Key Points Raised by the Speaker
• Despite increased levels of research over the past two decades, the incidence of different kinds of abuse and neglect remains unclear.
• Differing definitions of child abuse and neglect continue to hinder research, prevention, and treatment.
• Though the consequences of child maltreatment are better understood today than they were two decades ago, the contextual factors that influence maltreatment need more study.
• Child maltreatment research needs to move from the fringe to the mainstream, with increased funding and better use of research results to shape policy and practice.
Looking back provides an opportunity to look forward as well, said Cathy Spatz Widom, in her keynote address at the workshop. She is a distinguished professor in the psychology department at John Jay College, a faculty member at the Graduate Center of the City University of New York, and a member of the panel that produced the 1993 NRC report. Any such review has the temptation of painting a picture of great progress. “Alas, I think the story is more complicated,” she said.
The research literature on child abuse and neglect has undergone a substantial increase since 1993 (Figure 1). During the 1980s, approximately 8,000 medical and psychological articles were published in the
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2 Reflections on the 1993 NRC Report Understanding Child Abuse and Neglect Key Points Raised by the Speaker Despite increased levels of research over the past two decades, the incidence of different kinds of abuse and neglect remains unclear. Differing definitions of child abuse and neglect continue to hinder research, prevention, and treatment. Though the consequences of child maltreatment are better under- stood today than they were two decades ago, the contextual factors that influence maltreatment need more study. Child maltreatment research needs to move from the fringe to the mainstream, with increased funding and better use of research results to shape policy and practice. Looking back provides an opportunity to look forward as well, said Cathy Spatz Widom, in her keynote address at the workshop. She is a distinguished professor in the psychology department at John Jay Col- lege, a faculty member at the Graduate Center of the City University of New York, and a member of the panel that produced the 1993 NRC re- port. Any such review has the temptation of painting a picture of great progress. “Alas, I think the story is more complicated,” she said. EXPANSION OF RESEARCH The research literature on child abuse and neglect has undergone a substantial increase since 1993 (Figure 1). During the 1980s, approxi- mately 8,000 medical and psychological articles were published in the 7
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8 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE areas of child abuse and neglect. By the first decade of the 21st century, that number had risen to nearly 25,000. However, the approximate parity between the increases in medical and psychological articles obscures an important trend. In the areas of physical and sexual abuse, publications from medicine and from psy- chology are increasing at about the same rate. In the area of neglect, however, medical publications are increasing at a significantly faster rate than psychological publications. “I would suggest that we have neglect of neglect by psychologists,” said Widom. NATURE AND SCOPE OF CHILD MALTREATMENT More data are available today on the incidence and prevalence of child maltreatment than were available in 1993. (Chapter 4 of this summary addresses major data sources and trends over time.) However, fundamental questions remain, Widom noted. According to data from the National Incidence Studies (NISs), the incidence of child maltreatment declined 19 percent in the 12 years between NIS-3 and NIS-4. Most of the decline appears to be related to significant decreases in physical and 14000 12000 Number of Publications MEDICAL 10000 PSYCHOLOGICAL 8000 6000 4000 2000 0 1950- 1960- 1970- 1980- 1990- 2000- 1959 1969 1979 1989 1999 2009 Decade FIGURE 1 Published articles on child abuse and neglect: 1950-2009. SOURCE: Widom, 2012.
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9 REFLECTIONS ON THE 1993 NRC REPORT sexual abuse, whereas the level of child neglect has remained about the same. Other studies—for example, of hospital admissions—do not show such dramatic changes. This discrepancy needs further study, said Widom. Widom suggested that a more accurate picture of the nature and scope of maltreatment is needed. In particular, the picture needs to in- clude the types of child maltreatment currently excluded from existing official statistics. She recommended a series of large population-based epidemiological surveys that would include the types of maltreatment missed today. Ideally, these surveys would become part of a series ena- bling comparison of rates over time. DEFINITIONS OF CHILD ABUSE AND NEGLECT Less progress has been made than Widom might hope on definitions of child abuse and neglect. No gold standard exists to determine whether child abuse and neglect have occurred, she observed. For example, a pe- diatrician might have a low threshold for considering a situation to be abuse or neglect; a child protective services worker, guided by state laws and limited agency resources, might have a higher threshold; and a pros- ecutor might have the highest threshold in pursuing only the most serious cases. For researchers, knowledge gaps in the definition, identification, and assessment of child abuse mean that maltreated and control populations might not be comparable. Unless studies use the same or similar defini- tions, Widom remarked, findings will not converge. A related issue is that the amount of time a researcher spends as- sessing child maltreatment can also generate tensions. Survey instru- ments have notable advantages such as relative ease of administration and scoring, but some surveys include only a few items to assess mal- treatment, and these assessments may be vague or ambiguous. Also, child maltreatment is sometimes bundled with other life adversities, which runs counter to a recommendation from the 1993 NRC report to clarify the common and divergent pathways in the etiologies of different forms of maltreatment. Reliable and valid clinical diagnostic research instruments for child maltreatment are essential needs, said Widom. A consensus on research definitions should be established for each type of child maltreatment.
