold or victimization surveys. The 1993 NRC study described an array of research studies on defi- nitions of child maltreatment and various principles that could guide ef- forts to achieve greater consistency in future research studies. Since then, additional efforts have been made to improve the quality of definitions of child maltreatment used in both clinical and general population studies. Most notably, public health agencies and clinicians have made efforts to identify uniform definitions and data elements, including International Classification of Disease (ICD) codes, that can be used to classify child maltreatment injury and related health data and to incorporate these data into national health information databases, surveillance efforts, and diag- nostic procedures. For example: The Child Abuse Prevention and Treatment Act (CAPTA) (42 U.S.C.A. § 5106g), as amended by the CAPTA Reauthorization Act of 2010, defines child abuse and neglect as, at minimum: “Any recent act or failure to act on the part of a parent or care- taker which results in death, serious physical or emotional harm, sexual abuse or exploitation” or “An act or failure to act which presents an imminent risk of serious harm.” This definition of child abuse and neglect refers specifically to parents and other caregivers. A “child” under this definition generally means a person who is younger than age 18 or who is not an emancipated minor. This legislative definition guides federal policy and pro- grams, and sets minimum standards for states that accept
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127 APPENDIX D CAPTA funding. However, each state provides its own defini- tions of maltreatment within civil and criminal statutes, resulting in significant variation in terms of the scope of actions (or inac- tions) that may constitute abuse or neglect (http://www.child welfare.gov/can/defining/federal.cfm). The CDC website states that: “A consistent definition is needed to monitor the incidence of child maltreatment and examine trends over time. In addition, it helps determine the magnitude of child maltreatment and compare the problem across jurisdictions.” (http://www.cdc.gov/violenceprevention/childmaltreatment/defin itions.html). In January 2008, the CDC published the report Child Maltreat- ment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0 (Leeb et al., 2008). The report includes recommendations “designed to promote con- sistent terminology and data collection related to child maltreat- ment” that were developed through an extensive expert consultation process. The 2008 CDC report notes that prior ef- forts by the research and legal communities to develop consistent and uniform definitions of child maltreatment were not adequate for use in public health surveillance because many of the data sources used by the research and legal communities are not available to state and local public health officials: Because no public health-based definitions for child mal- treatment exist, public health officials continue to use terms related to child maltreatment in different ways and use dif- ferent terms to describe the same acts. Not surprising, these inconsistencies have contributed to varied conclusions about the incidence and prevalence of child abuse and neglect. (Leeb et al., 2008, p. 12) The CDC therefore developed uniform definitions and a set of recommended data elements to guide surveillance efforts by pub- lic health agencies. However, the report does not provide specif- ic instruments for surveillance nor does it offer clinical information for identifying child maltreatment. The uniform definition included in the CDC report is: “Child Maltreatment is any act or series of acts of commission or omis- sion by a parent or other caregiver that results in harm, potential
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128 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE for harm, or threat of harm to a child. Additional definitions are offered for each term in bold with specific examples.” The 2008 CDC report also describes the use of the ICD 9/10 codes for child maltreatment, which vary by hospital and region. The ICD codes provide a standard system for hospitals to code all discharge diag- noses and are used for reimbursement rates in the United States. These codes provide an alternative data source for monitoring the scope of child maltreatment, but it is important to note that many physicians may or may not use them. In addition to recording information about the na- ture, severity, and physiological location of injury, the ICD data include “E-codes” that provide information about the source or cause of the inju- ry. In the case of child maltreatment, the E-code may identify several characteristics of the perpetrator, including the person’s relationship to the child (Leeb et al., 2008). (See Box 3 for further details about the use of ICD codes in classifying child maltreatment injuries.) In its first Report to Congress on High Priority Evidence Gaps for Clinical Preventive Services, the U.S. Preventive Services Task Force identified “Interventions in Primary Care to Prevent Child Abuse and Neglect” as one of the high-priority areas in “Behavioral Intervention Research Topics That Deserve Further Research.” Approximately 1 million abused children are identified in the United States each year. Despite the dedication and hard work of people in many sectors, no one has discovered an effective role for the primary care system and primary care professionals in preventing child abuse and neglect. The Task Force recognizes that the solution to this issue will include many other efforts and hopes that needed research to find effective interventions initiated in primary care will be conduct- ed. Early research suggests that clinician referrals to home visitation by nurses during pregnancy and early childhood may reduce child abuse and neglect in selected populations, but additional research is needed. Future research must examine both the potential benefits and the potential unintended harms of interventions aimed at pre- venting child abuse and neglect. (Moyer et al., 2011, p. 12; see http://www.uspreventiveservicestaskforce.org/annlrpt/tfannrpt2011.pdf) Recent controlled studies have followed this lead and the field has begun to identify pediatric primary care-based prevention models that reduce maltreatment reports (Dubowitz et al., 2009).