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10 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE These definitions should be tested for relevance and usefulness in eco- nomically and culturally diverse populations. CONSEQUENCES OF CHILD MALTREATMENT The medical, cognitive, behavioral, and psychological conditions as- sociated with child maltreatment are better understood today than they were 20 years ago (Table 1). But, Widom said, contextual factors need much more study, including genes, poverty, parenting styles, beliefs re- garding discipline, cultural differences, and community resources. Fur- thermore, these contextual factors need to be studied in combination to understand both the causes and consequences of maltreatment. Research- ers need to design studies to test and analyze theoretical models using more sophisticated statistical techniques. The almost exclusive reliance on cross-sectional studies has limited progress in understanding the origins and causes of child abuse and ne- glect, Widom stated. This situation could be remedied by including child maltreatment in the National Children’s Study (NCS). Authorized by the National Children’s Health Act of 2000, the NCS plans to recruit and follow a nationally representative sample of 100,000 children from be- fore birth until age 21 to examine the effects of physical, chemical, and social environments on their growth, development, and health. Child maltreatment is not now included in the National Children’s Study. However, a planning workshop for the study indicated that inves- tigation of the causes and consequences of child maltreatment was an appropriate scientific hypothesis to test. Inclusion of this topic in the study could help identify early markers of problematic parent–child in- teractions and factors that contribute to the likelihood of child maltreat- ment. This could provide valuable information about the delivery of cost- effective interventions to prevent and address the consequences of child maltreatment. “I would urge anyone who is involved in a sentinel site or in a leadership position or on the advisory board of the NCS to lobby to have child maltreatment included as one of the focal topics,” said Widom. By contrast, Widom pointed to neurobiology as an example of an ar- ea where major progress has been made in understanding the conse- quences of early stress and maltreatment. Recent studies have shown that maltreatment is associated with critical changes in the central nervous system. (Chapter 5 describes some of these changes in more detail.) Sim-
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11 REFLECTIONS ON THE 1993 NRC REPORT ilarly, study of how interactions between genes and the environment af- fect the immune system has brought attention to child maltreatment re- search. Researchers studying the origins of many adult diseases have begun to recognize the importance of early experiences in shaping the neurological and hormonal pathways through which individuals handle stress and physical and emotional threats. Animal models also provide opportunities to understand transgenerational processes. “We have made great progress,” she said. TABLE 1 Outcomes Frequently Associated with Child Maltreatment Neurological/ Cognitive/ Social/ Psychological/ Medical Intellectual Behavioral Emotional Brain damage Lowered IQ Aggression Anxiety Neurobiologi- Inattention Truancy Depression Learning cal effects Running away Dysthymia Mental disorders Delinquency Low Poor reading retardation self-esteem Prostitution Speech Poor school Poor coping Teenage defects performance skills pregnancy Physical School Hostility Problem handicaps drop-out drinking Suicide and Physical Attempts Drug use health Posttraumatic Crime and problems stress disorder violence Death Dissociation Partner Increased violence Borderline health care personality Child abuse use disorder Unemploy- Antisocial ment personality disorder NOTE: This table shows outcomes often associated with child maltreat- ment, but the evidence linking child maltreatment to these outcomes var- ies in quality, quantity, and consistency. SOURCE: Widom, 2012.