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129 APPENDIX D BOX 3 Use of ICD Codes for Child Maltreatment Injuries and Mortality Data The World Health Organization prepares and publishes International Classification of Diseases (ICD) codes that guide cross-national compar- isons of disease, injury, and mortality trends (WHO, 1999, 2003). At pres- ent, the U.S. health care system uses the ICD-9-CM (Clinical Modifica- tion) codes for hospital data and the ICD-10 codes for child death cases (CDC and NCHS, 2009; Leventhal et al., 2012). In 2013 the United States is changing to ICD-10-CM for hospital data; the ICD-10 codes are already in use by most countries. The ICD-9 codes for “child maltreatment syndrome” are 995.50, .54, .55, or .59, which include abuse, emotional/psychological abuse, nutritional neglect, sexual abuse, physical abuse, shaken infant syndrome, and other child abuse and neglect. The ICD codes that classify fatalities from child maltreatment are “external cause of death: homicide” (ICD-9 E960-969) and “as- sault” (ICD-10 X85-Y09). The E-code E967 in ICD-9 (or Y07 in ICD-10) includes “external cause of death: child battering” and identifies the perpetrator of the abuse. In the United States, the ICD-10 codes are currently used on death certificate data only. The ICD-9 code for child neglect is E968.4, “Assault by other and unspecified means–criminal neglect, which includes the aban- donment of child, infant, or other helpless person with intent to injure or kill.” Other ICD-9 codes for homicide and injury purposely inflicted by other persons can sometimes be used to identify cases of mal- treatment if it is possible to describe the age of the child, the perpetrator is designated as a caregiver, and the assault occurs within a home. Separate ICD-10 codes for child maltreatment have also been creat- ed, but are not yet in common use in the United States. These include the “Y-codes” for specific acts, such as sexual assault by bodily force; neglect and abandonment by parent, by acquaintance or friend, or by a specified or unspecified person. They also include “other maltreatment syndromes” by parent, by acquaintance or friend, by official authorities, or by other specified or unspecified person (WHO, 2003).
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194 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE Dubowitz, H., R. R. Newton, A. J. Litrownik, T. Lewis, E. C. Briggs, R. Thompson, D. English, L.-C. Lee, and M. M. Feerick. 2005. Examination of a conceptual model of child neglect. Child Maltreatment 10(2):173-189. Dubowitz, H., S. Feigelman, W. Lane, and J. Kim. 2009. Pediatric primary care to help prevent child maltreatment: The Safe Environment for Every Kid (SEEK) model. Pediatrics 123(3):858-864. Egeland, B., D. Jacobvitz, and L. A. Sroufe. 1988. Breaking the cycle of abuse. Child Development 59(4):1080-1088. Egeland, B., T. Yates, K. Appleyard, and M. van Dulmen. 2002. The long-term consequences of maltreatment in the early years: A developmental pathway model to antisocial behavior. Children's Services 5(4):249-260. Ertem, I. O., J. M. Leventhal, and S. Dobbs. 2000. Intergenerational continuity of child physical abuse: How good is the evidence? Lancet 356(9232):814- 819. Fallon, B., N. Trocmé, J. Fluke, B. MacLaurin, L. Tonmyr, and Y.-Y. Yuan. 2010. Methodological challenges in measuring child maltreatment. Child Abuse & Neglect 34(1):70-79. Farrington, D. 2011. Families and crime. In Crime and public policy, edited by J. Wilson and J. Petersilia. New York: Oxford University Press. Pp. 130-157. FIFCFS (Federal Interagency Forum on Child and Family Statistics). 2011. America’s children: Key national indicators of well-being, 2011. Washington, DC: U.S. Goverment Printing Office. Finkelhor, D. 2007. Developmental victimology: The comprehensive study of childhood victimizations. In Victims of crime, 3rd ed., edited by R. C. Davis, A. J. Lurigio, and S. Herman. Thousand Oaks, CA: Sage Publications. Pp. 9- 34. Finkelhor, D. 2008. Childhood victimization: Violence, crime, and abuse in the lives of young people. New York: Oxford University Press. Finkelhor, D., and L. Jones. 