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12 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE ETHICAL ISSUES Ethical issues, such as legal reporting requirements, continue to pose difficulties, said Widom. Conducting research with maltreated children is challenging due to difficulties in recruiting samples, in navigating ethical and legal reporting requirements, and in collecting information from families where abuse has occurred. In particular, mandatory child abuse reporting laws make researchers fearful of losing participants because of the impact of reporting. This was an issue with the National Children’s Study, where the advisory board was concerned about the need to report, although communicable or life-threatening diseases also would need to be reported, said Widom. Early career investigators and institutional review boards (IRBs) need education in how to deal with these issues. Empirical evidence from several longitudinal studies reveals that these challenges are not insur- mountable. “The potential knowledge to be gained is critical to further our understanding of child abuse and neglect,” said Widom. SCIENCE POLICY FOR CHILD MALTREATMENT RESEARCH Finally, Widom addressed several issues involving science policy that were discussed in the 1993 NRC report. That report recommended that federal agencies concerned with child maltreatment research formu- late a national research plan. The creation of the Child Abuse and Ne- glect Working Group, which includes representatives of the National Institutes of Health (NIH) and other federal agencies, represents progress on this recommendation, she said, but more is needed. “We need to fig- ure out a way to raise the profile and importance of child abuse and ne- glect research,” she said. In particular, research on child maltreatment should be recognized as critical for the federal government’s children’s research agenda. Neurobiological studies provide an opportunity to integrate research on child maltreatment into the broader stress and trauma literatures. An- other such opportunity is the PhenX toolkit project developed by the NIH, in which groups of experts have developed phenotypic and expo- sure measures for use in genome-wide association studies (RTI Interna- tional, 2012). This toolkit includes a measure of exposure to violence and child abuse, which can provide genetics researchers and others with lim-
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13 REFLECTIONS ON THE 1993 NRC REPORT ited expertise in measurement of these constructs in a way to integrate them into multidisciplinary studies. Administrative and grant review processes need to ensure that re- viewers have adequate expertise with child maltreatment so that mal- treatment research proposals are evaluated on the basis of the quality of work proposed. In addition, special efforts are needed to find new funds for research on child maltreatment, Widom said. In 1992, research ex- penditures in the field were about $15 million. In 1997 they were $33.7 million, and the estimated budget for 2012 is $32 million. In comparison, $55 million goes for suicide and suicide prevention research, which is associated with child maltreatment (NIH, 2012). Also, the capabilities of the researchers who can contribute to child maltreatment research need to be sustained and improved. Relatively few postdoctoral fellowship awards from the NIH are devoted to this subject. A conference grant supports annual meetings of a child neglect consorti- um that brings together scholars in this area, and a data archive at Cornell holds summer training sessions. The interdisciplinary nature of child maltreatment research requires both specialized disciplinary expertise and opportunities for collaborative research. However, categorical funding for federal research programs creates significant barriers to collaborative or innovative efforts among researchers concerned with maltreatment. In many cases children and families reported for maltreatment experience multiple other problems, such as substance abuse, intimate partner violence, mental health disor- ders, poverty, inadequate housing, poor schools, and violent neighbor- hoods. Researchers working in these separate areas need systems to communicate with one another, Widom said. In addition, child and de- velopmental psychologists need to recognize child maltreatment as an important contributor to a wide range of social problems and family pa- thologies. A funding mechanism is needed that can reflect the interdisciplinary nature of child maltreatment research and extend to graduate and post- graduate training. Perhaps the new NIH initiative in translational re- search can provide a needed infusion of funding, Widom suggested. FROM ANALYSIS TO ACTION Finally, Widom examined how to translate research findings for practitioners and policy makers. Researchers in the field of child abuse
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14 CHILD MALTREATMENT RESEARCH, POLICY, AND PRACTICE and neglect are continually pressed to translate their findings into clinical applications as well as recommendations for policy and practice. With some exceptions, however, the infrastructure to support the dissemina- tion and translation of basic research findings into policy and practice is limited. Organizational changes need to improve the process by which child maltreatment research findings are converted into action. Progress in understanding child maltreatment has been slowed by many factors, including ethical and legal challenges, a lack of consensus in research definitions, and a lack of trained investigators. But perhaps the most important factor has been the perception that child maltreatment is a fringe issue, Widom concluded. It is not. “Child maltreatment re- mains a public health and a social welfare problem. It compromises the health of our children. It threatens their long-term physical and mental health as adults. It impacts their parenting practices. And it negatively affects their economic productivity as wage earners.” The high burden and long-lasting consequences of child maltreatment warrant increased investment in preventive and therapeutic strategies from early childhood, Widom added. “We need to bring child maltreatment research out of the fringe and into the mainstream.”