2006. Why have child maltreatment and child victimization declined? Journal of Social Issues 62(4):685-716. Finkelhor, D., R. K. Ormrod, H. A. Turner, and S. L. Hamby. 2005. Measuring poly-victimization using the Juvenile Victimization Questionnaire. Child Abuse & Neglect 29(11):1297-1312. Flynn, B., J. Furtado, T. Orbach, and J. Scott. 2011. Designing and implementing differential response systems in child protective services: A three state case study. Boston, MA: Department of Urban and Environmental Policy and Planning, Tufts University. Fraser, M. W., E. Walton, R. E. Lewis, P. J. Pecora, and W. K. Walton. 1996. An experiment in family reunification: Correlates of outcomes at one-year follow-up. Children and Youth Services Review 18(4-5):335-361. Garner, A. S., J. P. Shonkoff, B. S. Siegel, M. I. Dobbins, M. F. Earls, L. McGuinn, J. Pascoe, and D. L. Wood. 2012. Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science into lifelong health. Pediatrics 129(1):e224-e231.
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195 APPENDIX D Gilbert, R., J. Fluke, M. O’Donnell, A. Gonzalez-Izquierdo, M. Brownell, P. Gulliver, S. Janson, and P. Sidebotham. 2012. Child maltreatment: Variation in trends and policies in six developed countries. Lancet 379(9817):758-772. Gunnar, M. R., P. A. Fisher, and the Early Experience, Stress, and Prevention Science Network.2006. Bringing basic research on early experience and stress neurobiology to bear on preventive interventions for neglected and maltreated children. Development and Psychopathology 18(3):651-677. Hanson, R. F., S. Self-Brown, A. E. Fricker-Elhai, D. G. Kilpatrick, B. E. Saunders, and H. S. Resnick. 2006. The relations between family environment and violence exposure among youth: Findings from the National Survey of Adolescents. Child Maltreatment 11(1):3-15. Harris, W. W., F. W. Putnam, and J. A. Fairbank. 2004. Mobilizing trauma resources for children. Paper presented at Johnson and Johnson Pediatric Institute: Shaping the Future of Children’s Health, San Juan, Puerto Rico, February 12-16. Hembree-Kigin, T. L., and C. B. McNeil. 1995. Parent-child interaction therapy. New York: Plenum Press. Herrenkohl, R., and T. Herrenkohl. 2009. Assessing a child’s experience of multiple maltreatment types: Some unfinished business. Journal of Family Violence 24(7):485-496. HHS (U.S. Department of Health and Human Services). 2011. Child maltreatment 2010. Washington, DC: HHS. Hicks, B. M., S. C. South, A. C. DiRago, W. G. Iacono, and M. McGue. 2009. Environmental adversity and increasing genetic risk for externalizing disorders. Archives of General Psychiatry 66(6):640-648. Horwitz, S., M. Hurlburt, and J. Zhang. 2010. Patterns and predictors of mental health services use by children in contact with the child welfare system. In Child welfare and child well-being, edited by M. Webb, K. Dowd, B. Harden, J. Landsverk, and M. Testa. New York: Oxford University Press. Pp. 279-329. Hunter, W., and E. Knight. 1998. LONGSCAN research briefs, volume 1. Chapel Hill, NC: LONGSCAN Coordinating Center. Huntington, C. 2006. Rights myopia in child welfare. UCLA Law Review 53:637-700. Hussey, J. M., J. M. Marshall, D. J. English, E. D. Knight, A. S. Lau, H. Dubowitz, and J. B. Kotch. 2005. Defining maltreatment according to substantiation: Distinction without a difference? Child Abuse & Neglect 29(5):479-492. IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. IOM. 2002. Confronting chronic neglect: The education and training of health professionals on family violence. Washington, DC: National Academy Press. Isaacs, J. B. 2007. Cost-effective investments in children. Washington, DC: Brookings Institution.
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